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VRS-2 (Rev. 01/14)

INSTRUCTIONS FOR COMPLETING THE DESIGNATION OF BENEFICIARY Complete this form to designate a beneficiary for VRS Basic and Optional Group Life Insurance and for your defined benefit retirement contribution account. It is only necessary to designate a beneficiary if you want payment to be made in a method other than by order of precedence established by law. If you previously completed a VRS-2 and wish to change beneficiaries or now wish to choose the order of precedence, you must complete this form to revoke any prior designations. Please read the information provided on this form to understand your options for designating a beneficiary. Additional information is provided in your Handbook for Members, which is available on the VRS Web site (www.varetire.org) or from your human resources representative. Order of Precedence: You may choose the order established by law to provide payment of your benefits or you may designate specific beneficiaries to receive your benefits in the event of your death. The order of precedence is as follows: • To your spouse; • If no surviving spouse, to your natural or legally adopted children and descendents of your deceased natural or legally adopted

children; • If none of the above, to your parents equally or to the surviving parent; • If none of the above, to the duly appointed executor or administrator of your estate; • If none of the above, to your next of kin under the laws of the state where you reside at the time of your death. Life Insurance Benefits: Your VRS Basic and Optional Group Life Insurance benefits will be paid by order of precedence unless otherwise indicated in Part B of this form. Defined Benefit Retirement Benefits Death in Service:

If you are vested (have at least five years of service credit) and die while in service with a VRS-covered employer and your death is not work-related, VRS pays retirement benefits as follows:

• If no designation is made, or the death of all primary and contingent designated beneficiaries occurs prior to your death and another designation is not made, the beneficiary is determined by order of precedence.

• If you name your spouse, minor child(ren), or parent(s) as a beneficiary, or they are deemed the beneficiary by order of precedence, that person may receive a monthly benefit or may elect a refund of the contributions and accrued interest in your account to the exclusion of any other named beneficiary. The spouse will take precedence over a minor child, a minor child will take precedence over a parent.

• If the beneficiary named, or determined by order of precedence, is someone other than your spouse, minor child(ren), or parent(s), a refund of the contributions and interest credited to your account is paid.

If you are not vested and die while in service with a VRS-covered employer and your death is not work-related, VRS pays defined benefit retirement benefits in the form of a refund to your designated beneficiary. If you die while in service with a VRS-covered employer, and your death is work-related, VRS pays defined benefit retirement benefits as follows regardless of whether or not you are vested: • A refund of contributions and interest is paid to your designated beneficiary. If no designation is made, or the death of all of

your primary and contingent designated beneficiaries occurs prior to your death and another beneficiary is not designated, the contributions and interest credited to your account are refunded to the beneficiary as determined by order of precedence.

• In addition to the refund of contributions and interest, a monthly benefit is paid to your surviving spouse for life. If you have no surviving spouse, the monthly benefit is paid to your minor child(ren) until age 18. If you have no minor child(ren), the benefit is paid to your parent(s) for life. All benefits are governed by and subject to the Virginia Retirement Act (Title 51.1 of the Code of Virginia.)

Death After Retirement: If you die after your effective date of retirement and chose a payout option other than a Survivor Option, a refund of the contributions and interest that have not been paid to you as a monthly retirement benefit is refunded to your named beneficiary or, if no beneficiary designation is on file with VRS, to the first person qualifying by order of precedence. If you die after your effective date of retirement and chose a Survivor Option, your monthly retirement benefit payment continues to the person you named as your contingent annuitant. If you are retired, selected a survivor option and wish to change the name of the person you selected to receive the monthly benefit at the time of your death, contact VRS for further information. This form cannot be used to change the contingent annuitant you designated at retirement.

VRS-2 (Rev. 01/14)

Death After Termination: If you die after you have terminated your employment in a VRS-covered position but before beginning to receive a monthly retirement benefit and you have not taken a refund of the contributions and interest credited to your account prior to your death, a refund of the contributions and interest credited to your account is paid to your named beneficiary; or if no beneficiary designation is on file, to the first person qualifying by order of precedence. Other Key Points to Remember

1. This form is not used to designate a beneficiary for any defined contribution account funds that you may have as a part of your covered employment. You must contact your defined contribution plan provider directly to designate beneficiaries.

2. This form cannot be used to designate a beneficiary for your spouse’s or children’s coverage under the Optional Life Insurance Plan because you are the beneficiary of those benefits.

3. If you name multiple primary beneficiaries, other than those established by law for death in service benefits, the proceeds will be split equally, unless you instruct otherwise in the Share % box for each beneficiary on this form. If you need to designate additional beneficiaries, list them on the Designation of Beneficiary – Continuation (VRS-2A) at the time you complete the VRS-2 and send both forms to VRS.

4. To be valid, this form must be filled out completely using given names such as “Mary L. Doe” rather than “Mrs. John Doe.”

5. If a minor (child less than 18 years of age) is named as beneficiary, a guardian for the financial estate of the minor must be appointed by the court before benefits can be paid.

6. If an estate is named as beneficiary, a probated will appointing an administrator or executor must be provided or the court must appoint an administrator or an executor before benefits can be paid.

7. If a trust is named as beneficiary, list the name of the trustee and the date that the trust agreement was completed. Do not submit a copy of the trust with this form. A copy will be requested when the claim for benefits is made.

8. Forms that have been altered cannot be accepted. If you make an error when completing this form, either complete a new form or initial the information that was changed.

9. Beneficiary Types: When you choose beneficiaries, you must indicate whether each beneficiary is a primary or contingent beneficiary. Primary: Person(s) to receive the death benefits payable upon your death. Contingent: Person(s) to receive the death benefits payable upon your death, if the primary beneficiary(ies) dies before you.

9. Share %: You may provide less than 100% share to your beneficiaries. You may break down the shares designated in Part B different from those in Part C. Designations in Part B must total 100%, and designations in Part C must also total 100%.

Completing the Form

Part A. Member/Retiree Information Enter your personal information in boxes 1 though 6, and box 7 on the 2nd page. Your VRS identification number must be clearly displayed in boxes 1 and 7. The employer code is required in box 2 only if you are an active VRS member.

Part B. Designation of Beneficiary for VRS Basic and Optional Group Life Insurance Check the appropriate box to indicate whether you wish to have payment of basic and optional life insurance be made by order of precedence or have the payment made to beneficiaries you designate. If you choose to designate beneficiaries, enter each beneficiary’s full name, Social Security number and complete address as well as whether the beneficiary is primary or contingent, the person’s relationship to you, the percentage of life insurance to be paid to the person, and his or her birth date.

Part C. Designation of Beneficiary for Accumulated VRS Defined Benefit Retirement Contributions/Benefits Check the appropriate box to indicate whether you wish to have payment of VRS retirement contributions/benefits be made by order of precedence or have the payment made to beneficiaries you designate. If you choose to designate beneficiaries, enter each beneficiary’s full name, Social Security number and complete address as well as whether the beneficiary is primary or contingent, the person’s relationship to you, the percentage of retirement contributions/benefits to be paid to the person, and his or her birth date.

Part D. Certification Sign and date the member certification. Make a copy of the completed form for your records and mail the original to VRS.

VRS-2 (Rev. 01/14)

*VRS-000002*

DESIGNATION OF BENEFICIARY PART A. MEMBER/RETIREE INFORMATION 3. Name (First, Middle Initial, Last)

4. Are you retired? Yes No

5. Address (Street, City, State and Zip+4)

6. Birth Date

PART B. BENEFICIARIES FOR VRS BASIC AND OPTIONAL GROUP LIFE INSURANCE Check ONE: I revoke any previous designations and elect payment of VRS basic and optional group life insurance benefits to be

made by order of precedence established by law. If you check this box, do not complete the beneficiary information below. Continue to Part C. (Order of precedence is explained in the form instructions.)

I revoke any previous designations and elect payment of VRS basic and optional group life insurance benefits to the beneficiaries designated below. If you check this box, complete the beneficiary information below.

