health benefits

Hello Magnum Team, Open enrollment is November 8th-19th! Magnum is proud to provide a broad range of benefits and resources to support you and your family during life's uncertain moments. Working for you, we’re always looking for ways to make thoughtful updates and improvements to maximize the value of our benefits package. We’ve heard your feedback and we’re excited to share some updates with you, just in time for this year’s annual enrollment. Benefit Updates Include: Medical

• We’re excited to announce the medical premiums you pay are lowering for 2022!

• We’ll continue to offer the current 3 medical plans with the 6 different networks.

• Our medical partner, Medica, continues to work on expanding the network options to all employees, as these networks become available, we’ll look at expanding our network options.

Vision

• Our current plan is changing, so look for new rates.

Short-Term Disability (STD)

• For those employees currently not enrolled in STD, your benefit election will auto-enroll into the base plan during open enrollment for the 1/1/2022 effective date, (14-day elimination period with a $100 weekly benefit for 11 weeks).

• Be sure to verify your coverage and premiums for this enrollment.

• Ask your benefit counselor about your options. If you are receiving this message, you are required to attend an individual meeting with a certified counselor to make all your benefit elections/waivers in Businessolver between November 8th – Nov. 19th. Note: Even if you intend to waive coverage……You must schedule a call.

To schedule an appointment: Visit the website: www.enrollme.site/magnum The Benefit Counselor will contact you directly via the telephone number you provide.

OPEN ENROLLMENT GUIDE 2022

HEALTH BENEFITS

Questions? Contact Human Resources at (701) 561-7044, or email at [email protected].

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Table of Contents

Benefits Overview and Eligibility ..................................................................................................................... 3

Contact Information ....................................................................................................................................... 3

Medical .......................................................................................................................................................... 4

ConsumerMedical, Omada for Prevention and Omada for Diabetes ............................................................. 7

Medica’s Value-Added Services .................................................................................................................... 8

Medica’s Employee Assistance Program (EAP) .......................................................................................... 10

Health Savings Account (HSA) .................................................................................................................... 11

Frequently Asked Questions about HSAs ................................................................................................... 12

Dependent Care Reimbursement Flexible Spending Account (FSA) .......................................................... 13

Voluntary Dental .......................................................................................................................................... 14

Voluntary Vision ............................................................................................................................................ 15

Basic Life and Accidental Death and Dismemberment (AD&D) .................................................................. 16

Voluntary Supplemental Life and AD&D ....................................................................................................... 16

Voluntary Short-Term Disability (VSTD) ...................................................................................................... 18

Voluntary Long-Term Disability (VLTD) ....................................................................................................... 19

Voluntary Critical Illness with Cancer ........................................................................................................... 20

Voluntary Accident Insurance ....................................................................................................................... 21

UNUM’s $75 Annual Wellness Benefit ........................................................................................................ 23

Voluntary Whole Life Insurance ................................................................................................................... 24

UNUM’s Employee Assistance Program (EAP) ........................................................................................... 25

Annual Notices ............................................................................................................................................ 26

Additional HSA FAQs ................................................................................................................................... 38

Filing a Short-Term Disability Claim ............................................................................................................. 43

Unum Benefit Resources .............................................................................................................................. 47

This document is an outline of the coverage proposed by the carrier(s), based on information provided by your company. It does not include all of the terms, coverage, exclusions, limitations, and conditions of the actual contract language. The policies and contracts themselves must be read for those details. Policy forms for your reference will be made available upon request.

The intent of this document is to provide you with general information regarding the status of, and/or potential concerns related to, your current employee benefits environment. It does not necessarily fully address all of your specific issues. It should not be construed as, nor is it intended to provide, legal advice. Questions regarding specific issues should be addressed by your general counsel or an attorney who specializes in this practice area.

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Benefits Overview

Magnum, LTD. is proud to offer a comprehensive benefits package briefly summarized in this booklet.

A great deal of time and effort has been invested in designing, funding, and maintaining a quality benefit plan. You and your family can also play an important role in getting the most from your benefits by making sure that you understand them.

When possible, you are offered options so that you can select the plan that best fits your needs. To get the most value from your benefits, carefully consider which options are right for you and your family. Because your premiums are generally deducted on a pre-tax basis, IRS regulations may prohibit you from making enrollment changes outside of annual enrollment, unless you experience a qualifying event.

This booklet is intended to provide a summary of each of your benefit plans. Although care was taken to correctly describe these plans, you should consult your actual certificate of coverage for full details. If you have dependents who are enrolled in coverage, make sure that they have the opportunity to review this information as well.

Who is Eligible?

You and your dependents are eligible for Magnum, LTD’s benefits package on the first of the month following 30 days of employment, unless otherwise stated below. Eligible dependents include your spouse and children under age 26, married or unmarried.

When enrolling yourself, you will need to have your address and social security number readily available. When enrolling dependents (child(ren) and/or spouse), you will need to have their name, address, date of birth, and social security number readily available for each dependent.

Contact Information

If you have specific questions about any of the benefit plans, please contact the administrator listed below or your Human Resources.

