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2019 Benefit Guide

Plans effective April 1, 2019 to March 31, 2020

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TABLE OF CONTENTS

Overview 3

Eligibility 4

Locate an In-Network Provider 5

How to Enroll in Benefits 6

Medical 6-7

Health Savings Account (HSA) 8

Telemedicine 11

Cigna Healthy Rewards 12

Cigna Coach 13

Dental 14

Vision 15

Disability 16

Basic and Voluntary Life and AD&D 17

Dependent Care FSA 18

Pet Insurance 19

Employee Assistance Program 20

Accident and Critical Illness 21

Premiums 22

PTO Policy 23

Creditable Coverage Disclosure Notice 24-25

Important Contacts 26

This guide is designed to provide an overview of the benefit coverages available. 4th Source reserves the right to amend or change benefit offerings at any time. This guide is not a Summary Plan Description (SPD) nor a contract or guarantee of benefits coverage. Official plan and insurance documents govern your rights and benefits, including covered benefits, exclusions and limitations. If any discrepancy exists between this guide and the official documents, the official documents will prevail.

Additional documentation related to your benefits can be obtained through Employee Navigator or the Employee Care Center.

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Pre-Tax Benefits

Our Commitment

4th Source’s benefit program is designed to provide you with appropriate health coverage and financial security. 4th Source’s benefits program for eligible full-time employees includes Medical & Prescription, Health Savings Account (HSA), Dental, Vision, Telemedicine, Employee Assistance Program (EAP), Dependent Care FSA, Life & AD&D, Voluntary Life, Disability, Critical Illness, Accident, and Pet Insurance.

Open Enrollment is the time of year you are able to select your benefits program for the upcoming plan year. Your plan

year runs from April 1, 2019 through March 31, 2020. You must complete your enrollment online through Employee

Navigator, even if you are waiving coverage. All elections must be completed by March 27, 2019. If you do not take

action to enroll, you will not be able to join or make changes to the benefits plan until the next open enrollment period

(March 2020).

ALL New Hires: Your benefits being first of the month following your date of hire. All elections must be completed

within 30 days of when you become eligible. If you do not enroll within 30 days of becoming eligible, you may not be

able to join the benefits plan until the next annual open enrollment period (every March).

Benefits Enrollment

Because your share of the cost of the plan is taken from your paycheck on a pre-tax basis, the IRS stipulates that you

may only change your elections when a family status change takes place or during open enrollment. Examples of

family status change include:

• Marriage

• Adoption

• Birth

• Death of a Spouse / Dependent

• Divorce

• Obtaining/losing Medicare/Medicaid or Child Health Insurance Program (CHIP)

• Obtaining/losing eligibility for a State Employer Plan Premium Assistance Program

• Spouse obtaining/losing other group coverage (through his/her employer)

If you would like to change your coverage due to a qualified status change, you must notify human resources within thirty (30) days of the qualifying event. Otherwise, no changes will be allowed until the next annual open enrollment. Remember, if you change your benefit elections, your cost share of the premium contributions will change. (See SPD for complete list of family status changes).

OVERVIEW

Note that the IRS does not allow premiums for Domestic Partners to be taken out on a pre-tax basis. The IRS requires Domestic Partners to establish their own HSA account, if applicable.

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Employees

You are eligible for benefits if you are classified as an active, full-time employee scheduled at least 30 hours or more per week. Benefits will begin first of the month following date of hire.

Dependents You may also elect coverage for your dependents in some circumstances. Eligible dependents may include the following:

• Your Legal Spouse or Domestic Partner

• Dependent Children of you, your Spouse or Domestic Partner:

Dependent child who is supported primarily by you, and who is incapable of self-sustaining employment by reasons of mental or physical handicap (proof of their condition and dependence must be submitted)

For Medical - Dependent children up to age 26 regardless of financial dependency, residency, student status, employment or martial status. Coverage will end the last day of the calendar year in which they turn 26.

