Welcome to your employee beneﬁ ts. eﬁ ts.

Welcome to your employee benefi ts.Enroll in coverage now to help protect yourself and your loved ones in the future.

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Act Now to Help Protect What Matters Most

The life you’re building for yourself and your family is precious. Every fi nancial decision, every fi rst step, every milestone — these are the things that matter. Think of insurance as a fi nancial safety net that can help protect you when life doesn’t go as planned. Enrolling in coverage now is a small thing you can do to help make sure you and your loved ones keep moving forward.

In this guide, you’ll fi nd details about your group insurance options from Standard Insurance Company (The Standard) and the forms you need to start the application process.

Protection from the Unexpected

Even with medical insurance, a serious illness or accident — even a routine stay in the hospital — can be a drain on your fi nances. The following types of insurance pay a benefi t to help you pay the bills. Use the payment however you like to cover out-of-pocket medical costs and other living expenses.

Accident insurance pays a benefi t is paid directly to you if you receive treatment for an accident to help you cover out-of-pocket expenses. as you or a family member recuperates after an accident.

Critical Illness insurance helps you manage expenses during a serious illness, such as a heart attack, stroke or cancer. Use the benefi t, paid to you in a lump sum, for deductibles, copays, rent or groceries as you or a family member recovers.

With the insurance described above, you can take advantage of affordable group rates that will not increase as you get older. And if you leave your job, you can take your coverage with you.

Protection for Your Health

Dental insurance from The Standard provides coverage for dental care for you and your family, and gives you the ability to choose your own dentist. Visit www.standard.com/dental to search for an in-network dentist in your area.

Vision insurance provides coverage for vision care services for you and your family. It includes coverage for eye exams, and helps pay for contact lenses and glasses. Visit www.standard.com/vision to search for an in-network vision specialist.

Your Employer-Paid Benefi ts

• Basic Life insurance

• Dependents Life insurance

• Accidental Death &Dismemberment insurance

• Short Term Disability insurance

Benefi ts You CanApply for Now

• Accident insurance

• Critical Illness insurance

• Dental insurance

• Vision insurance

• Additional Life insurance

• Short Term Disability insurance

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Protection for Your Loved Ones

Life insurance helps provide support and stability to your family if something were to happen to you. It can help your family fi nancially through a diffi cult time and provide support into the future.

Accidental Death and Dismemberment (AD&D) insurance helps protect against a sudden fi nancial loss brought on by an accidental death. It can also help pay for the high cost of living associated with surviving an accident that results in a severe physical loss.

Protection for Your Paycheck

Your most valuable asset is your ability to earn an income. Disability insurance provides partial income replacement if you can’t work because of a qualifying disability caused by an illness, injury or pregnancy. The benefi t payments can help with bills that continue even when you can’t work, like your mortgage or rent — expenses medical insurance won’t cover.

Short Term Disability insurance pays a weekly benefi t to help you keep your fi nances on track when you’re out of work because of a disability.

Long Term Disability insurance pays a monthly benefi t if you experience a disability that lasts for several months or even years.

Ready to Apply? You’ll Find the Form Right Here

Once you’ve reviewed your options, the next step is to apply using the form(s) included at the end of this guide. Don’t forget to turn in your forms before your enrollment period ends.

Enroll Soon

Enrollment begins Monday, October 12and ends Friday, October 23

Attend your group meeting on:

• Thursday, October 15th, 2:00 p.m., Atlanta

• Monday, October 19th, 10:00 a.m., Houston

Enroll online at www.standard.com

Contact your employee benefi ts manager if you have questions about how to submit forms.

When you buy insurance through work, you have access to competitive group rates and the convenience of premiums deducted right from your paycheck.

Standard Insurance Company1100 SW Sixth AvenuePortland, OR 97204

www.standard.com

SI 16919 (5/15)

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Don’t let an accident stop your fi nancial plans. Accident insurance is an affordable way to help cover the gap between what your medical

insurance covers and what you’d owe out of pocket if you or a family member were to get

injured. It’s protection that’s also convenient: Your premium payments are deducted directly

from your paycheck.

Group Accident InsuranceKeep your fi nances on track when an accident happens.

Having an accident doesn’t just hurt you — it can also damage your fi nances. Your medical insurance will cover some of the expenses, but you’ll be left to foot the bills for your copays and deductible. Those can add up fast, especially if you’re unable to work while you recover. That’s where Group Accident insurance comes in: It helps protect your bank account from the out-of-pocket expenses that can come with an injury — whether you’re coping with a broken arm or recovering from a serious car accident.

Standard Insurance CompanyABC CompanyGroup Policy #123456

Some 31 million people sought care in the emergency room for unintended injuries in 2011.

Medical insurance helps — but it doesn’t pay for everything.

1 Source: FastStats, based on National Hospital Ambulatory Medical Care Survey: 2011 Emergency Departure Summary Tables, www.cdc.gov/nchs/fastats/accidental-injury.htm

2 Source: NerdWallet Health. In 2013, NerdWallet aggregated multiple sources and data sets to estimate the impact of medical bills on Americans that year.

An estimated 10 million working-aged Americans struggled to pay medical bills in 2013 — even though they had health insurance.

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In the event of a covered accident, your Accident insurance will pay a benefi t directly to you. You can use this money wherever you need it most — whether that’s to help with your deductible, copays and other medical bills, or your daily expenses while you recover.

Here’s how it works:

Let’s say your teenage daughter gets injured during tryouts for her school basketball team and goes to urgent care for treatment. Diagnosis: dislocated elbow and fracture of the forearm and wrist. Although surgery isn’t necessary, she will need follow-up appointments and physical therapy.

You’d get an additional 25% if your child is injured while participating in an organized athletic activity — whether it’s football practice, a soccer game or dance class.

Urgent Care Visit ...................................... $50

X-ray ......................................................... $50

Dislocated Elbow ...................................$800

Arm Fracture .......................................... $550

Wrist Fracture ......................................... $550

Physician Follow-up Appointment ........... $50

Physical Therapy Appointment .............. $100

BENEFITS PAID TO YOU

SUBTOTAL ......................................... $2,150

Youth Organized Sports Benefi t(25% of subtotal) .................................$538

Total paid directly to you .................$2,688

Ambulance .............................................$300

Emergency Room Visit ...........................$150

CAT Scan ............................................... $200

Hospital Admission Benefi t ................ $1,000

5-Day Hospital Confi nement($200 per day) ..................................... $1,000

Right Leg Fracture .............................. $4,000

Knee Cap Fracture ...............................$1,100

Pelvis Fracture .................................... $2,400

Physician Follow-up Appointment ........... $50

Physical Therapy Appointment ................ $50

BENEFITS PAID TO YOU

SUBTOTAL .......................................$10,250

Automobile Accident Benefi t .............$500

Transportation Benefi t ........................ $150

Lodging (4 days) .................................. $700

Total paid directly to you ............... $11,600

You’d get an additional $500 because you were injured in a car accident. Because you drove more than 100 miles for your follow-up appointment, you’d receive an extra $150. If a family member traveled to be near you while you were in the hospital, we’d pay additional benefi ts to help cover lodging expenses.

Imagine that you survive a serious car accident. After a trip to the ER, you stay in the hospital for several days while you recover. In the weeks following the accident, you have a follow-up appointment at a clinic in another city and physical therapy.

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Affordable Group RatesBecause you’ll be buying this insurance through ABC Company, you’ll have access to affordable group rates. You’ll also have the convenience of having your premium deducted directly from your paycheck. Your rates will not increase as you grow older, even if you continue your coverage after your employment with ABC Company ends (this is known as portability).

You can get a Health Maintenance Screening Benefi t of $50 each year just for going to the doctor for a covered wellness exam, such as a stress test or lipid panel — a routine preventive visit that typically costs you nothing under your medical insurance.

It pays to be well adjusted. If you need to see a chiropractor while you’re recovering from an accident, you can get a benefi t of $50 (up to two visits per accident, providing those visits are on different days).

Staying in a hospital can be costly, even with medical insurance coverage. You’ll receive a $1,000 benefi t if you’re admitted — plus $100 for every day you’re hospitalized.* And if you’re admitted or confi ned to a critical care unit while you’re in the hospital, you’ll receive additional critical care unit benefi ts.

*Up to 365 days per accident.

If you or a dependent travel at least 100 miles for treatment, you’ll receive a Transportation Benefi t of $150 for each day of travel.* We’ll pay a $175 Lodging Benefi t per day* if a family member travels with you or a dependent during treatment and has to pay for a place to stay.

*Maximum 30 days per accident; 90 days per year

Coverage for... Cost to you each month

You $16.58

You and your spouse $23.91

You and your children $29.02

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Emergency Care Benefi ts

Ambulance — Air $800

Ambulance — Ground $300

Emergency Room Visit $150

Urgent Care Visit $50

Initial Care Visit $50

Emergency Dental Care — Crown $200

Emergency Dental Care — Extraction $100

Outpatient X-Ray $50

Major Diagnostic Exam(such as CT scan, MRI, EEG)

$200

Transfusion Blood, Plasma or Platelets $300

These are actual benefi t amounts you could receive in the event of a covered accident:

Dislocations Non-surgical/Surgical

Ankle, Collarbone (sternoclavicular), Elbow, Foot, Hand, Lower Jaw, Shoulder, Wrist

$800/$1,600

Knee (not including kneecap) $900/$1,800

Collarbone (acromioclavicular), Spine $400/$800

Finger, Rib, Toe $150/$300

Hip $2,500/$5,000

Partial Dislocation 25% of the associated dislocation listed above (non-surgical)

Specifi c Injury Benefi ts

Burns $200–$10,000, depending on severity

Coma $7,500

Concussion $150

Eye Injury $200

Lacerations $75–$500, depending on size

Skin Graft 25%

Fractures Non-surgical/Surgical

Ankle, Arm (shoulder to elbow), Arm (elbow to wrist), Collarbone, Elbow, Foot, Hand, Kneecap, Lower Jaw, Shoulder Blade, Sternum, Wrist

$550/$1,100

Bones of Face, Coccyx, Nose, Rib, Vertebrae

$500/$1,000

Finger, Toe $100/$200

Hip $2,500/$5,000

Leg (hip to knee) $2,000/$4,000

Leg (knee to ankle), Pelvis, Vertebral Column

$1,200/$2,400

Skull (depressed) $4,000/$8,000

Skull (non-depressed) $1,500/$3,000

Chip Fracture 25% of associated fracture listed above (non-surgical)


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Surgical Benefi ts

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Tendon, Ligament, Rotator Cuff

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Repair of one $750

Repair of two or more $1,000

Ruptured Disc

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Abdominal/Thoracic Surgery

Exploratory $200

Laparoscopic Repair Surgery $750

Open Repair Surgery $1,500

Surgical Facility Benefi t $150

Hospital Benefi ts

Hospital Admission once per covered accident)

$1,000

Daily Hospital Confi nement (maximum 365 days per covered accident)

$200 per day

Critical Care Unit Admission* (once per covered accident)

$750

Daily Critical Care Unit Confi nement* (maximum 15 days per covered accident)

$200 per day

Daily Rehabilitation Facility (maximum 90 days per covered accident)

$100 per day

* Payable in addition to any Hospital Admission and/or DailyHospital Confi nement Benefi t you may be eligible to receive.

Follow-Up Care

Medical Appliance (e.g., wheelchair, cane or brace)

$100

Chiropractic Care (maximum 2 visits per covered accident, 1 per day)

$50 per day

Physician Follow-up (maximum 3 visits per covered accident, 1 per day)

$50 per day

Hearing Device $500

Prosthesis One: $500Two or more: $1,000

Occupational, Speech or Physical Therapy (maximum 3 visits per covered accident, 1 per day)

$50 per day

Additional Benefi ts

Lodging (per day, to a maximum of 30 days per covered accident and a total of 90 days per year)

$175

Transportation (per trip)(per day, to a maximum of 30 days per covered accident and a total of 90 days per year)

$150

Health Maintenance Screening Benefi t (once per calendar year)

$50

Automobile Accident Benefi t $500

Youth Organized Sports Benefi t Additional 25% of total benefi t payable

Accidental Death and Dismemberment (AD&D)

Accidental Death You: $50,000Spouse: $25,000Child: $12,500

In the event of a covered accidental dismemberment or impairment, this policy would pay a percentage of the Accidental Death benefi t:

Loss of both hands or feet 30%

Loss of one hand and one foot 30%

Loss of one hand or one foot 15%

Loss of one digit (fi nger or toe) 2%

Loss of two or more digits (fi ngers and/or toes)

5%

Uniplegia 15%

Hemiplegia, Paraplegia or Triplegia 30%

Quadriplegia 50%

Loss of sight (one eye); loss of hearing (one ear)

15%

Loss of sight (both eyes); loss of hearing (both ears)

30%

In the event of an accidental death, this policy would pay the full Accidental Death benefi t. In certain scenarios, it would also pay an additional percentage of the Accidental Death benefi t:

Air Bag Benefi t 10%

Helmet Benefi t 10%

Seat Belt Benefi t 10%

Repatriation/transportation of remains 10%

Death that occurs while aboard commercial transportation

100%

Line of Duty Benefi t 100%

If you or a dependent travel at least 50 miles for treatment, you’ll receive a Transportation Benefi t of $150 for each day of travel.* We’ll pay a $175 Lodging Benefi t per day* if a family member travels with you or a dependent during treatment and has to pay for a place to stay.*Maximum 30 days per accident; 90 days per year


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PortabilityThis coverage is portable. That means that you may be able to continue your coverage — at the same rate you would pay today — if your employment ends, the group policy terminates or your insurance ends because you no longer meet the eligibility requirements.

