State of New Hampshire

REQUEST FOR BID For

Voluntary Benefits

RFB # 2016-178

RESPONSE DUE BY: August 3, 2015 @ 11:00 AM E.D.T

Department of Administrative Services Risk Management Unit

TABLE OF CONTENTS

SECTION I: INTRODUCTION _____________________________________________________ 3 A. Background ................................................................................................................................................. 3 B. Current Administration ............................................................................................................................... 4 C. Objective ..................................................................................................................................................... 4 D. Proposed Voluntary Short Term Disability Plan Change ........................................................................... 5 E. Other Short Term Disability and Sick Pay Plans ........................................................................................ 5

SECTION II: BIDDING INSTRUCTIONS AND CONDITIONS __________________________ 6 A. Bid Conditions for the State of New Hampshire ........................................................................................ 6 B. RFB Estimated Timetable ......................................................................................................................... 11 C. Term of Contract ....................................................................................................................................... 12 D. Bid Eligibility Criteria .............................................................................................................................. 13 E. Award Criteria........................................................................................................................................... 14 F. Sub-Contracting ........................................................................................................................................ 14 G. Bidder Contacts ......................................................................................................................................... 14

SECTION III: SPECIFICATIONS FOR INSURANCE COVERAGE _____________________ 15 A. General Bid Specifications ........................................................................................................................ 15 B. Requested Voluntary Benefits .................................................................................................................. 15 C. Coverage Details for Voluntary Benefits .................................................................................................. 15 D. For Informationl Purposes Only – Voluntary Short Term Disability Plan Alternative ............................ 16

SECTION IV: SERVICE SPECIFICATIONS _________________________________________ 17 A. Claims Administration .............................................................................................................................. 17 B. Program Implementation/Enrollment........................................................................................................ 17 C. Reports ...................................................................................................................................................... 19

SECTION V: Proposed Rates_______________________________________________________ 20

SECTION VI: Performance Guarantee ______________________________________________ 21

APPENDICES ___________________________________________________________________ 22 A. Confirmation of Plan Form ....................................................................................................................... 23 B. RFB Attachments ...................................................................................................................................... 24 C. Plan Information and Documents ............................................................................................................. 26 D. Voluntary Benefits Payroll Deduction Register File Format .................................................................... 27 E. State of New Hampshire RFB Transmittal Letter ..................................................................................... 28 F. Sample P-37 Form Contract ...................................................................................................................... 29

SECTION I

INTRODUCTION

This Request for Bids (“RFB”) is issued by the State of New Hampshire, Department of Administrative Services, acting through the Risk Management Unit, for the procurement of voluntary benefits as described herein.

A. BACKGROUND

The State of New Hampshire currently allows employees who work a minimum of 30 hours per week the ability to purchase voluntary benefits. Newly hired or newly eligible employees have a 30-day eligibility window in which to apply for these benefits. The effective date of coverage is the 1st day of the month following the completion of one full month of benefits eligible employment. If an employee does not enroll during their new hire eligibility window, the next opportunity to enroll is during the annual benefits open enrollment with an effective date of January 1st. These benefits are currently offered through Employee Benefit Management, Inc. (EBM), as a licensed insurance producer. Eligible employees have the option to enroll in one or all of the following voluntary benefits on a 100% employee paid after-tax basis:

Coverage Plan Amount

Voluntary Short Term Disability

1st day accident (injury) / 8th day sickness / 26 week benefit period

$100 to $1,000 per week, up to 70% of gross weekly earnings (in $10 increments)

15th day accident (injury) / 15th day sickness / 52 week benefit period

$100 to $1,000 per week, up to 70% of gross weekly earnings (in $10 increments)

Employees may elect to supplement short term disability with accrued sick time, there is no offset to this benefit. Please note Proposed Plan Change in Section I.D.

Critical Illness

Insurance

Critical Illness Lump Sum Benefit Recurrent Critical Illness Benefit

Cancer Screening Benefit

Elect coverage from $10,000 to $50,000, (in $5,000 increments)

Benefit payment percentages vary by category and diagnosis (see schedule of

benefits)

Optional Rider – Cancer Screening Wellness Benefit Rider

Pays an additional $50 per covered person per calendar year per cancer screening test

Employee Accident Insurance

Base Plan (off the job only)

Accident Death Benefits, Dismemberment Benefits, and Extended Loss Accident

Coverage Benefit payments vary by type of injury/loss

(see outline of coverage)

Optional Rider –Enhanced Emergency Room Benefit Rider

Pays an additional $100, $200, or $300, in addition to base plan of $50

Optional Rider –Enhanced Physician Office/Urgent Care Benefit Rider

Pays an additional $25 or $50, in addition to base plan of $50

The State currently allows payment of premiums through voluntary employee after-tax payroll deduction; however, such voluntary benefits are not financially sponsored by the State. Premiums that are not able to be

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collected through payroll deduction are not put into arrears. It is each employee’s responsibility to make up missed payments outside of the payroll system through a mutual agreement with the producer. If a reimbursement is due to an employee, it is the vendor’s responsibility to refund the employee directly. Additional details on the benefits for the State are contained in the attached Plan Documentation.

The State currently has approximately 10,000 employees eligible for voluntary benefits. This population consists of both represented and unrepresented employees. Approximately 8,600 employees are represented by the State Employees’ Association of NH (SEA), SEIU Local 1984, NH Trooper’s Association, New England Police Benevolent Association (NEPBA), or Teamsters Local 633. These unions may provide access to voluntary benefits outside of the State’s benefits program. The current voluntary benefits enrollment by coverage in the State’s program is as follows:

Coverage Enrollment Voluntary Short Term Disability 1/8/26 175 Voluntary Short Term Disability 15/15/52 401 Critical Illness Insurance 42 Employee Accident Insurance 204

These enrollment numbers are for informational purposes only, and are not guaranteed to rollover into January 2016.

B. CURRENT ADMINISTRATION

EBM currently provides enrollment and administrative services for the voluntary short term disability, critical illness and accident insurance. Enrollment for these plans is currently handled through a paper enrollment process. During open enrollment and as requested by the State or by individual State agencies, EBM conducts on-site meetings to educate employees about how to elect these voluntary benefits. Paper enrollment forms are completed and returned to the respective vendors by the employees, Human Resource Representatives or by EBM for the short term disability, critical illness and/or accident insurance policies. From the enrollment information, EBM creates an electronic data file to be uploaded through the State’s FTP site.

EBM has been offering the State’s voluntary benefits through the following vendors:

Voluntary Short Term Disability –Trustmark since January 2012, prior Fort Dearborn as of 1999

Critical Illness Insurance –Transamerica since January 2012, prior Colorado Bankers as of 2006

Employee Accident Insurance –Boston Mutual, Inc. since January 2010, prior American Heritage as of 1999

Please see Appendix C for further details of plan administration being performed by EBM.

C. OBJECTIVE

The State is seeking bids from qualified vendors to provide administration and insurance producer services for the three voluntary benefits described in Section I.A above. The State will accept bids which may incorporate a partnership arrangement to accomplish this objective; however, the bid must be submitted by a single entity with the partner serving as a subcontractor (i.e., the State will only execute one contract as a result of this RFB). It is the intent of the State for bidders to duplicate the current coverages offered with the exception of proposed change to the Voluntary Short Term Disability program as outlined below.

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Any plan deviations must be noted on the deviations form provided. The State is interested in contracting with a qualified vendor that will offer a three-year contract commencing January 1, 2016 through December 31, 2018.

D. PROPOSED VOLUNTARY SHORT TERM DISABILITY PLAN CHANGE

Effective January 1, 2016, the voluntary short term disability will contain an offset for other forms of compensation, such as sick time. Currently there is no offset.

E. OTHER SHORT TERM DISABILITY AND SICK PAY PLANS

The plans listed below are for informational purposes only, to make bidders aware of other programs available to State employees, and are not part of this RFB process. These are disability and sick leave programs offered to State employees in addition to the Voluntary Short Term Disability program mentioned above and included in this RFB. SICK LEAVE Currently, the State allows full-time employees to accrue sick leave. Represented employees accrue Sick Leave in accordance with their respective collective bargaining agreements. In addition to sick leave, each agreement outlines potential disability pay if the employee is required to be out of work beyond the accrued sick leave balances. These collective bargaining agreements can be found on the State of New Hampshire Human Resources web page under Labor Relations at the following link: http://das.nh.gov/hr/sea.html Please see Appendix C for further details. SHORT TERM DISABILITY INCOME PROTECTION Short Term Disability Income Protection is an employer paid, short term disability program that provides salary continuation to an eligible employee who needs to be out of work beyond their accrued sick leave balance. This program is only available to unrepresented full-time State employees of the Executive Branch or State employees represented by the NEPBA or Teamsters Local 633 (approximately 1,500 eligible participants). Eligibility for this program became effective June 1, 2014. An employee must meet the 30 day waiting period and “exhaust” sick leave balance, whichever is later. Please see Appendix C for further details.

DAVIS & TOWLE INSURANCE GROUP Prior to EBM, Employees had the option to enroll in voluntary benefits through Davis & Towle Insurance Group. Although this contract is closed to new enrollment, approximately 1,435 employees continue to pay premiums through payroll deductions. The State does not endorse the program and employees must contact Davis & Towle for existing benefit information. There is no further information available on the programs being offered and provided by Davis & Towle to that limited population.

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SECTION II

BIDDING INSTRUCTIONS AND CONDITIONS

A. BID CONDITIONS FOR THE STATE OF NEW HAMPSHIRE, DEPARTMENT OF ADMINISTRATIVE SERVICES, RISK MANAGEMENT UNIT

1. RFB SCOPE

The Department of Administrative Services, Risk Management Unit, is soliciting bids for the procurement of administration and producer services for voluntary benefits for its eligible employees on a 100% employee paid after-tax basis.

2. MANDATORY INSTRUCTIONS FOR VENDORS

It is required that you complete all sections of the RFB and provide your Bid by the stated Bid Submission Deadline. All companies, producers, agents or underwriters submitting bids are construed to have agreed to all conditions set forth in the RFB. This RFB may not be altered or modified by bidders or bidding entities.

Failure to follow these instructions is grounds for rejection of your RFB response.

3. PUBLIC DISCLOSURE

a) Introduction

The State of New Hampshire has made it a priority through the Right-to-Know law (RSA 91-A), the TransparentNH initiative, and other statutes and practices to ensure that government activity is open and transparent. In general, these requirements allow for public review, disclosure and posting of government and public records. As such, the State is obligated to make public the information submitted in response to this RFB, any resulting contract, and information provided during the contractual relationship. The Right-to-Know law obligates the State to conduct an independent analysis of the confidentiality of the information submitted, regardless of whether it is marked confidential. In addition, the Governor and Council (G&C) contract approval process more specifically requires that pricing be made public and that any contract reaching the G&C agenda for approval be posted online.

b) Disclosure of Information Submitted in Response to RFB

Information submitted in response to this RFB is subject to public disclosure under the Right-to-Know law after a contract is actually awarded by G&C. Notwithstanding the Right-to-Know law, no information concerning the contracting process, including but not limited to information related to bids, communications between the parties or contract negotiations, shall be available until a contract is actually awarded by G&C. Confidential, commercial or financial information may be exempt from public disclosure under RSA 91-A:5, IV. If you believe any information submitted in response to this request for bid should be kept confidential, you must specifically identify that information where it appears in your submission in a manner that draws attention to the designation. You must also provide a letter to the person listed as the point of contact for this RFB, identifying the specific page number and section of the information you consider to be confidential, commercial or financial and providing your rationale for each designation. Marking or designating an entire bid, attachment or section as confidential shall neither be accepted nor honored by the State.

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Pricing, which includes but is not limited to, premium rates, administrative costs, and performance guarantees in your bid or any subsequently awarded contract shall be subject to public disclosure regardless of whether it is marked as confidential. Notwithstanding a bidder’s designations, the State is obligated by the Right-to-Know law to conduct an independent analysis of the confidentiality of the information submitted in a bid. If a request is made to the State by any person or entity to view or receive copies of any portion of your bid, the State shall first assess what information it is obligated to release. It will then notify you that a request has been made, indicate what, if any, information the State has assessed is confidential and will not be released, and specify the planned release date of the remaining portions of the bid. To halt the release of information by the State, a bidder must obtain and provide to the State, prior to the date specified in the notice, a court order valid and enforceable in the State of New Hampshire, at its sole expense, enjoining the release of the requested information. By submitting a bid, you acknowledge and agree that: • The State may disclose any and all portions of the bid or related materials which are not marked

as confidential and/or which have not been specifically explained in the letter to the person identified as the point of contact for this RFB;

• The State is not obligated to comply with your designations regarding confidentiality and must conduct an independent analysis to assess the confidentiality of the information submitted in your bid; and

• The State may, unless otherwise prohibited by court order, release the information on the date specified in the notice described above without any liability to you.

c) Electronic Posting of Resulting Contract

RSA 91-A obligates disclosure of contracts resulting from responses to RFBs. As such, the Secretary of State provides to the public any document submitted to G&C for approval, and posts those documents, including the contract, on its website. Further, RSA 9-F:1 requires that contracts stemming from RFBs be posted online. By submitting a bid you acknowledge and agree that, in accordance with the above mentioned statutes and policies, (and regardless of whether any specific request is made to view any document relating to this RFB), any contract resulting from this RFB that is submitted to G&C for approval will be made accessible to the public online via the State’s website.

4. REQUIRED CONTRACT TERMS AND CONDITIONS

The Transmittal Letter (attached hereto as Appendix E) must be signed and submitted with your RFB response. Failure to submit the Transmittal Letter with your response may result in rejection of your response.

The form contract P-37 (attached hereto as Appendix F) shall be part of this Bid and the basis for contract discussions. If and when a selection for an award is made, the successful vendor and the State shall promptly execute this form of contract, which is to be completed by incorporating the service requirements and price conditions established by the vendor’s offer. In addition to the fully and properly executed P-37, the successful vendor shall promptly provide the required documentation needed for Governor and Council approval. Such documents shall include, but may not be limited to, a Certificate of Authority/Vote, an original Certificate of Good Standing, and a Certificate of Insurance.

A current Certificate of Good Standing dated April 1, 2015, or later. The Certificate of Good Standing is available from the Secretary of State’s Office by calling (603) 271-3244 or (603) 271-3246 or by visiting http://sos.nh.gov/corp_div.aspx.

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If the successful vendor fails to return the above mentioned documents to the State immediately as specified by the State, the State reserves the right to award the contract to the next conforming bidder.

5. CERTIFICATE OF INSURANCE

The selected vendor shall, at its sole expense, obtain and maintain in force, and shall require any subcontractor or assignee to obtain and maintain in force, including for the benefit of the State, the following insurance:

a. General Liability Insurance. The vendor shall carry comprehensive general liability insurance in

accordance with Section 14 of the P-37 contract. Please provide a copy of your coverage as part of your bid submission.

b. Worker’s Compensation Insurance. The vendor shall certify compliance with, or exemption

from, the requirements of NH RSA 281-A, Workers’ Compensation, in accordance with Section 15 of the P-37 contract. Please provide a copy of your policy or letter of exemption as part of your bid submission.

6. VENDOR CERTIFICATIONS

All bidders must be duly registered as a vendor authorized to conduct business in the State of New Hampshire.

• STATE OF NEW HAMPSHIRE VENDOR APPLICATION. If you are not currently a registered vendor in the State, you shall complete a Vendor Application and W-9 Form and submit it to the NH Bureau of Purchase and Property. See the following website for information on obtaining and filing the required forms (no fee): http://das.nh.gov/Purchasing/vendorresources.asp

• NEW HAMPSHIRE SECRETARY OF STATE REGISTRATION Any person or persons

conducting business under any name other than his/her own legal name must register with the NH Secretary of State. Businesses are classified as 'Domestic' (in-state) or 'Foreign' (out-of-state). Please visit the following website to find out more about the requirements and filing fees for both classifications: http://sos.nh.gov/corp_div.aspx

7. RFB INQUIRIES

All questions regarding this RFB, including clarifications and proposed specification changes, must be submitted to Danielle Ruest, Department of Administrative Services, Bureau of Purchase and Property at Danielle.Ruest@nh.gov.

All questions or requests for modifications must be submitted in writing via e-mail no later than July 21, 2015, 1:00 PM E.D.T. The vendor must include complete contact information including the vendor’s name, telephone number, fax number, and e-mail address. The State shall attempt to provide any assistance or additional information of a reasonable nature, which might be required by interested vendors. The questions and answers will be consolidated and responded to via a written addendum or addendums that will be posted on the State’s Bureau of Purchase and Property website.

RFB inquiries must be submitted by an individual authorized to commit the organization to provide the services necessary to meet the requirements of this RFB.

8. RFB DELIVERY

Your RFB response must conform to the following criteria in order to be considered for evaluation:

Instructions for submitting in a sealed envelope/package:

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a. Exterior of the RFB response envelope or package shall be permanently marked identifying the vendor’s name and address, as well as the assigned RFB #2016-178.

b. RFB responses shall be addressed to the State of New Hampshire, Bureau of Purchase and Property, Attention: Danielle Ruest.

c. RFB responses must include: • One (1) original (clearly identified as such) copy of your RFB response; • Two (2) conforming copies (clearly identified as copies) of your RFB response; and • One (1) electronic copy* of your RFB response. • The original RFB response must include the State of NH Transmittal Letter (Appendix E),

signed by a person authorized to bind the company to all commitments made in the RFB response.

• RFB responses transmitted by facsimile will not be accepted or reviewed.

* In the event a discrepancy between a bid response in paper and electronic copy, the Vendor’s paper copy shall prevail.

Complete copy of RFB response to Segal Consulting:

a. A copy of your response must be sent to Segal Consulting.

b. The RFB response copy to Segal must include: • One (1) hardcopy of your RFB response; and • One (1) electronic copy of your RFB responses.

i. The electronic copy of your RFB should include the RFB ii. The electronic copy of your RFB should include the “SONH Voluntary Benefits

RFB 2015 Attachment Data” workbook file in MS Excel format. DO NOT PDF your response.

The State shall not be held liable for any costs incurred by the vendor in preparing or submitting an RFB response. Any and all damage, which may occur due to shipping, is the bidder’s responsibility.

9. ADDENDA

In the event it becomes necessary to add to or revise any part of this RFB prior to the scheduled bid submission deadline, the State shall post any Addenda on the State’s Bureau of Purchase and Property website. Before submitting your Bid, and periodically prior to bid closing, vendors are required to check the site for any addenda or other materials that may have been issued, that would affect this RFB. The website address is http://das.nh.gov/Purchasing/vendorresources.asp.

10. BID SUBMISSION DEADLINE

All RFB submissions must be received at the Bureau of Purchase and Property no later than 11:00 AM E.D.T. on Monday, August 3, 2015. Submissions received after the date and time specified will be marked as late and will not be eligible for consideration in the evaluation process.

All offers shall remain valid from the bid submission deadline until contract award, or no later than January 1, 2016. A vendor’s disclosure or distribution of bids other than to the Department of Administrative Services, Bureau of Purchase and Property, shall be grounds for disqualification.

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Vendors shall submit their bid to the State with a copy to Segal Consulting at the following locations:

State of New Hampshire C/O Danielle Ruest, Administrative Services New Hampshire Bureau of Purchase and Property 25 Capitol Street Concord, NH 03301-6312 (603) 271-2201 x227

Segal Consulting C/O Stephen L. Kuhn 116 Huntington Ave, 8th Floor Boston, MA 02116 (617) 424-7341

Bid responses shall be marked as:

State of New Hampshire, RFB# 2016-178 Due Date: August 3, 2015 @ 11:00 AM Voluntary Benefits

11. BID RECEIPT AND OPENING

To preserve the integrity of the bidding process, pricing and contents of bids will not be made public at the time of bid opening. For vendors wishing to attend a bid opening, only the names of the responders will be read.

12. ADDITIONAL INFORMATION

The State reserves the right to make a written request for additional information in writing from a vendor to assist in understanding or clarifying a bid response.

The State reserves the right to reject any and all bids, or any part thereof.

13. WAIVER OF MINOR IRREGULARITIES

The State reserves the right to waive minor irregularities in bids. Such waiver shall in no way modify the RFB requirements or excuse a vendor from full compliance with RFB specifications and other requirements if the vendor’s bid is selected.

14. REQUEST FOR REFERENCES

The State reserves the right to request references, at any time, during the evaluation process.

15. TERMS OF SUBMISSION

The State assumes no responsibility for understandings or representations concerning conditions made by its officers or employees prior to and in the event of the execution of a contract, unless such understanding or representations are specifically incorporated into this RFB. Verbal discussions pertaining to modifications or clarifications of this RFB shall not be considered part of this RFB unless confirmed in writing. Any information provided by the bidder verbally shall not be considered part of that bidder's response.

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16. RESTRICTION OF CONTACT WITH STATE EMPLOYEES

From the release date of this RFB, all contact with personnel employed by or under contract with the State related to this RFB, except those specifically mentioned in this RFB, is prohibited until the bid submission deadline and opening. Improper contact is grounds for rejection of your RFB response.

17. CANCELLATION

The State reserves the right to cancel all or any part of this RFB at any time. Cancellation of this RFB, in whole or in part, shall not bar the State from issuing an RFB for the same services or from purchasing the same services through other means.

B. RFB ESTIMATED TIMETABLE

Action Due Date (2015)

RFB Released Wednesday, July 15

Deadline for Bidder Inquiries and/or Requests for Clarification and Proposed Specification Changes Tuesday, July 21, 1:00 PM E.D.T

Response to Bidder Inquiries and/or Requests for Clarification and Proposed Specification Changes Monday, July 27

Bid Submission Deadline and Opening Monday, August 3, 11:00 AM E.D.T

Contract Effective Date Upon approval by the Governor & Executive Council *

* Vendor will begin insurance coverage effective January 1, 2016.

Important Note Regarding Contract Implementation Payments to the selected vendor shall not commence prior to January 1, 2016. The contract is effective upon the approval by Governor and Council assuming an implementation period of approximately 90 days. The vendor or licensed insurance producer shall be prepared to commence services immediately upon approval by the Governor and Council. No later than one week after approval, the vendor shall submit a detailed implementation plan subject to the Risk Management Unit’s approval that will include but not be limited to the following:

• Import of existing enrollment data • Development of interface between vendor and State system • Development of a Comprehensive Communication plan • Support of the State’s October/November 2015 Open Enrollment • Deliver benefits information to plan participants and all eligible employees of voluntary benefits,

including electronic information that can be posted on the Benefits webpage • Access to the State’s enrollment data by close of open enrollment for benefit program staff • Access to customer service by open enrollment for plan participants • Establish process for data and reporting access for the State

The project plan shall be updated thereafter as the State and bidder mutually agree. Implementation activities shall be conducted in close collaboration and with the approval of the Risk Management Unit.

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C. TERM OF CONTRACT

The term of the contract shall be for a three-year term, with policies to be renewed annually. The term of the contract shall commence January 1, 2016 and expire three years thereafter on December 31, 2018 with the option to extend for up to two additional years.

The State shall have the right to terminate the contract, if a contract is awarded, at any time by giving the vendor at least a thirty (30) days advance written notice.

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D. BID ELIGIBILITY CRITERIA

All bids shall meet or exceed the eligibility criteria described in this Section. Bids that are not in compliance shall be deemed non-responsive.

Each bid shall be evaluated initially to determine compliance with the Minimum Qualifications. Any bid that fails to meet one (1) or more of the below criteria may be eliminated from further consideration. Any bid that meets all of the minimum qualifications shall be further evaluated in accordance with the State’s selection criteria and other relevant factors. Generally, to receive consideration, a bid must unconditionally “confirm” it satisfies each qualification.

Eligibility Criteria Confirmation 1. The bid shall offer coverage for a full three-year term, with renewal rates guaranteed

through the contract period. The bid shall provide written documentation that the rate(s) are guaranteed for the three-year period.

2. The offer shall be the invoice premium the vendor intends each employee to pay. No additional taxes and/or fees beyond the premium rates proposed will be paid. Administrative functions will not be compensated separately.

3. The bidder/bidding entity is required to be a NH licensed insurance producer or a NH licensed business entity pursuant to NH RSA 402-J. All bids shall include proof of a NH license as issued by the NH Department of Insurance. Proof must be provided for the agent, producer, producer business entity, insurer, underwriter and any authorized person.

4. The bidder/bidding entity or insurance carrier’s rating contained in the most recent edition of A.M. Best’s Insurance Reports or its equivalent. The bidder/bidding entity shall have a minimum Best rating of B++ (or its equivalent rating from S&P or Moody’s).

5. Bids will only be considered from vendors that have a minimum of four years of experience in providing the similar services within the scope of this RFB. Failure to demonstrate this experience will be grounds for bid rejection.

6. No insurance agency or producer shall enter into a relationship or communicate with any carrier in such a manner that would result in the preclusion of other agencies or agents from obtaining the services of said insurance carrier shall constitute securing insurance services. The bidder/bidding entity shall not participate in “blocking the market” or any other non-competitive behavior in order to prevent other potential bidders from full and open competition in responding to this bid. Insurance producers submitting bids shall disclose the identity of all markets approached and provide a short narrative of each market’s response. Failure to comply with the terms of this section is grounds for disqualification. The bidding entity affirms it has followed these practices by signing the Transmittal Letter. (Appendix E of this RFB.)

7. Bids must include a complete response to all sections of this RFB.

8. Your bid must grandfather all current participants and their coverage elections.

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E. AWARD CRITERIA

Bids will only be considered from bidders/bidding entities meeting the Eligibility Criteria outlined in the preceding Paragraph D of this RFB.

If a contract is awarded, it shall be given to the carrier or licensed insurance producer who meets or exceeds the bid specifications offering the lowest pricing in grand total for Voluntary Benefits. The offer shall be the invoice premium the vendor intends the employees to pay. No additional taxes and/or fees beyond the premium rates proposed shall be paid.

Formal and final selection of the vendor, however, is contingent upon the proper execution of all contract documents (acceptable to the State) and the approval of Governor and Executive Council. If the State is unable to reach agreement with the vendor, the State may, at its sole discretion and at any time and without liability to the vendor, immediately terminate such contract discussions with the vendor and undertake discussion with the vendor submitting the next lowest priced bid meeting the RFB requirements, and so on. The State may, at its sole discretion, immediately terminate any and all contract discussions with any and all vendors at any time.

The State may cancel the RFB and/or reject any or all bid(s) at any time prior to the final execution of a contract.

F. SUB-CONTRACTING

If a vendor plans to utilize subcontractors for any portion of the services identified in this RFB, the vendor shall include the subcontractor information, to include the types of services or functions in which the vendor plans to subcontract, and a brief company profile. Said subcontractors shall meet all requirements described in this RFB. Subcontracting of services shall require prior approval by the State.