Full Name (Person or Estate) (First, Middle Initial, Last)

Social Security Number

Address (Street, City, State and Zip+4)

Beneficiary Type (Check one) Primary Contingent

Share % Relationship

Birth Date

Full Name (Person or Estate) (First, Middle Initial, Last)

Social Security Number

Address (Street, City, State and Zip+4)

Beneficiary Type (Check one) Primary Contingent

Share % Relationship

Birth Date

Full Name (Person or Estate) (First, Middle Initial, Last)

Social Security Number

Address (Street, City, State and Zip+4)

Beneficiary Type (Check one) Primary Contingent

Share % Relationship

Birth Date

Name of Trust Organization

Date of Trust

Address (Street, City, State and Zip+4)

Beneficiary Type (Check one) Primary Contingent

Share % Trustee or Organization Executive Officer

Are additional beneficiaries for Part B listed on a VRS-2A continuation form? Yes No

VIRGINIA RETIREMENT SYSTEM P.O. Box 2500 Richmond, Virginia 23218-2500 Toll Free 1-888-VARETIR (827-3847) www.varetire.org

1. Social Security Number

2. Employer Code

VRS-2 (Rev. 01/14)

PART C. BENEFICIARIES FOR VRS DEFINED BENEFIT MEMBER ACCOUNT RETIREMENT CONTRIBUTION/ BENEFITS

Check ONE: I revoke any previous designations and elect payment of VRS defined benefit retirement contributions/benefits to be

made by order of precedence established by law. If you check this box, do not complete the beneficiary information below. Continue to Part D. (Order of precedence is explained in the form instructions.)

I revoke any previous designations and elect payment of VRS defined benefit retirement contributions/benefits to the beneficiaries designated below. If you check this box, complete the beneficiary information below.

Full Name (Person or Estate) (First, Middle Initial, Last)

Social Security Number

Address (Street, City, State and Zip+4)

Beneficiary Type (Check one) Primary Contingent

Share % Relationship Birth Date

Full Name (Person or Estate) (First, Middle Initial, Last)

Social Security Number

Address (Street, City, State and Zip+4)

Beneficiary Type (Check one) Primary Contingent

Share % Relationship Birth Date

Full Name (Person or Estate) (First, Middle Initial, Last)

Social Security Number

Address (Street, City, State and Zip+4)

Beneficiary Type (Check one) Primary Contingent

Share % Relationship Birth Date

Name of Trust Organization

Date of Trust

Address (Street, City, State and Zip+4)

Beneficiary Type (Check one) Primary Contingent

Share % Trustee or Organization Executive Officer

Are additional beneficiaries for Part C listed on a VRS-2A continuation form? Yes No PART D. CERTIFICATION Member Certification: I do hereby revoke all previous designations of primary and contingent beneficiaries, if any, and designate the beneficiary(ies) as indicated on this form to receive the proceeds of the basic and optional group life and accidental death and dismemberment insurance policies administered by VRS if I am covered under those policies, and to receive the accumulated retirement contributions/benefits to my credit in VRS at the time of my death. I do hereby direct that should I survive all of the above-named primary and contingent beneficiaries, any amount(s) which otherwise would have been payable to such beneficiary(ies) shall be paid in the order of precedence established by law and as listed in the instructions of this form or to such other beneficiary(ies) as I shall hereafter designate by written designation filed with the VRS Board of Trustees in accordance with its procedures. The right to change the beneficiary(ies) designation without the consent of said beneficiary(ies) is reserved. All information I provide in this document is true and I understand that any willful falsification of facts presented may result in prosecution as provided by law. (Persons holding a Power of Attorney, acting under a Guardianship, or acting as a Trustee may not make or change any beneficiary designation unless the relevant documentation specifically grants the authority to do so. Persons not holding such documents may not make or change any member’s beneficiary designation unless granted the authority to do so by court order.)

Member Signature Date

7. Social Security Number:

03.14.2013 121240 Beneficiary Form - Page 3 of 4 GP24488-34

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¿­ ½«­¬±¼·¿² º±® Ö¿²» ܱ» «²¼»® ¬¸» ×±©¿ ËÌÓßò

Benefi ciary FormContract/Plan ID Number

03.14.2013 121240 GP24488-34Beneficiary Form - Page 4 of 4

If your spouse has a vested account in a retirement plan, federal law requires that you receive a special death benefit if your spouse dies before beginning to receive retirement benefits (or, if earlier, before the beginning of the period for which the retirement benefits are paid).

If you have been married to your spouse for at least one year (some plans may specify a shorter time period), you have the right to receive this payment for your life beginning after your spouse dies. The special death benefit is often called a qualified preretirement survivor annuity (QPSA). This death benefit will automatically be paid in a lump sum rather than as a QPSA if the value of the death benefit is $5,000* or less.

If the lump-sum value of the death benefit is greater than $5,000, the death benefit will be paid in the form of a QPSA. Other options may be available. The actual amount of the QPSA benefit will vary depending on the vested account balance, your age and the cost to purchase the benefit.

Your right to the QPSA benefit provided by federal law cannot be taken away unless you agree to give up that benefit. If you agree, your spouse can choose to have all or part of the death benefit paid to someone else. The person your spouse chooses to receive the death benefit is usually called the beneficiary. As an example, if you agree, your spouse can have the death benefit paid to his or her children instead of you.

Example: Pat and Robin Doe agree that Robin will not receive the QPSA benefit. Pat and Robin also decide that half of the death benefit that is paid from Pat’s vested account will be paid to Robin, and half of the death benefit will be paid to Pat and Robin’s child, Chris. The total death benefit is $200 per month. After Pat dies, the plan will pay $100 per month to Robin for the rest of Robin’s life. Chris will also receive payments from the plan as long as he lives. Chris will receive less than $100 per month because Chris, being younger than Robin, is expected to receive payments over a longer period.

Your choice to give up the QPSA benefit must be voluntary. It is your personal decision if you want to give up the right. If you sign this agreement, your spouse can choose the beneficiary who will receive the death benefit without telling you and without getting your agreement. Your spouse can change the beneficiary at any time before he or she begins receiving benefits or dies. You have the right to agree to allow your spouse to select only a particular beneficiary. If you want to allow your spouse to select only a particular beneficiary, check the box in Choice C under the My Beneficiary Choices section, which will limit the beneficiary choice to the one designated on this form.

You can agree to give up all or part of the QPSA benefit. If you do so, the plan will pay you the part of the benefit you did not give up, and pay the remaining part of the benefit to the person or persons selected by your spouse.

You can change your mind with respect to giving up your right to the QPSA benefit until the date your spouse dies. After that date, you cannot change this agreement. If you change your mind, you must notify the plan administrator in writing that you want to revoke the consent you give on this form.

You may lose your right to the QPSA benefit if your spouse and you become legally separated or divorced even if you do not sign this agreement. However, if you become legally separated or divorced, you might be able to get a special court order called a qualified domestic relations order (QDRO) that specifically protects your rights to receive the QPSA benefit or that gives you other benefits under this plan. If you are thinking about separating or getting a divorce, you should get legal advice on your rights to benefits from the plan.

Ï«¿´·B »¼ Ю»®»¬·®»³»²¬ Í«®ª·ª±® ß²²«·¬§ øÏÐÍß÷ Ò±¬·½»

ÏÐÍß Í°±«­¿´ ݱ²­»²¬ ¿²¼ ß¹®»»³»²¬

I understand that I have a right to a QPSA benefit from my spouse’s retirement account (see prior section for explanation of QPSA benefit) if my spouse dies prior to receiving retirement benefits — or if earlier, before the beginning of the period for which the retirement benefits are paid. I also understand that if the value of the QPSA benefit is $5,000* or less, the plan will pay the benefit to me in one lump-sum payment.

I agree to give up my right to the QPSA death benefit and to allow my spouse to choose another beneficiary to receive some or all of that benefit. I understand that by signing this agreement, my spouse can choose any beneficiary without telling me and without my consent agreement unless I limit my spouse’s choice to the particular beneficiary by checking the appropriate box in the My Beneficiary Choices section of this form. If I do not check this box, I understand that my spouse can change the beneficiary at any time before retirement benefits begin without telling me and without getting my approval.