Benefit Administrator Phone Website

Medical Medica 952.945.8000 www.medica.com

Health Savings Account (HSA) Further 651.662.5065 www.hellofurther.com

Flexible Spending Account (FSA) Further 651.662.5065 www.hellofurther.com

Voluntary Dental Delta Dental 800.553.9536 www.deltadentalmn.org

Voluntary Vision Avesis 800.828.9341 www.avesis.com

Group Life and Accidental Death and Dismemberment (AD&D)

UNUM 800.635.5597 www.unum.com

Voluntary Short-Term Disability (VSTD)


Voluntary Long-Term Disability (VLTD) UNUM 800.635.5597 www.unum.com

Voluntary Supplemental Life and AD&D


Voluntary Critical Illness with Cancer UNUM 800.635.5597 www.unum.com

Voluntary Accident UNUM 800.635.5597 www.unum.com

UNUM’s $75 Annual Wellness Benefit UNUM 800.635.5597 www.unum.com

Voluntary Whole Life UNUM 800.635.5597 www.unum.com

Consumer Medical Consumer Medical 888.361.3944 www.myconsumermedical.com

Merrill Lynch Merrill Lynch 800.228.4015 www.benefits.ml.com

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Medical Benefits Administered by Medica

Comprehensive and preventive healthcare coverage is important in protecting you and your family from the financial risks of unexpected illness and injury. A little prevention usually goes a long way — especially in healthcare. Routine exams and regular preventive care provide an inexpensive review of your health. Small problems can potentially develop into large expenses. By identifying the problems early, often they can be treated at little cost. Magnum, LTD. offers three medical plans through Medica: 3,000-0% HSA Plan, $5000-0% HSA Plan, or $6,350-0% HSA Plan.

$3,000-0% HSA Plan $5,000-0% HSA Plan $6,350-0% HSA Plan Benefit In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

Annual Deductible per Calendar Year

$3,000/person

$6,000/family

$7,500/person

$15,000/family

$5,000/person

$10,000/family

$7,500/person

$15,000/family

$6,350/person

$12,700/family

$7,500/person

$15,000/family

Annual Total Out-of-Pocket Maximum per Calendar Year

$3,000/person

$6,000/family

$15,000/person

$30,000/family $5,000/person

$10,000/family

$15,000/person

$30,000/family $6,350/person $12,700/family

$15,000/person $30,000/family

Preventive Care - Deductible does not apply

Routine Physical No charge 50% after deductible

No charge 50% after deductible


Immunizations, Well Child Care and Cancer Screenings


No charge

50% after deductible


Office Visits

Chiropractic Care No charge after

deductible 50% after deductible

No charge after deductible




Illness or Injury No charge after






Specialist Visit No charge after






Diagnostic Test X-Ray, Blood Work






Imaging CT / PET Scan, MRIs






Prescription Drugs - Up to a 31-day supply for Retail

Generic No charge after






Preferred Brand No charge after






Non-preferred Brand No charge after






Specialty No charge after

deductible Not covered


Not covered No charge after

deductible Not covered

Urgent Care Center No charge after

deductible No charge after





deductible

Hospital Emergency Room No charge after






deductible

Emergency Ambulance No charge after






deductible

Durable Medical Equipment and Prosthetics







Urgent or Emergency Care



Home Healthcare No charge after






This is a summary of benefits only and does not guarantee coverage. For a complete list of covered services and limitations/exclusions, please refer to the Plan Summary.

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Understanding your Network Options You have access to six comprehensive networks of providers. You can maximize your medical benefits by seeing in-network providers, so it is important to understand the differences between each of the following networks.

Medica Choice with Unitedhealthcare Choice Plus Network Medica Choice with Unitedhealthcare Choice Plus Network is an easy-to-use plan with a large, national network. You can visit any doctor, clinic or facility in the network without a referral.

Medica Elect Network With Medica Elect network, you enroll in a primary care clinic. The clinic coordinates your care and will help you find a specialist when you need one. Whenever you need care, you’ll start at your primary care clinic. Each family member may choose a different care system, as well as a different primary care clinic within their selected care system. You can change your primary care clinic and care system as often as once a month. Clinic changes become effective the first day of the month after you make your request (provided that you submit your change by the 20th of the current month). Medica Elect network offers in-network coverage within Minnesota and includes Allina Medical Clinics, Children’s Health Network, Hennepin Healthcare, Integrity Health Network, Lakeview Medical Care System, Minnesota HealthCare Network, Park Nicollet Health Services, RiverWay/ North Suburban Clinics, and St. Luke’s Care System.

Park Nicollet First with Medica Network Park Nicollet First with Medica offers comprehensive in-network coverage within Hennepin, Ramsey, and the surrounding 11 counties.

VantagePlus with Medica Network VantagePlus with Medica provides access to providers from M Health Fairview (the health care organization representing Fairview, University of Minnesota and M Physicians), North Memorial Health and many popular independent clinics.

Altru & You Network Altru & You with Medica provides access to providers in more than 30 communities in northeastern North Dakota and northwestern Minnesota. Members have access to more than forty primary care clinics and seventeen hospitals, including direct access to specialists and multiple specialty centers.

Essentia Choice Care with Medica Network Essentia Choice Care with Medica provides access to providers in more than 50 communities in northern Minnesota, eastern North Dakota and northwestern Wisconsin.

Coverage when you travel When you travel outside the Medica service area (Minnesota, North Dakota, South Dakota and western Wisconsin) you can get network coverage by visiting a provider in the Travel Program Network. This nationwide network is one of the largest in the country. If you have children attending college outside the service area, they can use this network, too. Contact Medica’s Customer Service for additional information 800.952.3455

How To Find a Network Provider To receive the highest level of benefits, see providers in your network. Go to medica.com/findadoctor, Select your network, Under Providers and facilities, click on “See your choices”

Choose the type of provider you’re looking for

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Employees on Bi-Weekly Pay (26 pay periods)

$3,000-0% HSA Plan

Passport Elect Park Nicollet First VantagePlus Altru & You Essentia

Employee $111.00 $92.94 $67.66 $74.88 $64.04 $56.81

Employee + Spouse $333.16 $289.80 $229.11 $246.45 $220.44 $203.11

Employee + Child(ren) $263.75 $229.43 $181.37 $195.10 $174.51 $160.78

Family $430.32 $374.32 $295.93 $318.32 $284.73 $262.33

$5,000-0% HSA Plan


Employee $51.97 $36.86 $15.71 $21.75 $28.16 $6.64

Employee + Spouse $191.66 $155.38 $104.60 $119.11 $97.34 $82.83


Family $247.55 $200.69 $135.09 $153.84 $125.72 $106.98

$6,350-0% HSA Plan


Employee $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Employee + Spouse $133.47 $100.10 $53.39 $66.74 $46.72 $33.38