For Dental & Vision - Dependent children to age 26. Coverage will end at the end of the calendar year in which the dependent child turns 26.

Voluntary Life - Dependent children to age 26. Coverage will end on the last day of the month in which the dependent child turns 26.

Health Savings Account - Tax Dependent as defined by the IRS.

Dependent Care FSA - Dependent children under the age of 13 or a dependent spouse or child who is physically or mentally unable to care for him or herself.

The term “child(ren)” includes:

A natural or legally adopted child; A foster child, if placed in your home with state statutes prior to their 18th birthday; A spouse’s child residing with you and dependent upon you for support; or a child whom you or your spouse have a legal obligation to support, even though not living with you.

Have Additional Questions regarding your Benefits? You can call our Employee Care Center and speak with a Benefits Specialist to help answer any additional questions you

may have related to our benefits. They can be reached at 866.784.2242 Monday through Friday from 8:30 a.m. until 5:00 p.m. Please be sure to mention that you’re an employee of 4th Source when calling.

Date of Birth and Social Security Number are required for dependents to enroll their domestic partner, spouse and/or children in the coverages provided. Make sure you have these available when enrolling through Employee Navigator.

*Employees are responsible for verifying eligibility of dependents upon enrollment and notifying Human Resources immediately when dependents no longer meet eligibility criteria. Failure to properly report loss of eligibility can result in denied claims, loss of coverage, and any additional fees will become the member’s responsibility.

ELIGIBILITY

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MEDICAL & DENTAL

Cigna www.Cigna.com

• On the top of the page, choose “Find a doctor”

• Under “Not a Cigna customer yet?” select “For Plans offered through your employer or school”

• Search by Location, and type keyword or name of doctor or facility. Also select a Plan:

Medical: Open Access Plus, OA Plus, Choice Fund OA Plus

Dental: Total Cigna DPPO (Cigna DPPO Advantage and Cigna DPPO)

• You can select additional filters to narrow your search

You can also call member services at 800.244.6224.

VISION

Cigna www.Cigna.com

• On the top of the page, choose “Find a doctor”

• Select Vision Directory (under “Additional Directories”)

• Enter your search criteria such as zip code, state, gender, preferred language

You can also call member services at 800.244.6224.

LOCATE A PROVIDER

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HOW TO ENROLL IN BENEFITS

Employee Navigator Summary

Welcome to Employee Navigator, our online benefit communication tool!

Please visit www.employeenavigator.com to view your personalized account. Login information was created the first

time you were hired and registered on the site. If you do not have your user name and password select “LOGIN” on

the upper right hand corner, and then select “Reset a Forgotten password”.

IF YOU HAVE NOT YET REGISTERED, follow the Instructions for Access below. Enter 4th Source as the company identifier and then your personal information to create your account.

Instructions for Access:

• Go to www.employeenavigator.com on your web browser.

• Click on the “LOGIN” button in the top right hand corner.

• If you are a new user, click “REGISTER AS A NEW USER” and that will take you to the Create Your Account Page.

Once you are logged in, click on the Let’s Begin, then Start Enrollment button to begin your enrollment elections.

4th Source

Good afternoon, Employee Name!

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HOW TO ENROLL IN BENEFITS

The Start Enrollments screen will walk you through confirming your account details and help you navigate through the list of benefits offered.

For each benefit, make your selection and then click Save & Continue at the bottom of the screen.

To view your Progress, click view steps.

Once you’ve made your election, a checkmark will appear next to the benefit. Look for the to verify that your election has been completed.

You will automatically move forward to the next benefit screen.

*To CHANGE A BENEFIT, click on the benefit you’d like to modify, make the change and click Save & Continue.

Once all sections have been completed and show a checkmark, you are ready to review and submit your elections.

ENROLLMENT SUMMARY

You MUST click on the green Click to Sign button in order to electronically sign your elections.

If this button is not green and you cannot click on it, it is because you have failed to make at least one of the benefit elections on your list. Review your list to see which benefit does not have a green checkmark next to it. You will need to go back and complete the elections that do not have a checkmark. Once all of the insurance benefits have a green

checkmark go back to the enrollment summary page to electronically sign your elections.