I understand I do not have to sign this agreement. I am signing this agreement voluntarily. If I do not sign this agreement, I will receive the QPSA benefit if my spouse dies before beginning to receive retirement benefits — or, if earlier, before the beginning of the period for which the retirement benefits are paid. I understand that if the value of the QPSA benefit is $5,000* or less, the plan will pay the benefit to me in one lump-sum payment.

Insurance products and plan administrative services are provided by Principal Life Insurance Company, a member of the Principal Financial Group®, Des Moines, IA 50392.

* Your plan can specify a lower dollar amount.

Benefi ciary Form Contract/Plan ID Number

03.14.2013 121240 Beneficiary Form - Page 1 of 4 GP24488-34

Contract/Plan ID Number

Location Number CTD01304

Principal Life Insurance CompanyDes Moines, IA 50306-9394

Retirement Plan Beneficiary Designation

Personal Information ø°´»¿­» °®·²¬ ©·¬¸ ¾´¿½µ ·²µ÷

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Choice A: Single Participant ø·²½´«¼»­ ©·¼±©»¼ô ¼·ª±®½»¼ ±® ´»¹¿´´§ ­»°¿®¿¬»¼÷

I am not married and designate the individual(s) named on Page 2 of this form to receive death benefits from the plan. I understand if I marry, this designation is void one year after my marriage (some plans specify a shorter period.) Ò±¬»æ ׺ ½¸¿²¹·²¹ §±«® ¾»²»B ½·¿®§ ¼«» ¬± ¿ ´»¹¿´ ­»°¿®¿¬·±²

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Choice B: Married with Spouse as Sole Beneficiary ø­°±«­»K­ ­·¹²¿¬«®» ·­ ²±¬ ®»¯«·®»¼÷

I am married and designate my spouse named on Page 2 of this form to receive all death benefits from the plan/contract.

Choice C: Married with Spouse Not as Sole Primary Beneficiary ÅÍ°±«­»K­ ­·¹²¿¬«®» ÎÛÏË×ÎÛÜ O ®»ª·»© ¬¸» Ï«¿´·B »¼

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I am married and designate the individual(s) named on Page 2 of this form to receive death benefits in accordance with the plan provisions. Note: If you are married and do not name your spouse as the sole primary beneficiary, your spouse must sign the consent below. The signature must be witnessed by a plan representative or notary public. If you are younger than age 35, your spouse must again consent to this in writing at the start of the plan year in which you reach age 35 for this designation to remain effect.

Notice to spouse: In signing, you are also verifying that you have read the QPSA notice and consent on the last page of this form.

By checking this box, I agree only to the beneficiary designation on this form. My spouse cannot change the beneficiary without my consent.

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/ / X / /

(Check if applicable) I certify that my spouse cannot be located to sign this consent. I will notify the plan sponsor if my spouse is located. Ò±¬»æ ׺ §±«® ­°±«­» ½¿²²±¬ ¾» ´±½¿¬»¼ô ½¸»½µ ¬¸·­ ¾±¨ ¿²¼ ¸¿ª» ·¬ ©·¬²»­­»¼ ¾§ ¬¸» °´¿² ®»°®»­»²¬¿¬·ª»ò ׬ ³«­¬ ¾» »­¬¿¾´·­¸»¼ ¬±

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I certify that spousal consent cannot be obtained because the spouse cannot be located.д¿² λ°®»­»²¬¿¬·ª» Í·¹²¿¬«®» Ü¿¬»

X / /

Benefi ciary Form

øÓ×÷

03.14.2013 121240 GP24488-34Beneficiary Form - Page 2 of 4

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Before completing, please read the instructions, examples and Qualified Preretirement Survivor Annuity notice on this form. You may name one or more primary and/or contingent beneficiaries. If you need more space to name beneficiaries, please attach a separate list that you have signed and dated. Note: Unless otherwise provided, if two or more beneficiaries are named, the proceeds shall be paid to the named beneficiaries, or to the survivor or survivors, in equal shares.

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If primary beneficiary(ies) is not living, pay death benefits to: In most circumstances, your contingent beneficiary(ies) will only receive a death benefit if the primary beneficiary predeceasesyou and the death benefit has not been paid in full.

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λ¿­±²æ Married Divorce - must attach divorce decree Other - provide reason:

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Benefi ciary Form Contract/Plan ID Number

How do I apply for Optional Life?Complete the enclosed Enrollment Application (VRS 39) contained in this pamphlet and send it – if applicable – with the completed Evidence of Insurability form (VRS-32) to P.O. Box 1193, Richmond, VA 23218-1193.

If you apply for Optional Life within 31 days from the date of employment:You may select any option, up to a maximum death benefit of $375,000, without providing Evidence of Insurability.

If you select an option that provides more than $375,000 of coverage:You will be required to submit an Evidence of Insurability form (VRS-32). Until coverage is approved, your coverage will be limited to the amount of the next-lowest option, not exceeding $375,000.

If you want to increase coverage after transferring from one State agency to another State agency:Evidence of Insurability will be required for any increases in coverage.

Spouse coverage amount determined by employee coverage option:Your spouse is guaranteed for Option 1 (one-half of your salary) if he or she applies within 31 days after you first become eligible for Optional Life coverage. If you select Option 2, 3 or 4, your spouse will be asked to furnish Evidence of Insurability for Minnesota Life’s approval before he or she will be covered. If the Evidence of Insurability is not approved, your spouse will continue to be insured for the amount provided under Option 1 (one-half of your salary).

If both you and your spouse are eligible for Optional Life as employees, you may not elect spouse coverage. Likewise, either you or your spouse, not both, may elect coverage for your children.

Child(ren) coverage amount determined by employee coverage option:Child(ren) will receive coverage at the level corresponding to the option you select. Children’s coverage also does not require proof of insurability, if coverage is applied for within 31 days of them becoming eligible to be insured.

If applying for coverage beyond 31 days after either the employment date or eligibility date:Application for Optional Life may also be made at any time beyond 31 days after either the employment date or eligibility date. Additional enrollment forms are also available through your benefits administrator or from Minnesota Life. Minnesota Life’s address is P.O. Box 1193, Richmond, VA 23218-1193. Or call 1-800-441-2258.

VRS-39Enrollment Application for VRS Optional Group Life Insurance

Minnesota Life Insurance Company - A Securian Company Richmond Branch Office P.O. Box 1193 Richmond, VA 23218-1193 Phone 1-800-441-2258

AA A abcd

Employer code (5 digits) Employer name Employee's annual salary

$

1 - EMPLOYEE INFORMATION

Social Security number Employee name (last, first, middle initial)

Street address City State Zip code

Sex Age Date of birth (mo/day/yr) Employment date (mo/day/yr) Payroll frequencyMale Married

Female Single

2 - ELECTION OF INSURANCE AMOUNTS

I wish to insure myself and my spouse and my child(ren).

Sign and date section 4, Payroll Deduction Authorization. (If you do not elect to be insured under the VRS Optional Planyou must complete section 5 below.)

OPTIONAL INSURANCE AMOUNTS

Option Employee Spouse Child(ren)

1 1 X Salary .5 X Salary $ 10,000

2 2 X Salary 1.0 X Salary $ 10,000

3 3 X Salary 1.5 X Salary $ 20,000

4 4 X Salary 2.0 X Salary $ 30,000

If the option you elected will provide insurance of $375,000 or higher, you must complete an Evidence of Insurability form(EOI). Your spouse must also complete an EOI form if you elected options 2,3, or 4. Optional amounts of insurance inexcess of $750,000 for an employee and $375,000 for a spouse are not provided. If you and your spouse are insured asemployees under the Basic VRS Group Life insurance plan neither of you is eligible for coverage as a spouse. If you donot apply when you are first eligible to do so, or within 31 days immediately thereafter, you must complete an EOI foryourself and eligible dependents you subsequently elect to insure.

3 - DEPENDENT INFORMATION

See reverse side for definition of Eligible Dependents (eligibility must be verified by Employer's Representative.)

How many children do you have who are less than 21 years of age?

How many children do you have who are age 21 to 25 and who are currently full-time students?

