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2023-24 Metlife Benefit Guide
Company-Sponsored Benefit Plans for Health, Wellness, and Peace of Mind Morris & Garritano BENEFITENROLLMENTGUIDE City of Morro Bay 2023 - 2024 Benefit Plan Year Employee 855-662-1029 | AdvocateServices@MorrisGarritano.com | License #0305584 Enrollment Guide We encourage eligible employees to review the plan information included in this enrollment guide. Please complete all highlighted areas of the enclosed enrollment forms and return them to your HR administrator. New Employees Who Can Enroll? All full-time benefit eligible employees who work a minimum of 30 hours/week, your spouse or domestic partner and children up to age 26. How Do I enroll? Pre-tax Disclaimer: If the employer has the ability to allow deductions to be paid on a pre-tax basis, employees will automatically be enrolled in this benefit. If any employee does not wish to participate in this plan, it is the employee’s responsibility to contact the plan administrator. When Will Coverage Begin? Employees are eligibile for benefits on the 1st of the month following 1 month after hire date. If You Have a Qualifying Event Qualifying events, such as marriage, divorce, birth or adoption of child, loss of coverage or a spouse’s open enrollment period, may allow you to make changes to current coverages. The coverage start date will be determined based on the type of event. If you experience a qualifying event and would like to make a change to current coverage, please notify your HR department as soon as possible to avoid delays or a lapse in coverage. Open Enrollment Guide All full-time benefit eligible employees who work a minimum of 30 hours/week, your spouse or domestic partner and children up to age 26. How Do I enroll? We encourage eligible employees to review the plan information included in this enrollment guide. Please complete all highlighted areas of the enclosed enrollment forms and return them to your HR administrator. When Will Coverage Begin? Enrollment Guide Please return enrollment forms to your HR Administrator by 11/15/2022 Who Can Enroll? Qualifying events, such as marriage, divorce, birth or adoption of child, loss of coverage or a spouse’s open enrollment period, may allow you to make changes to current coverages. The coverage start date will be determined based on the type of event. If you experience a qualifying event and would like to make a change to current coverage, please notify your HR department as soon as possible to avoid delays or a lapse in coverage. Employees may elect to change plans, add or cancel coverage for themselves and/or their eligible dependents. Changes will be effective 1/1/2023. If You Have a Qualifying Event Your Benefit Resources Benefits It's important to choose a health plan that best fits the needs of you and your family. Please carefully review the available plans prior to making your elections. Benefit Highlights Benefits PPO OON $25/$75 $25/$75 $2,500 $2,500 100%100% 90%90% 60%60% Negotiated Fee 90th % UCR Benefits MetLife Dental Plan MetLife Vision Plan Provider Network Deductible (Waived for Preventive) Annual Maximum Per Person Preventive (exams, cleanings, x-rays) Basic (fillings, oral surgery, endo, perio) Major (crowns, dentures, bridges, implants) Orthodontia (Child) Claim Payment Basis VSP Choice $0 Exams / $0 Eyewear One every 12 months One every 12 months This information is for comparative purposes only, and should not be used as a description of benefits. Please refer to your plan's Explanation of Benefits for full details of coverage. 50% up to $1,000 lifetime max One every 24 months (up to $130) In lieu of frames & lenses (up to $130) Provider Network Copays Exam Lenses Frames Contacts Pretreatment Estimate: Submission of a dental treatment plan to the insurance company PRIOR to the onset of non-emergency dental work is highly recommended. The carrier will provide both member and provider with a report of covered benefits and costs. Benefit Highlights Paid for by employer Benefits Benefit Amount Age Reduction MetLife Voluntary Life Benefits Benefits Employee Spouse Maximum Benefit 5x Annual Salary or $500,000 $100,000 Minimum Benefit $10,000 $5,000 Guarantee Issue $100,000 $25,000 Purchase in increments of $10,000 $5,000 Child Coverage (Age 6+ Mo) Age Reduction Spouse Rate based upon This information is for comparative purposes only, and should not be used as a description of benefits. Please refer to your plan's Explanation of Benefits for full details of coverage. $50,000 35% at age 65, additional 15% at age 70 MetLife Life/AD&D Benefits Voluntary Life/AD&D coverage is available in variable amounts for you and your dependents. Please see enrollment materials in this enrollment guide for rates and benefit information. Employees electing to add or increase coverage for themselves or dependents at open enrollment will require medical underwriting. You and/or your dependent will need to complete a health statement and submit to MetLife for review. Coverage and premiums will begin first of the month following the date approved by MetLife. 35% at age 65, additional 15% at age 70 Employee's Age Option of $1,000, $2,000, $4,000, $5,000 or $10,000 Benefit Benefit Highlights Paid for by employer Benefits This information is for comparative purposes only, and should not be used as a description of benefits. Please refer to your plan's Explanation of Benefits for full details of coverage. The Holman Group Employee Assistance Program Enhanced program to support emotional well-being and work-life balance. 24/7 telephone accessibility for consultation and referrals Up to 3 Face-to-face counseling sessions per issue and online video counseling Work-Life services, including child and elder care resources Unlimited access to the EAP website for tools, information and resources One 30 minute legal consultation per issue per benefit year Telephone financial consultations and Identity Monitoring Your Benefit Resources Your Benefit Resources You have all the information, now what do you do with it? These tools and resources are provided so you can make the most informed benefit selections for yourself and your family. Benefit Resources CARRIER NAME PHONE MEMBER WEBSITE Dental, Vision, Basic Life, Voluntary Life MetLife 800-438-6388 www.metlife.com Employee Assistance Program The Holman Group 800-321-2843 www.holmangroup.com Mental Health Resources & More Telemedicine 3) Email or Call an M & G Advocate *Are you reading a printed guide? Please visit the Benefit Resource Library to access links (URL in Medical Plan Resources) MEDICAL PLAN RESOURCES Benefit Resource Library: Plan Notices & Summary of Benefits & Coverages (SBCs) AdvocateServices@morrisgarritano.com An easy, convenient way to see telehealth and mental health providers 24/7 from the comfort of your home Employee Assistance Program (EAP): Website resources, telephone support, and 3 face-to-face sessions 855-662-1029 Information concerning your rights and responsibilities in regard to ERISA, COBRA, FMLA, HIPAA, and PPACA. Mental health resources and more: online, telephone, and face-to- face sessions available What can you do online with your carrier ICON One-click access to benefit info, virtual ID card, find care, check costs, see claims, and set up alerts Register for your member portal for full access to plan information, claims, and search for providersNon-Medical Carrier Websites Mobile Apps Benefit Resources www.morrisgarritano.com/employee-benefits-insurance/video-library/ Morris & Garritano's Advocate Services Team is available to assist you with: • Resolving Medicare service & claim issues • Understanding pertinent rules and rights such as qualifying events, COBRA, HSA limits • Resolving issues such as accessing services/in network providers in a timely manner Benefit plan notices can also be found at the Employee Benefits Resource Center. Notices include information concerning your rights and responsibilities in regard to ERISA, COBRA, FMLA, HIPAA, and PPACA. Employee Advocate Services 855-662-1029 | AdvocateServices@MorrisGarritano.com | Fax 805-543-3064 • Understanding the benefits and costs of plans • Understanding Medicare eligibility/plan options • Enrolling in Medicare plans • Resolving claim issues • Video Library Helpful Definitions Helpful Definitions It’s hard to make a decision when you don’t know the language. These definitions will help explain the key elements that make up your benefits program. Helpful Definitions Dental Annual Maximum The maximum amount the dental insurance plan will pay out towards your claims in