Attachment R – Current and Historical Rates - All Lines.pdf

Great news— It's time to renew your EyeMed Vision Care plan.

The Gloucester County Public Schools vision plan will automatically renew on 10/01/2024 without any changes. We've made this as simple as possible, with no signatures or additional paperwork needed. All we ask is that you retain this letter for your records.

Rates below will be effective 10/01/2024.

Tier Current Rate Renewal Rate

Employee Only $6.02 $6.02

Employee + Spouse $11.43 $11.43

Employee + Children $12.03 $12.03

Employee + Family $17.69 $17.69

We will continue to guarantee these rates for 48 months with the exception of changes in benefits, network, contributions, number of eligible employees or any future tax, fee or assessment imposed by the Federal or State governments.

We look forward to continuing our relationship. In addition to your same great savings, we have rotating members savings outlined on our Special Offers platform. We've highlighted a few reminders below:

Second pair discount: 40% off a complete second pair of prescription glasses* • Hearing Care discount: You could save up to 64% off retail for hearing aids and materials** Know Before You Go: Transparency tool helping estimate potential out-of-pocket costs— before heading to the eye doctor

Visit Member Web to see all of today's members' only offers and everyday discounts.

If you’d like to see additional plan design options or if there are any questions, don’t hesitate to contact me. Otherwise, there is no action required.

We know things change, so if there is a new contact person, please provide their contact information so I can follow up.

Thank you for your business.

Best regards, Mike Menzies (South) Account Manager EyeMedVisionSouth@eyemed.com 4000 Luxottica Place Mason, OH 45040

* May not be combined with any other offers or discounts. This is not insurance. Redeemable at any participating U.S. Sunglass Hut, Sunglass Hut at Macy’s or online, or at SunglassHut.com. Excludes Chanel, Maui Jim, Oakley, Tiffany and Tom Ford. Exclusions may apply. Limitations and exclusions may apply. For a complete list of current offers, EyeMed members may log into their member account at eyemed.com.

Hello

4860 Cox Road • Glen Allen, VA, 23060 • 804-873-5248• Brooke.Daley@ucci.com

Dwight Duren July 30, 2024 Gloucester County Public Schools 6099 T C Walker Road Gloucester, VA 23061

Re: Gloucester County Public Schools – Dental Insurance Renewal for 2024

Group Number(s): 922539-000/001/100/101/099/199/299/399; Account Number: 0227883

Dear Mr. Duren:

Thank you for allowing United Concordia to continue to service the dental needs of Gloucester County Public Schools. We appreciate the opportunity to provide the employees and their dependents with access to quality, affordable dental care. Please allow this letter to serve as formal notification of the renewal rates for the dental program for the period of October 1, 2024, through September 30, 2026.

Group Number(s): 922539-000/001/099/299

Rate Tier Current Rates Renewal Rates

Employee Only $43.99 $45.31

Employee & One Adult $77.15 $79.46

Employee & Child $77.15 $79.46

Employee & Children $122.57 $126.25

Employee & Family $122.57 $126.25

Group Number(s): 922539-100/101/199/399

Rate Tier Current Rates Renewal Rates

Employee Only $24.76 $25.50

Employee & One Adult $41.89 $43.15

Employee & Child $41.89 $43.15

Employee & Children $67.09 $69.10

Employee & Family $67.09 $69.10

Enclosed is a copy of the Renewal Acceptance Form. Please have an authorized representative sign and either scan a copy to my e-mail or mail it to the address below. If a signed copy of the form is not received by United Concordia, payment of the above renewal premiums will constitute acceptance of the United Concordia dental program and premiums.

Should you have any questions regarding the above rates, please contact me at 804-873-5248. United Concordia looks forward to continuing as the dental benefits insurer of choice.

Sincerely, Brooke Daley Senior Client Manager United Concordia Dental Attachment: Acceptance Form jessica.meyers Highlight

4860 Cox Road • Glen Allen, VA, 23060 • 804-873-5248• Brooke.Daley@ucci.com

Gloucester County Public Schools

United Concordia Renewal Acceptance Form

Funding: Fully Insured

Policy Period: October 1, 2024 through September 30, 2026

Account Number(s): 0223476

Group Number(s): 922539-000/001/099/299

Rate Tier Renewal Rates

Employee Only $45.31

Employee & One Adult $79.46

Employee & Child $79.46

Employee & Children $126.25

Employee & Family $126.25

Group Number(s): 922539-100/101//199/399

Rate Tier Renewal Rates

Employee Only $25.50

Employee & One Adult $43.15

Employee & Child $43.15

Employee & Children $69.10

Employee & Family $69.10

I, _____________________________________, as a duly authorized representative of the above named, do hereby accept the monthly premium rates as noted above.

Signature Date

Please return Acceptance to: Brooke Daley 4860 Cox Road Glen Allen, VA 23060 Brooke.Daley@ucci.com

The parties intend that this renewal may be accepted by email.

A signature transmitted by email will be as effective as an original signature for the purpose of acceptance.

Notice: United Concordia Dental requires at least 31 days written notice prior to termination of group policy

Dwight Duren

8/5/2024 mailto:Brooke.Daley@ucci.com

Prepared for: Gloucester County Public Schools

Presented by: USI - VIRGINIA

Proposal Prepared on:

July 1, 2024

Proposed Effective Date:

October 1, 2024

Long Term Disability Insurance

Standard Insurance Company

Your Employee Benefits Proposal

Proposed Effective Date October 1, 2024

Prepared for:

Gloucester County Public Schools

Plan 1- 4051441; Plan 2- 4059391; 1

Long Term Disability Insurance

Protect your employees' income and your company's bottom line. This insurance comes with innovative resources designed to help you build a more productive workplace. Our Workplace Possibilities(SM) program, included at no extra cost, helps employees stay on the job and return to work sooner. While not all claims can be shortened, our customers are currently experiencing anywhere from a 10% to a 25% reduction in disability days who participate in the Workplace Possibilities Program. That's just one example of how we add real value as your partner.

