OFFER OF COVERAGE

Eligibility.  We offer this coverage as indicated below:

·         Full time employees (40 or more hours per week)

·         Part-time employees.  To be eligible as a part-time employee, you must work at least 30 hours per week, and you must complete 600 hours of service before you become eligible.

·         Dependent children until age 26

·         Spouse

Coverage options. We are pleased to offer the benefits listed below:

Dental. We offer dental coverage as indicated below:

Plan 274: Orthodontics (Adult and children)

Life Insurance. We offer employee life insurance in the following amounts:

·         Two and a half times (2.5) salary

*Maximum of $350,000. All principal amounts of life insurance for each eligible employee have an equal corresponding amount of accident death and dismemberment coverage.

We also offer dependent life insurance in the following amounts:

·         $2,000

·         $8,000 – Additional amount that can be selected for $4.44 per month (paid by the employee

Long Term Disability Coverage. We are pleased to offer long-term disability coverage.

Long Term Disability Elimination Period:  90 days

Coverage Effective Date. For new employees, you must complete the probationary period. For new employees, coverage will become effective the first of the month following the probationary period.

Enrollment Procedures.

We have attached some important information about our coverage. This includes:

·         Summaries of Benefits and Coverage

·         Uniform Glossary

·         Special Enrollment Rights Notice (for new hires only)

·         CHIPRA Notice

·         Women’s Health and Cancer Rights Act Notice

Additional information will be provided if you decide to enroll.

If you wish to enroll, you should submit your enrollment as instructed no later than November 15, 2024.  If you complete your enrollment by that date, your coverage will become effective on January 01, 2025.  By enrolling in the plan, you authorize us to withhold your required contributions from your paychecks while your coverage is in effect.

If you decide not to enroll at this time, you should know that you will not have another chance to enroll until January 1 of next year or upon the occurrence of a “special enrollment event” as described in the Special Enrollment Rights Notice. Please sign below to acknowledge that you have received this offer of coverage.

Employee Signature: ________________________________________

Date: __________________

Note: This Offer of Coverage describes important information about your rights to elect health insurance coverage and other benefits. Please keep a copy for your records.