Family $172.39 $129.30 $68.95 $86.20 $60.34 $43.09

Premiums - Payroll Deductions

$3,000-0% HSA Plan


Employee $55.50 $46.47 $33.83 $37.44 $32.02 $28.41

Employee + Spouse $166.58 $144.90 $114.56 $123.23 $110.22 $101.55


Family $215.16 $187.16 $147.96 $159.16 $142.36 $131.17

$5,000-0% HSA Plan


Employee $25.99 $18.43 $7.86 $10.88 $14.08 $3.32

Employee + Spouse $95.83 $77.69 $52.30 $59.56 $48.67 $41.42


Family $123.77 $100.35 $67.54 $76.92 $62.86 $53.49

$6,350-0% HSA Plan


Employee $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Employee + Spouse $66.73 $50.05 $26.69 $33.37 $23.36 $16.69


Family $86.20 $64.65 $34.48 $43.10 $30.17 $21.55

OTR Drivers on Weekly Pay (52 pay periods)

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Magnum provides a broad range of benefits and wellbeing resources to support you and your family. We’re always looking for ways to make thoughtful updates and improvements to maximize the value of our benefits. Below are 3 programs available to you and your covered family members we want you to take advantage.

ConsumerMedical – New for 1/1/2022 – Watch for additional information Treatment Decision Support from ConsumerMedical provides confidential one-on-one guidance to help you make informed decisions about medical care and treatment. ConsumerMedical is available at no cost to you and your covered family members. You and your family receive expert guidance on:

The right diagnosis Treatment options that are best for your needs Doctors within network who are top-rated for your condition The most qualified in-network hospital for your care Support to help cope

You’ll get support from a team of nurses, physicians and other health care professionals over the phone, via secure email or text to help you better understand your medical condition and treatment options. You’ll receive recommendations on the best local, in-network doctors and hospitals for your needs and a second opinion if you need one. You can even get advice on suggested ques-tions to ask your doctor to make the most of your medical visits.

Omada for Prevention – New for 1/1/2022 – Watch for additional information BUILD HEALTHY HABITS THAT LAST As a Medica member, you can help reduce your risk for chronic disease through Omada for Prevention, a digital lifestyle change pro-gram. Combining the latest technology with ongoing personal support, you can make the changes that matter most — whether that’s around eating, activity, sleep or stress. It’s an approach that can help you lose weight and reduce your risks for type 2 diabetes and heart disease. Omada for Prevention is available at no cost to you and your covered family members. Program Features With Oma-da®, you’ll receive:

An interactive program with an engaging app to guide your journey anywhere, anytime. A wireless smart scale to monitor your progress. Weekly online lessons to empower you. § A professional Omada health coach to keep you on track. A small online group of participants to keep you engaged.

Omada for Diabetes – New for 1/1/2022 – Watch for additional information PERSONALIZED SUPPORT TO HELP MANAGE DIABETES AND IMPROVE BLOOD GLUCOSE CONTROL Omada engages participants in lifelong health, one-step at a time. By empowering participants to build skills that are personally rele-vant, at a pace that is manageable, and with the support of others, they will stay engaged and make changes that last. . Omada for Diabetes is available at no cost to you and your covered family members. Omada for Diabetes provides:

Coaching from a Certified Diabetes Care and Education Specialist (CDCES)

Diabetes curriculum based on Diabetes Self-Management Education and Support (DSMES)

Cellular scale, connected blood glucose meter, testing supplies and a continuous glucose monitor

Type 1 or Type 2 diabetes peer group support

Medication self-management

Health maintenance support

Anywhere access with Omada’s engaging app

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Medica’s Value-Added Services Medica responds to your needs with tailor-made services and resources that support you in improving your health and making the most of your benefits. Best of all, these are all a part of your benefit plan once you become a member. We’re ready when you are. Call Customer Service for any of the resources listed below.

myMedica.com What can Medica offer me? Check out your Medica member website, myMedica.com is your one-stop resource for all kinds of information to help you manage your health plan benefits and improve your health. Here are just a few of the many things you can do on myMedica.com:

Order ID Cards

Find out what’s covered by your plan

Track your claims

Check to see if a doctor or other health care provider participates in your network

See which drugs are on Medica’s preferred drug list - your best value

Chat with a nurse online

Learn about and participate in fun and effective health and wellness programs

After registering on myMedica.com, smartphone users can access a mobile version of the site. If you have any questions about this site or your benefits, call Customer Service at 800.952.3455.

Need Pharmacy Info on the Go? Go Mobile! You have access to a pharmacy mobile app that helps you save money and manage your prescription benefits. With the app you can:

Check drug costs and compare prices

Find a network pharmacy and get directions to any one of the many chains or smaller independent pharmacies in the network

View your ID Card

View your prescription history

Check drug interactions

Identify pills

You can download the free CVS Caremark™ app from the Apple Store on Google Play. You can also access these same pharmacy tools on your desktop on myMedica.com by logging in and choosing the ‘Pharmacies & Prescriptions’ tab.

24-Hour Nurse Line How can I get fast answers to healthcare questions? Call Medica CallLink® to speak to an experienced nurse for information and advice about general health issues, self-care for minor injuries and illnesses, or finding a network provider. The nurse line is open all day, every day, all year at 1.800.962.9497 (TTY, call the National Relay Center at 1.800.855.2880).