Sample List of Benefits

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HSA Open Access Plus

This plan is a High Deductible Health Plan (HDHP). On this plan you are responsible for the negotiated rate for services until you have satisfied your calendar year deductible (except for preventive care). Once you have reached your calendar year deductible you will be responsible for 10% coinsurance up to your calendar year out of pocket maximum. When you have satisfied your deductible and out of pocket maximum, Cigna will pay 100% of services provided by in network providers and facilities. You are eligible to contribute to a Health Savings Account if you enroll in this plan.

What is a Health Savings Account (HSA)?

A HSA is an account that can be used to pay for qualified medical expenses for you and your covered dependents. You can only make contributions to your H.S.A. while you are covered by a high deductible health plan. When you are not covered by a high deductible health plan you may no longer make contributions to your HSA; however, you can continue to use the account to pay for qualified medical expenses. Contributions you make to your HSA are tax-free which may reduce your taxable income. You may consult with your financial institution about opening an HSA if you are on the High Deductible Health Plan.

Open Access Plus

On this plan you will have copays for your day to day services such as office visits and prescription medication. These copays do not apply to your deductible or your out of pocket. Your deductible does apply to your out of pocket maximum for the calendar year. If you have an in or out patient procedure on this plan you will be responsible for your deductible. Advanced imaging (MRI, PET, CAT or Nuclear Medicine) services are subject to a copay.

Preventive Care

Because Preventive Care is important, all routine Preventive Care services under all of the medical plans such as an annual physical or annual visit for women to the OBGYN, would be 100% paid for by Cigna (even prior to the deductible being satisfied) with no cost to you.

Healthcare Terms:

• Copay—A specific dollar amount that you must pay for a specific service at the time when you receive the service.

• Deductible—A dollar amount you are responsible for before the plan will make any benefit payments. Each year, your deductible starts over (January 1st), in addition, you are only responsible for satisfying your deductible one time per year.

• Coinsurance—A method of cost-sharing between the member and the insurance carrier for your benefit expenses. If you have 10% coinsurance, then you pay 10% of your eligible expenses and the carrier pays the remaining 90%. The coinsur-ance begins after your deductible has been satisfied.

• Out of Pocket Maximum– The maximum amount you will be required to pay for your benefits, after which the plan will pay 100% of covered expenses. Your deductible, coinsurance and copays apply towards your out of pocket maximum.

• Negotiated Rate— The negotiated rate is the amount that the provider/facility and the carrier have agreed on for a par-ticular service. The negotiated rate varies by both doctor and procedure. You can call your doctor prior to an office Visit and/or a scheduled procedure to determine approximately what your negotiated rate may be for your service.

• Embedded—If you are enrolled in a family medical plan with an embedded deductible, your plan contains two components, an individual deductible and a family deductible. Each member of your family has the opportunity to have their insurance policy cover their medical bills prior to the entire dollar amount of the family deductible being met. The individual deductible is embedded in the family deductible.

MEDICAL

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MEDICAL

Carrier Cigna

Plan Name HSA Open Access Plus Open Access Plus

In-Network In-Network

Year Maximums Calendar Year Calendar Year

Deductible Medical & Rx Combined

Individual $1,500 $250

Family (Individual / Family Aggregate) $3,000 / $3,000 $250 / $750

Coinsurance (Amount Member Pays) 10% 10%

Out of Pocket Maximum Includes: All Covered Expenses Includes Deductible,

Coinsurance, Copays & Rx

Individual $4,000 $2,500

Family (Individual / Family Aggregate) $6,000 / $6,000 $2,500 / $5,000

Facility Services

In-Patient Hospital Visit 10% after Deductible 10% after Deductible

Outpatient Surgery - Hospital 10% after Deductible 10% after Deductible

Outpatient Surgery - Ambulatory 10% after Deductible 10% after Deductible

Emergency Room Visit 10% after Deductible $200

Urgent Care Visit 10% after Deductible $75

Physician Services

Preventive $0 $0

Primary Care Physician 10% after Deductible $20

Specialist 10% after Deductible $35

Independent Lab and Diagnostic Testing Services

Lab (Freestanding Facility) 10% after Deductible $0

X-Ray (Freestanding Facility) 10% after Deductible $0

Advanced Imaging (MRI, PET, CT Scans at Freestanding Facility) 10% after Deductible 10% after Deductible