G. BIDDER CONTACTS

Designate the individual(s) with the following responsibilities:

The individual(s) representing your company during the RFB process:

Representative Name:_______________ Phone #:______________ Email: ___________________

The individual(s) responsible for day-to-day service (if different):

Representative Name:_______________ Phone #:______________ Email: ___________________

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SECTION III SPECIFICATIONS FOR INSURANCE COVERAGE

A. GENERAL BID SPECIFICATIONS

1. NAMED INSURED:

The named insured is the employee electing coverage.

2. POLICY TERM:

The contract term shall be effective from January 1, 2016 through December 31, 2018, with policies to be renewed annually. The first policy term shall commence January 1, 2016 and expire thereafter on December 31, 2016. The second policy term shall commence January 1, 2017 and expire thereafter on December 31, 2017. The third policy term shall commence January 1, 2018 and expire thereafter on December 31, 2018.

B. REQUESTED VOLUNTARY BENEFITS

It is the intent of the State for bidders to duplicate the current coverages with the exception of the Voluntary Short Term Disability proposed change as outlined in Section I.D of this RFB. The State must be notified of any proposed deviation in plan design. If no deviation in benefit design is identified within your response, the State will assume the voluntary benefits can be duplicated exactly.

Please review all information provided or referenced below in Section III, provided in Appendix C, and throughout the RFB document and complete the “Confirmation of Plan Form” located in Appendix A. If no variations are provided on this form, it will be assumed that your organization can administer the current voluntary benefits exactly as written in this RFB document and the attached appendices.

C. COVERAGE DETAILS FOR VOLUNTARY BENEFITS (100% EMPLOYEE PAID AFTER-TAX)

1. Voluntary Benefits:

Voluntary Short Term Disability –See Appendix C, attached hereto, for current plan highlights/schedule of benefits. Employees may elect to use their accrued sick time to supplement their Short Term Disability with earned sick time, there is currently no offset.

Critical Illness Insurance –See Appendix C, attached hereto, for current plan highlights/schedule of benefits

Employee Accident Insurance –See Appendix C, attached hereto, for current plan highlights/schedule of benefits

Please also refer to summary table in Section I.A of RFB. Eligible employees are defined in #2 below.

2. Eligibility and Enrollment Conditions and Stipulations:

Voluntary Short Term Disability –See Appendix C, attached hereto, for current plan highlights/schedule of benefits

Critical Illness Insurance –See Appendix C, attached hereto, for current plan highlights/schedule of benefits

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Employee Accident Insurance –See Appendix C, attached hereto, for current plan highlights/schedule of benefits

Please also refer to summary table in Section I.A of RFB.

3. Plan Administration

Please see Appendix C for further details of plan administration being performed by EBM.

D. FOR INFORMATIONAL PURPOSES ONLY – VOLUNTARY SHORT TERM DISABILITY PLAN ALTERNATIVE In addition to receiving bids on the group Voluntary Short Term Disability program. The State is interested in receiving rates on a fully portable Individual Short Term Disability program that provides similar benefits to those offered under the current Voluntary Short Term Disability program. These rates will not be factored into the RFB analysis or contract award. Please complete the rate exhibits in Appendix B and provide information on this plan with your bid.

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SECTION IV SERVICE SPECIFICATIONS FOR CLAIMS ADMINISTRATION, PROGRAM

IMPLEMENTATION, REPORTS, INVOICING & PREMIUM PAYMENTS

A. CLAIMS ADMINISTRATION

It is not the intent of the State to be involved with filing claims to any significant degree. Vendors must specify their claims handling procedure and include a sample claim form with an example Explanation of Benefits with their bid response.

Vendors submitting bids shall provide written instructions on claim reporting requirements in the event a covered voluntary benefits claim occurs. All claim payments shall be made by the Vendor in accordance with New Hampshire statutory provisions and regulations.

Vendors must designate a liaison and a toll-free telephone number to handle all claims issues and inquiries from State personnel and ensure a response standard of two business days is met.

Vendors shall maintain regular business hours, which at a minimum shall include Monday through Friday, 7:00 AM – 7:00 PM.

Greater detail of the current administrative services provided by EBM (including additional services typically administered by the employer) and expected of the awarded bidder is provided in Appendix C.

B. PROGRAM IMPLEMENTATION/ENROLLMENT

1. Program Implementation/Enrollment.

Vendor shall be available to assist the State with all phases of implementation, which includes participating in the initial open enrollment to explain the plan and enroll State employees, preparing and distributing applicable forms and communication materials to State employees in concurrence with, or directed by, the Division of Personnel. Planning shall be done in a timely and organized manner with a timetable so that the transition is successful for a January 1, 2016 effective date. Sample enrollment materials, including forms, shall be submitted with your bid.

Further, at the sole expense of the vendor under the resulting contract, hereby agree to provide:

• Claim Forms. Claim forms and instructions shall be distributed to State agencies within thirty (30) days after contract award and as needed thereafter.

• Certificates of Coverage. Certificates of Coverage shall be furnished to all policy holders and the Division of Personnel within five (5) business days of request, throughout the contract term. Sample certificates of coverage and/or summary plan descriptions to be issued to participants shall be included in your bid response.

• Benefit Brochures. Comprehensive benefit brochures shall be made available to each covered participant at enrollment. An electronic version of the brochure shall be available for posting online on the Employee Benefits webpage. Individual certificates, member cards or other pertinent information shall be provided no later than thirty (30) days after the effective date or delivery of enrollment data.

• Service Representative. A service representative shall be made available to the State. Representatives shall be available at the initial open enrollment meetings to explain the plan and enroll State employees. The vendor warrants that all personnel engaged in the contract services shall be qualified to perform the services and shall be properly licensed and otherwise authorized to do so

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under all applicable laws. For example, insurance agents shall possess active producer licenses from the State and claims adjusters assigned to the State account shall possess active licenses from the State. The State reserves the right to require the vendor to remove and/or reassign any employee, including the lead staff member, from the State account due to unacceptable job performance.

• Open Enrollment Support. The vendor shall provide support during the State’s annual Open Enrollment, or as requested as part of a Special Enrollment. Depending upon plan changes and other business needs, the State reserves the right to determine whether it requires a passive or an active open enrollment period each year. At times, the State may require an additional enrollment period depending upon its business needs due to Collective Bargaining or other events that have an impact on employee plan offerings.

The State’s annual Open Enrollment period typically runs for two weeks and is expected to commence sometime late October/early-November 2015 for a January 1, 2016 effective date.

The vendor shall provide the following enrollment support:

• Work with the State and its individual agencies to plan and schedule on-site open enrollment activities (as requested by the State) to support the State’s 160 worksite locations, including all District Offices and Department of Transportation sheds to include:

a. Key employee/staff informational meetings to educate and/or remind key staff of the

enrollment process for all voluntary insurance plans and options for election; b. Face to face employee informational meetings that provide information to current and

prospective enrollees about the benefit options available to them;

• Attend human resource meetings to review current plans and any applicable plan changes being shared with employees for that Open Enrollment or special enrollment period; and

• At the conclusion of Open Enrollment, the vendor shall calculate the bi-weekly payroll

deductions and forward on to the State a full enrollment file to establish the deductions for that calendar year.

• Communications with Employees. All contents in orientation presentations, education sessions or any other materials being presented to State employees must be approved by the State prior to their release. The vendor shall provide, at a minimum, the following activities with respect to new hire orientations and/or educational sessions as requested by its agencies:

a. Promote employee participation in Voluntary Benefit programs via seminars, direct outreach and other educational campaigns as mutually agreed to by the State;

b. Provide employee communications such as benefit booklets, newsletters or similar informational materials, announcement posters, new hire letters and informational packets, etc.

2. Data Interface.

At no additional cost to the State, the vendor shall agree to work with the Risk Management Unit and/or the State’s designated data management team for data interface and/or data transfer matters. The file format will be as specified by the State. The State utilizes an enterprise resource planning (ERP) system by Infor, formerly known as Lawson S3 ERP to interface benefit enrollment and payroll data with vendors. The ERP system is internally referred to as NHFIRST.

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Upon the completion of each bi-weekly payroll process, a payroll deduction register is run from NH FIRST (PR275). The format of the payroll deduction register file is attached hereto in Appendix D. This format is similar for files sent to and received from the vendor. The successful vendor shall collaborate with the State when reviewing current systems and processes and make recommendations for improvement. It is the State’s standard to exchange data with its vendors using the State of New Hampshire’s Secure File Exchange Server. This Secure File Exchange Server is accessible by authorized users with Internet access. All data files on this server are encrypted while at rest. The data stays protected until downloaded by the receiver. Vendors are required to retrieve payroll deduction registers, as well as other related data, from this server. In addition, vendors will be required to use this method for sending data files to the State.

C. REPORTS

The vendor shall provide the State with enrollment activity and claims experience reporting on a quarterly basis. Payroll Deduction Report. The Contractor shall provide a weekly deduction change report as required for voluntary benefit administration as required by the State. (Note: data must be encrypted using the State’s designated software and placed on the State’s FTP site).

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SECTION V

PROPOSED RATES

Bidders must complete the Proposed Rate exhibits located in “Proposed Rate” tabs of the file label “SONH Voluntary Benefits RFB 2015 Attachment Data.xlsx” (Appendix B).

As set forth in Section II, E. of this RFB, bid award shall be based upon the carrier and/or licensed insurance producer who meets or exceeds the bid specifications offering the lowest pricing in grand total for Voluntary Benefits.

The offer shall be the invoice premium the vendor intends the State to pay. The State will not pay any additional taxes and/or fees beyond the premium rates proposed. Administrative functions will not be compensated separately. The bids shall offer coverage for a full three-year term. No partial bids shall be accepted. The undersigned herby agrees to perform the services in complete compliance with the terms and conditions of this bid at the rates quoted. Insurance producers shall clearly identify all carrier(s) approached in the submitted bid. Carriers must identify all insurance producers involved. Any and all commissions, fees and/or compensation paid by the insurance carrier to the agency in regards to this RFB shall be indicated in the rates provided in response to this RFB.

Carriers Approached Agent Commission or Fee

Bidders may also complete the Information Only rate exhibit located in “Informational Only - ISTD” tab of the file label “SONH Voluntary Benefits RFB 2015 Attachment Data.xlsx” (Appendix B).

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SECTION VI

PERFORMANCE GUARANTEE

The State requests that bidders agree to serve the State and its staff under the terms of a performance agreement executed between the two entities. The objective of the performance agreement is not to reduce your client revenue by invoking penalties but rather to reinforce your verbal and written assurances of quality service with tangible measurements. At a minimum, this performance agreement must include a subjective service guarantee that will be solely determined by the State’s benefits management; and a level of financial risk that is challenging yet fair. We request that the performance and corresponding financial penalty be reviewed each quarter. Please provide the total dollar amount at risk.

Benefit Program Amount at Risk

Voluntary Short Term Disability $__________

Critical Illness Insurance $__________

Employee Accident Insurance $__________

TOTAL $__________

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APPENDICES

Appendix A Confirmation of Plan Form

Appendix B RFB Attachments

Appendix C Plan Information & Documents

Appendix D Voluntary Benefits Payroll Deduction Register File Format

Appendix E State of New Hampshire RFB Transmittal Letter

Appendix F Sample P-37 Form Contract

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APPENDIX A

CONFIRMATION OF PLAN FORM This form needs to be completed and returned with your bid in order to be considered in the carrier evaluation process. Current Voluntary Short Term Disability Benefit, including the Proposed Change

We have reviewed the current benefit and proposed change and certify that:

[ ] The submitted bid includes no deviations.

[ ] The submitted bid adheres to the benefits with the following exceptions: ____________________________________________________________________________________________________________________________________________________________________

Current Critical Illness Insurance Benefit

We have reviewed the current benefit and certify that:

[ ] The submitted bid includes no deviations.

[ ] The submitted bid adheres to the plan design with the following exceptions: ____________________________________________________________________________________________________________________________________________________________________

Current Employee Accident Insurance Benefit

We have reviewed the current benefit and certify that:

[ ] The submitted bid includes no deviations.

[ ] The submitted bid adheres to the plan design with the following exceptions: ____________________________________________________________________________________________________________________________________________________________________

Current/Expected Enrollment and Administrative Services for all of the Voluntary Benefits

We have reviewed the current and expected administrative services and certify that:

[ ] The submitted bid includes no deviations.

[ ] The submitted bid adheres to expected administrative services with the following exceptions: ____________________________________________________________________________________________________________________________________________________________________

_____________________________ Signature _____________________________ Print Name _____________________________ Title

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APPENDIX B

RFB ATTACHMENTS SONH Voluntary Benefits RFB 2015 Attachment Data.xlsx

• Proposed Rates Exhibits – Please complete

• Data*

o Total Eligible Census (Census is from the State’s life insurance benefit. While the eligibility for voluntary benefits and life insurance benefits vary slightly, this census is representative of the actives that are eligible for the voluntary benefits.)

o Total Eligible Salary Census

o Voluntary Benefits Census/Elections

o Voluntary Short Term Disability Individual Claim Listings

SONH Voluntary Benefits RFB 2015 Attachment Experience.xlsx

• Voluntary Short Term Disability

o Historic Experience

o Open Claims Listing

o Closed Claims Listing

• Critical Illness

o Historic Experience

• Employee Accident

o Premium History

o Claims by Major Category

*To obtain the Census data, please complete the Census Request Form on the following page and send to Danielle Ruest at Danielle.Ruest@nh.gov or via fax at 603-271-7564.

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Census Request Form

We confirm that we are requesting this census for the sole purpose of responding to the State of New Hampshire’s Voluntary Benefits RFB. As a recipient of this census information, we will not use or disclose this information for any other purpose than to respond to the State's RFB. We will destroy this census information upon the completion of the RFB process.

We confirm that our bid will meet the Bid Eligibility Criteria identified in Section II.D of this RFB document.

We confirm:

� We are requesting this census for the sole purpose of responding to the State’s RFB;

� Our bid will meet the Bid Eligibility Criteria;

� Our bid meets the financial strength minimum ratings; and

� Our bid will include complete response to all sections of this RFB.

Signed: Title:

Print Name: Phone Number:

Company Name:

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APPENDIX C

PLAN INFORMATION & DOCUMENTS

Critical Illness • Critical Illness Brochure.pdf • Critical Illness Sample Certificate.pdf

Employee Accident • Employee Accident Brochure.pdf • Employee Accident Specimen Policy.pdf

Voluntary STD • Voluntary STD Brochure 2015.pdf • Voluntary STD Brochure through 2014.pdf • Voluntary STD Certificate 0_7_26.pdf • Voluntary STD Certificate 14_14_52.pdf

Plan Administration • EBM Plan Administration.pdf

Other Short Term Disability and Sick Pay Plans

The plans listed below are for informational purposes only, to make bidders aware of other programs available to State employees, and are not part of this RFB process. These are disability and sick leave programs offered to State employees in addition to the Voluntary Short Term Disability program mentioned above and included in this RFB.

Sick Leave Current Sick Leave benefits are specific to the collective bargaining agreements found on the State of New Hampshire Human Resources web page under Labor Relations at the following link: https://das.nh.gov/hr/sea.html Each collective bargaining agreement provides information on the Sick Leave benefits and any additional disability benefits in the following Articles:

• New England Police Benevolent Association – Article XI • NH Trooper’s Association – Article XI • State Employees’ Association of NH, SEIU Local 1984 – Article XI • Teamsters Local 633 – Article X

Supplemental Sick Leave & Short Term Disability Income Protection This information can be found on the State of New Hampshire Human Resources web page at the following link: https://das.nh.gov/hr/ShortTermDisability.html

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APPENDIX D: VOLUNTARY BENEFITS PAYROLL DEDUCTION REGISTER FILE FORMAT

PR275 COLUMN HEADING EXAMPLE DATA DATA DEFINITION

COMPANY 10 Identifies statewide reporting NAME STATE OF NEW HAMPSHIRE Name of company BEG-DATE 5/2/2014 Pay Period Begin Date END-DATE 5/15/2014 Pay Period Check Date

DED-CLASS VOL Identifies many deduction codes to one output for reporting purposes

CLASS-DESC VOL BENEFITS Long description of deduction class DED-CODE 3301 Deduction Code Number

CODE-DESC 26 WEEK SHORT TERM DISABILITY Deduction Code Description

PROCESS-LEVEL 9600 Agency Number PL-NAME TRANSPORTATION DEPT OF Agency Name EMPLOYEE 123456 Employee Identification Number FULL-NAME DOE, JANE Employee Name FICA-NBR XXX-XX-XXXX Social Security Number CHECK-NBR 10386840 Employee Check Number CHECK-DATE 5/2/2014 Pay Period Start Date DED-AMT 19.24 Employee Deduction Amount CODE-TOTAL 19.24 Deduction code total by Employee PROCESS-LEVEL-2 9600 Agency Number for totals by deduction code CODE-TOTAL-2 7004.32 Deduction code total by agency PROCESS-LEVEL-3 9600 Agency Number for totals by deduction Class CLASS-TOTAL 7004.32 Deduction Class total by agency CODE-TOTAL-3 82820.54 Grand Total by Deduction Code CLASS-TOTAL-2 82820.54 Grand Total by Deduction Class

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APPENDIX E: STATE OF NEW HAMPSHIRE RFB TRANSMITTAL LETTER

Date: ___________________ Company Name: _______________________________

Address: _______________________________ _______________________________

To: Point of Contact: Danielle Ruest Telephone: (603)-271-2201 x 227; Fax: (603) 271-7564 Email: Danielle.Ruest@nh.gov RE: RFB Name: Voluntary Benefits RFB Number: RFB # 2016-178 RFB Opening Date and Time: August 3, 2015 at 11:00 AM E.D.T. Dear Madam: [Insert Name of signor ___________________________________], on behalf of [Insert name of company submitting a Bid ____________________________________] (collectively referred to as “Vendor”) hereby submits an offer as contained in the written Bid submitted herewith to the State of New Hampshire in response to RFB # 2016-178 for Voluntary Benefits. [Print Signor name____________________________________] is authorized to legally obligate [Print Company Name __________________________________________]. Vendor attests to the fact that: 1. The Vendor has reviewed and agreed to be bound by all RFB terms and conditions. 2. The Vendor has not altered any of the language or other provisions contained in the RFB document. 3. The Vendor’s bid is effective from the RFB submission deadline until the contract effective date of January

1, 2016. 4. The prices Vendor has quoted in the bid were established without collusion with other eligible vendors. 5. The Vendor has read and fully understands this RFB, including the public disclosure sections. 6. Vendor’s official point of contact is ______________________________________________________

Title ________________________________ Telephone ___________________________ Email _______________________________

Authorized Signor Signature Printed _________________________________ Authorized Signor Signature _______________________________________ COUNTY:___________________________ STATE:____________________ NOTARY PUBLIC/JUSTICE OF THE PEACE On the _____ day of _______________, 2015, there appeared before me, the State and County foresaid a person who satisfactorily identified him/herself as ________________________________________ and acknowledge that he/she executed this document indicated above. In witness thereof, I hereunto set my hand and official seal. _________________________________________________________ (Notary Public/Justice of the Peace) My commission expires: _________________________________________________________ (Date)

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APPENDIX F: SAMPLE P-37 FORM CONTRACT Subject: VOLUNTARY BENEFITS

The State of New Hampshire and the Contractor hereby mutually agree as follows:

GENERAL PROVISIONS

1. IDENTIFICATION. 1.1 State Agency Name

1.2 State Agency Address

1.3 Contractor Name

1.4 Contractor Address

1.5 Contractor Phone Number

1.6 Account Number

1.7 Completion Date

1.8 Price Limitation

1.9 Contracting Officer for State Agency

1.10 State Agency Telephone Number

1.11 Contractor Signature

1.12 Name and Title of Contractor Signatory

1.13 Acknowledgement: State of , County of On , before the undersigned officer, personally appeared the person identified in block 1.12, or satisfactorily proven to be the person whose name is signed in block 1.11, and acknowledged that s/he executed this document in the capacity indicated in block 1.12. 1.13.1 Signature of Notary Public or Justice of the Peace [Seal] 1.13.2 Name and Title of Notary or Justice of the Peace 1.14 State Agency Signature

1.15 Name and Title of State Agency Signatory

1.16 Approval by the N.H. Department of Administration, Division of Personnel (if applicable) By: Director, On:

1.17 Approval by the Attorney General (Form, Substance and Execution) By: On: 1.18 Approval by the Governor and Executive Council By: On:

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2. EMPLOYMENT OF CONTRACTOR/SERVICES TO BE PERFORMED. The State of New Hampshire, acting through the agency identified in block 1.1 (“State”), engages contractor identified in block 1.3 (“Contractor”) to perform, and the Contractor shall perform, the work or sale of goods, or both, identified and more particularly described in the attached EXHIBIT A which is incorporated herein by reference (“Services”). 3. EFFECTIVE DATE/COMPLETION OF SERVICES. 3.1 Notwithstanding any provision of this Agreement to the contrary, and subject to the approval of the Governor and Executive Council of the State of New Hampshire, this Agreement, and all obligations of the parties hereunder, shall not become effective until the date the Governor and Executive Council approve this Agreement (“Effective Date”). 3.2 If the Contractor commences the Services prior to the Effective Date, all Services performed by the Contractor prior to the Effective Date shall be performed at the sole risk of the Contractor, and in the event that this Agreement does not become effective, the State shall have no liability to the Contractor, including without limitation, any obligation to pay the Contractor for any costs incurred or Services performed. Contractor must complete all Services by the Completion Date specified in block 1.7. 4. CONDITIONAL NATURE OF AGREEMENT. Notwithstanding any provision of this Agreement to the contrary, all obligations of the State hereunder, including, without limitation, the continuance of payments hereunder, are contingent upon the availability and continued appropriation of funds, and in no event shall the State be liable for any payments hereunder in excess of such available appropriated funds. In the event of a reduction or termination of appropriated funds, the State shall have the right to withhold payment until such funds become available, if ever, and shall have the right to terminate this Agreement immediately upon giving the Contractor notice of such termination. The State shall not be required to transfer funds from any other account to the Account identified in block 1.6 in the event funds in that Account are reduced or unavailable. 5. CONTRACT PRICE/PRICE LIMITATION/ PAYMENT. 5.1 The contract price, method of payment, and terms of payment are identified and more particularly described in EXHIBIT B which is incorporated herein by reference. 5.2 The payment by the State of the contract price shall be the only and the complete reimbursement to the Contractor for all expenses, of whatever nature incurred by the Contractor in the performance hereof, and shall be the only and the complete compensation to the Contractor for the Services. The State shall have no liability to the Contractor other than the contract price. 5.3 The State reserves the right to offset from any amounts otherwise payable to the Contractor under this Agreement those liquidated amounts required or permitted by N.H. RSA 80:7 through RSA 80:7-c or any other provision of law. 5.4 Notwithstanding any provision in this Agreement to the contrary, and notwithstanding unexpected circumstances, in no event shall the total of all payments authorized, or actually made hereunder, exceed the Price Limitation set forth in block 1.8. 6. COMPLIANCE BY CONTRACTOR WITH LAWS AND REGULATIONS/ EQUAL EMPLOYMENT OPPORTUNITY. 6.1 In connection with the performance of the Services, the Contractor shall comply with all statutes, laws, regulations, and orders of federal, state, county or municipal authorities which impose any obligation or duty upon the Contractor, including, but not limited to, civil rights and equal opportunity laws. In addition, the Contractor shall comply with all applicable copyright laws. 6.2 During the term of this Agreement, the Contractor shall not discriminate against employees or applicants for employment because of race, color, religion, creed, age, sex, handicap, sexual orientation, or national origin and will take affirmative action to prevent such discrimination. 6.3 If this Agreement is funded in any part by monies of the United States, the Contractor shall comply with all the provisions of Executive Order No. 11246 (“Equal Employment Opportunity”), as supplemented by the regulations of the United States Department of Labor (41 C.F.R. Part 60), and with any rules, regulations and guidelines as the State of New Hampshire or the United States issue to implement these regulations. The Contractor further agrees to permit the State or United States access to any of the Contractor’s books, records

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and accounts for the purpose of ascertaining compliance with all rules, regulations and orders, and the covenants, terms and conditions of this Agreement. 7. PERSONNEL. 7.1 The Contractor shall at its own expense provide all personnel necessary to perform the Services. The Contractor warrants that all personnel engaged in the Services shall be qualified to perform the Services, and shall be properly licensed and otherwise authorized to do so under all applicable laws. 7.2 Unless otherwise authorized in writing, during the term of this Agreement, and for a period of six (6) months after the Completion Date in block 1.7, the Contractor shall not hire, and shall not permit any subcontractor or other person, firm or corporation with whom it is engaged in a combined effort to perform the Services to hire, any person who is a State employee or official, who is materially involved in the procurement, administration or performance of this Agreement. This provision shall survive termination of this Agreement. 7.3 The Contracting Officer specified in block 1.9, or his or her successor, shall be the State’s representative. In the event of any dispute concerning the interpretation of this Agreement, the Contracting Officer’s decision shall be final for the State. 8. EVENT OF DEFAULT/REMEDIES. 8.1 Any one or more of the following acts or omissions of the Contractor shall constitute an event of default hereunder (“Event of Default”): 8.1.1 failure to perform the Services satisfactorily or on schedule; 8.1.2 failure to submit any report required hereunder; and/or 8.1.3 failure to perform any other covenant, term or condition of this Agreement. 8.2 Upon the occurrence of any Event of Default, the State may take any one, or more, or all, of the following actions: 8.2.1 give the Contractor a written notice specifying the Event of Default and requiring it to be remedied within, in the absence of a greater or lesser specification of time, thirty (30) days from the date of the notice; and if the Event of Default is not timely remedied, terminate this Agreement, effective two (2) days after giving the Contractor notice of termination; 8.2.2 give the Contractor a written notice specifying the Event of Default and suspending all payments to be made under this Agreement and ordering that the portion of the contract price which would otherwise accrue to the Contractor during the period from the date of such notice until such time as the State determines that the Contractor has cured the Event of Default shall never be paid to the Contractor; 8.2.3 set off against any other obligations the State may owe to the Contractor any damages the State suffers by reason of any Event of Default; and/or 8.2.4 treat the Agreement as breached and pursue any of its remedies at law or in equity, or both. 9. DATA/ACCESS/CONFIDENTIALITY/ PRESERVATION. 9.1 As used in this Agreement, the word “data” shall mean all information and things developed or obtained during the performance of, or acquired or developed by reason of, this Agreement, including, but not limited to, all studies, reports, files, formulae, surveys, maps, charts, sound recordings, video recordings, pictorial reproductions, drawings, analyses, graphic representations, computer programs, computer printouts, notes, letters, memoranda, papers, and documents, all whether finished or unfinished. 9.2 All data and any property which has been received from the State or purchased with funds provided for that purpose under this Agreement, shall be the property of the State, and shall be returned to the State upon demand or upon termination of this Agreement for any reason. 9.3 Confidentiality of data shall be governed by N.H. RSA chapter 91-A or other existing law. Disclosure of data requires prior written approval of the State.