My Health Rewards by Medica Get motivated to make positive changes. Here’s a program that rewards you for making better health decisions. Earn gift cards as you take an online health assessment or participate in health topics tailored to your needs and learning style. Access these Medica Personal RewardsSM features on the myMedica.com Health and Wellness Center.

Be Tobacco Free Journeys Available through My Health Rewards by Medica Real change is possible when you replace current habits with healthy new ones. That’s the power behind ‘Be Tobacco Free Journeys.’ Each journey moves you down the road to quitting for good through real-time practice gathering social support, prepping the environment, and getting past triggers. You choose the small steps that play to your strengths as you make your way through a Journey unique to you.

Health Club Reimbursement Looking for motivation to get to the gym? Join Fit Choices by Medica! You can earn a $20 monthly credit toward your health club dues— that’s up to $240 per year—for meeting your monthly attendance requirement! Getting started is simple—present your Medica ID card to a participating health club. Your health club will track your visits and sends verification to Medica. For more details, log on to mymedica.com and click on the ‘Health & Wellness’ tab. To verify eligibility or to learn more about your monthly attendance requirement, call Medica Customer Service at the number on the back of your ID card.

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Medica’s Value-Added Services Continued

Ovia Health

DAILY SUPPORT FOR FERTILITY, PREGNANCY AND PARENTING Ovia Health supports you through your entire parenthood journey. The Ovia Health apps offer personalized guidance, support and coaching to help achieve your health goals, from fertility health tracking, to getting pregnant, to navigating pregnancy, postpartum and parental wellness. Ovia Fertility, Ovia Pregnancy and Ovia Parenting app tools include:

Health and menstrual cycle tracker Pregnancy calendar and daily baby updates Child’s development checklist Daily health and wellness content Data and symptom feedback

Getting started with Ovia

Download one, or all three Ovia Health apps from the App Store or Google Play: Ovia Fertility, Ovia Pregnancy or Ovia Parenting

When signing up with your email, choose “I have Ovia Health as a benefit” before tapping “Sign up

Enter your state, health plan (Medica), employer name and personal details Sanvello ON-DEMAND HELP FOR STRESS, ANXIETY AND DEPRESSION Rethink how you manage your mental health. Sanvello gives you access to clinically proven techniques based on cognitive behavioral therapy for dealing with stress, anxiety, depression, or whatever else you may be going through. From coping tools to meditations to Guided Journeys, you’ll get help to manage your moods and thoughts so you can understand what works for you to feel better. Getting started with Sanvello

Download the Sanvello mobile app from the App Store or Google Play.

Open Sanvello and tap “Get Started.”

Complete the steps to create a Sanvello account.

After creating an account, select “Upgrade Via Insurance.”

Search for and select “Medica.”

Enter the information from your Medica ID card.

Use the help prompts for additional assistance if needed.

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Medica’s Employee Assistance Program (EAP) A lot on your mind? A ton of support. Life can throw a lot at you, from small inconveniences, like not having a dog walker, to big concerns, like debt. If you find yourself in a tough time, remember you can call anytime. Speak privately with a specialist 24/7 to help with everything from financial, legal or relationship concerns to trouble sleeping or stress. You and your family can call the Employee Assistance Program for things like:

Speak with a specialist who will connect you with reliable information and the right resources for your needs. Your call and conversations with EAP counselors and advisors are kept confidential, in accordance with the law. This service is available at no additional cost to you, as part of your benefit plan. You benefits include:

Three in-person counseling sessions covered at 100%

A 30-minute legal consultation by phone or in person (25% discount if you hire an attorney)

Guidance from a financial advisor to help with debt, foreclosure, financial planning and more

This program should not be used for emergency or urgent care needs. In an emergency, call 911 or go to the nearest emergency room. Learn more about your Medica Optum Employee Assistance Program at mymedica.com.

Call for the peace of mind you need. 24/7 Medica Optum Employee Assistance Program - 1.800.626.7944 Please note that the services included in this EAP through Medica can only be utilized by those - and their families - who are enrolled in one of the medical plans offered by your company. If you are not enrolled in one of the medical plans, we encourage you to utilize the EAP program featured later on this manual (see table of contents for exact page number).

Financial or legal concerns

Child and eldercare support

Stress, anxiety or depression

Living with chronic conditions

Parenting and family problems

Workplace or relationship issues

Community resources, like support groups

Dependency issues, like alcohol, tobacco, gambling or drugs

And much more

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Health Savings Account (HSA) Administered by Further

You are eligible to open a Health Savings Account if you enroll in the $3,000-0% HSA, $5,000-0% HSA, or the $6,350-0% HSA Plan offered by Magnum, LTD. Each of the plans offered by Magnum, LTD. are qualified High Deductible Health Plans (HDHP).

What is a Health Savings Account (HSA)? A Health Savings Account (HSA) is an account that can be funded with your pre-tax dollars, by you, your employer, or both, to help pay for eligible medical expenses not covered by an insurance plan, including the deductible, coinsurance, and even in some cases, health insurance premiums.

IMPORTANT: If you have an FSA Health Reimbursement account, your balance must be exhausted prior to establishing/contributing to a HSA. This means you should allow enough time for your last FSA reimbursements to be processed and the account to reflect a $0 balance.

How does the plan work?

Who is your HSA vendor? If you enroll in the HSA plan, you will have an HSA account setup with Further, the vendor who administers the account. You can find more information at www.hellofuther.com, or call their local customer service team at 651.662.5065 or 800.859.2144.

Who is Eligible for an HSA? Anyone who is:

Covered by a qualified High Deductible Health Plan (HDHP);

Not covered under another medical plan that is not a qualified HDHP, including a traditional medical flexible spending account (FSA), that either you or your spouse is enrolled in;

Not entitled to Medicare benefits; or

Not eligible to be claimed on another person’s tax return.