Covered Members

A regular employee of the Employer participating in the VA retirement plan 1 or 2 and Hybrid Pension for the first year working 20 or more hours per week working 20 or more hours per week.

Voluntary LTD Plan 1 Voluntary LTD Plan 2

Benefit Schedule 50% 60%

Insured Predisability Earnings

$12,000 $10,000

Maximum Monthly Benefit $6,000 $6,000

Minimum Monthly Benefit $100 $100

Benefit Waiting Period 180 Days 180 Days

Maximum Benefit Period 2 Years To SSNRA

Guarantee Issue Benefit Amount

Full Benefit Full Benefit

Employer Contribution 0% 0%

Minimum Participation Greater of 35% or 10 lives Greater of 35% or 10 lives

Taxability of Benefits Non-Taxable Non-Taxable

Own Occupation Period 24 Months 24 Months

Partial/Residual Disability Included Included

Preexisting Condition Period 3/12 3/12

Mental & Nervous Limitation 24 months 24 months

Substance Abuse Limitation 24 months 24 months

Other Limited Conditions 24 months 24 months

Return to Work Incentive 12 months 12 months

Employee Assistance Program Included: 3 face-to-face Included: 3 face-to-face

Prepared for:

Gloucester County Public Schools

Plan 1- 4051441; Plan 2- 4059391; 2

Additional Plan Design Details

• The Standard pays the employer's matching FICA and Medicare taxes and prepares W-2s for members receiving LTD benefits.

• The plan includes the Workplace Possibilities(SM) program, an innovative approach to addressing and reducing the causes of absence and disability - with innovative tools and resources designed to help keep your employees productive and on the job.

• This coverage includes a $25,000 Reasonable Accommodation Expense Benefit, which reimburses employers for workplace modifications that enable employees to return to or remain at work. The Reasonable Accommodation Expense Benefit is separate from the LTD claim payment.

• A Rehabilitation Plan Benefit is included, which increases the LTD benefit amount by 10% of predisability earnings, not to exceed the maximum benefit, when member is participating in an approved rehabilitation plan. This benefit will also assist in paying for approved expenses incurred by a disabled member a part of an approved rehabilitation plan.

• Survivors Benefit pays a lump sum equal to 3 times the non-integrated LTD benefit.

• Continuity of Coverage.

• The limitations included in the policy are combined lifetime limitations.

Prepared for:

Gloucester County Public Schools

Plan 1- 4051441; Plan 2- 4059391; 3

Cost

Voluntary LTD Plan 1

Members 77

Volume $419,419

Rate: Percent of earnings Lives Age Rate Volume Premium

0-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-999

.020

.020

.020

.060

.070

.100

.130

.180

.180

.180

.180

$0 $0 $0

$17,074 $30,990 $71,764

$101,781 $97,445 $73,257 $24,177 $2,931

$0 $0 $0

$10 $22 $72

$132 $175 $132 $44 $5

Monthly Premium $592

Rate Guarantee 3 years

Voluntary LTD Plan 2

Members 63

Volume $362,504

Rate: Percent of earnings Lives Age Rate Volume Premium

0-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-999

.080

.080

.080

.120

.190

.300

.450

.560

.560

.560

.560

$0 $0

$5,032 $21,914 $24,952 $84,006

$103,010 $52,631 $45,458 $25,501

$0

$0 $0 $4

$26 $47

$252 $464 $295 $255 $143

$0

Monthly Premium $1,486

Rate Guarantee 3 years

Assumptions

• Final rates are subject to change if actual enrollment varies from the assumed enrollment of 36%

• Sick leave payable to the member will be used as deductible income.

• Workers' compensation benefits will be considered deductible income.

• Benefits received from individual disability plans will not be used as deductible income.

• Primary and dependents Social Security benefits will be used as deductible income.

• Rates assume members participate in Social Security and Public Employee Retirement System.

jessica.meyers Highlight

Prepared for:

Gloucester County Public Schools

Plan 1- 4051441; Plan 2- 4059391; 4

Assumptions (continued)

• Rates include electronic documents. Printed certificates are available for an additional cost.

• Rates assume billing is centralized in one location.

Conditions

• We require evidence of insurability for:

– Members who enroll more than 31 days after they are first eligible for coverage.

– Members eligible under the current plan but not enrolled.

• Rate assumes that coverage is currently in force.

• Confirmation that you participate in Social Security and Public Employee Retirement System is required.

More Information

For additional information on the available features and benefits of Long Term Disability Insurance from The Standard:

Click here for California: http://www.standard.com/ca-group-long-term-disability Click here for all other states: http://www.standard.com/group-long-term-disability http://www.standard.com/ca-group-long-term-disability http://www.standard.com/group-long-term-disability

Prepared for:

Gloucester County Public Schools

Plan 1- 4051441; Plan 2- 4059391;

Producer Compensation Disclosure

We recognize the valuable role of insurance advisors, consultants and brokers ("producers") in helping their clients design an employee benefits program, and we support reasonable and fair compensation for these services. Producers may be eligible to receive compensation from The Standard.

The commission quoted in this proposal are noted below. Additionally, fees for administrative, marketing or consulting services may apply.

If applicable, fees are noted below.

Normal commission scale (www.standard.com/financial-professional/insurance-benefits/compensation) included for LTD.

Unless participation is declined by the producer or client, contingent compensation is additional compensation that may also be paid and is dependent on the satisfaction of one or more minimum requirements, such as a specified amount of new premium volume or persistency in connection with the producer's block of business. For information about our customary producer rewards program visit www.standard.com/financial-professional/insurance-benefits/compensation. Some producers may have a contingent compensation arrangement that differs from our customary program. Please consult with your producer for additional details.

About This Employee Benefits Proposal

We appreciate the opportunity to provide you with this benefit and cost summary proposal from The Standard. This document outlines certain important features of the group insurance coverages available. This is not a contract or an offer to contract for such coverages.

Detailed information about other important features of the coverage proposed is available on request. Just ask your broker/consultant or your representative at The Standard.

