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Hospital Indemnity Benefits Summary

Plan Summary for : 12856000 - Total Education Solutions Hospital Indemnity Inpatient Hospital Benefits Plan 1 Plan 2 500 days lifetime maximum unless otherwise noted Hospital Confinement $500 first day, $1,000 first day, $100 day 2+, $100 day 2+, 30 incident(s) pp/pcy 30 incident(s) pp/pcy Intensive Care Unit $500 first day, $1,000 first day, $200 day 2+, $200 day 2+, 10 incident(s) pp/pcy 10 incident(s) pp/pcy Wellness Screening $50 per day, $50 per day, 1 day(s) pp/pcy 1 day(s) pp/pcy Plan is HSA Compatible Yes Yes Portability Included Included Monthly Premium Plan 1 Plan 2 Employee $8.87 $13.37 Employee + Spouse $18.32 $27.70 Employee + Child(ren) $16.92 $25.42 Family $27.59 $41.54 pp/pcy= per person, per calendar year To Calculate: Weekly=Monthly cost x 12 ÷52; Bi-Weekly =Monthly cost x 12÷26; Semi-Monthly=Monthly cost x 12 ÷24 Please refer to the Description of Benefits included in this packet for additional information on your benefits. This policy has no pregnancy elimination period. These benefits are designed to be offered to those covered under a High-Deductible Health Plan ('HDHP') without the effect of disqualifying a participant from electing an HSA. Please consult with your Benefits Advisor to assist with determination that electing this limited benefit coverage is in fact permitted coverage under the rules applicable to an HSA. Hospital Indemnity insurance policies are not a replacement for a major medical policy or other comprehensive coverage and do not satisfy the minimum essential coverage requirements of the Affordable Care Act. They are designed to provide benefits at a preselected, fixed-dollar amount. Coverage may be subject to exclusions, limitations, reductions, and termination of benefit provisions. Hospital Indemnity policies are insured by Symetra Life Insurance Company located at 777 108th Avenue NE, Suite 1200, Bellevue, WA 98004, and are not available in all U.S. states or any U.S. territory. Coverage is provided under generic policy form number SBC-00500.

Description of Benefits for : 12856000 - Total Education Solutions Hospital Indemnity Insurance Inpatient Hospital/Intensive Care Unit First Day Benefits are paid on the first day of a covered hospital stay (whether that is a regular hospital bed or ICU) of 24 hours or more. The benefit is paid one time per hospital stay, regardless of whether the insured is moved from the regular bed to ICU, or vice versa. Inpatient Hospital/Intensive Care Unit Day 2+ Benefits are paid beginning the second day of a covered stay. ICU stays are included with the hospital stay benefit. Each facility has a calendar year maximum number of days as selected, 500 days per lifetime unless otherwise noted in the policy. Please refer to your Plan Summary for details. Wellness Screening This Rider provides a benefit if an Insured incurs an expense as a result of receiving any of the screening tests described in this Rider. There is a specified calendar year maximum number of screening tests for which a benefit will be paid. Please refer to your Plan Summary for details. Included tests: Abdominal aortic aneurysm ultrasonography Blood test for lipids, including total cholesterol, LDL, HDL and triglycerides Bone density screening Bone marrow testing Breast MRI Breast ultrasound CA 15-3 blood test for breast cancer CA 125 blood test for ovarian cancer Carotid Doppler CEA blood test for colon cancer Chest X-ray Child sports physicals Colonoscopy or virtual colonoscopy CT angiography Electrocardiogram Fasting blood glucose test Flexible sigmoidoscopies Mammograms Pap smears Prostate-specific antigen (PSA) test Serum cholesterol test to determine level of HDL and LDL Stress test on a bicycle or treadmill Testicular ultrasound Thermography ThinPrep Pap Test

Portability/Extension of Coverage Allows coverage to continue following termination of employment or loss of eligibility. Review the certificate of coverage to understand the full details of this provision. If there is any conflict between this information and the policy issued, the terms of the policy will prevail. Hospital Indemnity insurance policies are not a replacement for a major medical policy or other comprehensive coverage and do not satisfy the minimum essential coverage requirements of the Affordable Care Act. They are designed to provide benefits at a preselected, fixed-dollar amount. Coverage may be subject to exclusions, limitations, reductions, and termination of benefit provisions. Hospital Indemnity policies are insured by Symetra Life Insurance Company located at 777 108th Avenue NE, Suite 1200, Bellevue, WA 98004, and are not available in all U.S. states or any U.S. territory. Coverage is provided under generic policy form number SBC-00500.

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