Eligibility RequirementsTo be eligible for this coverage, you must be a regular employee of ABC Company, actively working in the United States at least 30 hours per week and a citizen or resident of the United States or Canada. Temporary and seasonal employees, full-time members of the armed forces, leased employees and independent contractors are not eligible.

You can choose to cover your spouse, a person to whom you are legally married, or your domestic partner as recognized by law, or your civil union partner. You can also cover your unmarried children from birth to age 26. Your children cannot be insured by more than oneemployee. Your spouse or children must not be full-timemembers(s) of the armed forces. You cannot be insuredas both an individual and a dependent.

A minimum number of eligible employees must apply and qualify for the proposed plan before Accident insurance coverage can become effective.

Your Effective DateYou must satisfy the eligibility requirements listed above, serve an eligibility waiting period, receive evidence of good health underwriting approval (if applicable), agree to pay premium, and be actively at work (able to perform all normal duties of your job) on the day before the scheduled effective date of insurance.

If you are not actively at work on the day before the scheduled effective date of insurance, your insurance will not become effective until the day after you complete one full day of active work as an eligible employee.

Please contact your human resources representative or plan administrator for more information regarding the requirements that must be satisfi ed for your insurance to become effective.

ExclusionsBenefi ts are not payable if an accident is caused or contributed to by any of the following:

• War or any act of war• Suicide or other intentionally self-infl icted injury, while

sane or insane

• Committing or attempting to commit an assault, felony oract of terrorism

• Active participation in a violent disorder or riot• The voluntary use or consumption of any poison,

chemical compound, drug or alcohol in excess of thelegal limit in the state your accident occurred

• Sickness existing at the time of the accident, includingany medical or surgical treatment or diagnosticprocedure for a sickness

• Travel or fl ight in or on any aircraft, except as a fare-paying passenger on a commercial aircraft

• Engaging in high-risk sports or activities such as (but not limited to) bungee jumping, parachuting, base jumping, mixed martial arts or mountain climbing

• An activity that arises out or in the course of anyemployment for wage or profi t due to your employmentat ABC Company

• Practicing for or participating in any semiprofessional or professional competitive athletic contests for which you receive any type of compensation

• Routine eye exams and dental procedures other than acrown or extraction for a tooth or teeth as a result of a covered accident

• Riding in or driving any automobile in a race, stunt showor speed test

• Cosmetic surgery or other procedure to improve yourappearance, unless it is necessary to correct a deformity or restore bodily function after a covered accident

• An accident that occurs while you or your dependent isincarcerated in a jail or penal or correctional institution

When Insurance EndsYour insurance ends if you notify your employer or policyholder to terminate your coverage, you stop making premium payments, your employment terminates, you cease meeting the member defi nition or the group policy terminates.

Child and spouse insurance ends when your insurance ends, they cease to meet the defi nition of child or spouse, you stop making premium payments for child or spouse insurance, spouse or child insurance is no longer offered under the group policy or the group policy terminates.

Group Insurance Certifi cateIf coverage becomes effective and you become insured, you will receive a group insurance certifi cate containing a detailed description of the insurance coverage including the defi nitions, exclusions, limitations, reductions and

Important DetailsHere’s where you’ll fi nd the nitty-gritty details about Accident insurance.


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terminating events. The controlling provisions will be in the group policy and certifi cate. The information present in this summary does not modify the group policy, certifi cate or the insurance coverage in any way.

This is a limited benefi t policy.

GP0614-ACC

Standard Insurance Company1100 SW Sixth AvenuePortland OR 97204

www.standard.com

SI 17615 (1/15)

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Group Critical Illness InsuranceHelp cover out-of-pocket expenses associated with a serious illness.

You may have medical insurance. But that doesn’t mean you’re covered for all of the expenses resulting from a serious illness that you probably haven’t budgeted for — things like co-pays, deductibles, loss of income, childcare and travel expenses. Group Critical Illness insurance helps fi ll the gap caused by these out-of-pocket costs, creating a fi nancial safety net for you and your family.


Help ensure your fi nancial plans stay healthy even when you’re not. Critical Illness insurance is an affordable way to make up the difference between what your

medical insurance covers and what you’d owe out of pocket if you or a family member were

diagnosed with a covered serious illness. It’s protection that’s also convenient: Your premium

payments are deducted directly from your paycheck.

Cancer patients carry rising burdens of health care-related out-of-pocket expenses: 42 percent reported a signifi cant subjective fi nancial burden and 46 percent used savings to defray out-of-pocket expenses.

“Cancer diagnosis puts people at greater risk for bankruptcy,” May 15, 2013, press release, Fred Hutchinson Cancer Research Center, www.fredhutch.org/en/news/releases/2013/05/cancer-diagnosis-greater-risk-bankruptcy.html

70 percent of people who had diffi culty paying medical bills in 2012 had some kind of health insurance.

70%

“Medical Debt Among People With Health Insurance,” Kaiser Family Foundation, 2012 National Health Inverview Survey(NHIS) data, Jan. 7, 2014, http://kff.org/private-insurance/report/medical-debt-among-people-with-health-insurance/

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Critical Illness insurance can make a big difference in your ability to pay out-of-pocket expenses associated with a serious illness. It pays a lump-sum benefi t directly to you upon diagnosis of a covered illness, regardless of your treatment costs or what’s covered by your medical insurance. Elect coverage in $5,000 increments between$5,000 and $50,000.

An Extra Layer of Protection

With Critical Illness insurance, you can:

• Update your coverage as needed. As your life circumstances change,increase* or decrease your coverage.

• Lock in your rate. For example, if you’re 35 when you apply forcoverage, you’ll pay a 35-year-old’s rate for as long as you have thecoverage.

• Take it with you. If you leave your job, you can take your coveragewith you.

• Pick and choose how to spend your benefi t. Spend your lump-sumbenefi t however you want.

• Protect your loved ones. Cover your spouse up to $30,000, as long asit’s not more than your benefi t amount. Your kids are automaticallycovered at 25 percent of the amount elected for yourself for the samecritical illnesses that you are. Kids are also covered for 21 additionalchildhood diseases, including cystic fi brosis, Down syndrome, musculardystrophy, spina bifi da and cerebral palsy.

• Receive a benefi t for taking care of your health. You and yourcovered loved ones receive a Health Maintenance Screening Benefi t of$50 once per calendar year when visiting the doctor for a coveredwellness exam, such as a cholesterol screening (part of a lipid panel) ormammogram — routine preventive visits that typically cost you nothingunder your medical insurance.

• Offset transportation costs. If you have to travel at least 100 milesfrom home for your treatment for a covered illness, a Transportation Benefi t of $75 for each day of travel will be paid.**

• Help with lodging costs. If a family member travels with you or a dependent at least 50 miles from your home for treatment and has to pay for a place to stay, a lodging benefi t of $75 per day will be paid.**

• Receive additional benefi ts. If you are diagnosed with a coveredillness again after a treatment-free period of 12 months, you will receive25 percent of the original benefi t amount. And if you are diagnosed witha different covered illness at least 90 days after the diagnosis of the fi rstcritical illness, you will receive 100 percent of your benefi t for thesubsequent critical illness.

* Evidence of good health may be necessaryin some cases; see the Important Detailssection for more information.

** Maximum 30 days per critical illness; 90 days per year.

Chances are good that a family

member, friend or colleague of yours

has endured a critical illness. You

may have even seen that person

struggle to pay the bills. Think of

Critical Illness insurance as fi nancial

peace of mind, so you don’t have to

choose between paying for medical

bills and helping send your daughter

to the college of her dreams.

Group Critical Illness Insurance

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John has $15,000 of Critical Illness insurance coverage. He makes an appointment with his doctor after feeling off for the past few weeks. Diagnosis: cancer with a good prognosis but a long road ahead. Within days of making a claim, John receives his Critical Illness insurance benefi t paid directly to him. As John undergoes intensive treatment over the next few months, he can use the benefi t for any purpose, including to pay for things that his medical insurance does not cover. Things like the deductible, co-pays, child care, certain medications, time away from work, alternative treatments and a special diet.

Part of John’s treatment is provided by a specialist in another city that is more than 100 miles from his home. In addition to his Critical Illness benefi t, he is able to use his Lodging and Transportation benefi ts to defray travel costs.

Here’s how it works:

Medical insurance deductible......................... $1,300

Out-of-pocket expenses over the course of six months ........................$5,000

Transportation to medical appointments and treatments ...........................$250

Lodging near treatment facility ....................... $1,370

Lost wages ......................................................$4,500

Alternative treatments and diets not covered by medical plan ..........................$4,500

SAMPLE OUT-OF-POCKET EXPENSES

TOTAL OUT-OF-POCKET EXPENSES ...... $16,920

CRITICAL ILLNESS BENEFIT .................... $15,000

OUT-OF-POCKET EXPENSES ......................$1,920

Costs are hypothetical. Actual costs will vary by state, cancer type, stage at diagnosis, treatments received and personal factors.

Critical Illness insurance can make a

big difference in your ability to pay

out-of-pocket expenses associated

with a serious illness that are not

covered by medical insurance.

Covered Conditions

Receive 100 percent of your coverage amount

• Severe coronary artery diseasewith recommendation forbypass surgery

• Carcinoma in situ (cancer thathas not metastasized)

• Heart attack

• Stroke

• Cancer

• End stage renal (kidney) failure

• Major organ failure

• Coma

• Paralysis of two or more limbs

• Loss of sight

Receive 25 percent of your coverage amount

Initial diagnosis and initial recommendation must occur after your coverage becomes effective.


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AL OUT-OF-POCKET EXPENSES-OF-POCKET EXPENSES ............ $16,920$

CRITICAL ILLNESS BENEFITNESS BENEFIT .................... ................. $15$1

OUT-OF-POCKET EXPENSESOUT-OF-POCKET EXPENS ...............

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Affordable Group RatesBecause you’ll be buying this insurance through ABC Company, you’ll have access to affordable group rates. You’ll also have the convenience of having your premium deducted directly from your paycheck. Your rates will not increase as you grow older, even if you continue your coverage after your employment with ABC Company ends (this is known as portability).

If you wish to apply for an amount greater than $20,000 for yourself or $10,000 for your spouse, complete a brief health questionnaire.

Coverage for... Coverage amount

You $5,000–$50,000 in increments of $5,000

Your spouse $5,000–$30,000 in increments of $5 ,000, as long as it’s not more than your coverage amount

Your children up to age 26 Automatically covered at 25% of your coverage amount

See the Important Details section for more information, including requirements, exclusions, age reductions and defi nitions.

The monthly premiums you would pay for Critical Illness insurance benefi ts are based on the ages of you and your spouse and whether or not you or your spouse use tobacco. Please note that coverage can be purchased in $1,000 increments.


Coverage Amount

Issue Ages

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

Non-Tobacco Monthly Rates

$5,000 4.31 5.29 6.39 1.40 2.00 2.65 3.40 4.45 5.75 6.75

$10,000 5.90 7.88 10.07 5.60 8.00 10.60 13.60 17.80 23.00 27.00

$15,000 7.50 10.47 13.74 8.40 12.00 15.90 20.40 26.70 34.50 40.50

$20,000 9.10 13.05 17.42 5.60 8.00 10.60 13.60 17.80 23.00 27.00

$25,000 10.70 15.64 21.10 29.15 37.42 51.59 71.11 107.25 146.98 196.32

$30,000 12.30 18.23 24.78 34.44 44.36 61.37 84.49 128.16 175.83 235.04

$35,000 12.30 18.23 24.78 34.44 44.36 61.37 84.79 128.16 175.83 235.04

$40,000 15.49 23.40 32.14 45.02 58.25 80.92 112.15 169.98 233.54 312.49

$45,000 15.49 23.40 32.14 45.02 58.25 80.92 112.15 169.98 233.54 312.49

$50,000 18.69 28.57 39.50 55.59 72.13 100.48 139.51 211.80 291.25 389.94

Coverage Amount

Issue Ages

< 25 25–29 30–34 35–39 40–44 45–4 9 50–54 55–59 60–64 65–70

Tobacco Monthly Rates

$5,000 4.86 6.40 8.53 11.75 15.38 21.81 31.02 48.09 67.03 89.62

$10,000 7.01 10.10 14.35 20.80 28.05 40.92 59.34 93.46 131.35 176.54

$15,000 9.17 13.79 20.17 29.85 40.72 60.02 87.66 138.84 195.67 263.46

$20,000 11.32 17.49 25.99 38.89 53.39 79.13 115.98 184.22 259.99 350.37

$25,000 13.47 21.19 31.80 47.94 66.06 98.24 144.29 229.60 324.31 437.29

$30,000 15.63 24.88 37.62 56.98 78.73 117.34 172.61 274.98 388.63 524.20

$35,000 15.63 24.88 37.62 56.98 78.73 117.34 172.61 274.98 388.63 524.20

$40,000 19.93 32.27 49.26 75.08 104.07 155.55 229.25 365.73 517.27 698.04

$45,000 19.93 32.27 49.26 75.08 104.07 155.55 229.25 365.73 517.27 698.04

$50,000 24.24 39.66 60.90 93.17 129.41 193.76 285.88 456.49 645.91 871.87

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he Important Details section for more information, includingortant Details section for more information, includinuirements, exclusions, age reductions and defi nitions.exclusions, age reductions and defi nitions.