You pay 100% of medical and prescription drug costs until you meet your deductible. You may make contributions to your

HSA pre-tax up to the IRS maximum. You can withdraw these funds tax-free and put them towards meeting your deductible or

Use your HSA to Help Pay Non-Preventive Expenses

$3,000 Individual

$6,000 Family

In-network preventive care such as annual check-ups, cancer

screenings, well-child care and immunizations are covered at 100% and some preventive

prescriptions.

Due to the structure of Magnum, LTD.’s HSA plan, by virtue of reaching your deductible, you

have satisfied your out-of-pocket max. The plan will now pay 100% for the remainder of

the calendar year.

Who funds your HSA Account? You are encouraged to contribute to your HSA account. Magnum, LTD. will also fund your HSA in the following amounts:

$11.50 over 26 pay periods for Bi-Weekly pay

$5.75 over 52 pay periods for Weekly pay

When and how often can I contribute to my Health Savings Account (HSA)? You, your employer or others can contribute to your HSA account through a payroll deduction(s) or as a lump sum deposit. You can contribute as often as you like, provided the annual 2022 contribution limits do not exceed:

$3,650 for Employee-Only coverage

$7,300 for family coverage

Individuals that are age 55 or older by the end of the tax year are eligible to make an additional contribution up to $1,000

For Additional Information and Frequently Asked Questions about HSAs, see page 38

$3,000-0% HSA (Example) Deductible

$3,000 Individual $6,000 Family

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Frequently Asked Questions about HSAs How do I manage my HSA? The HSA account is your account; the HSA dollars are your dollars. Since you are the account holder or HSA beneficiary, you manage your HSA account. You may choose when to use your HSA dollars or when not to use your HSA dollars. HSA dollars pay for any eligible expense. Most commonly, the HSA account holder will pay their out-of-pocket expenses (i.e. deductible and coinsurance) associated with their high deductible health plan with their HSA dollars.

What expenses are eligible for reimbursement from my HSA? HSA dollars may be used for qualified medical expenses incurred by the account holder and his or her spouse and dependents. Qualified medical expenses are expenses for medical care and are outlined within IRS Section 213(d). In summary, the IRS Section 213(d) states that “the expense has to be primarily for the prevention or alleviation of a physical or mental defect or illness.”

In addition to qualified medical expenses, the following insurance premiums may be reimbursed from an HSA:

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 ages 65 and over (assuming premiums are not collected through payroll on a pre-tax basis).

How do I pay for my expenses out of an HSA? The Further debit card is the fastest way to use your Health Savings Account (HSA) to pay for eligible expenses. Similar to your bank debit card, money is transferred directly from your account to your provider or merchant. No paper claims submission and no waiting for reimbursement. You have real-time access to your spending account dollars. Once you begin using your debit card, you can easily monitor your account and debit card transactions by logging into the Online Member Service Center at www.hellofurther.com.

What if I have HSA dollars left in my account at year-end? The money is yours to keep. It will continue to earn interest and will be available for you and your healthcare costs next year. Any dollars left in your HSA account at year-end will automatically roll over into next year’s HSA account.

Can I use the money in my account to pay for my dependents’ medical expenses? You can use the money in the account to pay for medical expenses for yourself, your spouse, or your dependent children. You can pay for expenses of your spouse and dependent children even if they are not covered by one Magnum, LTD.’s HSA plans.

What happens to my HSA dollars if I leave my employer? The funds are yours to keep. You may elect one of the following options:

Leave your funds in the current HSA account;

Transfer your funds to an HSA with your new employer (check to make sure there are no fees associated with the transfer); or

Transfer your funds to another qualifying account within 60 days.

For Additional Information and Frequently Asked Questions about HSAs, see page 38

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Dependent Care Reimbursement Flexible Spending Account (FSA) Administered by Further

You can save money on your dependent care and day care expenses with a Dependent Care Reimbursement Flexible Spending Account (FSA). You have the opportunity to set aside funds each pay period on a pre-tax basis to help you pay for your eligible dependent care expenses, such as day care for your child or elder care. Per paycheck contributions, which are determined by you and can only be changed one time per year during annual enrollment (or for a qualifying event), will be deposited into your FSA account. You pay no federal income or Social Security taxes on your contributions to an FSA - which means more money in your pocket!

Child care or elder care services may qualify for reimbursement if they meet these requirements:

The child must be under 13 years old or, if older, mentally or physically incapable of caring for himself or herself.

Must be provided by a facility or caretaker with a registered tax ID number.

The services may be provided inside or outside your home, but not by someone who is your dependent for income tax purposes, such as an older child, your spouse, or a grandparent who lives with you.

For more information on claiming the Dependent Care FSA Reimbursement and eligible Dependent Care Expenses, visit www.irs.gov/ pub/irs-pdf/p503.pdf.

Dependent Care Spending Limit for Reimbursement

$5,000 if filing jointly

$2,500 if filing singly

Plan Participation Requirements You do not have to be enrolled in the company medical, dental or vision to enroll in an FSA. You manage your FSA funds; you may not use money from your Health Care FSA to pay for dependent care expenses, or vice versa. You must re-enroll every year during Annual Enrollment in order to participate in the FSA benefit plan.

Here’s How an FSA Works

You decide the annual amount (up to the maximum) you want to contribute to the Dependent Care FSA based on your estimated dependent/childcare/elder care expenses.

Your contributions are deducted from each paycheck before income and Social Security taxes, and deposited into your FSA.

You pay for dependent care eligible expenses when incurred and then submit a reimbursement claim form or file the claim online.

You are reimbursed from your FSA. So, you actually pay your expenses with tax-free dollars.

Use It or Lose It… Federal tax laws require that a Section 125 Plan operate on a “use it or lose it” basis. This means that if you do not use the entire amount available for reimbursement under your Dependent Care Reimbursement FSA for a Plan Year, you will forfeit the unused amount and have no further claim to those funds after the Plan Year (and any run-out period) ends.

