l Dental

Dental Coverage

PLAN HIGHLIGHTS:

key* 00431737 0001 E V16.0

HARRIS STOWE STATE UNIVERSITY

Here is your new coverage. Make sure you are aware of the deadline date for your coverage elections.

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

Your Guardian plan number: 00431737

Learn more about Guardian atwww.guardianlife.com.

We’re ready to get working for youIf you’re like most employees, finding enough time in the day to accomplish your lengthyto-do list can often be no easy task.

As your Guardian coverage begins, we want you to know that we’re here for you every stepof the way and are committed to providing you with the resources to obtain fast, accurateanswers to your benefits-related questions.

One way in which we do this is through our online member resource, Guardian Anytimesm,which allows you to manage your benefits when it works best for you — day or night. Plus,it offers helpful resources to ensure you get access to the quality care you need.

We encourage you to take a couple minutes to check out and register for GuardianAnytimesm at www.GuardianAnytime.com. We promise it will be time well spent.

Welcome to Guardian!

Dental Plans YOUR GUARDIANPLAN OFFERS:Coverage of ViziLite Plusearly cancer detectionscreening exams

Maximum rollover If amember submits at leastone claim and stays underthe claims threshold, a partof the unused maximumwill be rolled over for usein future years.

Great selection of dentistsconvenient to you - yours islikely in our network!

Reliable claims payment fourdays on average

Find out if your dentist is inGuardians network atwww.GuardianAnytime.com

Let Guardian put its 30-plus yearsof dental benefits experience towork for you and your family.

Option 1: With your Managed Dental Care plan, you enjoy negotiated discounts from our network dentists. You pay a fixed copay for each coveredservice. Out-of-network visits are not covered.Option 2: With your PPO plan, you save money by visiting a PPO dentist. Out-of network visits are not covered.Option 3: With your PPO plan, you can visit any dentist; but you pay less out-of-pocket when you choose a PPO dentist. Out-of-network benefits arebased on a percentile of the prevailing fee data for the dentist's zip code.

Benefit information illustrated within this material reflects the plan covered by Guardian as of 08/09/2018

Your Dental Plan Option 1: Managed DentalCare

Option 2: Guardian PPO(underwritten by The GuardianLife Insurance Company ofAmerica)

Option 3: Guardian PPO(underwritten by The GuardianLife Insurance Company ofAmerica)

Network First Commonwealth DentalGuard Preferred DentalGuard Preferred

Your Monthly premium $16.22 $24.51 $36.54You and 1 dependent (Spouse or Child) $32.50 $48.82 $72.41You, spouse/domestic partner and child(ren) $46.57 $79.30 $122.39

Plan year deductible In-Network Out-of-Network In-Network Out-of-NetworkIndividual No deductible $50 N/A $0 $50Family limit 3 per family 3 per familyWaived for Preventive Not applicable Not applicable Preventive

Charges covered for you (co-insurance) Network only In-Network Out-of-Network In-Network Out-of-NetworkPreventive Care You pay a copay for each 100% Not Covered 100% 100%Basic Care covered procedure. See 80% Not Covered 100% 80%Major Care Plan Details, for 50% Not Covered 60% 50%Orthodontia more information. Not Covered (applies to all levels) 50% 50%

Annual Maximum Benefit $0 N/A $1000 $1000

Maximum Rollover Maximum Rollover is not No YesRollover Threshold applicable for this plan type. $500Rollover Amount $250Rollover In-network Amount $350Rollover Account Limit $1000

Lifetime Orthodontia Maximum Not Applicable Not Applicable Not Applicable $1000

Office visit copay $5 None None

Dependent Age Limits(Non-Student/Student) 25/26 25/26 25/26

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Please note: The plandetails listed here are someof the most commonservices related to dentalcoverage. The co-insurance percentages forthe PPO plan optionscorrespond to the coveragecategories of Preventive,Basic, Major andOrthodontia listed in thetable above.

Please Note: For yourManaged Dental Care plan,coinsurances relate to afixed copayment amount,please refer to your planschedule.

Some services may be paidunder a different categorythan listed. The actualco-insurance shownreflects your plan'scoverage.

CATEGORY PLAN DETAILS Option 1: Managed DentalCare

Option 2: Guardian PPO(underwritten by TheGuardian Life InsuranceCompany of America)

Option 3: Guardian PPO(underwritten by TheGuardian Life InsuranceCompany of America)

Plan Pays (on average) Plan pays (on average) Plan pays (on average)

Network only In-network Out-of-network In-network Out-of-network

Preventive Care Cleaning (prophylaxis) 100% 100% Not Covered 100% 100%Frequency: Once every 6 months Once Every 6 Months Once Every 6 Months

Fluoride Treatments 100% 100% Not Covered 100% 100%Limits: No Age Limits No Age Limits No Age Limits

Oral Exams 100% 100% Not Covered 100% 100%Periodontal Maintenance 80% 100% Not Covered 100% 100%

Frequency: Once every 6 months (applies toall tiers)

Once Every 6 Months Once Every 6 Months

(Standard)Sealants (per tooth) 80% 100% Not Covered 100% 100%X-rays 100% 100% Not Covered 100% 100%

X-rays other than bitewings inBasic 80%

Basic Care Anesthesia* Not Covered 80% Not Covered 100% 80%Fillings 80% 80% Not Covered 100% 80%Root Canal 50-80% 80% Not Covered 100% 80%Scaling & Root Planing (per quadrant) 80% 80% Not Covered 60% 50%Simple Extractions 80% 80% Not Covered 100% 80%

Major Care Bridges and Dentures 50% 50% Not Covered 60% 50%Inlays, Onlays, Veneers** 50% 50% Not Covered 60% 50%Perio Surgery 50% 50% Not Covered 60% 50%Repair & Maintenance ofCrowns, Bridges & Dentures 50% 50% Not Covered 60% 50%Single Crowns 50% 50% Not Covered 60% 50%Surgical Extractions 50% 50% Not Covered 60% 50%

Orthodontia Orthodontia $1,000 Savings Not Covered 50% 50%Limits: Adults & Child(ren) Child(ren)

This is only a partial list of dental services. Your certificate of benefits will show exactly what is covered and excluded. **For PPO and or Indemnity members, Crowns,Inlays, Onlays and Labial Veneers are covered only when needed because of decay or injury or other pathology when the tooth cannot be restored with amalgam orcomposite filing material. When Orthodontia coverage is for "Child(ren)" only, the orthodontic appliance must be placed prior to the age limit set by your plan; If full-timestatus is required by your in order to remain insured after a certain age; then orthodontic maintenance may continue as long as full-time student status is maintained. IfOrthodontia coverage is for "Adults and Child(ren)" this limitation does not apply. *General Anesthesia - restrictions apply. For PPO and or Indemnity members, Fillings-restrictions may apply to composite fillings.This document is a summary of the major features of the referenced insurance coverage. It is intended for illustrative purposes only and does not constitute a contract. The

insurance plan documents, including the policy and certificate, comprise the contract for coverage. The full plan description, including the benefits and all terms, limitationsand exclusions that apply will be contained in your insurance certificate. The plan documents are the final arbiter of coverage. Coverage terms may vary by state and actualsold plan. The premium amounts reflected in this summary are an approximation; if there is a discrepancy between this amount and the premium actually billed, the latterprevails.