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PortabilityThis coverage is portable. That means that you can continue your coverage — at the same rate you would pay today — if your employment ends, the group policy terminates or your insurance ends because you no longer meet the eligibility requirements.

Eligibility RequirementsTo be eligible for this coverage, you must be a regular employee of ABC Company, actively working in the United States at least 30 hours per week and a citizen or resident of the United States or Canada. Temporary and seasonal employees, full-time members of the armed forces, leased employees and independent contractors are not eligible.

You can choose to cover your spouse, a person to whom you are legally married, or your domestic partner as recognized by law, or your civil union partner. You can also cover your unmarried children from birth to age 26. Your children cannot be insured by more than oneemployee. Your spouse or children must not be full-time members(s) of the armed forces. You cannot be insured as both an individual and a dependent.

A minimum number of eligible employees must apply and qualify for the proposed plan before Critical Illness insurance coverage can become effective.

Your Effective DateYou must satisfy the eligibility requirements listed above, serve an eligibility waiting period, receive evidence of good health underwriting approval (if applicable), agree to pay premium, and be actively at work (able to perform all normal duties of your job) on the day before the scheduled effective date of insurance.

If you are not actively at work on the day before the scheduled effective date of insurance, your insurance will not become effective until the day after you complete 1 full day of active work as an eligible employee.

Please contact your human resources representative or plan administrator for more information regarding the requirements that must be satisfi ed for your insurance to become effective.

Changes in InsuranceTo increase your or your spouse’s insurance, you can apply in writing. Evidence of good health will be required:

• For increases in coverage

• If previously submitted evidence of good health wasnot approved by us

• For additional insurance due to a plan change

Reoccurrence Benefi tIf you or your dependents receive a benefi t for a covered critical illness and are later diagnosed with the same critical illness, a one-time reoccurrence benefi t will be paid if you or your dependents have:

• Been continuously insured under the group policybetween the initial and subsequent diagnosis orrecommendation

• Served a 12-month treatment-free period in connectionwith the critical illness during which you did not:

– Consult a physician or other licensed medicalprofessional

– Receive medical treatment, services or advice

– Undergo diagnostic procedures, including self-administered procedures

– Take prescribed drugs or medications

ExclusionsBenefi ts are not payable if a critical illness is caused or contributed to by any of the following:

• War or any act of war

• Attempted suicide or other intentionally self-infl ictedinjury, while sane or insane

• Committing or attempting to commit an assault, felonyor act of terrorism

• Active participation in a violent disorder or riot

• The voluntary use or consumption of any poison,chemical compound, drug or alcohol in excess of thelegal limit in the state the critical illness occurred,unless used or consumed according to the directionsof a physician

• Initial diagnosis outside of the United Statesor Canada

• Elective surgery or other procedure which:

– Does not promote the proper function of your oryour dependent’s body or prevent or treatsickness or injury

– Is directed at improving your or your dependent’sappearance, unless such surgery or procedure isnecessary to correct a deformity resulting from acongenital abnormality or disfi gurement

Note: This exclusion will not apply to a criticalillness caused or contributed to by your or yourdependent’s donation of an organ or tissue.

Important DetailsHere’s where you’ll fi nd the nitty-gritty details about Critical Illness insurance.


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o pay premium, and be actively at work (able topay premium, and be actively at work (able tall normal duties of your job) on the day beforall normal duties of your job) onscheduled effective date of insurance.scheduled effective date of i

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recommendationcommendation

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Preexisting Condition ExclusionPreexisting conditions can affect your coverage if they occurred at any time during the 365-day period just before the date your or your dependent’s insurance or additional insurance due to a plan change or an increase in coverage amount becomes effective. Preexisting conditions are defi ned as:

• A mental or physical condition (diagnosed ormisdiagnosed) for which you or your dependentconsulted a physician or other licensed medicalprofessional; received medical treatment, services oradvice; undergone diagnostic procedures includingself-administered procedures; or taken prescribeddrugs or medications.

• A mental or physical condition that was discovered orsuspected as a result of any medical examination,including a routine examination.

You or your dependent will not be covered for a critical illness if it is caused or contributed to by a preexisting condition or medical or surgical treatment of a preexisting condition. The preexisting condition will be covered if, on the date you or your dependent incur the critical illness:

• You or your dependent have been continuously insuredunder the group policy for 12 months

• You have been actively at work for at least 1 full dayafter the end of that 12 months

When Insurance EndsYour insurance ends if you notify your employer or policyholder to terminate your coverage, you stop making premium payments, your employment terminates, you reach age 70, you cease meeting the member defi nition or the group policy terminates.

Child and spouse insurance ends when your insurance ends, they cease to meet the defi nition of child or spouse, you stop making premium payments for spouse insurance, your spouse reaches age 70, spouse or child insurance is no longer offered under the group policy or the group policy terminates.

Group Insurance Certifi cateIf coverage becomes effective and you become insured, you will receive a group insurance certifi cate containing a detailed description of the insurance coverage, including the defi nitions, exclusions, limitations, reductions and terminating events. The controlling provisions will be in the group policy and certifi cate. The information presented in this summary does not modify the group policy or certifi cate or the insurance coverage in any way.


SAMPLE

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ach age 70, you cease meeting the member defiease meeting the member dor the group policy terminates. or the group policy terminates.

Child and spouse insurance ends when youChild and spouse insurance eends, they cease to meet the defi nition oet thspouse, you stop making premium pastop making preinsurance, your spouse reaches agce, your spouse reacheinsurance is no longer offered uninsurance is no longer offered the group policy terminates.the group policy terminate

Group Insurance Cep Insurance Ceoverage becomesverage becomes

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GP0614-CI


www.standard.com

SI 17616 (1/15)

IMPORTANT NOTICE TO PERSONS ON MEDICARE: THIS IS NOT MEDICARE SUPPLEMENT INSURANCE Some healthcare services paid for by Medicare may also trigger the payment of benefi ts from this policy.

This insurance pays a fi xed dollar amount, regardless of your expenses, for each day you meet the policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.

Medicare generally pays for most or all of these expenses.

Medicare pays extensive benefi ts for medically necessary services regardless of the reason you need them. These include:

• Hospitalization

• Physician services

• Hospice

• Outpatient prescription drugs if you are enrolled in Medicare Part D

• Other approved items and services

This policy must pay benefi ts without regard to other health benefi t coverage to which you may be entitled under Medicare or other insurance.

Before you buy this insurance:

• Check the coverage in all health insurance policies you already have.

• For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People withMedicare, available from Standard Insurance Company.

• For help in understanding your health insurance, contact your state insurance department or state health insurance program SHIP.


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17

GP0614-ACC

Health Maintenance Screening SI 17629 (8/15) EE

Regular checkups are important for the things you depend on — especially your health. You and your covered dependents will receive a cash benefi t each calendar year when completing any one of the 20 tests list below. It’s all part of the Health Maintenance Screening Benefi t that comes with your group insurance from Standard Insurance Company.

Approved Tests:✓ Abdominal aortic aneurysm ultrasound

✓ Ankle Brachial Index (ABI) screening for peripheralvascular disease

✓ Biopsies for cancer

✓ Bone density screening

✓ Breast ultrasound

✓ Cancer antigen 125 (CA 125) blood test for ovarian cancer

✓ Cancer antigen 15-3 (CA 15-3) for breast cancer

✓ Carcinoembryonic antigen (CEA) blood test for colon cancer

✓ Colonoscopy

✓ Complete Blood Count (CBC)

✓ Comprehensive Metabolic Panel (CMP)

✓ Electrocardiogram (EKG)

✓ Hemocult stool analysis

✓ Hemoglobin A1C - elevated for the last 90 days - DM

✓ Human Papillomavirus (HPV) vaccination

✓ Lipid panel

✓ Mammography

✓ Pap smears or thin prep pap test

✓ Prostrate specifi c (PSA) test

✓ Stress test on a bicycle or treadmill

The Standard is a marketing name for StanCorp Financial Group, Inc. and subsidiaries. Insurance products are offered by Standard Insurance Company of Portland, Oregon, in all states except New York. Product features and availability vary by state and are solely the responsibility of Standard Insurance Company.

Schedule your health screening test today, submit your claim and receive your cash benefi t.

+

=


www.standard.com

Health Maintenance ScreeningGet a Cash Benefi t Each Year for Covered Wellness Exams

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18

Voluntary Options ABC Company Highlight Sheet

Standard Insurance Company Benefit and Cost Summary Highlight Sheet

Plan 1: Dental Plan Summary Effective Date: 6/1/2015 Plan Benefit

Type 1 100% Type 2 80% Type 3 50%

Deductible $50/Calendar Year Type 2 & 3 Waived Type 1

3 Family Maximum Maximum (per person) $1,000 per calendar year Allowance 90th U&C Waiting Period None Annual Open Enrollment Included

Orthodontia Summary - Child Only Coverage Allowance U&C Plan Benefit 50% Lifetime Maximum (per person) $1,000 Waiting Period None

Sample Procedure Listing (Current Dental Terminology © American Dental Association.)Type 1 Type 2 Type 3

Routine Exam (2 per benefit period)

Bitewing X-rays (2 per benefit period)

Full Mouth/Panoramic X-rays (1 in 3 years)

Periapical X-rays Cleaning

(2 per benefit period) Fluoride for Children 18 and under

(1 per benefit period) Sealants (age 16 and under) Space Maintainers

Restorative Amalgams Restorative Composites Endodontics (nonsurgical) Endodontics (surgical) Periodontics (nonsurgical) Periodontics (surgical) Denture Repair Simple Extractions Complex Extractions Anesthesia

Onlays Crowns

(1 in 5 years per tooth) Crown Repair Prosthodontics (fixed bridge; removable

complete/partial dentures) (1 in 5 years)

Bleaching (cosmetic)

Monthly Rates Employee Only (EE) $47.52EE + Spouse $93.24EE + Children $139.12EE + Spouse & Children $184.84

About The Standard As a leading provider of employee benefits products and services, Standard Insurance Company is dedicated to meeting the unique insurance needs of each customer. More than 27,100 groups trust The Standard for group insurance products and services, and the company covers nearly 7 million employees.

Founded in Portland, Oregon, in 1906, The Standard has built a national reputation for delivering quality insurance products, personalized service and strong financial performance. The Standard wrote its first group insurance policy in 1951, and it remains in force today as a testament to the company's commitment to building successful long-term relationships.

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19



Customer Service Your local Standard Insurance Company Employee Benefits Sales and Service Office will provide most of the ongoing service for your plan and can be reached at 800.633.8575 during normal business hours. We will assign your company a service representative who will provide regular contact and address questions and concerns related to the plan or the services we provide.

We also make it easy for covered employees and dentists to contact us to confirm eligibility or request claims information by calling 1-800-547-9515. Our customer service representatives are available Monday through Thursday from 5:00 a.m. until 10:00 p.m. Pacific Time and until 4:30 p.m. Pacific Time on Friday. For plan information any time, access our automated voice response system or go online to standard.com.

Max BuilderSM This dental plan includes a valuable feature that allows qualifying plan participants to carryover part of their unused annual maximum. A participant earns dental rewards by submitting at least one claim for dental expenses incurred during the benefit year, while staying at or under the threshold amount for benefits received for that year. In addition, a person earning dental rewards who submits a claim for services received through the dental network earns an extra reward, called the PPO Bonus. Employees and their covered dependents may accumulate rewards up to the stated maximum carryover amount, and then use those rewards for any covered dental procedures subject to applicable coinsurance and plan provisions. If a plan participant doesn't submit a dental claim during a benefit year, all accumulated rewards are lost. But he or she can begin earning rewards again the very next year.

Benefit Threshold $500 Dental benefits received for the year cannot exceed this amount

Annual Carryover Amount

$250 Max Builder amount is added to the following year's maximum

Annual PPO Bonus $100 Additional bonus is earned if the participant sees a network provider

Maximum Carryover $1,000 Maximum possible accumulation for Max Builder and PPO Bonus combined

Dental Network Information Employees and dependents have access to an extensive nationwide network of member dentists. The cost-saving benefits of visiting a network member dentist are automatically available to all employees and dependents who are covered by any of The Standard's dental plans and who live in areas where the nationwide network is available. To find member dentists in your area, visit: http://www.standard.com/dental and click on "Find a Dentist." California Residents: When prompted to select your network, choose the network found on your ID Card.

Pretreatment While we don't require a pretreatment authorization form for any procedure, we recommend them for any dental work you consider expensive. As a smart consumer, it's best for you to know your share of the cost up front. Simply ask your dentist to submit the information for a pretreatment estimate to our customer relations department. We'll inform both you and your dentist of the exact amount your insurance will cover and the amount that you will be responsible for. That way, there won't be any surprises once the work has been completed.

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20



Open Enrollment If a member does not elect to participate when initially eligible, the member may elect to participate at the policyholder's next enrollment period. This enrollment period will be held each year and those who elect to participate in this policy at that time will have their insurance become effective on June 1.

Late Entrant Provision We strongly encourage you to sign up for coverage when you are initially eligible. If you choose not to sign up during this initial enrollment period, you will become a late entrant. Late entrants will be eligible for only exams, cleanings, and fluoride applications for the first 12 months they are covered.

Section 125 This plan is provided as part of the Policyholder's Section 125 Plan. Each employee has the option under the Section 125 Plan of participating or not participating in this plan. If an employee does not elect to participate when initially eligible, he/she may elect to participate at the Policyholder's next Annual Election Period.