14 | Magnum, LTD.

Voluntary Dental Administered by Delta Dental

Good oral care enhances your overall physical health, appearance, and mental well-being. Keep your teeth healthy and your smile bright with Magnum, LTD.’s dental benefit plan through Delta Dental. While enrolled in one of these options, you have access to Delta Dental’s unique dual-network, which allows you to choose from a broader selection of dentists within both of the following networks:

Delta Dental PPOsm gives you the lowest out-of-pocket costs. Participating dentists in the network agree to accept lower fees for procedures, providing larger discounts that result in savings for Delta Dental members.

Delta Dental Premier® is the largest dental network in the country. In fact, more than 4 out of 5 dentists in the nation have agreed to accept Delta Dental’s pre-negotiated fees for dental procedures.

As a Delta Dental subscriber, you may see any dentist. However, when you select a dentist within the Delta Dental PPO or Delta Dental Premier networks, you are guaranteed the fullest benefits from your program. If you seek dental care from a provider out-of-network, you will be responsible for paying any remaining balance above Delta Dental’s contracted rate. To find a network provider near you, call Delta Dental’s Customer Service at 800.553.9536 or visit www.deltadentalmn.org.

Benefits Delta Dental PPO

Delta Dental Premier

Out - of - Network

Calendar Year Plan Maximum (per person) $1,500 $1,500 $1,500

Lifetime Orthodontia Maximum (per person) $1,500 $1,500 $1,500

Annual Deductible - Does not apply to Diagnostic & Preventive services

$50 per person $150 per family



Covered Immediately - No Waiting Period

Diagnostic & Preventive - Annual Exam, Cleanings, X-Rays, Fluoride treatments, Space Maintainers, Sealants

100% 100% 100%

Basic Restorative Services - Emergency treatment for pain relief, Fillings

80% 80% 80%

Endodontics - Root canal therapy, pulpotomies 80% 80% 80%

Periodontics - surgical / non-surgical 80% 80% 80%

Oral Surgery - surgical / non-surgical extractions, other covered oral surgery

80% 80% 80%

Major Restorative - Crowns, crown repair 50% 50% 50% Prosthetic Repairs/Adjustments - Denture adjustments and repairs

50% 50% 50%

Prosthetics - Dentures, Bridges 50% 50% 50%

Orthodontics - Available for dependent child(ren) aged 8 to 18 50% 50% 50%

Services Covered After a 12 Month Waiting Period

Bi-Weekly Pay Weekly Pay

Employee $15.97 $7.98

Employee + Spouse $32.18 $16.09

Employee + Child(ren) $39.93 $19.97

Family $56.08 $28.04



15 | Magnum, LTD.

Voluntary Vision Insurance Administered by Avesis

Your eye examination and caring for your eyes is important to your overall health. Eye examinations diagnose much more than the need for corrective lenses. When enrolled in this plan, you have access to a comprehensive network of providers with Avesis. Though you can go to any vision provider, you will receive the highest benefit from the plan when you visit an in-network provider. When seeing an in-network provider, you will pay copays for services and materials, however, when you see an out-of-network provider, you will be reimbursed up to the plan’s out-of-network allowance. To find a network provider, visit www.avesis.com or call Avesis Customer Service at 800.828.9341.

Service In-Network Out-of-Network Reimbursement

Lenses — once every 12 months

Single Vision Lenses $10 copay Up to $25

Lined Bifocal Lenses $10 copay Up to $40

Lined Trifocal Lenses $10 copay Up to $50

Frames — once every 24 months

$10 copay; $50 wholesale allowance; up to a $150 retail value

Up to $45

Contact Lenses —Elective once every 12 months if you elect contacts instead of lenses/frames

$10 copay; $130 allowance Up to $110

Contact Lenses — Medically Necessary

No charge, covered in full Up to $250

Eye Exam — once every 12 months

$10 copay Up to $35

Lenticular Lenses $10 copay Up to $80

All Other Progressives Lenses Covered up to $50 + 20% off remaining

balance Up to $40

Level 1 Progressives Lenses $75 copay Up to $40

Level 2 Progressives Lenses $110 copay Up to $40



Bi-Weekly Pay Weekly Pay

Employee $3.60 $1.80

Employee + Spouse $8.34 $4.17

Employee + Child(ren) $8.34 $4.17

Family $8.34 $4.17

16 | Magnum, LTD.

Basic Life and Accidental Death & Dismemberment (AD&D) Administered by UNUM

Life and Accidental Death & Dismemberment (AD&D) This benefit is 100% paid by Magnum, LTD., and provides you with Life and Accidental Death and Dismemberment (AD&D) insurance of $15,000. The benefit will be reduced to 65% when you reach age 70 and 55% when you reach age 75. This is a Term Life Policy and does not build cash value.

Choosing your Beneficiaries When enrolling in Life and AD&D insurance, you have the opportunity to name both “primary” and “contingent” beneficiaries. In the event of your death, the designated primary beneficiary receives the death benefit. A contingent beneficiary would receive the death benefit if the primary beneficiary cannot be found. The best way to make sure that your death benefit is paid out correctly is to include your beneficiaries’ birth dates and social security numbers when designating your beneficiaries.

Voluntary Supplemental Life and Accidental Death & Dismemberment (AD&D) Administered by UNUM

You may purchase Life and AD&D insurance in addition to the company-provided coverage, for yourself, your spouse and dependent children on a payroll deduction basis. When you first become eligible, you can purchase up to the guarantee issued coverage without answering medical questions. If you apply for coverage that is above the Guaranteed Coverage Amount, or if you are applying for coverage after your initial eligibility period, you must fill out a Medical Evidence of Insurability form. This is a Term Life Policy and does not build cash value.