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EXCLUSIONS AND LIMITATIONSn Important Information about Guardians DentalGuard Indemnity and DentalGuard Preferred Network PPO plans:

This policy provides dental insurance only. Coverage is limited to those charges that are necessary to prevent,diagnose or treat dental disease, defect, or injury. Deductibles apply. The plan does not pay for: oral hygieneservices (except as covered under preventive services), orthodontia (unless expressly provided for), cosmetic orexperimental treatments (unless they are expressly provided for), any treatments to the extent benefits are payableby any other payor or for which no charge is made, prosthetic devices unless certain conditions are met, andservices ancillary to surgical treatment. The plan limits benefits for diagnostic consultations and for preventive,restorative, endodontic, periodontic, and prosthodontic services. The services, exclusions and limitations listedabove do not constitute a contract and are a summary only. The Guardian plan documents are the final arbiter ofcoverage. Contract # GP-1-DG2000 et al.

n This policy provides dental coverage only. This policy provides managed care dental benefits through a network ofparticipating general dentists and specialty care dentists. Except for limited emergency services, benefits will be provided forservices provided by the primary care dentist selected by the member. The member must pay the primary care dentist apatient charge/copayment for most covered services. No benefits will be paid for treatment by a specialist unless the patientis referred by his or her primary care dentist and the referral is approved under the policy. Only those services listed in thepolicys schedule of benefits are covered. Certain services are subject to frequency or other periodic limitations. Whereorthodontic benefits are specifically included, the policy provides for one course of comprehensive treatment per member.Unless specifically included, the Managed Dental Care policy does not provide orthodontic benefits if comprehensive

orthodontic treatment or retention is in progress as of the members effective date under the Managed Dental Care policy.The services, exclusions and limitations listed above do not constitute a contract and are a summary only. The applicableManaged Dental Care documents are the final arbiter of coverage .See your Certificate for complete specifics of allExclusions and Limitations. All products, unless otherwise noted, are underwritten by The Guardian Life. InsuranceCompany of America (Guardian) or one of the following wholly-owned Guardian subsidiaries: Managed Dental Care (CA);First Commonwealth Insurance Company (IL); First Commonwealth Limited Health Services Corporation (IN); FirstCommonwealth Limited Health Services Corporation of Michigan (MI); First Commonwealth of Missouri, Inc. (MO) andManaged DentalGuard, Inc. (NJ, OH and TX). Any reference to a specific product type, including but not limited to "DHMO"or Prepaid is not intended to refer to a specific state license designation, but rather is merely intended to refer to a generalproduct design. Such DHMO, or prepaid products, are licensed in the applicable jurisdiction. In addition, certain products areunderwritten by Dominion Dental Services, Inc. (DC, DE, MD, PA and VA) and LIBERTY Dental Plan of Nevada, Inc. (NV).Please see the applicable policy forms for details. In the event of conflict between this brochure and the policy forms, thepolicy forms shall control.

n For PPO and or Indemnity Special Limitation: Teeth lost or missing before a covered person becomes insured by this plan.A covered person may have one or more congenitally missing teeth or have lost one or more teeth before he becameinsured by this plan. We wont pay for a prosthetic device which replaces such teeth unless the device also replaces one ormore natural teeth lost or extracted after the covered person became insured by this plan.R3-DG2000

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Finding a dentist is easy

Go online – it just takes minutes! The best way to save money through your dental plan is by seeing a dentist in your plan’s network. Guardian’s Find a Provider site makes it easy for you to search for a dentist that meets your needs. Guardian’s Find a Provider site is available to you 24 hours a day, 7 days a week. • Customize your search by specialty, languages spoken and more • Get side-by-side comparisons of dentists’ information (ie. office status, distance) • Create a quick-list of “favorite” dentists — for easy reference online • Get maps and directions to a dentist’s office location • View your results online or have them faxed or emailed to you • Save your search criteria for easy access when you revisit the site • Create a customized directory of dentists • Nominate a dentist to be included in a network • And much more!

Just go to www.GuardianAnytime.com and click on “Find a Provider”. You can also find a dentist on the go from your smart phone – simply download our app.

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DH

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PLAN 3000 (M

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DIA

GN

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ICD0999

Office Visit Copay........................................................................................................$5

D0120Periodic Oral Evaluation

..............................................................................................$0D0140

Limited Oral Evaluation - Problem

Focused...............................................................$0

D0145Oral Eval for Patient under 3 &

Counseling with Primary Caregiver..........................$0

D0150Com

prehensive Oral Evaluation - New or Established Patient...................................$0D0160

Detailed & Extensive Evaluation, Problem

Focused...................................................$0

D0170Re-Eval - Lim

ited, Problem Focused (Est. Patient, Not Post-Operative)....................$0

D0171Re-Evaluation - Post-Operative Office Visit................................................................$0

D0180Com

prehensive Periodontal Examination, New or Established Patient......................$0

D0210Intraoral - Com

plete Series (Incl. Bitewings)..............................................................$0D0220

Intraoral - Periapical First Film...................................................................................$0

D0230Intraoral - Periapical Each Additional Film

.................................................................$0D0240

Intraoral - Occlusal Film..............................................................................................$0

D0270Bitewing - Single Film

.................................................................................................$0D0272

Bitewing X-Rays - 2 Films...........................................................................................$0

D0273Bitewing X-Rays - 3 Film

s...........................................................................................$0D0274

Bitewing X-Rays - 4 Films...........................................................................................$0

D0277Vertical Bitewings - 7 to 8 Film

s.................................................................................$0

D0330Panoram

ic Film...........................................................................................................$0

D0415Bacteriological Studies................................................................................................$0