Please note: Cosmetic benefits in an insurance policy may have income tax implications for both employer groups and plan participants. For example, the dollar value of the cosmetic benefit may be considered part of an individual's taxable income. For more information concerning the tax ramifications of cosmetic insurance benefits, please consult your legal or tax adviser.

This form is a benefit highlight, not a certificate of insurance.

SAMPLEE

rticipate at the policyhicipatect to participate in this polict to participate in this po

LEigible. If you choose not to sign up during thisnot to sign up during this

be eligible for only exams, cleanings, and be eligible for only exams, cleanings, and

PL25 Plan. Each employee has the option under t5 Plan. Each employee has the option under

employeemplo e does not elect to participate when int elect to participate when iext Annual Election Period.xt Annual Election Period

may have income tax implications for both employer may have income tax implications for both employesmetic benefit may be considered part of an individumetic benefit may be conside

smetic insurance benefits, please consult your legal tic insurance benefits, plea

e of insurance.ce.

21



Plan 1: Balanced Care Vision I Plan Summary Effective Date: 6/1/2015 VSP Choice Network Out of Network

Deductibles $10 Exam $10 Exam

$25 Eye Glass Lenses or Frames* $25 Eye Glass Lenses or Frames Annual Eye Exam Covered in full Up to $45 Lenses (per pair)

Single Vision Covered in full Up to $30 Bifocal Covered in full Up to $50 Trifocal Covered in full Up to $65 Lenticular Covered in full Up to $100 Progressive See lens options NA

Contacts Fit & Follow Up Exams Participant cost up to $60 No benefit

Elective Up to $130 Up to $105 Medically Necessary Covered in full Up to $210

Frames $130 Up to $70 Frequencies (months)

Exam/Lens/Frame 12/12/24 12/12/24 Based on date of service Based on date of service

*Deductible applies to a complete pair of glasses or to frames, whichever is selected.

Lens Options (participant cost)* VSP Choice Network Out of Network

Progressive Lenses Up to provider’s contracted fee for Lined Bifocal Lenses. The patient is responsible

for the difference between the base lens and the Progressive Lens charge.

Up to Lined Bifocal allowance.

Std. Polycarbonate Covered in full for dependent children $33 adults

No benefit

Solid Plastic Dye $15 (except Pink I & II)

No benefit

Plastic Gradient Dye $17 No benefit Photochromatic Lenses

(Glass & Plastic) $31-$82 No benefit

Scratch Resistant Coating $17-$33 No benefit Anti-Reflective Coating $43-$85 No benefit Ultraviolet Coating $16 No benefit*Lens Option participant costs vary by prescription, option chosen and retail locations.

Monthly Rates Employee Only (EE) $14.16 EE + Spouse $28.08 EE + Children $27.16 EE + Spouse & Children $41.08 SAMPL

Eectivctiv

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Monthly RatesMonthly Rates

SSAE AASSAAASSASAASSASAdrenSSASAEE + Spouse & ChildrenSSSA

22



Additional Balanced Care Vision I Choice Network Features Contact Lenses Elective Allowance can be applied to disposables, but the dollar amount must be used all at once

(provider will order 3 or 6 month supply). Applies when contacts are chosen in lieu of glasses. For plans without a separate contact lens fit & follow up exam allowance, the cost of the fitting and evaluation is deducted from the contact allowance.

Additional Glasses 20% discount off the retail price on additional pairs of prescription glasses (complete pair).

Frame Discount VSP offers a 20% discount off the remaining balance in excess of the frame allowance.

Laser VisionCare VSP offers an average discount of 15% on LASIK and PRK. The maximum out-of-pocket per eye for participants is $1,800 for LASIK and $2,300 for custom LASIK using Wavefront technology, and $1,500 for PRK. In order to receive the benefit, a VSP provider must coordinate the procedure.

Low Vision With prior authorization, 75% of approved amount (up to $1,000 is covered every two years).

Eye Care Plan Participant Service Balanced Care Vision I eye care from The Standard features the money-saving eye care network of VSP. Customer service is available to plan participants through VSP's well-trained and helpful service representatives. Call or go online to locate the nearest VSP network provider, view plan benefit information and more.

VSP Call Center: 1-800-877-7195 Service representative hours: 5 a.m. to 7 p.m. PST Monday through Friday, 6 a.m. to 2:30 p.m. PST Saturday Interactive Voice Response available 24/7

Locate a VSP provider at: standard.com/services View plan benefit information at: vsp.com

Section 125 This plan is provided as part of the Policyholder's Section 125 Plan. Each employee has the option under the Section 125 Plan of participating or not participating in this plan. If an employee does not elect to participate when initially eligible, he/she may elect to participate at the Policyholder's next Annual Election Period.

This form is a benefit highlight, not a certificate of insurance.

SAMPLEE

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This form is a benefit highlight, not a certificate of insuThis form is a benefit highlight, not a

23

Group Basic Life and Accidental Deathand Dismemberment InsuranceBasic Life insurance from Standard Insurance Company helps provide fi nancial protection by promising to pay a benefi t in the event of an eligible member’s, or his or her dependent’s, covered death. Basic Accidental Death and Dismemberment (AD&D) insurance may provide an additional amount in the event of an insured member’s covered death or dismemberment as a result of an accident.

The cost of this insurance is paid by ABC Company, except for the cost of your dependent’s insurance, which is paid by you through payroll deduction. Enrollment materials needed to elect coverage will be provided.

Eligibility

Standard Insurance CompanyABC CompanyGroup Policy #123456Effective Date January 1, 2016

Defi nition of a Member You are a member if you are an active employee of ABC Company and regularly working at least 40 hours each week. You are not a member if you are a temporary or seasonal employee, a full-time member of the armed forces, a leased employee or an independent contractor.

Eligibility Waiting Period If you are already a member on the date the group policy is effective, you are eligible on that date. If you become a member after the group policy effective date, you are eligible on the fi rst day of the month that follows or coincides with 60 consecutive days of membership.

Basic Life Coverage Amount Your Basic Life coverage amount is $25,000.

Basic AD&D Coverage Amount For a covered accidental loss of life, your Basic AD&D coverage amount is $25,000. For other covered losses, a percentage of this benefi t will be payable.

Age Reductions Basic Life and AD&D insurance coverage amounts reduce by 35 percent at age 65, by 50 percent at age 70, and by 65 percent at age 75.

Basic Dependents Life CoverageAmount

The Basic Dependents Life coverage amount for your eligible spouse/domestic partner is $10,000.

The Basic Dependents Life coverage amount for each of your eligible children is $5,000.

Benefi ts

SASASAMPLEental Death

ranceide fi nancial protection by promising to paye fi nancial protection by promising to pay

ndent’s, covered death. Basic Accidental Deaths, covered death. Basic Accidental Deathonal amount in the event of an insured membernal amount in the event of an insured membe

t.

cept for the cost of your dependent’s insuranceept for the cost of your dependent’s insurancaterials needed to elect coverage will be providterials needed to elect coverage will be provid

AMPYou are a member if you are anYou are a meCompany and regularly worCompany and reweek. You are not a memweek. You are not seasonal employee, a fsonal employee, a leased employee oa leased employee

If you are alreaIf you are alreis effective,s effmember membon theon th60

Basic Life Coverage Amo

AD&D Coverage Am

enefi ts


Other Basic Life Features and Services• Accelerated Benefi t

• Repatriation Benefi t

• Standard Secure Access account payment option

• Waiver of Premium

Other Basic AD&D Features and Services• Air Bag Benefi t

• Expanded AD&D Package

• Line of Duty Benefi t

This information is only a brief description of the group Basic Life/AD&D and Basic Dependents Life insurance policy sponsored by ABC Company. The controlling provisions will be in the group policy issued by The Standard. The group policy contains a detailed description of the limitations, reductions in benefi ts, exclusions and when The Standard and ABC Company may increase the cost of coverage, amend or cancel the policy. A group certifi cate of insurance that describes the terms and conditions of the group policy is available for those who become insured according to its terms. For costs and more complete details of coverage, contact your human resources representative.


www.standard.com

SI 13279 (1/15)

• Portability of Insurance Provision

• Right to Convert Provision

• Travel Assistance

• Common Disaster Benefi t

• Family Benefi ts Package

• Seat Belt Benefi t

Group Basic Life and Accidental Death and Dismemberment Insurance

SAMPLEces

&D and Basic Dependents Life insurance policy sponsore&D and Basic Dependents Life insurance policy sponsorued by The Standard. The group policy contains a detaileed by The Standard. The group policy contains a detaile

ndard and ABC Company may increase the cost of coverndard and ABC Company may increase the cost of covee terms and conditions of the group policy is available for trms and conditions of the group policy is available for

ls of coverage, contact your human resources representas of coverage, contact your human resources represent

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amily Benefi ts Packagemily B

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25

Life insurance coverage is designed to help provide fi nancial support and stability to your family should you pass away. Accidental Death and Dismemberment (AD&D) insurance provides an extra layer of protection if you die or become dismembered in an accident. You can also cover your eligible spouse and children.

This plan offers:• Competitive group rates

• The convenience of payroll deduction

• Benefi ts if you are dismembered, become terminally ill or die

Group Additional Life and AD&D InsuranceHelp protect your loved ones from fi nancial hardship.


About This CoverageIf you take no action, you’ll be covered for the basic amount of Life insurance. Consider whether that would be enough to help your family meet daily expenses, maintain their standard of living, pay off debt and fund your children’s education. If not, you may want to apply for additional coverage now.

Life Insurance

How Much Can I Apply For?

Your combined basic Life and additional Life amounts may not exceed a maximum of 5 times your annual earnings. The coverage amount for your spouse cannot exceed 50 percent of your combined basic and additional Life coverage. The coverage amount for your child(ren)cannot exceed 25 percent of your combined basic and additional Life coverage.

For You: $10,000 – $500,000 in increments of $10,000

For Your Spouse: $10,000 – $200,000 in increments of $10,000

For Your Child(ren):

$10,000 – $50,000 in increments of $10,000

AD&D

What Does My AD&D Benefi t Provide?

Amount can’t exceed 5 times your annual earnings. Note: Coverage for your spouse is limited to 50 percent of your coverage. Coverage for your child(ren) cannot exceed 25 percent of your coverage.

For Yourself: If you elect AD&D insurance coverage, the benefi t amount is the same as the Life insurance benefi t.

For Your Spouse: If you elect AD&D insurance coverage, the benefi t amount is the same as the Life Insurance benefi t.

For Your Child(ren):

If you elect AD&D insurance coverage, the benefi t amount is the same as the Life insurance benefi t.

Keep in mind that the amount payable for certain losses is less than 100 percent of the AD&D insurance benefi t.

See the Important Details section for more information, including requirements, exclusions, age reductions and defi nitions.

SSAMPLE

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SAMpply F

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Additional FeaturesYour coverage comes with some added features:

Life

Accelerated Benefi t If you become terminally ill, you may be eligible to receive up to 75 percent of your Life benefi t to a maximum of $5 00,000.

Travel Assistance1 Available 24 hours a day, this service connects you to resources when you’re traveling at least 100 miles from home or in a foreign country for up to 180 days.

Life Services Toolkit2 The Life Services Toolkit for employees and benefi ciaries allows employees and benefi ciaries to access online content for will preparation, identity theft support and other tools and calculators, and provides benefi ciaries with services for grief, and legal and fi nancial matters.

AD&D

Seat Belt and Air Bag Benefi ts The Standard may pay an additional benefi t if you die while wearing a seat belt, provided certain conditions are met. If the car’s air bags deploy during an accident, an air bag benefi t may also be payable.

Family Benefi ts Package This benefi t is designed to help surviving family members maintain their standard of living and pursue their dreams. Included in the package are benefi ts to help with child care, career adjustment for your spouse and higher education for your children.

Public Transportation The Standard may pay an additional benefi t if you die as a result of an accident that occurs while you are riding as a fare-paying passenger on public transportation.

1 Travel Assistance is provided through an arrangement with a service provider that is not affi liated with The Standard. Travel Assistance is not an insurance product in all states except Oregon. For more information, visit www.standard.com/individual/insurance/group-services/travel-assistance.

2 The Life Services Toolkit is offered through an arrangement with a service provider that is not affi liated with The Standard. For more information, visit www.standard.com/individual/insurance/group-services/life-services-toolkit.

Group Additional Life and AD&D Insurance

SAMPLEo receive up to 75 percent of your Lifeeceive up to 75 percent of yo

onnects you to resources when you’re traveling atces whenreign country for up to 180 days.days.

employees and benefi ciaries allows employees andloyees and benefi ciaries allows employees and ine content for will preparation, identity theft support andent for will preparation, identity theft support and

nd provides benefi ciaries with services for grief, and legal d provides benefi ciaries with services for grief, and lega

AMAMA

e Standard may pay an additional benefi t if you die while wStandard may pay an additional certain conditions are met. If the car’s air bags deploy durtain conditions are met. If the cbenefi t may also be payable.efi t may also be payable.

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s provided through an arrangement with a service providprovided through an arrangement with a service product in all states except Oregon. For more information, visuct in all states except Oregon. For more information, v

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ervices Toolkit is offered through an arrangement with a solkit is offered through an arrangement ion, visit www.standard.com/individual/insurance/grow.standard.com/individual/insurance/


How Much Your Coverage Costs Your basic Life insurance is paid for by ABC Company. If you choose to purchase additional coverage, you’ll have access to competitive group rates, which may be more affordable than those available through individual insurance. You’ll also have the convenience of having your premium deducted directly from your paycheck. How much your premium costs depends on a number of factors, such as your age and the benefi t amount.