Formulary / Prescription Drug List Name Advantage PDL Advantage PDL

Rx Deductible (Individual / Family) Combined with Medical Ded. $0

Prescription Tier Structure

Tier 1: $10 after Ded. Tier 1: $10

Tier 2: $35 after Ded. Tier 2: $35

Tier 3: $60 after Ded. Tier 3: $60

Specialty: Covered under

T1,T2, T3 Specialty:

Covered under T1,T2, T3

Mail Order Rx (90 day supply) 3 x Tier Copay after Ded. 3 x Tier Copay

Out of Network Benefits Out of Network Out of Network

Deductible (Individual / Family) $5,000 / $10,000 $500 / $1,500

Coinsurance (Amount Member Pays) 50% 40%

Out of Pocket (Individual / Family) $10,000 / $20,000 $5,000 / $10,000

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HEALTH SAVINGS ACCOUNT

If you elect the HSA Open Access Plus plan, you have the option to open a Health Savings Account (HSA) through HSA Bank. An HSA. is a financial account that you can use to accumulate tax-free funds to pay for qualified health care expenses, as defined by the Internal Revenue Service. The account acts like a regular checking account with a debit card that accrues interest. All money in the account is owned by you and is fully vested as soon as it is deposited. Funds can accumulate over time and the account is portable. When you use the funds for qualified health care expenses, you will not pay taxes. If you use the money for other expenses, you will pay a tax and a penalty fee.

Any un-used monies left in your Health Savings Account at the end of the calendar year will roll over to the next year for you to use.

4th Source contributes to this account on your behalf. The company will contribute $1.50 for every $1 you contribute to your HSA account!

Please Note: If you enroll your domestic partner in medical coverage you will only receive the individual contribution from 4th Source and you may only contribute the individual maximum to your HSA account (which includes 4th Source’s matching contribution).

Calendar Year Maximum 2019 Contribution Maximum (including 4th

Source’s contribution)

Individual (or Individual + Domestic Partner) $3,500

Individual + Legal Spouse $7,000

Individual + Child(ren) $7,000

Individual + Family $7,000

The Internal Revenue Service defines qualified medical expenses as amounts paid for the diagnosis, cure, or treatment of a disease, and for treatments affecting any part or function of the body. The expenses must be primarily to alleviate a physical or mental defect or illness.

Your Health Savings Account may reimburse:

• Qualified medical expenses incurred by the account beneficiary and spouse and dependents;

• COBRA premiums;

• Health insurance premiums while receiving unemployment benefits;

• Qualified long-term care premiums; and

• Any health insurance premiums paid, other than for a Medicare supplemental policy, by individuals age 65 or older.

• Distributions made from an H.S.A. to reimburse the account beneficiary for eligible expenses are excluded from gross income.

Over the counter (OTC) medicines and drugs are not considered eligible medical expenses for your H.S.A. Under the new health care reform legislation, OTCs and biologicals are eligible for reimbursement only if the request is accompanied by a doctor's prescription. This means items such as cough medicines, pain relievers, and acid controllers, are not eligible for reimbursement UNLESS there is a doctor's prescription submitted along with the reimbursement request. Insulin will remain eligible as a tax-free reimbursement without a prescription. OTC items which are not considered a drug or medicine include things such as bandages and reading glasses.

Qualified Medical Expenses

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TELEMEDICINE

First Stop Health provides you and your dependents telephonic medical care. All employees are eligible for this benefit regardless if you elect medical coverage. You are automatically enrolled for this benefit and you may also register dependent family members (up to 7 dependents) in this telemedicine program. This benefit is paid for 100% by 4th Source.