List information about your spouse and youngest child below:

Relationship Sex Social Security number Date of Birth (mo/day/yr)Name (first name, middle initial, last) Male

Your Spouse Female

Male Youngest Child Female

4 - PAYROLL DEDUCTION AUTHORIZATION

I hereby authorize my Employer to deduct from my compensation the amount necessary to provide the insurance amountsindicated above. I understand that the deduction amount will change as my age and annual salary change.

Signature Date signed

X

5 - WAIVER OF COVERAGE

I DO NOT wish to enroll for myself or for my eligible dependents in the VRS Optional Insurance Plan. I understand thatonce coverage is waived, I will have to furnish evidence of insurability for myself and eligible dependents if I wish tobecome insured at a later date.

Signature Date signed

X

6 - STATEMENT BY EMPLOYER'S REPRESENTATIVE

I certify that I believe the statements made herein are true and accurate, as disclosed by the records of this office, and theSocial Security Number and Annual Salary are correct as entered.

Employer's representative Title Date signed

X

*VRS-000039*

F52833 Rev 5-2014

ELIGIBLE DEPENDENTS

The following persons are eligible to be insured under the VRS Optional Group Life Insurance Plan:

Athe employee's spouse, and

Athe employee's unmarried, natural, or legally adopted children* who are not self-supporting, and

Athe employee's unmarried step-children* who live full-time with the employee in a parent-childrelationship and can be claimed as a dependent on the employee's Federal income tax return, and

Aany other children* if they are in the permanent court-ordered custody of the employee.

* less than 21 years of age (age 25 if a full-time college student).

Beneficiary Information

The employee's beneficiary for Optional Group Life Insurance is the same as designated for theemployee's Basic VRS Group Insurance. The employee is the beneficiary for the Optional GroupLife Insurance on the employee's spouse and children.

Voluntary Group Long Term Care Insurance ProgramCommonwealth of Virginia

Virginia Retirement System

© May 2014

Premium Payment Methods

If you elect to pay the premiums to Genworth Life on a quarterly, semi-annual or annual basis, you may be eligible for a premium discount. Or, you can pay the premiums through a monthly Electronic Fund Transfer from your checking or savings account. Some employers may offer employees the option to pay premiums through a payroll deduction.

Other Program Features

• If you apply within 60 days of employment, medical underwriting (proof of good health) will not be required. Medical underwriting is required of family members who apply; if you apply after 60 days from your hire date; or if you apply as a deferred member or retiree.

• At group rates, your premiums may be more affordable. Premium rates are guaranteed through March 1, 2020 and will change only if you make changes to your coverage.

• You can choose one of three benefit increase options that will allow you to increase your coverage over time to help protect against the rising cost of care.

How to Apply and More Information

Visit the Genworth Life website at www.genworth.com/cov, to apply online if you have recently been hired or you can download an application and apply by mail. You also can request an information kit that has everything you need to apply.

For more information about covered long-term care expenses and how to apply, call Genworth Life toll-free at 1-866-859-6060 or visit www.genworth.com/cov.

Covered Under the VSDP or VLDP Long-Term Care Plan?

If you are enrolled in the Virginia Sickness and

Disability Program (VSDP) or the Virginia Local

Disability Program (VLDP), you are covered

under the VSDP or VLDP Long-Term Care Plan

at no cost to you. For plan details, visit the

VRS website at www.varetire.org. See also

the Virginia Sickness and Disability Program Handbook or the Virginia Local Disability Program Handbook, available from your human

resource office or the VRS website.

COV Voluntary Group Long Term Care Insurance Program

The employee-paid COV Voluntary Group Long Term Care Insurance Program provides a maximum monthly benefit for covered long-term care expenses. The Virginia Retirement System (VRS) has contracted with the Genworth Life Insurance Company as the insurer for the program.

Am I Eligible?

If you are between the ages of 18 and 79 and work at least 20 hours a week, you are eligible to apply for the program if:

• You are a state employee or faculty member; or

• You are an employee of a local public school division or a political subdivision that has elected to participate in the program.

You also are eligible to apply if:

• You are a deferred member and vested with at least five years of service credit in VRS;

• You are a retiree receiving a VRS retirement benefit; or

• You are a retiree of a Virginia public college or university.

If you apply as a deferred member or a retiree, your employer is not required to have elected the program.

If you are eligible for the program, select family members between the ages of 18 and 79 also can apply. These family members include your spouse, adult children, parents, parents-in-law, step parents, step parents-in-law, grandparents, grandparents-in-law, step grandparents and step grandparents-in-law.

Coverage Overview

The COV Voluntary Group Long Term Care Insurance Program provides assistance with long-term care expenses, such as:

• Care in a nursing home or assisted living facility

• Home healthcare services

• Caregiver training

• Community-based care

Long-Term Care Coverage Protects Your Finances

Many of us don’t think about long-

term care as part of long-range

financial or retirement planning.

Most health insurance plans,

however, don’t cover services

such as nursing home care or care

at home to assist with bathing,

eating or other activities of daily

living. The cost of these services

can quickly deplete savings or

retirement income.

You may be eligible to apply

for coverage for yourself and

select family members in the

Commonwealth of Virginia (COV)

Voluntary Group Long Term Care

Insurance Program.

VRS-26 (Rev.06/15)

COMPLETING THE APPLICATION FOR PURCHASE OF PRIOR SERVICE CREDIT

Purchasing prior service credit increases your total years of service and counts toward the five years needed to become vested, your eligibility for retirement and the retiree health insurance credit. You may purchase prior service credit if you have ever received a VRS refund and returned to covered employment, or if you have other types of service, such as public service, that you are eligible to purchase. You may purchase all or part of your eligible service as long as it does not overlap with other VRS service or qualify you for benefits under another retirement plan. If you apply for and are approved to purchase multiple service periods, you must purchase the most recent period first. The cost to purchase the most recent period may be higher than other periods of service in your record. IMPORTANT NOTE: For most types of service, you can contact your employer directly. This application is only used for service that cannot be certified by your current employer (which includes non-covered service with a former employer who participated in VRS during your service period, other public service, or federal service that is not considered military service).

WHEN TO APPLY AND COST OF PURCHASE

You must apply for and pay for prior service credit while you are an active member. VRS Plan 1 Members: If you begin your purchase of prior service credit within three years of becoming eligible, the cost is five percent of your salary at the time of your purchase (or five percent of your average final compensation, if higher than your current salary and you make a lump-sum payment). After three years, the cost is based on an actuarial equivalent rate in most cases. VRS Plan 2 Members: If you begin your purchase of prior service credit within the first year of becoming eligible, the cost will be at a rate approximating the normal cost for the retirement program under which you are covered. Normal cost may be generally defined as the cost of one year of VRS service credit. After one year, the cost will be at an actuarial equivalent rate in most cases.

VRS must receive your completed and certified application at least 90 days before your effective date of termination or retirement to allow adequate processing time. HOW TO APPLY

1. Complete Part A of the application and enter your Social Security number at the top of each page. If you request a purchase of service credit from more than one employer, complete separate applications for each employer.

2. Forward the application to the employer where the service was earned. Your employer will complete Part B. 3. Have the employer where the service was earned certify the prior service in Part B and forward the completed

application to VRS at the address shown on the form. If you are purchasing federal or public service, have the employer forward the application to the retirement system in which you participated. The retirement system must complete Part C and return the form to VRS.

Note: Your application including your certification in Part A (and that of your former employer in Part B and the former retirement system or plan in which you participated, if required, in Part C) must be complete or it will be returned to you for the additional information. NOTIFICATION OF ELIGIBILITY

VRS will review your application and notify you of your eligibility to purchase the requested service. If you are eligible, VRS will send you a cost letter. The cost letter explains the cost, the months of service you may purchase, and the payment methods available to you. If you do not formally arrange to purchase your service within 90 days of receiving the cost letter and a salary increase is reported to VRS, you must request an updated cost letter. Please allow approximately four weeks for your application to be processed. Note: Do not send your payment to VRS until you receive the cost letter. METHODS OF PAYMENT

You may choose to pay for prior service credit by pre-tax or post-tax payroll deduction, by lump-sum payment or a combination of these methods. Lump-sum payment options include a personal check, a rollover from a qualified plan, or a trustee-to-trustee transfer. Detailed information about each type of payment is available on the VRS Web site at www.varetire.org under “Purchase of Prior Service” and will be sent with your cost letter.