Use this formula to calculate your premium payment:

Enter the amount of Life and AD&D coverage you are requesting (see benefi t amounts in the About This Coverage section).

This amount is an estimate of how much you’d pay each month.

To get a sense of your semi-monthly premium, divide your monthly premium amount by 2.

÷ 1000 = x

How much Life insurance do you need?

After a serious accident or death in the family, there are many unexpected expenses. Your benefi ts could help your family pay for:

• Outstanding debt

• Burial expenses

• Medical bills

• Your children’s education

• Daily expenses

Estimating your insurance needs depends on your unique circumstances. Use our online calculator at www.standard.com/life/needs to fi gure out how much insurance you need.

Age (as of 01/01/2016)

Your Rate* (Per $1,000 of Total Coverage)

Your Spouse’s Rate*(Per $1,000 of

Total Coverage)

<30 $0.050 $0.050

30–34 $0.050 $0.050

35–39 $0.057 $0.057

40–44 $0.085 $0.085

45–49 $0.122 $0.122

50–54 $0.210 $0.210

55–59 $0.339 $0.339

60–64 $0.460 $0.460

65–69 $0.820 $0.820

70–74 $1.800 $1.800

75+ $7.000 $7.000

=

Enter your rate from the rate table.

If you buy additional coverage for your spouse, your monthly rate is shown in the table below. Use the same formula to calculate the premium that you used for yourself, but use your spouse’s age and your spouse’s rate.

If you buy coverage for your child(ren), your monthly rate is $0.42 per $1,000, no matter how many children you’re covering.

* Includes a monthly AD&D rate of $0.0 3 per $1,000 of AD&D benefi t.


SAMPH

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40–44 $0.085$0.

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50–54 $0.210$

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** Includes a monthly AD&D rate of $Includes a monthly AD&D rate


Life and AD&D Insurance Eligibility Requirements

A minimum number of eligible employees must apply and qualify for the proposed plan before additional Life coverage can become effective. If this requirement is not met, the additional coverage will not become effective.To be eligible for coverage, you must be:

• A regular employee of ABC Company

• Actively working at least 30 hours per week

• For additional Life insurance, you must be insured forbasic life insurance through The Standard

Temporary and seasonal employees, full-time members of the armed forces, leased employees and independent contractors are not eligible.

You can choose to cover your spouse, a person to whom you are legally married, or your domestic partner as recognized by law. You may also choose to cover your child. Child means your unmarried child from live birth through age 20. Your child cannot be insured by more than one employee. Your spouse or children must not be full-time member(s) of the armed forces. You cannot be insured as both an individual and a dependent.

Medical Underwriting Approval for Life Coverage

Required for:

• Coverage amounts higher than the Guarantee IssueMaximum amount

• All late applications (applying 31 days after becomingeligible)

• Requests for coverage increases

• Reinstatements

• Employees eligible but not insured under the priorlife insurance plan

Visit www.standard.com/mhs to submit a medical history statement online.

Coverage Effective Date for Life Coverage

To become insured, you must meet the eligibility requirements listed in the sections above, receive medical underwriting approval (if applicable), apply for coverage and agree to pay premium and be actively at work (able to perform all normal duties of your job) on the day before the insurance is scheduled to be effective. If you are not actively at work on the day before the scheduled effective date of insurance including Dependents Life insurance,

your insurance will not become effective until the day after you complete one full day of active work as an eligible employee. In addition to meeting the requirements above, you must also apply for the additional coverage and agree to pay premium before insurance becomes effective. You may have a different effective date for your basic and additional coverage as well as coverage requiring medical underwriting approval.

Life and AD&D Age Reductions

Under this plan, your coverage amount reduces to 65 percent at age 65, to 50 percent at age 70 and to 35 percent at age 75. Your spouse’s coverage amount reduces by your spouse’s age as follows: to 65 percent at age 65, to 50 percent at age 70 and to 35 percent at age 75. If you or your spouse are age 65 or over, ask your human resources representative or plan administrator for the amount of coverage available.

Life Insurance Waiver of Premium

Your Life premiums may be waived if you:

• Become totally disabled while insured under this plan

• Are under age 65, and

• Complete a waiting period of 60 days, or if you receivean accelerated benefi t for a qualifying medical condition and are under age 50.

If these conditions are met, your basic and additional Life insurance coverage may continue without cost until age 75, provided you give us satisfactory proof that you remain totally disabled.

Life and AD&D Insurance Portability

If your insurance ends because your employment terminates, you may be eligible to buy portable group insurance coverage from The Standard.

Life Insurance Conversion

If your insurance reduces or ends, you may be eligible to convert your existing additional Life insurance to an individual Life insurance policy without submitting proof of good health.

Important DetailsHere’s where you’ll fi nd the nitty-gritty details about the plan.


SAMPLrs

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e and AD&D Age ReductionsD&D A

Under this plan, your coverage amount reducesUnder this plan, your coverage amount reducpercent at age 65, to 50 percent at age 70 apercent at age 65, to 50 percent at age 70 apercent at age 75. Your spouse’s coveragpercent at age 75. Your spouse’s coveragreduces by your spouse’s age as followyour spouse’s age as folloat age 65, to 50 percent at age 70 anto 50 percent at age 70 aage 75. If you or your spouse are If you or your spouse arehuman resources representativhuman resothe amount of coverage avathe amo

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Life Insurance Exclusions

You and your dependents are not covered for death resulting from suicide or other intentionally self-infl icted injury, while sane or insane. The amount payable will exclude amounts that have not been continuously in effect for at least two years on the date of death.

AD&D Benefi ts

The amount of the AD&D benefi t is equal to the amount payable for your or your spouse’s or child’s Life benefi t on the date of the accident. For all other covered losses, the amount is shown as a percentage of the amount payable for the benefi t on the date of the accident. No more than 100 percent of the AD&D benefi t will be paid for all losses resulting from one accident.

Any loss must be caused solely and directly by an accident within 365 days of the accident. A certifi ed copy of the death certifi cate is needed to prove loss of life.

Covered loss: Percentage of AD&Dbenefi t payable:

Life1 100%

One hand or one foot2 50%

Sight in one eye, speech or 50%hearing in both ears

Two or more of the 100%losses listed above

Thumb and index fi nger 25%of the same hand3

Quadriplegia 100%

Triplegia 75%

Hemiplegia 50%

Paraplegia 50%

Uniplegia 25%

All other losses must be certifi ed by a physician in the appropriate specialty determined by The Standard.

1 Includes loss of life caused by accidental exposure to adverse weather conditions or disappearance if disappearance is caused by an accident that reasonably could have resulted in your death.

2 Even if the severed part is surgically re-attached. This benefi t is not payable if an AD&D benefi t is payable for quadriplegia, triplegia, hemiplegia, paraplegia or uniplegia involving the same hand or foot.

3 This benefi t is not payable if an AD&D benefi t is payable for the loss of the entire hand.

AD&D Insurance Exclusions

You are not covered for death or dismemberment caused or contributed to by any of the following:

• Committing or attempting to commit an assault or

felony, or actively participating in a violent disorder or riot

• Suicide or other intentionally self-infl icted injury, whilesane or insane

• War or any act of war (declared or undeclared), andany substantial armed confl ict between organizedforces of a military nature

• Voluntary consumption of any poison, chemicalcompound, alcohol or drug, unless used or consumed according to the directions of a physician

• Sickness or pregnancy existing at the time of theaccident

• Pregnancy, except for a complication of pregnancyresulting from the accident

• Heart attack or stroke

• Medical or surgical treatment for any of the above

• Boarding, leaving or being in or on any kind of aircraft,unless you are a fare-paying passenger on acommercial aircraft

When Your Insurance Ends

Your insurance ends automatically when any of the following occur:

• The date the last period ends for which a premiumwas paid

• The date your employment terminates

• The date you cease to meet the eligibility requirements(insurance may continue for limited periods under certain circumstances)

• The date the group policy, or your employer’s coverageunder the group policy, terminates

• For each elective insurance coverage, the date thatcoverage terminates under the group policy

• The date your Life coverage ends, your AD&Dcoverage will end as well

In addition to the above requirements, your Dependents Life with AD&D coverage ends automatically on the date your dependent ceases to meet the eligibility requirements for a dependent. For more details on when your insurance ends, contact your human resources representative or plan administrator.

Group Insurance Certifi cate

If coverage becomes effective, and you become insured, you will receive a group insurance certifi cate containing a detailed description of the insurance coverage including the defi nitions, exclusions, limitations, reductions and terminating events. The controlling provisions will be in


SAMPLE

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AD&DAD&ayable:able:

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50%

100%

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100%100%

75%75%

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araplegia 50%aplegia 50%

Uniplegia 25%Uniplegia

All other losses must be certifi ed by a phye cerappropriate specialty determined by Thpecialty determ

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natureture

umption of any poison, chemical f any poison, chealcohol or drug, unless used or consumed unless used or consumed

to the directions of a physiciana physi

ess or pregnancy existing at the time of thess or pregnancy existing at the time of the dentnt

Pregnancy, except for a complication of pregnaregnancy, except for a complication of pregnresulting from the accidentresulting from the ac

•• Heart attack or strokeHeart attack or stroke

• Medical or surgical treatment for any surgical treatment for any

• Boarding, leaving or being in or og, leaving or being in or ounless you are a fare-paying ps you are a fare-paying pcommercial aircraftcommerc

When Your Insurance EWhen Y

Your insurance ends aYour insuranfollowing occur:following occu

• The date theThe date thwas paidas pai

• The d

• Th


the group policy. Neither the information presented in this summary nor the certifi cate modifi es the group policy or the insurance coverage in any way.

GP190-LIFE/S399, GP399-LIFE/TRUST,GP899-LIFE, GP190-LIFE/A997/S399, GP411-LIFE


www.standard.com

SI 12506 (4/15)


SAMPLE

31

Travel Assistance14684 (8/15) SI/SNY EE

Things can happen on the road. Passports get stolen or lost. Unforeseen events or circumstances derail travel plans. Medical problems surface at the most inconvenient times. Travel Assistance can help you navigate these issues and more at any time of the day or night.

You and your spouse are covered with Travel Assistance — and so are kids through age 251 — with your group insurance from The Standard.‡

Security That Travels with You

Travel Assistance is available when you travel more than 100 miles from home or internationally for up to 180 days for business or pleasure. It offers aid before and during your trip, including:

Passport, visa, weather and currency exchange information, health hazards advice and inoculation requirements

Emergency ticket, credit card and passport replacement, funds transfer and missing baggage

Connection to medical care providers and interpreter services

24/7/365 phone access to registered nurses for health and medication information, symptom decision support, and help understanding treatment options

Emergency evacuation to the nearest adequate medical facility and medically necessary repatriation to the employee’s home, including repatriation of remains2

Connection to a local attorney, consular offi cer or bail bond services

Logistical arrangements for ground transportation, housing and/or evacuation in the event of political unrest and social instability; for more complex situations, assists with making arrangements with providers of specialized security services


The Standard Life Insurance Company of New York

www.standard.com

‡ The Standard is a marketing name for StanCorp Financial Group, Inc. and subsidiaries. Insurance products are offered by Standard Insurance Company of 1100 SW Sixth Avenue, Portland, Oregon, in all states except New York, where insurance products are offered by The Standard Life Insurance Company of New York of 360 Hamilton Avenue, Suite 210, White Plains, New York. Product features and availability vary by state and company, and are solely the responsibility of each subsidiary. Each company is solely responsible for its own fi nancial condition. Standard Insurance Company is licensed to solicit insurance business in all states except New York. The Standard Life Insurance Company of New York is licensed to solicit insurance business in only the state of New York.

Contact Travel Assistance

800.527.0218United States, Canada, Puerto Rico, U.S. Virgin Islands and Bermuda

+1.410.453.6330Everywhere else

[email protected]

www.standard.com/travel

Global Intelligence Centerwww.standard.com/travelGroup #9061

Travel Assistance is available if you travel more than 100 miles from home or in a foreign country.

Contact800.527.0218: United States, Canada, Puerto Rico, U.S. Virgin Islands and Bermuda+1.410.453.6330: Everywhere [email protected]

UnitedHealthcare Global is not responsible for the availability or results of any medical, legal, or transportation services. You are responsible for obtaining all services not directly provided by UnitedHealthcare Global and for the expenses associated with them. All services must be arranged by UnitedHealthcare Global. No claims for reimbursement will be accepted.

1 Travel Assistance is provided through an arrangement with UnitedHealthcare Global, which is not affi liated with The Standard, and is subject to the terms and conditions, including exclusions and limitations, of the Emergency Travel Assistance Program Employee Description. UnitedHealthcare Global is solely responsible for providing and administering the included service. Travel Assistance is not an insurance product, except in Oregon. UnitedHealthcare Global is the marketing name for FronterMEDEX, Inc. This service is only available while insured underThe Standard’s group policy.

2 Must be arranged by UnitedHealthcare Global. Related medical services, medical supplies and a medical escort are covered where applicable and necessary.