A completed application must be submitted before a group can be considered for coverage. Insurance will be effective after the application is accepted by The Standard. If approved, we will issue a contract containing our customary language. It will not duplicate policy language from another carrier. The group contract will contain provisions and defined terms not described in this Employee Benefits Proposal. The group contract will control if there are discrepancies between it and this proposal.

This benefit and cost summary proposal expires on September 5, 2024, unless replaced or withdrawn by The Standard.

The proposed premium rate and plan design for each coverage are based on the underwriting data received by The Standard. Final premium rates and plan provisions will be determined by The Standard on the basis of: applicable state laws, policyholder contributions, confirmation of occupations, the actual composition of the group of persons who will become insured and our current underwriting rules and practices.

Financial Strength Ratings

For information about our Financial strengths ratings visit: https://www.standard.com/about-standard/company/financial-strength

The Standard is a marketing name for StanCorp Financial Group, Inc. and subsidiaries. Insurance products are offered by Standard Insurance Company of 1100 SW Sixth Avenue, Portland, Oregon in all states except New York. Product features and availability vary by state and are solely the responsibility of Standard Insurance Company.

www.standard.com/financial-professional/insurance-benefits/compensation www.standard.com/financial-professional/insurance-benefits/compensation https://www.standard.com/about-standard/company/financial-strength

Proposal Prepared on:

June 28, 2024

Proposed Effective Date:

October 1, 2024

Self-Funded Short Term Disability

Standard Insurance Company

Prepared for:

Gloucester County Public Schools

Plan 1- 12861; 1

Self-Funded Short Term Disability

Covered Members

An active employee of the Employer working 30 or more hours per week.

Advice to Pay

Benefit Schedule 66 2/3

Maximum Weekly Benefit $1,500

Benefit Waiting Period Accident

14 Days

Benefit Waiting Period Sickness

14 Days

Maximum Benefit Period 180 Days

Service Details

• No pre-funding required.

• The Standard will furnish full claim management with seamless transition to LTD, when appropriate.

• The Standard will handle communication with the claimant, employer and physician.

• The Standard will pay for all fees associated with undergoing independent medical exams or obtaining medical records deemed necessary by The Standard.

• We will advise on claim decisions and, if desired, calculate benefit amounts.

jessica.meyers Typewritten text Current Benefits

Prepared for:

Gloucester County Public Schools

Plan 1- 12861; 2

Cost

Advice to Pay

Members 392

Rate: Per Member $2.25

Monthly Fees $882

Rate Guarantee 3 years

Optional Features & Services

• Fees include minor wording modifications to The Standard's plan documents, claim submission forms and/or form letters. Any modifications to plan documents, claim submission forms, letters or other documents are subject to approval by The Standard.

Assumptions

• Fees do not include commissions.

• Fees include electronic documents. Printed documents are available for an additional cost.

• Fees assume non-occupational coverage.

Conditions

• May only be purchased with The Standard's Long Term Disability product.

More Information

For additional information on the available features and benefits of Self-Funded Short Term Disability from The Standard, click here:http://www.standard.com/self-funded-disability http://www.standard.com/self-funded-disability jessica.meyers Highlight

Prepared for:

Gloucester County Public Schools

Plan 1- 12861;

Producer Compensation Disclosure

We recognize the valuable role of insurance advisors, consultants and brokers ("producers") in helping their clients design an employee benefits program, and we support reasonable and fair compensation for these services. Producers may be eligible to receive compensation from The Standard.

The commission quoted in this proposal are noted below. Additionally, fees for administrative, marketing or consulting services may apply.

If applicable, fees are noted below.

No commissions included for Service.

Unless participation is declined by the producer or client, contingent compensation is additional compensation that may also be paid and is dependent on the satisfaction of one or more minimum requirements, such as a specified amount of new premium volume or persistency in connection with the producer's block of business. For information about our customary producer rewards program visit www.standard.com/financial-professional/insurance-benefits/compensation. Some producers may have a contingent compensation arrangement that differs from our customary program. Please consult with your producer for additional details.

About This Employee Benefits Proposal

We appreciate the opportunity to provide you with this benefit and cost summary proposal from The Standard. This document outlines certain important features of the group insurance coverages available. This is not a contract or an offer to contract for such coverages.

Detailed information about other important features of the coverage proposed is available on request. Just ask your broker/consultant or your representative at The Standard.

A completed application must be submitted before a group can be considered for coverage. Insurance will be effective after the application is accepted by The Standard. If approved, we will issue a contract containing our customary language. It will not duplicate policy language from another carrier. The group contract will contain provisions and defined terms not described in this Employee Benefits Proposal. The group contract will control if there are discrepancies between it and this proposal.

This benefit and cost summary proposal expires on September 5, 2024, unless replaced or withdrawn by The Standard.

The proposed premium rate and plan design for each coverage are based on the underwriting data received by The Standard. Final premium rates and plan provisions will be determined by The Standard on the basis of: applicable state laws, policyholder contributions, confirmation of occupations, the actual composition of the group of persons who will become insured and our current underwriting rules and practices.

Financial Strength Ratings

For information about our Financial strengths ratings visit: https://www.standard.com/about-standard/company/financial-strength

The Standard is a marketing name for StanCorp Financial Group, Inc. and subsidiaries. Insurance products are offered by Standard Insurance Company of 1100 SW Sixth Avenue, Portland, Oregon in all states except New York. Product features and availability vary by state and are solely the responsibility of Standard Insurance Company.

www.standard.com/financial-professional/insurance-benefits/compensation

Proposal Prepared on:

June 12, 2024

Proposed Effective Date:

October 1, 2024

Accident Insurance

Hospital Indemnity Insurance

Group Critical Illness Insurance

Standard Insurance Company

Prepared for:

Gloucester County Public Schools

Plan 1- 4051443; Plan 2- 4055339; 1

Accident Insurance

Nobody plans to have an accident - and most people don't budget for one, either. Accident insurance pays benefits directly to employees for treatment they receive due to an accident. It helps cover employee's out-of-pocket costs like medical deductibles and co-pays.