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10. TERMINATION. In the event of an early termination of this Agreement for any reason other than the completion of the Services, the Contractor shall deliver to the Contracting Officer, not later than fifteen (15) days after the date of termination, a report (“Termination Report”) describing in detail all Services performed, and the contract price earned, to and including the date of termination. The form, subject matter, content, and number of copies of the Termination Report shall be identical to those of any Final Report described in the attached EXHIBIT A. 11. CONTRACTOR’S RELATION TO THE STATE. In the performance of this Agreement the Contractor is in all respects an independent contractor, and is neither an agent nor an employee of the State. Neither the Contractor nor any of its officers, employees, agents or members shall have authority to bind the State or receive any benefits, workers’ compensation or other emoluments provided by the State to its employees. 12. ASSIGNMENT/DELEGATION/SUBCONTRACTS. The Contractor shall not assign, or otherwise transfer any interest in this Agreement without the prior written consent of the N.H. Department of Administrative Services. None of the Services shall be subcontracted by the Contractor without the prior written consent of the State. 13. INDEMNIFICATION. The Contractor shall defend, indemnify and hold harmless the State, its officers and employees, from and against any and all losses suffered by the State, its officers and employees, and any and all claims, liabilities or penalties asserted against the State, its officers and employees, by or on behalf of any person, on account of, based or resulting from, arising out of (or which may be claimed to arise out of) the acts or omissions of the Contractor. Notwithstanding the foregoing, nothing herein contained shall be deemed to constitute a waiver of the sovereign immunity of the State, which immunity is hereby reserved to the State. This covenant in paragraph 13 shall survive the termination of this Agreement. 14. INSURANCE. 14.1 The Contractor shall, at its sole expense, obtain and maintain in force, and shall require any subcontractor or assignee to obtain and maintain in force, the following insurance: 14.1.1 comprehensive general liability insurance against all claims of bodily injury, death or property damage, in amounts of not less than $250,000 per claim and $2,000,000 per occurrence; and 14.1.2 fire and extended coverage insurance covering all property subject to subparagraph 9.2 herein, in an amount not less than 80% of the whole replacement value of the property. 14.2 The policies described in subparagraph 14.1 herein shall be on policy forms and endorsements approved for use in the State of New Hampshire by the N.H. Department of Insurance, and issued by insurers licensed in the State of New Hampshire. 14.3 The Contractor shall furnish to the Contracting Officer identified in block 1.9, or his or her successor, a certificate(s) of insurance for all insurance required under this Agreement. Contractor shall also furnish to the Contracting Officer identified in block 1.9, or his or her successor, certificate(s) of insurance for all renewal(s) of insurance required under this Agreement no later than fifteen (15) days prior to the expiration date of each of the insurance policies. The certificate(s) of insurance and any renewals thereof shall be attached and are incorporated herein by reference. Each certificate(s) of insurance shall contain a clause requiring the insurer to endeavor to provide the Contracting Officer identified in block 1.9, or his or her successor, no less than ten (10) days prior written notice of cancellation or modification of the policy. 15. WORKERS’ COMPENSATION. 15.1 By signing this agreement, the Contractor agrees, certifies and warrants that the Contractor is in compliance with or exempt from, the requirements of N.H. RSA chapter 281-A (“Workers’ Compensation”). 15.2 To the extent the Contractor is subject to the requirements of N.H. RSA chapter 281-A, Contractor shall maintain, and require any subcontractor or assignee to secure and maintain, payment of Workers’ Compensation in connection with activities which the person proposes to undertake pursuant to this Agreement. Contractor shall furnish the Contracting Officer identified in block 1.9, or his or her successor, proof of Workers’ Compensation in the manner described in N.H. RSA chapter 281-A and any applicable renewal(s) thereof, which shall be attached and are incorporated herein by reference. The State shall not be responsible for payment of any Workers’ Compensation premiums or for any other claim or benefit for Contractor, or any subcontractor

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or employee of Contractor, which might arise under applicable State of New Hampshire Workers’ Compensation laws in connection with the performance of the Services under this Agreement. 16. WAIVER OF BREACH. No failure by the State to enforce any provisions hereof after any Event of Default shall be deemed a waiver of its rights with regard to that Event of Default, or any subsequent Event of Default. No express failure to enforce any Event of Default shall be deemed a waiver of the right of the State to enforce each and all of the provisions hereof upon any further or other Event of Default on the part of the Contractor. 17. NOTICE. Any notice by a party hereto to the other party shall be deemed to have been duly delivered or given at the time of mailing by certified mail, postage prepaid, in a United States Post Office addressed to the parties at the addresses given in blocks 1.2 and 1.4, herein. 18. AMENDMENT. This Agreement may be amended, waived or discharged only by an instrument in writing signed by the parties hereto and only after approval of such amendment, waiver or discharge by the Governor and Executive Council of the State of New Hampshire. 19. CONSTRUCTION OF AGREEMENT AND TERMS. This Agreement shall be construed in accordance with the laws of the State of New Hampshire, and is binding upon and inures to the benefit of the parties and their respective successors and assigns. The wording used in this Agreement is the wording chosen by the parties to express their mutual intent, and no rule of construction shall be applied against or in favor of any party. 20. THIRD PARTIES. The parties hereto do not intend to benefit any third parties and this Agreement shall not be construed to confer any such benefit. 21. HEADINGS. The headings throughout the Agreement are for reference purposes only, and the words contained therein shall in no way be held to explain, modify, amplify or aid in the interpretation, construction or meaning of the provisions of this Agreement. 22. SPECIAL PROVISIONS. Additional provisions set forth in the attached EXHIBIT C are incorporated herein by reference. 23. SEVERABILITY. In the event any of the provisions of this Agreement are held by a court of competent jurisdiction to be contrary to any state or federal law, the remaining provisions of this Agreement will remain in full force and effect. 24. ENTIRE AGREEMENT. This Agreement, which may be executed in a number of counterparts, each of which shall be deemed an original, constitutes the entire Agreement and understanding between the parties, and supersedes all prior Agreements and understandings relating hereto.

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VO

LUNTARY BENEFITS

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ALASSISTANCE

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CRITICAL ILLNESS INSURANCEUnderwritten by Transamerica Life Insurance Company, Cedar Rapids, Iowa.

An Ounce of PreventionCritical illness lump-sum benefits, recurrent critical

illness benefits and cancer screening tests.

Critical Illness insurance is designed to provide you with benefits to help pay for critical health care needs. Your policy provides a lump sum benefit for certain critical illnesses and additional benefits when you are initially diagnosed with the following conditions: heart attack, stroke, paralysis, burns, end-stage renal failure, and surgery including heart transplant, coronary bypass, angioplasty/stent and major organ transplant.

You choose your benefit amount. Benefits are also available for your spouse and children. If you elect dependent coverage, their benefit amount will be 50% of the benefit you elect.

Critical Illness Lump Sum BenefitCriticalAssistance Plus pays you a lump sum benefit equal to the Benefit Election multiplied by the applicable percentage shown in the Schedule of Benefits upon the initial positive diagnosis1 for the first ever occurrence of a covered critical illness within each category. If the benefit payment is less than 100% of the selected benefit amount, we will pay a lump sum benefit amount upon the diagnosis of a different type of critical illness within the same category. The maximum lifetime benefit is three times the selected lump sum benefit amount.

Recurrent Critical Illness BenefitThis benefit pays a lump sum benefit equal to 50% of the Critical Illness Lump Sum Benefit amount for critical illnesses not eligible for the Critical Illness Benefit. For example: If you are diagnosed for the first time with a heart attack and then diagnosed with a subsequent heart attack more than 12 months later, the full benefit will be paid for the initial heart attack and 50% of the benefit will be paid for the subsequent heart attack.

The following wellness benefits do not require a diagnosis, but must be performed to determine whether cancer exists.

Cancer Screening Benefit The Cancer Benefit Rider (Category 3), pays $50 per covered person per calendar year for a covered cancer screening test.

Covered Cancer Screening Tests

pap smears flexible sigmoidoscopy colonoscopy chest x-rays mammogram

thermography serum protein electrophoresis hemocult stool specimen biopsy bone marrow testing

CEA (for colon cancer) CA 125 (for ovarian cancer) PSA (prostate specific antigen) ultrasounds blood screenings

Cancer Screening Wellness Benefit RiderThis benefit pays an additional amount per calendar year for each covered person when a charge is incurred for a covered cancer screening test.

1 The positive diagnosis must be the first diagnosis for any critical illness within the same category as the critical illness just diagnosed and be made after the effective date of coverage and while coverage is in force.

Policy form series CPCI0200 and CCCI200. Forms may vary, coverage available where approved.This is a brief summary of CriticalAssistance Plus, Critical Illness Insurance. Limitations and Exclusions apply.

Refer to the policy, certificate and riders for complete details.

CAP01C(SNH)-0612

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Plan Design

Coverage Amount: Purchase coverage from 10,000 to 50,000, in increments of 5,000

Plan Benefits Percentage of Benefit

Category 1

Heart Attack 100%

Stroke 100%

Heart Transplant Surgery 100%

Coronary Bypass Surgery 25%

Angioplasty/Stent 5%

Category 2

Major Organ Transplant Surgery (excluding heart) 100%

End-Stage Renal Failure 100%

Paralysis not due to Stroke – all 4 limbs (50% if less than four limbs) 100%

Burns (3rd degree of 50% coverage) 100%

Category 3

Invasive Cancer 100%

Carcinoma in situ 25%

Prostate Cancer with TNM Classification T1 25%

Skin Cancer 5%

Cancer Screening Benefit $50

Plan Benefit Riders Cancer Screening Wellness Benefit Rider $50

Summary of BenefitsCritical Illness Lump Sum BenefitCriticalAssistance Plus pays you a lump sum benefit equal to the Benefit Election multiplied by the applicable percentage shown in the Schedule of Benefits upon the initial positive diagnosis* for the first ever occurrence of a covered critical illness within each category (as selected by your employer). If the benefit payment is less than 100% of the selected benefit amount, we will pay a lump sum benefit amount upon the diagnosis of a different type of critical illness within the same category.

The cumulative Critical Illness Lump Sum Benefit paid within each category will not exceed 100% of the benefit amount. The maximum lifetime benefit is three times the selected lump sum benefit amount.

* The positive diagnosis must be the first diagnosis ever for any critical illness within the same category as the critical illness just diagnosed and be made after the effective date of coverage and while coverage is in force.

Recurrent Critical Illness BenefitThis benefit pays a lump sum benefit equal to 50% of the Critical Illness Lump Sum Benefit amount for critical illnesses not eligible for the Critical Illness Benefit. The total recurrent benefit paid within each category will not exceed 50% of the benefit amount.

For example: If you are diagnosed for the first time with a heart attack and then diagnosed with a subsequent heart attack more than 12 months later, the full benefit will be paid for the initial heart attack and 50% of the benefit will be paid for the subsequent heart attack.

Cancer Screening Benefit (Category 3)For plans with the Cancer Benefit Rider, this benefit pays $50 per covered person per calendar year for one of the following covered cancer screening tests: mammogram, Pap smears, flexible sigmoidoscopy, PSA (prostate-specific antigen tests), chest x-rays, hemocult stool

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specimen, ultrasounds, CEA (blood test for colon cancer), CA 125 (blood test for ovarian cancer), biopsy, thermography, colonoscopy, se-rum protein electrophoresis, bone marrow testing, and blood screenings. These tests must be performed to determine whether cancer exists in a covered person. This is a preventive benefit; diagnosis of cancer is not required for this benefit to be payable. This benefit is limited to one payment per calendar year per covered person.

This wellness benefit will be paid in addition to any other benefit.

Additional Benefit

Cancer Screening Wellness Benefit RiderThis benefit pays the amount shown on the plan design per calendar year for each covered person when a charge is incurred for one of the following covered cancer screening tests: mammogram, Pap smears, flexible sigmoidoscopy, PSA (prostate-specific antigen tests), chest x-rays, hemocult stool specimen, ultrasounds, CEA (blood test for colon cancer), CA 125 (blood test for ovarian cancer), biopsy, thermogra-phy, colonoscopy, serum protein electrophoresis, bone marrow testing, and blood screenings.

These tests must be performed to determine whether cancer exists in a covered person. This is a preventive benefit; diagnosis of cancer is not required for this benefit to be payable. This benefit is limited to one payment per calendar year per covered person. This wellness ben-efit will be paid in addition to any other benefit.

CriticalAssistance Plus Limitations and Exclusions

CriticalAssistance Plus contains certain restrictions and exclusions, which are detailed below. It’s important that you fully understand these restrictions and limitations.

We may reduce or deny a claim or void coverage for loss incurred by a covered person a) during the first 2 years from the effective date of such coverage for any misstatements in the application which would have materially affected our acceptance of the risk; or b) at any time for fraudulent misstatements in the application.

Under no condition will we pay any benefits for losses or medical expenses incurred prior to the effective date.

Pre-Existing Condition ProvisionNo benefits are provided during the first 12 months for any critical illness that has been diagnosed, treated, or for which the covered person has incurred expense or has taken medication within 12 months prior to the effective date of such person’s coverage.

A pre-existing condition is a sickness or physical condition for which the insured:1. had treatment,2. incurred expense,3. took medication or4. received a diagnosis or advice from a physician, during the 12-month period immediately before the effective date of the insured’s

coverage. A pre-existing condition also includes a condition that manifests itself in a way that would cause a person to seek medical advice, diagnosis, care or treatment.

Other ExclusionsAdditionally, the CriticalAssistance Plus policy does not cover losses caused by, or as a result of the following:• conditionsotherthanthoseduetoacoveredcriticalillness.• thecoveredpersonparticipatingorattemptingtoparticipateinanillegalactivity.• thecoveredpersonintentionallycausingself-inflictedinjury.• thecoveredpersoncommittingorattemptingtocommitsuicide,whethersaneorinsane.Intheeventofsuicide,theCompany’sliability

may be limited to only the return of premiums paid. In Missouri, suicide is no defense to payment of benefits unless the Company can show the insured intended suicide when he/she applied/enrolled for coverage.

• surgeriesperformedoutsidetheUnitedStatesoritsterritories.• thecoveredperson’sinvolvementinanyperiodofarmedconflict.

Cancer Screening Wellness Benefit RiderWe will only pay this benefit once per calendar year for each covered person. Proof of the charges incurred for the cancer screening tests must be submitted with each new claim. We will only pay the cancer screening benefit once per calendar year for each covered person.

Termination of CoverageSubject to the Portability Option, your insurance will cease on the earliest of:1. The last day of the payroll deduction period during which you cease to be eligible for coverage;2. The end of the last period for which premium payment has been made to us;3. The last day of the payroll deduction period during which you terminate employment;

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4. The date the group master policy terminates; or (except in Florida)5. The date you send us a written notice that you want to cancel coverage.

The insurance on a dependent will cease on the earliest of:1. The date your coverage terminates; or2. The end of the last period for which premium payment has been made to us;3. The date the dependent no longer meets the definition of dependent; 4. The date the policy is modified to exclude dependent coverage; or 5. The date you send us a written notice that you want to cancel your dependent’s coverage.

We will have the right to terminate the coverage of any covered person who submits a fraudulent claim under the policy.

Portability OptionIf you lose eligibility for this insurance for any reason other than nonpayment of premiums, you will have the option to continue the coverage (including any riders, if applicable) by paying the premiums directly to the company or at our administrative office within 31 days after this insurance terminates. We will bill you directly for these premiums after you notify us to continue coverage. If you stop paying the premiums under this option, this coverage will continue, subject to the terms of the grace period.

Waiting Period There is no waiting period.

Additional Riders

Cancer Benefit Rider (Category 3)We will only pay for loss as a direct result of cancer, except for cancer screening. Proof of positive diagnosis must be submitted with each new claim. We will not pay for any disease or incapacity that has been caused, complicated, worsened, or affected by, or as a result of cancer or its treatment.

Information on producer compensation is available at www.transamericaworksite.com

Category 1: Heart Attack, Stroke, Heart Transplant, Coronary Bypass Surgery, Angioplasty/StentCategory 2: Major Organ Transplant, End-Stage Renal Failure, Paralysis, BurnsCategory 3: Invasive Cancer, Carcinoma in Situ, Prostate Cancer(TNM Classification of T1), Skin Cancer, $50 Cancer WellnessOptional Riders: Cancer Screening Wellness Benefit Rider (Additional $50)

Bi-Weekly PremiumsAge $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,00018-35 4.73$ 6.18$ 7.63$ 9.09$ 10.54$ 12.00$ 13.45$ 14.90$ 16.36$ 36-45 7.73 10.68 13.63 16.59 19.54 22.50 25.45 28.40 31.36 46-55 12.66 18.09 23.51 28.93 34.36 39.78 45.20 50.63 56.05 56-60 18.16 26.33 34.50 42.66 50.83 59.00 67.17 75.34 83.51 61-65 26.83 39.34 51.85 64.36 76.86 89.37 101.88 114.39 126.90 66+ 29.93 43.98 58.03 72.09 86.14 100.20 114.25 128.30 142.36

18-35 5.24$ 6.79$ 8.34$ 9.88$ 11.43$ 12.97$ 14.52$ 16.07$ 17.61$ 36-45 8.24 11.29 14.34 17.38 20.43 23.47 26.52 29.57 32.61 46-55 13.18 18.70 24.21 29.73 35.24 40.76 46.27 51.79 57.30 56-60 18.67 26.94 35.20 43.46 51.72 59.98 68.24 76.50 84.77 61-65 27.35 39.95 52.55 65.15 77.75 90.35 102.95 115.55 128.15 66+ 30.44 44.59 58.74 72.88 87.03 101.17 115.32 129.47 143.61

18-35 7.20$ 9.28$ 11.35$ 13.43$ 15.51$ 17.58$ 19.66$ 21.74$ 23.82$ 36-45 11.68 15.99 20.31 24.62 28.94 33.25 37.57 41.88 46.20 46 55 18 97 26 93 34 89 42 85 50 82 58 78 66 74 74 70 82 66

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46-55 18.97 26.93 34.89 42.85 50.82 58.78 66.74 74.70 82.66 56-60 26.86 38.77 50.68 62.58 74.49 86.40 98.31 110.22 122.12 61-65 39.60 57.88 76.15 94.43 112.71 130.98 149.26 167.54 185.82 66+ 44.68 65.49 86.31 107.12 127.94 148.75 169.57 190.38 211.20

Age $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,00018-35 7.36$ 10.13$ 12.90$ 15.66$ 18.43$ 21.20$ 23.97$ 26.74$ 29.51$ 36-45 14.70 21.13 27.57 34.01 40.45 46.89 53.33 59.76 66.20 46-55 28.22 41.42 54.62 67.82 81.02 94.22 107.42 120.62 133.82 56-60 44.65 66.06 87.48 108.90 130.31 151.73 173.14 194.56 215.97 61-65 48.57 71.95 95.33 118.70 142.08 165.46 188.83 212.21 235.59 66+ 54.06 80.19 106.31 132.43 158.56 184.68 210.80 236.93 263.05

18-35 7.87$ 10.74$ 13.60$ 16.46$ 19.32$ 22.18$ 25.04$ 27.90$ 30.77$ 36-45 15.21 21.74 28.27 34.80 41.34 47.87 54.40 60.93 67.46 46-55 28.74 42.03 55.32 68.61 81.90 95.20 108.49 121.78 135.07 56-60 45.17 66.67 88.18 109.69 131.20 152.70 174.21 195.72 217.23 61-65 49.09 72.56 96.03 119.50 142.97 166.44 189.90 213.37 236.84 66+ 54.58 80.80 107.01 133.23 159.44 185.66 211.87 238.09 264.30

18-35 10.85$ 14.75$ 18.65$ 22.55$ 26.45$ 30.35$ 34.25$ 38.15$ 42.05$ 36-45 21.37 30.53 39.69 48.85 58.02 67.18 76.34 85.50 94.66 46-55 40.43 59.12 77.82 96.51 115.20 133.89 152.58 171.28 189.97 56-60 63.05 93.05 123.05 153.05 183.05 213.05 243.05 273.05 303.05 61-65 68.22 100.80 133.38 165.97 198.55 231.14 263.72 296.31 328.89 66+ 76.66 113.47 150.28 187.08 223.89 260.70 297.51 334.32 371.12

This custom plan is incomplete without a state-specific proposal or brochure, which describes Issue State: New Hampshirethe benefits, exclusions, and limitations of policy form CPCI0200 or state variation thereof. Ver 10.17.2011a - 10/5/2012

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Policy Form WS-ACC (OJ) 8/08 335-1268 12/11Sp Acc - Rider 12/11, CA - Rider 12/11, EER - Rider 12/11, EPO - Rider 12/11

n A limited supplemental policy providing Accident Insurance.

n Coverage for Off the Job Accidents.

n Guaranteed Renewable for life.

Approved for use in: NH

EAOP Employee AccidentOption

Employee Accident InsuranceOff the Job Coverage

plus

Boston Mutual life insurance coMpany – 120 Royall Street • Canton, MA 02021

Protection for theUnexpected!

This product is endorsed by:

Does NOT coverOn the Job Accidents

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eligiBility and preMiuM rates

PORTABILITY

This policy is fully portable. If an employee leaves the group, he/she can keep this policy at the same premium rate which active employees are paying.

ELIGIBILITY FOR RIDERS *

All employees, spouses and/or children enrolled in the base plan are eligible for the following riders. These riders must be purchased on all enrolled family members.

• Enhanced Emergency Room Benefit Rider

• Enhanced Physician Office/Urgent Care Benefit Rider

* Riders may not be available in all states.

PLAN WEEKLY CONTRIBUTIONS

Employee Employee Employee Employee Only & Spouse Only & Children Only Spouse & Children

Base Plan - off the job only $2.65 $3.98 $5.38 $6.70

Enhanced EmergencyRoom Benefit Rider - per$100 benefit (max 3 units) $ .19 $ .37 $ .70 $ .87

Enhanced PhysicianOffice/Urgent Care Benefit Rider -per $25 benefit (max 2 units) $ .12 $ .24 $ .29 $ .41

ELIGIBILITY FOR BASE PLAN

All employees ages 18-70 and working a minimum of 15 hours a week are eligible for participation in the Accident Insurance plan; an enrolled employee may also insure their spouse (ages 18-70) and children (by blood or by law) under age 26. A spouse includes a partner in a civil union.

GUARANTEED RENEWABLE

Coverage is guaranteed renewable for life as long as premiums are paid.

EFFECTIVE DATE OF COVERAGE

Coverage becomes effective at 11:59 PM on the date of the signed application.

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Air Ambulance ...................................................... $500 Within 48 hours after the covered accident.

Ambulance ............................................................. $100 Within 90 days of the covered accident.

Appliance ............................................................... $100 Within 90 days after the covered accident. For mobility and personal locomotion.

Blood/Plasma/Platelets/Transfusion ................. $300 Within 90 days of the covered accident.

Burns .................................................... $750 to $10,000 Care by a physician within 72 hours after the covered accident. Scheduled amount based on degree of burn.

Concussion ........................................................... $100 Diagnosed by a physician within 72 hours after the covered accident.

Dislocations (Separated Joint) ................. $50 to $8,000 Based on the type of surgery and joint involved.

Emergency Dental Work ......................... $50 to $150 Based on whether tooth is extracted or repaired.

Emergency Room Care .......................................... $50 Examination and treatment within 72 hours after the covered accident. Can be increased by $100, $200 or $300 with the EnhancedEmergencyRoomBenefitRider.

Follow-Up Physician Care ................................... $50 Within 90 days of the covered accident.

Fractures ............................................... $25 to $10,000 Based on the type of surgery and bone involved.

Hospital Admission ......................................... $1,000 ($2,000 if immediately admitted into Intensive Care Unit) Within 6 months after the covered accident.

Hospital Confinement ....... $250 per day up to 365 days Within 6 months after the covered accident.

Hospital Intensive Care ...... $500 per day up to 30 days The confinement must begin within 30 days after the covered accident.

Initial Physician’s Office/Urgent Care Visit ........... $50 Within 60 days after the covered accident. Can be increased by$25or$50withtheEnhancedPhysicianOffice/Urgent CareBenefitRider.

Lacerations ................................................ $25 to $400 Repaired by a physician within 72 hours after the covered accident. Paid based on the total length of all lacerations received in any one covered accident.

Lodging .................................................. $100 per night Up to 30 days per covered accident. Hospital must be more than 100 miles from the insured person’s residence.

Major Diagnostic Exams .................................... $150 Per calendar year for CT scan, MRI or EEG as the result of a covered accident. Physical Therapy ..................................... $25 per day Maximum of 6 days. Within 6 months of covered accident.

Prosthetic Device/Artificial Limb ...... $500 to $1,000 Within 1 year of the covered accident.

Rehabilitation Unit ............................... $150 per day When confined in a rehab unit following hospitalization. Up to 30 days.

Ruptured Disc ...................................................... $400 Care by a physician within 60 days after the covered accident or repaired through surgery within 1 year after the covered accident.

Severe Eye Injury ................................................ $200 Within 90 days of the covered accident. Surgery (Abdominal or thoracic) ......................... $1,000 Within 72 hours after the covered accident. Benefit is $100 if exploratory surgery with no repair.

Tendon/Ligament/Rotator Cuff ....... $150, $600 or $900 Must be repaired within 90 days after the covered accident. The benefit is based on the number of repairs needed and repaired through surgery.

Torn Knee Cartilage ............................................ $750 Care by a physician within 60 days or repaired through surgery within 6 months after the covered accident. Benefit is $150 if exploratory arthroscopic surgery with no repair or if no surgery is performed.

Transportation .............................. $300 per round trip Up to 3 round trips per covered accident. For care more than 100 miles roundtrip from your home.

Boston Mutual’s accident policy provides the following accident only Benefits:

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accidental death and disMeMBerMent

BML’s Accident policy will provide the following benefits for injuries that are the result of a covered accident and cause death or dismemberment.

ACCIDENTAL DEATH BENEFITS:

COMMON CARRIER OTHER

Named Insured $100,000 $50,000 Spouse $100,000 $50,000 Child(ren) $20,000 $10,000

The Dismemberment Benefit is paid based on the number of limbs lost and/or the specific limb(s) lost.Loss of Finger, Toe, Hand, Foot or Sight of Eye .......................... $1,500 to $30,000 (schedule amount depending on loss)

BML can help with severe injuries by providing a benefit for the life-altering loss that results from an accident. Extended loss is an injury that within 365 days of the covered accident results in the total and irrecoverable loss of:

• both hands or both feet, or • sight of both eyes, or • one hand or one foot, or • hearing in both ears, or • both arms or both legs (or loss of use), or • the ability to speak • one arm or one leg (or loss of use), or

The Extended Loss Accident Coverage is payable after a 365 day elimination period and is reduced by 50% beginning on the day that the insured person reaches age 70.

COVERED PERSON BENEFIT AMOUNT PER LIFETIME

Named Insured $100,000 Spouse $100,000 Child(ren) $50,000

extended loss accident coverage

All benefits are subject to limitations as explained in the policy. They are payable once per covered accident and care and/or loss must occur within 90 days of the covered accident unless noted otherwise. This brochure provides a general description of the important features of Policy Form WS-ACC (OJ) 8/08.