the calendar year of your policy. Elective Contacts Co-Insurance Your percentage share of cost for a covered dental service, after the deductible has been met. UCR (Usual, Customary, Reasonable) If your plan covers the 90th% UCR charge, that means out of network claim are paid based on what 9 out of every 10 dentists in your local area charge. You are responsible for any balance above that amount. Vision Contacts for members who can elect to wear glasses or contacts. Non-Elective Contacts Contacts for members whose vision cannot be corrected with glasses. Standard vs Progressive Lenses Standard lenses have a line separating the different vision corrections (e.g. bi-focal or tri-focal). Progressive lenses include different vision corrections without the visible line. Helpful Definitions Pays a benefit to your beneficiary if your death is caused by an accident. You may also get a part of the benefit if an accident results in loss of sight, limb, etc. Conversion Ability to change your group life coverage to an individual policy after your employement ends. Age Reduction Benefit amount may reduce starting at age 65. Please see plan summary for details. Accidental Death & Dismemberment Basic Term Life Beneficiary The person who is eligible to receive the death benefit payment. Morris & Garritano Insurance Key Person, Buy-Sell & Individual Life Morris & Garritano 805-543-6887 Fax 805-543-3064 www.morrisgarritano.com | License #0305584 Home | Auto | Renters | Collections More than just your benefits... Medicare Are you turning 65 soon? Employees enrolled in employer-sponsored plans have options. You can enroll into Medicare or stay with your group plan - let us help you navigate which choice is best for you. Part A, B, & D Education | Plan Comparison | Enrollment Support Providing custom strategies and solutions for wealth preservation, business stability, and personal asset protection. Life | Disability Income | Long Term Care Personal Insurance Possessing the resources & experience to assist you and your family in managing your risk and planning for your future. Additional Materials Additional Materials Your carriers provide an array of valuable tools, resources, and added care options. Be sure to check out how they can support your wellness and overall health. DN-GCERT-GOLD GCERT ER Dental Benefit Summary 200 Park Ave., New York, NY 10166 © 2021 MetLife Services and Solutions, LLC L0720006170[exp1221][xNM] Dental Metropolitan Life Insurance Company Plan Design for: City of Morro Bay Date Prepared: October 21, 2021 The Preferred Dentist Program was designed to help you get the dental care you need and help lower your costs. You get benefi ts for a wide range of covered services — both in and out of the network. The goal is to deliver affordable protection for a health ier smile and a healthier you. Coverage Type: In -Network1 % of PDP Fee2 Out-of-Network1 % of R&C Fee4 Type A - Preventive 100% 100% Type B - Basic Restorative 90% 90% Type C - Major Restorative 60% 60% Type D - Orthodontia 50% 50% Deductible3 Individual $25 $25 Family $75 $75 Annual Maximum Benefit: Per Individual $2500 $2500 Orthodontia Lifetime Maximum - Ortho applies to Child Only Child to age 19 $1000 per Person $1000 per Person 1. "In -Network Benefits" refers to benefits provided under this plan for covered dental services that are provided by a participating dentist. "Out-of-Network Benefits" refers to benefits provided under this plan for covered dental services that are not provi ded by a participating dentist. 2. Negotiated fees refer to the fees that participating dentists have agreed to accept as payment in full for covered services, subject to any copayments, deductibles, cost sharing and benefits maximums. Negotiated fees are subject to change. 3. Applies to Type B and C services only. 4. Out-of-network benefits are payable for services rendered by a dentist who is not a participating provider. The Reasonable and Customary charge is based on the lowest of: • the dentist’s actual charge (the 'Actual Charge'), • the dentist’s usual charge for the same or similar services (the 'Usual Charge') or • the usual charge of most dentists in the same geographic area for the same or similar services as determined by MetLife (the 'Customary Charge'). For your plan, the Customary Charge is based on the 90th percentile. Services must be necessary in terms of generally accepted dental standards. DN-GCERT-GOLD GCERT ER Dental Benefit Summary 200 Park Ave., New York, NY 10166 © 2021 MetLife Services and Solutions, LLC L0720006170[exp1221][xNM] Selected Covered Services and Frequency Limitations* Type A - Preventive How Many/How Often: Oral Examinations 2 in a year Full Mouth X-rays 1 in 3 years Bitewing X-rays (Adult/Child) 1 in 12 months Prophylaxis - Cleanings 2 in a year Topical Fluoride Applications 1 in a year - Children to age 18 Sealants 1 in 60 months - Children to age 16 Space Maintainers 1 per lifetime per tooth area - Children up to age 16 Type B - Basic Restorative How Many/How Often: Amalgam and Composite Fillings 1 in 24 months. All teeth Repairs 1 in 12 months Endodontics Root Canal 1 per tooth per lifetime Periodontal Surgery 1 in 36 months per quadrant Periodontal Scaling & Root Planing 1 in 24 months per quadrant Periodontal Maintenance 2 in 1 year, includes 2 cleanings Oral Surgery (Simple Extractions) Oral Surgery (Surgical Extractions) Other Oral Surgery Emergency Palliative Treatment General Anesthesia Consultations 1 in 12 months Type C - Major Restorative How Many/How Often: Crowns/Inlays/Onlays 1 per tooth in 5 years Prefabricated Crowns 1 per tooth in 5 years Bridges 1 in 5 years Dentures 1 in 5 years Implant Services 1 service per tooth in 5 years - 1 repair per 5 years Type D – Orthodontia • Dependent children up to age 19. Age limitations may vary by state. Please see your Plan description for complete details. In the event of a conflict with this summary, the terms of the certificate will govern. • All dental procedures performed in connection with orthodontic treatment are payable as Orthodontia. • Benefits for the initial placement will not exceed 20% of the Lifetime Maximum Benefit Amount for Orthodontia. Periodic follow -up visits will be payable on a monthly basis during the scheduled course of the orthodontic treatment. Allowable expenses for the initi al placement, periodic follow-up visits and procedures performed in connection with the orthodontic treatment, are all subject to the Orthodontia coinsurance level and Lifetime Maximum Benefit Amount as defined in the Plan Summary. • Orthodontic benefits end at cancellation of coverage *Alternate Benefits: Where two or more professionally acceptable dental treatments for a dental condition exist, reimbursement is based on the least costly treatment alternative. If you and your dentist have agreed on a treatment that is more costly than the treatment upon which the plan benefit is based, you will be responsible for any additional payment responsibility. To avoid any misunderstandings, we sugg est you discuss treatment options with your dentist before services are rendered, and obtain a pretreatment estimate of benefits prior to receiving certain high cost services such as crowns, bridges or dentures. You and your dentist will each receive an Explanation of Benefits (EOB) ou tlining the services provided, your plan’s reimbursement for those services, and your out -of-pocket expense. Actual payments may vary from the pretreatment estimate depending upon annual maximums, plan frequency limits, deductibles and other limits applicable at time of payment. The service categories and plan limitations shown above represen t an overview of your Plan of Benefits. This document presents many services within each category, but is not a complete description of the Plan. Please see your Plan description/Insurance certificate for complete details. In the event of a conflict with this summary, the terms of your insurance certificate will govern. DN-GCERT -GOLD GCERT ER Dental Benefit Summary 200 Park Ave., New York, NY 10166 © 2021 MetLife Services and Solutions, LLC L0720006170[exp1221][xNM] We will not pay Dental Insurance benefits for charges incurred for: 1. Services which are not Dentally Necessary, those which do not meet generally accepted standards of care for treating the particular dental conditi on, or which We deem experimental in nature; 2. Services for which You would not be required to pay in the absence of Dental Insurance; 3. Services or supplies received by You or Your Dependent before the Dental Insurance starts for that person; 4. Services which are primarily cosmetic (For residents of Texas, see notice page section in your certificate). 