*VRS-000026* VRS-26 (Rev. 06/15)

APPLICATION FOR PURCHASE OF PRIOR SERVICE CREDIT

For most types of service, you may contact your employer directly. This application is only used for service that cannot be certified by your current employer, including non-covered service with a former employer who participated in VRS during your service period, federal service or other public service. If you choose to purchase service from more than one employer, you must complete a separate application for each employer. Include all service being requested from one employer on the same application.

PART A. MEMBER INFORMATION

3. Name (First, MI, Last)

4. Mailing Address (Street, City, State, Zip+4)

5. Previous Name(s) Used 6. Birth Date

7. Type of Service Requested Non-Covered Service with former employer who participated in VRS - Employment with a VRS-participating

employer, though you were not eligible for VRS coverage at that time. Your service will be calculated as one month of service for each 173 hours as certified by your employer. Qualifying types of service include: part-time or wage service, probationary service, Job Partnership Training Act (JPTA) service, Comprehensive Employment Training Act (CETA) service, and grant-funded service with a VRS-participating employer. Your period(s) of service must fall within the employer’s retirement coverage dates in VRS. During this time, your employer must not have contributed to an optional retirement plan or another retirement plan on your behalf; you may not receive a pension from any of the plans.

Public or federal service in other government agency not entitling you to a benefit with the employer’s retirement

system or any other public retirement benefit including benefits paid from a defined contribution plan. Public service is permanent, full-time, salaried service with another state agency, public school system, public institution of higher learning, or political subdivision in this or another state or territory of the United States. Federal service is permanent, full-time, salaried service with a federal agency. Service with a private employer is not eligible.

Previously refunded VRS service which was earned prior to July 1988.

8. Employer at Time of Service

9. Dates of Service

From: Through:

10. Are you entitled to a retirement benefit from a former retirement system as a result of the service listed above?

Yes No

11. Member Certification:

I certify the following: 1) the requested prior service credit shall not be used in the calculation of any retirement benefit received or to be received from any other retirement system including those attributable to employer contributions to a defined contribution plan, with the exception of Armed Services Reserve or National Guard pensions; 2) I am neither now receiving, nor entitled to receive, a benefit from any retirement system based on the service indicated above; and 3) all statements made by me, the undersigned member, are true and correct.

I understand: 1) that any person who knowingly makes any false statement or falsifies or permits the falsification of any record related to eligibility for membership in the Fund in any attempt to defraud the Fund shall be guilty of a Class 1 misdemeanor; 2) that if the employer is unable to certify the requested service, the purchase will not be allowed; 3) that if an error or misrepresentation is discovered, any adjustments to my account may affect my retirement benefits; and 4) that by signing below, I give permission for my previous employer and/or retirement system to release information about the requested service. Member’s Signature Date

1. Social Security Number

2. Daytime Phone Number

VIRGINIA RETIREMENT SYSTEM

P.O. Box 2500 Richmond, Virginia 23218-2500

Toll Free 1-888-VARETIR (827-3847)

www.varetire.org

VRS-26 (Rev.06/15)

PART B. EMPLOYER CERTIFICATION OF SERVICE

(Human Resources Representative: Complete this section.) Type of Service/Leave Credit to be Purchased From

(Month/Year) Through

(Month/Year)

13. Non-Covered Service with former employer who participated in VRS

Total Hours: ____________________

14. Federal Service

(Permanent, full-time, salaried. Identify any breaks in service in the section below.)

15. Public Service (Permanent, full-time, salaried. Identify any breaks in service in the section below.)

16. Explanation of breaks in service (for federal or public service)

17. Name of retirement system or plan in which member participated (for federal or public service)

18. Certification

I hereby certify that the service/leave period listed above is true and correct based on official records. For federal or public service, I hereby certify that this individual was engaged in public or federal employment in a permanent, full-time, salaried position with a state agency, public school system, public institution of higher learning, political subdivision in this or another state or territory of the United States, or with a federal agency during the above stated time period. Service with a private employer is not eligible. Further, to my knowledge, the service/leave period listed above is not used in the calculation of any retirement benefit received or to be received from any other retirement system including those attributable to employer contributions to a defined contribution plan, with the exception of reserve or national guard pensions. The Code of Virginia §51.1-124.10 states that any person who knowingly makes any false statement or falsifies or permits the falsification of any record related to eligibility for membership in the Fund in any attempt to defraud the Fund shall be guilty of a Class 1 misdemeanor.

Signature Phone Date Printed Name Title

Employing Agency Name Address

____________________________________________________ VRS 5-digit Employer Code (if it applies) City/State/Zip

12. Social Security Number

VRS-26 (Rev.06/15)

PART C. FORMER RETIREMENT SYSTEM CERTIFICATION

The individual identified in Part A would like to establish credit for federal or public (out-of-state or in-state) service with the Virginia Retirement System. This service may include employment with a federal agency, state agency, school board or political subdivision in this or another state or territory of the United States. Virginia law does not permit the purchase of this credit if the individual is eligible to receive a benefit under another retirement system/plan as a result of such employment.

20. Does the service listed in Part B accurately reflect the service in your system? Yes No

If no, enter dates of service: From: To:

21. Has this individual withdrawn all eligible contributions from your retirement system? Yes No

22. Certification (Choose the appropriate statement)

On the basis of official records, I hereby certify the service listed in Part B of this application is not used in the calculation of any retirement benefit the applicant is receiving or is entitled to receive from this retirement system including those attributable to employer contributions to a defined contribution plan, with the exception of reserve or national guard pensions.

On the basis of official records, I hereby certify the service listed in Part B of this application is used in the calculation of a retirement benefit the applicant is receiving or is entitled to receive from this retirement system including those attributable to employer contributions to a defined contribution plan, with the exception of reserve or national guard pensions.

Comments:

Signature Phone Date Preparer’s Printed Name Title

Retirement System/Plan Name Address City/State/Zip

Return this application to:

Virginia Retirement System P.O. Box 2500

Richmond, Virginia 23218-2500

19. Social Security Number

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SECTION I

USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION The Medical Plan of the Alexandria City Public Schools (the “Plan”) will use protected health information (“PHI”) to the extent of and in accordance with the uses and disclosures permitted by the Health Insurance Portability and Accountability Act of 1996 (“HIPPA”). Specifically, the Plan will use and disclose PHI for purposes related to health care treatment, payment for health care and health care operations. The Notice of Privacy Practices for the Plan is found in Section II. PAYMENT FOR HEALTH CARE Payment includes activities undertaken by the Plan to obtain premiums or determine or fulfill its responsibility for coverage and provision of Plan benefit that relate to an individual to whom health care is provided. These activities include, without limitation, the following:

1. Determination of eligibility, coverage and cost sharing amounts (for example, cost of a benefit, plan maximums and copayments as determined for an individual’s claim).

2. Coordination of benefits 3. Adjudication of health benefit claims (including appeals and other payment disputes). 4. Subrogation of health benefit claims. 5. Establishing employee contributions 6. Adjusting amounts due based on enrollee health status and demographic

characteristics. 7. Billing, collection, activities and related health care data processing. 8. Claims management and related health care data processing, including auditing

payments, investigating and resolving payment disputes and responding to participant inquires about payments.

9. Obtaining payment under a contract for reinsurance (including stop-loss and excess of loss insurance).

10. Medical necessity reviews or appropriateness of care of justification of charges reviews.

11. Utilization review, including precertification, preauthorization, concurrent review and retrospective review.

12. Disclosure to consumer reporting agencies related to the collection of premiums or reimbursement (the following PHI may be disclosed for payment purposes: name, address, date of birth, Social Security number, payment history, account number, name and address of the provider and/or health plan).

13. Reimbursement to the Plan. HEALTH CARE OPERATIONS Health Care Operations include, without limitation, the following activities:

1. Quality assessment. 2. Population-based activities relating to improving health or reducing health care costs,

protocol development, case management and care coordination, disease

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management, contacting health care providers and patients with information about treatment alternatives and related functions.