Employee Supplemental Life and AD&D You may purchase in increments of: $10,000

Guarantee issue: $180,000

Maximum amount you can purchase: Lesser of 5 x annual salary or $500,000

Spouse Supplemental Life and AD&D If you choose to enroll yourself, you may also enroll your spouse in Supplemental Life coverage.

You may purchase in increments of: $5,000

Guarantee issue: $50,000

Maximum amount you can purchase: Lesser of 100% of employee amount or $250,000

Child(ren) Supplemental Life and AD&D If you choose to enroll yourself, you may also enroll your child(ren) in Supplemental Life coverage. Children coverage is limited to age 19 or 25 if a full-time student.

You may purchase in increments of: $2,000

Maximum amount you can purchase: $10,000

The benefit available for children from 14 days to 6 months old is limited to $1,000. All amounts of dependent child coverage applied for up to the maximum of $10,000 are guaranteed without needing to provide Evidence of Insurability.

Guaranteed Issue - For amounts over Guarantee Issue amount of $180,000 for you or $50,000 for your spouse, you must complete an Evidence of Insurability form and be approved for the coverage. If the additional amount over $180,000 for you or $50,000 for your spouse is declined, you will still receive the Guarantee Issue amount. All amounts of dependent child coverage applied for ($2,000, $4,000, $5,000 or $10,000) are guaranteed without needing to provide Evidence of Insurability.

17 | Magnum, LTD.

Monthly Supplemental Life and AD&D Rates per $1,000

Age Employee Life Spouse Life

15 - 24 $0.105 $0.105

25 - 29 $0.103 $0.103

30 - 34 $0.129 $0.129

35 - 39 $0.181 $0.181

40 - 44 $0.279 $0.279

45 - 49 $0.444 $0.444

50 - 54 $0.658 $0.658

55 - 59 $0.965 $0.965

60 - 64 $1.277 $1.277

65 - 69 $1.796 $1.796

70 - 74 $3.398 $3.398

75 + $10.503 $10.503

Employee / Spousal AD&D $0.06

Child Life / AD&D $0.322 / $0.06

*Choose the age you will be when your coverage becomes effective.

What will it cost you per pay period?

Example Monthly Rate Calculated

A 38-year-old employee elects $50,000 of Voluntary Supplemental Life without Voluntary AD&D coverage (assuming 52 pay periods)

Monthly Rate Calculation Tool

Life Amount

Multiplied by Rate

Divided by 1,000

Multiplied by 12

periods per year

(26 or 52)*

Employee Supplemental Life

$50,000 $0.181 = $9,050 / 1,000 $9.05 x 12 $108.60 / 52 $2.09

Divided by 1,000

Multiplied by 12

periods per year (26 or 52)*

$ _

/ 1,000 $ ___ / (26 or 52)* $ _

$

/ 1,000 $ ___ / (26 or 52)* $ _

Spouse Supplemental Life $

/ 1,000 $ ___ / (26 or 52)* $ _

$

/ 1,000 $ ___ / (26 or 52)* $ _

Child Supplemental Life $

/ 1,000 $ ___ / (26 or 52)* $ _

Child Supplemental AD&D $

/ 1,000 $ ___ / (26 or 52)* $ _

Monthly Rate Calculation Tool

Voluntary Supplemental Life and Accidental Death & Dismemberment (AD&D) Cont.

18 | Magnum, LTD.

Voluntary Short-Term Disability (VSTD) Administered by UNUM If you become disabled, you may be unable to work and, therefore, your income may be reduced. Unfortunately, your expenses and bills always continue. If you experience a disability that kept you from earning an income, how would you pay for your mortgage/rent, groceries, credit card bills, car insurance, medical bills, and utilities? When purchasing this coverage, you choose from $100 to $2,400 a week (purchased in $100 increments). You can cover up to 60% of your pre-disability weekly income. There are two options to choose from: Option 1 provides 12 weeks of coverage with a 7 day waiting period, and Option 2 provides 11 weeks of coverage with a 14 day waiting period. Employees will be auto enrolled into Plan Option 2, the lowest cost plan, with $100 weekly benefit and are able to purchase additional coverage under both Options 1 and 2. Employees wishing to waive coverage will need to actively change their auto enrollment election.

Plan Options

Option 1 Option 2

Waiting Period 7 days for Accident; 7 days for Illness 14 days for Accident; 14 days for Illness

Percent of Income Replacement 60% of pre-disability earnings to a maximum

weekly benefit of $2,400 60% of pre-disability earnings to a maximum weekly

benefit of $2,400

Maximum Benefit Period 12 weeks 11 weeks

Pre-Existing Condition Limitation 3/12; if you received medical treatment, consultation, care or services including diagnostic measures for the condition, or took prescribed drugs or medicines for it in the 3 months prior to your effective date of coverage,

the disability will not be covered in the first 12 months after your effective date of coverage.

Monthly Rate per $100 Age Option 1 Option 2

<25 $4.607 $3.515

25-29 $5.720 $4.368

30-34 $7.644 $5.834

35-39 $7.904 $6.032

40-44 $9.100 $6.947

45-49 $11.398 $8.705

50-54 $15.236 $11.638

55-59 $20.800 $15.891

60-64 $26.364 $20.134

65+ $32.053 $24.482

weekly earnings replacement Maximum weekly benefit

$ / 52 $ x 60%

x 12 Divided by number of pay

periods per year (26 or 52)* $ / 100 $ x / (26 or 52)* $

Common Reasons to Purchase this Protection

Injuries Back Disorders Joint Disorders

Normal Pregnancy Digestive Disorders

Reasons to buy this coverage at work-TODAY

Competitive group rates you won’t find outside your workplace

If you apply during your initial enrollment, you can get this coverage without a health exam or medical questions

Premium is conveniently deducted from your paycheck

Premiums

How to file a STD claim, see page 43

*Your rate is based on the age you will be as of January 1st of this plan year.