5. Services which are neither performed nor prescribed by a Dentist except for those services of a licensed dental hygienist which are supervised and billed by a Dentist and which are for: • scaling and polishing of teeth; or • fluoride treatments. For NY Sitused Groups, this exclusion does not apply. 6. Services or appliances which restore or alter occlusion or vertical dimension. 7. Restoration of tooth structure damaged by attrition, abrasion or erosion. 8. Restorations or appliances used for the purpose of periodontal splinting. 9. Counseli ng or instruction about oral hygiene, plaque control, nutrition and tobacco. 10. Personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss. 11. Decoration , personalization or inscription of any tooth, device, appliance, crown or other dental work. 12. Missed appointments. 13. Services • covered under any workers’ compensation or occupational disease law; • covered under any employer liability law; • for which the employer of the person re ceiving such services is not required to pay; or • received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital. For North Carolina and Virginia Sitused Groups , this exclusion does not apply. 14. Services paid under any worker’s compensation, occupational disease or employer liability law as follows: • for persons who are covered in North Carolina for the treatment of an Occupational Injury or Sickness which are paid under the North Carolina Workers’ Compensation Act only to the extent such services are the liability of the employee, employer or workers’ compensation insurance carrier according to a final adjudication under the North Carolina Workers’ Compensation Act or an order of the North Carolina Industrial Commission approving a settlement agreement under the North Carolina Workers’ compensation Act ; • or for persons who are not covered in North Carolina, services paid or payable under any workers compensation or occupational disease law. This exclusion only applies for North Carolina Sitused Groups. 15. Services : • for which the employer of the person receiving such services is required to pay; or • received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital. This exclusion only applies for North Carolina Sitused Groups. 16. Services covered under any workers' compensation, occupational disease or employer liability law for which the employee/or Dependent received benefits under th at law. This exclusion only applies for Virginia Sitused Groups. 17. Services : • for which the employer of the person receiving such services is not required to pay; or • received at a facility maintained by the policyholder, labor union, mutual benefit association, or VA hospital. This exclusion only applies for Virginia Sitused Groups. 18. Services covered under other coverage provided by the Employer. 19. Temporary or provisional restorations. 20. Temporary or provisional appliances. 21. Prescription drugs. 22. Services for which the submitted documentation indicates a poor prognosis. 23. The following when charged by the Dentist on a separate basis: • claim form completion; • infection control such as gloves, masks, and sterilization of supplies; or • local anesthesia, non -intravenous conscious sedation or analgesia such as nitrous oxide. 24. Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing or biting of food. For NY Sitused Groups, this exclusion does not apply. 25. Caries susceptibility tests. 26. Initial installation of a fixed and permanent Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. 27. Other fixed Denture prosthetic services not described elsewhere in this certificate. 28. Precision attachments, except when the precision attachment is related to implant prosthetics. 29. Initial installation or replacement of a full or removable Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. 30. Addition of teeth to a partial removable Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. 31. Adjustment of a Denture made within 6 months after installation by the same Dentist who installed it. DN-GCERT -GOLD GCERT ER Dental Benefit Summary 200 Park Ave., New York, NY 10166 © 2021 MetLife Services and Solutions, LLC L0720006170[exp1221][xNM] 32. Implants to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. 33. Implants supported prosthetics to replace one o r more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. 34. Fixed and removable appliances for correction of harmful habits.1 35. Appliances or treatment for bruxism (grinding teeth), including but not limited to occlusal guards and night guards.1 36. Diagnosis and treatment of temporomandibular joint (TMJ) disorders. This exclusion does not apply to residents of Minnesota.1 37. Repair or replacement of an orthodontic device.1 38. Duplicate prosthetic devices or appliances. 39. Replacement of a lost or stolen appliance, Cast Restoration, or Denture. 40. Intra and extraoral photographic images. 41. Services or supplies fur nished as a result of a referral prohibited by Section 1 -302 of the Maryland Health Occupations Article. A prohibited referral is one in which a Health Care Practitioner refers You to a Health Care Entity in which the Health Care Practitioner or Health Care Practitioner’s immediate family or both own a Beneficial Interest or have a Compensation Agreement. For the purposes of this exclusion, the terms “Referral”, “Health Care Practitioner” , “Health Care Entity”, “Beneficial Interest” and Compensation Agreement have the same meaning as provided in Section 1 -301 of the Maryland Health Occupations Article. This exclusion only applies for Maryland Sitused Groups 1Some of these exclusions may not apply. Please see your Certificate of Insurance. DN-GCERT -GOLD GCERT ER Dental Benefit Summary 200 Park Ave., New York, NY 10166 © 2021 MetLife Services and Solutions, LLC L0720006170[exp1221][xNM] Common Questions … Important Answers Who is a participating dentist? A participating, or network, dentist is a general dentist or specialist who has agreed to accept negotiated fees as payment i n full for covered services provided to plan members, subject to any deductibles, copayments, cost sharing and benefit maximums. Negotiated fees typically range from 30-45% below the average fees charged in a dentist’s community for the same or substantially similar services.* In addition to the standard MetLife network, your employer may provide you with access to a select network of dental providers that may be unique to your employer’s dental program. When visiting these providers, you may receive a better benefit, have lower out-of-pocket costs and/or have access to care at facilities at your works ite. Please sign into MyBenefits for more details. * Based on internal analysis by MetLife. Negotiated fees refer to the fees that participating dentists have agreed to accept as payment in full for covered services, subject to any copayments, deductibles, cost sharing and benefits maximums. Negotiated fees are subject to change. Savings from enrolling in a dental benefits plan will depend on various factors, including the cost of the plan, how often members visit a dentist and the cost of services rendered. Negotiated fees are subject to change. How do I find a participating dentist? There are thousands of general dentists and specialists to choose from nationwide --so you are sure to find one that meets your needs. You can receive a list of these parti cipating dentists online at www.metlife.com/dental or call 1 -800-275-4638 to have a list faxed or mailed to you. What services are covered by my plan? Please see your Certificate of Insurance for a list of covered services. May I choose a non-participating dentist? Yes. You are always free to select the dentist of your choice. However, if you choose a non -participating (out-of-network) dentist, your out-of-pocket costs may be greater than your out-of-pocket costs when visiting an in -network dentist. Can my dentist apply for participation in the network? Yes. If your current dentist does not participate in the network and you would like to encourage him or her to apply, ask your dentist to visit www.metdental.com, or call 1-866-PDP-NTWK for an application.* The website and phone number are for use by dental professionals only. * Due to contractual requirements, MetLife is prevented from soliciting certai n providers. How are claims processed? Dentists may submit your claims for you which means you have little or no paperwork. You can track your claims online and eve n receive email alerts when a claim has been processed. If you need a claim form, visit www.metlife.com/dental or request one by calling 1-800-275-4638. Can I get an estimate of what my out-of-pocket expenses will be before receiving a service? Yes. You can ask for a pretreatment estimate. Your general dentist or specialist usually sends MetLife a plan for your care a nd requests an estimate of benefits. The estimate helps you prepare for the cost of dental services. We recommend that you request a pre-treatment estimate for services in excess of $300. Simply have your dentist submit a request online at www.metdental.com or call 1-877-MET-DDS9. You and your dentist will receive a benefit estimate for most procedures while you are still in the office. Actual payments may vary depending upon plan maximums, deductibles, frequency limits and other conditions at time of payment. Can MetLife help me find a dentist outside of the U.S. if I am traveling? Yes. Through international dental travel assistance services* you can obtain a referral to a local dentist by calling +1 -312-356-5970 (collect) when outside the U.S. to receive immediate care u ntil you can see your dentist. Coverage will be considered under your out-of-network benefits.** Please remember to hold on to all receipts to submit a dental claim. *International Dental Travel Assistance services are administered by AXA Assistance USA, Inc. (AXA Assistance). AXA Assistance provides dental referral services only. AXA Assistance is not affiliated with MetLife and any of its affiliates, and the services they provide are separate and apart from the benefits provided by MetLife. Referral ser vices are not available in all locations. ** Refer to your Certificate of Insurance for your out-of-network dental coverage. How does MetLife coordinate benefits with other insurance plans? Coordination of benefits provisions in dental benefits plans are a set of rules that are followed when a patient is covered b y more than one dental benefits plan. These rules determine the order in which the plans will pay benefits. If the MetLife dent al benefit plan is primary, MetLife will pay the full amount of benefits that would normally be available under the plan. If the MetLife dental benefit plan is secondary, most coordination of benefits provisions require MetLife to determine benefits afte r benefits have been determined under the primary plan. The amount of benefits payable by MetLife may be reduced due to the benefits paid under the primary plan. Do I need an ID card? DN-GCERT -GOLD GCERT ER Dental Benefit Summary 200 Park Ave., New York, NY 10166 © 2021 MetLife Services and Solutions, LLC L0720006170[exp1221][xNM] No, You do not need to present an ID card to confirm that you are eligible. You should notify your dentist that you are enrolled in a MetLife Dental Plan. Your dentist can easily verify information about your coverage through a toll -free automated Computer Voice Response system. Do my dependents have to visit the same dentist that I select? No. You and your dependents each have the freedom to choose any dentist. If I do not enroll during my initial enrollment period can I still purchase Dental Insurance at a later date? Yes, employees who do not elect coverage during enrollmen t period may still elect coverage later. Dental coverage would be subject to the following waiting periods. • No waiting period on Preventive Services • 6 months on Basic Restorative (Fillings) • 12 months on all other Basic Services • 24 months on Majo r Services • 24 months on Orthodontia Services (if applicable) Like most group benefits programs, MetLife group benefits programs contain certain exclusions, waiting periods, reductions an d terms for keeping them in force. The certificate of insurance s ets forth the plan terms and provisions, including the exclusions and limitations. VI-STAND Vision Benefit Summary 200 Park Ave., New York, NY 10166 © 2021 MetLife Services and Solutions, LLC L0720006150[exp1221][All States] Vision Plan Summary Metropolitan Life Insurance Company With your Vision Preferred Provider Organization Plan, you can: •Go to any licensed vision specialist and receive coverage. Just remember your benefit dollars go further when you stay in network. •Choose from a large network of ophthalmologists, optometrists and opticians, from private practices to retailers like Costc o ® Optical, Walmart, Sam’s Club and Visionworks. In-network value added features: Additional lens enhancements: In addition to standard lens enhancements, enjoy an average 20-25% savings on all other lens enhancements.1 Savings on glasses and sunglasses: Get 20% savings on additional pairs of prescription glasses and non - prescription s unglasses, including lens enhancements. At times, other promotional offers may also be available.1 Laser vision correction: 2 Savings averaging 15% off the regular price or 5% off a promotional offer for laser surgery including PRK, LASIK and Custom LASIK. This offer is only available at MetLife participating locations. In-network benefits There are no claims for you to file when you go to a participating vision specialist. Simply pay your copay and, if applicable, any amount over your allowance at the t ime of service. Frequency Eye exam Once every 12 months • Eye health exam, dilation, prescription and refraction for glasses: Covered in full. • Retinal imaging: Up to a $39 copay on routine retinal screening when performed by a private practice provider . Frame Once every 24 months • Allowance: $130 after $0 eyewear copay. • Costco, Walmart and Sam’s Club: $70 allowance after $0 eyewear copay. You will receive an additional 20% savings on the amount that you pay over your allowance. This offer is available from all participating locations except Costco , Walmart and Sam’s Club. Standard corrective lenses Once every 12 months • Single vision, lined bifocal, lined trifocal, lenticular: Covered in full after $0 eyewear copay. Standard lens enhancements 1 Once every 12 months • Polycarbonate (child up to age 18) and Ultraviolet (UV) coating: Covered in full.. • Progressive Standard, Progressive Premium/Custom, Polycarbonate (adult), Photochromic, Anti -reflective, Scratch -resistant coatings and Tints: Your cost will be limited to a copay that MetLife has negotiated for you. These copays can be viewed after enrollm ent at www.metlife.com/mybenefits . Contact lenses instead of eye glasses Once every 12 months • Contact fitting and evaluation: Covered in full with a maximum copay of $60. • Elective lenses: $130 allowance. • Necessary lenses: Covered in full after eyewear copay. We’re here to help Find a Vision provider at www.metlife.com/vision Download a claim form at www.metlife.com/mybenefits For general questions go to www.metlife.com/mybenefits or call 1-855-MET-EYE1 (1-855-638-3931) VI-STAND Vision Benefit Summary 200 Park Ave., New York, NY 10166 © 2021 MetLife Services and Solutions, LLC L0720006150[exp1221][All States] Out-of-network reimbursement You pay for services and then submit a claim for reimbursement. The same benefit frequencies for In -network benefits apply. Once you enroll, visit www.metlife.com/mybenefits for detailed out-of-network benefits information. • Eye exam: up to $45 • Single vision lenses: up to $30 • Progressive lenses: up to $50 • Frames: up to $70 • Lined bifocal lenses: up to $50 • Contact lenses: • Lined trifocal lenses: up to $65 • Elective up to $105 • Lenticular lenses: up to $100 • Necessary up to $210 VI-STAND Vision Benefit Summary 200 Park Ave., New York, NY 10166 © 2021 MetLife Services and Solutions, LLC L0720006150[exp1221][All States] Exclusions and Limitations of Benefits This plan does not cover the following services, materials and treatments: Services and Eyewear • Services and/or materials not specifically included in the Vision Plan Benefits Overview (Schedule of Benefits). • Any portion of a charge above the Maximum Benefit Allowance or reimbursement indicated in the Schedule of Benefits. • Any eye examination or corrective eyewear required as a condition of employment. • Services and supplies received by you or your Dependent before the Vision Insurance starts. • Missed appointments. • Services or materials resulting from or in the course of a Covered Person ’s regular occupation for pay or profit for which the Covered Person is entitled to benefits under any Workers’ Compensation Law, Employer’s Liability Law or similar law. You must promptly claim and notify the Company of all such benefits. • Local, state and/or federal taxes, except where MetLife is required by law to pay. • Services or materials received as a result of disease, defect, or injury due to war or an act of war (declared or undeclared), taking part in a riot or insurrection, or committing or attempting to commit a felony. • Services and materials obtained while outside the United Sta tes, except for emergency vision care. • Services, procedures, or materials for which a charge would not have been made in the absence of insurance. • Services: (a) for which the employer of the person receiving such services is not required to pay; or (b) received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital. • Services, to the extent such services, or benefits for such services, are available under a Government Plan. This exclusion will apply whether or not the person receiving the services is enrolled for the Government Plan. We will not exclude payment of benefits for such services if the Government Plan requires that Vision Insurance under the Group Policy be paid first. Government Plan means any p lan, program, or coverage which is established under the laws or regulations of any government. The term does not include any plan, program, or coverage provided by a government as an employer or Medicare. • Plano lenses (lenses with refractive correction of less than ± .50 diopter). • Two pairs of glasses instead of bifocals. • Replacement of lenses, frames and/or contact lenses, furnished under this Plan which are lost, stolen, or damaged, except at the normal intervals when Plan Benefits are otherwise available. • Contact lens insurance policies and service agreements. • Refitting of contact lenses after the initial (90 day) fitting period. • Contact lens modification, polishing, and cleaning. Treatments • Orthoptics or vision training and any associated supplemental testing. • Medical and surgical treatment of the eye(s). Medications • Prescription and non -prescription medication 1 All lens enhancements are available at participating private practices. Maximum copays and pricing are subject to change without notice. Please check with your provider for details and copays applicable to your lens choice. Please contact your local Costco, Walmart and Sam’s Club to confirm availability of lens enhancements and pricing prior to receiving services. Additional discounts may not be available in certain states. 2 Custom LASIK coverage only available using wavefront technology with the microkeratome surgical device. Other LASIK procedures may be performed at an additional cost to the member. Additional savings on laser vision care is only available at participating locations. Important: If you or your family members are covered by more than one health care plan, you may not be able to collect benefits from both plans. Each plan may require you to follow its rules or use specific doctors and hospitals, and it may be impossible to comply with both plans at the same time. Before you enroll in this plan, read all of the rules very carefully and compare them with the rules of any other plan that covers you or your family. M130D MetLife Vision benefits are underwritten b y Metropolitan Life Insurance Company, New York, NY. Certain claims and network administration services are provided through Vision Service Plan (VSP), Rancho Cordova, CA. VSP is not affiliated with Metropolitan Life Insurance Company or its affiliates. Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, reductions, limitations, waiting periods, and terms for keeping them in force. Please contact MetLife or your plan administrator for costs and complete details. LI-GCERT-BASIC GCERT Life Benefit Summary 200 Park Ave., New York, NY 10166 © 2021 MetLife Services and Solutions, LLC L0520004455[exp0622][All States] Basic Term Life / AD&D Metropolitan Life Insurance Company Plan Design for: City of Morro Bay Date Prepared: October 21, 2021 For All Active Full-Time Employees Excluding Managers, Directors, Superintendants, Fire Chief, Tehcnicians, Analysts, Policy Chief, Senior Planner - All Active Full-Time Managers, Directors, Superintendants, Fire Chief, Tehcnicians, Analysts, Policy Chief, Senior Planner working at least 36 hours per week Basic Life $50,000 Accidental Death & Dismemberment An amount equal to Your Basic Life Insurance. Plan Maximum $50,000 Non-Medical Maximum $50,000 Age Reduction Formula (reduces by) Reduces by 35% at age 65, and to 50% of the original amount at age 70 Employee Contribution • Basic Life • AD&D 0% 0% Term Life Features (1): • Continuation of Life insurance while totally disabled as defined by the Group Policy (2) • Accelerated Benefits Option (3) • Life Settlement Account (4) • Grief Counseling (5) • Funeral Discounts and Planning Services (6) Additional Features: • WillsCenter.com (7) AD&D Features (1): • Seat Belt Benefit (8) • Air Bag Benefit • Child Care Benefit • Common Carrier Benefit • Life Settlement Account (4) LI-GCERT-BASIC GCERT Life Benefit Summary 200 Park Ave., New York, NY 10166 © 2021 MetLife Services and Solutions, LLC L0520004455[exp0622][All States] What Is Not Covered? Like most insurance plans, this plan has exclusions. In addition, a reduction schedule may apply. Please see your benefits administrator or certificate for specific details. Accidental Death & Dismemberment insurance does not include payment for any loss which is caused by or contributed to by: physical or mental illness, diagnosis of or treatment of the illness; an infection, unless caused by an external wound accidentally sustained; suicide or attempted suicide; injuring oneself on purpose; the voluntar y intake or use by any means of any drug, medication or sedative, unless taken as prescribed by a doctor or an over -the-counter drug taken as directed; voluntary intake of alcohol in combination with any drug, medication or sedative; war, whether declared or undeclared, or act of war, insurrection, rebellion or riot; committing or trying to commit a felony; any poison, fumes or gas , voluntarily taken, administered or absorbed; service in the armed forces of any country or international authority, except the United States National Guard; operating, learning to operate, or serving as a member of a crew of an aircraft; while in any aircraft for the purpose of descent from such aircraft while in flight (except for self preservation); or operating a veh icle or device while intoxicated as defined by the laws of the jurisdiction in which the accident occurs. Life and AD&D coverages are provided under a group insurance policy (Policy Form GPNP99 or G2130 -S) issued to your employer by MetLife. Life and AD&D coverages under your employer’s plan terminates when your employment ceases when your Life and AD&D contributions cease, or upon termination of the group insurance policy. Should your life insurance coverage terminate for reasons other than non-payment of premium, you may convert it to a MetLife individual permanent policy without providing medical evidence of insurability. This summary provides an overview of your plan’s benefits. These benefits are subject to the terms and conditions of the contract between MetLife and your employer. Specific details regarding these provisions can be found in the certificate. If you have additional questions regarding the Life Insurance program underwritten by MetLife, please contact your benefits administrator or MetLife. Like most group life insurance policies, MetLife group policies contain exclusions, limitations, terms and conditions for keeping them in force. Please see your certificate for complete details. (1) Features may vary depending on jurisdiction. (2) Total disability or totally disabled means your inability to do your job and any other job for which you may be fit by educat ion, training or experience, due to injury or sickness. Please note that this benefit is only available after you have participate d in the Basic/Supplemental Term Life Plan for 1 year and it is only available to the employee. (3) When life expectancy is certified by a physician to be 12 months or less. The Accelerated Benefits Option (ABO) is su bject to state availability and regulation. The ABO benefits are intended to qualify for favorable federal tax treatment in which case the benefits will not be subject to federal taxation. This information was written as a supplement to the marketing of l ife insurance products. Tax laws relating to accelerated benefits are complex and limitations may apply. You are advised to consult with and rely on an indepe ndent tax advisor about your own particular circumstances. Receipt of ABO benefits may affect yo ur eligibility, or that of your spouse or your family, for public assistance programs such as medical assistance (Medicaid), Temporary Assistance to Needy Families (TANF), Supplementary Social Security Income (SSI) and drug assistance programs. You are adv ised to consult with social service agencies concerning the effect that receipt of ABO benefits will have on public assistance eligibility for you, your spouse o r your family. This is a life insurance benefit that also gives you the option to accelerate so me or all of the death benefit in the event you meet the criteria for a qualifying event described in the policy. This policy or certificate does not provide long -term care insurance subject to California long-term care insurance law. This policy or certificate is not a California Partnership for Long-Term Care program policy. This policy or certificate is not a Medicare supplement (policy or certificate). (4) Subject to state law, and/or group policyholder direction, the Total Control Account is provided for all Life and AD&D benefits of $5,000 or more. The TCA is not insured by the Federal Deposit Insurance Corporation or any government agency. The assets backing TCA are maintained in MetLife’s general account and ar e subject to MetLife’s creditors. MetLife bears the investment risk of the assets backing the TCA, and expects to earn income sufficient to pay interest to TCA Accountholders and to provide a prof it on the operation of the TCAs. Guarantees are subject to t he financial strength and claims paying ability of MetLife. (5) Grief Counseling services are provided through an agreement with LifeWorks US Inc. LifeWorks is not an affiliate of MetLif e, and the services LifeWorks provides are separate and apart from the insurance provided by MetLife. LifeWorks has a nationwide network of over 30,000 counselors. Counselors have masters or doctoral degrees and are licensed professionals. The Grief Counseling program does not provide support for issues such as: domestic issues, parenting issues, or marital/relationship issues (other than a finalized divorce). For such issues, members should inquire with their human resources department about available company resources. This program is available to insureds, their dependents and beneficiaries who have received a serious medical diagnosis or suffered a loss. Events that may result in a loss are not covered under this program unless and until such loss has occurr ed. Services are not avail able in all jurisdictions and are subject to regulatory approval. Not available on all policy forms. (6) Services and discounts are provided through a member of the Dignity Memorial® Network, a brand name used to id entify a network of licensed funeral, cremation and cemetery providers that are affiliates of Service Corporation International (toget her with its affiliates, “SCI”), 1929 Allen Parkway, Houston, Texas. The online planning site is provided by SCI Shared Re sources, LLC. SCI is LI-GCERT-BASIC GCERT Life Benefit Summary 200 Park Ave., New York, NY 10166 © 2021 MetLife Services and Solutions, LLC L0520004455[exp0622][All States] not affiliated with MetLife, and the services provided by Dignity Memorial members are separate and apart from the insurance provided by MetLife. Not available in some states. Planning services, expert assistance, and bereavement trave l services are available to anyone regardless of affiliation with MetLife. Discounts through Dignity Memorial’s network of funeral provider s are pre- negotiated. Not available where prohibited by law. If the group policy is issued in an approved state, th e discount is available for services held in any state except KY and NY, or where there is no Dignity Memorial presence (AK, MT, ND, SD, and WY). For MI and TN, the discount is available for “At Need” services only. Not approved in AK, FL, KY, MT, ND, NY and WA. (7) WillsCenter.com is a document service provided by SmartLegalForms, Inc., an affiliate of Epoq Group, Ltd. SmartLegalForms, Inc. is not affiliated with MetLife and the WillsCenter.com service is separate a nd apart from any insurance or service provided by MetLife. The WillsCenter.com service does not provide access to an attorney, does not provide legal advice, and may not be su itable for your specific needs. Please consult with your financial, legal, and t ax advisors for advice with respect to such matters. (8) The Seat Belt Benefit is payable if an insured person dies as a result of injuries sustained in an accident while driving or riding in a private passenger car and wearing a properly fastened seat belt _or a child restraint if the insured is a child_. In su ch case, his or her benefit can be increased by 10 percent of the Full Amount — but not less than $1,000 or more than $25,000. LI-GCERT-SUPP-OVER EOL Benefit Summary 200 Park Ave., New York, NY 10166 © 2021 MetLife Services and Solutions, LLC L0320002511[exp0422][All States] Supplemental Term Life Metropolitan Life Insurance Company Plan Design for: City of Morro Bay Date Prepared: October 21, 2021 For All Active Full-Time Employees Excluding Managers, Directors, Superintendants, Fire Chief, Tehcnicians, Analysts, Policy Chief, Senior Planner - All Active Full-Time Managers, Directors, Superintendants, Fire Chief, Tehcnicians, Analysts, Policy Chief, Senior Planner working at least 36 hours per week Build Your Benefit With MetLife's Supplemental Term Life insurance, your employer gives you the opportunity to buy valuable life insurance coverage for yourself, your spouse and your dependent children -- all at affordable group rates. Employee Spouse & Child Spouse1 Child Life Coverage: provides a benefit in the event of death Schedules: Increments of $10,000 Increments of $5,000 Flat Amount: $1,000, $2,000, $4,000, $5,000, or $10,000 Non Medical Maximum $100,000 $25,000 $10,000 Overall Benefit Maximum The lesser of 5 times Your Basic Annual Earnings, or $500,000 $100,000 $10,000 AD&D Coverage: provides a benefit in the event of death or dismemberment resulting from a covered accident Schedules: Yes (benefit amount is same as Supplemental Term Life coverage) Yes (benefit amount is same as Supplemental Term Life coverage) Yes (benefit amount is same as Supplemental Term Life coverage) AD&D Maximum Maximum amount is same as Supplemental Term Life coverage Maximum amount is same as Supplemental Term Life coverage Maximum amount is same as Supplemental Term Life coverage Employee Contribution 100% 100% 100% Any purchase or increase in benefits, which does not take place within 31 days of employee’s or dependent's eligibility effec tive date is subject to evidence of insurability. Coverage is subject to the approval of MetLife. To request coverage: 1. Choose the amount of employee coverage that you want to buy. 2. Look up the premium costs for your age group for the coverage amount you are selecting on the chart below. 3. Choose the amount of coverage you want to buy for your s pouse. Again, find the premium costs on the chart below. Note: Premiums are based on your age, not your spouse’s. 4. Choose the amount of coverage you want to buy for your dependent children. The premium costs for each coverage option are shown below. 5. Fill in the enrollment form with the amounts of coverage you are selecting. (To request coverage over the non -medical maximum, please see your Human Resources representative for a medical questionnaire that you will need to complete.) Remember, you must p urchase coverage for yourself in order to purchase coverage for your spouse or children. LI-GCERT -SUPP-OVER EOL Benefit Summary 200 Park Ave., New York, NY 10166 © 2021 MetLife Services and Solutions, LLC L0320002511[exp0422][All States] Employee Age Employee & Spouse Coverage -- Monthly Premium For: Dependent Child Coverage2 Monthly Premium For: $1,000 $10,000 $20,000 $40,000 $50,000 $100,000 $1,000 $0.29 Under 30 $0.10 $1.01 $2.02 $4.04 $5.05 $10.10 30-34 $0.12 $1.25 $2.50 $5.00 $6.25 $12.50 $2,000 $0.58 35-39 $0.14 $1.37 $2.74 $5.48 $6.85 $13.70 40-44 $0.18 $1.84 $3.68 $7.36 $9.20 $18.40 $4,000 $1.16 45-49 $0.27 $2.65 $5.30 $10.60 $13.25 $26.50 50-54 $0.41 $4.09 $8.18 $16.36 $20.45 $40.90 $5,000 $1.46 55-59 $0.61 $6.13 $12.26 $24.52 $30.65 $61.30 60-64 $0.90 $8.95 $17.90 $35.80 $44.75 $89.50 $10,000 $2.91 65-69 $1.55 $15.53 $31.06 $62.12 $77.65 $155.30 70+ $2.50 $25.01 $50.02 $100.04 $125.05 $250.10 Due to rounding, your actual payroll deduction amount may vary slightly. Features available with Supplemental Life Grief Counseling3: You, your dependents, and your beneficiaries access to grief counseling sessions and funeral related concierge services to help cope with a loss – at no extra cost. Grief counseling services provide confidential and professional support during a difficult time to help address personal and funeral planning needs. At your time of need, you and your dependents have 24/7 acc ess to a work/life counselor. You simply call a dedicated 24/7 toll -free number to speak with a licensed professional experienced in helping individuals who have suffered a loss. Sessions can either take place in -person or by phone. You can have up to f ive face-to -face grief counseling sessions per event to discuss any situation you perceive as a major loss, including but not limited to death, bankruptcy, divorce, terminal illness, or losing a pet.3 In addition, you ha ve access to funeral assistance for locating funeral homes and cemetery options, obtaining funeral cost estimates and comparisons, and more. You can access these services by calling 1-1-888-319-7819 or log on to www.metlifegc.lifeworks.com (Username: metlifeassist; Password: support). Funeral Discounts and Planning Services 4: As a MetLife group life policyholder, you and your family may have access to funeral discounts, planning and support to help honor a loved one’s life - at no additional cost to you. Dignity Memorial provides you and your loved ones access to discounts of up to 10% off of funeral, cremation and cemetery services through the largest network of funeral homes and cemeteries in the United States. When using the Dignity Memorial Network you have access to convenient plann ing services - either online at www.finalwishesplanning.com, by phone (1-866-853-0954), or by paper - to help make final wishes easier to manage. You also have access to assistance from compassionate funeral planning experts to help guide you and your fami ly in making confident decisions when planning ahead as well as bereavement travel services - available 24 hours, 7 days a week, 365 days a year - to assist with time-sensitive travel arrangements to be with loved ones. Will Preparation5:Like life insurance, a carefully prepared Will is important. With a Will, you can define your most important decisions such as who will care for your children or inherit your property. By enrolling for Supplemental Term Life coverage , you will have in p erson access to MetLife Legal Plans' network of 14,000+ participating attorneys for preparing or updating a will, living will and power of attorney. When you enroll in this plan, you may take advantage of this benefit at no additional cost to you if you us e a participating plan attorney. To obtain the legal plan's toll -free number and your company's group access number, contact your employer or your plan administrator for this information. MetLife Estate Resolution Services (ERS)4 :is a valuable service of fered under the group policy. A MetLife Legal Plan attorney will consult with your beneficiaries by telephone or in person regarding the probate process for your estate. The attorney w ill also handle the probate of your estate for your executor or admin istrator.. This can help alleviate the financial and administrative burden upon your loved ones in their time of need. Portability6: If your present employment ends, you can choose to continue your current life benefits. What Is Not Covered? Like most insurance plans, this plan has exclusions. Supplemental and Dependent Life Insurance do not provide payment of benefits for death caused by suicide within the first two years (one year in North Dakota) of the effective date of the certi ficate, or payment of increased benefits for death caused by suicide within two years (one year in North Dakota or Colorado) of an increase in coverage. In addition, a reduction schedule may apply. Please see your benefits administrator or certificate for specific details. Accidental Death & Dismemberment insurance does not include payment for any loss which is caused by or contributed to by: physical or mental illness, diagnosis of or treatment of the illness; an infection, unless caused by an external wound accide ntally GEF02-1 ADM SUBMISSION INSTRUCTIONS After completion, make a copy for your records and return the original to MetLife Administration, P.O. Box 14593, Lexington, KY 40512-4593 Fax MetLife at 1-888-505-7446 Page 1 of 4 EF-ST-V441S-CA (06/16) Metropolitan Life Insurance Company, New York, NY ENROLLMENT • CHANGE FORM GROUP CUSTOMER INFORMATION (To be Completed by the Recordkeeper) Name of Group Customer/Employer Group Customer # Division Class Dept Code Date of Hire (MM/DD/YYYY) Coverage Effective Date (MM/DD/YYYY) Original COBRA Effective Date if applicable (MM/DD/YYYY) COBRA Termination Date if applicable (MM/DD/YYYY) YOUR ENROLLMENT INFORMATION (To be Completed by the Employee in blue or black ink) Name (First, Middle, Last) Social Security # – – Male Female Single Married Address (Street, City, State, Zip Code) Date of Birth (MM/DD/YYYY) Employee Retiree Job Title: Basic Annual Earnings: $ Salaried Hourly Hours Worked Per Week: New Enrollment Change in Enrollment COBRA Continuation If due to a Qualifying Event, enter date (MM/DD/YYYY) I have read my enrollment materials and I request coverage for the benefits for which I am or may become eligible. I understand the amounts of insurance I request must comply with and are limited by the plan design described in my enrollment materials . ► If you are enrolling during the initial enrollment period, you must complete this Hospitalization question for Supplemental/Optional Life, Supplemental/Optional Dependent Spouse/Domestic Partner Life and Supplemental/Optional Dependent Child Life. Have you been Hospitalized as defined below (not including well-baby delivery) in the past 90 days? Employee Yes No Spouse/Domestic Partner Yes No Child(ren) Yes No If a Proposed Insured has been Hospitalized within the last 90 days a Statement of Health must be completed for the person to whom the “yes” applies. Hospitalized means admission for inpatient care in a hospital; receipt of care in a hospice facility, intermediate care facility, or long term care facility; or receipt of the following treatment wherever performed: chemotherapy, radiation therapy, or dialysis . ► If you are enrolling after the initial enrollment period, you must complete a Statement of Health form for all amounts you ar e requesting except amounts of Voluntary Short Term Disability Benefits. Term Life and Accidental Death & Dismemberment (AD&D) Insurance Basic Life 1 and AD&D (Core) Basic Dependent Spouse/Domestic Partner 2 Life 1,3 Basic Dependent Child Life 3 Supplemental/Optional Life 1 and AD&D (Buy up) Enter amount requested $ Supplemental/Optional Dependent Spouse/Domestic Partner 2 Life 1,3 and AD&D (Buy up) Enter amount requested $ Supplemental/Optional Dependent Child Life 3 and AD&D (Buy up) Enter amount requested $ Supplemental/Optional Life 1 (Buy up) Enter amount requested $ Supplemental/Optional Dependent Spouse/Domestic Partner 2 Life 1,3 (Buy up) Enter amount requested $ Supplemental/Optional Dependent Child Life 3 (Buy up) Enter amount requested $ 1 Life Insurance may include an Accelerated Benefits Option under which a terminally ill insured can accelerate a portion of hi s or her life insurance amount. An interest and expense charge may be deducted from the accelerated payment. Receipt of accelerated benefits may affect eligibility for public assistance. This benefit may be taxable and you are advised to seek assistance from a personal tax advisor. 2 Domestic Partner includes your registered Domestic Partner if you and your Domestic Partner are registered as domestic partners, civil union partners or reciprocal beneficiaries with a government agency or office where such registration is available. It also includes your non -registered Domestic Partner if you and your Domestic Partner have either a substantial interest in the other engendered by love and affection; or a lawful and substantial economic interest in the continued life, health or bodily safety of each other, as distinguished from an interest which would aris e only by, or would be enhanced in value by, the death, disablement or injury of the other person. By enrolling such Domestic Partner for coverage and signing this enrollment form, you are attesting to such relationship. 3 Amounts will be subject to state limits, if applicable. GEF09-1a Page 2 of 4 EF-ST-V441S-CA (06/16) Metropolitan Life Insurance Company, New York, NY Disability Income Insurance Short Term Disability Benefits Voluntary Short Term Disability Benefits Enter amount requested in a multiple of $50. $ Long Term Disability Benefits Dental Insurance First select your option Dental Dental Dual Option High Option Low Option Then select your level of coverage Employee Only Employee + Spouse/Domestic Partner 1 Employee + Child(ren) Employee + Spouse/Domestic Partner 1 + Child(ren) Vision Insurance Select your level of coverage Employee Only Employee + Spouse/Domestic Partner 1 Employee + Child(ren) Employee + Spouse/Domestic Partner 1 + Child(ren) Dependent Information If you are applying for coverage for your Spouse/Domestic Partner and/or Child(ren), please provide the information requested below: Name of your Spouse/Domestic Partner (First, Middle, Last) Date of Birth (MM/DD/YYYY) Male Female Name(s) of your Child(ren) (First, Middle, Last) Date of Birth (MM/DD/YYYY) Male Female Male Female Male Female Male Female Check here if you need more lines. Provide the additional information on a separate piece of paper and return it with your enrollment form. 1 Domestic Partner includes your registered Domestic Partner if you and your Domestic Partner are registered as domestic partne rs, civil union partners or reciprocal beneficiaries with a government agency or office where such registration is available. It also includes your non -registered Domestic Partner if you and your Domestic Partner have either a substantial interest in the other engendered by love and affection; or a lawful and substantial economic interest in the continued life, health or bodily safety of each other, as distinguished from an interest which would arise on ly by, or would be enhanced in value by, the death, disablement or injury of the other person. By enrolling such Domestic Partner for coverage and signing this enrollment form, you are attesting to such relationship. GEF02-1 ADM FRAUD WARNINGS Before signing this enrollment form, please read the warning for the state where you reside and for the state where the contract under which you are applying for coverage was issued. Alabama, Arkansas, District of Columbia, Louisiana, Massachusetts, New Mexico, Ohio, Rhode Island and West Virginia : Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claima nt for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or a ward payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statem ent of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. Kansas and Oregon: Any person who knowingly presents a materially false statement in an application for insurance may be guilty of a criminal offense and may be subject to penalties under state law. Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Maine, Tennessee and Washington: It is a crime to knowingly provide false, incomplete or misleading informa tion to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. GEF09-1a Page 3 of 4 EF-ST-V441S-CA (06/16) Metropolitan Life Insurance Company, New York, NY Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. New Jersey: Any person who files an application containing any false or misleading information is subject to criminal and civil penalties. New York (only applies to Accident and Health Benefits): Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose o f misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, mak es any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Puerto Rico: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or files, assists or abets in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same l oss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be incr eased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years. Vermont: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. Virginia: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated the state law. Pennsylvania and all other states: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penaltie s. BENEFICIARY DESIGNATION FOR EMPLOYEE INSURANCE I designate the following person(s) as primary beneficiary(ies) for any amount payable upon my death for the MetLife insurance coverage applied for in this enrollment form. With such designation any previous designation of a beneficiary for such coverage is hereby revoked. I understand I have the right to change this designation at any time. I also understand that unless otherwise specified in the group insurance certificate, insurance due upon the death of a Dependent is payable to the Employee. Check if you need more space for additional beneficiaries and attach a separate page. Include all beneficiary information, and sign/date t he page. Full Name (First, Middle, Last) Social Security # Date of Birth (Mo./Day/Yr.) Relationship Share % Address (Street, City, State, Zip) Phone # Full Name (First, Middle, Last) Social Security # Date of Birth (Mo./Day/Yr.) Relationship Share % Address (Street, City, State, Zip) Phone # Full Name (First, Middle, Last) Social Security # Date of Birth (Mo./Day/Yr.) Relationship Share % Address (Street, City, State, Zip) Phone # Payment will be made in equal shares or all to the survivor unless otherwise indicated. TOTAL: 100% If all the primary beneficiary(ies) die before me, I designate as contingent beneficiary(ies): Full Name (First, Middle, Last) Social Security # Date of Birth (Mo./Day/Yr.) Relationship Share % Address (Street, City, State, Zip) Phone # Full Name (First, Middle, Last) Social Security # Date of Birth (Mo./Day/Yr.) Relationship Share % Address (Street, City, State, Zip) Phone # Payment will be made in equal shares or all to the survivor unless otherwise indicated. TOTAL: 100% GEF09-1a Page 4 of 4 EF-ST-V441S-CA (06/16) Metropolitan Life Insurance Company, New York, NY DECLARATIONS AND SIGNATURE By signing below, I acknowledge: 1. I have read this enrollment form and declare that all information I have given is true and complete to the best of my knowledge and belief. 2. I declare that I am actively at work on the date I am enrolling and, if I am enrolling for any contributory life insurance, that I was actively at work for at least 20 hours during the 7 calendar days preceding my date of enrollment. I understand that if I am not actively at work on the s cheduled effective date of insurance, such insurance will not take effect until I return to active work. 3. I understand that, on the date dependent insurance for a person is scheduled to take effect, the dependent must not be confined at home under a physician’s care, receiving or applying for disability benefits from any source, or Hospitalized. If the dependent does not meet this requirement on such date, the insurance will take effect on the date the dependent is no longer confined, receiving or applying for disability benefits from any source, or Hospitalized. 4. I understand that if I do not enroll for life or disability coverage (other than Voluntary Short Term Disability coverage) during the initial enrollment period, or if I do not enroll for the maximum amount of coverage for which I am eligible, evidence of insurability satisfactory to MetLife may be required to enrol l for or increase such coverage after the initial enrollment period has expired. Coverage will not take effect, or it will be limit ed, until notice is received that MetLife has approved the coverage or increase. I understand that if I do not enroll for Voluntary Short Term Disability coverage during the initial enrollment period, or if I do not enroll for the maximum amount of coverage for which I am eligible, coverage will be limited if I enroll for or increase such coverage after the initial enrollment period has expired. I understand that if I do not enroll for dental coverage during the initial enrollment period, a waiting period may be required before I can enroll for such coverage after the initial enrollment period has expired. I understand that if I do not enroll for vision coverage during the initial enrollment period, I cannot enroll for such coverage until the next annual enrollment period. 5. I understand that if I do not sign the payment authorization below, coverage for which contributions are required will not take effect until I have provided such authorization. 6. I affirmatively decline coverage for any benefits for which I am eligible which I do not request on this enrollment form. 7. I have read the Beneficiary Designation section provided in this enrollment form and I have made a designation if I so choose. 8. I have read the applicable Fraud Warning(s) provided in this enrollment form. Signature of Employee Print Name Date Signed (MM/DD/YYYY) PAYMENT AUTHORIZATION By signing below, I authorize my employer to deduct the required contributions from my earnings for my coverage. This authorization applies to such coverage until I rescind it in writing. Signature of Employee Print Name Date Signed (MM/DD/YYYY) Sign Here Sign Here