3. Rating provider and Plan performances, including accreditation, certification, licensing or credentialing activities.

4. Underwriting, premium rating and other activities relating to creation, renewal or replacement of a contract of health insurance or health benefits, and ceding, securing or placing a contract for reinsurance of risk relating to health care claims (including stop-loss insurance and excess of loss insurance).

5. Conducting or arranging for medical reviews, legal services and auditing functions, including fraud and abuse detection and compliance programs.

6. Business planning and development, such as conducting cost-management and planning-related analyses related to managing or operating the Plan, including formulary development and administration, development or improvement of payment methods or coverage policies.

7. Business management and general administrative activities of the Plan, including, without limitation:

a. Management activities relating to the implementation of and compliance with HIPPA’s administrative simplification requirements, or

b. Customer service, including the provision of data analyses for policyholders, Plan Sponsors of other customers.

8. Resolution of internal grievances. 9. Due diligence is connection with the sale or transfer of assets to a potential successor

in interest, if the potential successor in interest is a “covered entity” under HIPPA or, following completion of the sale or transfer, will become a covered entity under HIPPA.

THE PLAN WILL USE AND DISCLOSE PHI AS REQUIRED BY LAW AND AS PERMITTED BY AUTHORIZATION OF THE PRATICIPANT OR BENEFICIARY With an authorization, the Plan will disclose PHI to the Disability Insurance Plan or any other benefit plan of Alexandria City Public Schools that requires PHI as a prerequisite to obtain benefits for purposes related to administration of those plans. ALEXANDRIA CITY PUBLIC SCHOOLS IS THE PLAN SPONSOR The Plan Sponsor agrees to:

1. Not use or further disclose PHI other than as permitted or required by the Plan document or as requires by HIPPA.

2. Ensure that any agents, including a subcontractor, to whom the Plan Sponsor provides PHI received from the Plan, agree to the same restrictions and conditions that apply to the Plan Sponsor with respect to such PHI.

3. Not use or disclose PHI for employment-related actions and decisions unless authorization by an individual.

4. Nor use or disclose PHI in connection with any other benefit or employee benefit plan of the Plan Sponsor unless authorized by an individual.

5. If it becomes aware, report to the Play any PHI use or disclosure that is inconsistent with the uses or disclosures as permitted by HIPPA.

6. Make PHI available to an individual in accordance with HIPPA’s access requirement.

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7. Make PHI available for amendment and incorporate any amendments to PHI in accordance with HIPPA.

8. If requested by an individual, make available the information required to provide an accounting of disclosures in accordance with HIPPA.

9. Make internal practices, books and records relating to the use and disclosure of PHI received from the Plan available to the United States Department of Health and Human Service’s Secretary for the purpose of determining the Plan’s compliance with HIPPA.

10. If feasible, return or destroy all PHI received from the Plan that the Plan Sponsor still maintains in any form, and retain no copies of such PHI when no longer needed for the purpose for which disclosure was made (or if return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction impracticable).

ADQUATE SEPERATION BETWEEN THE PLAN AND THE PLAN SPONSOR MUST BE MAINTAINED In accordance with HIPPA, only the following employee or classes of employees of Alexandria City Public Schools may be given access to PHI: Employee Relations Office, Department of Human Resources LIMITATIONS OF PHI ACCESS AND DISCLOSURE The persons described above may only have access to and use and disclose PHI for Plan administration functions that the Plan Sponsor performs for the plan. NONCOMPLIANCE ISSUES If the persons described above do not comply with this policy, the Plan Sponsor shall provide a mechanism for resolving issues of noncompliance, including disciplinary sanctions.

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SECTION II

HEALTH INSURANCE “REQUIRED DISCLOSURES AND NOTICES” NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THIS NOTICE IS EFFECTIVE OCTOBER 1, 2008. If you have questions about this notice, please contact the Employee Relations Office at (703) 619-8010. WHO WILL FOLLOW THIS NOTICE? This notice describes the medical information practices of the Medical Plan of the Alexandria City Public Schools (the “Plan”) and that of any third party in the administration of Plan claims. OUR PLEDGE REGARDING MEDICAL INFORMATION The Plan understands that medical information about you and your health is personal. The plan is committed to protecting medical information about you. The Plan creates a record of the health care claims reimbursed under the Plan for Plan administration purposes. This notice applies to all of the medical records the Plain maintains. Your personal doctor or health care provider may have different policies or notices regarding the doctor’s use and disclosure of your medical information created in the doctor’s office or clinic. This notice will tell you about the ways in which the Plan may use and disclose medical information about you. It also describes our obligations and your rights regarding the use and disclosure of medical information. This Plan is required by law to:

make sure that medical information that identifies you is kept private; give you this notice of our legal duties and privacy practices with respect to medical

information about you; and follow the terms of the notice that is currently in effect.

HOW THE PLAN MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following categories describe different ways that the Plan uses and discloses medical information. For each category of uses or disclosures the Plan will explain what the Plan means and present some examples. Not every use or disclosure in a category will be listed. All of the ways the Plan is permitted to use and disclose information will fall within one of the categories. For treatment (as described in applicable regulations) The Plan may use or disclose medical information about you to facilitate medical treatment or services by providers. The Plan may disclose medical information about you to providers including doctors, nurses, technicians, medical students, or other hospital personnel who are involved with taking care of you. For example, the Plan might disclose information about your

Page 5

prior prescriptions to a pharmacist to determine if a pending prescription is contraindicative with prior prescriptions. For payment (as described in applicable regulations) The Plan may use and disclose medical information about you to determine eligibility for Plan benefits, to facilitate payment for the treatment and services you receive from health care providers, to determine benefit responsibility under the Plan, or to coordinate Plan coverage. For example, the Plan may tell your health care provider about your medical history to determine whether a particular treatment is experimental, investigational, or medically necessary or to determine whether the Plan will cover the treatment. The Plan may also share medical information with utilization review or precertification service provider. Likewise, the Plan may share medical information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments. For Health Care Operations (as described in applicable regulations) The Plan maybe use and disclose medical information about you for other Plan operations. These use and disclosures are necessary to run the Plan. For example, the Plan may use medical information in connection with: conducting quality assessments and improvement activities, underwriting, premium rating, and other activities relating to Plan coverage, submitting claims for stop-loss (or excess loss) coverage, conducting or arranging for medical review, legal services, and fraud and abuse detection programs, business planning and development such as cost management; and business management and general Plan administrative activities. As Required By Law The Plan will disclose medical information about you when required to do so by federal, state or local law. For example, the Plan may disclose medical information when required by a court order in a litigation proceeding such as malpractice action. To Avert a Serious Threat to Health or Safety The Plan may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. For example, the Plan may disclose medical information about you in a proceeding regarding the licensure of a physician. SPECIAL SITUATIONS Disclosure to Health Plan Sponsor Information may be disclosed to another health plan maintained by the Plan Sponsor for purposes of facilitating claims payment under that plan. In addition, medical information may be disclosed to the Plan Sponsor solely for purpose of administering benefits under the Plan. Organ and Tissue Donation If you are an organ donor, the Plan may release medical information to organizations that handle organ procurement or organ, eye tissue transplantation or to an organ donation bank as necessary to facilitate organ or tissue donation and transplantation.

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Military and Veterans If you are a member of the armed forces, the Plan may release medical information about you as required by military command authorities. The Plan may also release medical information about foreign military personnel to the appropriate foreign military authority. Worker’s Compensation The Plan may release medical information about you for worker’s compensation or similar programs. These programs provide benefits for work-related injuries or illness. Public Health Risks The Plan may disclose medical information about you for public health activities. These activities generally include the following:

to prevent or control disease, injury or disability; to report births and deaths; to report child abuse or neglect; to report reactions to medications or problems with products; to notify people of recalls of products they may be using; to notify a person who may have been exposed to a disease or may be at risk for

contracting or spreading a disease or condition; to notify the appropriate government authority if the Plan believes a patient has been

the victim of abuse, neglect or domestic violence. The Plan will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities The Plan may disclose medical information to a health oversight agency for activities authorized by the law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. Lawsuits and Disputes If you are involved in a lawsuit of a dispute, the Plan may disclose medical information about you in response to a court or administrative order. The Plan may also disclose medical information about you in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. Law Enforcement The Plan my release medical information if asked to do so by law enforcement official:

in response to a court order, subpoena, warrant, summons or similar process; to identify or locate a suspect, fugitive, material witness, summons or similar process; about the victim of a crime if, under certain limited circumstances, the Plan is unable to

obtain the person’s agreement; about a death the Plan believes may be a result of criminal conduct; about criminal conduct at the hospital, and in emergency circumstances to report a crime; the location of the crime or victims; or

the identity, description or location of the person who committed the crime.