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CIGNA HEALTHY REWARDS

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COACH BY CIGNA

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DENTAL

4th Source’s Dental coverage is offered through Cigna. Cigna offers coverage for both In and Out of Network for this plan. Preventive Care is covered at 100% by Cigna.

Note:

* You are only required to satisfy your deductible one time per calendar year.

**Usage of out of network benefits on these plans could result in balance billing & higher maximum out of pocket than shown.

Carrier Cigna

Plan Name / Network PPO

In-Network

Primary Dentist Required? No

Individual / Family Calendar Year Deductible $50 / $150

Reimbursement Basis Negotiated Fee Schedule

Preventive Care

Benefit Percentage 0%

Deductible Waived? Yes

Other Services

Basic Services 20% after Deductible

Major Services 50% after Deductible

Endodontics/Periodontics 20% after Deductible

Calendar Year Maximum $2,250

Orthodontia

Benefit Percentage 50%

Deductible Waived? Yes

Adult, Child(ren) Coverage Dependent children up to

age 19

Lifetime Maximum $1,500

Out of Network Benefits Out of Network

Individual / Family Calendar Year Deductible $50 / $150

Reimbursement Basis 90th Percentile

Preventive Services 100%

Deductible Waived? Yes

Basic Services 20% after Deductible

Major Services 50% after Deductible

Orthodontia 50%

Calendar Year Maximum (Preventive, Basic & Major) $2,250

Lifetime Maximum (Orthodontia) $1,500

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VISION

4th Source’s Vision coverage is offered through Cigna. Cigna offers coverage for In-Network providers.

Carrier Cigna

Plan Name / Network Vision Plan 2925

Eye Exam In Network

Exam Copay $10

Frequency Once Every 12 Months

Lenses

Single Vision $25

Bi-Focal $25

Tri-Focal $25

Lenticular $25

Frequency Once Every 12 Months

Frames

Frame Benefit / Allowance $130 Allowance

Frequency Once Every 24 Months

Contact Lenses*

Elective Selection lenses covered in full;

Non-Selection lenses $110 Allowance

Medically Necessary Covered in Full

Laser Vision Correction

Benefit / Discount Discount Available

* Contacts are in lieu of lenses & frames benefit

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Long Term Disability (LTD) is insurance for your paycheck. This benefit is set up to help provide you with long term income continuation in the event you become ill or injured for a period greater than 90 consecutive days.

The benefit begins on the 91st day and allots you 60% of your monthly earnings to a maximum of $15,000 a month until you reach Social Security Normal Retirement Age.

This benefit is 100% paid for by 4th Source and is offered through Cigna.

Long Term Disability

DISABILITY

Short Term Disability Voluntary Short Term Disability (STD) is set up to protect your paycheck. It provides for short term income continuation if you become disabled from a covered accidental bodily injury, sickness or pregnancy. Benefits begin on day 8 for in the event of an accident or an illness. This benefit pays 60% of your weekly salary to a maximum of $3,000 per week, for up to 12 weeks of continued disability. This benefit is 100% paid for by 4th Source and is offered through Cigna.

NOTE: Pre-existing conditions will apply to the LTD disability policies in which if you have seen a doctor, taken medication or been diagnosed with a condition in the 3 months prior to the effective date, you will need to be insured on the plan for 12 months before a claim will be paid due to a pre-existing condition.

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Basic Life and Accidental Death & Dismemberment

All Full Time eligible employees are provided with Basic Life and AD&D. This benefit is 100% paid for by 4th Source. The Basic Life and AD&D provides your beneficiary with a benefit of 100% of Annual Salary (up to $100,000). It is your responsibility to add your beneficiary(ies) in Employee Navigator when you choose your benefits. Please Note– after age 65, your life insurance amount will be reduced based on an age-reduction schedule.