Covered Members

A regular employee of the Employer working 20 hrs per week

Select - Plan 2 Premier - Plan 1

Minimum Employee Participation

10 Lives 10 Lives

Employer Contribution 0% 0%

Policy Situs State VA VA

Type of Coverage 24 Hour 24 Hour

Ages Eligible for Coverage 18–99 for Employee and Spouse; Birth to age 26 for children 18–99 for Employee and Spouse; Birth to age 26 for children

Termination Age None for Employee and Spouse; 26 for children None for Employee and Spouse; 26 for children

Plan Design

Select - Plan 2 Premier - Plan 1

Emergency Care Benefits

Air Ambulance $600 $1,500

Blood, Plasma, Platelets $150 $600

Emergency Dental (Crown) $150 $350

Emergency Dental (Extraction) $50 $150

Emergency Room Benefit $100 $200

Ground Ambulance $200 $600

Initial Physician's Office $50 $60

Major Diagnostic Exam $100 $300

Urgent Care $50 $60

X-Ray $25 $60

Specific Injury Benefits

Burns, 2nd Degree, <15% $100 $500

Burns, 2nd Degree, >15% $500 $1,500

Burns, 3rd Degree, <15% $1,500 $7,500

Burns, 3rd Degree, >15% $7,500 $12,500

Coma $5,000 $15,000

Concussion $100 $200

Eye Injury $150 $300

Lacerations, < 2” $50 $100

Prepared for:

Gloucester County Public Schools

Plan 1- 4051443; Plan 2- 4055339; 2

Plan Design (continued)

Select - Plan 2 Premier - Plan 1

Lacerations, 2" - 6" $100 $400

Lacerations, > 6" $400 $800

Skin Graft 25% of Burn Benefit 50% of Burn Benefit

Fracture Benefits Non-Surgical/Surgical

Ankle, Arm, Collarbone, Elbow, Foot, Hand, Kneecap, Lower Jaw, Shoulder Blade, Sternum, Wrist

$350/$700 $650/$1,300

Bones of Face, Coccyx, Nose, Vertebrae

$300/$600 $750/$1,500

Finger, Toe $75/$150 $200/$400

Hip $1,500/$3,000 $3,000/$6,000

Leg (hip to knee) $800/$1,600 $3,000/$6,000

Leg (knee to ankle), Pelvis, Vertebral Column

$800/$1,600 $1,700/$3,400

Rib $300/$600 $500/$1,000

Skull (Depressed) $2,750/$5,500 $5,250/$10,500

Skull (Non-Depressed) $800/$1,600 $2,000/$4,000

Chip Fracture 25% of Non-Surgical Fracture Amount 25% of Non-Surgical Fracture Amount

Dislocation Benefits Non-Surgical/Surgical

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

$450/$900 $1,000/$2,000

Collar Bone (Acromioclavicular)

$200/$400 $500/$1,000

Finger, Rib, Toe $100/$200 $200/$400

Hip $1,500/$3,000 $3,500/$7,000

Knee $450/$900 $1,000/$2,000

Spine $200/$400 $500/$1,000

Partial Dislocation 25% of Non-Surgical Dislocation Amount 25% of Non-Surgical Dislocation Amount

Surgical Benefits

Knee Cartilage Repair $400 $1,000

Knee Cartilage Exploratory Surgery

$150 $250

Tendon, Ligament, Rotator Cuff Repair of One

$400 $1,000

Tendon, Ligament, Rotator Cuff Repair of Two or More

$600 $1,500

Tendon, Ligament, Rotator Cuff Exploratory Surgery

$150 $250

Prepared for:

Gloucester County Public Schools

Plan 1- 4051443; Plan 2- 4055339; 3

Plan Design (continued)

Select - Plan 2 Premier - Plan 1

Raptured Disk, Repair $400 $1,000

Abdominal/Thoracic Exploratory Surgery

$150 $400

Abdominal/Thoracic Laparoscopic Surgery

$500 $1,000

Abdominal/Thoracic Open Surgery

$1,000 $2,000

Outpatient Surgical Facility $50 $500

Hospital Benefits

Critical Care Unit Admission $500 $1,000

Daily Rehabilitation Facility $50/day up to 90 days per accident $150/day up to 90 days per accident

Daily Critical Care Unit Confinement

$200/day up to 15 days $200/day up to 15 days

Daily Hospital Confinement $100/day up to 365 days $400/day up to 365 days

Hospital Admission $500 $1,500

Follow-Up Care Benefits

Medical Appliance $50 $200

Chiropractic $25 up to 2 days $60 up to 2 days

Follow-Up Care Treatment $50 up to 2 days $70 up to 3 days

Hearing Device $400 $600

Prosthesis, One $250 $1,000

Prostheses, Two or More $500 $2,000

Therapy Services $50 up to 2 days $50 up to 4 days

Additional Benefits

Youth Organized Sports 25% Additional of total benefits 25% Additional of total benefits

Health Maintenance Screening Benefit

$50 $50

Lodging (up to 30 days per Accident)

$150/per day $200/per day

Transportation (up to 30 days per Accident)

$100/per day $200/per day

Accidental Death & Dismemberment Benefits

Accidental Death – Employee $25,000 $100,000

Accidental Death – Spouse $12,500 $50,000

Accidental Death – Child $6,250 $25,000

Accidental Death & Dismemberment Benefits

Percentage of Accidental Death Benefits Percentage of Accidental Death Benefits

Common Carrier 100% 100%

Loss of Two or More Fingers or Toes

5% 5%

Prepared for:

Gloucester County Public Schools

Plan 1- 4051443; Plan 2- 4055339; 4

Plan Design (continued)

Select - Plan 2 Premier - Plan 1

Loss of One Finger or One Toe 2% 2%

Loss of Both Hands, or Both Feet

30% 30%

Loss of One Hand or One Foot 15% 15%

Loss of One Hand and One Foot

30% 30%

Loss of Sight for Both Eyes 30% 30%

Loss of Hearing of Both Ears 30% 30%

Loss of Sight in One Eye 15% 15%

Loss of Hearing in One Ear 15% 15%

Accidental Impairment Benefits

Percentage of Accidental Death Benefits Percentage of Accidental Death Benefits

Uniplegia 15% 15%

Paraplegia 30% 30%

Triplegia 30% 30%

Hemiplegia 30% 30%

Quadriplegia 50% 50%

Airbag Benefit 10% 10%

Helmet Benefit 10% 10%

Seatbelt Benefit 10% 10%

Repatriation Benefit 10% 10%

Additional Plan Design Details

• A Youth Organized Sports benefit is included with EE+CH and Family coverage. If a covered child 18 age or younger is injured while playing an organized sport, the Standard pays an additional 25% of the total benefits for treatment received.

• If multiple fractures and/or dislocations are sustained in a covered accident, the Standard pays for each fracture and/or each dislocation.

• Critical Care Admission and Critical Care Confinement pay in addition to the Hospital Admission and Hospital Confinement daily benefit.

• Auto-pay is available for the Health Maintenance Screening benefit when covered screenings are completed by employees at their employer's Health Fair.

• The Health Maintenance Screening Benefit pays an annual benefit when the insured receives one of the twenty-two covered health screening tests, including novel infectious disease testing (including COVID-19), lipid panel, mammography, and colonoscopy.

• Portability is automatically included. Employees are able to take their Accident coverage with no change in coverage or rates.

• Benefits paid under the Accident Insurance policy when purchased with employee post-tax income are excluded from claimant gross income under current federal tax law.

• 24 hour - Coverage includes accidents that occur anytime, including work related accidents.

Prepared for:

Gloucester County Public Schools

Plan 1- 4051443; Plan 2- 4055339; 5

Cost

Monthly Premium

Select - Plan 2 Premier - Plan 1

Employee $5.86 $14.23

Employee and Spouse $9.47 $20.65

Employee and Child(ren) $11.11 $27.06

Employee and Family $17.47 $33.49

• To convert monthly rates to deductions, multiply by twelve, then divide by the number of deductions per year and round to two decimals.

Assumptions

• No Underwriting required.

• This proposal assumes 858 eligible lives.

• Proposal assumes coverage is currently inforce with another carrier.

Conditions

• Minimum of 10 lives enrolled is required.

• The proposed rates are guaranteed for 27 months.

• No competing Accident plan will be offered on payroll deduction.

• Proposed rate includes electronic documents.

• New hires will be enrolled on a perpetual basis.

• A recent proposed Department of Treasury clarification may change the taxability of any Accident benefits paid with pre-tax premium.

Any impacted groups and individuals will be notified after final Department of Treasury ruling if changes are required.

Exclusions

Benefits are not payable if the accident was caused or contributed by the following:

– War or act of war.

– Suicide or other intentionally self-inflicted Injury, while sane or insane.

– Committing or attempting to commit an assault, felony, act of terrorism, or actively participating in a violent disorder or riot.

– The voluntary use or consumption of any poison, chemical compound, drug, or alcohol in excess of the legal limit in the state in which the accident occurred, unless used or consumed according to the directions of a health care provider.

– Sickness existing at the time of the accident, including any medical or surgical treatment or diagnostic procedure for a sickness.

– Travel or flight in or on any aircraft (certain exceptions apply, including as a fare paying passenger on a regularly scheduled commercial flight).

Prepared for:

Gloucester County Public Schools

Plan 1- 4051443; Plan 2- 4055339; 6

Exclusions (continued)

– Engaging in high risk sports or activities.

– Practicing for, or participating in, any semi-professional or professional competitive athletic contests.

– Routine eye exams and dental procedures other than a crown or extraction for a tooth or teeth as a result of a covered accident.

– Riding in or driving any automobile in a race, stunt show, or speed test.

– Cosmetic surgery, unless such surgery or procedure is necessary to correct a deformity or restore bodily function resulting from covered accident.

– Any accident which arises out of or in the course of the insured's incarceration in a jail, penal, or correctional institution.

Prepared for:

Gloucester County Public Schools

Plan 2- 4055109; 7

Hospital Indemnity Insurance

A trip to the hospital can be costly - and many employees aren't prepared for the out of pocket expenses that come with a hospital stay, even with medical coverage. Hospital Indemnity insurance pays cash benefits to employees in the event of a hospitalization, regardless of treatment costs or other insurance coverage. It's an affordable way for employees to keep their finances on track.

Covered Members

A regular employee of the Employer working 20 hrs per week

HSA - Plan 2

Minimum Employee Participation

10 Lives

Employer Contribution 0%

Policy Situs State VA

Ages Eligible for Coverage 18-99 for Employee and Spouse; Birth to age 26 for children

Termination Age None for Employee and Spouse; 26 for children

Plan Design

HSA - Plan 2

Hospital Confinement Benefit $150/Day

Number of Covered Days per Hospital Confinement

365 Days

Hospital Admission $1500/Calendar year

Critical Care Unit (CCU) Confinement - Pays in addition to Hospital Confinement benefit

$200/Day

Number of Covered Days per CCU Confinement

15 days

Health Maintenance Screening $50

Annual Open Enrollment Included

Pre-existing Limitation None

Prepared for:

Gloucester County Public Schools

Plan 2- 4055109; 8

Additional Plan Design Details

• Premium is waived if you are confined to a hospital for more than 30 days.

• Critical Care Confinement pays in addition to the Hospital Confinement benefit.

• The Health Maintenance Screening Benefit pays an annual benefit when the insured receives one of the twenty-two covered health screening tests, including novel infectious disease testing (including COVID-19), lipid panel, mammography, and colonoscopy.

• Auto-pay is available for the Health Maintenance Screening benefit when covered screenings are completed by employees at their employer's Health Fair.

• Provides coverage for injuries and illnesses, including pregnancy.

• Continuity of coverage is included.

• Portability is automatically included. Employees are able to take their Hospital Indemnity coverage with no change in coverage.

• Benefits paid under the Hospital Indemnity insurance policy when purchased with employee post-tax income are excluded from claimant gross income under current federal tax law.

• Evidence of insurability is not required at initial enrollment or during the annual open enrollment period. Members and dependents that do not enroll when they are first eligible may enroll during the annual open enrollment period.

• Plans that include the Hospital Confinement and/or CCU Confinement Benefit are compatible with an Health Savings Account (HSA).

Plans that include the Hospital Admission Benefit and/or CCU Admission Benefit may not be compatible with an HSA. Consult your tax advisor for advice.

• This is a limited benefit policy.

Prepared for:

Gloucester County Public Schools

Plan 2- 4055109; 9

Cost

Monthly Premium

HSA - Plan 2

Employee $19.30

Employee and Spouse $32.95

Employee and Child(ren) $27.19

Employee and Family $48.47

To convert monthly rates to deductions, multiply by twelve, then divide by the number of deductions per year and round to two decimals.

Assumptions

• This proposal assumes 858 eligible lives.

• Proposal assumes coverage is currently inforce with another carrier.

• Applicants must have comprehensive health coverage in order to be eligible to apply for Hospital Indemnity insurance.

Conditions

• No competing Hospital Indemnity plan will be offered on payroll deduction.

• Rates are Guaranteed for 27 months.

• Proposed rate includes electronic documents. Printed certificates are available for an additional cost.

• New hires will be enrolled on a perpetual basis.

• Credit for prior service toward satisfaction of employee waiting period.

• A recent proposed Department of Treasury clarification may change the taxability of any Hospital Indemnity benefits paid with pre-tax premium. Any impacted groups and individuals will be notified after final Department of Treasury ruling if changes are required.

Exclusions

• Benefits are not payable if the injury or sickness was caused or contributed to by any of the following:

– War or act of war.

– Attempted suicide or other intentionally self-inflicted Injury, while sane or insane.

– Committing or attempting to commit an assault, felony, act of terrorism, or actively participating in a violent disorder or riot.

– Alcoholism, drug abuse, misuse of alcohol or any other substance, the voluntary use or consumption of any drug or alcohol in excess of the legal limit in the state in which an injury occurred, or taking of drugs unless used or consumed according to the directions of a health care provider. This exclusion does not apply to a Sickness.

– Travel or flight in or on any aircraft (certain exceptions apply, including as a fare paying passenger on a regularly scheduled commercial flight).

Prepared for:

Gloucester County Public Schools

Plan 2- 4055109; 10

Exclusions (continued)

– Dental care or dental procedures, unless treatment is the result of an Injury.

– Routine newborn nursing or well-baby care.

– Hospital confinement of a newborn child following the child's birth unless the confinement is a result of an injury or sickness.

– Riding in or driving any automobile in a race, stunt show, or speed test.

– Surgery or other procedure which is directed at improving the insured's appearance, unless such surgery or procedure is necessary to correct a deformity or to restore bodily function resulting from an injury or sickness.

– Any injury or sickness which arises out of or in the course of an insured's incarceration in a jail, penal or correctional institution.

Prepared for:

Gloucester County Public Schools

Plan 1- 4051440; 11

Group Critical Illness Insurance

A major illness can blindside anyone, even an employee with medical insurance. Copays, deductibles, alternative treatments and other out-of-pocket expenses can add up quickly. Critical Illness insurance pays cash benefits directly to your employees to help reduce the financial burden that can come with a serious illness.

Covered Members

A regular employee of the Employer working 20 hrs per week

Premier - Plan 1

Minimum Employee Participation

10 Lives

Employer Contribution 0%

Policy Situs State VA

Ages Eligible for Coverage 18-99 for Employee and Spouse; Birth to age 26 for children

Termination Age None for Employee and Spouse; 26 for children

Plan Design

Premier - Plan 1

Covered Conditions Coverage Percentage or Flat Amount

Cancer 100%

Carcinoma In Situ (non-invasive cancer)

25%

End-stage Renal (Kidney) Failure

100%

Major Organ Failure 100%

Myocardial Infarction (Heart Attack)

100%

Severe Coronary Artery Disease with Recommendation of Bypass 25%

Stroke 100%

Coma 100%

Paralysis 100%

Loss of Sight 100%

Occupational Hepatitis 100%

Occupational HIV 100%

Advanced Alzheimer's Disease 100%

Advanced Multiple Sclerosis 100%

Advanced Parkinson's Disease 100%

Prepared for:

Gloucester County Public Schools

Plan 1- 4051440; 12

Plan Design (continued)

Premier - Plan 1

Covered Conditions Coverage Percentage or Flat Amount

Amyotrophic Lateral Sclerosis 100%

Benign Brain Tumor 100%

Bone Marrow Transplant 100%

Loss of Hearing 100%

Loss of Speech 100%

21 Childhood Diseases 100%

Additional Occurrence Benefit

– Separation Period

None

Coverage Amount: Employee $10,000 to $30,000 in increments of $10,000

Coverage Amount: Spouse $10,000 to $30,000 in increments of $10,000

Coverage Amount: Child (at no additional charge)

50% of the Employee Amount

Rates Attained Age, Unisex, Blended

Guarantee Issue (Employee) $30,000

Guarantee Issue (Spouse) $30,000

Annual Open Enrollment Included

Pre-existing Condition None

Health Maintenance Screening Benefit

$100 per insured per calendar year

Portability Included

Reoccurrence 100%

Reoccurrence Treatment-Free Period

6-month

Additional Plan Design Details

• Covered Child critical illness: Anal Atresia, Anencephaly, Biliary Atresia, Cerebral Palsy, Cleft Lip or Cleft Palate, Club Foot, Coarctation of the Aorta, Cystic Fibrosis, Diaphragmatic Hernia, Down's Syndrome, Gastroschisis, Hirschsprung's Disease, Hypoplastic Left Heart Syndrome, Infantile Hypertrophic Pyloric Stenosis, Muscular Dystrophy, Omphalocele, Patent Ductus Arteriosis, Spina Bifida Cystica with Myelomeningocele, Tetralogy of Fallot, Transposition of the Great Arteries.