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Corners, Medical Examiners and Funeral Directors The Plan may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person to determine the cause of death. The Plan may also release medical information about patients of the hospital to funeral directors as necessary to carry out their duties. National Security and Intelligence Activities The Plan may release medical information about you to the custody of a law enforcement official for intelligence counterintelligence, and other national security activities authorized by law. Inmates If you are an inmate of a correctional institution or under the custody of a law enforcement official, the Plan may release medical information about you to the correctional institution or law enforcement official. This release would be necessary:

a. for the institution to provide you with health care: b. to protect your health safety or the health safety of others, c. for the safety and security of the correctional institution

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU You have the following rights regarding medical information the Plan maintains about you: Rights to Inspect and Copy You have the right to inspect and copy medical information that may be used to make decisions about your Plan benefits. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Employee Relations Office at (703) 619-8010. If you request a copy of the information, the Plan may charge a fee for the costs of copying, mailing or other supplies associated with your request. The Plan may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Right to Amend If you feel the medical information the Plan has bout is incorrect of incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Plan. To request an amendment, your request must be made in writing and submitted to the St. Director, Risk Management. In addition, you must provide a reason that supports your request. The Plan may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, the Play may deny your request if you ask to amend information that:

is not part of the medical information kept by or for the Plan; was not created by us, unless the person or entity that created the information is no

longer available to make the amendment: is not part of the information which you would be permitted to inspect and copy; or is accurate and complete

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Right to and Accounting of Disclosures You have the right to request an “accounting disclosures” where such disclosure was made for any purpose other than treatment, payment, or health care options. To request this list or accounting of disclosures, you much submit your request in writing to the Office of Employment Relations. Your request must stat a time period which may not b longer than six years and may not include dates before April 2003. Your request should indicate in what form you want the list (for example, paper or electronic). The first list you request within a 12 month period will be free. For additional lists, the Plan may charge you for the costs of providing the list. The Plan will notify you of the costs involved and you may choose to withdraw or modify your request before any costs incurred. Rights to Request Restrictions You have the right to request a restriction or limitation on the medical information the Plan uses or discloses about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information the Plan discloses about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that the Plan not use or disclose information about a surgery you had. The Plan is not required to agree to your request. To request restrictions, you must make your request in writing to the Sr. Director, Risk Management. In your request, you must tell us:

a. what information you want to limit; b. whether you want to limit our use, disclosure or both; and c. to whom you want the limits to apply, for example, disclosures to your spouse.

Right to Request Confidential Communications You have the right to request that the Plan communicate with you about medical matter in a certain way or at a certain location. For example, you can ask that the Plan only contact you at work or by mail. To request confidential communications, you must make your request in writing to the Employee Relations. The Plan will not ask you the reason for your request. The Plan will accommodate all reasonable requests. Your requests must specify how or where you wish to be contacted. Right to Receive Notification of any Security Breaches If the Plan has any unsecured protected health information about you, and that unsecured information us accessed, acquired or disclosed by or to an unauthorized person, you have the right to receive notification about such security breach. The Plan will abide by breach notification requirements under the law. A Not About Personal Representatives You may exercise your rights through a personal representative. Your personal representatives will be required to produce evidence of his/her authority to act on your behalf before that person will be given access to your PHI or allowed to take any action for you. Proof of such authority may take one of the following forms:

Page 9

a power of attorney for health care purposes, notarized by a notary public; a court order of appointment of the person as the conservator or guardian of the

individual; or an individual who is the parent of a minor child. The Plan retains discretion to deny

access to your PHI to a personal representative to provide protection to those vulnerable people who depend on others to exercise their rights under these rules and who may be subject to abuse or neglect. This also applies to personal representatives.

Right to a Paper Copy of This Notice You have the right to a paper copy of this notice. You may ask us to give you copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at Alexandria City Public School website www.acps.k12.va.us or contact the Employee Relations at (703) 619-8010. Changes to This Notice The Plan reserves the right to change this notice. The Plan reserves the right to make the revised or changed notice effective for medical information the Plan already has about you as well as any information the Plan receives in the future. The Plan will post a copy of the current notice on the Alexandria City Public Schools Intranet. The notice will contain on the first page, in the top right-hand corner, the effective date. Complaints If you believe your privacy rights have been violated you may file a complaint with the Plan. To file a complaint with the Plan, contact Employee Relations at (703) 619-8010. All complaints must be submitted in writing. In addition to filing a complaint with the Plan you me file a complaint with the Secretary of the Department of Health and Human Services. Office for Civil Rights, U.S. Department of Health and Human Services For all complaints filed by e-mail send to: OCRComplaint@hhs.gov. You will not be penalized for filing a complaint. Other Uses of Medical Information Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us with permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you provoke your permission, the Plan will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that the Plan is unable to take back any disclosures the Plan has already made with your permission, and that the Plan is required to retain our records of the care that the Plan provided to you. INITIAL NOTICE REGARDIG HIPAA’S SPECIAL ENROLLMENT PROVISON A federal law called HIPPA requires that we notify you about your right to enroll in the plan under its “special enrollment provision” if you acquire a new dependent, or if you can decline

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coverage under this plan for yourself or an eligible dependent while other coverage is in effect and last lose that other coverage for certain qualifying reasons. Loss of Other Coverage (Excluding Medical or a State Children’s Health Insurance Program) If you decline enrollment for yourself or for an eligible dependent (including your spouse) while other health insurance or group health plan coverage is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your ‘dependents’ other coverage). However, you must request enrollment within 30 days after your or your ‘dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). Loss of Coverage for Medical or a State Children’s Health Insurance Program If you decline enrollment for yourself or for an eligible dependent (including your spouse) while Medicaid coverage or coverage under a state children’s health insurance program is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage. However, you must request enrollment within 60 days after your or your ‘dependents’ coverage ends under Medicaid of a state Children’s health insurance program. New Dependent by Marriage, Birth, Adoption, or Placement for Adoption If you have a new dependent as a result of marriage, birth, adoption, or placement of adoption, you may be able to enroll yourself and your new dependents. However, you must request within 30 days after the marriage, birth, adoption, or placement for adoption.

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General Notice of COBRA Continuation Coverage Rights

Introduction You are receiving this notice because you have recently become covered under a group health plan (the Plan). This notice contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you when you would otherwise lose your group health coverage. It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage. For additional information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees. What is COBRA Continuation Coverage? COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because either one of the following qualifying events happens:

Your hours of employment are reduced, or

Your employment ends for any reason other than your gross misconduct. If you are the spouse of an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because any of the following qualifying events happens:

Your spouse dies;

Your spouse’s hours of employment are reduced;

Your spouse’s employment ends for any reason other than his or her gross misconduct;

Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or

Page 2

You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of any of the following qualifying events happens:

The parent-employee dies;

The parent-employee’s hours of employment are reduced;

The parent-employee’s employment ends for any reason other than his or her gross misconduct;

The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);

The parents become divorced or legally separated; or

The child stops being eligible for coverage under the plan as a “dependent child.” When is COBRA Coverage Available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. When the qualifying event is the end of employment or reduction of hours of employment, death of the employee, commencement of a proceeding in bankruptcy with respect to the employer, or the employee's becoming entitled to Medicare benefits (under Part A, Part B, or both), the employer must notify the Plan Administrator of the qualifying event. You Must Give Notice of Some Qualifying Events For the other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to: Benefits Staff, Human Resource Department, Alexandria City Public Schools, 1340 Braddock Place, Alexandria, Virginia 22314. How is COBRA Coverage Provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the death of the employee, the employee's becoming entitled to Medicare benefits (under Part A, Part B, or both), your divorce or legal separation, or a dependent child's losing eligibility as a dependent child, COBRA continuation coverage lasts for up to a total of 36 months. When the qualifying event is the end of employment or reduction of the employee's hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement. For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months