LIFE AND AD&D

Voluntary Life Voluntary Life gives you the opportunity to purchase additional life insurance for you and your family. This coverage is offered through Cigna.

Covers Benefit Amount

Employee You may elect life insurance in increments of $10,000 up to 5x your annual salary or $500,000, whichever is lesser.

You can elect up to $100,000 (if under the age of 65) with no medical questions asked. This is commonly referred to as the Guarantee Issue.

Open Enrollment: Evidence of Insurability is requested for any employee electing coverage over the Guarantee Issue, increasing current coverage, or electing for the first time.

If you elect Voluntary Life Insurance for yourself, you also have the opportunity to elect coverage for your spouse and/or children.

Spouse You may elect life insurance in increments of $5,000 not to exceed 100% of the employee’s elected amount up to a maximum of $250,000.

You can elect up to $25,000 (not to exceed 100% of employees amount) on their spouse with no medical questions asked. This is commonly referred to as the Guarantee Issue.

Open Enrollment: Evidence of Insurability is requested for any employee electing spousal coverage over the Guarantee Issue, increasing current coverage, or electing for the first time.

Child(ren) You may elect coverage in increment amounts of $2,000 up to $10,000 amount for all dependent children to age 26. Birth to 6 months there is a benefit of $500.

Portability of coverage is available for basic life and voluntary life coverage. You will have 31 days from the date you leave to contact Cigna to convert or port the policy(ies).

If you elect an amount in excess of the Guarantee Issue amount, you will be required to complete and submit Evidence of Insurability.*

*If you are currently carrying life insurance with Unum in excess of the Guaranteed amount available through Cigna, you Open Enrollment election of the same amount will not require EOI.

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DEPENDENT CARE FSA

A Flexible Spending Account (FSA) is an employee benefit plan that allows you to set aside money from your paycheck, on a pre-tax basis, to pay for eligible healthcare expenses. When you elect a FSA, you reduce your taxes while paying for services you would have paid for anyway. Your contributions are exempt from Social Security, Medicare and Federal income tax and can equate to a savings between 15% and 40% (depending upon your tax bracket.) Any unused money left in your FSA account will be forfeited as it does NOT rollover into the next plan year.

Dependent Care Flexible Spending Account As a participant in the Dependent Care Reimbursement Account FSA, you may receive reimbursement for eligible child care expenses (children under the age of 13 or one who is incapable of self-care) and eligible dependent adult care expenses. In general, eligible expenses must be for the care of a qualified dependent and enable you (and if married, your spouse) to be gainfully employed, look for work or attend school full time. Accumulation of funds from your paycheck into the Dependent Care Reimbursement Account is required before reimbursement is provided. The maximum amount you may contribute to the Dependent Care FSA is $5,000.

You will not receive a card for use. You must file for reimbursement through Discovery Benefits website or mobile app.

For rules and tax consequences related to your FSA, please refer to your SPD, your tax advisor and/or the IRS.

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PET INSURANCE

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EMPLOYEE ASSISTANCE PROGRAM

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WORKSITE BENEFITS

4th Source also offers Accident and Critical Illness coverage. If you experience a covered claim, Unum will pay a cash benefit directly to you. The amount that you will receive depends on the type of injury and care received. You can use the money from Unum for any purpose - for example, to help meet out-of-pocket medical costs or help with everyday expenses.

Accident

Accidents happen all of the time, and the out-of-pocket costs that may accompany a resulting injury—like fracturing your wrist or dislocating your shoulder—can add up quickly. Unum’s Accident coverage pays you a cash benefit if you’re hurt as a result of a covered accident. This extra money can help protect you from the financial impact of injury.

Examples of covered accidents: Loss of limb, severe dislocations and fractures, burns, lacerations. This plan covers on & off the job injuries.

Critical Illness

Being sick is often unexpected, and so are the costs that come with it. Unum’s Critical Illness coverage pays you a cash benefit if you are diagnosed with a covered condition so that you can focus more on your health and less on your financial health. Your premium cost will vary based on your age and election amount.