Travel AssistanceExplore the World with Confi dence

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‡

n 100 miles from100 mss or pleasure. It offers s or pleasure. It offers

ency exchange information,ency exchange information,culation requirementsulation requirement

ard and passport replacement, fundsd passport replacemeggage

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ing treatment optionsg treatment opt

ncy evacuation to the nearest adequate medicauation to the nearest adequamedically necessary repatriation to the employessary repatriation to the em

cluding repatriation of remainsuding repatriation of rema 2

Connection to a local attorney, consular offi ceonnection to a local attorney, cbail bond servicesbond services

Logistical arrangements for ground transtical arrangements for ground traand/or evacuation in the event of polir evacuation in the event of poinstability; for more complex situatity; for more complex situaarrangements with providers of ments with

‡ ‡ The Standard is a marketing name for StanCorp Fi The Standard is a marketing namInsurance products are offered by Standard Insred bPortland, Oregon, in all states except New Yogon, in all states excThe Standard Life Insurance Company of dard Life Insurance CompWhite Plains, New York. Product featuree Plains, New York. Product featsolely the responsibility of each subssolely the responsibility of each subfi nancial condition. Standard Insufi nancial condition. Standard Iall states except New York. Theork. Tsolicit insurance business inness in

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32

Group Short Term Disability InsuranceProtect your income and those who depend on it.

This coverage replaces a portion of your income when you can’t work because of a qualifying disability. Even if you’re healthy now, it’s important to protect yourself and the people who count on your income. This insurance can help you pay the bills when you’re unable to work.




• Benefi ts for a qualifying disability that occurs on or off the job

About This CoverageYou will be automatically enrolled in the base plan if you do not elect buy-up coverage and the policy becomes effective. See the Important Details section for more information, including requirements, exclusions and defi nitions.

Base coverage provided by ABC Company at no cost to you

Buy-up coverage you can purchase, paid for by you

What Your Benefi t ProvidesThis is the benefi t you’d receive if you were to suffer a qualifying disability. Eligible earnings are your weekly insured predisability earnings, as defi ned by the group policy. Your benefi t amount will be reduced by deductible income; see the Important Details section for a list of deductible income sources.

40% of your eligible earnings, up to a maximum of $5,000 per week.

An additional 20% for a total of 60% of your eligible earnings, up to a maximum of $5,000 per week.

When Your Benefi ts BeginIf you suffer a qualifying disability, your benefi t waiting period is the length of time you must be continuously disabled before you can begin receiving your weekly benefi t.

• 1 day for accidental injury• 8 days for physical

disease, pregnancy ormental disorder

• 1 day for accidental injury• 8 days for physical

disease, pregnancy ormental disorder

How Long Your Benefi ts LastThis is the maximum length of time you could be eligible to receive a weekly disability benefi t.

90 days 90 daysSSAMPLEInsurance

ork because of a qualifying disability. Even if k because of a qualifying disability. Even if ple who count on your income. This insurance ho count on your income. This insurance

MPLs:

e of payroll deduction

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CoverageCoenrolled in the base plan if you do not elect buy-urolled in the base plan if you do not elect buy

rtant Details section for more information, includietails section for more information, includ

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nefi t Providesou’d receive if you were to suffe

ligible earnings are your weekly nsured predisability earnings, as defi ned by the group policy. Your benefi t amount will be reincome; see the Important Details

s.

4

Your Benefi ts Beginf you suffer a qualifying disability, yperiod is the length of time you mdisabled before you can beg

ow Long Your B


Group Short Term Disability Insurance


How Much Your Coverage CostsYour base policy is paid for by ABC Company and costs you nothing. If you choose to purchase buy-up coverage, you’ll have access to competitive group rates that may be more affordable than those available through individual insurance. You’ll also have the convenience of having your premium deducted directly from your paycheck. How much your premium costs depends on a number of factors, such as your age and benefi t amount.

Use this formula to calculate your premium payment for your buy-up coverage:

Enter your weekly earnings (cannot be more than $5,000).




x ÷ 10 =

Not being able to work also means not being able to earn a paycheck. As you consider whether to purchase Buy-Up Short Term Disability insurance, think about the expenses you would need to cover if you were to become disabled:

• Mortgage or rent

• Utilities

• Groceries

• Medical bills

• Car insurance

• Childcare costs

Your base plan replaces 40% of your income. Would you be able to pay your bills on such a reduced paycheck? If not, consider applying for more coverage. For help fi guring out how much coverage you need, use our online calculator at standard.com/disability/needs.

Your Age (as of 01/01/2016)

Rate per $10 of weekly benefi t

<30 $0.65

30–34 $0.76

35–39 $0.58

40–44 $0.55

45–49 $0.70

50–54 $0.78

55–59 $0.93

60–64 $1.19

65+ $1.27

Help With Returning To Work This plan provides incentives to help you get back to work. For instance, we’ll help pay for some of the expenses associated with participating in an approved rehabilitation plan. This may include expenses related to training and education, child and elder care, and job searching, among other expenses.

If a worksite modifi cation would enable you to return to work, we can help your employer make approved modifi cations by covering some or all of the cost.

Daily Hospital Benefi t You can receive a benefi t for each day during your benefi t waiting period that you are confi ned in a hospital for at least four hours.

SAMPLCoverage Costsverage Costsompany and costs you nothing. If you choose to pd costs you nothing. If

oup rates that may be more affordable than thosmay be more affordable onvenience of having your premium deducted direng your premium deducted

pends on a number of factors, such as your age aends on a number of factors, such as your age

SAMalculate your premium

ybe

Enter your rate from the rate table

SSASSSSSge 1/01/2016)

Rateof week

<30< $0.6$0

30–34

35–39

40–4440

45–4945–49

–54

PPLEto help you get back to work.o help you get back to w

y for some of the expensesr some of the expensesating in an approved rehabilitationan approved reha

e expenses related to training and elated to trainnd elder care, and job searching, among ob sear

modifi cation would enable you to returnmodifi cation would enable you to retuwe can help your employer make approvedhelp your employer make approved

cations by covering some or all of the cost.ations by covering some or all of the cost.

You can receive a benefi t for each day during yoou can receive a benefi t for each day during ywaiting period that you are confi ned in a hospwaiting period that you are confi ned in a hosfour hours.fou


Eligibility RequirementsTo be eligible for coverage, you must be:

• A regular employee of ABC Company working in theUnited States


• A citizen or resident of the United States or Canada


Employee Coverage Effective DateTo become insured, you must meet the eligibility requirements listed above, apply for coverage and agree to pay premium, receive medical underwriting approval and be actively at work (able to perform all normal duties of your job) on the day before the scheduled effective date of insurance. If you are not actively at work on the day before the scheduled effective date of insurance, your insurance will not become effective until the day after you complete one full day of active work as an eligible employee.

All late applications (applying 31 days after becoming eligible) are subject to medical underwriting approval. Employees eligible but not insured under the prior Short Term Disability insurance plan are also subject to medical underwriting approval. Please contact your human resources representative or plan administrator for more information regarding the requirements that must be satisfi ed for your insurance to become effective.

Defi nition of DisabilityYou will be considered disabled if, as a result of physical disease, injury, pregnancy or mental disorder:

• You are unable to perform the material duties of yourown occupation, and

• You suffer a loss of at least 20 percent in yourpredisability earnings when working in your ownoccupation.

You are not considered disabled merely because your right to perform your own occupation is restricted, including a restriction or loss of license.

ExclusionsSubject to state variations, you are not covered for a disability caused or contributed to by any of the following:

• Your committing or attempting to commit an assault orfelony, or your active participation in a violent disorder or riot

• An intentionally self-infl icted injury

• War or any act of war (declared or undeclared, and anysubstantial armed confl ict between organized forces ofa military nature)

• An activity arising out of or in the course of anyemployment for wage or profi t

LimitationsShort Term Disability benefi ts are not payable for any period when you are:

• Not under the ongoing care of a physician

• Not participating in good faith in a plan, program orcourse of medical treatment or vocational training oreducation approved by The Standard, unless yourdisability prevents you from participating

• Confi ned for any reason in a penal or correctionalinstitution

• Able to work and earn at least 20 percent of yourpredisability earnings in your own occupation but youelect not to

• Receiving sick-leave pay, annual or personal leave pay,or other salary continuation from your employer

When Your Benefi ts EndYour Short Term Disability benefi ts end automatically on the date any of the following occur:

• You are no longer disabled

• Your maximum benefi t period ends

• Long term disability benefi ts become payable to youunder a long term disability plan

• Benefi ts become payable under any other disabilityinsurance plan under which you become insuredthrough employment during a period of temporaryrecovery

• You fail to provide proof of continued disability andentitlement to benefi ts

• You pass away

• Your work earnings equal or exceed 80 percent of yourpredisability earnings



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ation regarding the requirements that must beding the requirements that must besfi ed for your insurance to become effective.surance to become effective.

Defi nition of DisabilityDefi nition of DisabilityYou will be considered disabled if, as a resuYou will be considered disabdisease, injury, pregnancy or mental disocy o

• You are unable to perform the mare unable to perform thown occupation, andwn occupation, and

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ontributed to by any of the followingtributed to by any of the

ng or attempting to commit an assault or pting to commit an assault or our active participation in a violent disorderation in a violent disorder

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•• An activity arising out of or in the coursearising out of or in the coursemployment for wage or profi tnt for wage or profi t

LimitationsonsShort Term Disability benefi ts aShort Term period when you are:period w

• Not under the ongoingot und

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•


Deductible IncomeYour benefi ts will be reduced if you have deductible income while receiving Short Term Disability benefi ts. Deductible income includes:

• Sick pay, annual or personal leave pay, severance pay orother forms of salary continuation (including donatedamounts) paid

• Amounts under any workers’ compensation law orsimilar law

• Amounts under unemployment compensation law

• Amounts because of your disability from any othergroup insurance

• Disability or retirement benefi ts under your employer’sretirement plan

• Amounts under any state disability income benefi t lawor similar law

• Earnings from work activity while you are disabled

• Earnings or compensation included in your predisability earnings which you receive or are eligible to receive while STD benefi ts are payable

• Amounts due from or on behalf of a third partybecause of your disability, whether by judgment,settlement or other method

• Any amount you receive by compromise, settlement orother method as a result of a claim for any of the above

When Your Insurance EndsYour insurance ends automatically when any of the following occur:



• The date the group policy (or your employer’s coverageunder the group policy) terminates

• The date you cease to meet the eligibility requirements(insurance may continue for limited periods undercertain circumstances)

• The date ABC Company ends participation in thegroup policy

Group Insurance Certifi cateIf coverage becomes effective, and you become insured, you will receive a group insurance certifi cate containing a detailed description of the insurance coverage including the defi nitions, exclusions, limitations, reductions and

terminating events. The controlling provisions will be in the group policy. Neither the information presented in this summary nor the certifi cate modifi es the group policy or the insurance coverage in any way.

GP399-STD, GP899-STD, GP309-STD, GP209-STD, GP399/ASSOC, GP399-STD/TRUST, GP190-STD/S399


www.standard.com

SI 12510 (3/15)


SAMPLE

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SISI 1251012510 (3/15) (3/15)

36

Health Advocacy Solution15512 (8/15) SI/SNY EE

When you’re sick or injured, the last thing you want to do is line up doctors, fi gure out bills and try to get straight answers about your healthcare. A Personal Health Advocate can help during these times, as well when routine care or other services are needed. It’s one of the benefi ts of the Health Advocacy Solution* available through your group insurance coverage from The Standard.‡

A Personal Health Advocate isn’t just for you — your spouse or domestic partner, children, parents and parents-in-law can also take advantage of this valuable benefi t.

A Personal Health Advocate Is on Your SideThere’s no need to take on the healthcare system by yourself. A Personal Health Advocate will stay with your case until it’s resolved. Personal Health Advocates — typically registered nurses — can help:

Coordinate care between you, physicians, medical institutions and insurers

Locate doctors, dentists, hospitals, alternative medicine practitioners and wellness services

Answer questions about your prescription drug coverage and options to help control costs

Explain information and medical terminology associated with your medical condition

Obtain appropriate approvals from insurance companies for needed services or negotiating billing and payment arrangements

Locate care and services for eldercare or for people with special needs, and assistance with Medicare and Medicaid

* Health Advocacy services are providedthrough an arrangement with HealthAdvocateTM, a leading health assistance andsupport company. Health Advocate is notaffi liated with The Standard or with anyinsurance or third-party provider. HealthAdvocate does not replace health insurancecoverage, provide medical care orrecommend treatment. The Health Advocacyservice is not an insurance product.

‡ The Standard is a marketing name forStanCorp Financial Group, Inc. andsubsidiaries. Insurance products are offeredby Standard Insurance Company ofPortland, Oregon, in all states except NewYork, where insurance products are offeredby The Standard Life Insurance Company ofNew York of White Plains, New York. Productfeatures and availability vary by state andcompany, and are solely the responsibility ofeach subsidiary. Each company is solelyresponsible for its own fi nancial condition.Standard Insurance Company is licensed tosolicit insurance business in all states exceptNew York. The Standard Life InsuranceCompany of New York is licensed to solicitinsurance business in only the state of NewYork.



www.standard.com

Rely on your Personal Health Advocate to:• Find the right doctors,

specialists and hospitals• Untangle medical bills• Locate eldercare and

support services• Help you save time and

worry less• Secure second opinions,

schedule appointmentsand more

Personal Health AdvocateA Champion to Help Navigate the Healthcare System Maze

Contact Health AdvocateTM

Phone: 866.695.8622 24 hours a day, seven days a week

Personal Health Advocates are available Monday–Friday, 8 a.m.–9 p.m. Eastern time

Email: [email protected]

Web: members.healthadvocate.com

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37

Group Long Term Disability InsuranceProtect your income when you’re coping with a long-lasting disability.