Page 3

after the date of the qualifying event (36 months minus 8 months). Otherwise, when the qualifying event is the end of employment or reduction of the employee’s hours of employment, COBRA continuation coverage generally lasts for only up to a total of 18 months. There are two ways in which this 18-month period of COBRA continuation coverage can be extended. Disability extension of 18-month period of continuation coverage If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage. Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event while receiving 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given to the Plan. This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies, becomes entitled to Medicare benefits (under Part A, Part B, or both), or gets divorced or legally separated, or if the dependent child stops being eligible under the Plan as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. How much does COBRA Coverage Cost? Each qualified beneficiary is required to pay the entire cost of COBRA. The amount a qualified beneficiary may be required to pay may not exceed 102 percent (or, in the case of an extension of Cobra coverage due to a disability, 150 percent) of the cost to the group health plan (including both employer and employee contributions) for coverage of a similarly situated plan participant of beneficiary who is not receiving COBRA coverage. The required payment for each month of continuation coverage for each option is provided on the Election Form. When and how must Payment for COBRA Coverage be made? All COBRA premiums must be paid by check. First payment for COBRA coverage If you elect continuation coverage, you do not have to send any payment with the Election Form. However, you must make your first payment for COBRA coverage not later than 45 days after the date of your election. The “date of your election” is the date the Election Notice is

post-marked, if mailed sent by express delivery service (such as UPS), or delivered in person to the ACPS Human Resources

Page 4

If you do not make your first payment for COBRA coverage in full within 45 days after the day of your election, you will lose all COBRA rights under the Plan. Your first payment must cover the cost of COBRA coverage from the time your coverage under the Plan would have otherwise terminated up through the end of the month in which you make your first payment. You may contact the ACPS office of Benefit at (703)824-6665 to confirm the correct amount of your first payment. Please make checks payable to Alexandria City Public Schools. Medical, Dental, and/or health FSA claims for reimbursement will not be processed and paid until you have elected COBRA and made the first payment for it. Monthly payments for COBRA coverage After you make your first payment for COBRA coverage, you will be required to make monthly payments for each subsequent month of coverage. The amount due for each month of coverage for each qualified beneficiary is provided on the Election Form. These costs are subject to change. Payments for a given month of COBRA coverage are due on the first day of that month. If you make a monthly payment on or before the first day of the month to which it applies, your coverage under the Plan will continue for that month without any breaks. ACPS will not send periodic notices of payments due for these months. Grace periods for monthly payments Although monthly payments are due on the first day of each month, you will be given a grace period of 30 days after the first day of the month to make each monthly payment. Your COBRA coverage will be provided for each month as long as payment for that month is made before the end of the grace period for that payment. However, if you pay a monthly payment later than the first day of the month to which it applies, but before the end of the grace period for the month, your coverage under the Plan will be suspended as of the first day of the month and then retroactively reinstated (going back to the first day of the month) when the monthly payment is received. This means that any claim you submit for the benefits while your coverage is suspended may be denied and may have to be resubmitted once your coverage is reinstated. If you fail to make a monthly payment before the end of the grace period for that month, you will lose all right to COBRA coverage under the Plan. Your first payment should be sent to: Benefits Office, Department of Human Resources Alexandria City Public Schools 1340 Braddock Place Alexandria, VA 22314 Subsequent payments for continuation coverage should be sent to: COBRA Payment Accounting, Department of Finance Alexandria City Public Schools 1340 Braddock Place Alexandria, VA 22314

Page 5

If mailed, your payment is considered to have been made on the date that it is postmarked. If hand-delivered, your payment is considered to have been made when it is received by the individual at the address specified above. You will not be considered to have made any payments by mailing or hand delivering a check if your check is returned due to insufficient funds or otherwise. More Information about Individuals Who May Be Qualified Beneficiaries Children born to or placed for adoption with the covered employee during COBRA coverage period: A child born to, adopted by, or placed for adoption with a covered employee during a period of COBRA coverage is considered to be a qualified beneficiary provided that, if the covered employee is a qualified beneficiary, the covered employee has elected COBRA coverage for himself or herself. The child’s COBRA coverage begins when the child is enrolled in the Plan, whether through special enrollment or open enrollment, and it lasts for as long as COBRA coverage lasts for other family members of the employee. To be enrolled in the Plan, the child must satisfy the otherwise applicable Plan eligibility requirements (for example, regarding age). Alternate recipients under QMCSO’s: A child of the covered employee who is receiving benefits under the Plan pursuant to a Qualified Medical Child Support Order (QMCSO) received by ACPS during the covered employee’s period of employment with ACPS is entitled to the same rights to elect COBRA as an eligible dependent child of the covered employee. If You Have Questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa. Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website. Keep Your Plan Informed of Address Changes In order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Plan Administrator

Benefits Staff Department of Human Resources

Alexandria City Public Schools 1430 Braddock Place

Alexandria, Virginia 22314 (703) 619-8010

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Alexandria City Public Schools Department of Human Resources May, 2017 Page 1

New Health Insurance Marketplace Coverage Options and Your Health Coverage

PART A: General Information Key parts of the Patient Protection and Affordable Care Act (PPACA) took effect in 2014 and there is a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment based health coverage offered by Alexandria City Public Schools. What is the Health Insurance Marketplace?

The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The

Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be

eligible for a new kind of tax credit that lowers your monthly premium. Open enrollment for health insurance

coverage through the Marketplace typically begins in November of each year for coverage starting the following

January. Outside of the Open Enrollment period, you can also enroll if you have a life event such as losing other

health coverage, getting married, or having a baby. For more details, visit www.healthcare.gov.

Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income. Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit.* Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution - as well as your employee contribution to employer-offered coverage- is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis. How Can I Get More Information? For more information about your coverage offered by Alexandria City Public Schools, please check your summary plan description on Alexandria City Public Schools web site, www.acps.k12.va.us/Page/517 or email HRBenefits@acps.k12.va.us. The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area. * An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs.

Alexandria City Public Schools Department of Human Resources May, 2017 Page 2

PART B: Information about Health Coverage Offered by Alexandria City Public Schools This section contains information about any health coverage offered by your employer, Alexandria City Public Schools. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide the below information. This information is numbered to correspond with the Marketplace application.

3. Employer Name

Alexandria City Public Schools

4. Employer Identification Number (EIN)

54-6001106

5. Employer Address

1340 Braddock Place, Suite 520

6. Employer Phone Number

703-619-8010

7. City

Alexandria

8. State

Virginia

9. ZIP Code

22314

10. Who can we contact about employee health coverage at this job?

Alexandria City Public Schools, Department of Human Resources, Benefits Office

11. Phone Number (if different from above) 12. Email Address

hrbenefits@acps.k12.va.us

Here is some basic information about health coverage offered by Alexandria City Public Schools: As your employer, we offer a health plan to:

Full and part-time benefit eligible employees scheduled to work at least 20 hours per week. Eligible dependents (spouse and dependent children to age 26).

This coverage meets the minimum value standard*, and the cost of this coverage to you is intended to be affordable, based on employee wages.

Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors to determine whether you may be eligible for a premium discount. For example, if your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), or you are newly employed mid-year, or you have other income losses, you may still qualify for a premium discount. If you decide to shop for coverage in the Marketplace online, www.HealthCare.gov will guide you through the process. Here is the employer information you will enter when you visit www.HealthCare.gov to find out if you can get a tax credit to lower your monthly premiums. The information below corresponds to the Marketplace Employer Coverage Tool and may help you understand your coverage choices.

13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months? Yes

14. Does the employer offer a health plan that meets the minimum value standard? Yes

15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee:

a. How much would the employee have to pay in premiums for this plan? Benefit eligible full time employees working 30+ hours a week pay from $25.76 to $51.52

1 depending on the employee group. Contact HRbenefits@acps.k12.va.us for more details.

b. How often? Twice a month.

* An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs.