general health system - baton rouge generalextranet.brgeneral.org/documents/2014 annual enrollment...

Annual Enrollment for 2014 will be held from Tuesday, October 1st – Friday, November 1st.

Annual Enrollment is your opportunity to enroll in or make changes to your benefits. Annual Enrollment for 2014 is simple.

Do you wish to keep your current benefit plans and options? If so, do nothing and your benefits will rollover into the 2014 plan year (with the exception of medical & dependent care spending accounts. IRS regulations require that these plans be re-elected each year.)

Do you want to make changes to your current benefit plans and options? If so, call the Benefits Department at (225) 237-1573. The Benefits Team is here to assist you Monday through Friday from 7:00 am - 7:30 pm, during the Annual Enrollment season. If you need assistance over the weekend, please call (225) 284-5296 or (225) 921-4772.

Before making decisions about your 2014 benefit elections, please review your current benefit options & coverage levels to make sure they are still right for you. You can access your current benefit information by logging onto Employee Self Service & clicking on the Current Benefit

Information Tab.

Employee Self Service can be accessed from the GHS intranet homepage by clicking on the “Quick Links” box on the right hand side of the page. The GHS intranet homepage can be

accessed from any desktop computer within the organization, or by visiting: www.brgeneral.org, and clicking on the intranet link located at the bottom of the page.

If you have forgotten your Employee Self Service password, please contact the Baton Rouge General IT Help Desk at (225) 381-6440

General Health System 2014 Annual Enrollment Newsletter

WHAT STEPS DO I NEED TO TAKE?

http://www.brgeneral.org/

• Your first paycheck in 2014 will be on January

• Your first paycheck of 2014 will be received on Friday, January 3rd. This paycheck will reflect time worked from December 15th – December 28th. Any benefit changes made during annual enrollment will be effective January 1, 2014, therefore your first premium deduction(s) for the 2014 plan year will appear on your January 17th paycheck. Please note, coverage will end on January 11th for any benefit you may be terminating. Therefore, the final premium will be deducted on your January 17th paycheck.

• There will be no deduction for medical and/or dependent flexible spending accounts on the January 3rd paycheck. The annual amount elected for these benefits will be divided over the course of 25 paychecks, instead of 26. For example, if you are enrolled in a flexible spending account at $1,000.00 annually, $40.00 will be deducted from your paycheck for 25 pay periods. The first FSA deduction for 2014 will appear on your January 17th paycheck.

• Remember to log onto Employee Self Service and review your paycheck deductions for your January 17th paycheck. Please contact the Benefits Department immediately at (225) 237-1573, if you notice any discrepancies. Listed below are some of the most commonly used benefit deduction codes that are shown on paychecks. You will only see the deduction codes for the benefits you are enrolled in.

Deduction Name

Description

Health EE Health Insurance 401KEC 401(k) Deduction Cancer Plan Cancer & Specified Disease Dental Ins Dental Insurance DepFSA Dependent Flexible Spending MedFSA Medical Flexible Spending Optional Life Optional Life Insurance Salary Life 1x-5x Salary Life Insurance DepLife Dependent Life Insurance Short Term Short Term Disability Insurance Vision Vision Insurance Critical Illness Critical Illness Insurance

Once again, we are very pleased to announce there will be no premium increase for the employee health plan in 2014. In addition, there will be no premium increases for any other benefit plans offered in 2014.

Good News!!

Paycheck Deduction Information

GPT Cash-Out Reminder

Earlier this year, employees were offered the option to cash out GPT accruals for a period of either (8) pay periods, or (4) pay periods. Employees who elected to participate in the GPT Cash Out option will receive the payout for their frozen GPT accruals on their November 22nd paycheck.

If you are adding a dependent spouse or child(ren) to your health insurance plan you must complete a Dependent Eligibility Affidavit (DEA) in its entirety and return to the Benefits Department no later than November 15, 2013. Your coverage level will not be changed, and your dependent will not be added if a completed DEA is not received by this date. For your convenience a DEA has been included in this packet.

Effective January 1, 2014, the General Health System employee health plan will begin covering rental costs for hospital grade breast pumps, when rented through the Baton Rouge General Employee Pharmacy. Members that are utilizing this new plan feature will be required to pay the rental fee up-front at the pharmacy, and then file a claim for reimbursement with WEB TPA.

Effective January 1, 2014, our pharmacy benefit manager (PBM) will be changing from Medco/ExpressScripts to Catamaran Rx. Due to the change in PBM’s all employees who are enrolled in the health insurance plan will receive new ID cards.

Please be sure to destroy your old ID card and replace it with your new one. It is extremely

important that you present your new ID card at the pharmacy for prescriptions that you may be

filling on or after January 1, 2014.

If you fail to notify the pharmacy that you’ve had a change in pharmacy benefits it’s likely the pharmacist will try processing your prescription through our old PBM, and the claim will be denied.

If you are participating in the General Health System employee health plan it is your responsibility to make sure you are utilizing the appropriate network providers for your healthcare needs. Remember that inpatient and outpatient services must be performed at BRGMC or another GHS facility. If services are available at one of our facilities but preformed elsewhere – no coverage will be extended for the services incurred.

The Employee Health Plan utilizes the Verity Health Net provider network. A complete listing of the Verity Health Net provider network is available at www.verityhealth.com.

All health plan members should receive new ID cards by December 31, 2013. If you have not received your

new card by December 31st, please contact WEBTPA at (888)-792-2423.

As part of the requirements of the Patient Protection and Affordable Care Act (PPACA), the General Health System employee health plan will no longer apply pre-existing condition exclusions to any enrollee, effective

January 1, 2014.

Health Plan Updates

Enclosed in this Annual Enrollment packet are the Summary Annual Reports for our employee benefit plans. These reports are furnished in connection with reporting and disclosure regulations for employee benefit plans, and are for informational purposes only. These reports require no action from you. If you have any questions about the Summary Annual Reports, please call the Benefits Department at (225) 237-1573.

Summary Annual Reports

http://www.verityhealth.com/

If you are electing or changing any of these benefit plans, please remember: • An application must be submitted if you are electing short-term disability, life insurance, cancer & serious

disease, or critical illness policies during annual enrollment. An application must also be submitted if you are making changes to any existing polices you are currently enrolled in. Decreasing the value of a policy is considered a change, and an application must be submitted in order for the change to be approved.

• In order for your election to be approved, the completed application must be returned to the Benefits Department no later than November 15th. Coverage for these polices, and changes to these policies cannot be extended without the completed application.

• The effective date for life insurance policies are subject to approval from the vendor and coverage will not be extended until the vendor notifies us in writing that the policy has been approved.

Short-term, Life, Cancer & Serious Disease and Critical Illness Policies

BRG Fit! Update

Each year, we try to improve the personal health and wellness of our employees. During the 2012-2013 seasons, 2,684 biometric screenings were completed. 380 employees who were outside of their target weight were successful in reducing their body weight by 5% or more. Congratulations to those that have made this significant improvement! We are looking forward to the 2013-2014 season, and want to encourage even more employees to make progress in their personal health and wellness.

The BRG Fit! biometric screenings will begin on November 4, 2013 and will continue through March 31, 2014. Multiple screening opportunities will be offered again at both the Mid City and Bluebonnet campuses.

Employees will once again have the opportunity to qualify for incentive awards. Full time employees can earn up to $250.00, and Part time employees can earn up to $125.00. Enclosed in this packet is detailed information concerning the 2013-2014 BRG Fit! Wellness Program, please refer to this flyer for information pertaining to employee eligibility.

Please note this important change: Last year employees were offered the opportunity to complete 4 out of 6 classes in the “Get Fit” educational series as an alternate option to earn the additional wellness incentive. However, this year the “Get Fit” educational series will NOT be offered as an option for earning the additional incentive. Please refer to the BRG Fit! flyer for additional information. 401(k)

Effective January 1, 2014, employees who are age 50 or older, and who have contributed the maximum deferral limit before the end of the 2014 plan year, will be automatically enrolled in the catch-up provision. The 401(k) catch -up provision allows employees age 50 or older to contribute up to an additional $5,500 annually. No special enrollment is required. (subject to plan limits)

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Health Insurance

High Option Full-Time

(1.0 – 0.9) Part-Time

(0.8 – 0.6)

Single $71 $85 Employee/Child $130 $149 Employee/Spouse $152 $176 Family $220 $262

(A biweekly premium discount may apply to non-tobacco using health plan members)

Basic Option Full-Time

(1.0 – 0.9) Part-Time

(0.8 – 0.6)

Single $54 $55 Employee/Child $85 $100 Employee/Spouse $99 $118 Family $164 $190

(A biweekly premium discount may apply to non-tobacco using health plan members)

It is the responsibility of health plan members’ to ensure they are utilizing the appropriate network providers for healthcare needs. Remember to inform physicians that your healthcare services should be performed at The General.

Coverage begins on the 1st day of employment for full-time employees & 90th day of employment for part-time employees.

High Option deductible is $250 per person & maximum out of pocket expenses are $3,000. Basic Option deductible is $900 per person & maximum out of pocket expenses are $6,000.

High Option $25 co-pay & Basic Option $30 co-pay for office visits with a primary care physician, pediatrician, urgent care/after hour clinic or mental health provider.

High Option $30 co-pay & Basic Option $35 co-pay for office visits with a specialist. Charges billed by a specialist are subject to deductible.

All charges billed for laboratory & x-ray services are subject to deductible, with the exception of mammograms & annual pap smear screenings. In addition, deductible will be waived for any laboratory & x-ray services that are incurred at the BRGMC & the Employee & Family Clinic. Deductible will also be waived for any x-ray services that are incurred at Baton Rouge Radiology Imaging Center.

Inpatient & outpatient services must be performed at BRGMC or another GHS facility. If services are available at a GHS facility but performed elsewhere, no payment will be made for the services.

Some of the outpatient services available at BRGMC or other GHS facilities include: surgical procedures, CT Scans, MRI’s, Mammograms, Bone Density Scans, Sleep Study Testing, Cardiac Stress Testing, Cardiac Rehab, Nuclear Stress Testing, Physical Therapy, Occupational Therapy & Speech Therapy.

100% coverage for inpatient & outpatient services performed at BRGMC or another GHS facility. All inpatient services are subject to deductible & a $100 co-pay per day will apply ($300 maximum). All outpatient services are subject to deductible & a $50 co-pay will apply. No co-pay will apply on CT scans are MRI’s.

90% coverage for outpatient Physical, Occupational & Speech Therapy services when performed at BRGMC. When certain types of outpatient therapy services are not available at BRGMC, network coverage will be extended at 70%. All outpatient therapy services are subject to deductible.

Emergency room services should only be utilized in the event of a life threatening or emergent situation. A penalty will apply to payment for emergency room claims billed with a diagnosis considered to be non-life threatening or non-emergent, if the services were incurred at BRGMC. If non-life threatening or non-emergent services are incurred at another hospital facility the charges will not be covered by the plan. Emergency Room visits are subject to a $100 co-pay & services are also subject to deductible.

High Option & Basic Option pharmacy deductible is $50 per person.

BRGMC Pharmacy Co-pays $5 - Generic

$25 - Formulary $40 – Non-Formulary

$85 Specialty Oral or Injectibles (Can Only Be Filled At BRGMC)

Retail Pharmacy Co-pays >$15 or 20% of the cost of the drug - Generic

>$35 or 30% of the cost of the drug - Formulary >$50 or 40% of the cost of the drug – Non-Formulary

Specialty Oral or Injectibles Are Not Available Through A Retail Pharmacy

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Health Insurance (continued)

The Employee Health Plan utilizes the Verity Health Net provider network. A complete listing of the Verity Health Net provider network is available at www.verityhealth.com.

For purposes of the health plan regarding the Patient Protection and Affordable Care Act:

• The health plan believes the plan is a “grandfathered health plan”.

• The lifetime limit on the dollar value of benefits no longer applies.

• Individuals whose coverage ended, or who were denied coverage (or were not eligible), because the availability of dependent coverage of children ended before attainment of age 26 are eligible.

• You have the right to designate any primary care provider that participates in our network & who is available to accept you and your family.

• You do not need prior authorization in order to obtain access to obstetrical or gynecological care from a health care professional participating in our network that specializes in obstetrics or gynecology.

• The plan can not apply pre-existing condition exclusions to any covered enrollee

Employee & Family Clinic

The Employee & Family Clinic is operated through the Family Health Center, located at 3801 North Boulevard. The Bluebonnet location is operated through the Metabolic Spectrum Center; located at 8490 Picardy #600, Suite D.

$10 co-pay for office visits for employee health plan members & their dependents.

Deductible is waived for all laboratory & radiology charges for employee health plan members & their dependents.

Employees not participating in the employee health plan may also use the Employee & Family Clinic, but services will be billed according to the limitations of their insurance plan. Employees who are not enrolled in an insurance plan will receive a 35% discount on all physician services.

Dental Insurance

Premium (+) Option Premium Option Single $11.15 Single $ 9.81 Employee/Spouse $23.34 Employee/Spouse $20.71 Employee/Child(ren) $27.07 Employee/Child(ren) $23.99 Family $39.26 Family $34.88

(Premiums listed above are per pay period)

Coverage is effective on the 1st of the month, following 30 days of employment.

Traditional dental plan – see any dentist, anywhere at any time or access a dentist in the network & save on out of pocket expenses.

100% coverage for preventative care every 6 months – deductible waived.

80% coverage for non-restorative basic services, which includes fillings, denture repair, anesthesia, simple extractions & complex extractions.

50% coverage for major services, which includes inlays, onlays, crowns, crown repair, endodontic therapy, periodontal therapy & prosthodontics. A 12 month waiting period applies for major dental services.

Dependent orthodontics are covered at 50%, with a $1,500 lifetime maximum. A 12 month waiting period applies for orthodontic services.

Dental claims are processed at the 90th percentile of reasonable & customary charges.

Cancer & Specified Disease Insurance

Single $7.08 Family $11.84



This is a supplemental policy that provides income if a member is diagnosed with Cancer or any of the specified diseases covered under the policy (see brochure for complete list of specified diseases covered under the policy).

A $50 wellness benefit is built into this plan just for having an annual cancer screening done.

Coverage under this policy does not replace any group health benefits you may have – it supplements any group coverage you have.

This policy is guaranteed renewable for life.

Vision Insurance

Single $3.18 Employee/Child(ren) $5.23 Employee/Spouse $5.53 Family $8.28



$10 co-pay for eye exam with a network provider.

$25 co-pay for eye glasses, up to $130 in value. Eye glass frames may be replaced once every 24 months.

Free contact lenses, up to $130 in value.

Receive a 15% - 20% discount on all LASIK & PRK procedures.

Provider network includes individual optometrist & ophthalmologists & major retail businesses such as Walmart, Sam’s Club, Target & JCPenney’s.


Company Paid Life Insurance

This company paid policy is available for all full-time employees with 1 year of service & is equal to 1X the employees’ annual salary (policy amount does not exceed $50,000).

Optional Term Life Insurance


$10,000 optional term life insurance policy is available for only $1.31 per pay period.

A salary supplemental policy is available at 1X, 2X, 3X, 4X or 5X your annual salary. Your premium is based on your age & salary (total policy can’t exceed $500,000)

If elected at the time of hire, policies are guaranteed issue up to $250,000.

Dependent term life insurance is available for $1.15 per pay period. Policy includes 10,000 spousal coverage, $5,000 dependent coverage & $2,500 coverage for newborns up to 6 months of age.

Interim Disability This disability policy is company paid & funded for all full-time employees with 1 year of continuous full-time service.

Policy pays 60% of an employee’s base annual salary after the total disability absence has exceeded 60 days & will continue to pay through the 90th day of the disability.

Payments are processed through the GHS bi-weekly payroll, so benefit deductions are automatically withheld & employees don’t have the hassle of making manual premium payments.

Long Term Disability

Policy is company paid & available to all employees with (1) year of continuous full-time service.

Policy pays 60% of an employee’s base salary after the total disability or absence period has exceeded the policy’s (90) day elimination period.

Monthly disability payments are capped at no more than $10,000.

Voluntary Short Term Disability


Coverage begins on the 15th day of the illness or disability.

Benefits are paid up to 26 weeks (6 months).

Employees have the option to pick their weekly benefit, up to 65% of their base salary, with a maximum benefit of $6,000 monthly.

Payments are processed on a bi-weekly basis.

401(k) Retirement Plan

Upon hire, all eligible employees will be automatically enrolled in the 401(k) retirement plan.

2% of an eligible employee’s compensation will be deferred into the 401(k) retirement plan at the beginning of the pay period, following 30 days of employment.

Employees have the option to contribute 1% to 30% of their annual salary, up to the legal limit.

GHS will match 50% of the first 6% of pay that employees contribute after 1 year of employment & 1,000 hours worked. The company matched contribution is subject to IRS limitations.

Investment changes or salary reduction changes can be made on line at any time through Fidelity Investments. Visit Fidelity Investments online at www.fidelityinvestments.com.

Employees are 100% vested in the 401(K) retirement plan after 3 years of service for the company matched contributions.

Critical Illness Insurance


Policy provides benefits for (13) critical illnesses & is payable from 25% to 100% of the coverage amount you choose.

Premiums are based on your age & the amount of coverage you choose to elect (see Critical Illness brochure for age brackets & biweekly premiums).

Policy provides a lump sum benefit payable to you upon diagnosis of a critical illness & also when a reoccurrence or additional occurrence is diagnosed.

If elected at the time of hire policy is guaranteed issue up to $15,000.

Participants may receive an annual benefit for receiving one of (19) covered health screenings (for a complete list of the covered screenings see the Critical Illness Insurance brochure).

Covered Critical Illness

% Amount Covered

Myocardial Infraction (Heart Attack) 100%** Stroke 100% Invasive Cancer 100%** Major Organ Transplant 100% ESRD (Kidney Failure) 100% Loss of Sight 100%* Coma 100%* Paralysis 100%* Brain Damage 100% Ruptured Cerebral Carotid 100% Aortic Aneurysm 100% Coronary Artery Bypass 25%* Carcinoma in Situ 25%*

* Payable once per lifetime. ** Benefits paid for Carcinoma in Situ, Skin Cancer & Coronary Artery Bypass reduce the benefit payable for subsequently diagnosed Invasive Cancer & Heart Attack, respectively.

http://www.fidelityinvestments.com/

Employee Assistance Program

The Employee Assistance Program (EAP) is designed to assist employees & their families with concerns related to physical illness, mental or emotional disturbance, chemical/substance abuse & dependency. The EAP also provides assistance related to marital, legal or financial concerns, preparation of wills & identity theft.

Employees may receive up to 3 free visits with a counselor or behavioral health specialist through the EAP. If further visits are necessary a referral may be given.

The EAP program is administered through the Cigna Assistance Program & is available 24 hours a day, 7 days a week by calling (800) 538-3543.

Flexible Spending Accounts

Flexible Spending Accounts are reimbursable pre-tax savings accounts that are available for dependent care and/or medical spending expenses. Flexible Spending Accounts also help to lower your taxable income.

Medical spending annual election amounts can be as little as $5 per pay period & no more than $100 per pay period. Total annual election amounts cannot exceed $2,500.

Dependent spending annual elections amounts can be as little as $5.00 per pay period & no more than $200 per pay period. Total annual election amounts cannot exceed $5,000.

No taxes are deducted from the reimbursements you receive. Reimbursements are processed through Diversified Benefit Services & mailed directly to your home. Direct deposit is available for both dependent care & medical spending accounts.

An automatic reimbursement option is also available for medical spending accounts if you are enrolled in the General Health System group health plan.

Up to $1,000 may be rolled over from one plan year to the next for medical spending accounts. Claim expenses incurred January 1st – March 15th of the new plan year may be used towards the rolled over amount.

The deadline for submitting claims incurred in the prior plan year is April 15th.

Examples of eligible expenses for medical spending accounts include deductibles, dental care, co-pays, co-insurance expenses, eye exams, glasses, contact lenses, hearing exams & hearing aids.

Flexible spending account balances are available online 24 hours a day, 7 days a week through www.dbsbenefits.com.

General Paid Time

GPT accumulation begins upon hire for all regular full-time & regular part-time employees & is calculated per pay period, based on an employee’s fte value & hours worked.

There is a (90) day waiting period before GPT can be used, with the exception of official company holidays.

Accumulated GPT amounts include vacation, holiday & sick pay for full-time employees & vacation & holiday pay for part-time employees. Reduced part-time employees do not accumulate GPT.

GPT can be used with management approval, at the employees’ discretion.

GHS recognized company holidays include: New Years Day, 4th of July, Labor Day, Thanksgiving Day & Christmas Day.

Full-Time FTE Accrual Accumulations Years of Service

Accrual Per Hour Paid

Days Per Year

0-5 years 0.085 22 days* 5-10 years 0.104 27 days*

10-20 years 0.112 29 days* 20+ years 0.123 32 days*

*Days per year calculation is based on 1.0 FTE value

Part-Time FTE Accrual Accumulations Years of Service


Days Per Year

0-5 years 0.065 13 days* 5-10 years 0.085 17 days*

10-20 years 0.092 19 days* 20+ years 0.104 21 days*

*Days per year calculation is based on 0.8 FTE value

Annual Maximum Carryover Amounts Years of Service


Days Per Year

0-5 years 280 hours 35 days 5-10 years 320 hours 40 days

10-20 years 336 hours 42 days 20+ years 360 hours 45 days

http://www.umr.com/

BRGeneral Fit! Employee Wellness

Incentive Card Eligibility for 2013-2014

Employees with a full-time (0.9 or 1.0) or part-time (0.8 or 0.6) status as of October 1, 2013 will be eligible for the wellness incentive card.

Wellness Incentive Cards will be awarded according to the following guidelines:

To qualify for the incentive card:

Full Time Employees

Part Time Employees

Complete the

Biometric Screening1

$100

$50

Complete the Body Mass Index (BMI) Evaluation

Additional $150

Additional $75

This year empl0yees may only earn the additional incentive if:

■ Their BMI was in the qualifying range at last year’s screening and remains in the qualifying range at this year’s screening

(see BMI chart on back)

or

■ If their BMI is greater than 27, their body weight must be

reduced by 5% from last year’s measurement2

(see example shown below)

IMPORTANT NOTE for 2013-2014:

Last year employees were offered the opportunity to

complete 4 out of 6 classes in the “Get Fit” educational

series as an alternate option to earn the additional

wellness incentive. However, this year the “Get Fit”

educational series will NOT be offered as an option for

earning the additional incentive.

Total Incentive = $250

Total Incentive = $125

Example: Based on last year’s screening, an employee with a height of 65 inches and a weight of 200 pounds would have a Body Mass Index of 33. Since this BMI is greater than 27, the employee would need to reduce their weight by 5% or 10 lbs (5% of 200 is 10). This employee would need to reduce their weight from 200 lbs to 190 lbs to be eligible for the additional incentive award.

1If you complete the required lab work and measurements as part of a visit to your primary care physician, send the

results to the BRGeneral Fit! team so the data can be recorded. 2If you did not participate in the biometric screening process last year, the BMI measurement will be taken at your initial

screening this year. If a reduction of weight is necessary to qualify for the additional incentive award, all employees will

have until June 30, 2014 to follow up with the BRGeneral Fit! team with regard to their final weight/BMI measurement.

BMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54Height

(inch)

5891 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167 172 177 181 186 191 196 201 105 210 215 220 224 229 234 239 244 248 253 258

5994 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173 178 183 188 193 198 203 208 212 217 222 227 232 237 242 247 252 257 262 267

6097 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179 184 189 194 199 204 209 215 220 225 230 235 240 245 250 255 261 266 271 276

61100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185 190 195 201 206 211 217 222 227 232 238 243 248 254 259 264 269 275 280 285

62104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191 196 202 207 213 218 224 229 235 240 243 251 256 262 267 273 278 284 289 295

63107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197 203 208 214 220 225 231 237 242 248 254 259 265 270 278 282 287 293 299 304

64110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204 209 215 221 227 232 238 244 250 256 262 267 273 279 285 291 296 302 308 314

65114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210 216 222 228 234 240 246 252 258 264 270 276 282 288 294 300 306 312 318 324

66118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216 223 229 235 241 247 253 260 266 272 278 284 291 297 303 309 315 322 328 334

67121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223 230 236 242 249 255 261 268 274 280 287 293 299 306 312 319 325 331 338 344

68124 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230 236 243 249 256 262 269 276 282 289 295 302 308 315 322 328 335 341 348 354

69128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236 243 250 257 263 270 277 284 291 297 304 311 318 324 331 338 345 351 358 365

70131 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243 250 257 264 271 278 285 292 299 306 313 320 327 334 341 348 355 362 369 376

71136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250 257 265 272 279 286 293 301 308 315 322 329 338 343 351 358 365 372 379 386

72140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258 265 272 279 287 294 302 309 316 324 331 338 346 353 361 368 375 383 390 397

73144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265 272 280 288 295 302 310 318 325 333 340 348 355 363 371 378 386 393 401 408

74148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272 280 287 295 303 311 319 326 334 342 350 358 365 373 381 389 396 404 412 420

75152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279 287 295 303 311 319 327 335 343 351 359 367 375 383 391 399 407 415 423 431

76156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287 295 304 312 320 328 336 344 353 361 369 377 385 394 402 410 418 426 435 443

Normal Overweight Obese Extreme Obesity

BRGeneral FIT! BMI Qualification Range

144

SUMMARY ANNUAL REPORT GENERAL HEALTH SYSTEM LONG TERM DISABILITY PLAN

This is a summary of the annual report of the General Health System Long Term Disability Plan for the plan year beginning January 1, 2012 and ending December 31, 2012. The annual report has been filed with U.S. Department of Labor’s Pension and Welfare Benefits Administration, as required under the Employee Retirement Income Security Act of 1974 (ERISA). General Health System has committed itself to pay all insurance premiums incurred under the terms of the plan. The plan has a contract with Guardian Life Insurance Company to pay all long-term disability claims incurred under the terms of the plan. The total premiums paid for the 2012 plan year were $352,019. A total of 1,834 persons were participants in or beneficiaries of the plan at the end of the plan year, although not all of the persons had yet earned the right to receive benefits. Your Rights to Additional Information You have a right to receive a copy of the full annual report, or any part thereof, on request. The items listed below are included in that report. 1. Fiduciary information, including transactions

between the plan and parties-in-interest (that is, persons who have certain relationships with the plan);

2. Insurance information including sales commissions paid by insurance carriers.

To obtain a copy of the full annual report, or any part thereof, write or call General Health System, 8490 Picardy Ave., Bldg. 100A, Baton Rouge, LA 70809, (225) 237-1551. The charge to cover copying costs will be $.25 per page. You also have the right to receive from the plan administrator, on request and at no charge, a statement of the assets and liabilities of the plan and accompanying notes, or a statement of income and expenses of the plan and accompanying notes, or both. If you request a copy of the full annual report from the plan administrator, these two statements and accompanying notes will be included as part of that report. The charge to cover copying costs given above does not include a charge for the copying of these portions of the report because these portions are furnished without charge. You also have the legally protected right to examine the annual report at the main office of the plan, General Health System 8490 Picardy Avenue, Bldg. 100A, Baton Rouge, Louisiana 70809, and at the U.S. Department of Labor in Washington, D.C., or to obtain a copy from the U.S. Department of Labor upon payment of copying costs. Requests to the Department should be addressed to: Public Disclosure Room, N-1513, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210.

SUMMARY ANNUAL REPORT GENERAL HEALTH SYSTEM HEALTH PLAN

This is a summary of the annual report of the General Health System Health Plan for the plan year beginning January 1, 2012 and ending December 31, 2012. The annual report has been filed with U.S. Department of Labor’s Pension and Welfare Benefits Administration, as required under the Employee Retirement Income Security Act of 1974 (ERISA). General Health System has committed itself to pay all health claims incurred under the terms of the plan through an Administrative Services Only contract with WEB-TPA, Inc. The plan has a contract with HCC Life Insurance Company to pay certain health claims incurred under the terms of the plan. The total premiums paid for the 2012 plan year were $253,380. Basic Financial Statement Benefits under the plan are provided through a trust fund. Plan expenses were $14,243,575. These expenses included $741,412 in administrative and plan expenses and $13,502,163 in benefits paid to participants and beneficiaries. A total of 2,234 employees were participating in the plan at the end of the plan year, although not all of the persons had yet earned the right to receive benefits. Your Rights to Additional Information You have a right to receive a copy of the full annual report, or any part thereof, on request. The items listed below are included in that report. 1. Fiduciary information, including transactions



To obtain a copy of the full annual report, or any part thereof, write or call General Health System, 8490 Picardy, Bldg. 100A, Baton Rouge, LA 70809, (225) 237-1551. The charge to cover copying costs will be $.25 per page.

You also have the right to receive from the plan administrator, on request and at no charge, a statement of the assets and liabilities of the plan and accompanying notes, or a statement of income and expenses of the plan and accompanying notes, or both. If you request a copy of the full annual report from the plan administrator, these two statements and accompanying notes will be included as part of that report. The charge to cover copying costs given above does not include a charge for the copying of these portions of the report because these portions are furnished without charge.

You also have the legally protected right to examine the annual report at the main office of the plan, General Health System 8490 Picardy Avenue, Bldg. 100A, Baton Rouge, Louisiana 70809, and at the U.S. Department of Labor in Washington, D.C., or to obtain a copy from the U.S. Department of Labor upon payment of copying costs. Requests to the Department should be addressed to: Public Disclosure Room, N-1513, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210.

SUMMARY ANNUAL REPORT GENERAL HEALTH SYSTEM

GROUP LIFE AND AD&D PLAN This is a summary of the annual report of the General Health System Group Life and AD&D Plan for the plan year beginning January 1, 2012 and ending December 31, 2012. The annual report has been filed with U.S. Department of Labor’s Pension and Welfare Benefits Administration, as required under the Employee Retirement Income Security Act of 1974 (ERISA). The plan has a contract with Guardian Life Insurance Company to pay certain life claims incurred under the terms of the plan. The total premiums paid for the 2012 plan year were $458,619. A total of 1,834 persons were participants in or beneficiaries of the plan at the end of the plan year, although not all of the persons had yet earned the right to receive benefits. Your Rights to Additional Information You have a right to receive a copy of the full annual report, or any part thereof, on request. The items listed below are included in that report. 1. Fiduciary information, including transactions



To obtain a copy of the full annual report, or any part thereof, write or call the General Health System, 8490 Picardy, Bldg. 100A, Baton Rouge, LA 70809, (225) 237-1551. The charge to cover copying costs will be $.25 per page. You also have the right to receive from the plan administrator, on request and at no charge, a statement of the assets and liabilities of the plan and accompanying notes, or a statement of income and expenses of the plan and accompanying notes, or both. If you request a copy of the full annual report from the plan administrator, these two statements and accompanying notes will be included as part of that report. The charge to cover copying costs given above does not include a charge for the copying of these portions of the report because these portions are furnished without charge. You also have the legally protected right to examine the annual report at the main office of the plan, General Health System 8490 Picardy Avenue, Bldg. 100A, Baton Rouge, Louisiana 70809, and at the U.S. Department of Labor in Washington, D.C., or to obtain a copy from the U.S. Department of Labor upon payment of copying costs. Requests to the Department should be addressed to: Public Disclosure Room, N-1513, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210.


FLEX IN:GENERAL FLEXIBLE BENEFITS PLAN

This is a summary of the annual report of the General Health System Flex In: General Flexible Benefits Plan for the plan year beginning January 1, 2012 and ending December 31, 2012. The annual report has been filed with U.S. Department of Labor’s Pension and Welfare Benefits Administration, as required under the Employee Retirement Income Security Act of 1974 (ERISA). General Health System has committed itself to pay certain premiums incurred under the terms of the plan. A total of 3,153 persons were participants in or beneficiaries of the plan at the end of the plan year, although not all of the persons had yet earned the right to receive benefits. Your Rights to Additional Information You have a right to receive a copy of the full annual report, or any part thereof, on request. The item listed below is included in that report.

• Fiduciary information, including transactions between the plan and parties-in-interest (that is, persons who have certain relationships with the plan).

To obtain a copy of the full annual report, or any part thereof, write or call the General Health System, 8490 Picardy, Bldg. 100A, Baton Rouge, LA 70809, (225) 237-1558. The charge to cover copying costs will be $.25 per page. You also have the right to receive from the plan administrator, on request and at no charge, a statement of the assets and liabilities of the plan and accompanying notes, or a statement of income and expenses of the plan and accompanying notes, or both. If you request a copy of the full annual report from the plan administrator, these two statements and accompanying notes will be included as part of that report. The charge to cover copying costs given above does not include a charge for the copying of these portions of the report because these portions are furnished without charge. You also have the legally protected right to examine the annual report at the main office of the plan, General Health System 8490 Picardy Avenue, Bldg. 100A, Baton Rouge, Louisiana 70809, and at the U.S. Department of Labor in Washington, D.C., or to obtain a copy from the U.S. Department of Labor upon payment of copying costs. Requests to the Department should be addressed to: Public Disclosure Room, N-1513, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210.


RETIREMENT PLUS PLAN

This is a summary of the annual report for General Health

System Retirement Plus Plan, Employer Identification Number 72-0475545, Plan No. 002 for the period January 1, 2012 through December 31, 2012. The annual report has been filed with the Employee Benefits Security Administration, U.S.

Department of Labor, as required under the Employee Retirement Income Security Act of 1974 (ERISA).

Basic Financial Statement

Benefits under the plan are provided through a trust fund. Plan expenses were $6,686,137. These expenses included $116,255 in administrative expenses and $6,560,983 in benefits paid to participants and beneficiaries and $8,899 in other expenses. A total of 4111 persons were participants in or beneficiaries of the plan at the end of the plan year.

The value of plan assets, after subtracting liabilities of the plan, was $82,852,663, as of December 31, 2012 compared to $70,703,368 as of January 1, 2012. During the plan year, the plan experienced an increase in its net assets of $12,149,295. This increase includes unrealized appreciation and depreciation in the value of plan assets; that is, the difference between the value of the plan's assets at the end of the year and the value of the assets at the beginning of the year or the cost of assets acquired during the year. The plan had total income of

$18,835,432, including employer contributions of $2,198,665, employee contributions of $6,599,868, other contributions of $544,193, realized losses of $1,323 from the sale of assets, and earnings from investments of $9,494,029.

Your Rights to Additional Information You have the right to receive a copy of the full annual report, or any part thereof, on request. The items listed below are included in that report:

1. financial information and information on payments to service providers;

2. information regarding any CCTs, PSAs, MTs, or 103-12Ies;

3. an accountant's report;

4. assets held for investment;

To obtain a copy of the full annual report, or any part thereof, write or call General Health System, 8490 Picardy Avenue, Baton Rouge, LA 70809, (225) 237-1550.

You also have the right to receive from the Plan Administrator, on request and at no charge, a statement of the assets and liabilities of the plan and accompanying notes, or a statement of income and expenses of the plan and accompanying notes, or both. If you request a copy of the full annual report from the Plan Administrator, these two statements and accompanying notes will be included as part of that report.

You also have the legally protected right to examine the annual report at the main office of the plan at General

Health System, 8490 Picardy Avenue, Baton Rouge, LA 70809, and at the U.S. Department of Labor in Washington, D.C. or to obtain a copy from the U.S. Department of Labor upon payment of copying costs. Requests to the Department should be addressed to: Public Disclosure Room, N1513, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210.

OMB 0938-0990

CMS Form 10182-CC Updated April 1, 2011

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including

the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the

accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Important Notice from GENERAL HEALTH SYSTEM About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with GENERAL HEALTH SYSTEM and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a

Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. GENERAL HEALTH SYSTEM has determined that the prescription drug coverage offered by the General Health System Employee Health Plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

____________________________________________________________________________________________________________________

When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.

However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current GENERAL HEALTH SYSTEM coverage will not be affected.

Co-pay Structure for Prescriptions Filled at Baton Rouge General Medical Center Outpatient Pharmacy

$5 – Generic $25 – Formulary

$40 – Non-Formulary $85 Specialty Oral or Injectibles

(Can Only Be Filled At BRGMC Outpatient Pharmacy)

Co-pay Structure for Prescriptions Filled at A Retail Pharmacy

>$15 or 20% of the cost of the drug - Generic >$35 or 30% of the cost of the drug - Formulary

>$50 or 40% of the cost of the drug – Non-Formulary Specialty Oral or Injectibles Are Not Available

Through A Retail Pharmacy – They Must Be Purchased From The Baton Rouge General Outpatient Pharmacy

OMB 0938-0990

CMS Form 10182-CC Updated April 1, 2011

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including

the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the

accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

If you do decide to join a Medicare drug plan and drop your current General Health System Employee Health Plan coverage, be aware that you and your dependents will not be able to get this coverage back. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with the General Health System Employee Health Plan and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact the General Health System Benefits Department for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through the General Health System Employee Health Plan changes. You also may request a copy of this notice at any time. For More Information About Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage:

Visit www.medicare.gov Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You”

handbook for their telephone number) for personalized help Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable

coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). Date: October 1, 2013 Name of Entity/Sender: General Health System Contact--Position/Office: Benefits Department Address: 8490 Picardy Avenue, Building 100A Phone Number: (225) 237-1573

General Health System: Basic Option Summary of Benefits and Coverage: What this Plan Covers &What it Costs

Coverage Period: 01/01/2014 – 12/31/2014

Coverage For: All Basic Option Participants │Plan Type: PPO

Questions: Call 1-866-889-8977or visit us at www.webtpa.com. If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at www.healthcare.gov or call 1-866-889-8977 to request a copy.

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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document http://home.ghsbtr.net/homepage or by calling1-866-889-8977.

ImportantQuestions Answers WhythisMatters:

What is the overall deductible?

$900 person – coinsurance and co-payments do not apply towards the deductible.

You must pay all the cost up to the deductible amount before this plan begins to pay for covered

services you use. Check your policy or plan document to see when the deductible starts over (usually,

but not always, January 1st). See the chart starting on page 2 for how much you pay for covered

services after you meet the deductible.

Are there other

deductibles for specific

services?

Yes.$50 person / $150 family. There are no other specific deductible.

You must pay all of the costs for these services up to the specific deductible amount before this plan

begins to pay for those services.

Is there an out–of– pocket limit on my expenses?

Yes. For participating providers $6,000 person.

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your

share of the cost of covered services. This limit helps you plan for health care expenses.

What is not included in

the out–of–pocket limit?

Premiums, balance-billed

charges, and health care this

plan doesn’t cover.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Is there an overall annual limit on what the plan pays?

Yes. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services,

such as office visits.

Does this plan use a network of providers?

Yes. See www.verityhealth.com

for a list of participating

providers or call 1-866-889-

8977.

If you use an in-network doctor or other healthcare provider, this plan will pay some or all of the costs

of covered services. Be aware, your in-network doctor or hospital may use an out-of-network

providerfor some services. Plans use the term in-network, preferred, or participating for providers in

their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Do I need a referral to

see a specialist?

No. You don’t need a referral

to see a specialist. You can see the specialistyou choose without permission from this plan.

Are there services this plan doesn’t cover?

Yes. Some of the services this plan doesn’t cover are listed on page 4. See your policy or plan document for

additional information about excluded services.

http://home.ghsbtr.net/homepage



Coverage Period: 01/01/2014 – 12/31/2014



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• Co-payments are fixed dollar amounts (for example, $15) you pay for covered healthcare, usually when you receive the service.

• Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven’t met your deductible.

• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

• This plan may encourage you to use participating providers by charging you lower deductibles, co-payments and co-insurance amounts.

Common Medical Event Services You May Need

Your Cost If You Use A

Limitations & Exclusions GHS Tier 1 Provider

In-Network Tier 2 Provider

Out-of-Network Provider

If you visit a health

care provider’soffice or

clinic

Primary care visit to treat an

injury or illness $30 visit $30 visit Not Covered $10 visit for Employee Clinic visits.

Specialist visit $35 visit $35 visit Not Covered Deductible applies.

Other practitioner office visit $35 visit $35 visit Not Covered Deductible applies. 20% co-insurance

applies to chiropractic care services.

Preventive

care/screening/immunization $30 visit $30 visit Not Covered See plan document for specific exams.

If you have a test

Diagnostic test (x-ray, blood

work) No Charge Not Covered Not Covered

Cost quoted is based on outpatient facility

services – see plan document for other

specifics.

Imaging (CT/PET scans, MRIs) Deductible Applies Not Covered Not Covered Non-precertification penalty reduces benefit

by 50% of allowed amount.

If you need drugs to

treat your illness or

condition

Generic $5 co-payment >$15 or 20%

co-insurance Not Applicable

$50 RX deductible per person, $150 RX

deductible per family. Preferred Brand Drugs $25 co-payment

>$35 or 30%


Non-Preferred Brand Drugs $40 co-payment >$45 or 40%



Coverage Period: 01/01/2014 – 12/31/2014



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Common

Medical Event Services You May Need


Limitations and Exclusions GHS

Tier 1 Provider

In-Network Tier

2 Provider

Out-of-Network

Provider

Continued:

More information

about prescription

drug coverage is

available at

www.catamaranrx.com

Specialty Drugs $85 co-payment Not Applicable Not Applicable

$50 RX deductible per person, $150

RX deductible per family. Only

available at BR General Pharmacy.

If you have outpatient

surgery

Facility Fee (e.g., ambulatory

surgery center). $50 co-payment $100 co-payment Not Covered

Deductible applies. Non-precertification

penalty reduces payable benefit by

50%. Authorization for services at a

network facility will only be authorized if

service not available at a GHS facility. Physician / Surgeon Fees 0% co-insurance 20% co-insurance Not Covered

If you need immediate

medical attention

Emergency Room Services $100 co-payment $100 co-payment,

20% co-insurance

$100 co-payment,

20% co-insurance

Deductible applies. If diagnosis is not

considered emergent, then services will

be paid at 50% at BR General and will

not be covered for other providers.

Emergency Medical Transportation Not Applicable Not Applicable $50 co-payment,

20% co-insurance

Deductible applies. $50 co-payment

applies to ground transfer. $150 co-

payment applies to air transfer.

Urgent Care Not Applicable $30 co-payment Not Covered

Deductible applies to all lab and x-ray

charges. Co-payment waived if

services rendered are accident related.

If you have a hospital

stay

Facility Fee (e.g., hospital room)

$100 co-payment

per day / $300

max co-payment

$300 co-payment

per day / $900

max co-payment,

20% co-insurance

Not Covered







Coverage Period: 01/01/2014 – 12/31/2014



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Common




Tier 1 Provider

In-Network

Tier 2 Provider

Out-of-Network

Provider

If you have mental

health, behavioral

health, or substance

abuse needs

Mental/Behavioral Health

Outpatient Services $30 per visit $30 per visit Not Covered Deductible applies.

Mental/Behavioral Health Inpatient

Services

$100 co-payment

per day / $300

max co-payment

$300 co-payment

per day / $900

max co-payment,

20% co-insurance

Not Covered





service not available at BR General.

Substance Use Disorder Outpatient

Services $30 per visit $30 per visit Not Covered Deductible applies.

Substance Use Disorder Inpatient

Services

$100 co-payment

per day / $300

max co-payment

$300 co-payment

per day / $900

max co-payment,

20% co-insurance

Not Covered






If you are pregnant

Prenatal and postnatal care $35 per visit $35 per visit Not Covered Deductible applies.

Delivery and all inpatient services $100 co-payment Not Covered Not Covered

Deductible is waived on facility charges

but applies to all other inpatient

services. Non-precertification penalty

reduces payable benefit by 50%.

If you need help

recovering or have

other special health

needs

Home Health Care Not Applicable 20% co-insurance Not Covered



50%. 60 visits combined annual limit

for Physical, Occupational & Cardiac

Rehab services. 25 visit annual limit for

Speech Rehab services and Home

Health services.

Rehabilitation Services 10% co-insurance Not Covered Not Covered


Coverage Period: 01/01/2014 – 12/31/2014



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Common




Tier 1 Provider

In-Network

Tier 2 Provider

Non-Network

Provider

Continued:

If you need help

recovering or have


needs

Habilitation Services Not Covered Not Covered Not Covered Services are not covered by the plan.

Skilled Nursing

$100 co-payment

per day / $300

max co-payment

$300 co-payment

per day / $900

max co-payment,

20% co-insurance

Not Covered






Durable Medical Equipment 0% co-insurance 20% co-insurance Not Covered

Deductible applies. Pre-certification

required on all DME over $500. Non-

precertification penalty reduces

payable benefit by 50%.

Hospice Care Not Applicable 20% co-insurance Not Covered



50%.

If your child needs

dental or eye care

Eye Exam Not Covered Not Covered Not Covered

Services are not covered by the plan. Glasses Not Covered Not Covered Not Covered

Dental Check-up Not Covered Not Covered Not Covered

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)

Acupuncture

Dental Care (Adult)

Habilitation Services

Non-Emergency Care When Traveling Outside the U.S.

Bariatric Surgery

Dental Care (Child)

Hearing Aids

Routine Eye Care (Adult)

Routine Foot Care

Cosmetic Surgery

Glasses

Infertility Treatment

Routine Eye Care (Child)


Coverage Period: 01/01/2014 – 12/31/2014



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Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)

Chiropractic Care

Weight Loss Programs

Long-Term Acute Care Private Duty Nursing

Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue may also apply.

For more information on your rights to continue coverage, contact the plan at 1-225-237-1573. You may also contact your state insurance department, U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: WEB-TPA at 1-866-889-8977, you may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.

Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage”. This plan or policy does provide minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––

http://www.dol.gov/ebsa

http://www.cciio.cms.gov/

http://www.dol.gov/ebsa/healthreform


7 of 8

General Health System: Basic Option Coverage Examples

Coverage Period: 01/01/2014 – 12/31/2014


Hospital Charges (Mother) $2,700

Routine Obstetric Care $2,100

Hospital Charges (Baby) $900

Anesthesia $900

Laboratory Tests $500

Prescriptions $200

Radiology $200

Vaccines, Other Preventive $40

Total $7,540

Prescriptions $1,500

Medical Equipment and Supplies $1,300

Office Visits and Procedures $730

Education $290



Total $4,100

Deductible - Medical $900

Deductible - Prescription $50

Co-payments $180

Co-insurance $0

Limits or Exclusions $0

Total $1,130

Deductibles $900

Co-payments – Pre & Post Natal $390

Co-payment - Hospital $100

Co-insurance $0


Total $1,390

About these Coverage

Examples:

These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.

Having A Baby (Normal Delivery)

Amount Owed to Providers: $7,540 Plan Pays: $6,150 Patient Pays: $1,390

Sample Care Costs:

Managing Type 2 Diabetes (Routine Maintenance of a Well-Controlled Condition)

Amount Owed to Providers: $4,100 Plan Pays: $2,970 Patient Pays: $1,130 Sample Care Costs:

This is not a cost estimator.

Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different.

See the next page for important information about these examples.

Patient Pays:

Patient Pays:

Note: These numbers assume the patient is using

GHS Tier 1 providers & has given notice of the

pregnancy to the plan. If you are pregnant and have

not given notice of your pregnancy, your costs may

be higher. For more information please contact

WEB-TPA at 1-866-889-8977.


a GHS Tier 1 provider & is participating in our

diabetes wellness program. If you have diabetes

and do not participate in the wellness program,

your costs may be higher. For more information

about the diabetes wellness program, please

contact the Metabolic Spectrum Center at 225-

819-1175.


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General Health System: Basic Option Coverage Examples

Coverage Period: 01/01/2014 – 12/31/2014


Questions and Answers About the Coverage Examples:

What are some of the assumptions behind the Coverage Examples?

• Costs don’t include premiums.

• Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.

• The patient’s condition was not an excluded or preexisting condition.

• All services and treatments started and ended in the same coverage period.

• There are no other medical expenses for any member covered under this plan.

• Out-of-pocket expenses are based only on treating the condition in the example.

• The patient received all care from in- network providers. If the patient had received care from out-of-network

providers, costs would have been higher.

What does a Coverage Example show?

For each treatment situation, the Coverage Example helps you see how deductibles, co- payments, and co-insurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited.

Does the Coverage Example predict my own care needs?

No. Treatments shown are just examples.

The care you would receive for this condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.

Does the Coverage Example predict my future expenses?

No. Coverage Examples are not cost

estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on The care you receive, the prices your providers charge, and the reimbursement Your health plan allows.

Can I use Coverage Examples to compare plans?

Yes. When you look at the Summary of

Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the plan provides.

Are there other costs I should consider when comparing plans?

Yes. An important cost is the premium you

pay. Generally, the lower your premium, the more you’ll pay in out-of- pocket costs, such as co-payments, deductibles, and co-insurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.

General Health System: High Option Summary of Benefits and Coverage: What this Plan Covers &What it Costs

Coverage Period: 01/01/2014 – 12/31/2014

Coverage For: All High Option Participants │Plan Type: PPO


1 of 8

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document http://home.ghsbtr.net/homepage or by calling1-866-889-8977.

ImportantQuestions Answers WhythisMatters:

What is the overall deductible?

$250 person – coinsurance andco-payments do not applytowards the deductible.

You must pay all the cost up to the deductible amount before this plan begins to pay for covered

services you use. Check your policy or plan document to see when the deductible starts over (usually,

but not always, January 1st). See the chart starting on page 2 for how much you pay for covered

services after you meet the deductible.

Are there other

deductibles for specific

services?

Yes.$50 person / $150 family. There are no other specific deductible.

You must pay all of the costs for these services up to the specific deductible amount before this plan

begins to pay for those services.

Is there an out–of– pocket limit on my expenses?

Yes. For participating providers $3,000 person.

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your

share of the cost of covered services. This limit helps you plan for health care expenses.

What is not included in

the out–of–pocket limit?

Premiums, balance-billed

charges, and health care this

plan doesn’t cover.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Is there an overall annual limit on what the plan pays?

Yes. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services,

such as office visits.

Does this plan use a network of providers?

Yes. See www.verityhealth.com

for a list of participating

providers or call 1-866-889-

8977.

If you use an in-network doctor or other healthcare provider, this plan will pay some or all of the costs

of covered services. Be aware, your in-network doctor or hospital may use an out-of-network

providerfor some services. Plans use the term in-network, preferred, or participating for providers in

their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Do I need a referral to

see a specialist?

No. You don’t need a referral

to see a specialist. You can see the specialistyou choose without permission from this plan.

Are there services this plan doesn’t cover?

Yes. Some of the services this plan doesn’t cover are listed on page 4. See your policy or plan document for

additional information about excluded services.

http://home.ghsbtr.net/homepage



Coverage Period: 01/01/2014 – 12/31/2014



2 of 8

• Co-payments are fixed dollar amounts (for example, $15) you pay for covered healthcare, usually when you receive the service.

• Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven’t met your deductible.

• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

• This plan may encourage you to use participating providers by charging you lower deductibles, co-payments and co-insurance amounts.

Common Medical Event Services You May Need


Limitations & Exclusions GHS Tier 1 Provider

In-Network Tier 2 Provider

Out-of-Network Provider

If you visit a health

care provider’soffice or

clinic

Primary care visit to treat an

injury or illness $25 visit $25 visit Not Covered $10 visit for Employee Clinic visits.

Specialist visit $30 visit $30 visit Not Covered Deductible applies.

Other practitioner office visit $30 visit $30 visit Not Covered Deductible applies. 20% co-insurance

applies to chiropractic care services.

Preventive

care/screening/immunization $25 visit $25 visit Not Covered See plan document for specific exams.

If you have a test

Diagnostic test (x-ray, blood

work) No Charge Not Covered Not Covered

Cost quoted is based on outpatient facility

services – see plan document for other

specifics.

Imaging (CT/PET scans, MRIs) Deductible Applies Not Covered Not Covered Non-precertification penalty reduces benefit

by 50% of allowed amount.

If you need drugs to

treat your illness or

condition

Generic $5 co-payment >$15 or 20%


$50 RX deductible per person, $150 RX

deductible per family. Preferred Brand Drugs $25 co-payment

>$35 or 30%


Non-Preferred Brand Drugs $40 co-payment >$45 or 40%



Coverage Period: 01/01/2014 – 12/31/2014



3 of 8

Common




Tier 1 Provider

In-Network Tier

2 Provider

Out-of-Network

Provider

Continued:

More information

about prescription

drug coverage is

available at

www.catamaranrx.com

Specialty Drugs $85 co-payment Not Applicable Not Applicable

$50 RX deductible per person, $150

RX deductible per family. Only

available at BR General Pharmacy.

If you have outpatient

surgery

Facility Fee (e.g., ambulatory

surgery center). $50 co-payment $100 co-payment Not Covered






If you need immediate

medical attention

Emergency Room Services $100 co-payment $100 co-payment,

20% co-insurance

$100 co-payment,

20% co-insurance

Deductible applies. If diagnosis is not

considered emergent, then services will

be paid at 50% at BR General and will

not be covered for other providers.

Emergency Medical Transportation Not Applicable Not Applicable $50 co-payment,

20% co-insurance

Deductible applies. $50 co-payment

applies to ground transfer. $150 co-

payment applies to air transfer.

Urgent Care Not Applicable $25 co-payment Not Covered Deductible applies to all lab and x-ray

charges.

If you have a hospital

stay

Facility Fee (e.g., hospital room)

$100 co-payment

per day / $300

max co-payment

$300 co-payment

per day / $900

max co-payment,

20% co-insurance

Not Covered







Coverage Period: 01/01/2014 – 12/31/2014



4 of 8

Common




Tier 1 Provider

In-Network

Tier 2 Provider

Out-of-Network

Provider

If you have mental

health, behavioral

health, or substance

abuse needs

Mental/Behavioral Health

Outpatient Services $25 per visit $25 per visit Not Covered Deductible applies.

Mental/Behavioral Health Inpatient

Services

$100 co-payment

per day / $300

max co-payment

$300 co-payment

per day / $900

max co-payment,

20% co-insurance

Not Covered






Substance Use Disorder Outpatient

Services $25 per visit $25 per visit Not Covered Deductible applies.

Substance Use Disorder Inpatient

Services

$100 co-payment

per day / $300

max co-payment

$300 co-payment

per day / $900

max co-payment,

20% co-insurance

Not Covered






If you are pregnant

Prenatal and postnatal care $30 per visit $30 per visit Not Covered Deductible applies.

Delivery and all inpatient services $100 co-payment Not Covered Not Covered

Deductible waived on facility fees but

applies to all other inpatient services.

Non-precertification penalty reduces


If you need help

recovering or have


needs

Home Health Care Not Applicable 20% co-insurance Not Covered



50%. 60 visits combined annual limit

for Physical, Occupational & Cardiac

Rehab services. 25 visit annual limit for

Speech Rehab services and Home

Health services.

Rehabilitation Services 10% co-insurance Not Covered Not Covered


Coverage Period: 01/01/2014 – 12/31/2014



5 of 8

Common




Tier 1 Provider

In-Network

Tier 2 Provider

Non-Network

Provider

Continued:

If you need help

recovering or have


needs

Habilitation Services Not Covered Not Covered Not Covered Services are not covered by the plan.

Skilled Nursing

$100 co-payment

per day / $300

max co-payment

$300 co-payment

per day / $900

max co-payment,

20% co-insurance

Not Covered






Durable Medical Equipment 0% co-insurance 20% co-insurance Not Covered

Deductible applies. Pre-certification

required on all DME over $500. Non-

precertification penalty reduces


Hospice Care Not Applicable 20% co-insurance Not Covered



50%.

If your child needs

dental or eye care

Eye Exam Not Covered Not Covered Not Covered

Services are not covered by the plan. Glasses Not Covered Not Covered Not Covered

Dental Check-up Not Covered Not Covered Not Covered

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)

Acupuncture

Dental Care (Adult)

Habilitation Services

Non-Emergency Care When Traveling Outside the U.S.

Bariatric Surgery

Dental Care (Child)

Hearing Aids

Routine Eye Care (Adult)

Routine Foot Care

Cosmetic Surgery

Glasses

Infertility Treatment

Routine Eye Care (Child)


Coverage Period: 01/01/2014 – 12/31/2014



6 of 8

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)

Chiropractic Care

Weight Loss Programs

Long-Term Acute Care Private Duty Nursing

Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue may also apply.

For more information on your rights to continue coverage, contact the plan at 1-225-237-1573. You may also contact your state insurance department, U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: WEB-TPA at 1-866-889-8977, you may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.

Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage”. This plan or policy does provide minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––

http://www.dol.gov/ebsa

http://www.cciio.cms.gov/

http://www.dol.gov/ebsa/healthreform


7 of 8

General Health System: High Option Coverage Examples

Coverage Period: 01/01/2014 – 12/31/2014


Hospital Charges (Mother) $2,700

Routine Obstetric Care $2,100

Hospital Charges (Baby) $900

Anesthesia $900


Prescriptions $200

Radiology $200


Total $7,540

Prescriptions $1,500

Medical Equipment and Supplies $1,300

Office Visits and Procedures $730

Education $290



Total $4,100

Deductible - Medical $250

Deductible - Prescription $50

Co-payments $150

Co-insurance $0


Total $650

Deductibles $250

Co-payments – Pre & Post Natal $330

Co-payment - Hospital $100

Co-insurance $0


Total $680

About these Coverage

Examples:

These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.

Having A Baby (Normal Delivery)

Amount Owed to Providers: $7,540 Plan Pays: $6,860 Patient Pays: $680

Sample Care Costs:

Managing Type 2 Diabetes (Routine Maintenance of a Well-Controlled Condition)

Amount Owed to Providers: $4,100 Plan Pays: $3,450 Patient Pays: $650 Sample Care Costs:

This is not a cost estimator.

Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different.

See the next page for important information about these examples.

Patient Pays:

Patient Pays:


GHS Tier 1 providers & has given notice of the

pregnancy to the plan. If you are pregnant and have

not given notice of your pregnancy, your costs may

be higher. For more information please contact

WEB-TPA at 1-866-889-8977.


a GHS Tier 1 provider & is participating in our

diabetes wellness program. If you have diabetes

and do not participate in the wellness program,

your costs may be higher. For more information

about the diabetes wellness program, please

contact the Metabolic Spectrum Center at 225-

819-1175.


8 of 8

General Health System: High Option Coverage Examples

Coverage Period: 01/01/2014 – 12/31/2014


Questions and Answers About the Coverage Examples:

What are some of the assumptions behind the Coverage Examples?

• Costs don’t include premiums.

• Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.

• The patient’s condition was not an excluded or preexisting condition.

• All services and treatments started and ended in the same coverage period.

• There are no other medical expenses for any member covered under this plan.

• Out-of-pocket expenses are based only on treating the condition in the example.

• The patient received all care from in- network providers. If the patient had received care from out-of-network

providers, costs would have been higher.

What does a Coverage Example show?

For each treatment situation, the Coverage Example helps you see how deductibles, co- payments, and co-insurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited.

Does the Coverage Example predict my own care needs?

No. Treatments shown are just examples.

The care you would receive for this condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.

Does the Coverage Example predict my future expenses?

No. Coverage Examples are not cost

estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on The care you receive, the prices your providers charge, and the reimbursement Your health plan allows.

Can I use Coverage Examples to compare plans?

Yes. When you look at the Summary of

Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the plan provides.

Are there other costs I should consider when comparing plans?

Yes. An important cost is the premium you

pay. Generally, the lower your premium, the more you’ll pay in out-of- pocket costs, such as co-payments, deductibles, and co-insurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.

Subsequent Occurrence Benefit (Different Category)

100% of the Amount of Insurance. Occurrences must be separated by at least 6 months.Re-Occurrence Benefit (Same Category)

50% of the Amount of Insurance. Occurrence must be separated 18 months

• Cancer Related:.........................................................• Cardiovascular Related:...........................................

• Other:.........................................................................

Lifetime Maximum Benefit per Category 200% of the Amount of Insurance

General Health System

The Critical Illness option provides a lump sum benefit paid directly to the insured following a positive diagnosis of each covered critical illness. Benefits are paid directly to the insured in additional to any other benefits Employee benefit amounts available from $5,000 to $50,000 in $5,000 increments. Guaranteed Issue for Employee $15,000 - Applies to new hires only.

Underwritten by

This Plan Highlights and overview is a limited description of the Voluntary Group Critical Illness policy form LRS-9401.Please refer to the actual certificate of coverage for more detail description of benefits and plan provisions.

COVERED CRITICAL ILLNESSES

• Carcinoma in SITU ........................................................• Heart Attack ..................................................................• Coronary Artery Bypass Surgery ................................• Stroke .............................................................................

CRITICAL ILLNESSES FALL INTO ONE OF THREE CATEGORIES AS FOLLOWS:

• Major Organ Transplant ...............................................• Kidney (Renal) Failure ..................................................

Financial Protection for the unexpected

100% of Insurance Amount25% of Insurance Amount

25% of Insurance Amount100% of Insurance Amount

100% of Insurance Amount


Life Threatening Cancer; Carcinoma in SITUHeart Attack; Stroke; Coronary Artery Bypass,Ruptured Cerebral, Carotid or Aortic AneurysmKidney (Renal) Failure; Major Organ Transplant,

Blindness, Coma, Paralysis, Severe Brain Damage

Voluntary Group Critical IllnessEspecially designed for the employees of

Especially designed for the employees of

• Cancer ............................................................................



• Enhanced Plan Includes: Paralysis, Coma, Brain Damage, Blindness, Ruptured Cerebral,

Carotid or Aortic Aneurysm......................................

• Breast ultrasound or mammography• Blood test for lipids including LDL, HDL and triglycerides• Chest x-ray• Colonoscopy• Pap smear• PSA (blood test for prostate cancer)• Stress test on a bicycle or treadmill

For Employee. This benefit pays $50 for one health screening benefit performed during a twelve month period for the Insured.

Underwritten by

Benefit Waiting Period - 30 Days from coverage effective datePre-Existing Conditions Limitation - 12 month look back/ 12 month waiting period from effective dateRate Structure - Age-banded premiums are based on the age on the coverage effective date. Premiums are basedon the attained age each policy anniversary date. Age Reduction Schedule - The plan has an age reduction schedule of 50% of the original purchase amount at age 70.Portability - The plan is Portable and employees can continue their coverage if they leave employment.Employees are required to complete an application for Portability within 30 days of theiremployment termination date. The Insured must have been covered for 12 months to beeligible to Port the coverage.

$50 Health Screening Benefit

$50 Health Screening Benefit

BiWeekly EE Premiums

• Fasting blood glucose test• Bone marrow testing• CA 15-3 (blood test for breast cancer)• CA 125 (blood test for ovarian cancer)• CEA• Flexible sigmoidoscopy• Hemoccult stool analysis• Serum Protein Electrophoresis (blood test for myeloma)

Covered Health Screening Tests Include:

Voluntary Group Critical IllnessEspecially designed for the employees of


PLAN HIGHLIGHTS

Underwritten by

Page 1 of 2

WAITING PERIODS:

BENEFIT PERIOD:

BENEFIT AMOUNTS: Employees can choose from $100 to $1400Not to exceed 65% of weekly earnings.

14 Days Injury/ 14 Days Sickness

26 weeks

The information provided here is a brief description of the important features of the RSL insurance plan.It is not a certificate of insurance or evidence of coverage.


Financial Protection for the unexpected

Short Term Disability provides a weekly income in the event you are unableto work due to a covered accident, sickness, or pregnancy. The coverage isNon-Occupational / Off-the-Job only.

Guaranteed Issue $1400.00 - at group’s initial enrollment or during annual enrollment or as a newlyhired employee.

Pre-existing Condition Limitation - 6/12Pre-existing Benefit - 100% of benefit purchased for up to 2 weeks.

Partial Disability Benefit - Yes.

Waiver of Premium - Yes.

Claim Payment - paid on a weekly basis on all eligible claims.

Rates - Attained Age Rated

Definition of Disability: An employee is considered disabled when he/she is unable to performhis/her job, is not doing any work for payment, and is under the regularcare of a physician. This definition may vary by state.

Short Term Disability Income PlanEspecially designed for the employees of

Underwritten by

Page 2 of 2

Age$100 $150 $200 $250 $300 $350$125 $175 $225 $275 $325 $375 $400

< 40

40-49

50-59

60+

4.48 8.96 13.44 17.93

22.41 26.89 31.37

35.85 40.33 44.82 49.30 53.78 58.26 62.74

5.60 6.72 7.84 10.08 11.20 12.32 15.69 16.81

19.05 20.17 21.29 23.53 24.65 25.77 28.01 29.13 30.25 33.61

$425 $475 $525 $575 $625 $675$450 $500 $550 $600 $650 $700

< 40

40-49

50-59

60+

14.57

< 40

40-49

50-59

60+

$9.710

$13.500

$15.480

$17.550

38.09 51.5442.57 56.02 60.50

6.23 12.46 18.69 24.92

31.15 37.38 43.62

49.85 56.08 62.31 68.54 74.77 81.00 87.23

7.79 9.35 10.90 14.02 15.58 17.13 21.81 23.37

26.48 28.04 29.60 32.71 34.27 35.83 38.94 40.50 42.06 46.73

52.96 71.6559.19 77.88 84.12

20.25

7.14 14.29 21.43 28.58

35.72 42.87 50.01

57.16 64.30 71.45 78.59 85.74 92.88 100.02

8.93 10.72 12.50 16.08 17.86 19.65 25.01 26.79

30.36 32.15 33.94 37.51 39.30 41.08 44.65 46.44 48.23 53.58

60.73 82.1667.87 89.31 96.45

23.22

8.10 16.20 24.30 32.40

40.50 48.60 56.70

64.80 72.90 81.00 89.10 97.20 105.30 113.40

10.13 12.15 14.18 18.23 20.25 22.28 28.35 30.38

34.43 36.45 38.48 42.53 44.55 46.58 50.63 52.65 54.68 60.75

68.85 93.1576.95 101.25 109.35

26.33

Age

Age

$750

$1000 $1100 $1150 $1200 $1250 $1300 $1350 $1400 $950 $900$850$800

BiWeekly Premiums

The information provided here is a brief description of the important features of the RSL insurance plan.It is not a certificate of insurance or evidence of coverage.

MonthlyRates

Per $100


Short Term Disability Income PlanEspecially designed for the employees of

Weekly Benefits

Weekly Benefits

Weekly Benefits

Dependents who may be covered under your medical benefit plans are one of the following:

A child under 26 years of age, which includes natural children, step children & adopted children. Children who are eligible for their own employer-sponsored coverage are not considered eligible dependents for the health insurance plan.

Unmarried, totally disabled children over 26 who are incapable of self-sustaining employment as the result of a mental or physical handicap.

Please list the dependents that are eligible to be covered under your health insurance plan election.

If your spouse is enrolled on both their employer’s plan and the COMPANY plan standard coordination of benefit rules will apply for all applicable benefits. Therefore the COMPANY plan will pay spousal claims on a secondary basis for all applicable benefits.

If your spouse is enrolled in family coverage on their employer’s plan and you are enrolled in family coverage on the COMPANY plan standard coordination of benefit rules will apply. Therefore primary coverage for eligible dependent children will be assigned to the plan of the parent whose birthday occurs earliest in a calendar year. Secondary coverage will be assigned to the plan of the parent whose birthday occurs latest in a calendar year.

I certify that the answers provided on this form are true and correct. A person may be committing insurance fraud if he or she submits a form containing a false or deceptive statement with the intent to defraud (or knowing that he or she is helping to defraud). I acknowledge that I am responsible for any future and past claims incurred by ineligible dependents. I understand that, at any time, the COMPANY may require me to provide legal documentation to support my dependents’ eligibility status. Documents may includge but are not limited to: Marriage Certificates, Birth Certificates, Adoption documents, Proof of Disability, etc.

Full Name Relationship to

Employee Social Security

Number Date of

Birth Gender Is Child(ren) Eligible for Medi-

cal Coverage through their Em-ployer (Yes / No)?

Dependent Eligibility Verification Affidavit

Employee Signature: _______________________________________ Date: _______________________________

Required

Required

Required

Required

Required

Required

Failure to provide signature and date will result in coverage not being extended.

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*COMPLETE THIS FORM IF YOU ARE ADDING ANY DEPENDENTS TO YOUR HEALTH INSURANCE*

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**Completed form must be returned to the Benefits Office by Nov. 15, 2013 or coverage will not be extended. Please use postage-paid envelope provided**

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Reliance Standard Life Insurance Company Enrollment and Statement of Health

LRS-9457-0111 Home Office: Chicago, Illinois/Administrative Office: Philadelphia, PA

Page 1 of 3

Name of Employer General Health System

Location/Division

Policy # and Class # VCI800090 / 1

Policy # and Class #



Bill Group 000001

Application Type: Initial Eligibility/New Hire Late Applicant Other

Increase Approved Annual Enrollment

Change in Status: Nature of Change(s):

Date of Change: If marriage, divorce or birth of a child, please provide copy of document.

Employee/Member Information – Always Complete

Are you actively performing all the duties of your occupation or profession? Yes No If “No,” explain:

Coverage Elected and Amounts

Coverage Enroll or Decline1

Current Amount

Increase or Decrease Total Amount Applied For Monthly Premium

Voluntary Critical Illness: Employee

Enroll Decline

+$___________ -$____________

$__________ See Premium Table

1"Enroll" authorizes employer to payroll deduct premiums.

Submit completed Enrollment and Statement of Health form to: Reliance Standard P.O. Box 7818 Philadelphia, PA 19101-7818 We do not accept faxed forms.

Name

Social Security Number

Gender

Date of Birth

Age

State of Birth

Date of Hire

Address

City

State

Zip

Phone Number

Occupation

Annual Compensation

Hours Worked Per Week

Email Address

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*COMPLETE THIS FORM IF YOU ARE ELECTING CRITICAL ILLNESS INSURANCE*

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Page 2 of 3

Employee/Member Name

Date of Birth

Health Questions

Answer all questions on this page for each person being underwritten for insurance. For any "Yes" answer, underline the condition and record details in the space provided on the next page. Failure to provide details of a condition will cause a delay in the review of your application.

EMPLOYEE

Enter height and weight. Ht. __ft. ___in.

Wt. _____ lbs

1. In the past 10 years, have you been treated for or diagnosed as having: heart, liver (biliary cirrhosis) or kidney disorder; an abnormal colonoscopy requiring follow-up; neurological disorder; diabetes; high blood pressure; thyroid disorder; stroke; transient ischemic attack (TIA); cancer and/or tumor malignant or benign; mental or nervous disorder; or been advised to have treatment for drug abuse (illegal or prescription drugs) or alcoholism?

Yes No

2. In the past 10 years, have you been diagnosed with or treated for: chronic pain; arthritis (lupus, rheumatoid or osteoarthritis); musculoskeletal (back, neck or muscle) condition; respiratory disorder including asthma, chronic obstructive pulmonary disease (COPD); or emphysema?

Yes No

3. Have you: (a) in the past year had: fever persisting more than one month; significant involuntary weight loss; diarrhea persisting more than one month; oral candidiasis (thrush); or lymphadenopathy (enlarged or swollen glands)? or (b) in the past 10 years ever tested positive or been treated for HIV (Human Immunodeficiency Virus) antibodies, AIDS or AIDS-related complex (ARC)?

Yes No

4. In the past 10 years, have you: (a) consulted with or been examined or treated by a physician, practitioner or specialist (include routine physicals only when there is an existing or newly diagnosed medical condition)? (b) been in a hospital or other facility for observation, diagnosis, treatment or an operation? or (c) been prescribed medication(s) (other than for colds, flu or allergies)?

Yes No

5. Are you currently pregnant? In the past 10 years, have you been diagnosed with: abnormal uterine bleeding; abnormal pap smear; abnormal mammogram requiring additional studies or with recommendation of breast biopsy?

Yes No

Answer question 6 only if applying for Critical Illness insurance.

6. Have two or more of your biological parents, brothers or sisters (either living or dead) been diagnosed with the same condition from the following list of conditions: diabetes, heart disease, stroke, kidney disease or cancer (other than skin cancer)?

Yes No

Employee/Member Primary Care Physician's Full Name

Office Phone Number

Address

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*ALL QUESTIONS MUST BE ANSWERED*


Page 3 of 3

Employee/Member Name Date of Birth

Details

Please provide all names used for medical records (if different than the names provided on this form):

For each “Yes” response to a health question, please provide details below.

Question # Illness or Nature of Injury Date Physician’s Full Name and Address (if different than Primary)

If you need more space, check here . Complete, sign and date a separate sheet of paper and attach it to this page.

Read, Sign and Date Below

I understand and agree that: • The information provided on this Enrollment and Statement of Health form is true and correct to the best of my knowledge. • The insurance requested will become effective in accordance with the individual effective date information in the Policy; any amount

subject to evidence of insurability will not become effective until approved by Reliance Standard and Reliance Standard has the right to refuse my request. Coverage is subject to a minimum participation requirement at the employer level and if the minimum is not met, coverage may not be issued even though an enrollment form has been completed. An effective date is subject to eligibility requirements, satisfaction of service waiting period (if applicable) and payment of first premium when due. An effective date may be deferred for an employee not actively at work and enrolled dependents confined to a hospital or at home.

• Benefits are subject to terms and conditions of the Policy. • For age-banded rate plans, premiums increase as an employee moves from one age band to the next. • If payroll deduction of premiums begins prior to Reliance Standard’s processing of the enrollment form, it does not mean coverage is in

effect; premiums paid for coverage not issued will be returned. I further understand and agree that if I am applying after the expiration of my initial eligibility period, all medical tests and costs for attending physician reports may be without expense to Reliance Standard Life Insurance Company and I may be responsible for paying the expenses, if any. I acknowledge receipt of the "Designation of Beneficiary" form and “Important Information Regarding Applications for Insurance” and “Notice Regarding Information Practices”. If a Designation of Beneficiary form is not completed or one is not on file with the Plan Administrator, the provisions of the Policy will determine to whom benefits, if any, will be payable. AUTHORIZATION: I authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company, organization, institution, person or the MIB, Inc. to release any information or record(s) on me or my health to be used in determining the acceptability of my application for insurance. I authorize any such information or record(s) to be released to Reliance Standard Life Insurance Company, its reinsurers or authorized representatives. I also authorize Reliance Standard or its reinsurers to make a brief report of my personal health information to the MIB. This authorization, or a photographic copy, shall be as binding as the original and valid for a period not exceeding twelve (12) months from this date. I understand that I (or my authorized representative) will be sent a copy of this Authorization upon request. Please Note: During an approved enrollment, guaranteed issue amounts of insurance will not require a Statement of Health form provided the Enrollment form is complete, signed and received by your employer during your enrollment period and: a) you are not a late applicant with respect to insurance for yourself; or b) during your present service with your employer or an affiliate, you have not, with respect to insurance with Reliance Standard or an affiliate: had an application withdrawn; been previously declined; had coverage postponed; or voluntarily terminated; or c) the enrollment period is not one with specific guaranteed issue/health acceptability rules.

X ____________________________________ _______________ Employee’s/Member's Signature Date (required at all times)

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Designation of Beneficiary

Policyholder

Policy Number(s)

Insured Name


I hereby designate the following as my beneficiary (ies) under the above policy number(s): Primary Beneficiary(ies)

Full Name and Address (Please Print) Percentage* (Must total 100%)

Date of Birth Relationship Social Security Number

* If no percentages are indicated, benefits will be divided equally between all primary beneficiaries. Contingent Beneficiary(ies) (applicable only if you are not survived by one or more primary beneficiaries)

Full Name and Address (Please Print) Percentage* (Must total 100%)

Date of Birth Relationship Social Security Number

* If no percentages are indicated, any benefits payable to contingent beneficiaries will be divided equally between all contingent beneficiaries.

This beneficiary designation revokes all revocable prior beneficiary designations.

Unless you indicate otherwise, if any beneficiary predeceases you, that beneficiary's share will be divided pro-rata among the surviving beneficiaries of the same class (primary or contingent).

If no beneficiary (primary or contingent) survives you, payment will be made pursuant to the terms of the applicable policy.

Date

Signature of Insured

Important Information Regarding Applications for Insurance

The information provided on the Enrollment and Statement of Health form will be used in determining the insurability of a person proposed for insurance. Responsible parties completing and submitting a Statement of Heath form are required to be made aware of the following statements concerning the consequences of insurance fraud. The lack of an applicable statement shall not constitute a defense against penalties.

ARKANSAS and LOUISIANA — Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. COLORADO — It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. FLORIDA — Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. KENTUCKY — Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. MAINE — It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. MARYLAND — Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NEW JERSEY — Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. NEW MEXICO — Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefits or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. NEW YORK (health insurance only) — Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. OHIO — Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. PENNSYLVANIA — Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime, and subjects such person to criminal and civil penalties. RHODE ISLAND — Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. TENNESSEE, VIRGINIA, WASHINGTON — It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. WASHINGTON, DC — WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

KEEP THIS INFORMATION PAGE FOR YOUR RECORDS.

Home Office: Chicago, Illinois Administrative Office: Philadelphia, Pennsylvania

NOTICE REGARDING INFORMATION PRACTICES In considering this Application, Reliance Standard Life Insurance Company ("we", "us" or "our") collects certain information about all proposed insureds ("you" or "your"). The precise information varies according to the amount and type of coverage you apply for. Generally, we seek information about your: (1) age; (2) occupation; (3) physical condition; (4) medical history; (5) hobbies; and (6) other relevant activities. You are the most important source of information, but we may also verify or collect information on you or your family from: (1) physicians; (2) other health care providers; (3) employers; (4) other insurers to which you have applied; (5) consumer investigative organizations; and (6) the MIB, Inc. The MIB is a not-for-profit organization of life insurance companies which operates an information exchange for its members. This information may alert us to a need for further investigation, but under MIB rules such information cannot be used: (1) either wholly or in part to increase the premium for insurance; or (2) to deny issuance of insurance. We may collect information by: (1) phone; (2) correspondence; or (3) personal contact. Information will be treated as confidential. Reliance Standard Life Insurance Company or its reinsurers may, however, with your authorization make a brief report to the MIB. If you apply to another MIB member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, the MIB, upon request, will supply such company with the information in its file. The information supplied to other member companies may alert them to a need for further investigation. In some circumstances, however, information may be released to third parties without your authorization (with the exception of the MIB). These include persons or organizations who are: (1) performing business functions for us; (2) conducting actuarial or scientific studies or audits; or (3) our reinsurers. We or our reinsurers may also release information to other life insurance companies to whom you apply for life or health insurance coverage, or to whom a claim for benefits is submitted. Please be assured that although such disclosures may occur, they are not always or even often made. When a disclosure is necessary, only as much information as is reasonably necessary to achieve the intended purpose will be disclosed. You have the right to acquire and, if necessary, correct any personal information we or the MIB collect. Upon written request to us, we will within 30 days of receipt: (1) inform you of the nature and substance of the recorded information; (2) permit personal viewing and copying of the information in our possession; (3) disclose the identities of those persons such information has been disclosed to within the last two years; and (4) provide you with procedures for correction, amendment or deletion of the recorded information. Medical information will be disclosed to a physician that you choose. You may write to us for a fuller explanation of our information practices. You may also contact the MIB via its website (www.mib.com) or by telephone to arrange for disclosure of any information it may have on you. The MIB's toll-free telephone number is 866-692-6901. If you question the accuracy of information in the MIB's file, you may contact the MIB in writing and seek correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of the MIB's information office is 50 Braintree Hill, Suite 400, Braintree, Massachusetts 02184-8734.

KEEP THIS NOTICE FOR YOUR RECORDS.


http://www.mib.com/

Reliance Standard Life Insurance Company Enrollment and Statement of Health


Page 1 of 3

Name of Employer General Health System

Location/Division

Policy # and Class # VPS325653 / 1




Bill Group 000001

Application Type: Initial Eligibility/New Hire Late Applicant Other

Increase Approved Annual Enrollment

Change in Status: Nature of Change(s):

Date of Change: If marriage, divorce or birth of a child, please provide copy of document.

Employee/Member Information – Always Complete

Are you actively performing all the duties of your occupation or profession? Yes No If “No,” explain:

Coverage Elected and Amounts

Coverage Enroll or Decline1

Current Amount

Increase or Decrease Total Amount Applied For Monthly Premium

Voluntary STD: Employee2 Enroll Decline

+$_______per Week -$_______per Week

$________per Week See Premium Table

1"Enroll" authorizes employer to payroll deduct premiums.

2Statement of Health may be required.

Submit completed Enrollment and Statement of Health form to: Reliance Standard P.O. Box 7818 Philadelphia, PA 19101-7818 We do not accept faxed forms.

Name


Gender

Date of Birth

Age

State of Birth

Date of Hire

Address

City

State

Zip

Phone Number

Occupation

Annual Compensation

Hours Worked Per Week

Email Address

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*COMPLETE THIS FORM IF YOU ARE ELECTING SHORT TERM DISABILITY*

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X

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coverage effective 1/1/2014

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Page 2 of 3

Employee/Member Name

Date of Birth

Health Questions

Answer all questions on this page for each person being underwritten for insurance. For any "Yes" answer, underline the condition and record details in the space provided on the next page. Failure to provide details of a condition will cause a delay in the review of your application.

EMPLOYEE

Enter height and weight. Ht. __ft. ___in.

Wt. _____ lbs

1. In the past 10 years, have you been treated for or diagnosed as having: heart, liver (biliary cirrhosis) or kidney disorder; an abnormal colonoscopy requiring follow-up; neurological disorder; diabetes; high blood pressure; thyroid disorder; stroke; transient ischemic attack (TIA); cancer and/or tumor malignant or benign; mental or nervous disorder; or been advised to have treatment for drug abuse (illegal or prescription drugs) or alcoholism?

Yes No

2. In the past 10 years, have you been diagnosed with or treated for: chronic pain; arthritis (lupus, rheumatoid or osteoarthritis); musculoskeletal (back, neck or muscle) condition; respiratory disorder including asthma, chronic obstructive pulmonary disease (COPD); or emphysema?

Yes No

3. Have you: (a) in the past year had: fever persisting more than one month; significant involuntary weight loss; diarrhea persisting more than one month; oral candidiasis (thrush); or lymphadenopathy (enlarged or swollen glands)? or (b) in the past 10 years ever tested positive or been treated for HIV (Human Immunodeficiency Virus) antibodies, AIDS or AIDS-related complex (ARC)?

Yes No

4. In the past 10 years, have you: (a) consulted with or been examined or treated by a physician, practitioner or specialist (include routine physicals only when there is an existing or newly diagnosed medical condition)? (b) been in a hospital or other facility for observation, diagnosis, treatment or an operation? or (c) been prescribed medication(s) (other than for colds, flu or allergies)?

Yes No

5. Are you currently pregnant? In the past 10 years, have you been diagnosed with: abnormal uterine bleeding; abnormal pap smear; abnormal mammogram requiring additional studies or with recommendation of breast biopsy?

Yes No

Employee/Member Primary Care Physician's Full Name

Office Phone Number

Address

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Page 3 of 3

Employee/Member Name Date of Birth

Details

Please provide all names used for medical records (if different than the names provided on this form):

For each “Yes” response to a health question, please provide details below.

Question # Illness or Nature of Injury Date Physician’s Full Name and Address (if different than Primary)

If you need more space, check here . Complete, sign and date a separate sheet of paper and attach it to this page.

Read, Sign and Date Below

I understand and agree that: • The information provided on this Enrollment and Statement of Health form is true and correct to the best of my knowledge. • The insurance requested will become effective in accordance with the individual effective date information in the Policy; any amount

subject to evidence of insurability will not become effective until approved by Reliance Standard and Reliance Standard has the right to refuse my request. Coverage is subject to a minimum participation requirement at the employer level and if the minimum is not met, coverage may not be issued even though an enrollment form has been completed. An effective date is subject to eligibility requirements, satisfaction of service waiting period (if applicable) and payment of first premium when due. An effective date may be deferred for an employee not actively at work and enrolled dependents confined to a hospital or at home.

• Benefits are subject to terms and conditions of the Policy. • For age-banded rate plans, premiums increase as an employee moves from one age band to the next. • If payroll deduction of premiums begins prior to Reliance Standard’s processing of the enrollment form, it does not mean coverage is in

effect; premiums paid for coverage not issued will be returned. I further understand and agree that if I am applying after the expiration of my initial eligibility period, all medical tests and costs for attending physician reports may be without expense to Reliance Standard Life Insurance Company and I may be responsible for paying the expenses, if any. I acknowledge receipt of “Important Information Regarding Applications for Insurance” and “Notice Regarding Information Practices”. AUTHORIZATION: I authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company, organization, institution, person or the MIB, Inc. to release any information or record(s) on me or my health to be used in determining the acceptability of my application for insurance. I authorize any such information or record(s) to be released to Reliance Standard Life Insurance Company, its reinsurers or authorized representatives. I also authorize Reliance Standard or its reinsurers to make a brief report of my personal health information to the MIB. This authorization, or a photographic copy, shall be as binding as the original and valid for a period not exceeding twelve (12) months from this date. I understand that I (or my authorized representative) will be sent a copy of this Authorization upon request. Please Note: During an approved enrollment, guaranteed issue amounts of insurance will not require a Statement of Health form provided the Enrollment form is complete, signed and received by your employer during your enrollment period and: a) you are not a late applicant with respect to insurance for yourself; or b) during your present service with your employer or an affiliate, you have not, with respect to insurance with Reliance Standard or an affiliate: had an application withdrawn; been previously declined; had coverage postponed; or voluntarily terminated; or c) the enrollment period is not one with specific guaranteed issue/health acceptability rules.

X ____________________________________ _______________ Employee’s/Member's Signature Date (required at all times)

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Important Information Regarding Applications for Insurance

The information provided on the Enrollment and Statement of Health form will be used in determining the insurability of a person proposed for insurance. Responsible parties completing and submitting a Statement of Heath form are required to be made aware of the following statements concerning the consequences of insurance fraud. The lack of an applicable statement shall not constitute a defense against penalties.

ARKANSAS and LOUISIANA — Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. COLORADO — It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. FLORIDA — Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. KENTUCKY — Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. MAINE — It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. MARYLAND — Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NEW JERSEY — Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. NEW MEXICO — Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefits or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. NEW YORK (health insurance only) — Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. OHIO — Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. PENNSYLVANIA — Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime, and subjects such person to criminal and civil penalties. RHODE ISLAND — Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. TENNESSEE, VIRGINIA, WASHINGTON — It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. WASHINGTON, DC — WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

KEEP THIS INFORMATION PAGE FOR YOUR RECORDS.


NOTICE REGARDING INFORMATION PRACTICES In considering this Application, Reliance Standard Life Insurance Company ("we", "us" or "our") collects certain information about all proposed insureds ("you" or "your"). The precise information varies according to the amount and type of coverage you apply for. Generally, we seek information about your: (1) age; (2) occupation; (3) physical condition; (4) medical history; (5) hobbies; and (6) other relevant activities. You are the most important source of information, but we may also verify or collect information on you or your family from: (1) physicians; (2) other health care providers; (3) employers; (4) other insurers to which you have applied; (5) consumer investigative organizations; and (6) the MIB, Inc. The MIB is a not-for-profit organization of life insurance companies which operates an information exchange for its members. This information may alert us to a need for further investigation, but under MIB rules such information cannot be used: (1) either wholly or in part to increase the premium for insurance; or (2) to deny issuance of insurance. We may collect information by: (1) phone; (2) correspondence; or (3) personal contact. Information will be treated as confidential. Reliance Standard Life Insurance Company or its reinsurers may, however, with your authorization make a brief report to the MIB. If you apply to another MIB member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, the MIB, upon request, will supply such company with the information in its file. The information supplied to other member companies may alert them to a need for further investigation. In some circumstances, however, information may be released to third parties without your authorization (with the exception of the MIB). These include persons or organizations who are: (1) performing business functions for us; (2) conducting actuarial or scientific studies or audits; or (3) our reinsurers. We or our reinsurers may also release information to other life insurance companies to whom you apply for life or health insurance coverage, or to whom a claim for benefits is submitted. Please be assured that although such disclosures may occur, they are not always or even often made. When a disclosure is necessary, only as much information as is reasonably necessary to achieve the intended purpose will be disclosed. You have the right to acquire and, if necessary, correct any personal information we or the MIB collect. Upon written request to us, we will within 30 days of receipt: (1) inform you of the nature and substance of the recorded information; (2) permit personal viewing and copying of the information in our possession; (3) disclose the identities of those persons such information has been disclosed to within the last two years; and (4) provide you with procedures for correction, amendment or deletion of the recorded information. Medical information will be disclosed to a physician that you choose. You may write to us for a fuller explanation of our information practices. You may also contact the MIB via its website (www.mib.com) or by telephone to arrange for disclosure of any information it may have on you. The MIB's toll-free telephone number is 866-692-6901. If you question the accuracy of information in the MIB's file, you may contact the MIB in writing and seek correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of the MIB's information office is 50 Braintree Hill, Suite 400, Braintree, Massachusetts 02184-8734.

KEEP THIS NOTICE FOR YOUR RECORDS.


http://www.mib.com/

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INSURANCE ENROLLMENT FORM Life Insurance Company of North America (LINA) a CIGNA Company (herein called the Insurance Company) • The applicant must sign and date this form.

EMPLOYER General Health Systems

Important: Please enter all dates in mm/dd/yyyy format. Please print (preferably in black ink)

EMPLOYEE SECTION

Mr. Mrs. Ms. (Check One) Employee Name Social Security # Birthdate

Address City State Zip

Work Phone Home Phone Employee ID # Sex: M F

Important: You must complete the medical questions in this application if you apply for life insurance: (1) as a newly hired employee you are applying more than 31 days after you are eligible to elect benefits; (2) you were eligible under the prior plan and enroll or increase your insurance amount(s) after the completion of the Initial Enrollment period.

COMPLETE IF ELECTING SPOUSE COVERAGE

I am currently married and my date of marriage is

Spouse Information

Name (First) (Last) Social Security #

Birthdate Sex: M F

TERM LIFE INSURANCE — POLICY NO. FLX-965541

Applicant

Voluntary Employee-Paid Coverage

DeclineEmployee

Spouse

Child(ren)

Requested Amount

Guaranteed Coverage Amount* 1 2 3 4 5 times salary $250,000

$10,000

Number of $ 10,000 units__________ $10,000

Number of $ 5,000 units ___________ $5,000

*Guaranteed Coverage Amount is only available during Initial Enrollment and at such other times as identified and outlined in offering materials. Amounts of insurance may be limited by state law.

ACCIDENT INSURANCE — POLICY NO. OK-966642

I select the following insurance amount: Employee Benefit Amount: 1 2 3 4 5 times salary $10,000

ACCEPTANCE/DECLINATION

I accept the insurance coverages elected above. If premiums are to be paid by payroll, I authorize my employer to deduct the necessary amounts from my earnings. If I have not elected coverage, I understand that if I wish to participate at a later date, I may be required to furnish evidence of insurability at my own expense and that coverage is subject to the insurance company's approval.

Signature Date

Please Sign Here

See next page for Beneficiary Designation Return this form to your employer. Be sure to make a copy for your own records.

10/2012

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*COMPLETE THIS FORM IF YOU ARE ELECTING LIFE INSURANCE*

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CONTINUE ON REVERSE SIDE

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Applicant’s Name Social Security #

BENEFICIARY To specify a beneficiary, complete the section below. You will be the beneficiary for your spouse and child(ren) unless you specify otherwise. When specifying multiple beneficiaries, you must indicate the percentage of distribution for each. If there is not enough room to specify all beneficiaries, attach, sign and date a separate sheet of paper using the format below.

TERM LIFE INSURANCE — POLICY NO. FLX-965541

Insured Beneficiary Percentage Social Security # Date of Birth Relationship

Employee

Spouse

Child(ren)

ACCIDENT INSURANCE — POLICY NO.OK-966642

Insured Beneficiary Percentage Social Security # Date of Birth Relationship

Employee

Spouse

Child(ren)

Community Property Laws—If you are married, reside in a community property state (Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington or Wisconsin), and name someone other than your spouse as beneficiary payment of benefits may be delayed or disputed unless your spouse also signs the beneficiary designation. Spouse Signature Date

Owner Signature Date

GUIDELINES FOR DESIGNATION OF BENEFICIARIES General - Please be sure to include the beneficiary’s full name, social security number and relationship to you. Providing this information can help expedite the claim process by making it easier to locate and verify beneficiaries. Minors - While you may designate minors as beneficiaries, please note that claim payments may be delayed due to special issues raised by these designations. In the event of a claim and the beneficiary is a minor child, the insurance proceeds will not be released to the minor child. The insurance proceeds may be paid to a duly appointed guardian of the child’s estate. You may want to obtain the assistance of an attorney in drafting your beneficiary designation. Trust as Beneficiary - You may designate a trust as beneficiary, using the following form: “To [name of trustee], trustee of the [name of trust], under a trust agreement dated [date of trust].” If you wish to designate a testamentary trust as beneficiary (i.e., one created by will), you should recognize the possibility that your will, which was intended to create this trust, may not be admitted to probate (because it is lost, contested, or superseded by a later will). Claim payment delays can result if the beneficiary designation doesn’t provide for this situation. Life Status Changes - We recommend that you review your beneficiary designation when significant life status events occur, such as marriage, divorce, or birth of a child. See an Attorney! The above guidelines are general and are not intended to be relied on as legal advice. Unless your designation is a simple one, we recommend that you obtain the assistance of an attorney in drafting your beneficiary designation. A qualified attorney can help assure that your beneficiary designation correctly reflects your intentions, is clear and unambiguous, and meets legal requirements.

Return this form to your employer. Be sure to make a copy for your own records.

Are you changing any of your existing coverage due to a qualifying event such as marriage, birth, or adoption?

AMERICAN HERITAGE LIFE INSURANCE COMPANY (AHL)1776 AMERICAN HERITAGE LIFE DRIVE

JACKSONVILLE, FLORIDA 32224

EMPLOYEE’S NAME Last (Sr, Jr, etc) First M.I.

HOME ADDRESS (Street or P.O. Box)

SEX

EVIDENCE OF INSURABILITY AND ENROLLMENT FORMCheck appropriate box(es)

�� Group Voluntary Accident �� Group Voluntary Hospital Indemnity�� Group Voluntary Cancer/Specified Disease �� Heritage Choice Dental (enrollment only)

SOCIAL SECURITY NUMBER

CITY STATE ZIP

BIRTHDAY (MM/DD/YEAR)

JOB TITLE

GROUP POLICY NAME (If different from the employer name)

PLANT OR DIVISION

BENEFICIARY’S NAME (Last, First, M.I.) RELATIONSHIP

��Yes ��No ��Yes ��No��Yes ��No��Yes ��No

If “Yes”, please complete the following: Qualifying EventDate of Qualifying Event Current Certificate Number

Do you wish to terminate this coverage? ��Yes ��No

Cancer ��Yes ��No Accident ��Yes ��No Hospital Indemnity ��Yes ��No

PHONE NUMBER EMPLOYER DATE OF HIRE (MM/DD/YEAR)

HEIGHT WEIGHT CURRENT EARNINGS

(also check appropriate box)$�� Hourly�� Weekly��Bi-weekly (26)

AWD4502LA Page 1 of 4 (05/04)

Do you currently have any of the following individual products with AHL?

If you answered “Yes” to any of the products, please enter the Policy Number

If “Yes”, please enter effective date of termination

�� Monthly�� Semi-monthly (24)�� Annually

�� Married�� Single

Group Voluntary Cancer/Specified Disease Heritage Choice DentalGroup Voluntary AccidentGroup Voluntary Hospital Indemnity

Dependent’s Name(s)(Last, First, M.I.)

Sex Date ofBirth

(MM/DD/YEAR)

Social SecurityNumber

Spouse

Child

Child

Child

Child

Choose Plan(s):Accident Cancer Hospital Dental

Premium/Billing Mode Case Number Agent Number Percentage Credit��Monthly ��Semi-monthly ��Bi-weekly��Weekly ��Other Employee NumberDate of First Deduction

Situs StateCash With Application

DEPENDENT COVERAGE SECTION(Please complete if dependent coverage elected. Use additional paper if needed.)

GENERAL INFORMATION SECTION(Please complete entire section for all coverages)

NotesFor AHL Home Office use only

Please print with black ink

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*COMPLETE THIS FORM IF YOU ARE ELECTING CANCER & SERIOUS DISEASE INSURANCE*

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Accident��Yes ��No Base Units

��Employee Only��Family

Section 125

��Yes ��NoTotal Mode Premium

$

��Off the Job Accident��On and Off the Job Accident

��Off the Job Accident and Sickness��On and Off the Job Accident and Sickness

��On and Off the Job Accident for Insured Spouse*��On and Off the Job Accident and Sickness for Insured Spouse*

Optional Disability Riders for Employee

Optional Disability Riders for Spouse

*Available only when family coverage is selected and the insured spouse has worked 25 hours perweek for 3 or more consecutive months.

Disability RiderUnits

Employee

Spouse

Cancer/Specified Disease��Yes ��No

Benefits Hospital Radiation /Chemotherapy

Plan

SurgeryRelated

Units

Units

Misc.

��Employee Only��Family ��Yes ��No

Initial DiagnosisOption ��

Intensive CareOption ��

Cancer ScreeningOption ��

Total Mode Premium

$

1

Section 125

Hospital Indemnity��Yes ��No

BenefitsHospitalRelated

Plan��Yes ��No

Section 125

��Yes ��No

Section 125

Diagnostic / WellnessOption ��

PrescriptionDrug Option ��

DisabilityRider ��

Life Rider��

Total Mode Premium

$

Total Mode Premium

$

1

Surgery / InpatientPhysician

OutpatientRelated

��Employee Only��Employee+Spouse��Employee+Child(ren)��Family

��Employee Only��Employee+Spouse��Employee+Child��Family

��Plan 1��Plan 2��Plan 3

��Plan 4��Plan 5

Heritage Choice Dental��Yes ��No

AWD4502LA (05/04)

SELECTION OF COVERAGE SECTION(Answer Yes or No and complete for each coverage selected)

EVIDENCE OF INSURABILITY AND ENROLLMENT FORM

Page 2 of 4

Were you covered under your Employer’s prior Dental Plan? ��Yes ��No AHL Home Office Use OnlyIf “Yes”, please enter the date coverage effective P1NG1 P1NG2 P1NG3

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Non-Medical Questionnaire

If any of the questions 2-8 below are answered “yes”, please list the required health history on the next page.

Riders Only

Accident &SicknessDisability

Riders

Accident Has any person to be insured, in the last 3 years, had his/her driver’s license suspended or revokedor been arrested for reckless or drunken driving and/or been involved in 3 or more motor vehicleaccidents? If “yes”, provide additional details on the next page.Has any person to be insured, within the last 2 years, had, been treated for, or been told by amember of the medical profession that he/she has: diabetes, emphysema, asthma, epilepsy,hepatitis, mental or nervous illness, ulcers, any disorder of the central nervous system (to includemuscular dystrophy or multiple sclerosis); Parkinson’s Disease; lupus; rheumatoid arthritis;fibromyalgia; chronic fatigue syndrome; any disorder of the heart, kidneys, liver, lungs, pancreas orback; paralysis; optic neuritis; cancer (except basal cell skin cancer), malignant tumor, leukemia,Hodgkin’s Disease; or stroke?

Has any person to be insured had any medical or surgical procedures (including organ transplant)advised or recommended by a doctor but not done at this time?

�� Yes�� No

�� Yes�� No

�� Yes�� No

�� Yes�� No

�� Yes�� No

�� Yes�� No�� Yes�� No

�� Yes�� No

�� Yes�� No


�� Yes�� No

�� Yes�� No


�� Yes�� No

1.

2.

Has any person to be insured, in the last 2 years, been treated for or counseled for alcohol or drugabuse?

AllCoverages

Is any person to be insured actively at work now and has he/she worked at least 20 hours each weekperforming all duties at his/her regular occupation at his/her regular place of employment for the last3 months except for minor illness or injury of 1 week or less, or normal pregnancy?

3.

AllCoverages

Cancer

IntensiveCare

OptionalBenefit(Cancer

Only)

Is any person to be insured now being treated, or ever been treated or diagnosed by a member ofthe medical profession for Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex(ARC), or ever tested positive for antigens or antibodies to an AIDS virus?

Is any person to be insured currently undergoing any diagnostic test for, now being treated for, orever been treated for, cancer or any malignancy which includes: carcinoma; sarcoma; Hodgkin’sDisease; leukemia; lymphoma; or any malignant tumor?Is any person to be insured now being treated for, or ever been treated for: a stroke; a heart attack;a heart condition; heart trouble; or any abnormality of the heart (including artery disease)?

4a.

b.

c.

c.

d.

e.

5.

6a.

b.

HospitalIndemnity

HospitalIndemnity

8.

Is any person to be insured currently being treated for, or has any person ever been treated for,cancer or any malignancy which includes: carcinoma; sarcoma; Hodgkin’s Disease; leukemia;lymphoma; or any malignant tumor; a stroke; a heart attack; a heart condition; heart trouble; anyabnormality of the heart (including artery disease); or diabetes?

Has any person to be insured, within the last 3 years, been treated for, or been told by a member ofthe medical profession that he or she has: epilepsy; hepatitis; muscular dystrophy or muscularsclerosis or any disorder of the central nervous system; Parkinson’s Disease; lupus; any disorder ofthe kidneys, liver, lungs; paralysis; been counseled for alcohol or drug abuse; or had any medicalor surgical procedure recommended but not done at this time?

7a.

Has any person to be insured been diagnosed with hypertension or high blood pressure?

If the answer to [4b] is yes, in the last year has he/she had either: (1) a systolic blood pressurereading higher than 150 more than once; or (2) a diastolic blood pressure reading higher than 100more than once?


If the answer to [6b] is yes, in the last year has he/she had either: (1) a systolic blood pressurereading higher than 150 more than once; or (2) a diastolic blood pressure reading higher than 100more than once?

b.

c.


If the answer to [7b] is yes, in the last year has he/she had either a: (1) systolic blood pressurereading higher than 150 more than once or (2) diastolic blood pressure reading higher than 100more than once?

AWD4502LA (05/04)

EVIDENCE OF INSURABILITY SECTION(Please complete each question applicable to coverages selected. Does not apply to Dental.)


Page 3 of 4

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Only answer #1,#2,#5

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Only answer #1,#2,#5

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CERTIFICATION, UNDERSTANDING AND AUTHORIZATIONSI CERTIFY that the statements and answers contained on this form are made by me, are complete and true, are correctly and fullyrecorded and that no important circumstance or information has been withheld or omitted. These statements and answers are offered toAmerican Heritage Life Insurance Company as an inducement to grant insurance, and I understand that American Heritage Life InsuranceCompany may use misstatements or misrepresentations to contest the validity of any coverage provided on the basis of this evidence ofinsurability. FRAUD NOTICE: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit orknowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines andconfinement in prison. · I UNDERSTAND that the “effective date” of my elected coverages will be the effective date recorded on theCertificate, not the date this Evidence of Insurability form is signed. · I AUTHORIZE any physician, medical practitioner, hospital, clinicor other medical facility, insurance company, or other organization, institution or person, that has records or knowledge of me or my healthto to give to American Heritage Life, it’s subsidiaries or its reinsurers any information. I acknowledge receipt of the Important Notice AboutPrivacy. A copy of this authorization is as valid as the original. This authorization applies to any dependent on whom insurance isrequested. This authorization is valid for a period of 24 months from the date signed. I understand that I may revoke this authorization atany time by notifying American Heritage Life in writing of my desire to do so. · I ALSO AUTHORIZE my employer to deduct from my salaryor wages, if applicable, the necessary premium for the coverages requested above. This signature also verifies the accuracy of theinformation on this enrollment form. I understand that if I refuse any coverage for which I am eligible, satisfactory proof of insurabilitymay be required, at my own expense, should I desire to apply for it at a later date. Any such application may be declined on the basis ofsuch proof.

Employee’s Signature Signed at Date Signed

AWD4502LA (05/04)

Use this space for any additional explanation of questions 2-8 on page 3. Indicate the applicablequestion number and person to whom it applies. Use additional paper if needed.

(City and State)

PERSON REASONNature of any illness, injury,

or diagnosis

DATESIncluding duration of

illness

NAMES AND ADDRESSESOF HOSPITALS AND/OR PHYSICIANS


REQUIRED HEALTH HISTORY*Include diagnosis, dates, and duration along with names and addresses of all attending physicians and

medical facilities.

Page 4 of 4

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IMPORTANT NOTICE ABOUT PRIVACY:In processing your application, an investigative report may be made. Information obtained through interviews with third parties,such as family members, business associates, financial sources, friends, neighbors, or others with whom you are acquainted.This inquiry includes information as to your character, general information and personal characteristics. You have the right tomake a written request within a reasonable period of time for a complete and accurate disclosure of additional informationconcerning the nature and scope of the investigation.AWDIN4502-1

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