Examples of covered conditions: Heart attack, stroke, cancer, major organ failure, severe burns, paralysis

These coverages are not designed to replace your medical coverage, but to offset the out of pocket expenses you incur such as copays, deductible or coinsurance. Unum reimburses you directly for eligible claims.

Accident — Per Pay Period Cost

Employee Only $7.47 Employee + Child(ren) $12.85

Employee + Spouse $11.69 Employee + Family $18.31

Wellness Screening Benefit If you enroll in the Critical Illness and or Accident plan, you can receive a Wellness Screening Benefit from Unum! To promote healthy lifestyles and early detection, Unum will pay

members $50 once per calendar year upon receiving proof of an eligible health screening like an electrocardiogram, diabetes test, or mammogram.

Age Brackets

Employee Spouse

Monthly Rates per $1,000 of

Coverage Monthly Rates per $1,000 of

Coverage

Non-Tobacco Tobacco Non-Tobacco Tobacco

Under 25 $0.52 $0.79 $0.52 $0.79

25 - 29 $0.58 $0.94 $0.58 $0.94

30 - 34 $0.75 $1.34 $0.75 $1.34

35 - 39 $1.02 $1.96 $1.02 $1.96

40 - 44 $1.44 $2.88 $1.44 $2.88

45 - 49 $1.98 $3.98 $1.98 $3.98

50 - 54 $2.62 $5.31 $2.62 $5.31

55 - 59 $3.45 $6.76 $3.45 $6.76

60 - 64 $4.42 $8.10 $4.42 $8.10

65 - 69 $4.97 $8.44 $4.97 $8.44

70 - 74 $8.91 $13.61 $8.91 $13.61

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Your premium deduction each paycheck is based on your coverage election. To determine your cost per pay period, use the tables below.

Medical - Cigna

Dental - Cigna

ate Tier Structure

Rate Tier Structure

Rate Tier Structure 2 Year Rate Guarantee 2 Year

Vision - Cigna

PREMIUMS

Cost Per Pay Period You Pay

Semi-Monthly

4th Source Pays

Monthly

Payroll Frequency (Semi-Monthly)

Employee Only $0.00 $34.52

Employee + Spouse $17.27 $34.52

Employee + Child(ren) $24.38 $34.52

Employee + Family $44.90 $34.52

Cost Per Pay Period You Pay

Semi-Monthly

4th Source Pays

Monthly

Payroll Frequency (Semi-Monthly)

Employee Only $0.00 $5.53

Employee + Spouse $2.50 $5.53

Employee + Child(ren) $3.38 $5.53

Employee + Family $5.90 $5.53

Cost Per Pay Period You Pay

Semi-Monthly

4th Source Pays

Monthly

You Pay

Semi-Monthly

4th Source Pays

Monthly

HSA Open Access Plus Open Access Plus

Payroll Frequency (Semi-Monthly)

Employee Only $24.75 $453.24 $120.00 $360.34

Employee + Spouse $151.25 $773.36 $270.00 $744.68

Employee + Child(ren) $145.75 $734.08 $255.00 $714.63

Employee + Family $214.50 $1,109.36 $390.00 $1,056.96

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PTO POLICY

4th Source believes that employees work more successfully and efficiently when they regularly take time away from work. It is the Company's intent to provide full-time employees with PTO (Paid Time Off). PTO will be based on employment level and years of service.

PTO is paid time off provided by the company to be used for vacation days, sick days, personal days, etc., and is in addition to regularly scheduled Company holidays.

Managers are responsible for coordinating the PTO schedules of their staff in order to balance the personal needs of each employee with the workflow demand of the department and the Company.

Eligibility

a. Regular Full-time employees will be awarded PTO in accordance with the approved PTO schedule, which is subject to change from time to time at management’s discretion.

