Your Select Benefits coverage is provided under a group insurance policy that pays benefits at a preselected, fixed dollar amount. Coverage is designed to help reduce your out-of-pocket health-related expenses and benefits will be paid regardless of any other coverage you may have.

Select Benefits is not a replacement for a major medical plan or any other comprehensive coverage and does not satisfy the requirements of the Affordable Care Act (ACA). If the benefit amount provided by the policy does not cover the entire cost of the visit or procedure, you are responsible for any remaining balance.

The Policy AdministratorSelect Benefit Administrators (SBA) handles the administration of your Select Benefits coverage. This includes verification of eligibility, billing and claims payment.

SBA is available to help you understand and use your benefits. Please feel free to contact them with any questions or concerns.

How Does It Work?To use the coverage, follow these steps:

Present your ID card to your provider at the time of service. If you need to use your coverage before you receive your insurance card, contact SBA before your visit and ask for the case number. Give your provider this number along with the SBA customer service phone number.

Ask your provider to bill the policy administrator, SBA, and accept an assignment of benefits. If your provider will not accept the assignment, or if you wish to be paid directly, you will need to file a claim yourself.

To file a claim yourself, complete a Select Benefits claim form and return it to SBA. You will need a signed Authorization for Release of Medical Information form and an itemized bill from the provider listing dates of service, procedure codes and diagnosis codes. SBA cannot process your claim without these codes.

Pay the provider any outstanding balance due. Any charges that remain after the claim has been paid to the provider are your responsibility.

Contact Information

SBM-5985 5/15

Select Benefit Administrators (SBA)Customer Service Hours: Monday through Friday, 6:30 a.m. to 5 p.m., CT

Toll-free phone: 1-800-497-3699Email: symsba@symetra.comFax: (715) 682-5919P.O. Box 440Ashland, WI 54806 1

2

3

Select Benefits Fixed-Payment Medical Insurance

A guide to using your Select Benefits coverage

Scan to download and save this contact information to your smartphone.

Select Benefits policies are insured by Symetra Life Insurance Company, 777 108th Avenue NE, Suite 1200, Bellevue, WA 98004.

Select Benefit Administrators is an administrative division of Symetra Life Insurance Company.

Symetra Life Insurance Company 777 108th Avenue NE, Suite 1200 Bellevue, WA 98004-5135www.symetra.com Symetra® is a registered service mark of Symetra Life Insurance Company.

Visit the provider and present your insurance card(s) prior to service.9

If the provider has not billed SBA, then you can file the claim and the benefit will be paid directly to you.

SBA

See below for instructions on how to file a claim directly with SBA.3

After the service, the provider could bill one or both insurance companies.

If the claim is paid in full by the other insurance company, the provider may or may not bill SBA. If the provider bills SBA, your benefit will be paid to the provider according to the policy.

0

1

To file a claim with SBA, follow these steps:

1. At the time of service, show your ID card(s). The provider may or may not submit a claim to SBA, but theyare more likely to submit it if they have a copy of your card on file.

2. Be sure to obtain a receipt for payments made at the time of service and an itemized bill listing dates ofservice, procedure codes and diagnosis codes.

3. To file the claim yourself, complete a Select Benefits claim form and return it to SBA. You will need to includea signed Authorization for Release of Medical Information form as well as the documents mentioned above instep two.

Select Benefit Administrators Attn: Claims Dept.PO Box 440Ashland, WI 54806Fax (715) 682-5919

Mail or faxclaims to:

4. You will receive payment in accordance with the policy and state insurance law requirements.

If you have questions about using your coverage, please contact SBA at 1-800-497-3699, Monday through Friday, 6:30 a.m. to 5 p.m., CT.

Symetra Life Insurance Company 777 108th Avenue NE, Suite 1200 Bellevue, WA 98004-5135www.symetra.com Symetra® is a registered service mark of Symetra Life Insurance Company.

Select Benefits policies are insured by Symetra Life Insurance Company, 777 108th Avenue NE, Suite 1200, Bellevue, WA 98004. Select Benefit Administrators is an administrative division of Symetra Life Insurance Company.

SBM-5756/Sup 3/14

As an insured in your company’s Select Benefits group insurance policy, you are free to use any doctor you choose. Regardless of any other insurance coverage that you may have, you are entitled to the full amount of the fixed benefit that the policy allows. Should the bill be paid in full by your other insurance, you can file the claim yourself and Select Benefit Administrators (SBA), will pay the benefit directly to you.

Using Select Benefits as supplemental insurance

Value-Add Benefits

Help is just a phone call away

continued >

Your coverage includes 24/7 access to value-add benefits and programs, provided by Health Advocate, at no additional cost to you.

These services can help you and your eligible family members with a wide range of health care and insurance-related issues.

SBM-6132 11/15

EAP+Work/Life™

This confidential program offers unlimited, toll-free access to licensed professional counselors and work/life specialists for short-term assistance with a wide range of family- and work-related issues. Educational materials, webinars and other resources are available through a dedicated website. Specialists can help you address:

• Stress, depression and anxiety

• Substance abuse

• Financial and legal problems

• Divorce, grief and loss

• Child and elder care concerns

Health AdvocacyUnlimited access to a Personal Health Advocate, typically a registered nurse supported by medical directors and benefits and claims specialists, who can help:

• Find qualified doctors, hospitals and other providers

• Explain conditions and treatments

• Resolve billing and claims issues

• Arrange for second opinions and the transfer of medical records

• Clarify health insurance benefits and answer coverage questions

Medical Bill Saver™

Expert negotiators will work with providers to reduce the cost of medical and dental bills that are not covered by your insurance—saving you time and money. Our skilled negotiators can:

• Help reduce your out-of-pocket costs on non-covered bills

• Handle negotiations and obtain provider signoff

• Provide you with an itemized summary of the outcome and payment terms

Wellness CoachingOur Wellness Coaching program provides a personalized, action-oriented approach to help you and your eligible family members reach and maintain your best possible health. Features include:

• Unlimited confidential support from a personal Wellness Coach by telephone, email or secure web messaging

• A comprehensive website featuring a personalized health profile to identify health risks, wellness tools and trackers, and self-guided programs on weight loss, nutrition and exercise

NurseLine™

You can reach a registered nurse 24 hours a day, 7 days a week for trusted advice when you need it most. Our experienced nurses are available to:

• Answer questions about symptoms or medications

• Offer self-care information for non-urgent health issues

• Explain health conditions and treatments

• Direct you to the appropriate care for immediate attention, if needed

Value-add programs are offered by Health AdvocateTM through Symetra Life Insurance Company. Health Advocate, a subsidiary of West Corporation, is not affiliated with any insurance or third party provider. Health Advocate does not replace health insurance coverage, provide medical care or recommend treatment.

Select Benefit Administrators is an administrative division of Symetra Life Insurance Company.

Symetra Life Insurance Company 777 108th Avenue NE, Suite 1200 Bellevue, WA 98004-5135 www.symetra.com Symetra® is a registered service mark of Symetra Life Insurance Company.

Who’s eligible?Your Health Advocate benefits are available to enrolled members, their spouse, dependent children, parents and parents-in-law. The Wellness Coaching feature is available to enrolled members, their spouse and dependent children age 18+.

Questions?For more information about your Health Advocate benefits or your specific group coverage, contact your company’s benefits representative or contact Select Benefit Administrators at symsba@symetra.com or 1-800-497-3699.

Fixed-Payment Indemnity Policy Plan 2

Inpatient Hospital Benefits500 days per lifetime unless noted Hospital Stay $500 per day,

10 days pp/pcy1

Intensive Care Unit $1,000 per day,10 days pp/pcy

Substance Abuse Facility $500 per day,10 days pp/pcy

Mental Health Facility $250 per day, 180 days lifetime maximum 10 days pp/pcy Nursing Facility $250 per day 60 consecutive days per stay maximum. This benefit is paid only if following a covered hospital stay of at least three consecutive days and the insured is under age 65.

Health Advocacy Services IncludedEAP+Work/Life Program IncludedWellness Coaching Program IncludedSurvivor Benefit Included

Bi-Weekly Premium Rates are based on 26 Pay Periods per year

Employee $11.00Employee + Spouse $23.46Employee + Children $18.05Family $32.66

1pp/pcy=per person, per calendar year

$19.60

The Policyholder will determine the minimum required hours to be eligible for coverage. The minimum weekly hours to be established must be at least 15 hours.

Patient advocacy services are included at no additional cost. These services are provided by Health Advocate, Inc., 3043 Walton Road Suite 150, Plymouth Meeting, PA 19462. This is not an insured benefit.

EAP+Work/Life and Wellness Coaching Programs are included at no additional cost. These programs are provided by Health Advocate, Inc., 3043 Walton Road Suite 150, Plymouth Meeting, PA 19462. This is not an insured benefit.

These benefits are designed to be offered to those covered under a High-Deductible Health Plan ('HDHP') without the effect of disqualifying a participant from electing an HSA. Please consult with your Benefits Advisor to assist with determination that electing this limited benefit coverage is in fact permitted coverage under the rules applicable to an HSA.

Select Benefits insurance policies are not a replacement for a major medical policy or other comprehensive coverage and do not satisfy the minimum essential coverage requirements of the Affordable Care Act. They are designed to provide benefits at a preselected, fixed-dollar amount. Coverage may be subject to exclusions, limitations, reductions, and termination of benefit provisions. Select Benefits policies are insured by Symetra Life Insurance Company located at 777 108th Avenue NE, Suite 1200, Bellevue, WA 98004, and are not available in all U.S. states or any U.S. territory. Coverage is provided under generic policy form numbers SBC-00500, LGC-9095, and LGC-10011 or LGC-9072.

IncludedIncluded

$6.61$14.08$10.83

10 days pp/pcy$150 per day,10 days pp/pcy$150 per day

IncludedIncluded

$300 per day,10 days pp/pcy1

$600 per day,10 days pp/pcy$300 per day,

Select Benefits Plan Summary for Collaborative for Educational Services - Fixed Payment

Fixed-Payment Indemnity Insurance

Plan 1

LG - 12079_MA(15.0) 1 / 2 03/09

Select Benefits Description Of Benefits for Collaborative for Educational Services - Fixed Payment

Inpatient Hospital Benefit

Health Advocacy

NurseLine™

Medical Bill Saver™

EAP+Work/Life

Wellness Coaching

Survivor Benefit

Fixed-Payment Indemnity Insurance

Benefits are paid on the first day of a covered stay. ICU, substance abuse, mental health and nursing facility stays are included with the hospital stay benefit. Each facility has a calendar year maximum number of days as selected, 500 days per lifetime unless otherwise noted in the policy. Please refer to your Plan Summary for details.

Personalized assistance with a full range of health coverage and insurance-related issues such as locating doctors and other providers, scheduling appointments, getting cost estimates and more.

Direct access to a registered nurse 24/7 for non-urgent concerns.

Help negotiating with providers for medical and dental bills that are not covered by your insurance.

Licensed professional counselors and work/life specialists provide confidential, short-term help with personal, family and work-related issues.

Unlimited access to highly trained wellness coaches by telephone, email or instant messaging. Includes a comprehensive, secure wellness website.

If an employee dies while insured, any covered dependents will be extended benefits (except Dependent Life, Group Accident, and Critical Illness) without premium payments for up to two years after the employee's death. This is as long as the plan remains in force and the covered dependent meets the coverage requirements in the policy.

Select Benefits insurance policies are not a replacement for a major medical policy or other comprehensive coverage and do not satisfy the minimum essential coverage requirements of the Affordable Care Act. They are designed to provide benefits at a preselected, fixed-dollar amount. Coverage may be subject to exclusions, limitations, reductions, and termination of benefit provisions. Select Benefits policies are insured by Symetra Life Insurance Company located at 777 108th Avenue NE, Suite 1200, Bellevue, WA 98004, and are not available in all U.S. states or any U.S. territory.

Group Accident Coverage

Help when the unexpected happens

Accidents happen. When they occur, out-of-pocket costs for things such as doctor visits, X-rays and physical therapy can add up fast. Group accident coverage from Symetra Life Insurance Company can help.

How it worksYou are being offered group accident coverage for three (3) separate accidents per year. The coverage pays benefits for eligible expenses incurred as a result of an accident (unless covered by workers’ compensation or similar law) up to the benefit amount selected per occurrence. This means that eligible expenses related to a specific accident occurrence—even if incurred on different days or with different providers—will be covered under the same per occurrence benefit.

Eligible expenses related to an accident occurrence will be paid at 100% up to the preselected benefit amount. You are responsible for any remaining balances.

You may receive up to three (3) benefits per year. Each per occurrence benefit is tied to a specific accident and cannot be used to cover expenses related to any other accident occurrence.

SBM-6272 6/15

After an accident, unexpected medical costs can make a bad situation even more stressful. Group accident coverage can help relieve some of the financial pressure.

Example 2Eligible incurred expenses

Example 1 Eligible incurred expenses

Here are two examples of how benefits would be paid on a benefit amount of $2,500 per accident occurrence:

Emergency room $720X-ray and lab tests $510Diagnostic testing (MRI) $850Physician fees $300Physical therapy $690

Total expenses $3,070

Benefits paid = $2,500Out-of-pocket costs = $570

Urgent care $310Lab tests $235X-rays $280Physician fees $120Chiropractic services $510

Total expenses $1,455

Benefits paid = $1,455Out-of-pocket costs = $0

Eligible benefitsBenefits will be paid for eligible expenses that are incurred as a result of an accident that occurs while you are covered under the group accident policy. The combined benefits paid for medical, dental, surgical, inpatient hospital, X-ray and lab and inpatient prescription drug expenses will not exceed the maximum benefit amount shown in the Summary of Benefits.

Expenses must be incurred within 52 weeks from the date of the accident and the first expense must be incurred within 60 days after the date of the accident.

Medical benefitsServices and supplies provided or prescribed by a licensed physician or other licensed health care provider for the following:

• Nursing services

• Physician’s office visits

• Hospital emergency room visits

• Outpatient hospital visits

• Urgent care visits

• Chiropractic visits

• Rehabilitation services

Dental benefitsDental benefits will be provided for eligible expenses incurred for procedures performed by a licensed physician or licensed dentist in connection with an accident. Procedures include:

• A closed or open reduction of a fracture

• Dislocation of the jaw

• Injury to natural teeth

Surgical benefitsSurgical benefits will be provided for eligible expenses incurred for surgical procedures performed by a licensed physician in connection with an accident.

Inpatient hospital benefitsInpatient hospital benefits will be provided for eligible expenses incurred in connection with an accident while covered under this policy only if all of the following conditions are met:

• The insured is confined in a hospital

• A charge is made for room and board

• The entire duration of such hospital confinement isrecommended and approved by a physician

• Confinement is the result of a non-occupational accident

• The services and supplies are not excluded under theexclusions and limitations provision of the policy

X-ray and laboratory benefitsBenefits will be provided for eligible expenses incurred in connection with an accident while covered under the policy when they are ordered or performed by a physician.

Inpatient prescription drugsBenefits will be provided for eligible expenses incurred in connection with an accident if the insured is confined in a hospital and the drugs are prescribed by a physician and administered in the hospital by a licensed health care provider.

Symetra Life Insurance Company 777 108th Avenue NE, Suite 1200 Bellevue, WA 98004-5135www.symetra.comSymetra® is a registered service mark of Symetra Life Insurance Company.

Select Benefits insurance policies are designed to provide benefits at a preselected, fixed dollar amount. They are not a replacement for a major medical policy or other comprehensive coverage and may be subject to exclusions, limitations, reductions and termination of benefit provisions. Select Benefits policies are insured by Symetra Life Insurance Company, 777 108th Avenue NE, Suite 1200, Bellevue, WA 98004. Policy form number is LGC-10011 10/11 in most states and is not available in all U.S. states or any U.S. territory.

Group Accident Policy Plan 1 Plan 2

Group Accident Benefit Coverage per occurrence up to $5,000 up to $10,000 Occurrences 3 pp/pcy1 max. 3 pp/pcy1 max.

Health Advocacy Services Included IncludedEAP+Work/Life Program Included IncludedWellness Coaching Program Included IncludedDomestic Partner Benefit Included Included

Bi-Weekly Premium Bi-Weekly Rates are Based on 26 Pay Periods Per Year

Employee $9.87 $11.02

Employee + Spouse $21.03 $23.48

Employee + Children $16.17 $18.06

Family $29.28 $32.70

The Policyholder will determine the minimum required hours to be eligible for coverage. The minimum weekly hours to be established must be at least 15 hours.

Patient advocacy services are included at no additional cost. These services are provided by Health Advocate, Inc., 3043 Walton Road Suite 150, Plymouth Meeting, PA 19462. This is not an insured benefit.

EAP+Work/Life and Wellness Coaching Programs are included at no additional cost. These programs are provided by Health Advocate, Inc., 3043 Walton Road Suite 150, Plymouth Meeting, PA 19462. This is not an insured benefit.

Select Benefits Plan Summaryfor Collaborative for Educational Services - Fixed Payment

Group Accident Benefit

Health Advocacy

NurseLine™

Medical Bill Saver™

EAP+Work/Life

Wellness Coaching

Description of Benefit

This benefit pays eligible expenses up to the benefit amount selected per accident occurrence. Expenses must be incurred within 52 weeks from the date of the accident with the first expense incurred within 60 days of the date of the accident.

Personalized assistance with a full range of health coverage and insurance-related issues such as locating doctors and other providers, scheduling appointments, getting cost estimates and more.

Select Benefits insurance policies are not a replacement for a major medical policy or other comprehensive coverage and do not satisfy the minimum essential coverage requirements of the Affordable Care Act. They are designed to provide benefits at a preselected, fixed-dollar amount. Coverage may be subject to exclusions, limitations, reductions, and termination of benefit provisions. Select Benefits policies are insured by Symetra Life Insurance Company located at 777 108th Avenue NE, Suite 1200, Bellevue, WA 98004, and are not available in all U.S. states or any U.S. territory. Coverage is provided under generic policy form number LGC-10011.

Direct access to a registered nurse 24/7 for non-urgent concerns.

Help negotiating with providers for medical and dental bills that are not covered by your insurance.

Licensed professional counselors and work/life specialists provide confidential, short-term help with personal, family and work-related issues.

Unlimited access to highly trained wellness coaches by telephone, email or instant messaging. Includes a comprehensive, secure wellness website.

Critical Illness Insurance

Financial support after a serious medical condition

continued >

It’s estimated that three out of four healthy individuals over the age of 40 will become critically ill at some point during their lives.1

Are your finances protected if this happens to you?

Many people diagnosed with cancer, heart attack or other life-altering conditions face unexpected out-of-pocket costs. Critical illness insurance can provide a bit of relief by paying a lump-sum benefit that can be used for anything—transportation, child care, other expenses—allowing you to concentrate on your recovery rather than finances.

Policy features

• Provides a lump-sum payment upon the diagnosis of a covered critical illness

• Benefits are paid directly to you and can be used any way you choose

• Pays regardless of any other coverage you may have

• Guaranteed issue amounts are available with no medical underwriting

• Spousal/dependent coverage may be available

How it works

If you are diagnosed with a covered critical illness after the policy is in effect, you will

receive a payment that is equal to the benefit amount of your policy multiplied by the

percentage for that covered illness as shown in the table below.

Covered critical illness conditions2

Percentage of

benefit amount paid*

Category 1 Invasive cancer 100%

Minor cancer 25%

Category 2 Heart attack 100%

Stroke 100%

Coronary artery disease needing surgery or angioplasty

25%

Category 3 Coma due to accident 100%

Occupational HIV infection 100%

Loss of sight 100%

Loss of speech 100%

Loss of hearing 100%

Major organ failure 100%

End-stage renal disease 100%

Paralysis due to accident 100%

Severe burns 100%

* The benefit amount reduces by 50% starting at age 70.

Covered conditions are grouped into three categories. If the diagnosed critical illness

does not qualify for the full benefit amount (in other words, the percentage is less than

100%), you could receive an additional lump-sum benefit upon diagnosis of a different

type of critical illness within the same category up to the 100% maximum. Benefits in

different categories are subject to a separation period of 12 months between diagnoses.2

SBM-6233 7/15

Symetra Life Insurance Company

777 108th Avenue NE, Suite 1200

Bellevue, WA 98004-5135

www.symetra.com

Symetra® is a registered service mark of

Symetra Life Insurance Company.

Critical illness insurance policies are designed to provide benefits at a preselected, fixed dollar amount for specific critical illness conditions. Coverage may be subject to exclusions, limitations, reductions and termination of benefit provisions. Critical illness policies are insured by Symetra Life Insurance Company, 777 108th Avenue NE, Suite 1200, Bellevue, WA 98004. Root policy form number is SBC 00500 6/14 in most states and is not available in all U.S. states or any U.S. territory.

1 Mueller, E., & Spencer, L. (2012) Critical Illness Plans; Addressing Your Client’s Needs. Health Care Reform Magazine, March 2012.

2 May vary by state.

To review your critical

illness benefits, please

refer to the policy or

talk with your human

resources representative.

Once you enroll, you

can contact the policy

administrator, Select

Benefit Administrators,

at symsba@symetra.com

or 1-800-497-3699.

What is critical illness insurance?

This type of policy provides a lump-sum payment upon the diagnosis of a covered

condition after the effective date of the policy. Benefits are paid directly to you and

may be used for anything you need.

Is my critical illness benefit taxable?

Benefit payments under this policy may be considered taxable income to the extent

you pay premiums on a pre-tax basis or your employer pays premiums on your behalf

without including them in your income. Symetra reports taxable income to you and the

IRS as required on tax form 1099-MISC. For more information, consult your tax advisor.

What if I have already been diagnosed with a covered critical illness?

Symetra’s Critical Illness policy has a pre-existing conditions limitation.2 Benefits will

not be paid for any condition or illness that is diagnosed or treated during the 12

months before the effective date of your policy. However, a pre-existing condition may

be eligible for benefits if the condition is re-diagnosed at least 12 months after the

effective date of the coverage.

What is my lump-sum benefit?

That depends on your policy. Please refer to your enrollment materials or ask your

human resources representative. Covered conditions are paid at the amount shown in

the policy until you reach your 70th birthday. At age 70, the benefit reduces to 50% of

the total amount.

Can I get coverage for my spouse or my children?

Yes. Spousal coverage is available at up to 50% of the primary insured’s coverage

amount. Dependent child coverage is 25% of the primary insured’s coverage,

up to $10,000.

If I have disability insurance, do I need critical illness insurance too?

Disability income insurance helps individuals maintain their standard of living while

recovering from a disabling illness or injury. While having these benefits is an important

part of your financial plan, critical illness insurance provides additional support to help

cover expenses after the diagnosis of a serious condition.

Will I need to answer medical questions?

Not if you elect a benefit within the guaranteed issue amount. If you are eligible and

choose coverage over the guaranteed issue amount outlined in your enrollment

materials, you will need to complete a medical questionnaire.

Is there a benefit waiting period?

Yes. The benefit waiting period is 30 days2 following the date your coverage under the

policy takes effect.

When will I receive my benefit payment?

Generally, Symetra will make a decision on your claim within 30 days of receiving your

completed claim form. In some circumstances, this period may be extended up to an

additional 15 days.

Employee Eligibility: An employee must be actively at work, employed by the eligible group and performing for wage or profit all of the normal duties required of a job. The minimum number of 20 hours/week must be met.

Critical Illness insurance policies are designed to provide benefits at a preselected, fixed-dollar amount, for specific critical illness conditions. Coverage may be subject to exclusions, limitations, reductions, and termination of benefit provisions. The policies do not satisfy the minimum essential coverage requirements of the Affordable Care Act. Critical Illness policies are insured by Symetra Life Insurance Company, 777 108th Avenue NE, Suite 1200, Bellevue, WA 98004. Base policy form number is SBC 00500 in most states and is not available in all U.S. states or any U.S. territory. Symetra® is a registered

Employee Plan Design forCollaborative for Educational Services, Inc

Critical IllnessIntroduction to Critical Illness

To help guard against the financial impact of a critical illness, employees and members are looking for additional coverage that offers another layer of protection. Consider critical illness coverage as another way to combat the costs associated with an illness that may easily add financial pressure to an already stressful situation.

How It Works

Upon diagnosis of a covered critical illness after the policy is in effect, the insured will receive a lump sum benefit amount that can be used in any way chosen. Covered conditions are divided into categories and each condition pays a fixed percentage of the benefit amount between 25% and 100%.

Benefit Categories

The following are the Benefit Categories for your Critical Illness coverage provided by your Employer:

Category 1 Invasive cancer: 100%, minor cancer: 25%

Category 2 Heart attack and stroke: 100%, coronary artery disease needing surgery or angioplasty: 25%

Category 3 Coma due to accident, occupational HIV infection, loss of sight, loss of speech, loss of hearing, major organ failure, end-stage renal failure, paralysis due to accident, severe burns: 100%

Category 4 Advanced Alzheimer's disease, multiple sclerosis, Parkinson's disease, ALS and other motor neuron diseases: 100%

Employee Benefit Amount(s)

Critical Illness benefit: $5,000, $10,000, $15,000Guaranteed Issue Amount: Up to $15,000

Dependent Benefit Amount(s)

Spouse: 50% of the employee's benefit. Guaranteed Issue Amount: Up to $5,000Child: 25% of the employee's benefit, not to exceed $10,000. Guaranteed Issue Amount: Up to $10,000

Coverage Details

Benefit Reduction Schedule

The benefit amount for employee, spouse, and child is reduced by 50% on the policy anniversary date that occurs on or follows the employee's 70th birthday.

Benefit Waiting Period

Coverage begins 30 days2 from the date of enrollment. If the coverage amount is later increased,

another 30-day2 waiting period will apply.Pre-existing Conditions

Benefits are not paid for any condition diagnosed or treated during the 12 months2 before the effective date of coverage. New claims for pre-existing condition are covered once the policy has

been in effect for 12 months2.

Separation Period The time period between the diagnosis dates of different critical illnesses in either the same or another critical illness category. Benefits for different covered illnesses may be payable if the dates

of diagnosis are separated by at least 12 months2.

Continuation of Coverage

Allows primary insured to continue coverage if employment terminates. This benefit is not available for spouse/domestic partner or dependents.

$ 0.97 $ 1.93 $ 2.90 $ 1.25 $ 2.49 $ 3.74 $ 1.70 $ 3.41 $ 5.11 $ 2.91 $ 5.82 $ 8.73 $ 4.62 $ 9.24 $ 13.86 $ 6.78 $ 13.56 $ 20.33 $ 10.06 $ 20.13 $ 30.19 $ 14.55 $ 29.10 $ 43.65 $ 20.98 $ 41.97 $ 62.95 $ 34.33 $ 68.66 $ 102.99 $ 47.00 $ 94.00 $ 140.99 $ 63.32 $ 126.64 $ 189.96 $ 84.07 $ 168.14 $ 252.20 $ 125.84 $ 251.68 $ 377.52 $ 1.45 $ 2.90 $ 4.35 $ 1.87 $ 3.74 $ 5.60 $ 2.56 $ 5.12 $ 7.68 $ 4.37 $ 8.73 $ 13.10 $ 6.93 $ 13.87 $ 20.80 $ 10.17 $ 20.34 $ 30.51 $ 15.10 $ 30.19 $ 45.29 $ 21.83 $ 43.66 $ 65.49 $ 31.45 $ 62.90 $ 94.35 $ 51.49 $ 102.97 $ 154.46 $ 70.53 $ 141.06 $ 211.60 $ 95.03 $ 190.05 $ 285.08 $ 126.05 $ 252.11 $ 378.16 $ 188.84 $ 377.68 $ 566.51 $ 1.22 $ 2.44 $ 3.66 $ 1.50 $ 3.00 $ 4.51 $ 1.93 $ 3.87 $ 5.80 $ 3.15 $ 6.30 $ 9.45 $ 4.85 $ 9.69 $ 14.54 $ 6.98 $ 13.97 $ 20.95 $ 10.27 $ 20.54 $ 30.81 $ 14.76 $ 29.51 $ 44.27 $ 21.18 $ 42.36 $ 63.54 $ 34.55 $ 69.11 $ 103.66 $ 47.23 $ 94.46 $ 141.69 $ 63.56 $ 127.12 $ 190.69 $ 84.07 $ 168.14 $ 252.20 $ 125.84 $ 251.68 $ 377.52 $ 1.70 $ 3.41 $ 5.11 $ 2.12 $ 4.24 $ 6.36 $ 2.78 $ 5.56 $ 8.34 $ 4.59 $ 9.19 $ 13.78 $ 7.15 $ 14.30 $ 21.45 $ 10.37 $ 20.75 $ 31.12 $ 15.30 $ 30.61 $ 45.91 $ 22.02 $ 44.05 $ 66.07 $ 31.66 $ 63.33 $ 94.99 $ 51.71 $ 103.42 $ 155.12 $ 70.67 $ 141.34 $ 212.01 $ 95.18 $ 190.35 $ 285.53 $ 126.15 $ 252.30 $ 378.46 $ 188.84 $ 377.68 $ 566.51

NON-TOBACCO MONTHLY RATES RateEmployee Attained Age $5,000 $10,000 $15,000

60-6465-6970-7475-79

24 or less25-2930-3435-3940-4445-49

55-5960-64

80-8485+

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24 or less25-2930-34

50-5455-59

65-6970-7475-7980-8485+

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+ S

po

use 35-39

40-4445-4950-54

60-6465-6970-7475-79

24 or less25-2930-3435-3940-4445-49

55-5960-64

80-8485+

Em

plo

yee

+ C

hil

d(r

en)

24 or less25-2930-34

50-5455-59

65-6970-7475-7980-8485+

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amil

y 35-3940-4445-4950-54

$ 0.97 $ 1.93 $ 2.90 $ 1.41 $ 2.81 $ 4.22 $ 2.42 $ 4.85 $ 7.27 $ 4.53 $ 9.07 $ 13.60 $ 8.29 $ 16.58 $ 24.87 $ 13.16 $ 26.33 $ 39.49 $ 20.07 $ 40.15 $ 60.22 $ 29.55 $ 59.10 $ 88.65 $ 44.01 $ 88.02 $ 132.04 $ 72.64 $ 145.28 $ 217.91 $ 95.42 $ 190.83 $ 286.25 $ 115.17 $ 230.34 $ 345.50 $ 131.37 $ 262.75 $ 394.12 $ 155.89 $ 311.79 $ 467.68 $ 1.45 $ 2.90 $ 4.35 $ 2.11 $ 4.22 $ 6.32 $ 3.64 $ 7.28 $ 10.92 $ 6.80 $ 13.60 $ 20.39 $ 12.44 $ 24.88 $ 37.32 $ 19.75 $ 39.50 $ 59.25 $ 30.12 $ 60.24 $ 90.35 $ 44.34 $ 88.68 $ 133.02 $ 65.96 $ 131.93 $ 197.89 $ 108.94 $ 217.88 $ 326.82 $ 143.20 $ 286.39 $ 429.59 $ 172.83 $ 345.66 $ 518.49 $ 196.99 $ 393.97 $ 590.96 $ 233.93 $ 467.87 $ 701.80 $ 1.22 $ 2.44 $ 3.66 $ 1.69 $ 3.39 $ 5.08 $ 2.74 $ 5.49 $ 8.23 $ 4.90 $ 9.81 $ 14.71 $ 8.68 $ 17.37 $ 26.05 $ 13.57 $ 27.14 $ 40.70 $ 20.49 $ 40.97 $ 61.46 $ 29.97 $ 59.94 $ 89.91 $ 44.42 $ 88.84 $ 133.26 $ 73.11 $ 146.22 $ 219.33 $ 95.89 $ 191.77 $ 287.66 $ 115.61 $ 231.21 $ 346.82 $ 131.37 $ 262.75 $ 394.12 $ 155.89 $ 311.79 $ 467.68 $ 1.70 $ 3.41 $ 5.11 $ 2.39 $ 4.78 $ 7.18 $ 3.95 $ 7.90 $ 11.85 $ 7.15 $ 14.31 $ 21.46 $ 12.82 $ 25.63 $ 38.45 $ 20.15 $ 40.30 $ 60.45 $ 30.53 $ 61.06 $ 91.58 $ 44.73 $ 89.47 $ 134.20 $ 66.41 $ 132.82 $ 199.23 $ 109.40 $ 218.81 $ 328.21 $ 143.48 $ 286.96 $ 430.43 $ 173.10 $ 346.21 $ 519.31 $ 197.14 $ 394.28 $ 591.42 $ 233.93 $ 467.87 $ 701.80

EmployeeAttained Age

TOBACCO MONTHLY RATES

$5,000 $10,000 $15,000

60-6465-6970-7475-79

24 or less25-2930-3435-3940-4445-49

55-5960-64

80-8485+

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24 or less25-2930-34

50-5455-59

65-6970-7475-7980-8485+

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24 or less25-2930-3435-3940-4445-49

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24 or less25-2930-34

50-5455-5960-6465-6970-7475-79

45-4950-5455-5960-64

80-8485+

65-6970-7475-7980-8485+

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Coronary Artery Disease Needing Surgery or Angioplasty is defined as coronary artery disease with blockages in one or more coronary artery(s) demonstrated on cardiac catheterization coronary angiography that requires the insured to undergo either coronary artery bypass surgery or coronary angioplasty. A specialist must report that the insured requires surgical intervention on the coronary artery(s) following clinically accepted cardiovascular surgery guidelines.

CATEGORY 2Heart Attack (Myocardial Infarction)

Heart Attack (Myocardial Infarction) is defined as the ischemic death of a portion of the heart muscle due to a blockage of one or more coronary arteries. The diagnosis must be made by a specialist and based on all three of the following criteria: 1) new clinical presentation; 2) electrocardiographic changes consistent with an evolving heart attack; 3) serial measurement of cardiac biomarkers.

Stroke

Stroke is defined as cerebrovascular incident resulting in an irreversible death of brain tissue due to intracranial hemorrhage or cerebral infarction due to embolism or thrombosis in an intra-cranial vessel. This event must result in permanent neurological functional impairment with objective neurological abnormal signs on physical examination by a specialist at least 30 days after the event.

Coronary Artery Disease Needing Surgery or Angioplasty

Critical Illness insurance provides a lump sum payment upon the first diagnosis of a covered condition once coverage is in effect. Covered conditions are grouped into benefit categories. Benefits for covered conditions will be paid at a percentage of the policy amount per category (up to 100%). Below are the definitions of the conditions covered.

CATEGORY 1Invasive Cancer

Invasive Cancer is defined as a malignant tumor characterized by the uncontrolled growth and spread of malignant cells with invasion and destruction of normal tissue. The term cancer may include leukemia, lymphoma, sarcoma, and Hodgkin's disease. Invasive Cancer must be diagnosed by a specialist according to a pathological or clinical diagnosis.

Minor Cancer

Minor Cancer is defined as a diagnosis of one of the following four malignant cancers: 1) carcinoma in-situ; 2) malignant prostate cancer; 3) malignant melanoma; 4) malignant thyroid cancer. The diagnosis must be confirmed with a report from a specialist that includes the pathology report.

Description of Benefits forCollaborative for Educational Services, Inc

Critical Illness

Critical Illness Benefit

Paralysis Due to Accident

Paralysis Due to Accident is defined as paralysis with quadriplegia, paraplegia, hemiplegia, or diplegia, as the result of an accident that occurred while covered under the policy. There must be complete and permanent loss of use of two or more limbs that is present for a continuous period of at least 180 days.

Severe Burns

Severe Burns is defined as having sustained third degree burns. The third degree burns must cover at least 20% of the surface area of an insured's body.

Loss of Hearing is defined as permanent reduction of hearing in both ears to a point that the insured is unable to hear sounds at or below (90 decibels). The diagnosis must be made by a specialist as diagnosed by audiometric testing.

Major Organ Failure

Major Organ Failure is defined as the failure of bone marrow, heart, liver, lung, pancreas, or small bowel. A specialist must determine that a transplant of one or a combination of the above mentioned organs is necessary to treat organ failure in the insured. The insured must be included on an official USA transplant waiting list such as the United Network for Organ Sharing (UNOS) or the National Marrow Donor Program (NMDP).

End Stage Renal Failure (Kidney Failure)

End Stage Renal Failure (Kidney Failure) is defined as the total and irreversible failure of both kidneys which requires permanent regular renal dialysis or a kidney transplant. A specialist must confirm that either of the following is necessary: 1) The insured must undergo regular renal dialysis at least weekly; 2) The insured needs a kidney transplant and is included on an official USA transplant waiting list such as the United Network for Organ Sharing (UNOS).

Occupational Human Immunodeficiency Virus (HIV) Infection is defined as infection with the human immunodeficiency virus (HIV) resulting from an accidental injury which exposed the insured to HIV-contaminated blood or bodily fluids during the course of the duties of the insured's normal occupation. The accident causing the infection of HIV must have occurred in the United States and while covered under the policy.

Loss of Sight

Loss of Sight is defined as permanent and irreversible loss of sight in both eyes. A specialist must clinically confirm that the insured's corrected visual acuity is 20/200 or less or the field of vision is less than 20 degrees in both eyes.

Loss of Speech

Loss of Speech is defined as permanent loss of the ability to speak to the extent that the insured is unintelligible to another person with normal hearing. The insured must be able to demonstrate that the loss has been continuous for at least 180 days. The diagnosis of loss must be made by a specialist.

Loss of Hearing

CATEGORY 3Coma Due to Accident

Coma due to accident is defined as a coma that results from an accidental injury that occurred while covered under the policy. This diagnosis must be supported by evidence of the following: 1) no response to external stimuli; 2) life support measures are necessary to sustain life; 3) brain damage resulting in permanent neurological deficit.

Occupational Human Immunodeficiency Virus (HIV) Infection Due to Accident

Parkinson's Disease

Parkinson's disease is diagnosed by a specialist and defined as unequivocal diagnosis of idiopathic Parkinson's disease. Disease characteristics include resting tremor, rigidity, bradykinesia and gait disturbance compatible with the diagnosis of Parkinson's disease.

Continuation of Coverage during Temporary Absence

If absent from work due to illness or injury, all coverage may be continued for a period of 3 consecutive months from the date last actively at work.

Personal Leave of Absence

If on a documented leave of absence, all coverage may be continued for up to 1 month following the date last actively at work. If the leave terminates prior to the agreed upon date, this continuation will cease immediately.

The following is a partial list of exclusions. If there is any conflict between this information and the policy issued, the terms of the policy will prevail.

Illness or Injury:

Advanced Alzheimer's Disease

Advanced Alzheimer's Disease is diagnosed by a specialist and defined as dementia due to Alzheimer's disease, where there is progressive and permanent deterioration of memory and intellectual capacity where the insured is unable to perform independently, at least two of five defined "Activities of Daily Living" for a continuous period of at least 180 days. The diagnosis must be supported by clinically accepted standardized cognitive testing and neurological examination.

Amyotrophic Lateral Sclerosis (ALS) and other Motor Neuron Diseases

Amyotrophic Lateral Sclerosis (ALS) and other Motor Neuron Diseases is diagnosed by a specialist and defined as spinal muscular atrophy, progressive bulbar palsy, amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease) or primary lateral sclerosis. There must be objective evidence of motor dysfunction with muscle weakness for a continuous period of time of at least 90 days.

Multiple Sclerosis

Multiple Sclerosis diagnosed by a specialist and defined as permanent functional neurological impairment with objective evidence of motor or sensory dysfunction confirmed by objective neurological investigations (i.e. lumbar puncture, evoked visual responses, evoked auditory responses and MRI evidence of lesions of the central nervous system).

CATEGORY 4

Coverage may continue beyond the day it would otherwise cease under the termination provisions if the insured is absent from work due to any of the following reasons. In no event will coverage continue beyond the maximum time shown below for any temporary absence. If the insured is eligible to continue coverage for more than one reason, the periods of continuation will run concurrently. The continuation periods may not be applied consecutively. Continuation of coverage is subject to the payment of required premium.

caused by a pre-existing condition if it is diagnosed in the first 12 months after coverage takes effect;caused by alcoholism or drug addiction.

Critical Illness insurance policies are designed to provide benefits at a preselected, fixed-dollar amount, for specific critical illness conditions. Coverage may be subject to exclusions, limitations, reductions, and termination of benefit provisions. The policies do not satisfy the minimum essential coverage requirements of the Affordable Care Act. Critical Illness policies are insured by Symetra Life Insurance Company, 777 108th Avenue NE, Suite 1200, Bellevue, WA 98004. Base policy form number is SBC 00500 in most states and is not available in all U.S. states or any U.S. territory. Symetra® is a registered service mark of Symetra Life Insurance Company.

No benefit will be paid for a critical illness diagnosed before coverage takes effect. In addition, benefits will not be paid when the Insured has a critical illness that is:

diagnosed during any Benefit Waiting Period;not diagnosed by a specialist or diagnosed by a physician outside the United States;diagnosed more than once while covered under the policy;

Symetra® is a registered service mark of Symetra Life Insurance Company. Select Benefit Administrators is an administrative division of Symetra Life Insurance Company, 777 108th Ave NE, Suite 1200, Bellevue, WA 98004-5135.

SBC-00991-ENR 12/13 Page 1 of 2

Symetra Life Insurance Company 777 108th Avenue NE, Suite 1200 Bellevue, WA 98004-5135

Mailing Address: Select Benefit Administrators PO Box 440 Ashland, WI 54806 Overnight deliveries to: 118 3rd Street East Ashland, WI 54806 Phone 1-800-497-3699 Fax (715) 682-5919

ENROLLMENT/CHANGE REQUEST For Select Benefits Group Insurance

Group Information (To be Completed by Employer)

Group name Effective date for action requested Group number

Newly-Eligible Request Subsequent Enrollment Period Special Enrollment Request

Reason____________________________________________________________________________________________

Authorized Representative signature (required) Date

Name (printed) Title

Your Information (To be completed by individual requesting coverage)

Name Social Security number

Date of birth Date of hire Gender

M F Home phone Work phone

Job title / occupation I am actively working

Yes No

Average number of hours worked per week

Home address City State Zip

Email address Marital Status

Single Married Divorced Legally Separated Separated Widowed Domestic Partner Civil Union Common Law

Action Requested

Enroll in the coverage for insurance as selected below.

Change (add, increase, decrease, terminate) my current coverage, as shown below.

Update information about me, my dependents and/or beneficiaries.

Terminate all current coverage.

Enroll in critical illness buy-up benefit.

Coverage

Fixed-Payment Medical Option

Identify coverage option

Self Self plus spouse Self plus child(ren) Self plus family

Accident Option

Identify coverage option

Self Self plus spouse Self plus child(ren) Self plus family Decline

SBC-00991-ENR 12/13 Page 2 of 2

Coverage (continued)

Critical Illness* Option

(Indicate current amount)

Option

(Indicate requested amount)

Self Self plus spouse Self plus child(ren) Self plus family Decline

Have you used nicotine in the past 12 months?

Yes No

Dependent Information (Complete to add, change or terminate coverage for dependents. List additional dependents on a separate sheet and attach to this form.) No person can be insured under any policy as both a certificateholder and a dependent, or as a dependent of more than one certificateholder. The effective date of coverage for a dependent who is confined may be delayed.

Name

Date of birth Gender

M F Full-time student

Yes No Relationship

Home address (if different than your address) City State Zip

Add Change Terminate

Coverage: Fixed-Payment Medical Accident Critical Illness Short Term Disability

Name

Date of birth Gender

M F Full-time student

Yes No Relationship

Home address (if different than your address) City State Zip

Add Change Terminate

Coverage: Fixed-Payment Medical Accident Critical Illness Short Term Disability

Signatures (Sign and date only one option below. Retain a copy for yourself. Provide the original to your insured group’s representative.)

Authorization (If you are enrolling in, changing or updating coverage)

I, the undersigned, elect the insurance coverage which I selected above and for which I am eligible under the terms of the group policy (or policies) insured by Symetra Life Insurance Company. I authorize the deduction from my earnings for any contribution I am required to make toward the cost of this insurance. I understand that an election of coverage for critical illness benefits may be subject to acceptance of evidence of insurability. I further understand that I may not be able to make any changes to my elected coverage until the next enrollment period.

I designate the beneficiary(ies) named on this form to receive any benefits payable in the event of my death.

All information submitted by me on this form to the best of my knowledge and belief is true and complete.

This form replaces all Enrollment/Change Request forms previously submitted.

Enrollee/Employee signature Date

Waiver (If you are declining or terminating all coverage.)

I, the undersigned, hereby waive my right at this time to elect the insurance coverage which I did not select above. I understand that if I do not enroll within 30 days of the date I am first eligible, that I may have to wait to obtain coverage until the next enrollment period. Further, I understand that I may not be able to obtain coverage for life insurance, disability, or critical illness benefits in the future without submitting satisfactory evidence of insurability to Symetra Life Insurance Company for approval. I also understand that Symetra Life Insurance Company will have the right to refuse my request for insurance.

Reason: I already have insurance Other________________________________________________________

All information submitted by me on this form to the best of my knowledge and belief is true and complete.

This form replaces all Enrollment/Change Request forms previously submitted.

Enrollee/Employee signature Date