This coverage is designed to replace a portion of your income when you’re disabled for an extended period of time due to a qualifying disability and help you get back to work when you’re ready. Long Term Disability (LTD) insurance benefi ts can help you pay your bills and safeguard your savings when you’re unable to work. Whether you’re out for a few months or several years, this benefi t can help you protect your income — and those who depend on it.



• Benefi ts for a qualifying disability that occurs on or off the job

About This CoverageWhat Your Benefi t ProvidesThis is the amount per month you would receive if you were to suffer a qualifying disability. Eligible earnings are your monthly insured predisability earnings, as defi ned by the group policy. Your monthly benefi t will be reduced by deductible income. Please see the Important Details section for a list of deductible income sources.

60% of your eligible earnings, up to a maximum of $25,000 per month.

Benefi t amounts greater than $5,000 require that you answer health questions. Submit a medical history statement online at www.standard.com/mhs.

How Long Your Benefi ts LastThis is the maximum length of time you could be eligible to receive disability benefi ts for a continuous disability.

Until your Social Security Normal Retirement Age (SSNRA).

If you become disabled when you are 62 or older, please see the Important Details section for information about your maximum benefi t period.

See the Important Details section for more information, including requirements, exclusions and defi nitions.SAMPLEnsurance

sting disability.bility.

MPLyou’re disabled for an extended period of timeou’re disabled for an extended period of time

you’re ready. Long Term Disability (LTD) insurane ready. Long Term Disability (LTD) insuras when you’re unable to work. Whether you’re owhen you’re unable to work. Whether you’re o

ct your income — and those who depend on it.ct your income — and those who depend on it

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ayroll deduction

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eceive disability benefi ts for a cont

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Group Long Term Disability Insurance

Help With Returning To Work This plan provides incentives to help you get back to work. For instance, we’ll help you pay for some of the expenses associated with participating in an approved rehabilitation plan.

If a worksite modifi cation would enable you to return to work, we can help your employer make approved modifi cations by covering some or all of the cost.

You may also be eligible to receive an additional benefi t of 10 percent of your predisability earnings for participating in an approved rehabilitation plan, subject to the plan maximum.

Survivors Benefi t If you die while receiving benefi ts, your survivor may be eligible to receive a lump sum payment.

Support When You Need It You’ll have access to an Employee Assistance Program. This is a valuable confi dential counseling resource if you’re experiencing personal or work-related issues.

Lifetime Security Benefi t Additional benefi ts may be payable to you if your LTD benefi ts end due to the maximum benefi t period, you remain disabled and you are unable to perform two or more activities of daily living or are suffering severe cognitive impairment.

Cost of Living Adjustment Your LTD benefi t will be increased annually by an amount equal to the rate of increase in the Consumer Price Index (CPI-W) up to a maximum of 10 percent.

Assisted Living Benefi t Your benefi t will be increased to 80 percent of your predisability earnings when you are unable to perform two or more activities of daily living or suffering severe cognitive impairment. The maximum benefi t amount cannot exceed $5,000 in addition to the LTD benefi t.

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How Much Your Coverage Costs Because this insurance is offered through ABC Company, you’ll have access to competitive group rates that may be more affordable than those available through individual insurance. You’ll also have the convenience of having your premium deducted directly from your paycheck. How much your premium costs depends on a number of factors, such as your age and benefi t amount.

Use this formula to calculate your premium payment:

Enter your monthly earnings (cannot be more than $25,000).



x ÷ 100 =

As you consider Long Term Disability insurance, evaluate what makes sense for you.

Getting by without a paycheck isn’t easy, especially for an extended period of time. Make sure you have enough fi nancial protection to help you with housing costs, utilities and other bills.

To estimate you insurance needs, you’ll need to consider your unique circumstances. Use our online calculator at www.standard.com/disability/needs.

Your Age (as of 01/01/2016)

Rate Percentage

<30 0.29

30–34 0.51

35–39 0.87

40–44 1.28

45–49 1.79

50–54 2.45

55–59 2.98

60–64 2.87

65–69 2.59

70–74 4.48

75+ 5.95


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Eligibility Requirements

A minimum number of eligible employees must apply and qualify for the proposed plan before coverage can become effective. If this requirement is not met, this plan will not become effective. To be eligible for coverage, you must be:

• A regular employee of ABC Company


• A citizen or resident of the United States or Canada


Employee Coverage Effective Date

To become insured, you must meet the eligibility requirements listed above, apply for coverage and agree to pay premium, receive medical underwriting approval and be actively at work (able to perform all normal duties of your job) on the day before the scheduled effective date of insurance. If you are not actively at work on the day before the scheduled effective date of insurance, your insurance will not become effective until the day after you complete one full day of active work as an eligible employee.

All late applications (applying 31 days after becoming eligible), requests for coverage increases and reinstatements are subject to medical underwriting approval. Employees eligible but not insured under the prior Long Term Disability insurance plan are also subject to medical underwriting approval. Please contact your human resources representative or plan administrator for more information regarding the requirements that must be satisfi ed for your insurance to become effective.

Defi nition of Disability

For the benefi t waiting period and the fi rst 12 months that Long Term Disability benefi ts are payable, you will be considered disabled if, as a result of physical disease, injury, pregnancy or mental disorder:

• You are unable to perform with reasonable continuitythe material duties of your own occupation, and

• You suffer a loss of at least 20 percent in yourpredisability earnings when working in your ownoccupation.

You are not considered disabled merely because your right to perform your own occupation is restricted, including a restriction or loss of license.

After the benefi t waiting period and the fi rst 12 months that Long Term Disability benefi ts are payable, you will be considered disabled if, as a result of a physical disease, injury, pregnancy or mental disorder, you are unable to perform with reasonable continuity the material duties of any occupation.

Maximum Benefi t Period

If you are younger than 62 when you become disabled, you are eligible to receive benefi t payments until you reach Social Security Normal Retirement Age (SSNRA). If you become disabled when you are 62 or older, the benefi t duration is determined by your age when disability begins:

Age Maximum Benefi t Period

62 To SSNRA, or 3 years 6 months, whichever is longer

63 To SSNRA, or 3 years, whichever is longer

64 To SSNRA, or 2 years 6 months, whichever is longer

65 2 years

66 1 year 9 months

67 1 year 6 months

68 1 year 3 months

69+ 1 year

Exclusions

Subject to state variations, you are not covered for a disability caused or contributed to by any of the following:

• Your committing or attempting to commit an assault orfelony, or your active participation in a violent disorderor riot

• An intentionally self-infl icted injury

• War or any act of war (declared or undeclared, and anysubstantial armed confl ict between organized forces ofa military nature)

• The loss of your professional or occupational license orcertifi cation



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• A preexisting condition or the medical or surgicaltreatment of a preexisting condition unless on the dateyou become disabled, you have been continuouslyinsured under the group policy for a specifi ed period oftime, and you have been actively at work for at leastone full day after the end of the exclusion period

Preexisting Condition Provision

A preexisting condition is a mental or physical condition whether or not diagnosed or misdiagnosed:

• For which you or a reasonably prudent person wouldhave consulted a physician or other licensed medicalprofessional; received medical treatment, services oradvice; undergone diagnostic procedures, includingself-administered procedures; or taken prescribeddrugs or medications

• Which, as a result of any medical examination,including routine examination, was discovered orsuspected

Preexisting Condition Period: The 180-day period just before your insurance becomes effective

Limitations

Long Term Disability benefi ts are not payable for any period when you are:

• Not under the ongoing care of a physician in theappropriate specialty, as determined by The Standard

• Not participating in good faith in a plan, program or course of medical treatment or vocational training or education approved by The Standard, unless your disability prevents you from participating

• Confi ned for any reason in a penal or correctionalinstitution

• Able to work and earn at least 20 percent of yourindexed predisability earnings, but you elect not towork throughout the own occupation period.

In addition, the length of time you can receive Long Term Disability payments will be limited if:

• You reside outside of the United States or Canada

• Your disability is caused or contributed to by mentaldisorders, substance abuse or the environment, chronic fatigue conditions, chronic pain conditions, carpal tunnel or repetitive motion syndrome or temporomandibular joint disorder or craniomandibular joint disorder

When Your Benefi ts End

Your Long Term Disability benefi ts end automatically on the date any of the following occur:

• You are no longer disabled

• You maximum benefi t period ends

• Benefi ts become payable under any other disabilityinsurance plan under which you become insured through employment during a period of temporary recovery

• You fail to provide proof of continued disability andentitlement to benefi ts

• You pass away

• The date your work earnings equal or exceed 80percent of your indexed predisability earnings

Deductible Income

Your benefi ts will be lower if you have deductible income, which is income you receive or are eligible to receive while receiving Long Term Disability benefi ts. Deductible income includes:

• Sick pay, annual or personal leave pay, severance payor other forms of salary contribution (including donatedamounts) paid

• Benefi ts under any workers’ compensation law orsimilar law

• Amounts under unemployment compensation law

• Social Security disability or retirement benefi ts,including benefi ts for your spouse and children

• Amounts because of your disability from any othergroup insurance

• Disability or retirement benefi ts under your employer’sretirement plan

• Benefi ts under any state disability income benefi t lawor similar law

• Earnings from work activity while you are disabled

• Earnings or compensation included in yourpredisability earnings which you receive or are eligibleto receive while LTD benefi ts are payable

• Amounts due from or on behalf of a third partybecause of your disability, whether by judgment,settlement or other method

• Any amount you receive by compromise, settlement orother method as a result of a claim for any of the above


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Benefi t Calculation – Example

The LTD benefi t amount is determined by multiplying your insured predisability earnings by the specifi ed benefi t percentage. This amount is then reduced by deductible income. In the example below, the LTD benefi t amount is 60 percent of insured predisability earnings. If your monthly earnings before becoming disabled were $4,500, and you now receive a monthly Social Security disability benefi t of $1,200 and a monthly retirement benefi t of $900, your monthly LTD benefi t would be calculated as follows:

Insured predisability earnings $4,500

LTD benefi t percentage x 60%

$2,700

Less Social Security disability benefi t -$1,200

Less retirement benefi t -$900

Amount of LTD benefi t $600*

* Please note your LTD benefi t amount may vary basedon your own circumstances including earnings, whetheryour employer has a retirement plan and the amount oftheir contribution.

When Your Insurance Ends

Your insurance ends automatically when any of the following occur:



• The date the group policy terminates

• The date you cease to meet the eligibility requirements(insurance may continue for limited periods undercertain circumstances)

• The date ABC Company ends participation in thegroup policy

Conversion

You may have the option to obtain Long Term Disability conversion insurance after the termination of your insurance with ABC Company, if you meet the requirements defi ned by the group policy.

Group Insurance Certifi cate

If coverage becomes effective, and you become insured, you will receive a group insurance certifi cate containing a detailed description of the insurance coverage including the defi nitions, exclusions, limitations, reductions and terminating events. The controlling provisions will be in the group policy. Neither the information presented in this summary nor the certifi cate modifi es the group policy or the insurance coverage in any way.

GP190-LTD/S399, GP399-LTD/TRUST, GP899-LTD, GP209-LTD, GP608-LTD, GP190-LTD/ASSOC/S399, GP190-LTD/TRUST/S399, GP491-LTD/TRUST/S399, GP190-LTD/S399, GP399-LTD/TRUST, GP899-LTD, Series 90


www.standard.com

SI 12501 (1/15)


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Employee Assistance Program-317201 (8/15) SI/SNY EE

There are times in life when you might need a little help coping or fi guring out what to do. Take advantage of the Employee Assistance Program* (EAP) which includes WorkLife Services and is available to you and your family in connection with your group insurance from The Standard.‡ It’s confi dential — information will be released only with your permission or as required by law.

Connection to Resources, Support and GuidanceYou, your dependents (including children to age 26) and all household members can contact clinicians 24/7 by phone, online, live chat, email and text. There’s even a mobile EAP app. Receive referrals to support groups, a network counselor, community resources or your health plan. If necessary, you’ll be connected to emergency services.

Your program includes up to three face-to-face assessment and counseling sessions per issue. EAP services can help with:

Emotional well-being

Addictions such as alcohol and drug abuse

Life improvement and goal-setting

Family, marital and other relationship issues

Stress or anxiety with work or family

Depression, grief, loss and emotional well-being

Financial and legal concerns

Identity theft and fraud resolution

Online will preparation

WorkLife Services WorkLife Services are provided in connection with your insurance coverage. Get help with referrals for important needs like education, adoption, travel, daily living and care for your pet, child or elderly loved one.

Online ResourcesVisit www.eapbda.com to explore a wealth of information online, including videos, guides, articles, webinars, resources, self-assessments and calculators.

* The EAP service is provided through an arrangement with Bensinger, DuPont & Associates (BDA), which is not affi liated with The Standard. BDA is solely responsible for providing and administering the included service. EAP is not an insurance product and is provided to groups of 10–2,499 lives. This service is only available while insured under The Standard’s group policy.

‡ The Standard is a marketing name for StanCorp Financial Group, Inc. and subsidiaries. Insurance products are offered by Standard Insurance Company of 1100 SW Sixth Avenue, Portland, Oregon, in all states except New York, where insurance products are offered by The Standard Life Insurance Company of New York of 360 Hamilton Avenue, Suite 210, White Plains, New York. Product features and availability vary by state and company, and are solely the responsibility of each subsidiary. Each company is solely responsible for its own fi nancial condition. Standard Insurance Company is licensed to solicit insurance business in all states except New York. The Standard Life Insurance Company of New York is licensed to solicit insurance business in only the state of New York.

With EAP, assistance is immediate and personal with no hand-offs.



www.standard.com

Contact EAP

888.293.6948TDD: 800.327.183324 hours a day, seven days a week

www.eapbda.comEnter standard as the login ID and eap4u as the password

NOTE: It’s a violation of your company’s contract to share this information with individuals who are not eligible for this service.

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SI 17401 (3/15)

Standard Insurance Company Enrollment and ChangeTo Be Completed By Applicant

Apply for Coverage Name Change Former Name __________________________________________

Add Dependent Delete Dependent Date of Add/Delete ______________________________________

Reinstatement Benefi ciary Change Complete Benefi ciary Section

Your Full Name Social Security Number Birth DateMale Female

Address City State ZIP

Phone Number Job Title/Occupation

Employer Name Hours Worked Per Week Are you Actively At Work? Yes No

Earnings $_________________ Per Hour Week Month Year

Have you or your Spouse used tobacco in any form in the last 12 months? You Yes No Your Spouse Yes No

Spouse Full NameMale Female Birth Date

Coverage Check with your Human Resources Department about coverage options, minimum and maximums available to you and, if applicable, Evidence Of Insurability requirements.

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

Life with AD&D (Employer Paid)

Short Term Disability Insurance

Short Term Disability (Employer Paid) Short Term Disability (Employee Paid)

Long Term Disability Insurance

Long Term Disability (Employee Paid)

Accident Insurance

You only You and your Spouse You and your Child(ren) (no Spouse) You, your Spouse and your Child(ren)

Critical Illness InsuranceIf the coverage option you select requires Evidence Of Insurability, please complete the questions below for you and/or your Spouse.

Employee* $10,000 $20,000 $30,000 Other $_________________

Spouse $5,000 $10,000 $15,000 Other $_________________

If applying for Critical Illness coverage for your Spouse, is your Spouse gainfully employed or capable of performing the material duties of an occupation? Yes No*Eligible child(ren) are automatically covered at 25% of your Coverage Amount.

You Spouse

Yes No Yes No

1. In the past 12 months have you or your Spouse had any symptom or been informed by a medicalprofessional of any abnormal test result which resulted in a recommendation to have any diagnostictest or procedure which has not yet been completed?

2. Has a medical professional ever diagnosed you or your Spouse as having or prescribed medicationfor Acquired Immune Defi ciency Syndrome (AIDS), AIDS Related Complex (ARC) or HumanImmunodefi ciency Virus (HIV) antibodies?

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SI 17401 (3/15)

Your Full Name

3. In the past 10 years, have you or your Spouse had, been treated for or been diagnosed by a medical professional as having:• diabetes (other than during pregnancy); heart disorder; angina; arterial disease; heart attack;

angioplasty; coronary artery bypass; high blood pressure (hypertension) treated with three (3) or more medications; rheumatic fever; stroke; transient ischemic attack;

• renal disease (excluding kidney stone or urinary tract infection); pancreas disorder; liver cirrhosis; hepatitis (excluding hepatitis A);

• benign brain tumor; systemic lupus; muscular dystrophy; poliomyelitis; osteomyelitis or neurological disorder?

• Addison’s disease; sickle cell anemia; hemophilia; paralysis; organ transplant; tuberculosis; or lung disease (excluding asthma or acute pneumonia)?

4. In the past 10 years, have you or your Spouse had, been treated for or been diagnosed by a medical professional as having cancer or malignancy (excluding non-melanoma skin cancer); bone marrow disorder, ulcerative colitis or Crohn's disease?

Dental Insurance (See below)

Dental (Employee Paid) Plan 1 Plan 2 Plan 3

Dental You only You and your Spouse You and your Child(ren) (no Spouse) You, your Spouse and your Child(ren)Are you covered for Dental insurance under another plan? Yes No Are one or more Dependents? Yes No

Vision Insurance (See below)

Balanced Care Vision (Employee Paid)

Vision You only You and your Spouse You and your Child(ren) (no Spouse) You, your Spouse and your Child(ren)Are you covered for Vision insurance under another plan? Yes No Are one or more Dependents? Yes No

List Dependents to enroll or delete. Add sheet for additional Dependents if needed.

Full Name Date of Birth Full Name Date of Birth

Spouse M F Child 2

M F

Child 1 M F Child 3

M F

Dental and Vision Insurance Waiver: Contributory Dental and/or Vision InsuranceThe insurance coverage available to me and my Dependents has been explained to me and I do not want to enroll at this time. I understand that if I elect to enroll in the future, the insurance coverage may be subject to a Late Enrollment Penalty.I decline Dental and/or Vision insurance for myself. I decline Dental and/or Vision insurance for one or more Dependents.

Benefi ciary This designation applies to your Life and Accidental Death and Dismemberment Insurance, if any, available through your Employer. Unless specifi ed otherwise on a separate sheet of paper, this designation will also apply to your Accident Insurance, if any, available through your Employer. Designations are not valid unless signed, dated, and delivered in accordance with the terms of the Group Policy during your lifetime.

Primary Full Name AddressSoc. Sec. No If known Relationship

% of Benefi tTotal must equal 100%

Contingent Full Name AddressSoc. Sec. No If known Relationship

% of Benefi tTotal must equal 100%

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SAAnefi ciarynefi ciaThis designation applies to your Life and Accihis designation applies to your LEmployer. Unless specifi ed otherwise on a Employer. Unless specifi ed otherwInsurance, if any, available through your nsurance, if any, available through yaccordance with the terms of the Groccordance with the terms of the Gr

ry Full Name

SI 17401 (3/15)

Your Full Name

Consent To Electronic TransactionsPursuant to applicable state and federal electronic transaction laws, I consent to sending and receiving electronic records and to the use of electronic signatures. This consent applies to information, documents, including but not limited to, forms, applications, statements, claims, cancellation and nonrenewal notices where permitted by law, privacy notices or other communications made or exchanged under any plans, insurance policies or products offered or administered by Standard Insurance Company (The Standard). These electronic documents and communications may be sent to the email address I provide and in some cases may be made available to me at a website portal with notifi cation at the email address I provide.

I understand that I will need to have web browser software and Adobe® Reader® software on a computer capable of accessing the Internet and a valid email address to access and retain these electronic records. A confi rmation email will be sent from XXX@ standard.com to the email address that I provide below. I will click on the link provided in that email to confi rm my email address and electronic delivery election, and will add [email protected] to my safe senders list to ensure the email is not blocked or sent to a spam folder. I may request a paper version of any of the electronically furnished documents at any time by contacting The Standard at 888.000.0000 and the document will be provided. There may be a charge for a paper version of certain documents. I will inform The Standard at [email protected] if my email address changes or if I prefer to receive communications at a different email address. In addition, I may withdraw this consent at any time by notifying The Standard by email at [email protected] or at 888.000.0000 that I no longer consent to sending and receiving electronic records or to the use of electronic signatures. The withdrawal of my consent shall be effective no later than ten business days after receipt of the withdrawal by The Standard. Withdrawing consent to receive information and documents electronically may result in a charge for a paper version of certain documents.

The Standard may choose to offer additional online services in the future that it will provide under terms and conditions other than or in addition to those described above. Therefore, as a condition of accessing or receiving those additional services, I may be asked to agree to different or additional terms and conditions.

I agree and consent to the terms and conditions set forth in this Consent to Electronic Transactions section, including, butnot limited to, the use of electronic signatures. I agree to receive all mailings and communications electronically at the email address provided below.

Email Address

For Accident, Critical Illness, Hospital Indemnity Insurance:

These benefi ts are under limited benefi t insurance policies. These policies are a supplement to health insurance and are not a substitute for major medical coverage. They are not intended to satisfy the individual mandate of the Affordable Care Act (ACA) or provide the minimum essential coverage required by the ACA. Lack of major medical coverage (or other minimum essential coverage) may result in an additional payment with your taxes.

Signature I wish to make the choices indicated on this form, including, if applicable, consent to the terms and conditions set forth in the Consent to Electronic Transactions section. If electing coverage, I authorize deductions from my wages to cover my contribution, if required, toward the cost of insurance. I understand that my deduction amount will change if my coverage or costs change. I represent that the statements contained herein, including, if applicable, those made in response to the Evidence Of Insurability questions, are true and complete to the best of my knowledge and belief, and I understand that they form the basis of any coverage under the Group Policy(ies). I understand that any misstatements or failure to report information which is material to the issuance of coverage may be used as a basis for rescission of my insurance and/or denial of payment of a claim. I agree to notify Standard Insurance Company (The Standard) of any change in my medical condition while my enrollment application is pending. I acknowledge that I have read the Fraud Notices. I agree that if my application is approved by The Standard, the effective date of any coverage will be determined in accordance with the terms of the Group Policy(ies), including any applicable Active Work requirement and my coverage will be subject to all terms and conditions of the Group Policy(ies).

Signature of Applicant (Member/Employee) Date

Enroller (If applicable) Enroller ID Date

3 of 5

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ectronic records or to the use of electronic signactronic records or to the use of electronic signsiness days after receipt of the withdrawal by Thness days after receipt of the withdrawal by T

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ness, Hospital Indemnity Insurance:ss, Hospital Indemnity Insuranc

under limited benefi t insurance policited benefi t insurancce and are not a substitute for majoce and are not a substitute for ma

ndividual mandate of the Affordablevidual mandate of the Affordableoverage required by the ACA. Lack oe required by the ACA. L

l coverage) may result in an addition) may result in an additio

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onsent to Electronic Transactions section. If eleconsent to Electronic Transactions if required, toward the cost of insurance. I underequired, toward the cost of insuranrepresent that the statements contained herepresent that the statements containquestions, are true and complete to the buestions, are true and complete to theoverage under the Group Policy(ies). verage under the Group Policy(ies).

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SI 17401 (3/15)

Benefi ciary Information• Your designation revokes all prior designations.• Benefi ts are only payable to a contingent Benefi ciary if you are not survived by one or more primary Benefi ciary(ies).• If you name two or more Benefi ciaries in a class:

1. Two or more surviving Benefi ciaries will share equally, unless you provide for unequal shares.2. If you provide for unequal shares in a class, and two or more Benefi ciaries in that class survive, we will pay each surviving

Benefi ciary his or her designated share. Unless you provide otherwise, we will then pay the share(s) otherwise due to anydeceased Benefi ciary(ies) to the surviving Benefi ciaries pro rata based on the relationship that the designated percentageor fractional share of each surviving Benefi ciary bears to the total shares of all surviving Benefi ciaries.

3. If only one Benefi ciary in a class survives, we will pay the total death benefi ts to that Benefi ciary.• If a minor (a person not of legal age), or your estate, is the Benefi ciary, it may be necessary to have a guardian or a legal

representative appointed by the court before any death benefi t can be paid. If the Benefi ciary is a trust or trustee, the writtentrust must be identifi ed in the Benefi ciary designation. For example, “Dorothy Q. Smith, Trustee under the trust agreementdated __________.”

• A power of attorney must grant specifi c authority, by the terms of the document or applicable law, to make or change a• Benefi ciary designation. If you have questions, consult your legal advisor.• Dependents Insurance, if any, is payable to you, if living, or as provided under your Employer's coverage under the Group

Policy.

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SI 17401 (3/15)

Fraud NoticesALABAMA, MARYLAND, RHODE ISLAND: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefi t or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fi nes and confi nement in prison.

ARKANSAS, MAINE, OHIO: Some states require us to inform you that any person who knowingly and with intent to injure, defraud or deceive an insurance company, or other person, fi les a statement containing false or misleading information concerning any fact material hereto commits a fraudulent insurance act which is subject to civil and/or criminal penalties, depending upon the state. Such actions may be deemed a felony and substantial fi nes may be imposed.

COLORADO: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fi nes, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who kindly provides false, incomplete, or misleading facts or information to the policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

DISTRICT OF COLUMBIA: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fi nes. In addition, an insurer may deny insurance benefi ts if false information materially related to a claim was provided by the applicant.

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

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

LOUISIANA, NEW MEXICO: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefi t or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fi nes and confi nement in prison.

NEW JERSEY: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

NEW YORK: Any person who knowingly and with intent to defraud any insurance company or other person fi les an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent act, which is a crime, and shall be subject to a civil penalty not to exceed fi ve thousand dollars and the stated value of the claim for each such violation.

NORTH CAROLINA: Any person who, with the intent to injure, defraud, or deceive an insurer or insurance claimant fi les an application for insurance or a statement of claim, knowing that the application or statement contains false or misleading information concerning any fact or matter material to the clam is guilty of a Class H felony and may subject the individual to criminal and civil penalties.

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

PUERTO RICO: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or fi le, assist or abet in the fi ling of a fraudulent claim to obtain payment of a loss or any other benefi t, or fi les more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fi ne of no less than fi ve thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a fi xed term of three (3) years, or both. If aggravating circumstances exist, the fi xed jail term may be increased to a maximum of fi ve (5) years; if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years.

TENNESSEE, VIRGINIA, WASHINGTON: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fi nes, and denial of insurance benefi ts.

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Enrollment BookletSI 17697 (9/15)

Standard Insurance Company For more than 100 years we have been dedicated to our core purpose: to help people achieve fi nancial well-being and peace of mind. Headquartered in Portland, Ore., The Standard is a nationally recognized provider of Group Disability, Life, Dental and Vision insurance and Individual Disability insurance.

To learn more about products from The Standard, visit www.standard.com.

Welcome to your employee beneﬁ ts. eﬁ ts.

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