Schedule (Days per year)

4th Year begins Jan. 1 after 3rd Anniversary

7th Year begins Jan. 1 after 6th Anniversary

A. Employees will be awarded PTO in their first month of hire, prorated on an annualized basis. This is a “use it or lose it” policy. PTO must be used during the calendar year in which it is awarded, and it may not be carried over to the following calendar year or paid out upon termination of the employee’s employment, except where required by law. PTO is a benefit, not an earned wage.

B. Employees will not be awarded PTO while on FMLA, Maternity Leave, or disability leaves.

Procedures

A. Employees are required to obtain the approval of their immediate manager for all PTO requests.

B. Employees who request greater than one week (40 consecutive hours) of PTO require written approval from their immediate manager a minimum of two (2) weeks prior to the requested PTO.

B. If more than one employee applies for PTO during the same time period, the business needs of the department/Company will be taken into consideration by the manager in granting approval.

D. The Company will not grant more than two (2) weeks of consecutive PTO without prior approval from the Human Resources department.

Holidays

Company designated holidays, which falls during an employee's PTO, are not counted against PTO balance.

Years of Service O thru 3 4 thru 6 7 +

SVP/EVP/C Level 23 28 30 Max

Director/VP 20 25 27

All Other 17 22 24

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Important Notice from 4th Source About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with 4th Source and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:

Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

4th Source has determined that the prescription drug coverage offered by Cigna is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

__________________________________________________________________________ When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current 4th Source coverage will not be affected. You can keep this coverage if you elect part D and the Cigna plan will coordinate with Part D coverage. If you do decide to join a Medicare drug plan and drop your current 4th Source coverage, be aware that you and your

dependents may not be able to get this coverage back.

CREDITABLE COVERAGE NOTICE

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When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with 4th Source and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through 4th Source changes. You also may request a copy of this notice at any time. For More Information About Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage:

Visit www.medicare.gov

Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help

Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).

Date: April 1, 2019 Name of Entity/Sender: 4th Source, Inc. Contact – Position / Office: Laura Lopez Address: 2502 N Rocky Point Drive Suite 960 Tampa, FL 33607 Phone Number: 813.940.3094

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Associate Contact Information Notes

Employee Care Center Monday—Friday 8:30 am to 5 pm EST

866.784.2242

mybenefits@bks-partners.com

All Benefit Questions & Claims Assistance

Cigna

Policy #622235

Medical Member Services

Medical Member Services: 866.494.2111

Mail Order Pharmacy: 800.285.4812

www.mycigna.com

Personalized Medical ID Cards

mailed to each employee and

dependent. These can also be pulled on

myCigna.com and the Cigna app.

Cigna

Policy #622235

Dental Member Services

Dental Member Services: 800.244.6224

www.mycigna.com

Dental ID cards are generic and will not be

mailed to the members. You can

provide your SSN in order to receive dental

services from your provider.

Cigna

Policy #622235

Vision Member Services

Vision Member Services: 877.478.7557

www.mycigna.com

Personalized Vision ID cards mailed

to each employee.

Cigna

Policy #SGM60881 (Life)

Policy #SOK606556 (AD&D)

Policy #SGD609494 (LTD)

Policy #SGD609493 (STD)

Life Member Services

Disability Member Services

Disability and Life Insurance Member Ser-vices: 866.494.2111

www.mycigna.com

Report a Disability

Complete an EOI

UNUM

Policy # P9124 (Accident), R0640086 (CI)

Worksite Benefits Member Services

Critical Illness & Accident Member Services: 800.635.5597

File a Claim

Submit for Wellness Benefit

First Stop Health

Telemedicine

888.691.7867

www.fshealth.com

Call for a free consultation with a

doctor for minor ailments such as a cold

or allergies

HSA Bank

Health Savings Account Member Services

800.357.6246

www.hsabank.com

Online Account

Management

Discovery Benefits

Dependent Care FSA

866.451.3399

www.discoverybenefits.com

File for Reimbursement

Healthy Paws

Pet Insurance

855.898.8991

www.healthypawspetinsurance.com

Use the link on page 19 for a free quote!

IMPORTANT CONTACTS

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NOTES

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