• Spouse coverage cannot exceed 100% of the employees Coverage Amount.

• The diagnosis of a covered critical illness must occur while the insured is covered under the group policy and after the effective date of coverage.

• Portability is automatically included. Employees are able to take their Critical Illness coverage with no change in coverage.

• Continuity of Coverage is included.

• Additional Occurrence Benefit: The amount payable for any additional covered critical illness that is different and subsequent to an initial critical illness is 100% of the coverage amount.

• Reoccurrence Benefit: If a critical illness benefit is payable and there is a subsequent diagnosis or recommendation for the same critical illness, a reoccurrence benefit is payable if the insured has been continuously insured under the group policy between the initial and subsequent diagnosis or recommendation, and completes the applicable treatment free period noted in the table above.

Prepared for:

Gloucester County Public Schools

Plan 1- 4051440; 13

Additional Plan Design Details (continued)

• The Health Maintenance Screening Benefit pays an annual benefit when the insured receives one of the twenty-two covered health screening tests, including novel infectious disease testing (including COVID-19), lipid panel, mammography, and colonoscopy.

• Health Maintenance Screening Benefit: Auto-pay is available for covered screenings completed by employees at their employer's Health Fair.

• Additional services with Health Advocacy Select include access to specialists for a second opinion upon approval of a covered claim.

• Benefits paid under the Critical Illness Insurance policy when purchased with employee post-tax income are excluded from claimant gross income under current federal tax law.

• Evidence of insurability is not required at initial enrollment or during the annual open enrollment period. Members and spouses that do not enroll when they are first eligible may enroll during the annual open enrollment period.

• If replacement coverage, the following will be required:

– Current plan certificate.

– Plan inventory/census showing who is currently enrolled and coverage amount.

– Current benefit amounts may need to be reviewed for eligibility to be carried forward to this plan.

Prepared for:

Gloucester County Public Schools

Plan 1- 4051440; 14

Attained Age Monthly Premium - Premier - Plan 1

Employee

Blended

18-29 30-39 40-49 50-59 60-69 70+

$10,000 $4.20 $5.90 $11.20 $22.30 $40.50 $101.70

$20,000 $8.40 $11.80 $22.40 $44.60 $81.00 $203.40

$30,000 $12.60 $17.70 $33.60 $66.90 $121.50 $305.10

Spouse

Blended

18-29 30-39 40-49 50-59 60-69 70+

$10,000 $4.20 $5.90 $11.20 $22.30 $40.50 $101.70

$20,000 $8.40 $11.80 $22.40 $44.60 $81.00 $203.40

$30,000 $12.60 $17.70 $33.60 $66.90 $121.50 $305.10

Prepared for:

Gloucester County Public Schools

Plan 1- 4051440; 15

Annual Rate Per $1,000

Premier - Plan 1

Age Band Blended

18-29 $5.04

30-39 $7.08

40-49 $13.44

50-59 $26.76

60-69 $48.60

70+ $122.04

• To convert annual rates to deductions, multiply by units of coverage, divide by the number of deductions per year and round to the nearest penny.

Prepared for:

Gloucester County Public Schools

Plan 1- 4051440; 16

Conditions

• No competing critical illness plan will be offered on payroll deduction.

• Rates are guaranteed for 27 months.

• Proposed rate includes electronic documents. Printed certificates are available for an additional cost.

• New hires will be enrolled on a perpetual basis.

• Credit for prior service toward satisfaction of employee waiting period.

• A recent proposed Department of Treasury clarification may change the taxability of any Critical Illness benefits paid with pre-tax premium. Any impacted groups and individuals will be notified after final Department of Treasury ruling if changes are required.

Assumptions

• Proposal assumes coverage is currently inforce with another carrier.

• This proposal assumes 858 eligible lives.

• Employee age used for spouse rates.

• On the effective date of the new policy with The Standard, members who elect to enroll at that time, the rates will be based on the member's age on that effective date. For late enrollees and subsequent new members, the rates will be based upon the member's age on the date we approve the coverage. Member rates will increase over time as members age into older age bands. For members increasing coverage, the rates for the total amount of coverage will be based upon the age of the member on the date we approve the coverage.

Exclusions and Limitations

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

– War or act of war.

– Attempted suicide or other intentionally self-inflicted Injury, while sane or insane.

– Committing or attempting to commit an assault, felony, act of terrorism, or actively participating in a violent disorder or riot.

– The voluntary use or consumption of any poison, chemical compound, drug, or alcohol in excess of the legal limit in the state in which the critical illness occurred, unless used or consumed according to the directions of a Physician.

– Elective surgery or other procedure which: (a) Does not promote the proper function of the body or prevent or treat sickness or injury (b) Is directed at improving the insured's appearance, unless such cosmetic surgery or procedure is necessary to correct a deformity resulting from a congenital abnormality or disfigurement (c) This exclusion will not apply to a critical illness caused or contributed to by donation of an organ or tissue.

• This is a limited benefit policy.

Prepared for:

Gloucester County Public Schools

Plan 1- 4051440;

Producer Compensation Disclosure

We recognize the valuable role of insurance advisors, consultants and brokers ("producers") in helping their clients design an employee benefits program, and we support reasonable and fair compensation for these services. Producers may be eligible to receive compensation from The Standard.

The commission quoted in this proposal are noted below. Additionally, fees for administrative, marketing or consulting services may apply.

If applicable, fees are noted below.

Heaped commission scale (https://www.standard.com/financial-professional/insurance-benefits/compensation) included for Accident Insurance Plan 1, Accident Insurance Plan 2, Critical Illness Insurance Plan 1, Hospital Indemnity Insurance Plan 2.

Unless participation is declined by the producer or client, contingent compensation is additional compensation that may also be paid and is dependent on the satisfaction of one or more minimum requirements, such as a specified amount of new premium volume or persistency in connection with the producer's block of business. For information about our customary producer rewards program visit https://www.standard.com/financial-professional/insurance-benefits/compensation. Some producers may have a contingent compensation arrangement that differs from our customary program. Please consult with your producer for additional details.

About This Employee Benefits Proposal

We appreciate the opportunity to provide you with this benefit and cost summary proposal from The Standard. This document outlines certain important features of the group insurance coverages available. This is not a contract or an offer to contract for such coverages.

Detailed information about other important features of the coverage proposed is available on request. Just ask your broker/consultant or your representative at The Standard.

A completed application must be submitted before a group can be considered for coverage. Insurance will be effective after the application is accepted by The Standard. If approved, we will issue a contract containing our customary language. It will not duplicate policy language from another carrier. The group contract will contain provisions and defined terms not described in this Employee Benefits Proposal. The group contract will control if there are discrepancies between it and this proposal.

This benefit and cost summary proposal expires on September 10, 2024, unless replaced or withdrawn by The Standard.

The proposed premium rate and plan design for each coverage are based on the underwriting data received by The Standard. Final premium rates and plan provisions will be determined by The Standard on the basis of: applicable state laws, policyholder contributions, confirmation of occupations, the actual composition of the group of persons who will become insured and our current underwriting rules and practices.

Financial Strength Ratings

For information about our Financial strengths ratings visit: https://www.standard.com/about-standard/company/financial-strength

The Standard is a marketing name for StanCorp Financial Group, Inc. and subsidiaries. Insurance products are offered by Standard Insurance Company of 1100 SW Sixth Avenue, Portland, Oregon in all states except New York. Product features and availability vary by state and are solely the responsibility of Standard Insurance Company.

https://www.standard.com/financial-professional/insurance-benefits/compensation https://www.standard.com/financial-professional/insurance-benefits/compensation

Fixed Administrative Costs (ASO)

GLOUCESTER COUNTY SCHOOL BOARD

Effective October 1, 2025 through September 30, 2026

Current 10/1/2025 through

9/30/2026

10/1/2026 through

9/30/2027

10/1/2027 through

9/30/2028

10/1/2028 through

9/30/2029

10/1/2029 through

9/30/2030

PCPM PCPM PCPM PCPM PCPM PCPM

Subscribers 587 587 Members 1,195 1,195

Medical and Pharmacy Administration $26.54 $11.36 $0.00 $0.00 $0.00 $0.00 Pharmacy Rebate Offset ($143.55) ($171.05) $0.00 $0.00 $0.00 $0.00

Fully Insured Vision Premium $2.04 $2.04 $0.00 $0.00 $0.00 $0.00

Composite Total: ($114.97) ($157.65) $0.00 $0.00 $0.00 $0.00 Annual fixed administrative costs based on assumed enrollment:

($809,849) ($1,110,487) $0 $0 $0 $0

Authorized Signature: _____________________________________________

Title: ____________________

Date: ____________________

Additional Fee Disclosures:

0537688-06

Fixed Administrative Costs

See Additional Service Fees and Pharmacy Pricing for disclosure of additional service fees which are not included on this cost summary.

The Pharmacy Rebate Offset reflects the National Formulary. The offset may be adjusted if a different pharmacy formulary is sold.

Stop Loss Options (ASO)

GLOUCESTER COUNTY SCHOOL BOARD

Group Number(s): L03319

Effective October 1, 2025 through September 30, 2026

Option 1 - $200,000 Specific Stop Loss with 125% Aggregate Stop Loss

Specific Stop Loss limit: $200,000 125%

Specific Stop Loss contract basis: Paid in 12 * Paid in 12

* Accumulation basis for claims will be incurred since October 1, 2021.

Lines of coverage Included: Med And Rx Med And Rx

Specific Stop Loss Maximum: Unlimited $2,000,000

Specific Stop Loss accumulation: Per Member

Commissions: 0.00% 0.00%

Renewal rate guarantee 60.00%

Claims Run Out Coverage Included: Yes

Annual

This Stop Loss offer is: FIRM Minimum Aggregate Stop Loss limit: $9,941,545

This Stop Loss offer expires: 6/28/2025 Estimated Policy Period Claims Maximum: $13,255,393

Specific Stop Loss Premiums Composite

PCPM

Annualized

Total

Current $238.17 $1,677,669

Renewal $271.51 $1,912,516

Rate Change 14.00%

Aggregate Stop Loss Premiums Composite

PCPM

Annualized

Total

Current $13.47 $94,883

Renewal $14.82 $104,364

Rate Change 9.99%

Admin Annualized Total -$1,110,487

Fixed Costs Annualized Total $906,393

Monthly Aggregate Factors Employee Employee +

Spouse

Employee +

Child

Employee +

Children

Employee +

Family

Annualized

Total

166 39 27 49 60

Current $1,217.36 $2,989.11 $1,868.24 $1,868.24 $3,487.31 $8,038,583

Renewal $1,205.29 $2,959.46 $1,849.70 $1,849.70 $3,452.71 $7,958,843

135 26 13 32 40

Current $1,121.24 $2,753.09 $1,720.71 $1,720.71 $3,211.95 $5,146,292

Renewal $1,153.98 $2,833.46 $1,770.95 $1,770.95 $3,305.73 $5,296,551

Current $13,184,875

Renewal $13,255,393

Rate Change 0.5%

A No New Lasers provision is included in this offer. Existing lasers will be reviewed and could be modified. See Assumptions & Conditions exhibit for more details.

Aggregate Stop Loss contract basis:

Aggregate Stop Loss percentage reimbursable:

Aggregate Stop Loss Maximum:

Lines of coverage Included:

Commissions:

Payment Limit:

Additional terms for self-funded groups

This proposal guarantees your subsequent year’s renewal will be capped at 60%.

Total

(Custom) Anthem HealthKeepers OA 25

1000/30%/5500 ($250 ded, $15/$50/$90/20% to

$200) HealthKeepers Network

Total

(Custom) Anthem HealthKeepers OA HSA

3300/0%/4000 (Med Ded, $10/$30/$50/20% to

$200, Prev Rx) HealthKeepers Network

Total