D0460Pulp Vitality Tests

........................................................................................................$0D0470

Diagnostic Casts..........................................................................................................$0

PR

EV

EN

TIV

ED1110

Prophylaxis - Adult......................................................................................................$0D1120

Prophylaxis - Child.....................................................................................................$0

D1206Topical Fluoride Varnish, Therapeutic Application for M

od to High Caries RiskPatients

........................................................................................................................$0D1208

Topical Application Of Fluoride - Excluding Varnish..................................................$0

D1310Nutritional Counseling for Control of Dental Disease

................................................$0D1330

Oral Hygiene Instructions............................................................................................$0D1351

Sealant - Per Tooth......................................................................................................$6

D1352Preventive Resin Restoration in M

od - High Caries Risk Patient - Perm Tooth

.........$6D1510

Space Maintainer - Fixed - Unilateral.......................................................................$34

D1515Space M

aintainer - Fixed - Bilateral..........................................................................$52D1520

Space Maint-Rem

ovable - Unilateral.........................................................................$34D1525

Space Maint-Rem

ovable - Bilateral...........................................................................$52D1550

Re-cement or Re-bond Space M

aintainer.................................................................$17D1555

Removal of a Space M

aintainer, By Dentist Who Did Not Originally Place

................$4

MIN

OR

RE

STO

RA

TIV

ED2140

Amalgam

- 1 Surface, Primary or Perm

anent...........................................................$12D2150

Amalgam

- 2 Surfaces, Primary or Perm

anent..........................................................$15D2160

Amalgam

- 3 Surfaces, Primary or Perm

anent..........................................................$18D2161

Amalgam

- 4 or More Surfaces, Prim

ary or Permanent............................................$21

D2330Resin-Based Com

posite - 1 Surface, Anterior..........................................................$15D2331

Resin-Based Composite - 2 Surfaces, Anterior........................................................$19

D2332Resin-Based Com

posite - 3 Surfaces, Anterior........................................................$22D2335

Resin-Based Comp - 4 or M

ore Surfaces or Involving Incisal Angle (Anterior)......$24D2390

Resin-Based Composite Crown, Anterior.................................................................$60

D2391Resin-Based Com

posite - 1 Surface, Posterior........................................................$44D2392

Resin-Based Composite - 2 Surfaces, Posterior.......................................................$56

D2393Resin-Based Com

posite - 3 Surfaces, Posterior.......................................................$68D2394

Resin-Based Composite - 4 or M

ore Surfaces, Posterior.........................................$72D2929

Prefabricated Porcelain/Ceramic Crown – Prim

ary Tooth........................................$75

D2990Resin Infiltration of Incipient Sm

ooth Surface Lesions...............................................$9

EN

DO

DO

NT

ICS

D3110Pulp Cap - Direct (Excluding Final Restoration).........................................................$7

D3120Pulp Cap - Indirect (Excluding Final Restoration)......................................................$7

D3220Therapeutic Pulpotom

y (Excluding Final Restoration).............................................$18D3221

Pulpal Debridement, Prim

ary & Perm

anent Teeth.....................................................$11D3222

Partial Pulpotomy for Apexogenesis – Perm

. Tooth with Incomplete Root..............$18

D3230Pulp Therapy, Anterior Prim

ary.................................................................................$47

D3240Pulp Therapy, Posterior Prim

ary...............................................................................$52

D3310Endodontic Therapy, Anterior Tooth (Excluding Final Restoration)..........................$74

D3320Endodontic Therapy, Bicuspid Tooth (Excluding Final Restoration)

........................$93D3330

Endodontic Therapy, Molar (Excluding Final Restoration).....................................$324

D3351Apexification/Recalcification Initial Visit...................................................................$56

D3352Apexification/Recalcification Interim

Visit.................................................................$37D3353

Apexification/Recalcification Final Visit..................................................................$130D3410

Apicoectomy - Anterior............................................................................................$194

D3421Apicoectom

y - Bicuspid (First Root).......................................................................$235D3425

Apicoectomy - M

olar (First Root)............................................................................$242D3426

Apicoectomy (Each Additional Root).........................................................................$87

D3427Periradicular Surgery without Apicoectom

y............................................................$186D3430

Retrograde Filling - Per Root....................................................................................$53

D3450Root Am

putation Per Root.......................................................................................$110D3920

Hemisection (Incl. Root Rem

oval/Excludes Rct).....................................................$104D3950

Canal Prep & Fit of Preform

ed Post (By Other Than Dentist Who Placed Post)......$11

PE

RIO

DO

NT

ICS

D4210Gingivectom

y Or Gingivoplasty - 4 or More Teeth Per Quadrant...........................$151

D4211Gingivectom

y or Gingivoplasty - 1 to 3 Teeth, Per Quadrant...................................$55D4240

Gingival Flap Procedure, w/Root Planing - 4 or More Teeth Per Quadrant............$177

D4241Gingival Flap Procedure, w/Root Planing - 1 to 3 Teeth, Per Quadrant.................$112

D4212Gingivectom

y or Gingivoplasty to Allow Access For Restorative Procedure, PerTooth

..........................................................................................................................$39D4245

Apically Positioned Flap..........................................................................................$187D4249

Clinical Crown Lengthening - Hard Tissue.............................................................$223D4260

Osseous Surgery (Incl. Elevation of a Full Thickness Flap & Closure) - 4 or

More Teeth Per Quad

...............................................................................................$335D4261

Osseous Surgery (Incl. Elevation of a Full Thickness Flap & Closure) - 1 to 3

Teeth, Per Quad........................................................................................................$235D4268

Surgical Revision Procedure, Per Tooth, Inclusive in Surgery...................................$0

D4341Scaling &

Root Planing - 4 or More Teeth Per Quadrant..........................................$28

D4342Scaling &

Root Planing - 1 to 3 Teeth, Per Quadrant...............................................$20D4355

Full Mouth Debridem

ent to Enable Comprehensive Evaluation &

Diagnosis..........$12

D4381Loc. Deliv. Chem

o Agent, Controlled Release into Crevice, Per Tooth.......................$8D4910

Periodontal Maintenance...........................................................................................$17

D4921Gingival Irrigation - Per Quadrant...............................................................................$2

OR

AL SU

RG

ERY

D7111Extraction, Coronal Rem

nants - Deciduous Tooth......................................................$9

D7140Extraction, Erupted Tooth or Exposed Root (Elevation and/or Forceps Rem

oval)....$14D7210

Surg Removal of Erupted Tooth Requiring Rem

oval of Bone and/or Sectioning ofTooth; Inc. M

ucoperiosteal Flap if Indicated.............................................................$70

D7220Rem

oval of Impacted Tooth - Soft Tissue..................................................................$85

D7230Rem

oval of Impacted Tooth - Partially Bony

...........................................................$114D7240

Removal of Im

pacted Tooth - Completely Bony

......................................................$139D7241

Removal of Im

pacted Tooth - Completely Bony, with Unusual Surg Com

p...........$152

D7250Surgical Rem

oval of Residual Tooth Roots (Cutting Procedure)..............................$67D7280

Surgical Access of an Unerupted Tooth (Non-Orthodontic)...................................$139D7310

Alveoloplasty w/Extractions - Per Quadrant..............................................................$61D7311

Alveoloplasty w/Ext - 1 To 3 Teeth or Spaces, Per Quadrant....................................$50D7320

Alveoloplasty Not w/Extractions - Per Quadrant.......................................................$98D7321

Alveoloplasty Not w/Extractions - 1 to 3 Teeth or Spaces Per Quadrant..................$71D7450

Removal of Benign Odontogenic Cyst or Tum

or (Diameter 1.25 Cm

)..................$107D7510

Incision & Drainage of Abscess - Intraoral Soft Tissue

............................................$50D7511

Incision & Drainage of Abscess - Intraoral Soft Tissue - Com

plicated....................$29

D7960Frenulectom

y (Frenectomy or Frenotom

y) - Separate Procedure...........................$102D7963

Frenuloplasty...........................................................................................................$130D7972

Surgical Reduction of Fibrous Tuberosity.................................................................$67

CR

OW

NS

D2510Inlay - M

etallic - 1 Surface*....................................................................................$182

D2520Inlay - M

etallic - 2 Surfaces*..................................................................................$217

D2530Inlay - M

etallic - 3 or More Surfaces*

....................................................................$268D2542

Onlay - Metallic - 2 Surfaces*.................................................................................$245

D2543Onlay - M

etallic - 3 Surfaces*.................................................................................$288D2544

Onlay - Metallic - 4 or M

ore Surfaces*...................................................................$290D2610

Inlay - Porcelain Ceramic 1 Surf.............................................................................$207

D2620Inlay - Porcelain Ceram

ic 2 Surf.............................................................................$230D2630

Inlay - Porcelain Ceramic 3 Surf.............................................................................$429

D2642Onlay - Porcelain Ceram

ic 2 Surf............................................................................$260D2643

Onlay - Porcelain Ceramic 3 Surf............................................................................$291

D2644Onlay - Porcelain Ceram

ic 4+ Surf.........................................................................$311D2650

Inlay - Resin 1 Surf..................................................................................................$172D2651

Inlay - Resin 2 Surf..................................................................................................$190D2652

Inlay - Resin 3 Surf..................................................................................................$206D2662

Onlay - Resin 2 Surf................................................................................................$200D2663

Onlay - Resin 3 Surf................................................................................................$230D2664

Onlay - Resin 4+ Surf..............................................................................................$240D2710

Crown - Resin-Lab..................................................................................................$205

D2720Crown - Resin, High Noble M

etal*........................................................................$309

D2721Crown - Resin, Base M

etal......................................................................................$308D2722

Crown - Resin, Noble Metal...................................................................................$308

D2740Crown - Porcelain/Ceram

ic Substrate.....................................................................$323D2750

Crown - Porcelain Fused to High Noble Metal*

.....................................................$302D2751

Crown - Porcelain Fused to Predominantly Base M

etal.........................................$266D2752

Crown - Porcelain Fused to Noble Metal................................................................$297

D2780Crown - 3/4 Cast High Noble M

etal*......................................................................$323D2781

Crown - 3/4 Cast Predominantly Base M

etal.......................................................... $303D2782

Crown - 3/4 Cast Noble Metal................................................................................$299

D2783Crown - 3/4 Porcelain/Ceram

ic..............................................................................$323 11

*Designated restorations include high noble metal (gold). The actual cost of this metal may be added to the patient’s responsibility at the time ofservice. The payment responsibilities listed above are valid as of January 1, 2016. The payment responsibilities are subject to revision onJanuary 1 of each year. A complete description of benefits, limitations and exclusions is included in your subscription certificate.Current Dental Terminology © 2015 American Dental Association. All rights reserved.

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D2790Crown - Full Cast High Noble M

etal*.....................................................................$323

D2791Crown - Full Cast Predom

inantly Base Metal.........................................................$303

D2792Crown - Full Cast Noble M

etal................................................................................$196D2794

Crown - Titanium.....................................................................................................$323

D2910Re-cem

ent or Re-bond Inlay, Onlay, Veneer or Partial Coverage Restoration............$8

D2915Re-cem

ent or Re-bond Indirectly Fabricated or Prefabricated Post & Core...............$8

D2920Re-cem

ent or Re-bond Crown.....................................................................................$8D2930

Prefabricated Stainless Steel Crown - Primary Tooth

...............................................$69D2931

Prefabricated Stainless Steel Crown - Permanent Tooth...........................................$71

D2932Prefabricated Resin Crown

........................................................................................$75D2933

Prefabricated Stainless Steel Crown with Resin Window

..........................................$75D2934

Prefabricated Esthetic Coated Stainless Steel Crown - Primary Tooth

.....................$75D2940

Protective Restoration................................................................................................$10D2941

Interim Therapeutic Restoration - Prim

ary Dentition..................................................$7

D2949Restorative Foundation for an Indirect Restoration

...................................................$32D2950

Core Buildup, Incl. any Pins When Required............................................................$58

D2951Pin Retention - Per Tooth, in Addition to Restoration...............................................$13

D2952Cast Post &

Core in Addition to Crown*................................................................$107

D2953Each Additional Cast Post - Sam

e Tooth*.................................................................$10D2954

Prefabricated Post & Core in Addition to Crown

......................................................$78D2957

Each Additional Prefabricated Post - Same Tooth.......................................................$7

D2971Additional Procedures to Construct New Crown Under Existing Partial..................$59

D2980Crown Repair.............................................................................................................$54

FIXE

D B

RID

GE

SD6205

Pontic - Indirect Resin Based Composite

...............................................................$205D6210

Pontic - Cast High Noble Metal*.............................................................................$323

D6211Pontic - Cast Predom

inantly Base Metal.................................................................$303

D6212Pontic - Cast Noble M

etal.......................................................................................$299D6214

Pontic - Titanium.....................................................................................................$323

D6240Pontic - Porcelain Fused to High Noble M

etal*......................................................$323D6241

Pontic - Porcelain Fused to Predominantly Base M

etal..........................................$244D6242

Pontic - Porcelain Fused to Noble Metal................................................................$291

D6245Pontic - Porcelain/Ceram

ic.....................................................................................$323

D6250Pontic - Resin, High Noble M

etal*..........................................................................$323D6251

Pontic - Resin, Base Metal......................................................................................$289

D6252Pontic - Resin, Noble M

etal....................................................................................$302D6545

Retainer - Cast Metal for Resin Bonded Fixed Prosthesis*

....................................$111D6548

Retainer - Porcelain for Resin Bonded Prosthesis..................................................$111D6549

Resin Retainer - for Resin Bonded Fixed Prosthesis................................................$55

D6600Retainer Inlay - Porcelain/Ceram

ic, Two Surfaces..................................................$230

D6601Retainer Inlay - Porcelain/Ceram

ic, Three or More Surfaces..................................$429

D6602Retainer Inlay - Cast High Noble M

etal, Two Surfaces*..........................................$217D6603

Retainer Inlay - Cast High Noble Metal, Three or M

ore Surfaces*.........................$268

D6604Retainer Inlay - Cast Predom

inately Base Metal, Two Surfaces..............................$217

D6605Retainer Inlay - Cast Predom

inately Base Metal, Three or M

ore Surfaces.............$268

D6606Retainer Inlay - Cast Noble M

etal, Two Surfaces....................................................$217

D6607Retainer Inlay - Cast Noble M

etal, Three or More Surfaces....................................$268

D6608Retainer Onlay - Porcelain/Ceram

ic, Two Surfaces.................................................$260D6609

Retainer Onlay - Porcelain/Ceramic, Three or M

ore Surfaces................................$291

D6610Retainer Onlay - Cast High Noble M

etal, Two Surfaces*........................................$245

D6611Retainer Onlay - Cast High Noble M

etal, Three or More Surfaces*........................$288

D6612Retainer Onlay - Cast Predom

inately Base Metal, Two Surfaces

............................$245D6613

Retainer Onlay - Cast Predominately Base M

etal, Three or More Surfaces............$288

D6614Retainer Onlay - Cast Noble M

etal, Two Surfaces...................................................$245D6615

Retainer Onlay - Cast Noble Metal, Three or M

ore Surfaces..................................$288

D6624Retainer Inlay - Titanium

.........................................................................................$217D6634

Retainer Onlay - Titanium........................................................................................$245

D6710Retainer Crown - Indirect Resin Based Com

posite.................................................$205

D6720Retainer Crown - Resin with High Noble M

etal*.....................................................$308D6721

Retainer Crown - Resin with Predominately Base M

etal.........................................$308D6722

Retainer Crown - Resin with Noble Metal...............................................................$308

D6740Retainer Crown - Porcelain/Ceram

ic.......................................................................$323D6750

Retainer Crown - Porcelain Fused to High Noble Metal*

.......................................$323D6751

Retainer Crown - Porcelain Fused to Predominately Base M

etal...........................$243D6752

Retainer Crown - Porcelain Fused to Noble Metal..................................................$291

D6780Retainer Crown - 3/4 Cast High Noble M

etal*........................................................$322D6781

Retainer Crown - 3/4 Cast Predominately Base M

etal............................................$303D6782

Retainer Crown - 3/4 Cast Noble Metal..................................................................$299

D6783Retainer Crown - 3/4 Porcelain/Ceram

ic................................................................$323

D6790Retainer Crown - Full Cast High Noble M

etal*.......................................................$323D6791

Retainer Crown - Full Cast Predominately Base M

etal...........................................$275D6792

Retainer Crown - Full Cast Noble Metal..................................................................$299

D6794Retainer Crown - Titanium

......................................................................................$323D6930

Re-cement or Re-bond Fixed Partial Denture

...........................................................$12D6980

Fixed Partial Denture Repair, by report......................................................................$55

LAB

IAL V

EN

EE

RS

D2960Labial Veneer (Resin Lam

inate) - Chairside............................................................$176D2961

Labial Veneer (Resin Laminate) - Lab

.....................................................................$199D2962

Labial Veneer (Porcelain Laminate) - Lab

...............................................................$268

DE

NT

UR

ES

D5110Com

plete Denture - Maxillary

.................................................................................$403D5120

Complete Denture - M

andibular..............................................................................$403D5130

Imm

ediate Denture - Maxillary

................................................................................$417D5140

Imm

ediate Denture - Mandibular............................................................................$417

D5211M

axillary Partial - Resin Base.................................................................................$268

D5212M

andibular Partial - Resin Base..............................................................................$268D5213

Maxillary Partial - Cast M

etal Framework w/Resin Bases.......................................$436

D5214M

andibular Partial - Cast Metal Fram

ework w/Resin Bases...................................$420D5221

Imm

ediate Maxillary Partial - Resin Base

...............................................................$281D5222

Imm

ediate Mandibular Partial - Resin Base............................................................$281

D5223Im

mediate M

axillary Partial - Cast Metal Fram

ework w/Resin Bases.....................$458D5224

Imm

ediate Mandibular Partial - Cast M

etal Framework w/Resin Bases

.................$440D5225

Maxillary Partial - Flexible Base..............................................................................$436

D5226M

andiublar Partial - Flexible Base.........................................................................$440D5281

Removable Unilateral Partial Denture......................................................................$210

D5410Adjust Com

plete Denture - Maxillary........................................................................$18

D5411Adjust Com

plete Denture - Mandibular....................................................................$18

D5421Adjust Partial Denture - M

axillary.............................................................................$18

D5422Adjust Partial Denture - M

andibular.........................................................................$18D5510

Repair Broken Complete Denture Base

.....................................................................$55D5520

Replace Missing or Broken Teeth - Com

plete Denture (Each Tooth)........................$43D5610

Repair Resin Denture Base........................................................................................$40

D5620Repair Cast Fram

ework..............................................................................................$41D5630

Repair or Replace Broken Clasp - Per Tooth.............................................................$51

D5640Replace Broken Teeth - Per Tooth

.............................................................................$33D5650

Add Tooth to Existing Partial Denture.......................................................................$44

D5660Add Clasp to Existing Partial Denture - Per Tooth

....................................................$57D5670

Replace All Teeth & Acrylic on Cast M

etal Framework - M

axillary......................... $174D5671

Replace All Teeth & Acrylic on Cast M

etal Framework - M

andibular.....................$174D5710

Rebase Complete M

axillary Denture.......................................................................$141

D5711Rebase Com

plete Mandibular Denture....................................................................$141

D5720Rebase M

axillary Partial Denture............................................................................$139

D5721Rebase M

andibular Partial Denture.........................................................................$139D5730

Reline Complete M

axillary Denture (Chairside)........................................................$78D5731

Reline Complete M

andibular Denture (Chairside)....................................................$78D5740

Reline Maxillary Partial Denture (Chairside).............................................................$71

D5741Reline M

andibular Partial Denture (Chairside).........................................................$71D5750

Reline Complete M

axillary Denture (Laboratory)....................................................$118D5751

Reline Complete M

andibular Denture (Laboratory)................................................$114D5760

Reline Maxillary Partial Denture (Laboratory).........................................................$107

D5761Reline M

andibular Partial Denture (Laboratory).....................................................$107D5850

Tissue Conditioning, Maxillary

.................................................................................$44D5851

Tissue Conditioning, Mandibular..............................................................................$44

ORT

HO

DO

NT

ICS

D8080Com

prehensive Orthodontic Treatment of the Adolescent Dentition (age 18 and

under) Class I and II............................................................................................$3,172D8090

Comprehensive Orthodontic Treatm

ent of the Adult Dentition (age 19 and over)Class I and II........................................................................................................$3,453

D8660Pre-Orthodontic Treatm

ent Examination to M

onitor Growth and Development.....$205

D8680Orthodontic Retention (Rem

oval of Appliances, Construction & Placem

ent OfRetainer(s))..............................................................................................................$260

D8681Rem

ovable Orthodontic Retainer Adjustment..............................................................$0

MISC

ELLA

NE

OU

SD9110

Palliative (Emergency) Treatm

ent of Dental Pain - Minor Procedure

.........................$9D9210

Local Anesthetic, Not in Conjunction with Operative Procs.......................................$0D9215

Local Anesthesia-In Conjunction with Operative or Surgical Procedures (Inclusivein those Procedures)...................................................................................................$0

D9230Analgesia, Nitrous Oxide.............................................................................................$5

D9310Consultation - Diagnostic Service Provided by Dentist or Physician Other ThanRequesting Dentist or Physician

...............................................................................$12D9430

Office Visit for Observation (During Regularly Scheduled Hours)..............................$5D9440

Office Visit for Observation (After Regularly Scheduled Hours).................................$5D9450

Case Presentation, Detailed & Extensive Treatm

ent Planning....................................$0

D9910Application of Desensitizing M

edicament, Per Visit...................................................$5

D9911Application of Desensitizing Resin for Cervical and/or Root Surface-Per Tooth........$6

D9951Occlusal Adjustm

ent - Limited

..................................................................................$11D9952

Occlusal Adjustment - Com

plete...............................................................................$28 12

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TheGuardian

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ofAmerica

Enrollment/Change

FormPage

1of4

GuardianLife,P.O.Box

981585,ElPaso,TX

79998-1585

PlanAdm

inistrator:StephanieColem

an

Pleaseprintclearly

andm

arkcarefully.

qThe

GuardianLife

Insurancecom

panyofAm

ericaunderw

ritesgroup

termlife,accidentaldeath

anddism

emberm

ent,Shortterm

disability,Longterm

disability,criticalillness,dentalAndvision

coverages.

qFirstCom

monw

ealthofM

issouri,Inc.FirstCom

monw

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grouppre-paid

dentalcoverage

CE

F2015-RR

-MO

EmployerNam

e:HAR

RIS

STOW

ESTATE

UN

IVERSITY

GroupPlan

Number:00431737

BenefitsEffective:_____________

PLEASECHECK

APPROPRIATEBOX

qInitialEnrollm

entq

Re-Enrollment

qAdd

Employee/Dependents

qDrop/Refuse

Coverageq

Information

Change

qIncrease

Amount

qFam

ilyStatus

Change

Class:___________________Division:_________________

SubtotalCode:____________________(Ifapplicable,please

obtainthis

fromyourEm

ployer)

AboutYou:SocialSecurity

Number

First,MI,LastNam

e:___

______

-______

-______

______

AddressCity

StateZip

Gender:qM

qF

DateofBirth

(mm

-dd-yy):____-____

-____Phone:(

)-

EmailAddress:

Areyou

married

ordoyou

havea

spouse?q

Yes qNo

Dateofm

arriage/union:____-____-_____Do

youhave

childrenorotherdependents?

qYes q

NoPlacem

entdateofadopted

child:____-____-_____

AboutYourJob:Hours

worked

perweek:_______

JobTitle:

Work

Status:

qActive

qRetired

qCobra/State

ContinuationDate

offulltime

hire:____-____

-____

AboutYourFamily:

Pleaseinclude

thenam

esofthe

dependentsyou

wish

toenrollforcoverage.A

dependentisa

personthatyou,

asa

taxpayer,claim;w

horelies

onyou

forfinancialsupport;andforw

homyou

qualifyfora

dependencytax

exception.Dependency

taxexem

ptionsare

subjecttoIR

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ationm

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asa

grandchild,aniece

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e)

Address/City/State/Zip:

Phone:()

-

Gender

qM

qF

SocialSecurityNum

ber

_____-_____

-_____

DateofBirth

(mm

-dd-yyyy)

____-____

-____

Child/Dependent1:

Address/City/State/Zip:

Phone:()

-

qAdd

qDrop

Gender

qM

qF

SocialSecurityNum

ber

_____-_____

-_____

DateofBirth

(mm

-dd-yyyy)

____-____

-____

Status(check

allthatapply)q

Student(posthighschool)

qDisabled

qNon

standarddependent

Child/Dependent2:

Address/City/State/Zip:

Phone:()

-

qAdd

qDrop

Gender

qM

qF

SocialSecurityNum

ber

_____-_____

-_____

DateofBirth

(mm

-dd-yyyy)

____-____

-____

Status(check

allthatapply)q

Student(posthighschool)

qDisabled

qNon

standarddependent

2

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Address/City/State/Zip:

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qAdd

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Gender

qM

qF

SocialSecurityNum

ber

_____-_____

-_____

DateofBirth

(mm

-dd-yyyy)

____-____

-____

Status(check

allthatapply)q

Student(posthighschool)

qDisabled

qNon

standarddependent

Child/Dependent4:

Address/City/State/Zip:

Phone:()

-

qAdd

qDrop

Gender

qM

qF

SocialSecurityNum

ber

_____-_____

-_____

DateofBirth

(mm

-dd-yyyy)

____-____

-____

Status(check

allthatapply)q

Student(posthighschool)

qDisabled

qNon

standarddependent

Drop

Coverage:q

DropEm

ployeeq

DropDependents

Thedate

ofwithdraw

alcannotbepriorto

thedate

thisform

iscom

pletedand

signed.LastDay

ofCoverage:_____-_____-_____q

Termination

ofEmploym

entq

Retirement

LastDayW

orked:_____-_____-_____q

OtherEvent:_____________Date

ofEvent:_____-_____-_____

CoverageBeing

Dropped:

qDental

qEm

ployeeq

Spouseq

Child(ren)q

Visionq

Employee

qSpouse

qChild(ren)

qBasic

Lifeq

Employee

qSpouse

qChild(ren)

qVoluntary

Lifeq

Employee

qSpouse

qChild(ren)

qVAD&

Dq

Employee

qSpouse

qChild(ren)

qCriticalIllness

qEm

ployeeq

Spouseq

Child(ren)q

Accidentq

Employee

qSpouse

qChild(ren)

qCancer

qEm

ployeeq

Spouseq

Child(ren)q

Multi-Coverage

qLong

TermDisability

qShortTerm

Disability

LossO

fOtherCoverage:

Iand/ormy

dependentsw

erepreviously

coveredunderanotherinsurance

plan.Lossofcoverage

was

dueto:

qTerm

inationofEm

ployment:

_____-_____-_____q

Divorce_____-_____-_____

qDeath

ofSpouse_____-_____-_____

qTerm

ination/ExpirationofCoverage

_____-_____-_____Coverage

Lostq

Dentalq

Vision

Ihavebeen

offeredthe

abovecoverage(s)and

wish

todrop

enrollmentforthe

following

reasons:q

Coveredunderanotherinsurance

planq

Other____________________________________________________(additionalinform

ationm

aybe

required)

DentalCoverage:

Youm

ustbeenrolled

tocoveryourdependents.

Checkonly

onebox.

YourMonthly

Premium

Employee

OnlyEm

ployeeand

1Dependent

EE,Spouse&

Dependent/Child(ren)Option

1:Managed

DentalCare(underw

rittenby

FirstCom

monw

ealthofM

issouri,Inc.)q

$16.22q

$32.50q

$46.57

Option2:Guardian

PPO(underw

rittenby

TheGuardian

LifeInsurance

Company

ofAmerica)

q$24.51

q$48.82

q$79.30

Option3:Guardian

PPO(underw

rittenby

TheGuardian

LifeInsurance

Company

ofAmerica)

q$36.54

q$72.41

q$122.39

IfM

anagedDentalCare

coverageis

elected,youm

usthavea

Primary

CareDentist(PCD).Please

designateyourPCD(s)by

listingdentaloffice

locationnum

ber(s)foreachperson.Please

visitguardianlife.comfora

listofproviders.Ifyoudo

notselectaPCD,one

willbe

assignedforyou.

Employee

_________________________Spouse

_________________________Child(ren)_____________________________

qIdo

notwantthis

coverage.Ifyoudo

notwantthis

DentalCoverage,pleasem

arkallthatapply:

qIam

coveredunderanotherDentalplan

qM

yspouse

iscovered

underanotherDentalplanq

My

dependentsare

coveredunderanotherDentalplan

Signature

lIunderstand

thatmy

dependent(s)cannotbeenrolled

foracoverage

ifIamnotenrolled

forthatcoverage.

lIunderstand

thattheprem

iumam

ountsshow

nabove

areestim

ationsand

areforillustrative

purposesonly.

lSubm

issionofthis

formdoes

notguaranteecoverage.Am

ongotherthings,coverage

iscontingentupon

underwriting

approvalandm

eetingthe

applicableeligibility

requirements

assetforth

inthe

applicablebenefitbooklet.

GuardianGroup

PlanNum

ber:00431737Please

printemployee

name:

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lIfcoverage

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entrantpenaltiesm

ayapply.You

may

alsohave

toprovide,atyourow

nexpense,proofofeach

person'sinsurability.Guardian

oritsdesignee

hasthe

righttorejectyourrequest.

lPlan

designlim

itationsand

exclusionsm

ayapply.Forcom

pletedetails

ofcoverage,pleasereferto

yourbenefitbooklet.Statelim

itationsm

ayapply.

lIhereby

applyforthe

groupbenefit(s)thatIhave

chosenabove.

lIunderstand

thatImustm

eeteligibilityrequirem

entsforallcoverages

thatIhavechosen

above.

lIagree

thatmy

employerm

aydeductprem

iums

fromm

ypay

iftheyare

requiredforthe

coverageIhave

chosenabove.

lIacknow

ledgeand

consenttoreceiving

electroniccopies

ofapplicableinsurance

relateddocum

ents,inlieu

ofpapercopies,tothe

extentpermitted

byapplicable

law.I

may

changethis

electiononly

byproviding

thirty(30)day

priorwritten

notice.

lIattestthatthe

information

providedabove

istrue

andcorrectto

thebestofm

yknow

ledge.

Anyperson

who

with

intenttodefraud

anyinsurance

company

orotherpersonfiles

anapplication

forinsuranceorstatem

entsofclaim

containingany

knowingly,false

information,orconceals

forpurposeofm

isleadinginform

ationconcerning

anyfactm

aterialhereto,comm

itsa

fraudulentinsuranceact,w

hichis

acrim

e,andm

ayalso

besubjectto

civilpenalties,ordenialofinsurancebenefits.

Thestate

inw

hichyou

residem

ayhave

aspecific

statefraud

warning.Please

refertothe

attachedFraud

Warning

Statements

page.

Thelaw

sofNew

Yorkrequire

thefollow

ingstatem

entappear:Anyperson

who

knowingly

andw

ithintentto

defraudany

insurancecom

panyorotherperson

filesan

applicationforinsurance

orstatementofclaim

containingany

materially

falseinform

ation,orconcealsforthe

purposeofm

isleading,information

concerningany

factm

aterialthereto,comm

itsa

fraudulentinsuranceact,w

hichis

acrim

e,andshallalso

besubjectto

acivilpenalty

nottoexceed

fivethousand

dollarsand

thestated

valueofthe

claimforeach

suchviolation.(Does

notapplyto

LifeInsurance.)

SIGNATUREOF

EMPLOYEE

X___________________________________________

DATE______________________

EnrollmentKit

00431737,0001,EN

FraudW

arningStatem

ents

Thelaw

sofseveralstates

requirethe

following

statements

toappearon

theenrollm

entform:

Alabama:Any

personw

hoknow

inglypresents

afalse

orfraudulentclaimforpaym

entofaloss

orbenefitorwho

knowingly

presentsfalse

information

inan

applicationfor

insuranceis

guiltyofa

crime

andm

aybe

subjecttorestitution

finesorconfinem

entinprison,orany

combination

thereof.

Arizona:ForyourprotectionArizona

lawrequires

thefollow

ingstatem

enttoappearon

thisform

.Anyperson

who

knowingly

presentsa

falseorfraudulentclaim

forpayment

ofaloss

issubjectto

criminaland

civilpenalties.

California:ForyourprotectionCalifornia

lawrequires

thefollow

ingto

appearonthis

form:Any

personw

hoknow

inglypresents

falseorfraudulentclaim

forthepaym

entofaloss

isguilty

ofacrim

eand

may

besubjectto

finesand

confinementin

stateprison.

Colorado:Itisunlaw

fultoknow

inglyprovide

false,incomplete,orm

isleadingfacts

orinformation

toan

insurancecom

panyforthe

purposeofdefrauding

orattempting

todefraud

thecom

pany.Penalties

may

includeim

prisonment,fines,denialofinsurance,and

civildamages.

Anyinsurance

company

oragentofaninsurance

company

who

knowingly

providesfalse,incom

plete,ormisleading

factsorinform

ationto

apolicy

holderorclaimantforthe

purposeofdefrauding

orattempting

todefraud

thepolicy

holderorclaimantw

ithregard

toa

settlementoraw

ardpayable

frominsurance

proceedsshallbe

reportedto

theColorado

DivisionofInsurance

within

theDepartm

entofRegulatory

Agencies.

Connecticut,Iowa,Kansas,Nebraska,Oregon,and

Vermont:Any

personw

hoknow

ingly,andw

ithintentto

defraudany

insurancecom

panyorotherperson,files

anapplication

ofinsuranceorstatem

entofclaimcontaining

anym

ateriallyfalse

information

orconceals,forthepurpose

ofmisleading,inform

ationconcerning

anyfactm

aterialthereto,m

aybe

guiltyofa

fraudulentinsuranceact,w

hichm

aybe

acrim

e,andm

ayalso

besubjectto

civilpenalties.

Delaware,Indiana

andOklahom

a:WARNING:Any

personw

hoknow

ingly,andw

ithintentto

injure,defraudordeceive

anyinsurer,m

akesany

claimforthe

proceedsofan

insurancepolicy

containingany

false,incomplete

ormisleading

information

isguilty

ofafelony.

DistrictofColumbia:W

ARNING:Itisa

crime

toprovide

falseorm

isleadinginform

ationto

aninsurerforthe

purposeofdefrauding

theinsurerorany

otherperson.Penaltiesinclude

imprisonm

entand/orfines.Inaddition,an

insurermay

denyinsurance

benefits,iffalseinform

ationm

ateriallyrelated

toa

claimw

asprovided

bythe

applicant.

Florida:Anyperson

who

knowingly

andw

ithintentto

injure,defraud,ordeceiveany

insurerfilesa

statementofclaim

oranapplication

containingany

false,incomplete,or

misleading

information

isguilty

ofafelony

ofthethird

degree.

Kentucky:Anyperson

who

knowingly

andw

ithintentto

defraudany

insurancecom

panyorotherperson

filesa

statementofclaim

containingany

materially

falseinform

ationorconceals,forthe

purposeofm

isleading,information

concerningany

factmaterialthereto

comm

itsa

fraudulentinsuranceact,w

hichis

acrim

e.

Louisianaand

Texas:Anyperson

who

knowingly

presentsa

falseorfraudulentclaim

forpaymentofa

lossorbenefitis

guiltyofa

crime

andm

aybe

subjecttofines

andconfinem

entsin

stateprison.

Maine,Tennessee,Virginia

andW

ashington:Itisa

crime

toknow

inglyprovide

false,incomplete

ormisleading

information

toan

insurancecom

panyforthe

purposeof

defraudingthe

company.Penalties

may

includeim

prisonment,fines

oradenialofinsurance

benefits.

Maryland

andRhode

Island:Anyperson

who

knowingly

andw

illfullypresents

afalse

orfraudulentclaimforpaym

entofaloss

orbenefitorknowingly

andw

illfullypresents

falseinform

ationin

anapplication

forinsuranceis

guiltyofa

crime

andm

aybe

subjecttofines

andconfinem

entinprison.

4

Minnesota:A

personw

hofiles

aclaim

with

intenttodefraud

orhelpscom

mita

fraudagainstan

insurerisguilty

ofacrim

e.

NewHam

pshire:Anyperson

who,w

itha

purposeto

injure,defraudordeceive

anyinsurance

company,files

astatem

entofclaimcontaining

anyfalse,incom

pleteor

misleading

information

issubjectto

prosecutionand

punishmentforinsurance

fraud,asprovided

inN.H.Rev.Stat.Ann.§

638:20

NewJersey:Any

personw

hoknow

inglyfiles

astatem

entofclaimcontaining

anyfalse

ormisleading

information

issubjectto

criminaland

civilpenalties.

NewM

exico:Anyperson

who

knowingly

presentsa

falseorfraudulentclaim

forpaymentora

lossorbenefitorknow

inglypresents

falseinform

ationin

anapplication

forinsurance

isguilty

ofacrim

eand

may

besubjectto

civilfinesand

criminalpenalties

ordenialofinsurancebenefits.

Ohio:Anyperson

who

with

intenttodefraud

orknowing

thathe/sheis

facilitatinga

fraudagainstan

insurer,submits

anapplication

orfilesa

claimcontaining

afalse

ordeceptive

statementis

guiltyofinsurance

fraud.

Pennsylvania:Anyperson

who

knowingly

andw

ithintentto

defraudany

insurancecom

panyorotherperson

filesan

applicationforinsurance

orstatementofclaim

containingany

materially

falseinform

ationorconceals

forthepurpose

ofmisleading,inform

ationconcerning

anyfactm

aterialtheretocom

mits

afraudulentinsurance

act,w

hichis

acrim

eand

subjectssuch

personto

criminaland

civilpenalties.

Thank You

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Date form submitted:

© 2005 The Guardian Life Insurance Company of America,7 Hanover Square, New York 10004

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