This brochure is not the insurance contract and only the actual policy provisions will control. Before purchasing coverage, refer to the Policy or Outline of Coverage for state-specific description of benefit provisions, exclusions and limitations.

general inforMation

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We will not pay benefits for losses that are caused by or are the result of any Insured Person:

1. practicing for or participating in any semi-professional or professional competitive athletic contests for which any type of compensation or remuneration is received; 2. having any sickness or declining process caused by a sickness, including physical or mental infirmity. We also will not pay benefits to diagnose or treat the sickness. Sickness means any illness, infection, disease or any other abnormal physical condition which is not caused by any Injury;

3. intentionally self-inflicted Injury;

4. committing suicide or attempted suicide, while sane or insane;

5. receiving injuries due to an act of declared or undeclared war;

6. actively serving in any of the armed forces, or units auxiliary thereto, including the National Guard or any Military Reserve;

7. driving any taxi for wage, compensation, or profit;

8. having Mental or Nervous Disorders;

9. suffering from alcoholism or drug addiction;

10. suffering from a loss sustained or contracted while driving or operating a vehicle while intoxicated (intoxicated means that your blood alcohol content meets or exceeds the legal presumption of intoxication under the laws of the state where the accident occurred) or under the influence of any illicit or Controlled Substance unless administered on the advice of a Physician; or

11. sustaining a loss to which a contributing cause was the commission of or an attempt to commit a felony.

12. incurring an injury while the Insured Person is working for pay or profit.

policy exclusions - what we will not pay for

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ACCIDENT ONLYENHANCED PHYSICIAN OFFICE/ URGENT

CARE BENEFIT RIDER

EPO-Rider 12/11 - Available for additional premium

We will pay an additional $25 or $50 benefit amount when an insured person requires initial examination and care by a Physician in a physician’s office or urgent care facility. The care must be within 60 days of the covered accident and the services provided must be the result of a covered accident and not for routine examinations or preventative testing. Payable once per Covered Accident. This benefit is paid in addition to the $50 Physician’s Office/Urgent Care benefit in the base policy.

optional Benefit riders

ACCIDENT ONLYENHANCED EMERGENCY ROOM

BENEFIT RIDER

EER-Rider 12/11 - Available for additional premium

We will pay an additional $100, $200 or $300 benefit amount when an insured person is cared for in a hospital emergency room within 72 hours after the covered incident. This amount is paid in addition to the base policy Emergency Room benefit of $50.

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Accidents Do Happen! Theyoftenoccurinplaceswhereyoufeelmostsafe.

Did you know that?

• 1 out of 9 people each year seek medical attention for an injury.

• The average household cost associated with lost wages, medical and other injury related expenses is $5,700.

• There are over 41 million visits each year to hospital emergency rooms and over 40 million visits to physician’s offices for injuries.

• Most injuries occur in or around the home (46.4%) followed by injuries at recreational and sport facilities (14.2%) and highways and parking lots (13.3%).

• Basketball and bicycling are the leading sports-related activities requiring emergency room treatment.

• 9 out of 10 deaths and more than two thirds of all disabling injuries occur off-the-job.

• The leading causes of injury in the home are falls, poisoning, choking, drowning and fire.

• A fatal injury occurs every 4 minutes and a disabling injury occurs every second.

• Source: Injury Facts, 2008 Edition

While many health insurance plans will cover most of the major expenses,you could still be left with out-of-pocket expenses such as co-payments, deductibles,

transportationandlodgingcostsandemergencyroomexpenses.

Are you prepared for these extra expenses?

Let BML’s Employee Accident Option Plus give you protection for the unexpected!

Policy Form WS-ACC (OJ) 8/08 335-1268 12/11Sp Acc - Rider 12/11, CA - Rider 12/11, EER - Rider 12/11, EPO - Rider 12/11

Boston Mutual life insurance coMpany

120 Royall Street • Canton, MA 02021800-669-2668

www.bostonmutual.com

Approved for use in: NH

SUMMARY OF THE 1996 NEW HAMPSHIRE LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION ACT (RSA 408-B) AND

NOTICE CONCERNING COVERAGE LIMITATIONS AND EXCLUSIONS

Residents of New Hampshire who purchase life insurance, health insurance, and annuities should know that the insurance companies licensed in New Hampshire to write these types of insurance are members of the New Hampshire Life and Health Insurance Guaranty Association. The purpose of this Association is to assure that policyholders will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its policy obligations. If this should happen, the Association will assess its other member insurance companies for the money to pay the covered claims of policyholders who live in New Hampshire and, in some cases, to keep coverage in force. This protection is not a substitute for consumers' care in selecting companies that are well managed and financially stable. The valuable extra protection provided by these insurers through the Guaranty Association is not unlimited, however, as noted below.

IMPORTANT DISCLAIMER

The New Hampshire Life and Health Insurance Guaranty Association may not provide coverage for this policy. If coverage is provided, it may be subject to substantial limitations or exclusions and require continued residency in New Hampshire. Other conditions may preclude coverage.

Coverage is NOT provided for your policy or any portion of it that is not guaranteed by the insurer or for which you have assumed the risk, such as a variable contract sold by prospectus.

Insurance companies or their agents are required by law to give or send you this notice. However, insurance companies and their agents are prohibited by law from using the existence of the Association to induce you to purchase any kind of insurance policy.

This information is provided by:

New Hampshire Life and Health Insurance Guaranty Association 47 Hall Street, Suite 2 Concord, NH 03301

(603) 226-9114

New Hampshire Department of Insurance 56 Old Suncook Road

Concord, NH 03301-7317 (603) 271-2261

SUMMARY:

The 1996 state law that provides for this safety-net coverage is called the New Hampshire Life and Health Insurance Guaranty Association Act. Below is a brief summary of this law's coverage, exclusions and limits. This summary does not cover all provisions of the law; nor does it in any way change anyone's rights or obligations under the Act or the rights or obligations of the Association.

COVERAGE:

Generally, individuals will be protected by the New Hampshire Life and Health Insurance Guaranty Association if they live in this state and hold a life or health insurance policy or an annuity contract, or if they are insured under a group insurance contract issued by a member insurer. The beneficiaries, assignees or payees of insured persons are protected as well, even if they live in another state. CD300530 Page 1

Coverage provided under this Act may be different from coverage provided prior to 1996, as coverage is determined by the governing Act in effect on the date that the Association becomes obligated.

EXCLUSIONS FROM COVERAGE: Persons holding such policies or contracts are NOT protected by this Association if: (a) they are not residents of the state of New Hampshire, except under certain very specific circumstances; (b) they are eligible for protection under the laws of another state; (c) their policy was issued by a nonprofit hospital or medical service organization, an HMO, a fraternal

benefit society, a mandatory state pooling plan, a mutual assessment company or any entity that operates on an assessment basis, an insurance exchange, or any entity similar to any of the above.

The Association also does NOT provide coverage for: (a) any policy or portion of a policy or contract not guaranteed by the insurer or under which the risk is

borne by the policy holder or contract holder; (b) any policy or contract of reinsurance, unless assumption certificates have been issued; (c) interest rate guarantees that exceed certain statutory limitations; (d) any plan or program of an employer, association, or similar entity to provide life, health, or annuity

benefits to its employees or members to the extent that the plan or program is self-funded or uninsured, including, but not limited to, benefits payable by an employer, association, or similar entity;

(e) dividends, experience rating credits, or fees for services in connection with this policy; (f) any policy or contract issued in this state by an insurer at a time when it was not licensed or

authorized to do business in New Hampshire; (g) any unallocated annuity contract issued to an employee benefit plan protected under the federal

Pension Benefit Guaranty Corporation; (h) any portion of any unallocated annuity contract which is not issued to or in connection with a specific

employee, union, or association of natural persons benefit plan or a government lottery; (i) any portion of a policy or contract to the extent that the required assessments are preempted by

federal or state law.

LIMITS ON AMOUNT OF COVERAGE: The Act also limits the amount the Association is obligated to pay. The Association cannot pay more than what the insurance company would owe under a policy or contract.

With respect to any one life, the Association will pay a maximum of $300,000 - no matter how many policies and contracts there were with the same company, even if they provided different types of coverages. Within this overall $300,000 limit, the Association will not pay more than $100,000 in cash surrender values, $100,000 in health insurance benefits, $100,000 in present value of annuities, or $300,000 in life insurance death benefits.

With respect to any one contract holder of an unallocated annuity contract, not including a governmental retirement plan established under Section 401, 403(b) or 457 of the U.S. Internal Revenue Code, the Association will pay a maximum of $5,000,000 in benefits, irrespective of the number of such contracts held by that contract holder.

ADDITIONAL INFORMATION: Policyholders should contact the New Hampshire Insurance Department with questions they may have with regard to concerns about their rights under the Act and procedures for filing a complaint to allege a violation of the Act.

Policyholders may contact the New Hampshire Insurance Department for sources of information about the financial condition of insurers.

CD300530 Page 2

TRANSAMERICA LIFE INSURANCE COMPANY Home Office: Cedar Rapids, IA 52499

Administrative Office: 1400 Centerview Drive, PO Box 8063, Little Rock, AR 72203-8063

GROUP CRITICAL ILLNESS INDEMNITY INSURANCE OUTLINE OF COVERAGE FOR POLICY CPCI0200 WITH CERTIFICATE CCCI0200

A. Read Your Certificate Carefully. This Outline of Coverage provides a very brief description of the important

features of your Certificate. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both You and Your insurance company. It is, therefore, important that you READ YOUR CERTIFICATE CAREFULLY.

B. Critical Illness Indemnity Insurance. Policies of this category are designed to provide, to persons insured, a

lump sum benefit ONLY when a Covered Person is diagnosed with the First Occurrence of a Critical Illness. Coverage is not provided for basic hospital, basic medical-surgical or major medical expenses.

C. Critical Illness Benefit - Critical Illness Benefit - If a Covered Person is diagnosed with the First Occurrence

of a Critical Illness, We will pay a lump sum benefit equal to the Benefit Amount multiplied by the applicable percentage shown in the Schedule of Benefits provided that the positive diagnosis is made after the Effective Date of this Certificate and while this Certificate is in force. First Occurrence - A Critical Illness that was diagnosed for the very first time and is the first Critical Illness ever diagnosed within the applicable Category to which the diagnosed Critical Illness belongs. (Diagnosis can occur after death, if the death is due to a Critical Illness.)

If the total Critical Illness Benefit paid in a Category is less than 100% of the Benefit Amount, We will pay a

lump sum benefit equal to the Benefit Amount multiplied by the applicable percentage shown in the Schedule of Benefits upon the diagnosis of a different type of Critical Illness within the same Category. The cumulative Critical Illness Benefit paid within each Category will not exceed 100% of the Benefit Amount.

Category 1 Coverage - The specified Critical Illnesses that are always included in Your Certificate are heart attack, stroke, heart transplant surgery, coronary bypass surgery, and angioplasty. Category 2 Coverage - This Category of Critical Illnesses may be a part of Your Certificate's coverage and if so, they include major organ transplants (excluding heart), end stage renal failure, paralysis not due to stroke (all four limbs), and burns. Recurrent Critical Illness Benefit - A "Recurrent Critical Illness" is a covered Critical Illness that is not eligible for payment under the Critical Illness Benefit. If a Covered Person is diagnosed with a Recurrent Critical Illness, We will pay a lump sum benefit equal to 50% of the Benefit Amount multiplied by the applicable percentage shown in the Schedule of Benefits, subject to any applicable maximum benefit payment limitation, provided that the positive diagnosis is made after the Effective Date and while this Certificate is in force. A recurrence of the same type of Critical Illness is not eligible for the Recurrent Critical Illness Benefit, unless: 1. The diagnosis for the prior occurrence was at least 12 months from the most recent diagnosis; and 2. The Covered Person has been Treatment Free for at least 12 months. The total Recurrent Critical Illness Benefit paid within each Category will not exceed 50% of the Benefit Amount. Lifetime Maximum Benefit - The total benefits paid under the Certificate, including any attached Riders, will not exceed the Lifetime Maximum Benefit listed in the Schedule of Benefits for each Covered Person. Benefit Payments - Benefit payments will be made directly to You, unless You assign benefits. Proof of any Critical Illness diagnosis must be submitted to Us. Dependents are covered at a percentage of the Benefit Amount as stated in the Schedule of Benefits.

D. Exclusions and Limitations - We do not cover losses caused by, or as a result of, the following: 1. Conditions other than those due to a covered Critical Illness. 2. The Covered Person participating or attempting to participate in an illegal activity. 3. The Covered Person intentionally causing self-inflicted injury.

CCI-OC-02-00 Page 1

4. The Covered Person committing or attempting to commit suicide, whether sane or insane. 5. The Covered Person's involvement in any period of armed conflict. 6. Surgeries performed outside the United States or its Territories. Under no condition will We pay any benefits for losses or medical expenses incurred prior to the Effective Date.

We may reduce or deny a claim or void the Certificate for loss incurred by a Covered Person: 1. During the first 2 years from the Effective Date of such coverage for any misstatements in the Application

which would have materially affected Our acceptance of the risk; or 2. At any time for fraudulent misstatements in the Application.

Pre-Existing Condition Limitation - No benefits are provided during the first 12 months for any Critical Illness that has been diagnosed, treated, or for which the Covered Person has incurred expense or has taken medication within 12 months prior to the Effective Date of such person's coverage.

E. Renewability, Termination, Portability

1. Renewability - Your coverage under the Group Policy will continue so long as premiums are paid when due or within the Grace Period and the master policy remains in force.

2. Termination - Subject to the Portability Option, Your insurance will cease on the earliest of:

a. The last day of the payroll deduction period during which You cease to be eligible for coverage; b. The end of the last period for which premium payment has been made to Us; c. The last day of the payroll deduction period during which You terminate employment; or d. The date the Policy terminates.

The insurance on a Dependent will cease on the earliest of:

a. The date Your coverage terminates; b. The end of the last period for which premium payment has been made to Us; c. The date the Dependent no longer meets the definition of Dependent; or d. The date the Policy is modified so as to exclude Dependent coverage.

3. Portability Option - If You lose eligibility for this insurance for any reason other than nonpayment of

premiums, You will have the option to continue this Certificate (including any Riders, if applicable) by paying the premiums directly to Us at Our Administrative Office within 31 days after this insurance stops. We will bill You for these premiums. If You stop paying the premiums under this option, this coverage will continue subject to the terms of the Grace Period.

F. Optional Benefits - The following benefits may be included as part of Your coverage under the Group Master

Policy and Your Certificate if selected by the Policyholder. Please read your Certificate carefully.

Cancer Benefit Rider - CRCAN200 - This Rider adds the Category 3 Cancer coverage shown on the Schedule of Benefits of the Certificate to which this Rider is attached. Benefits for this Rider will be paid in accordance with the Benefit Provisions section in the Certificate. For purposes of this Rider, the word "Cancer" includes Skin Cancer, Carcinoma In Situ, Invasive Cancer, or Prostate Cancer with TNM Classification of T1. Cancer Screening Wellness Benefit - We will pay $50 per Calendar Year for each Covered Person when a charge is incurred for one of the following Cancer screening tests: mammogram, Pap smears, flexible sigmoidoscopy, PSA (prostate-specific antigen tests), chest x-rays, hemocult stool specimen, ultra sounds, CEA (blood test for colon cancer), CA 125 (blood test for ovarian cancer), biopsy, thermography, colonoscopy, serum protein electrophoresis, bone marrow testing, and blood screenings. These tests must be performed to determine whether Cancer exists in a Covered Person. This is a preventive benefit; diagnosis of Cancer is not required for this benefit to be payable. This benefit is limited to one payment per Calendar Year per Covered Person. Benefit payments will be made directly to You, unless You assign benefits. Proof of Loss must be submitted to Us for each incurred expense.

CCI-OC-02-00 Page 2

What We Will Not Pay - 1. We will only pay for loss as a direct result of Cancer, except for Cancer screening. Proof of Positive

Diagnosis must be submitted with each new claim. We will not pay for any disease or incapacity that has been caused, complicated, worsened, or affected by, or as a result of Cancer or its treatment.

2. We may reduce or deny a claim or void this Rider for loss incurred by a Covered Person: a. During the first 2 years from the Effective Date of this Rider for any misstatements in the Application

which would have materially affected Our acceptance of the risk; or b. At any time for fraudulent misstatements in the Application.

3. With respect to the benefits offered by this Rider, the "Time Limit on Certain Defenses" provision of the Contract will apply from the Effective Date of this Rider.

Under no condition will We pay any benefits for losses or medical expenses incurred prior to the Effective Date of this Rider.

Occupational HIV Benefit Rider - CRHIV200 - This Rider adds the Category 4 Occupational HIV coverage shown on the Schedule of Benefits of the Certificate. Benefits for this Rider will be paid in accordance with the Benefit Provisions section in the Certificate.

If the Covered Person receives an Initial Positive Diagnosis of HIV that is contracted during the course of employment, and after the Effective Date of this Rider, We will pay a lump sum benefit equal to the Benefit Amount multiplied by the applicable percentage shown in the Schedule of Benefits. For the purposes of this Rider, Occupational HIV means a Critical Illness for which a positive diagnosis is made by a Physician. It must be based on diagnostic criteria generally accepted by the medical profession. The cause of the HIV must be from a needle stick/sharp injury or by a mucous membrane exposure to blood or bloodstained bodily fluid. Such exposure must occur during the 12 months preceding the Initial Positive Diagnosis and while this Rider is in force. The accident must have occurred while the Covered Person was following their normal occupational duties and reported in accordance with the established occupational procedures for such accidents. The Covered Person must have undergone a blood test within 5 days of the accident which indicated the absence of HIV or antibodies to such a virus and the accident followed up including a further blood test within 12 months indicating the presence of HIV or antibodies to such a virus. What We Will Not Pay - We may reduce or deny a claim or void this Rider for loss incurred by a Covered Person: 1. During the first 2 years from the Effective Date of this Rider for any misstatements in the Application which

would have materially affected Our acceptance of the risk; or 2. At any time for fraudulent misstatements in the Application; or 3. With respect to the benefits offered by this Rider, the "Time Limit on Certain Defenses" provision of the

Contract will apply from the Effective Date of this Rider. No benefits are payable for HIV that was not contracted during the course of employment as a result from occupational duties. Under no condition will We pay any benefits for losses or medical expenses incurred prior to the Effective Date of this Rider.

Quality of Life Benefit Rider - CRLIF200 - This Rider provides that the Covered Person may elect to receive a portion of the Contract's Benefit Amount on a monthly basis when the Covered Person becomes eligible for benefits by being certified as a Chronically Ill Individual and is Confined to a Nursing or Assisted Living Facility, subject to terms and conditions defined in this Rider. What We Will Pay - We will pay the percentage of the Benefit Amount shown on the Schedule of Benefits on a monthly basis, subject to all of the following conditions: 1. The Covered Person is Confined in a Nursing or Assisted Living Facility and Confinement begins while this

Rider is in force; 2. Confinement services are included in the Covered Person's Plan of Care; 3. The Covered Person is a Chronically Ill Individual; 4. The Covered Person satisfies the Elimination Period; 5. The Covered Person is at least 70 years old; 6 The Rider has been in force for at least 5 years;

CCI-OC-02-00 Page 3

7. The Contract to which this Rider is attached is in force; and 8. The Contract has not been assigned.

Total benefits paid under this Rider will not exceed 100% of the Benefit Amount when combined with all other benefit payments under the Certificate and all other Riders. The Benefit Amount will be reduced by each amount paid under this Rider. Waiver of Premium - For each Contract month or partial Contract month that the Covered Person receives benefits under this Rider, We will waive the premium for their Contract.

What We Will Not Pay - We will not pay Rider benefits for loss resulting from any of the following: 1. Any benefits after 100% or more of the Benefit Amount under the Certificate to which Rider is attached has

been paid out for First Occurrence or Recurrent benefits. 2. With respect to the benefits offered by this Rider, the "Time Limit on Certain Defenses" provision of the

Contract will apply from the Effective Date of this Rider. 3. Confinement received outside the United States and its territories. Cancer Screening Wellness Benefit Rider CRWEL200 – We will pay the amount shown on the Schedule of Benefits per Calendar Year for each Covered Person when a charge is incurred for one of the following Cancer screening tests: mammogram, Pap smears, flexible sigmoidoscopy, PSA (prostate-specific antigen tests), chest x-rays, hemocult stool specimen, ultra sounds, CEA (blood test for colon cancer), CA 125 (blood test for ovarian cancer), biopsy, thermography, colonoscopy, serum protein electrophoresis, bone marrow testing, and blood screenings.

These tests must be performed to determine whether Cancer exists in a Covered Person. This is a preventive benefit; diagnosis of Cancer is not required for this benefit to be payable. This benefit is limited to one payment per Calendar Year per Covered Person. Benefit payments will be made directly to You, unless You assign benefits. Proof of Loss must be submitted to Us for each incurred expense. What We Will Not Pay 1. We will only pay this benefit once per Calendar Year for each Covered Person. Proof of the charges

incurred for the Cancer screening tests must be submitted with each new claim. 2. We may reduce or deny a claim or void this Rider for loss incurred by a Covered Person:

a. During the first 2 years from the Effective Date of this Rider for any misstatements in the Application which would have materially affected Our acceptance of the risk; or

b. At any time for fraudulent misstatements in the Application. 3. With respect to the benefits offered by this Rider, the "Time Limit on Certain Defenses" provision of the

Contract will apply from the Effective Date of this Rider. Under no condition will We pay any benefits for losses or medical expenses incurred prior to the Effective Date of this Rider.

CCI-OC-02-00 Page 4

TRANSAMERICA LIFE INSURANCE COMPANY Home Office: Cedar Rapids, IA 52499

A Stock Company Policyholder: STATE OF NEW HAMPSHIRE Address: 25 CAPITAL STREET CONCORD, NH 03301 Policy Number: SI00026912 Policy Effective Date: JANUARY 1, 2012 Policy Anniversary Date: FEBRUARY 1 Premium Rate Guarantee Date: JANUARY 1, 2013 Governing Jurisdiction: New Hampshire Transamerica Life Insurance Company ("the Company," "We," "Us," and "Our") agrees to pay the benefits described in this Group Master Policy (“Policy”), subject to all terms, conditions, and limitations, in consideration of: 1. The Policyholder Application, a copy of which is attached to and made a part of this Policy; and 2. The payment of the first premium. By Our acceptance of the first premium paid by the Policyholder (“You,” “Your,” and “Yours”) and by Your receipt of this Policy, You agree: 1. To be bound by the terms of this Policy; and 2. To pay all premiums to Us according to the terms of this Policy. This Policy is subject to the laws of the governing jurisdiction in which it is issued. It is signed for the Company at Our Home Office to take effect on the Policy Effective Date.

General Counsel and Secretary President

Group Master Policy for Critical Illness Indemnity Insurance

LUMP SUM BENEFIT FOR SPECIFIED CRITICAL ILLNESSES ONLY PRE-EXISTING CONDITIONS ARE NOT COVERED DURING THE FIRST 6 MONTHS

READ YOUR POLICY CAREFULLY NONPARTICIPATING - NO ANNUAL DIVIDENDS

Administrative Office:

1400 Centerview Drive, PO Box 8063 Little Rock, AR 72203-8063

Customer Service: 1-888-763-7474 CPCI02NH Page 1

TABLE OF CONTENTS

Policy Sections Pages DEFINITIONS .................................................................................................................................... 3 ELIGIBILITY....................................................................................................................................... 3

Employee Or Member And Dependent Eligibility Requirements ................................................ 3 PREMIUMS........................................................................................................................................ 4

Premium Calculation And Due Dates.......................................................................................... 4 Premium Rate Guarantee ........................................................................................................... 4 Grace Period ............................................................................................................................... 4 Change In Premium Rates .......................................................................................................... 4

POLICY CHANGES .......................................................................................................................... 4 Who May Change This Policy ..................................................................................................... 4 When Policy Changes Are Effective............................................................................................ 4 POLICYHOLDER PROVISIONS ....................................................................................................... 5

Termination.................................................................................................................................. 5 Duties .......................................................................................................................................... 5 Minimum Participation Requirement ........................................................................................... 5

GENERAL PROVISIONS .................................................................................................................. 5 Certificates................................................................................................................................... 5 Conformity With State Laws ........................................................................................................ 5 Entire Contract............................................................................................................................. 5 Legal Action................................................................................................................................. 6 New Insureds .............................................................................................................................. 6 Time Limit On Certain Defenses ................................................................................................. 6 CERTIFICATE PROVISIONS MADE A PART OF THIS POLICY..................................................... 6 CPCI02NH Page 2

DEFINITIONS The defined terms below are subject to the provisions of this Policy: Active Service - The Insured is: 1. Performing in the usual manner all of the regular duties of his or her occupation on a scheduled work day; and 2. These duties are performed at one of the places of business where the Insured normally does such duties or at

some location to which his or her employment sends the Insured. The Insured is said to be in Active Service on a day which is not a scheduled work day only if he or she would be able to perform in the usual manner all of the regular duties of his or her occupation if it were a scheduled work day, and he or she were in Active Service on the last preceding regular work day. Amendment, Endorsement, or Rider – Any form issued by Us which adds, modifies, changes, or deletes any Policy or Certificate provisions or benefits. Application – The form completed and signed to apply or enroll for this insurance coverage. Certificate – The document given to each Insured that describes the terms of the insurance made available to insured employees or members and their insured Spouses and/or insured Dependent Children, as defined in the Certificate, if applicable. Effective Date or Policy Effective Date - The date coverage is in effect is shown on the cover page of this Policy. The Effective Date will start at 12:01 AM at the main place of business of the Policyholder. Evidence of Insurability – The correct and complete answers to the questions in the Application and medical history, if necessary, which may be used by Us to base Our acceptance of any proposed Covered Person. Group Master Policy or Policy – The complete contract of insurance, which includes the Policy as issued to You, as well as any Certificates issued to each Insured, including any Amendments, Endorsements, Riders, and Applications. Insured – The eligible employee or member, as defined by the Policyholder, who has been approved by Us for coverage, and whose name appears on the Certificate’s Schedule of Benefits. Policyholder – The entity named on the cover page of this Policy.

ELIGIBILITY

EMPLOYEE OR MEMBER AND DEPENDENT ELIGIBILITY REQUIREMENTS Employees or Members - To be eligible, an employee or member must: 1. Meet eligibility requirements as selected on the Policyholder’s Application; 2. Provide satisfactory Evidence of Insurability to Us, if required; and 3. Be in Active Service on the Effective Date of coverage. An Application must be completed, and any required premium paid, within 31 days of the date enrollment is offered to the employee or member. If such Application is not made within that 31-day period, the employee or member will be considered a late enrollee and may be required to submit satisfactory Evidence of Insurability in order for coverage to become effective. Dependents - If Dependent coverage is available, a Dependent will be eligible for such coverage on the later of the following dates: 1. The day an employee or member becomes eligible for coverage; or 2. The day a Dependent first meets the definition of Dependent. The Insured may elect Dependent coverage by: 1. Applying for Dependent coverage within 31 days of the date the Dependent becomes eligible; 2. Providing satisfactory Evidence of Insurability to Us, if required, and 3. Completing any required form for payroll deduction, if applicable.

CPCI02NH Page 3

If such Application for Dependent coverage is not made within that 31-day period, the Spouse or Child will be considered a late enrollee and may be required to submit satisfactory Evidence of Insurability in order for coverage to become effective. If an employee or member and his or her Spouse are both eligible as an employee or member, the Children may be insured as Dependents of either the employee or member or his or her Spouse, but not both.

PREMIUMS Premium Calculation And Due Dates - The premium due will be the sum of the premiums applicable for all Insureds. You must pay the premiums to Us at Our Administrative Office. The premiums are due and payable to Us in advance by You on each premium due date. The first premium due date is the Policy Effective Date. Premium Rate Guarantee - These premium rates are guaranteed until the date shown on the Policy's cover page and are subject to the Change in Premium Rates provision. Grace Period - A Grace Period of 31 days will be allowed for each premium payment after the first premium. Coverage will stay in force during this time. This Policy will terminate at the end of the Grace Period if the premium has not been paid. You must still pay all unpaid premiums. This includes the premium due for the Grace Period. If coverage is canceled on a premium due date and the premium has been paid through that date, the Grace Period will not apply. If cancellation is during the Grace Period, You will be liable for any unpaid premium including the pro rata premium for that part of the Grace Period during which coverage was in force. Change in Premium Rates - We have the right to change the premium rates on any premium due date after the end of the Premium Rate Guarantee. If the rates are changed, We will give You at least a 31-day advance written notice. If an increase takes place on a date other than a premium due date, a pro rata premium for the increase will be due on the next premium due date. The pro rata premium will be for the period from the date of the increase to the next premium due date. If such premium is not paid when due, the coverage will automatically be terminated as of the date the pro rata premium was due. Any partial payment of premium will be refunded. If the premiums increase because a change in benefits increases Our liability, premium rates may be changed on the date that Our liability is increased without regard to any Premium Rate Guarantee.

POLICY CHANGES Who May Change This Policy - The terms of this Policy may be changed at any time by written agreement between You and Us. Only Our President, Vice President, Secretary, or an Assistant Secretary can authorize a change in this Policy. Such an authorization must be in writing and signed by an officer. The terms of this Policy can be changed only by endorsement or amendment signed by an officer of Transamerica Life Insurance Company. No agent has the right to change or waive any terms of this Policy. All changes are subject to the laws of the governing jurisdiction. When Policy Changes Are Effective - Unless You and We agree otherwise in writing, the Effective Date of any change in benefits will be the first day of the calendar month that coincides with or next follows the date We send notice to You of the change in benefits and any corresponding change in premiums.

POLICYHOLDER PROVISIONS Termination - This Policy will end on the earliest of the following events: 1. If You submit a 60-day advance written request to Us to terminate this Policy, this Policy will terminate on the

date specified in that request; 2. If We give a 60-day advance written notice to You that We intend to terminate this Policy, this Policy will

terminate on the date specified in that notice; 3. If any premium payable by You is not paid within its Grace Period, this Policy will terminate on the day after the

end of the Grace Period; CPCI02NH Page 4

4. If You fail to comply with any terms of this Policy or the Application, or otherwise fail to fulfill any obligations or duties under or pertaining to this insurance, or fail to comply with or cooperate with Us in satisfying the requirements of any applicable law or regulation pertaining to this insurance, this Policy will terminate on the 45th day after We have given You written notice of Our intent to terminate; or

5. If the number of Insureds during any 12-month period does not meet the Minimum Participation Requirement, this Policy may terminate at Our discretion on the 32nd day after We have given You written notice of Our intent to terminate.

Termination of an Insured’s coverage that was effective prior to the date Your coverage terminated will be governed by the Termination of Insurance provision of the Certificate. You are required to notify Us of any such termination. Duties - Your duties will include, but are not limited to, the following: 1. As required, give Us any and all information We determine to be necessary for the enrollment of Your

employees or members (and their Spouses and/or Dependent Children, if such coverage is available and has been elected and approved by Us), and for the determination of their eligibility.

2. Receive and forward to Us, the Applications of Your employees or members. 3. Maintain records pertaining to the insurance of Your employees or members as We may reasonably require

while this Policy is in force and for two years after this Policy terminates, and allow Us the opportunity to examine these records at any reasonable time during normal business hours.

4. Pay premiums to Us. 5. In the event that any of this insurance is to be stopped:

a. You are required to notify the insured employees or members by either giving them a written notice or mailing a notice to their last known address as shown in Your records; and

b. You are required to provide the insured employees or members with a notice of their right to opt for the Portability Option, as described in the Certificate.

Minimum Participation Requirement – You must maintain the participation levels described in the Policyholder Application. If participation falls below the minimum participation limit, We have the right to cancel this Policy.

GENERAL PROVISIONS Certificates - A Certificate will be issued for delivery to each Insured. The Certificate will describe: 1. The benefits under this Policy; 2. To whom benefits will be paid; 3. The limitations and terms of this Policy; and 4. All other essential features of the Policy. If more than one Certificate is issued to an Insured under this Policy, only the last one issued will be in effect. Conformity With State Laws - A provision of the Policy and any Certificate that conflicts with a law of the governing jurisdiction is hereby changed to meet the minimum standards of that law. Entire Contract - The entire contract consists of: this Policy; Policyholder Application; the Certificates; any attached Amendments, Endorsements, Riders; and Insureds’ Applications. Legal Action - No legal action may be brought to recover under the Policy and any Certificate: 1. Within 60 days after written Proof of Loss has been furnished as required; or 2. More than three years from the time written Proof of Loss is required to be furnished. New Insureds - The group originally insured may be modified from time to time to add eligible new persons in accordance with the terms of the Policy. Time Limit On Certain Defenses - Misstatements in the Application - We will not use any statement, except fraudulent statements, to void or reduce benefits after this Policy has been in force for two years from the Effective Date of coverage. Any such statement would have to be in a signed form. This also applies to all Riders. Any increase in benefit amounts would be subject to a new two year contestable period for the increased amount only. All statements made are considered representations and not warranties. No such statement will be used in any contest, unless a copy of such statement has been furnished to You. The validity of this Policy cannot be contested after two years from its date of issue, except for nonpayment of premiums.

CPCI02NH Page 5

CERTIFICATE PROVISIONS MADE A PART OF THIS POLICY The remainder of this Policy consists of the provisions that appear in the Certificate, including any Amendments, Endorsements, or Riders, that describe the insurance made available to the employees or members (and their Spouses and/or Dependent Children, if applicable) under this Policy. CPCI02NH Page 6

TRANSAMERICA LIFE INSURANCE COMPANY Home Office: Cedar Rapids, IA 52499

A Stock Company This Certificate explains the Group Master Policy for Critical Illness Indemnity Insurance ("Policy") that is underwritten by Transamerica Life Insurance Company (the "Insurer"). Read it closely to become familiar with Your coverage. Terms important to understanding this Certificate are defined in the Definitions section or in separate Certificate Provisions and are capitalized in this Certificate. Important Notice - Benefits are payable for loss due to a covered Critical Illness while the Covered Person is insured under the Policy, subject to the provisions of this coverage. The Policy does not provide benefits for any other sickness or condition. The Policy under which this Certificate is issued may be amended or canceled, as stated in its provisions. Such an action may be taken without the consent of or notice to any Covered Person. Premiums are subject to periodic changes. The benefits for Dependents described in this Certificate will be applicable to each of Your Dependents only if You are insured and You have applied for Dependent coverage. Any Application requesting Dependent coverage must be approved by Us, and the required premium paid for each Dependent. This Certificate is signed for the Company at Our Home Office to take effect on the Effective Date.

General Counsel and Secretary President

Certificate for Group Critical Illness Indemnity Insurance

LUMP SUM BENEFIT FOR SPECIFIED CRITICAL ILLNESSES ONLY PRE-EXISTING CONDITIONS ARE NOT COVERED DURING THE FIRST 6 MONTHS

READ YOUR CERTIFICATE CAREFULLY NONPARTICIPATING - NO ANNUAL DIVIDENDS

Notice to Buyer: This is a specified disease Certificate. This Certificate provides limited benefits.

Benefits provided are supplemental and are not intended to cover all medical expenses. Read Your Certificate carefully with the outline of coverage and the Buyer's Guide.

Administrative Office:

1400 Centerview Drive, PO Box 8063 Little Rock, AR 72203-8063

Customer Service: 1-888-763-7474 CCCI02NH Page 1

TABLE OF CONTENTS

Certificate Sections Pages

SCHEDULE OF BENEFITS......................................................................... 2 DEFINITIONS .............................................................................................. 3 ELIGIBILITY AND EFFECTIVE DATE ......................................................... 5 BENEFIT PROVISIONS .............................................................................. 7 EXCLUSIONS AND LIMITATIONS.............................................................. 7 Pre-Existing Condition Limitation............................................................ 7 PREMIUMS.................................................................................................. 8 TERMINATION OF INSURANCE ................................................................ 8 PORTABILITY OPTION............................................................................... 8 CLAIMS PROVISIONS ................................................................................ 8 GENERAL PROVISIONS............................................................................. 9 CCCI02NH Page 1A

SCHEDULE OF BENEFITS INSURED: XXXX XXXXXX AGE AT ISSUE: XX CERTIFICATE NUMBER: XXXXXXXXXXXX EFFECTIVE DATE: XXXX X, XXXX COVERAGE TYPE: [INDIVIDUAL, RATE CLASS: [NONTOBACCO OR TOBACCO] SINGLE PARENT FAMILY, FAMILY] TOTAL PREMIUM: $XX.XX PREMIUM MODE: [MONTHLY] INSURED BENEFIT AMOUNT: $XX,XXX DEPENDENT BENEFIT AMOUNT: $XX,XXX PER COVERED DEPENDENT INSURED LIFETIME MAXIMUM BENEFIT: $XXX,XXX DEPENDENT LIFETIME MAXIMUM BENEFIT: $XX,XXX PER COVERED DEPENDENT TYPE OF COVERAGE PERCENTAGE OF BENEFIT AMOUNT CATEGORY 1 Heart Attack 100% Stroke 100% Heart Transplant Surgery 100% Coronary Bypass Surgery 25% Angioplasty/Stent 5% CATEGORY 2 Major Organ Transplants (excluding Heart) 100% End Stage Renal Failure 100% Paralysis Not Due to Stroke (all 4 limbs) 100%; 50% (if fewer than 4 limbs) Burns 100% OPTIONAL BENEFIT RIDERS CATEGORY 3 - Cancer Benefit Rider Invasive Cancer 100% Carcinoma In Situ 25% Prostate Cancer with TNM Classification of T1 25% Skin Cancer 5% Cancer Screening Wellness Benfit Rider $50 per Covered Person per Calendar Year CCCI02NH Page 2

DEFINITIONS The defined terms below are subject to the provisions of the Policy and this Certificate. Active Service – You are: 1. Performing in the usual manner all of the regular duties of Your occupation on a scheduled work day; and 2. These duties are performed at one of the places of business where You normally do such duties or at some

location to which Your employer sends You. You are said to be in Active Service on a day which is not a scheduled work day only if You would be able to perform in the usual manner all of the regular duties of Your occupation if it were a scheduled work day, and You were in Active Service on the last preceding regular work day. Amendment, Endorsement, or Rider – Any form issued by Us which adds, modifies, changes, or deletes any Policy or Certificate provisions or benefits. Application – The form completed and signed to apply or enroll for this insurance coverage. Calendar Year - The period from January 1 through December 31 of the same year. Category - A grouping of Critical Illnesses as identified within the Schedule of Benefits. Each separate Category comes with its own set of benefits. Certificate – This document that describes Your Critical Illness Indemnity Insurance coverage. Child(ren) - A Child of Yours who is unmarried; under the age of 26; dependent upon You for more than 50% of his or her support and maintenance; who lives with You; and is: 1. A natural Child; or 2. A legally adopted Child or a Child who has been placed for adoption with You; or 3. A stepchild, grandchild, or foster Child; or 4. A Child for whom You have been appointed legal guardian; or 5. A Child not living with You, but for whom You are legally required to provide support. If a Covered Dependent Child has reached age 26, but is incapable of self-support because of mental or physical handicap, We will continue the Child's coverage under the following conditions: 1. The Child must be incapacitated; 2. We must receive proof of incapacity within 31 days after coverage would otherwise terminate; 3. We may require additional proof of such incapacity from time to time, but not more often than once a year after

the Child attains age 26; and 4. Your coverage must remain in force. Covered Person - Any or all of the following: You, Your Spouse or Your Child(ren), who have been accepted by Us for coverage. Critical Illness - One of the illnesses or conditions listed below for which positive diagnosis is made by a Physician. It must be based on diagnostic criteria generally accepted by the medical profession, as explained below: Heart Attack – The ischemic death of a portion of heart muscle as a result of obstruction of one or more of the coronary arteries. A positive diagnosis must be supported by either of the following criteria: 1. The presence of 3 or more of the following indicators:

a. typical chest pain suggestive of Heart Attack; b. new EKG changes indicative of myocardial infarction; c. diagnostic increase of specific cardiac markers typical for Heart Attack; and d. confirmatory imaging studies, or

2. In the event of death, an autopsy confirmation identifying Heart Attack as the cause of death will be accepted.

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Severe Stroke – A cerebrovascular event resulting in permanent neurological damage, including infarction, hemorrhage, or embolization of brain tissue from an extracranial source. The diagnosis must be based on: 1. Documented neurological deficits; and 2. Confirmatory neuroimaging studies. Severe Stroke does not include cerebral symptoms due to: 1. Transient Ischemic Attack (TIA); 2. Reversible neurological deficit; 3. Migraine; 4. Cerebral injury resulting from trauma or hypoxia; or 5. Vascular disease affecting the eye, optic nerve or vestibular functions. Heart Transplant Surgery - A Covered Person undergoing surgery as a recipient of a transplant of a human heart. Coronary Bypass Surgery - Undergoing of a surgical operation to correct narrowing or blockage of one or more coronary arteries with bypass grafts on the advice of a board-certified cardiologist. Angiographic evidence to support the necessity for this surgery will be required. The following procedures are not considered coronary artery by-pass surgery: balloon angioplasty; laser embolectomy; atherectomy; stent placement; or other non-surgical procedures. Angioplasty/Stent - Balloon angioplasty or other forms of catheter-based percutaneous transluminal coronary artery therapy to correct the narrowing or blockage of one or more coronary arteries. Coronary angioplasty must be performed by a Physician who is also a board-certified cardiologist. This benefit is confined to the heart; therefore, angioplasty/stenting of renal arteries or other peripheral arteries are excluded from this benefit. Major Organ Transplant (excluding Heart) – A Covered Person undergoing surgery as a recipient of a transplant of a human lung, liver, kidney or pancreas. End Stage Renal Failure – The end stage failure which presents a chronic irreversible failure of both kidneys, and requires treatment by renal dialysis or kidney transplant. Paralysis - Means quadriplegia, paraplegia, or hemiplegia that is expected to last for a continuous 12-month period or longer from the date of diagnosis to determine if paralysis is permanent. "Quadriplegia" means the complete and irreversible paralysis of both upper and lower limbs. "Paraplegia" means the complete and irreversible paralysis of both lower limbs. "Hemiplegia" means the complete and irreversible paralysis of the upper and lower limbs on the same side of the body. "Limb" means an entire arm or an entire leg. A benefit will not be paid for paralysis that results from a severe stroke or psychiatric related causes. Burns - The cosmetic disfigurement of body surface or area that is a full-thickness or third-degree burn covering at least 50% of the body surface. A full-thickness or third-degree burn is the injury and destruction of skin through the entire thickness or depth of the dermis and possibly to underlying tissue with a loss of fluid and sometimes shock caused by exposure to fire, heat, caustics, electricity, or radiation. Dependent – Your Child or Spouse as defined in this Certificate. Effective Date - The date coverage is in effect is shown on the Schedule of Benefits. The Effective Date will start at 12:01 AM at the main place of business of the Policyholder. Evidence of Insurability – The correct and complete answers to the questions in Our Application and medical history, if necessary, which may be used by Us to base Our acceptance of any proposed Covered Person. First Occurrence - A Critical Illness that was diagnosed for the very first time and is the first Critical Illness ever diagnosed within the applicable Category to which the diagnosed Critical Illness belongs. (Diagnosis can occur after death, if the death is due to a Critical Illness.) Grace Period – The period of 31 days allowed for each premium payment after the first premium. Group Master Policy or Policy – The complete contract of insurance, which includes the Policy as issued to the Policyholder, as well as any Certificates issued to Insureds, including any Amendments, Endorsements, Riders, and Applications. CCCI02NH Page 4

Hospital - A licensed institution that has on its premises or in facilities available to the Hospital on a contractual prearranged basis and under the supervision of a staff of one or more duly licensed Physicians: 1. Laboratory, X-ray equipment and operating rooms where major surgical operations may be performed by

licensed Physicians; 2. Permanent and full-time facilities for the care of overnight resident bed patients under the supervision of a

licensed Physician; 3. 24-hour nursing service by graduate registered nurses; and 4. A patient's written history and medical records. The term “Hospital” does not include an institution or that part of an institution operated as: 1. A place for rehabilitation; 2. A place for rest, or for the aged; 3. A nursing or convalescent home; 4. A long term nursing unit or geriatrics ward; or 5. An extended care facility for the care of convalescent, rehabilitative or ambulatory patients. Immediate Family Member – You, Your Spouse, Child, mother, father, brother, sister, or other close family member of the Covered Person. Insured – The employee or member covered for this insurance and named in the Schedule of Benefits. Physician - A licensed practitioner of the healing arts who: 1. Performs only those services permitted by his or her license; and 2. Is not an Immediate Family Member. Policyholder – The entity named on the cover page of the Policy. Pre-Existing Condition – A sickness or physical condition for which the Covered Person: 1. Had treatment; or 2. Incurred expense; or 3. Took medication; or 4. Received a diagnosis or advice from a Physician,

during the 6-month period immediately before the Effective Date of the Covered Person’s coverage. The term “Pre-Existing Condition” will also include a condition that manifests itself in a way that would cause an ordinarily prudent person to seek medical advice, diagnosis, care, or treatment. Schedule of Benefits or Schedule - The benefit schedule set forth in this Certificate. Spouse - Your legally married Spouse named in the Application. If You are not legally married, “Spouse” may include Your common law spouse if named in the Application and if legally recognized in the state in which You reside. Treatment Free - The Covered Person is no longer receiving care from a Physician, nor regular office visits, or being prescribed medication for a Critical Illness, other than routine check ups or maintenance medication for that Critical Illness. We, Us, or Our – The Insurer that underwrites this coverage: Transamerica Life Insurance Company. You, Your, or Yours - The Insured.

ELIGIBILITY AND EFFECTIVE DATE Effective Dates and Coverage Type are shown on the Schedule of Benefits. Coverage will start on such date at 12:01 AM at the main place of business of the Policyholder. Effective Dates for all persons added to coverage after this Certificate is issued will be reflected by an endorsement to the Certificate. The Insured may select from three Coverage Types: Individual, Single Parent Family, or Family. CCCI02NH Page 5

Coverage Type - The Insured may select: 1. Individual coverage for You only; or 2. Single Parent Family coverage for You and Your Children; or 3. Family coverage for You, Your Children, and Your Spouse. Employee or Member Eligibility - To be eligible for insurance, You must: 1. Meet eligibility requirements as selected on the Policyholder’s Application; 2. Satisfactorily answer all eligibility and other questions on the Application and must provide Evidence of

Insurability satisfactory to Us, if We ask for it; and 3. Be in Active Service. Employee or Member Effective Date - Your insurance will take effect on the Effective Date of the Policy if: 1. You completed an Application on or before said Effective Date; and 2. You are in Active Service; and 3. Your first premium is paid and received by Us. If You are not eligible for this coverage on the Policy Effective Date, Your coverage will take effect on the first day of the month which coincides with or next follows the date You first become eligible and are approved for coverage. Additionally, Your first premium must have been received by Us, and all provisions listed in the Employee or Member Eligibility provision above, must be met. If You are not in Active Service on what otherwise would be the Effective Date, Your coverage will be deferred until the first of the month following the date You are in Active Service. Dependent Eligibility - If Dependent coverage is available, a Dependent will be eligible for such coverage on the later of the following dates: 1. The day You become eligible for coverage; or 2. The day he or she first meets the definition of Dependent. You may elect Dependent coverage by: 1. Applying for Dependent coverage within 31 days of the date the Dependent becomes eligible; 2. Providing Evidence of Insurability satisfactory to Us, if We ask for it; and 3. Completing any required form for payroll deduction, if applicable. You must complete an Application for enrollment of a Spouse or Child, and pay any required premium within 31 days of the date Your Spouse or Child meets these eligibility criteria. If such Application is not made within that 31-day period, Your Spouse or Child will be considered a late enrollee and may be required to submit satisfactory Evidence of Insurability in order for coverage to become effective. Any eligible Dependent who does not become a Covered Person on Your Effective Date may be added to this Certificate subject to: 1. The completion of an Application; 2. Satisfaction of any Evidence of Insurability requirements; and 3. Payment of any additional premium, if required. If You and Your Spouse are both eligible as an employee or member, the Children may be insured as Dependents of either You or Your Spouse, but not both. Dependent Effective Date - The Effective Date of coverage for each eligible Dependent will be on the first day of the month that coincides with or next follows: 1. Our acceptance of the Application; and 2. Our receipt of the first premium. However, if on such date Your coverage has not yet taken effect, the Effective Date for Dependent coverage will be the same as Your Effective Date. Newborn Child Effective Date - A newborn Dependent Child will become insured for coverage automatically on the day he or she is born, as long as You have Single Parent Family or Family coverage in force on that date. CCCI02NH Page 6

If You do not have such coverage in force, the newborn Child's coverage will not continue past the 31-day period following birth, unless: 1. You have notified Us by the end of the 31-day period of the addition of such newborn Child; and 2. You have paid any applicable additional premium.

BENEFIT PROVISIONS Critical Illness Benefit – If a Covered Person is diagnosed with the First Occurrence of a Critical Illness, We will pay a lump sum benefit equal to the Benefit Amount multiplied by the applicable percentage shown in the Schedule of Benefits provided that the positive diagnosis is made after the Effective Date of this Certificate and while this Certificate is in force. If the total Critical Illness Benefit paid in a Category is less than 100% of the Benefit Amount, We will pay a lump sum benefit equal to the Benefit Amount multiplied by the applicable percentage shown in the Schedule of Benefits upon the diagnosis of a different type of Critical Illness within the same Category. The cumulative Critical Illness Benefit paid within each Category will not exceed 100% of the Benefit Amount. Recurrent Critical Illness Benefit - A "Recurrent Critical Illness" is a covered Critical Illness that is not eligible for payment under the Critical Illness Benefit. If a Covered Person is diagnosed with a Recurrent Critical Illness, We will pay a lump sum benefit equal to 50% of the Benefit Amount multiplied by the applicable percentage shown in the Schedule of Benefits, subject to any applicable maximum benefit payment limitation, provided that the positive diagnosis is made after the Effective Date and while this Certificate is in force. A recurrence of the same type of Critical Illness is not eligible for the Recurrent Critical Illness Benefit, unless: 1. The diagnosis for the prior occurrence was at least 12 months from the most recent diagnosis; and 2. The Covered Person has been Treatment Free for at least 12 months. The total Recurrent Critical Illness Benefit paid within each Category will not exceed 50% of the Benefit Amount. Lifetime Maximum Benefit - The total benefits paid under this Certificate, including any attached Riders, will not exceed the Lifetime Maximum Benefit listed in the Schedule of Benefits for each Covered Person. Benefit Payments - Benefit payments will be made directly to You. Proof of any Critical Illness diagnosis must be submitted to Us. Dependents are covered at a percentage of the Benefit Amount as stated in the Schedule of Benefits.

EXCLUSIONS AND LIMITATIONS We do not cover losses caused by, or as a result of, the following: 1. Conditions other than those due to a covered Critical Illness. 2. The Covered Person participating or attempting to participate in an illegal activity. 3. The Covered Person intentionally causing self-inflicted injury. 4. The Covered Person committing or attempting to commit suicide, whether sane or insane. 5. The Covered Person’s involvement in any period of armed conflict. 6. Surgeries performed outside the United States or its Territories. Under no condition will We pay any benefits for losses or medical expenses incurred prior to the Effective Date. We may reduce or deny a claim or void the Certificate for loss incurred by a Covered Person during the first 2 years from the Effective Date of such coverage for any misstatements in the Application which would have materially affected Our acceptance of the risk. Pre-Existing Condition Limitation - No benefits are provided during the first 6 months for any Critical Illness that has been diagnosed, treated, or for which the Covered Person has incurred expense or has taken medication within 6 months prior to the Effective Date of such person's coverage. CCCI02NH Page 7

PREMIUMS All premiums are payable on or before the date they are due. We have the right to change the premium rates on any premium due date in accordance with the terms of the Policy. If the rates are changed, We will give at least a 31-day advance written notice to the Policyholder, or to You if the Portability Option is in effect. If an increase takes place on other than a premium due date, a pro rata premium for the increase will be due on the next premium due date. The pro rata premium will be for the period from the date of the increase to the next premium due date. If such premium is not paid when due, the coverage will automatically be terminated as of the date the pro rata premium was due. Any partial payment of premium will be refunded. If the premiums increase because a change in benefits increases Our liability, premium rates may be changed on the date that Our liability is increased, without regard to any premium rate guarantee.

TERMINATION OF INSURANCE Subject to the Portability Option, Your insurance will cease on the earliest of: 1. The last day of the payroll deduction period during which You cease to be eligible for coverage; 2. The end of the last period for which premium payment has been made to Us; 3. The last day of the payroll deduction period during which You terminate employment; 4. The date the Policy terminates; or 5. The date You send Us a written notice that You want to cancel coverage. The insurance on a Dependent will cease on the earliest of: 1. The date Your coverage terminates; 2. The end of the last period for which premium payment has been made to Us; 3. The date the Dependent no longer meets the definition of Dependent; 4. The date the Policy is modified to exclude Dependent coverage; or 5. The date You send Us a written notice that You want to cancel Your Dependent's coverage. We will have the right to terminate the coverage of any Covered Person who submits a fraudulent claim under the Policy.

PORTABILITY OPTION

If You lose eligibility for this insurance for any reason other than nonpayment of premiums, You will have the option to continue this Certificate (including any Riders, if applicable) by paying the premiums directly to Us at Our Administrative Office within 31 days after Your insurance terminates. We will bill You for these premiums after You notify Us to continue this coverage. If You stop paying the premiums under this option, this coverage will continue, subject to the terms of the Grace Period. All Dependent coverage terminates the date Your coverage terminates for any reason.

CLAIMS PROVISIONS Claim Forms - Claim forms should be used for filing Proof of Loss. We will send such form to the claimant within 15 days of receipt of notice of claim. If We fail to supply the proper claim forms within 15 days, You can give proof in writing, setting forth the nature and extent of the loss within the time stated in the Proof of Loss Provision. Claims Procedure - Due Proof of Loss must be submitted to Us at Our Administrative Office. You or a personal representative may obtain a claim form by calling Our toll-free telephone number listed on the Cover Page. Notice of Claim - Written notice of claim must be given to Us at Our Administrative Office, or to Our agent. Such notice should be made within 30 days after any loss covered by the Policy. If it is not reasonably possible to give notice within that time, the claim may not be denied or reduced due to the delay. CCCI02NH Page 8

Payment of Claim Benefits - All benefits payable under the Policy will be paid to You. Any benefits that are not paid at Your death will be paid to Your Spouse, or if there is no Spouse, then to Your estate. We may pay up to $1,000.00 of such benefit to one of Your relatives at Our discretion. Such payment fully discharges Us to the extent of the payment. Physical Examinations and Autopsy - We have the right to have a Covered Person examined by a Physician of Our choice as often as reasonably necessary while a claim is pending. We will pay for such examination. In case of death, We may request an autopsy where it is not forbidden by law. Proof of Loss - Satisfactory written Proof of Loss must be given to Us at Our Administrative Office. In case of a claim for loss for which a periodic payment is provided contingent upon continuing loss, such satisfactory written Proof of Loss must be sent within 90 days after the termination of the period for which We are liable. For any other loss, proof must be sent within 90 days after the date of such loss. Failure to furnish such proof within such time will not invalidate nor reduce any claim if it was not reasonably possible to furnish such proof and that it was furnished as soon as it was reasonably possible. Time of Payment of Claims - Benefits for a covered loss will be paid after We receive satisfactory written Proof of Loss.

GENERAL PROVISIONS Changes to this Certificate - Only Our President, Vice President, Secretary, or an Assistant Secretary may make any changes to this Certificate and then only in writing. No agent or Policyholder has authority to change the Policy or this Certificate or to waive any of its provisions. Any changes are subject to the laws of the governing jurisdiction. Conformity with State Laws - A provision of the Policy and/or Certificate that conflicts with a law of the governing jurisdiction is hereby changed to meet the minimum standards of that law. Entire Contract - The Entire Contract consists of the Policy, this Certificate, any attached Amendments, Endorsements, or Riders, the Policyholder’s Application, and Your Application. Grace Period - A Grace Period of 31 days will be allowed for each premium payment after the first premium is paid. Coverage will stay in force during this time. The coverage under the Policy and/or Certificate will terminate at the end of the Grace Period if the premium has not been paid. You must still pay all unpaid premium. This includes the premium due for the Grace Period. If coverage is canceled on a premium due date and the premium has been paid through that date, the Grace Period will not apply. If coverage is canceled during the Grace Period, You will be liable for any unpaid premium including the pro rata premium for that part of the Grace Period during which coverage was in force. Benefits may be reduced by the amount of any due, but unpaid premiums. Legal Action - No legal action may be brought to recover under the Policy and/or Certificate: 1. Within 60 days after written Proof of Loss has been furnished as required; or 2. More than three years from the time written Proof of Loss is required to be furnished. Misstatement of Age - If the Covered Person’s age has been misstated, the Covered Person’s true age will be used to adjust the premium or adjust the benefits paid. Misstatement of Tobacco Use Status - If the Covered Person’s tobacco use status has been misstated on the Application for this insurance coverage, the Covered Person’s true tobacco use status will be used to adjust the premium or adjust the benefits paid, subject to the Misstatements in the Application paragraph of the Time Limit on Certain Defenses provision. No Dividends Payable - This Certificate does not participate in the profits or surplus earnings of Our Company. Other Insurance With Us - If You have more than one Critical Illness policy or certificate with Us, only the one chosen by You will remain in effect. We will refund all premiums paid for any other such coverage for the period of time duplicate coverage was in effect.

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Time Limit on Certain Defenses Misstatements in the Application - We will not use any statement to void or reduce benefits after this Certificate has been in force during Your lifetime for two years from the Effective Date of coverage. Any such statement would have to be in a signed form. This also applies to all Riders. Any increase in benefit amounts would be subject to a new two year contestable period for the increased amount only. All statements made are considered representations and not warranties. No such statement will be used in any contest, unless a copy of such statement has been furnished to You. Pre-Existing Conditions - No claim for loss incurred or disability that starts after 6 months from the Effective Date will be reduced or denied because a physical condition, not excluded by name or specific description before the date of loss, had existed before the Effective Date of coverage. When Notice is to be Given by Us – Any notice to You will be sent to Your last known address. CCCI02NH Page 10

Company which issued the Policy or Certificate (referred to as “Contract” herein) to which this form is attached: Transamerica Life Insurance Company - Home Office: Cedar Rapids, Iowa

Administrative Office: 1400 Centerview Drive, PO Box 8063, Little Rock, Arkansas 72203-8063

ENDORSEMENT This Endorsement is made part of the Contract to which it is attached, and is subject to all its provisions which are not in conflict with the provisions of this Endorsement. The Effective Date of this endorsement is the same as the Effective Date of the Contract to which it is attached or January 1, 2011, whichever is later. Beginning on January 1, 2011, the definition of Child is hereby amended as follows: - The limiting age for a Child is now increased to cover Children through age 25. - Any restriction that requires a Child be unmarried is now removed. - Any restriction that requires a Child be a full-time student is now removed. - Any restriction that requires a Child be living with you is now removed, with the exception of grandchildren

(where available). - Any restriction that requires a Child be financially dependent on you is now removed, with the exception of

grandchildren (where available). In all other respects the provisions and conditions of the Contract remain the same. Signed for the Company at our Home Office on its Effective Date by:

General Counsel and Secretary

Accepted by: Title: _________________________________________________________________ (e.g. Insured, Owner, Guardian, or Officer Position if signing for a Group Policyholder) Date: __________________________________________ XE100100

1

GROUP BENEFITS DISCLOSURE POLICY

Transamerica Employee Benefits (TEB) is a marketing division of Transamerica Life Insurance Company and Transamerica Financial Life Insurance Company. TEB markets and administers voluntary insurance benefits through a network of licensed insurance agents. These agents are typically appointed to sell our products, and products of other providers, and receive various forms of compensation from us for the services provided. We believe our compensation arrangements with our agents have been conducted with honesty, fairness and integrity. In addition, we realize that having trusted relationships between our agents and our customers is essential to all involved. To ensure this trust continues and to address any concerns within the industry, we recently outlined our policy on agent compensation disclosure.

TEB’s policy supports transparency and full disclosure of agent compensation to our customers and prospective customers. In addition, we have put controls in place to facilitate this disclosure and obligate our agents to disclose compensation information to customers: 1) when asked by a customer; 2) when receiving both a fee from the customer and compensation from TEB; and 3) when otherwise required by law. Agents must comply with all applicable laws in the sale of TEB products, including any pertaining to the disclosure of compensation information.

TEB’s Group Benefits Compensation Disclosure Notice (below) describes the various means by which agents may be compensated for the sale of our products. It is the responsibility of your agent to share with you, specific information surrounding his or her compensation arrangements with TEB. Accordingly, please direct any compensation disclosure questions directly to your agent. COMPENSATION DISCLOSURE NOTICE TO ALL POLICYHOLDERS

Agents selling and servicing our products are paid a commission, which varies by the type of insurance policy sold and the state where the policy was sold, and is based on a percentage of the premium received in the first year, and at policy renewal. Agents may receive advances or loans against anticipated commissions for cases sold or to be sold. These advances may or may not require the payment of interest, depending upon the agent’s total business and historical experience with TEB.

Agents may receive other compensation in the form of cash or non-cash awards or prizes, based upon a variety of factors that may include the level of premium written or earned, persistency and growth of premium, or other performance measures. Agents who manage, supervise or recruit other agents or wholesale our products and services to other agents, may receive commission overrides on business that results from their efforts.

Some of our agents may receive additional payments for administrative services provided to our benefit plans. Fees for these services may be calculated on a per policy or per certificate basis or upon the premium volume associated with a specific case. TEB may additionally reimburse these agent/ administrators for certain expenses, such as the cost of mailings.

Agents may occasionally obtain exclusive rights to market TEB products or services to agents, employers, employees or association members. Certain groups or associations may also agree to endorse TEB’s products to their members. TEB may pay a fee for these exclusive marketing rights or endorsements. See your proposed plan documents or policy certificate package for more information on any such arrangements.

For up to date information regarding our compensation practices, please consult our website at: www.transamericaemployeebenefits.com.

TRANSAMERICA LIFE INSURANCE COMPANY Home Office: Cedar Rapids, IA 52499

Administrative Office: 1400 Centerview Drive, PO Box 8063, Little Rock, AR 72203-8063 (Hereinafter called "the Company," "We," "Us," or "Our")

CANCER BENEFIT RIDER

This Rider is attached to and made part of the Contract, as defined below, as of the Effective Date. It is issued in consideration of any statements made in the Application and payment of any required initial premium. Except as shown in this Rider, the provisions of the Contract will prevail. While this Rider is in force, We will pay benefits described in the "What We Will Pay" section of this Rider.

DEFINITIONS

In addition to the definitions contained in the Contract, the following definitions apply to this Rider. Cancer - For purposes of this Rider, the word "Cancer" includes Skin Cancer, Carcinoma In Situ, Invasive Cancer, or Prostate Cancer with TNM Classification of T1, as defined herein. Carcinoma In Situ - Cancer that is in the natural or normal place, confined to the site of origin without having invaded neighboring tissue. Clinical Diagnosis - A Clinical Diagnosis of Cancer is based on the study of symptoms. Contract - The Policy for Group Critical Illness Indemnity Insurance and any Certificate, if applicable, to which this Rider is attached. Effective Date - The Effective Date of the Contract or the date shown for this Rider if added to the Contract at a later date. First Occurrence - A Critical Illness that was diagnosed for the very first time and is the first Critical Illness ever diagnosed within the applicable Category to which the diagnosed Critical Illness belongs. (Diagnosis can occur after death, if the death is due to a Critical Illness.) If Category 3 coverage is shown on the Schedule of Benefits, a diagnosis of Skin Cancer prior to the Effective Date will not be considered a First Occurrence. Initial Positive Diagnosis/Initially Positively Diagnosed - Cancer must be diagnosed by a Pathological or Clinical Diagnosis. An Initial Positive Diagnosis is the first time a Covered Person has received a Pathological Diagnosis based on the medical criteria as accepted by the American Board of Pathology or the Osteopathic Board of Pathology for the Cancer being investigated. We will accept a Clinical Diagnosis in lieu of a Pathological Diagnosis only when: 1. A Pathological Diagnosis cannot be made because it is medically inappropriate or life-threatening; 2. There is medical evidence to support the diagnosis; and 3. A Physician is treating a Covered Person for Cancer. Invasive Cancer - A Cancer which is evidenced by the presence of a malignant tumor characterized by uncontrolled and abnormal growth and spread of malignant cells, and the invasion of tissue. Leukemia, Hodgkin's Disease (except Stage 1 Hodgkin's Disease), and malignant melanoma will be considered Invasive Cancer. Invasive Cancer does not include: 1. Pre-malignant conditions or conditions with malignant potential; 2. Prostatic Cancers which are histologically described as TNM Classification T1 (including T1(a) or T1(b), or of

other equivalent or lesser classification); and 3. Any malignancy associated with the diagnosis of HIV. Pathological Diagnosis - A Pathological Diagnosis of Cancer is based on a microscopic study of fixed tissue or preparations from the hemic (blood) system. This type of diagnosis must be done by a certified pathologist whose diagnosis of malignancy is in keeping with the standards set up by the American Board of Pathology. Prostate Cancer with TNM Classification of T1- Microscopic tumors of the prostate that are neither palpable nor visible on transrectal ultrasonography. CRCAN2NH Page 1

Skin Cancer - Basal cell epithelioma or squamous cell carcinoma. Skin Cancer does not include malignant melanoma or mycosis fungoides, which are not considered skin cancers under this Rider for the purpose of paying benefits.

WHAT WE WILL PAY This Rider adds the Category 3 Cancer coverage shown on the Schedule of Benefits of the Certificate to which this Rider is attached. Benefits for this Rider will be paid in accordance with the Benefit Provisions section in the Certificate. Cancer Screening Wellness Benefit - We will pay $50 per Calendar Year for each Covered Person when a charge is incurred for one of the following Cancer screening tests: mammogram, Pap smears, flexible sigmoidoscopy, PSA (prostate-specific antigen tests), chest x-rays, hemocult stool specimen, ultra sounds, CEA (blood test for colon cancer), CA 125 (blood test for ovarian cancer), biopsy, thermography, colonoscopy, serum protein electrophoresis, bone marrow testing, and blood screenings. These tests must be performed to determine whether Cancer exists in a Covered Person. This is a preventive benefit; diagnosis of Cancer is not required for this benefit to be payable. This benefit is limited to one payment per Calendar Year per Covered Person. Benefit payments will be made directly to You. Proof of Loss must be submitted to Us for each incurred expense.

WHAT WE WILL NOT PAY 1. We will only pay for loss as a direct result of Cancer, except for Cancer screening. Proof of Positive Diagnosis

must be submitted with each new claim. We will not pay for any disease or incapacity that has been caused, complicated, worsened, or affected by, or as a result of Cancer or its treatment.

2. We may reduce or deny a claim or void this Rider for loss incurred by a Covered Person during the first 2 years from the Effective Date of this Rider for any misstatements in the Application which would have materially affected Our acceptance of the risk.

3. With respect to the benefits offered by this Rider, the "Time Limit on Certain Defenses" provision of the Contract will apply from the Effective Date of this Rider.

Under no condition will We pay any benefits for losses or medical expenses incurred prior to the Effective Date of this Rider.

WHEN THIS RIDER ENDS

This Rider will terminate for any one of the following reasons which occurs first: 1. The Contract terminates; or 2. Failure to pay the renewal premium before the end of the Grace Period; or 3. Our receipt of the Policyholder's written request to terminate this Rider. Termination due to Item 3 will be on the next renewal date, after Our receipt of the written notice, or any later specified date, if the mode of premium payment is monthly. Otherwise, it will be on the date of Our receipt of such written notice, or any later date as indicated by the Policyholder. Any premium paid in advance of the termination date due to Item 3 will be refunded to the Insured. This Rider is signed for the Company at Our Home Office to take effect on the Effective Date of this Rider.

General Counsel and Secretary President

CRCAN2NH Page 2

TRANSAMERICA LIFE INSURANCE COMPANY Home Office: Cedar Rapids, IA 52499

Administrative Office: 1400 Centerview Drive, PO Box 8063, Little Rock, AR 72203-8063 (Hereinafter called "the Company," "We," "Us," or "Our")

CANCER SCREENING WELLNESS BENEFIT RIDER

This Rider is attached to and made part of the Contract, as defined below, as of the Effective Date. It is issued in consideration of any statements made in the Application and payment of any required initial premium. Except as shown in this Rider, the provisions of the Contract will prevail. While this Rider is in force, We will pay benefits described in the "What We Will Pay" section of this Rider.

DEFINITIONS

In addition to the definitions contained in the Contract, the following definitions apply to this Rider. Calendar Year - The period from January 1 through December 31 of the same year. Cancer - A disease evidenced by the presence of a malignancy characterized by the uncontrolled and abnormal growth and spread of malignant cells in any part of the body. This includes carcinoma, sarcoma, malignant melanoma, lymphoma, leukemia, Hodgkin's Disease or any malignant tumor. Contract - The Policy for Group Critical Illness Indemnity Insurance and any Certificate, if applicable, to which this Rider is attached. Effective Date - The Effective Date of the Contract or the date shown for this Rider if added to the Contract at a later date.

WHAT WE WILL PAY Cancer Screening Wellness Benefit - We will pay the amount shown on the Schedule of Benefits per Calendar Year for each Covered Person when a charge is incurred for one of the following Cancer screening tests: mammogram, Pap smears, flexible sigmoidoscopy, PSA (prostate-specific antigen tests), chest x-rays, hemocult stool specimen, ultra sounds, CEA (blood test for colon cancer), CA 125 (blood test for ovarian cancer), biopsy, thermography, colonoscopy, serum protein electrophoresis, bone marrow testing, and blood screenings. These tests must be performed to determine whether Cancer exists in a Covered Person. This is a preventive benefit; diagnosis of Cancer is not required for this benefit to be payable. This benefit is limited to one payment per Calendar Year per Covered Person. Benefit payments will be made directly to You. Proof of Loss must be submitted to Us for each incurred expense.

WHAT WE WILL NOT PAY 1. We will only pay this benefit once per Calendar Year for each Covered Person. Proof of the charges incurred

for the Cancer screening tests must be submitted with each new claim. 2. We may reduce or deny a claim or void this Rider for loss incurred by a Covered Person during the first 2 years

from the Effective Date of this Rider for any misstatements in the Application which would have materially affected Our acceptance of the risk.

3. With respect to the benefits offered by this Rider, the "Time Limit on Certain Defenses" provision of the Contract will apply from the Effective Date of this Rider.

Under no condition will We pay any benefits for losses or medical expenses incurred prior to the Effective Date of this Rider. CRWEL2NH Page 1

WHEN THIS RIDER ENDS

This Rider will terminate for any one of the following reasons which occurs first: 1. The Contract terminates; or 2. Failure to pay the renewal premium before the end of the Grace Period; or 3. Our receipt of the Policyholder's written request to terminate this Rider. Termination due to Item 3 will be on the next renewal date, after Our receipt of the written notice, or any later specified date, if the mode of premium payment is monthly. Otherwise, it will be on the date of Our receipt of such written notice, or any later date as indicated by the Policyholder. Any premium paid in advance of the termination date due to Item 3 will be refunded to the Insured.

This Rider is signed for the Company at Our Home Office to take effect on the Effective Date of this Rider.

General Counsel and Secretary President

CRWEL2NH Page 2

State of New Hampshire Voluntary Benefits – EBM Plan Administration VOLUNTARY SHORT TERM DISABILITY (VSTD)

• EBM has played multiple roles over the years, always at the direction and authorization of the STATE. o EBM coordinated the original ON SITE, ONE on ONE enrollment across the STATE, a three month

process. o EBM has coordinated ON SITE, GROUP MEETINGS across the STATE. EBM contacted all State

Vendors, including them in this process, culminating in 3 weeks of meetings. o EBM has coordinated the annual enrollment via our ENROLLMENT CENTER. o EBM has managed mass mailings when replacing products. o EBM produced 129 “STATE VENDOR Manual”, including brochures, contacts, protocols. o EBM, licensed agents and TPA, represents all the Voluntary carriers (Boston Mutual, Trustmark,

Transamerica). o Preparation for the annual Enrollment begins in May, is underway in earnest in August, and

spikes in October with the construction of the On Site calendar, culminating with On Site visits in for 3 weeks ending just before Thanksgiving. This gives each employee an opportunity to attend a meeting close to work or along their commute to work.

o Following Thanksgiving, Employees are given 2 weeks to enroll. o EBM collects applications, rendering the payroll deductions we transmit to BoA for payroll

deductions to hit the first paycheck of the new plan year. o EBM submits a file feed to Trustmark, in which New Hires, Changes and Terms are transmitted

monthly. CRITICAL ILLNESS (CI)

• EBM has played multiple roles over the years, always at the direction and authorization of the STATE. o EBM coordinated the original ON SITE, ONE on ONE enrollment across the STATE, a three month

process. o EBM has coordinated ON SITE, GROUP MEETINGS across the STATE. EBM contacted all State

Vendors, including them in this process, culminating in 3 weeks of meetings. o EBM has coordinated the annual enrollment via our ENROLLMENT CENTER. o EBM has managed mass mailings when replacing products. o EBM produced 129 “STATE VENDOR Manual”, including brochures, contacts, protocols. o EBM, licensed agents and TPA, represents all the Voluntary carriers (Boston Mutual, Trustmark,

Transamerica). o Preparation for the annual Enrollment begins in May, is underway in earnest in August, and

spikes in October with the construction of the On Site calendar, culminating with On Site visits in for 3 weeks ending just before Thanksgiving. This gives each employee an opportunity to attend a meeting close to work or along their commute to work.

o Following Thanksgiving, Employees are given 2 weeks to enroll. o Applications render the payroll deductions to be processed and transmitted to BoA for payroll

deductions to hit the first paycheck of the new plan year. o Changes are managed OnLine o Benefit IS PORTABLE o Undefined RATE LOCK as premiums are Insurance Commission approved.

EMPLOYEE ACCIDENT (EA)

• EBM has played multiple roles over the years, always at the direction and authorization of the STATE. o EBM coordinated the original ON SITE, ONE on ONE enrollment across the STATE, a three month

process. o EBM has coordinated ON SITE, GROUP MEETINGS across the STATE. EBM contacted all State

Vendors, including them in this process, culminating in 3 weeks of meetings. o EBM has coordinated the annual enrollment via our ENROLLMENT CENTER. o EBM has managed mass mailings when replacing products. o EBM produced 129 “STATE VENDOR Manual”, including brochures, contacts, protocols. o EBM, licensed agents and TPA, represents all the Voluntary carriers (Boston Mutual, Trustmark,

Transamerica). o Preparation for the annual Enrollment begins in May, is underway in earnest in August, and

spikes in October with the construction of the On Site calendar, culminating with On Site visits in for 3 weeks ending just before Thanksgiving. This gives each employee an opportunity to attend a meeting close to work or along their commute to work.

o Following Thanksgiving, Employees are given 2 weeks to enroll. o EBM collects applications, rendering the payroll deductions we transmit to BoA for payroll

deductions to hit the first paycheck of the new plan year. o Changes are managed ON LINE with carrier o Benefit IS PORTABLE o Undefined RATE LOCK as premiums are Insurance Commission approved.

Sample Bi-Weekly (26 Pay) Rates for $300 Weekly Benefit

Plan highlights• Pays weekly benefits if you are out of work due

to a non-occupational accident or sickness including pregnancy.

• Guaranteed issue for new hires – up to $1,000 weekly, providing you are actively at work.

• You choose the benefit amount that fits your needs and budget, up to 70 percent of your gross weekly income, $1,000 per week maximum.

• You choose your benefit plan: fifteenth-day coverage for injury or illness, 52-week benefit period; OR first-day coverage for injury, eighth-day coverage for illness, 26-week benefit period.

• Benefits are mailed on a weekly basis.

• Waives premium if you remain totally disabled for 30 days during the benefit period.

You count on your paycheck to provide the things

you need today and to achieve the dream you have

for tomorrow. But, what would

happen if it were suddenly

taken away because of

an unexpected injury

or illness?

Disability Income insurance replaces part of your paycheck when you are disabled1 and unable to work. It can help you meet financial obligations when you don’t have a paycheck coming in.

What’s more your disability insurance benefits are yours to use any way you want. Use them to help with:

• Rent or mortgage • Credit card and automobile payments • Child care and housekeeping • Medical insurance copays and deductible

1 As defined by policy/certificate.

Imagine life without a paycheck.

Age 0/07/26 14/14/52

30-34

35-39

40-44

45-49

50-54

55-59

$15.78

$15.78

$14.95

$17.17

$20.77

$25.48

$14.40

$14.40

$14.40

$16.62

$19.94

$24.09

Rates shown are for illustrative purposes only. Actual payroll deduction amounts may vary by plus or minus 3 cents. An application for insurance must be completed to obtain coverage.

Bottom line:

Disability Income insurance helps protect your

financial future by going to work when you can’t.

It’s that simple.

©2011 Trustmark Insurance Company, Lake Forest, IL P485-1042 (1-15)

LimitationsPre-existing condition limitation is a sickness or injury for which you received medical treatment, consultation, care or services including diagnostic measures, or had taken prescribed drugs or medicines in the 12 months immediately prior to your effective date. No benefits will be paid for any disability caused by or resulting from a pre-existing condition that begins in the first six months after your effective date.

Exclusions: No benefits are paid for disability that results from intentionally self-inflicted injury or attempted suicide, while sane or insane; or attempt to commit a felony; engaging in an illegal occupation; war or act of war, declared or undeclared; participation in a riot; riding in or driving any motor-driven vehicle in a race, stunt show or speed test; operating, learning to operate, serving as

a crew member of or jumping or falling from any aircraft; including those which are not motor driven. This does not include flying as fare-paying passenger; abuse of or addiction to alcohol or drugs whether legal or illegal; mental illness, however, Alzheimer’s disease and other organic senile dementias are covered; loss of professional license, occupational license, or certification, or having a work-related injury accident or sickness.

Claim forms can be requested by calling EBM at 888.269.2744. Claim checks, explanation of benefit statements, and any other correspondence in connection with a claim is mailed directly to your home address.

Plan VGD-404 is underwritten by Trustmark Insurance Company, Lake Forest, Illinois, 60045

Terms you need to knowTotal disability means you are unable, due to non-occupational sickness or injury, to do the substantial and material duties of your regular job and you are not doing any work for pay or benefits.

Partial disability means you are unable, due to non-occupational sickness or injury, to do the substantial and material duties of your regular job; you have a 20 percent loss in pre-disability earnings due to the same non-occupational sickness or injury; and you are not totally disabled.

Injury means accidental bodily injury, which is treated by a doctor within 30 consecutive days of the injury.

Sickness means illness, infection, disease, pregnancy or any other abnormal condition, not caused by an injury.

Non-occupational sickness or injury means a sickness or injury that did not result from a person’s work or occupation.

It’s your story. Help protect it with Short-Term Disability insurance.

100/44/0/0

0/0/0/100

0/0/0/0

100/68/0/31

100/65/30/70

60/20/5/10

®

®

®

®

®

® Learn more and enroll. Contact EBM at 888-269-2744 or for more information visit: http://admin.state.nh.us/hr/flexible_spending.html

Full-­‐time,  active  employees,  age  17-­‐70,  working  30+  hours  per  week,  employed  at  least  1  month  prior  to  application  date.

Age Age Age Age Age Age Age Age Age Age17-­‐25 25-­‐29 30-­‐34 35-­‐39 40-­‐44 45-­‐49 50-­‐54 55-­‐59 60-­‐64 65-­‐70$1.14 $1.14 $1.14 $1.14 $1.08 $1.24 $1.50 $1.84 $2.10 $2.76

Weekly Age Age Age Age Age Age Age Age Age AgeBenefit 17-­‐25 25-­‐29 30-­‐34 35-­‐39 40-­‐44 45-­‐49 50-­‐54 55-­‐59 60-­‐64 65-­‐70100 $5.26 $5.26 $5.26 $5.26 $4.98 $5.72 $6.92 $8.49 $9.69 $12.74110 $5.79 $5.79 $5.79 $5.79 $5.48 $6.30 $7.62 $9.34 $10.66 $14.01120 $6.31 $6.31 $6.31 $6.31 $5.98 $6.87 $8.31 $10.19 $11.63 $15.29130 $6.84 $6.84 $6.84 $6.84 $6.48 $7.44 $9.00 $11.04 $12.60 $16.56140 $7.37 $7.37 $7.37 $7.37 $6.98 $8.01 $9.69 $11.89 $13.57 $17.83150 $7.89 $7.89 $7.89 $7.89 $7.48 $8.58 $10.38 $12.74 $14.54 $19.11160 $8.42 $8.42 $8.42 $8.42 $7.98 $9.16 $11.08 $13.59 $15.51 $20.38170 $8.94 $8.94 $8.94 $8.94 $8.47 $9.73 $11.77 $14.44 $16.48 $21.66180 $9.47 $9.47 $9.47 $9.47 $8.97 $10.30 $12.46 $15.29 $17.45 $22.93190 $10.00 $10.00 $10.00 $10.00 $9.47 $10.87 $13.15 $16.14 $18.42 $24.20200 $10.52 $10.52 $10.52 $10.52 $9.97 $11.45 $13.85 $16.98 $19.38 $25.48210 $11.05 $11.05 $11.05 $11.05 $10.47 $12.02 $14.54 $17.83 $20.35 $26.75220 $11.58 $11.58 $11.58 $11.58 $10.97 $12.59 $15.23 $18.68 $21.32 $28.02230 $12.10 $12.10 $12.10 $12.10 $11.46 $13.16 $15.92 $19.53 $22.29 $29.30240 $12.63 $12.63 $12.63 $12.63 $11.96 $13.74 $16.62 $20.38 $23.26 $30.57250 $13.15 $13.15 $13.15 $13.15 $12.46 $14.31 $17.31 $21.23 $24.23 $31.85260 $13.68 $13.68 $13.68 $13.68 $12.96 $14.88 $18.00 $22.08 $25.20 $33.12270 $14.21 $14.21 $14.21 $14.21 $13.46 $15.45 $18.69 $22.93 $26.17 $34.39280 $14.73 $14.73 $14.73 $14.73 $13.96 $16.02 $19.38 $23.78 $27.14 $35.67290 $15.26 $15.26 $15.26 $15.26 $14.46 $16.60 $20.08 $24.63 $28.11 $36.94300 $15.78 $15.78 $15.78 $15.78 $14.95 $17.17 $20.77 $25.48 $29.08 $38.22310 $16.31 $16.31 $16.31 $16.31 $15.45 $17.74 $21.46 $26.33 $30.05 $39.49320 $16.84 $16.84 $16.84 $16.84 $15.95 $18.31 $22.15 $27.18 $31.02 $40.76330 $17.36 $17.36 $17.36 $17.36 $16.45 $18.89 $22.85 $28.02 $31.98 $42.04340 $17.89 $17.89 $17.89 $17.89 $16.95 $19.46 $23.54 $28.87 $32.95 $43.31350 $18.42 $18.42 $18.42 $18.42 $17.45 $20.03 $24.23 $29.72 $33.92 $44.58360 $18.94 $18.94 $18.94 $18.94 $17.94 $20.60 $24.92 $30.57 $34.89 $45.86370 $19.47 $19.47 $19.47 $19.47 $18.44 $21.18 $25.62 $31.42 $35.86 $47.13380 $19.99 $19.99 $19.99 $19.99 $18.94 $21.75 $26.31 $32.27 $36.83 $48.41390 $20.52 $20.52 $20.52 $20.52 $19.44 $22.32 $27.00 $33.12 $37.80 $49.68400 $21.05 $21.05 $21.05 $21.05 $19.94 $22.89 $27.69 $33.97 $38.77 $50.95410 $21.57 $21.57 $21.57 $21.57 $20.44 $23.46 $28.38 $34.82 $39.74 $52.23420 $22.10 $22.10 $22.10 $22.10 $20.94 $24.04 $29.08 $35.67 $40.71 $53.50430 $22.62 $22.62 $22.62 $22.62 $21.43 $24.61 $29.77 $36.52 $41.68 $54.78440 $23.15 $23.15 $23.15 $23.15 $21.93 $25.18 $30.46 $37.37 $42.65 $56.05

Bi-­‐Weekly  Cost

Monthly  Cost  per  $10  of  Weekly  Benefit

State  of  New  HampshireVOLUNTARY  SHORT  TERM  DISABILITY  0/7/26

Maximum  Weekly  Benefit  Amount$100  to  $1,000  per  week  up  to  70%  of  earnings

Plan  Design0  day  injury,  7  day  sickness,  26  week  benefit  period

Eligibility

Weekly Age Age Age Age Age Age Age Age Age AgeBenefit 17-­‐25 25-­‐29 30-­‐34 35-­‐39 40-­‐44 45-­‐49 50-­‐54 55-­‐59 60-­‐64 65-­‐70450 $23.68 $23.68 $23.68 $23.68 $22.43 $25.75 $31.15 $38.22 $43.62 $57.32460 $24.20 $24.20 $24.20 $24.20 $22.93 $26.33 $31.85 $39.06 $44.58 $58.60470 $24.73 $24.73 $24.73 $24.73 $23.43 $26.90 $32.54 $39.91 $45.55 $59.87480 $25.26 $25.26 $25.26 $25.26 $23.93 $27.47 $33.23 $40.76 $46.52 $61.14490 $25.78 $25.78 $25.78 $25.78 $24.42 $28.04 $33.92 $41.61 $47.49 $62.42500 $26.31 $26.31 $26.31 $26.31 $24.92 $28.62 $34.62 $42.46 $48.46 $63.69510 $26.83 $26.83 $26.83 $26.83 $25.42 $29.19 $35.31 $43.31 $49.43 $64.97520 $27.36 $27.36 $27.36 $27.36 $25.92 $29.76 $36.00 $44.16 $50.40 $66.24530 $27.89 $27.89 $27.89 $27.89 $26.42 $30.33 $36.69 $45.01 $51.37 $67.51540 $28.41 $28.41 $28.41 $28.41 $26.92 $30.90 $37.38 $45.86 $52.34 $68.79550 $28.94 $28.94 $28.94 $28.94 $27.42 $31.48 $38.08 $46.71 $53.31 $70.06560 $29.46 $29.46 $29.46 $29.46 $27.91 $32.05 $38.77 $47.56 $54.28 $71.34570 $29.99 $29.99 $29.99 $29.99 $28.41 $32.62 $39.46 $48.41 $55.25 $72.61580 $30.52 $30.52 $30.52 $30.52 $28.91 $33.19 $40.15 $49.26 $56.22 $73.88590 $31.04 $31.04 $31.04 $31.04 $29.41 $33.77 $40.85 $50.10 $57.18 $75.16600 $31.57 $31.57 $31.57 $31.57 $29.91 $34.34 $41.54 $50.95 $58.15 $76.43610 $32.10 $32.10 $32.10 $32.10 $30.41 $34.91 $42.23 $51.80 $59.12 $77.70620 $32.62 $32.62 $32.62 $32.62 $30.90 $35.48 $42.92 $52.65 $60.09 $78.98630 $33.15 $33.15 $33.15 $33.15 $31.40 $36.06 $43.62 $53.50 $61.06 $80.25640 $33.67 $33.67 $33.67 $33.67 $31.90 $36.63 $44.31 $54.35 $62.03 $81.53650 $34.20 $34.20 $34.20 $34.20 $32.40 $37.20 $45.00 $55.20 $63.00 $82.80660 $34.73 $34.73 $34.73 $34.73 $32.90 $37.77 $45.69 $56.05 $63.97 $84.07670 $35.25 $35.25 $35.25 $35.25 $33.40 $38.34 $46.38 $56.90 $64.94 $85.35680 $35.78 $35.78 $35.78 $35.78 $33.90 $38.92 $47.08 $57.75 $65.91 $86.62690 $36.30 $36.30 $36.30 $36.30 $34.39 $39.49 $47.77 $58.60 $66.88 $87.90700 $36.83 $36.83 $36.83 $36.83 $34.89 $40.06 $48.46 $59.45 $67.85 $89.17710 $37.36 $37.36 $37.36 $37.36 $35.39 $40.63 $49.15 $60.30 $68.82 $90.44720 $37.88 $37.88 $37.88 $37.88 $35.89 $41.21 $49.85 $61.14 $69.78 $91.72730 $38.41 $38.41 $38.41 $38.41 $36.39 $41.78 $50.54 $61.99 $70.75 $92.99740 $38.94 $38.94 $38.94 $38.94 $36.89 $42.35 $51.23 $62.84 $71.72 $94.26750 $39.46 $39.46 $39.46 $39.46 $37.38 $42.92 $51.92 $63.69 $72.69 $95.54760 $39.99 $39.99 $39.99 $39.99 $37.88 $43.50 $52.62 $64.54 $73.66 $96.81770 $40.51 $40.51 $40.51 $40.51 $38.38 $44.07 $53.31 $65.39 $74.63 $98.09780 $41.04 $41.04 $41.04 $41.04 $38.88 $44.64 $54.00 $66.24 $75.60 $99.36790 $41.57 $41.57 $41.57 $41.57 $39.38 $45.21 $54.69 $67.09 $76.57 $100.63800 $42.09 $42.09 $42.09 $42.09 $39.88 $45.78 $55.38 $67.94 $77.54 $101.91810 $42.62 $42.62 $42.62 $42.62 $40.38 $46.36 $56.08 $68.79 $78.51 $103.18820 $43.14 $43.14 $43.14 $43.14 $40.87 $46.93 $56.77 $69.64 $79.48 $104.46830 $43.67 $43.67 $43.67 $43.67 $41.37 $47.50 $57.46 $70.49 $80.45 $105.73840 $44.20 $44.20 $44.20 $44.20 $41.87 $48.07 $58.15 $71.34 $81.42 $107.00850 $44.72 $44.72 $44.72 $44.72 $42.37 $48.65 $58.85 $72.18 $82.38 $108.28860 $45.25 $45.25 $45.25 $45.25 $42.87 $49.22 $59.54 $73.03 $83.35 $109.55870 $45.78 $45.78 $45.78 $45.78 $43.37 $49.79 $60.23 $73.88 $84.32 $110.82880 $46.30 $46.30 $46.30 $46.30 $43.86 $50.36 $60.92 $74.73 $85.29 $112.10890 $46.83 $46.83 $46.83 $46.83 $44.36 $50.94 $61.62 $75.58 $86.26 $113.37900 $47.35 $47.35 $47.35 $47.35 $44.86 $51.51 $62.31 $76.43 $87.23 $114.65910 $47.88 $47.88 $47.88 $47.88 $45.36 $52.08 $63.00 $77.28 $88.20 $115.92920 $48.41 $48.41 $48.41 $48.41 $45.86 $52.65 $63.69 $78.13 $89.17 $117.19930 $48.93 $48.93 $48.93 $48.93 $46.36 $53.22 $64.38 $78.98 $90.14 $118.47940 $49.46 $49.46 $49.46 $49.46 $46.86 $53.80 $65.08 $79.83 $91.11 $119.74950 $49.98 $49.98 $49.98 $49.98 $47.35 $54.37 $65.77 $80.68 $92.08 $121.02960 $50.51 $50.51 $50.51 $50.51 $47.85 $54.94 $66.46 $81.53 $93.05 $122.29970 $51.04 $51.04 $51.04 $51.04 $48.35 $55.51 $67.15 $82.38 $94.02 $123.56980 $51.56 $51.56 $51.56 $51.56 $48.85 $56.09 $67.85 $83.22 $94.98 $124.84990 $52.09 $52.09 $52.09 $52.09 $49.35 $56.66 $68.54 $84.07 $95.95 $126.111000 $52.62 $52.62 $52.62 $52.62 $49.85 $57.23 $69.23 $84.92 $96.92 $127.38

Full-­‐time,  active  employees,  age  17-­‐70,  working  30+  hours  per  week,  employed  at  least  1  month  prior  to  application  date.

Age Age Age Age Age Age Age Age Age Age17-­‐25 25-­‐29 30-­‐34 35-­‐39 40-­‐44 45-­‐49 50-­‐54 55-­‐59 60-­‐64 65-­‐70$1.04 $1.04 $1.04 $1.04 $1.04 $1.20 $1.44 $1.74 $2.02 $2.64

Weekly Age Age Age Age Age Age Age Age Age AgeBenefit 17-­‐25 25-­‐29 30-­‐34 35-­‐39 40-­‐44 45-­‐49 50-­‐54 55-­‐59 60-­‐64 65-­‐70100 $4.80 $4.80 $4.80 $4.80 $4.80 $5.54 $6.65 $8.03 $9.32 $12.18110 $5.28 $5.28 $5.28 $5.28 $5.28 $6.09 $7.31 $8.83 $10.26 $13.40120 $5.76 $5.76 $5.76 $5.76 $5.76 $6.65 $7.98 $9.64 $11.19 $14.62130 $6.24 $6.24 $6.24 $6.24 $6.24 $7.20 $8.64 $10.44 $12.12 $15.84140 $6.72 $6.72 $6.72 $6.72 $6.72 $7.75 $9.30 $11.24 $13.05 $17.06150 $7.20 $7.20 $7.20 $7.20 $7.20 $8.31 $9.97 $12.05 $13.98 $18.28160 $7.68 $7.68 $7.68 $7.68 $7.68 $8.86 $10.63 $12.85 $14.92 $19.50170 $8.16 $8.16 $8.16 $8.16 $8.16 $9.42 $11.30 $13.65 $15.85 $20.71180 $8.64 $8.64 $8.64 $8.64 $8.64 $9.97 $11.96 $14.46 $16.78 $21.93190 $9.12 $9.12 $9.12 $9.12 $9.12 $10.52 $12.63 $15.26 $17.71 $23.15200 $9.60 $9.60 $9.60 $9.60 $9.60 $11.08 $13.29 $16.06 $18.65 $24.37210 $10.08 $10.08 $10.08 $10.08 $10.08 $11.63 $13.96 $16.86 $19.58 $25.59220 $10.56 $10.56 $10.56 $10.56 $10.56 $12.18 $14.62 $17.67 $20.51 $26.81230 $11.04 $11.04 $11.04 $11.04 $11.04 $12.74 $15.29 $18.47 $21.44 $28.02240 $11.52 $11.52 $11.52 $11.52 $11.52 $13.29 $15.95 $19.27 $22.38 $29.24250 $12.00 $12.00 $12.00 $12.00 $12.00 $13.85 $16.62 $20.08 $23.31 $30.46260 $12.48 $12.48 $12.48 $12.48 $12.48 $14.40 $17.28 $20.88 $24.24 $31.68270 $12.96 $12.96 $12.96 $12.96 $12.96 $14.95 $17.94 $21.68 $25.17 $32.90280 $13.44 $13.44 $13.44 $13.44 $13.44 $15.51 $18.61 $22.49 $26.10 $34.12290 $13.92 $13.92 $13.92 $13.92 $13.92 $16.06 $19.27 $23.29 $27.04 $35.34300 $14.40 $14.40 $14.40 $14.40 $14.40 $16.62 $19.94 $24.09 $27.97 $36.55310 $14.88 $14.88 $14.88 $14.88 $14.88 $17.17 $20.60 $24.90 $28.90 $37.77320 $15.36 $15.36 $15.36 $15.36 $15.36 $17.72 $21.27 $25.70 $29.83 $38.99330 $15.84 $15.84 $15.84 $15.84 $15.84 $18.28 $21.93 $26.50 $30.77 $40.21340 $16.32 $16.32 $16.32 $16.32 $16.32 $18.83 $22.60 $27.30 $31.70 $41.43350 $16.80 $16.80 $16.80 $16.80 $16.80 $19.38 $23.26 $28.11 $32.63 $42.65360 $17.28 $17.28 $17.28 $17.28 $17.28 $19.94 $23.93 $28.91 $33.56 $43.86370 $17.76 $17.76 $17.76 $17.76 $17.76 $20.49 $24.59 $29.71 $34.50 $45.08380 $18.24 $18.24 $18.24 $18.24 $18.24 $21.05 $25.26 $30.52 $35.43 $46.30390 $18.72 $18.72 $18.72 $18.72 $18.72 $21.60 $25.92 $31.32 $36.36 $47.52400 $19.20 $19.20 $19.20 $19.20 $19.20 $22.15 $26.58 $32.12 $37.29 $48.74410 $19.68 $19.68 $19.68 $19.68 $19.68 $22.71 $27.25 $32.93 $38.22 $49.96420 $20.16 $20.16 $20.16 $20.16 $20.16 $23.26 $27.91 $33.73 $39.16 $51.18430 $20.64 $20.64 $20.64 $20.64 $20.64 $23.82 $28.58 $34.53 $40.09 $52.39440 $21.12 $21.12 $21.12 $21.12 $21.12 $24.37 $29.24 $35.34 $41.02 $53.61

State  of  New  HampshireVOLUNTARY  SHORT  TERM  DISABILITY  14/14/52

Monthly  Cost  per  $10  of  Weekly  Benefit

Bi-­‐Weekly  Cost

$100  to  $1,000  per  week  up  to  70%  of  earningsMaximum  Weekly  Benefit  Amount

Plan  Design14  day  injury,  14  day  sickness,  52  week  benefit  period

Eligibility

Weekly Age Age Age Age Age Age Age Age Age AgeBenefit 17-­‐25 25-­‐29 30-­‐34 35-­‐39 40-­‐44 45-­‐49 50-­‐54 55-­‐59 60-­‐64 65-­‐70450 $21.60 $21.60 $21.60 $21.60 $21.60 $24.92 $29.91 $36.14 $41.95 $54.83460 $22.08 $22.08 $22.08 $22.08 $22.08 $25.48 $30.57 $36.94 $42.89 $56.05470 $22.56 $22.56 $22.56 $22.56 $22.56 $26.03 $31.24 $37.74 $43.82 $57.27480 $23.04 $23.04 $23.04 $23.04 $23.04 $26.58 $31.90 $38.55 $44.75 $58.49490 $23.52 $23.52 $23.52 $23.52 $23.52 $27.14 $32.57 $39.35 $45.68 $59.70500 $24.00 $24.00 $24.00 $24.00 $24.00 $27.69 $33.23 $40.15 $46.62 $60.92510 $24.48 $24.48 $24.48 $24.48 $24.48 $28.25 $33.90 $40.96 $47.55 $62.14520 $24.96 $24.96 $24.96 $24.96 $24.96 $28.80 $34.56 $41.76 $48.48 $63.36530 $25.44 $25.44 $25.44 $25.44 $25.44 $29.35 $35.22 $42.56 $49.41 $64.58540 $25.92 $25.92 $25.92 $25.92 $25.92 $29.91 $35.89 $43.37 $50.34 $65.80550 $26.40 $26.40 $26.40 $26.40 $26.40 $30.46 $36.55 $44.17 $51.28 $67.02560 $26.88 $26.88 $26.88 $26.88 $26.88 $31.02 $37.22 $44.97 $52.21 $68.23570 $27.36 $27.36 $27.36 $27.36 $27.36 $31.57 $37.88 $45.78 $53.14 $69.45580 $27.84 $27.84 $27.84 $27.84 $27.84 $32.12 $38.55 $46.58 $54.07 $70.67590 $28.32 $28.32 $28.32 $28.32 $28.32 $32.68 $39.21 $47.38 $55.01 $71.89600 $28.80 $28.80 $28.80 $28.80 $28.80 $33.23 $39.88 $48.18 $55.94 $73.11610 $29.28 $29.28 $29.28 $29.28 $29.28 $33.78 $40.54 $48.99 $56.87 $74.33620 $29.76 $29.76 $29.76 $29.76 $29.76 $34.34 $41.21 $49.79 $57.80 $75.54630 $30.24 $30.24 $30.24 $30.24 $30.24 $34.89 $41.87 $50.59 $58.74 $76.76640 $30.72 $30.72 $30.72 $30.72 $30.72 $35.45 $42.54 $51.40 $59.67 $77.98650 $31.20 $31.20 $31.20 $31.20 $31.20 $36.00 $43.20 $52.20 $60.60 $79.20660 $31.68 $31.68 $31.68 $31.68 $31.68 $36.55 $43.86 $53.00 $61.53 $80.42670 $32.16 $32.16 $32.16 $32.16 $32.16 $37.11 $44.53 $53.81 $62.46 $81.64680 $32.64 $32.64 $32.64 $32.64 $32.64 $37.66 $45.19 $54.61 $63.40 $82.86690 $33.12 $33.12 $33.12 $33.12 $33.12 $38.22 $45.86 $55.41 $64.33 $84.07700 $33.60 $33.60 $33.60 $33.60 $33.60 $38.77 $46.52 $56.22 $65.26 $85.29710 $34.08 $34.08 $34.08 $34.08 $34.08 $39.32 $47.19 $57.02 $66.19 $86.51720 $34.56 $34.56 $34.56 $34.56 $34.56 $39.88 $47.85 $57.82 $67.13 $87.73730 $35.04 $35.04 $35.04 $35.04 $35.04 $40.43 $48.52 $58.62 $68.06 $88.95740 $35.52 $35.52 $35.52 $35.52 $35.52 $40.98 $49.18 $59.43 $68.99 $90.17750 $36.00 $36.00 $36.00 $36.00 $36.00 $41.54 $49.85 $60.23 $69.92 $91.38760 $36.48 $36.48 $36.48 $36.48 $36.48 $42.09 $50.51 $61.03 $70.86 $92.60770 $36.96 $36.96 $36.96 $36.96 $36.96 $42.65 $51.18 $61.84 $71.79 $93.82780 $37.44 $37.44 $37.44 $37.44 $37.44 $43.20 $51.84 $62.64 $72.72 $95.04790 $37.92 $37.92 $37.92 $37.92 $37.92 $43.75 $52.50 $63.44 $73.65 $96.26800 $38.40 $38.40 $38.40 $38.40 $38.40 $44.31 $53.17 $64.25 $74.58 $97.48810 $38.88 $38.88 $38.88 $38.88 $38.88 $44.86 $53.83 $65.05 $75.52 $98.70820 $39.36 $39.36 $39.36 $39.36 $39.36 $45.42 $54.50 $65.85 $76.45 $99.91830 $39.84 $39.84 $39.84 $39.84 $39.84 $45.97 $55.16 $66.66 $77.38 $101.13840 $40.32 $40.32 $40.32 $40.32 $40.32 $46.52 $55.83 $67.46 $78.31 $102.35850 $40.80 $40.80 $40.80 $40.80 $40.80 $47.08 $56.49 $68.26 $79.25 $103.57860 $41.28 $41.28 $41.28 $41.28 $41.28 $47.63 $57.16 $69.06 $80.18 $104.79870 $41.76 $41.76 $41.76 $41.76 $41.76 $48.18 $57.82 $69.87 $81.11 $106.01880 $42.24 $42.24 $42.24 $42.24 $42.24 $48.74 $58.49 $70.67 $82.04 $107.22890 $42.72 $42.72 $42.72 $42.72 $42.72 $49.29 $59.15 $71.47 $82.98 $108.44900 $43.20 $43.20 $43.20 $43.20 $43.20 $49.85 $59.82 $72.28 $83.91 $109.66910 $43.68 $43.68 $43.68 $43.68 $43.68 $50.40 $60.48 $73.08 $84.84 $110.88920 $44.16 $44.16 $44.16 $44.16 $44.16 $50.95 $61.14 $73.88 $85.77 $112.10930 $44.64 $44.64 $44.64 $44.64 $44.64 $51.51 $61.81 $74.69 $86.70 $113.32940 $45.12 $45.12 $45.12 $45.12 $45.12 $52.06 $62.47 $75.49 $87.64 $114.54950 $45.60 $45.60 $45.60 $45.60 $45.60 $52.62 $63.14 $76.29 $88.57 $115.75960 $46.08 $46.08 $46.08 $46.08 $46.08 $53.17 $63.80 $77.10 $89.50 $116.97970 $46.56 $46.56 $46.56 $46.56 $46.56 $53.72 $64.47 $77.90 $90.43 $118.19980 $47.04 $47.04 $47.04 $47.04 $47.04 $54.28 $65.13 $78.70 $91.37 $119.41990 $47.52 $47.52 $47.52 $47.52 $47.52 $54.83 $65.80 $79.50 $92.30 $120.631000 $48.00 $48.00 $48.00 $48.00 $48.00 $55.38 $66.46 $80.31 $93.23 $121.85

Sample Bi-Weekly Rates for $300 Weekly Benefit

Plan highlights• Pays weekly benefits if you are out of work due

to a non-occupational accidents or sickness including pregnancy.

• Guaranteed acceptance – up to $1,000 weekly, providing you are actively at work.

• You choose the benefit amount that fits your needs and budget, up to 70 percent of your gross weekly income, $1,000 per week maximum.

• You choose your benefit plan: fifteenth-day coverage for injury or illness, 52-week benefit period; OR first-day coverage for injury, eighth-day coverage for illness, 26-week benefit period.

• Benefits are mailed on a weekly basis.

• Waives premium if you remain totally disabled for 30 days during the benefit period.

You count on your paycheck to provide the things

you need today and to achieve the dream you have

for tomorrow. But, what would

happen if it were suddenly

taken away because of

an unexpected injury

or illness?

Disability Income insurance replaces part of your paycheck when you are disabled1 and unable to work. It can help you meet financial obligations when you don’t have a paycheck coming in.

What’s more your disability insurance benefits are yours to use any way you want. Use them to help with:

• Rent or mortgage • Credit card and automobile payments • Child care and housekeeping • Medical insurance copays and deductible

1 As defined by policy/certificate.

Imagine life without a paycheck.

Age 0/07/26 14/14/52

30-34

35-39

40-44

45-49

50-54

55-59

$11.91

$11.91

$11.22

$13.02

$15.65

$19.25

$10.94

$10.94

$10.80

$12.46

$15.09

$18.14

Rates shown are for illustrative purposes only. Actual payroll deduction amounts may vary by plus or minus 3 cents. An application for insurance must be completed to obtain coverage.

Bottom line:

Disability Income insurance helps protect your financial future by going to work when you can’t. It’s that simple.

©2011 Trustmark Insurance Company, Lake Forest, IL P485-1042 (9-12)

LimitationsPre-existing condition limitation is a sickness or injury for which you received medical treatment, consultation, care or services including diagnostic measures, or had taken prescribed drugs or medicines in the 12 months immediately prior to your effective date. No benefits will be paid for any disability caused by or resulting from a pre-existing condition that begins in the first six months after your effective date.

Exclusions: No benefits are paid for disability that results from intentionally self-inflicted injury or attempted suicide, while sane or insane; or attempt to commit a felony; engaging in an illegal occupation; war or act of war, declared or undeclared; participation in a riot; riding in or driving any motor-driven vehicle in a race, stunt show or speed test; operating, learning to operate, serving as

a crew member of or jumping or falling from any aircraft; including those which are not motor driven. This does not include flying as fare-paying passenger; abuse of or addiction to alcohol or drugs whether legal or illegal; mental illness, however, Alzheimer’s disease and other organic senile dementias are covered; loss of professional license, occupational license, or certification, or having a work related injury accident or sickness.

Claim forms can be requested by calling EBM at 888.269.2744. Claim checks, explanation of benefit statements, and any other correspondence in connection with a claim is mailed directly to your home address.

Plan VGD-404 is underwritten by Trustmark Insurance Company, Lake Forest, Illinois, 60045

Terms you need to knowTotal disability means you are unable, due to non-occupational sickness or injury, to do the substantial and material duties of your regular job and you are not doing any work for pay or benefits.

Partial disability means you are unable, due to non-occupational sickness or injury, to do the substantial and material duties of your regular job; you have a 20 percent loss in pre-disability earnings due to the same non-occupational sickness or injury; and you are not totally disabled.

Injury means accidental bodily injury, which is treated by a doctor within 30 consecutive days of the injury.

Sickness means illness, infection, disease, pregnancy or any other abnormal condition, not caused by an injury.

Non-occupational sickness or injury means a sickness or injury that did not result from a person’s work or occupation.

It’s your story. Help protect it with Short-Term Disability insurance.

100/44/0/0

0/0/0/100

0/0/0/0

100/68/0/31

100/65/30/70

60/20/5/10

®

®

®

®

®

® Learn more and enroll. Contact EBM at 888-269-2744 or for more information visit: http://admin.state.nh.us/hr/flexible_spending.html

State of New Hampshire VOLUNTARY SHORT TERM DISABILITY 0/7/26

Maximum Weekly Benefit Amount $100 to $1,000 per week up to 70% of earnings

 Plan Design 

0 day injury, 7 day sickness, 26 week benefit period  

Eligibility Full‐time, active employees, age 17‐70, working 30+ hours per week, employed at least 1 month prior to application date.

Monthly Cost per $10 of Weekly Benefit 

  

 

  

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Age  Age   Age   Age   Age  Age  Age  Age   Age  Age 

17‐25  25‐29   30‐34   35‐39   40‐44  45‐49  50‐54  55‐59   60‐64  65‐70 

$0.86  $0.86   $0.86   $0.86   $0.81  $0.94  $1.13  $1.39   $1.58  $2.08 

Weekly  Age  Age  Age  Age Age Age Age Age  Age Age

Benefit  17‐25  25‐29  30‐34  35‐39 40‐44 45‐49 50‐54 55‐59  60‐64 65‐70

100  $3.97  $3.97  $3.97  $3.97 $3.74 $4.34 $5.22 $6.42  $7.29 $9.60

110  $4.37  $4.37  $4.37  $4.37 $4.11 $4.77 $5.74 $7.06  $8.02 $10.56

120  $4.76  $4.76  $4.76  $4.76 $4.49 $5.21 $6.26 $7.70  $8.75 $11.52

130  $5.16  $5.16  $5.16  $5.16 $4.86 $5.64 $6.78 $8.34  $9.48 $12.48

140  $5.56  $5.56  $5.56  $5.56 $5.23 $6.07 $7.30 $8.98  $10.21 $13.44

150  $5.95  $5.95  $5.95  $5.95 $5.61 $6.51 $7.82 $9.62  $10.94 $14.40

160  $6.35  $6.35  $6.35  $6.35 $5.98 $6.94 $8.34 $10.26  $11.67 $15.36

170  $6.75  $6.75  $6.75  $6.75 $6.36 $7.38 $8.87 $10.91  $12.40 $16.32

180  $7.14  $7.14  $7.14  $7.14 $6.73 $7.81 $9.39 $11.55  $13.13 $17.28

190  $7.54  $7.54  $7.54  $7.54 $7.10 $8.24 $9.91 $12.19  $13.86 $18.24

200  $7.94  $7.94  $7.94  $7.94 $7.48 $8.68 $10.43 $12.83  $14.58 $19.20

210  $8.34  $8.34  $8.34  $8.34 $7.85 $9.11 $10.95 $13.47  $15.31 $20.16

220  $8.73  $8.73  $8.73  $8.73 $8.22 $9.54 $11.47 $14.11  $16.04 $21.12

230  $9.13  $9.13  $9.13  $9.13 $8.60 $9.98 $12.00 $14.76  $16.77 $22.08

240  $9.53  $9.53  $9.53  $9.53 $8.97 $10.41 $12.52 $15.40  $17.50 $23.04

250  $9.92  $9.92  $9.92  $9.92 $9.35 $10.85 $13.04 $16.04  $18.23 $24.00

260  $10.32  $10.32  $10.32  $10.32 $9.72 $11.28 $13.56 $16.68  $18.96 $24.96

270  $10.72  $10.72  $10.72  $10.72 $10.09 $11.71 $14.08 $17.32  $19.69 $25.92

280  $11.11  $11.11  $11.11  $11.11 $10.47 $12.15 $14.60 $17.96  $20.42 $26.88

290  $11.51  $11.51  $11.51  $11.51 $10.84 $12.58 $15.12 $18.60  $21.15 $27.84

300  $11.91  $11.91  $11.91  $11.91 $11.22 $13.02 $15.65 $19.25  $21.88 $28.80

310  $12.30  $12.30  $12.30  $12.30 $11.59 $13.45 $16.17 $19.89  $22.61 $29.76

320  $12.70  $12.70  $12.70  $12.70 $11.96 $13.88 $16.69 $20.53  $23.34 $30.72

330  $13.10  $13.10  $13.10  $13.10 $12.34 $14.32 $17.21 $21.17  $24.06 $31.68

340  $13.50  $13.50  $13.50  $13.50 $12.71 $14.75 $17.73 $21.81  $24.79 $32.64

350  $13.89  $13.89  $13.89  $13.89 $13.08 $15.18 $18.25 $22.45  $25.52 $33.60

360  $14.29  $14.29  $14.29  $14.29 $13.46 $15.62 $18.78 $23.10  $26.25 $34.56

370  $14.69  $14.69  $14.69  $14.69 $13.83 $16.05 $19.30 $23.74  $26.98 $35.52

380  $15.08  $15.08  $15.08  $15.08 $14.21 $16.49 $19.82 $24.38  $27.71 $36.48

390  $15.48  $15.48  $15.48  $15.48 $14.58 $16.92 $20.34 $25.02  $28.44 $37.44

400  $15.88  $15.88  $15.88  $15.88 $14.95 $17.35 $20.86 $25.66  $29.17 $38.40

410  $16.27  $16.27  $16.27  $16.27 $15.33 $17.79 $21.38 $26.30  $29.90 $39.36

420  $16.67  $16.67  $16.67  $16.67 $15.70 $18.22 $21.90 $26.94  $30.63 $40.32

430  $17.07  $17.07  $17.07  $17.07 $16.08 $18.66 $22.43 $27.59  $31.36 $41.28

440  $17.46  $17.46  $17.46  $17.46 $16.45 $19.09 $22.95 $28.23  $32.09 $42.24

Bi‐Weekly Cost 

 

  

Weekly  Age  Age  Age  Age Age Age Age Age  Age  Age

Benefit  17‐25  25‐29  30‐34  35‐39 40‐44 45‐49 50‐54 55‐59  60‐64  65‐70

450  $17.86  $17.86 $17.86  $17.86 $16.82 $19.52 $23.47 $28.87  $32.82  $43.20

460  $18.26  $18.26 $18.26  $18.26 $17.20 $19.96 $23.99 $29.51  $33.54  $44.16

470  $18.66  $18.66 $18.66  $18.66 $17.57 $20.39 $24.51 $30.15  $34.27  $45.12

480  $19.05  $19.05 $19.05  $19.05 $17.94 $20.82 $25.03 $30.79  $35.00  $46.08

490  $19.45  $19.45 $19.45  $19.45 $18.32 $21.26 $25.56 $31.44  $35.73  $47.04

500  $19.85  $19.85 $19.85  $19.85 $18.69 $21.69 $26.08 $32.08  $36.46  $48.00

510  $20.24  $20.24 $20.24  $20.24 $19.07 $22.13 $26.60 $32.72  $37.19  $48.96

520  $20.64  $20.64 $20.64  $20.64 $19.44 $22.56 $27.12 $33.36  $37.92  $49.92

530  $21.04  $21.04 $21.04  $21.04 $19.81 $22.99 $27.64 $34.00  $38.65  $50.88

540  $21.43  $21.43 $21.43  $21.43 $20.19 $23.43 $28.16 $34.64  $39.38  $51.84

550  $21.83  $21.83 $21.83  $21.83 $20.56 $23.86 $28.68 $35.28  $40.11  $52.80

560  $22.23  $22.23 $22.23  $22.23 $20.94 $24.30 $29.21 $35.93  $40.84  $53.76

570  $22.62  $22.62 $22.62  $22.62 $21.31 $24.73 $29.73 $36.57  $41.57  $54.72

580  $23.02  $23.02 $23.02  $23.02 $21.68 $25.16 $30.25 $37.21  $42.30  $55.68

590  $23.42  $23.42 $23.42  $23.42 $22.06 $25.60 $30.77 $37.85  $43.02  $56.64

600  $23.82  $23.82 $23.82  $23.82 $22.43 $26.03 $31.29 $38.49  $43.75  $57.60

610  $24.21  $24.21 $24.21  $24.21 $22.80 $26.46 $31.81 $39.13  $44.48  $58.56

620  $24.61  $24.61 $24.61  $24.61 $23.18 $26.90 $32.34 $39.78  $45.21  $59.52

630  $25.01  $25.01 $25.01  $25.01 $23.55 $27.33 $32.86 $40.42  $45.94  $60.48

640  $25.40  $25.40 $25.40  $25.40 $23.93 $27.77 $33.38 $41.06  $46.67  $61.44

650  $25.80  $25.80 $25.80  $25.80 $24.30 $28.20 $33.90 $41.70  $47.40  $62.40

660  $26.20  $26.20 $26.20  $26.20 $24.67 $28.63 $34.42 $42.34  $48.13  $63.36

670  $26.59  $26.59 $26.59  $26.59 $25.05 $29.07 $34.94 $42.98  $48.86  $64.32

680  $26.99  $26.99 $26.99  $26.99 $25.42 $29.50 $35.46 $43.62  $49.59  $65.28

690  $27.39  $27.39 $27.39  $27.39 $25.80 $29.94 $35.99 $44.27  $50.32  $66.24

700  $27.78  $27.78 $27.78  $27.78 $26.17 $30.37 $36.51 $44.91  $51.05  $67.20

710  $28.18  $28.18 $28.18  $28.18 $26.54 $30.80 $37.03 $45.55  $51.78  $68.16

720  $28.58  $28.58 $28.58  $28.58 $26.92 $31.24 $37.55 $46.19  $52.50  $69.12

730  $28.98  $28.98 $28.98  $28.98 $27.29 $31.67 $38.07 $46.83  $53.23  $70.08

740  $29.37  $29.37 $29.37  $29.37 $27.66 $32.10 $38.59 $47.47  $53.96  $71.04

750  $29.77  $29.77 $29.77  $29.77 $28.04 $32.54 $39.12 $48.12  $54.69  $72.00

760  $30.17  $30.17 $30.17  $30.17 $28.41 $32.97 $39.64 $48.76  $55.42  $72.96

770  $30.56  $30.56 $30.56  $30.56 $28.79 $33.41 $40.16 $49.40  $56.15  $73.92

780  $30.96  $30.96 $30.96  $30.96 $29.16 $33.84 $40.68 $50.04  $56.88  $74.88

790  $31.36  $31.36 $31.36  $31.36 $29.53 $34.27 $41.20 $50.68  $57.61  $75.84

800  $31.75  $31.75 $31.75  $31.75 $29.91 $34.71 $41.72 $51.32  $58.34  $76.80

810  $32.15  $32.15 $32.15  $32.15 $30.28 $35.14 $42.24 $51.96  $59.07  $77.76

820  $32.55  $32.55 $32.55  $32.55 $30.66 $35.58 $42.77 $52.61  $59.80  $78.72

830  $32.94  $32.94 $32.94  $32.94 $31.03 $36.01 $43.29 $53.25  $60.53  $79.68

840  $33.34  $33.34 $33.34  $33.34 $31.40 $36.44 $43.81 $53.89  $61.26  $80.64

850  $33.74  $33.74 $33.74  $33.74 $31.78 $36.88 $44.33 $54.53  $61.98  $81.60

860  $34.14  $34.14 $34.14  $34.14 $32.15 $37.31 $44.85 $55.17  $62.71  $82.56

870  $34.53  $34.53 $34.53  $34.53 $32.52 $37.74 $45.37 $55.81  $63.44  $83.52

880  $34.93  $34.93 $34.93  $34.93 $32.90 $38.18 $45.90 $56.46  $64.17  $84.48

890  $35.33  $35.33 $35.33  $35.33 $33.27 $38.61 $46.42 $57.10  $64.90  $85.44

900  $35.72  $35.72 $35.72  $35.72 $33.65 $39.05 $46.94 $57.74  $65.63  $86.40

910  $36.12  $36.12 $36.12  $36.12 $34.02 $39.48 $47.46 $58.38  $66.36  $87.36

920  $36.52  $36.52 $36.52  $36.52 $34.39 $39.91 $47.98 $59.02  $67.09  $88.32

930  $36.91  $36.91 $36.91  $36.91 $34.77 $40.35 $48.50 $59.66  $67.82  $89.28

940  $37.31  $37.31 $37.31  $37.31 $35.14 $40.78 $49.02 $60.30  $68.55  $90.24

950  $37.71  $37.71 $37.71  $37.71 $35.52 $41.22 $49.55 $60.95  $69.28  $91.20

960  $38.10  $38.10 $38.10  $38.10 $35.89 $41.65 $50.07 $61.59  $70.01  $92.16

970  $38.50  $38.50 $38.50  $38.50 $36.26 $42.08 $50.59 $62.23  $70.74  $93.12

980  $38.90  $38.90 $38.90  $38.90 $36.64 $42.52 $51.11 $62.87  $71.46  $94.08

990  $39.30  $39.30 $39.30  $39.30 $37.01 $42.95 $51.63 $63.51  $72.19  $95.04

1000  $39.69  $39.69 $39.69  $39.69 $37.38 $43.38 $52.15 $64.15  $72.92  $96.00

 

State of New Hampshire VOLUNTARY SHORT TERM DISABILITY 14/14/52

Maximum Weekly Benefit Amount $100 to $1,000 per week up to 70% of earnings

 Plan Design 

14 day injury, 14 day sickness, 52 week benefit period  

Eligibility Full‐time, active employees, age 17‐70, working 30+ hours per week, employed at least 1 month prior to application date.

Monthly Cost per $10 of Weekly Benefit 

  

 

 

   

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bi‐Weekly Cost 

Age   Age   Age   Age  Age  Age  Age  Age  Age   Age 

17‐25   25‐29   30‐34   35‐39  40‐44  45‐49  50‐54  55‐59  60‐64   65‐70 

$0.79   $0.79   $0.79   $0.79  $0.78  $0.90  $1.09  $1.31  $1.53   $2.00 

Weekly   Age   Age   Age   Age  Age  Age  Age  Age   Age  Age 

Benefit   17‐25   25‐29  30‐34   35‐39  40‐44  45‐49  50‐54  55‐59   60‐64  65‐70 

100   $3.65   $3.65   $3.65   $3.65  $3.60  $4.15  $5.03  $6.05   $7.06  $9.23 

110   $4.01   $4.01   $4.01   $4.01  $3.96  $4.57  $5.53  $6.65   $7.77  $10.15 

120   $4.38   $4.38   $4.38   $4.38  $4.32  $4.98  $6.04  $7.26   $8.47  $11.08 

130   $4.74   $4.74   $4.74   $4.74  $4.68  $5.40  $6.54  $7.86   $9.18  $12.00 

140   $5.10   $5.10   $5.10   $5.10  $5.04  $5.82  $7.04  $8.46   $9.89  $12.92 

150   $5.47   $5.47   $5.47   $5.47  $5.40  $6.23  $7.55  $9.07   $10.59  $13.85 

160   $5.83   $5.83   $5.83   $5.83  $5.76  $6.65  $8.05  $9.67   $11.30  $14.77 

170   $6.20   $6.20   $6.20   $6.20  $6.12  $7.06  $8.55  $10.28   $12.00  $15.69 

180   $6.56   $6.56   $6.56   $6.56  $6.48  $7.48  $9.06  $10.88   $12.71  $16.62 

190   $6.93   $6.93   $6.93   $6.93  $6.84  $7.89  $9.56  $11.49   $13.42  $17.54 

200   $7.29   $7.29   $7.29   $7.29  $7.20  $8.31  $10.06  $12.09   $14.12  $18.46 

210   $7.66   $7.66   $7.66   $7.66  $7.56  $8.72  $10.56  $12.70   $14.83  $19.38 

220   $8.02   $8.02   $8.02   $8.02  $7.92  $9.14  $11.07  $13.30   $15.54  $20.31 

230   $8.39   $8.39   $8.39   $8.39  $8.28  $9.55  $11.57  $13.91   $16.24  $21.23 

240   $8.75   $8.75   $8.75   $8.75  $8.64  $9.97  $12.07  $14.51   $16.95  $22.15 

250   $9.12   $9.12   $9.12   $9.12  $9.00  $10.38  $12.58  $15.12   $17.65  $23.08 

260   $9.48   $9.48   $9.48   $9.48  $9.36  $10.80  $13.08  $15.72   $18.36  $24.00 

270   $9.84   $9.84   $9.84   $9.84  $9.72  $11.22  $13.58  $16.32   $19.07  $24.92 

280   $10.21   $10.21   $10.21   $10.21  $10.08  $11.63  $14.09  $16.93   $19.77  $25.85 

290   $10.57   $10.57   $10.57   $10.57  $10.44  $12.05  $14.59  $17.53   $20.48  $26.77 

300   $10.94   $10.94   $10.94   $10.94  $10.80  $12.46  $15.09  $18.14   $21.18  $27.69 

310   $11.30   $11.30   $11.30   $11.30  $11.16  $12.88  $15.60  $18.74   $21.89  $28.62 

320   $11.67   $11.67   $11.67   $11.67  $11.52  $13.29  $16.10  $19.35   $22.60  $29.54 

330   $12.03   $12.03   $12.03   $12.03  $11.88  $13.71  $16.60  $19.95   $23.30  $30.46 

340   $12.40   $12.40   $12.40   $12.40  $12.24  $14.12  $17.10  $20.56   $24.01  $31.38 

350   $12.76   $12.76   $12.76   $12.76  $12.60  $14.54  $17.61  $21.16   $24.72  $32.31 

360   $13.13   $13.13   $13.13   $13.13  $12.96  $14.95  $18.11  $21.77   $25.42  $33.23 

370   $13.49   $13.49   $13.49   $13.49  $13.32  $15.37  $18.61  $22.37   $26.13  $34.15 

380   $13.86   $13.86   $13.86   $13.86  $13.68  $15.78  $19.12  $22.98   $26.83  $35.08 

390   $14.22   $14.22   $14.22   $14.22  $14.04  $16.20  $19.62  $23.58   $27.54  $36.00 

400   $14.58   $14.58   $14.58   $14.58  $14.40  $16.62  $20.12  $24.18   $28.25  $36.92 

410   $14.95   $14.95   $14.95   $14.95  $14.76  $17.03  $20.63  $24.79   $28.95  $37.85 

420   $15.31   $15.31   $15.31   $15.31  $15.12  $17.45  $21.13  $25.39   $29.66  $38.77 

430   $15.68   $15.68   $15.68   $15.68  $15.48  $17.86  $21.63  $26.00   $30.36  $39.69 

440   $16.04   $16.04   $16.04   $16.04  $15.84  $18.28  $22.14  $26.60   $31.07  $40.62 

  

 

Weekly   Age   Age   Age   Age  Age  Age  Age  Age   Age  Age 

Benefit   17‐25   25‐29  30‐34   35‐39  40‐44  45‐49  50‐54  55‐59   60‐64  65‐70 

450   $16.41   $16.41   $16.41   $16.41  $16.20  $18.69  $22.64  $27.21   $31.78  $41.54 

460   $16.77   $16.77   $16.77   $16.77  $16.56  $19.11  $23.14  $27.81   $32.48  $42.46 

470   $17.14   $17.14   $17.14   $17.14  $16.92  $19.52  $23.64  $28.42   $33.19  $43.38 

480   $17.50   $17.50   $17.50   $17.50  $17.28  $19.94  $24.15  $29.02   $33.90  $44.31 

490   $17.87   $17.87   $17.87   $17.87  $17.64  $20.35  $24.65  $29.63   $34.60  $45.23 

500   $18.23   $18.23   $18.23   $18.23  $18.00  $20.77  $25.15  $30.23   $35.31  $46.15 

510   $18.60   $18.60   $18.60   $18.60  $18.36  $21.18  $25.66  $30.84   $36.01  $47.08 

520   $18.96   $18.96   $18.96   $18.96  $18.72  $21.60  $26.16  $31.44   $36.72  $48.00 

530   $19.32   $19.32   $19.32   $19.32  $19.08  $22.02  $26.66  $32.04   $37.43  $48.92 

540   $19.69   $19.69   $19.69   $19.69  $19.44  $22.43  $27.17  $32.65   $38.13  $49.85 

550   $20.05   $20.05   $20.05   $20.05  $19.80  $22.85  $27.67  $33.25   $38.84  $50.77 

560   $20.42   $20.42   $20.42   $20.42  $20.16  $23.26  $28.17  $33.86   $39.54  $51.69 

570   $20.78   $20.78   $20.78   $20.78  $20.52  $23.68  $28.68  $34.46   $40.25  $52.62 

580   $21.15   $21.15   $21.15   $21.15  $20.88  $24.09  $29.18  $35.07   $40.96  $53.54 

590   $21.51   $21.51   $21.51   $21.51  $21.24  $24.51  $29.68  $35.67   $41.66  $54.46 

600   $21.88   $21.88   $21.88   $21.88  $21.60  $24.92  $30.18  $36.28   $42.37  $55.38 

610   $22.24   $22.24   $22.24   $22.24  $21.96  $25.34  $30.69  $36.88   $43.08  $56.31 

620   $22.61   $22.61   $22.61   $22.61  $22.32  $25.75  $31.19  $37.49   $43.78  $57.23 

630   $22.97   $22.97   $22.97   $22.97  $22.68  $26.17  $31.69  $38.09   $44.49  $58.15 

640   $23.34   $23.34   $23.34   $23.34  $23.04  $26.58  $32.20  $38.70   $45.19  $59.08 

650   $23.70   $23.70   $23.70   $23.70  $23.40  $27.00  $32.70  $39.30   $45.90  $60.00 

660   $24.06   $24.06   $24.06   $24.06  $23.76  $27.42  $33.20  $39.90   $46.61  $60.92 

670   $24.43   $24.43   $24.43   $24.43  $24.12  $27.83  $33.71  $40.51   $47.31  $61.85 

680   $24.79   $24.79   $24.79   $24.79  $24.48  $28.25  $34.21  $41.11   $48.02  $62.77 

690   $25.16   $25.16   $25.16   $25.16  $24.84  $28.66  $34.71  $41.72   $48.72  $63.69 

700   $25.52   $25.52   $25.52   $25.52  $25.20  $29.08  $35.22  $42.32   $49.43  $64.62 

710   $25.89   $25.89   $25.89   $25.89  $25.56  $29.49  $35.72  $42.93   $50.14  $65.54 

720   $26.25   $26.25   $26.25   $26.25  $25.92  $29.91  $36.22  $43.53   $50.84  $66.46 

730   $26.62   $26.62   $26.62   $26.62  $26.28  $30.32  $36.72  $44.14   $51.55  $67.38 

740   $26.98   $26.98   $26.98   $26.98  $26.64  $30.74  $37.23  $44.74   $52.26  $68.31 

750   $27.35   $27.35   $27.35   $27.35  $27.00  $31.15  $37.73  $45.35   $52.96  $69.23 

760   $27.71   $27.71   $27.71   $27.71  $27.36  $31.57  $38.23  $45.95   $53.67  $70.15 

770   $28.08   $28.08   $28.08   $28.08  $27.72  $31.98  $38.74  $46.56   $54.37  $71.08 

780   $28.44   $28.44   $28.44   $28.44  $28.08  $32.40  $39.24  $47.16   $55.08  $72.00 

790   $28.80   $28.80   $28.80   $28.80  $28.44  $32.82  $39.74  $47.76   $55.79  $72.92 

800   $29.17   $29.17   $29.17   $29.17  $28.80  $33.23  $40.25  $48.37   $56.49  $73.85 

810   $29.53   $29.53   $29.53   $29.53  $29.16  $33.65  $40.75  $48.97   $57.20  $74.77 

820   $29.90   $29.90   $29.90   $29.90  $29.52  $34.06  $41.25  $49.58   $57.90  $75.69 

830   $30.26   $30.26   $30.26   $30.26  $29.88  $34.48  $41.76  $50.18   $58.61  $76.62 

840   $30.63   $30.63   $30.63   $30.63  $30.24  $34.89  $42.26  $50.79   $59.32  $77.54 

850   $30.99   $30.99   $30.99   $30.99  $30.60  $35.31  $42.76  $51.39   $60.02  $78.46 

860   $31.36   $31.36   $31.36   $31.36  $30.96  $35.72  $43.26  $52.00   $60.73  $79.38 

870   $31.72   $31.72   $31.72   $31.72  $31.32  $36.14  $43.77  $52.60   $61.44  $80.31 

880   $32.09   $32.09   $32.09   $32.09  $31.68  $36.55  $44.27  $53.21   $62.14  $81.23 

890   $32.45   $32.45   $32.45   $32.45  $32.04  $36.97  $44.77  $53.81   $62.85  $82.15 

900   $32.82   $32.82   $32.82   $32.82  $32.40  $37.38  $45.28  $54.42   $63.55  $83.08 

910   $33.18   $33.18   $33.18   $33.18  $32.76  $37.80  $45.78  $55.02   $64.26  $84.00 

920   $33.54   $33.54   $33.54   $33.54  $33.12  $38.22  $46.28  $55.62   $64.97  $84.92 

930   $33.91   $33.91   $33.91   $33.91  $33.48  $38.63  $46.79  $56.23   $65.67  $85.85 

940   $34.27   $34.27   $34.27   $34.27  $33.84  $39.05  $47.29  $56.83   $66.38  $86.77 

950   $34.64   $34.64   $34.64   $34.64  $34.20  $39.46  $47.79  $57.44   $67.08  $87.69 

960   $35.00   $35.00   $35.00   $35.00  $34.56  $39.88  $48.30  $58.04   $67.79  $88.62 

970   $35.37   $35.37   $35.37   $35.37  $34.92  $40.29  $48.80  $58.65   $68.50  $89.54 

980   $35.73   $35.73   $35.73   $35.73  $35.28  $40.71  $49.30  $59.25   $69.20  $90.46 

990   $36.10   $36.10   $36.10   $36.10  $35.64  $41.12  $49.80  $59.86   $69.91  $91.38 

1000   $36.46   $36.46   $36.46   $36.46  $36.00  $41.54  $50.31  $60.46   $70.62  $92.31