What will it cost you per pay period? 1) Calculate your weekly disability benefit.

2) Calculate your cost per paycheck. Enter the weekly benefit amount you would want if disabled. This amount needs to be in $100 increments from $100 to the maximum weekly benefit available (calculated in step 1). Enter your rate from the rate chart above, based on your age and plan options you want:

19 | Magnum, LTD.

Voluntary Long-Term Disability (VLTD) Administered by UNUM Meeting your basic living expenses can be a real challenge if you become disabled. Your options may be limited to personal savings, spousal income, and possibly Social Security. Over a long period of time, this can eat through the financial safety nets you’ve worked hard to build. This long-term benefit provides protection for your most valuable asset – your ability to earn an income. You can purchase coverage from $200 to $11,000 a month (purchased in $100 increments), up to 60% of your pre-disability monthly income.

monthly earnings replacement

Maximum monthly benefit not to exceed $11,000

Round to nearest $100 $ / 12 $ x 60%

x 12 Divided by number of pay

periods per year (26 or 52)*

$ / 100 $ x / (26 or 52)* $

Benefit Summary

Elimination Period 90 days of disability

Percent of Income Replacement 60% of pre-disability earnings to a maximum monthly benefit of $11,000

Maximum Benefit Period Social Security

Pre-Existing Condition Limitation 3/12; if you received medical treatment, consultation, care or services including diagnostic measures for the condition, or took prescribed drugs or medicines for it in the 3 months prior to your effective date of coverage,

the disability will not be covered in the first 12 months after your effective date of coverage.

Premiums Monthly Rate per $100

Age Rate

<25 $0.27

25-29 $0.34

30-34 $0.60

35-39 $0.98

40-44 $1.70

45-49 $2.37

50-54 $3.14

55-59 $3.87

60-64 $3.74

65-69 $3.09

70+ $2.51

Reasons to buy this coverage at work-TODAY

Competitive group rates you won’t find outside your work-place

If you apply during your initial enrollment, you can get this coverage without a health exam or medical questions

Premium is conveniently deducted from your paycheck This plan covers disabilities that leave you unable to work

or only able to part-time.


2) Calculate your cost per paycheck. Enter the monthly benefit amount you would want if disabled. This amount needs to be in $100 increments from $200 to the maximum monthly benefit available (calculated in step 1). Enter your rate from the rate chart above:

20 | Magnum, LTD.

Voluntary Critical Illness with Cancer Administered by UNUM Out-of-pocket costs associated with an unexpected health issue can be as high as $14,444 for a critical illness, according to a recent survey. Recent studies have shown 42% of all personal bankruptcies are a result of medical expenses. The study also reveals that 78% of those who filed had medical insurance. Voluntary Critical Illness insurance can help you fill the gap of coverage when you are enrolled in a medical plan with a high deductible.

Plan Details

Benefit & Eligibility

Employee: $10,000 or $20,000; employee must be actively at work Spouse: $5,000 or $10,000; age 17 to 64 Child(ren): Dependent Children, newborns to age 26, are automatically covered at 25% of the employee benefit amount (no additional cost)

For amounts over Guarantee Issue amount of $10,000 for your or $5,000 for your spouse, you must complete an Evidence of Insurability form and be approved for the coverage. If the amount over $10,000 for you or $5,000 for your spouse is declined, you will still receive the Guarantee Issue amount. Dependent Children are covered for 25% of the employee coverage amount without Evidence of Insurability.

Covered Conditions

Receive 100% of the benefit amount for: Cancer, Heart Attack, Kidney Failure, Major Organ Transplant, Stroke, Permanent Paralysis as result of Covered Accident, Coma as result of Severe Traumatic Brain Injury, Blindness, and Benign Brain Tumor. Receive 25% of the benefit amount for: Carcinoma in Situ and Coronary Artery Bypass Surgery.

This is a summary of covered illnesses; consult the plan document for a full listing.

Benefit Reduction Benefit reduces by 50% on the policy anniversary date following the insured’s 70th birthday.

Pre-Existing Conditions 12/12; Pre-existing condition is an illness or injury for which you received treatment within the 12 months prior to your effective date of coverage. Disabilities that occur during the first 12 months of coverage due to a pre-existing condition are excluded.

Additional Features Health Screening Benefit: $75 annual benefit for each person on the plan when you have a specified health screening test performed. Portability: You can keep your coverage if your employment status changes.

Exclusions and

Generally, benefits will not be paid for a claim incurred in hazardous or illegal occupations, hobbies, or activities. For a full listing of exclusions and limitations, including state-specific exclusions, please refer to your plan document. This plan does not cover sickness / illness.

Monthly Premium per $10,000 of Coverage Age Non-Tobacco Tobacco

<25 $8.00 $11.00

25-29 $8.60 $12.60

30-34 $10.50 $16.90

35-39 $13.40 $23.70

40-44 $18.00 $33.60

45-49 $23.90 $45.50

50-54 $30.80 $59.90

55-59 $39.80 $75.60

60-64 $50.20 $90.20

65-70 $56.20 $93.90

70+ $98.80 $150.10


by 12

x 12

/ (26 or 52)* $ _

For Additional Information, see page 47

21 | Magnum, LTD.

Voluntary Accident Insurance Administered by UNUM

Accidents can lead to trips to the emergency room and the doctor’s office, which could amount to bills and expenses not covered by your medical and disability insurance. Recent studies have shown 42% of all personal bankruptcies are a result of medical expenses. The study also reveals that 78% of those who filed had medical insurance.

Accidents can happen any time, to anyone and when you least expect them – and they can be costly. Even quality medical plans can leave you with extra expenses to pay. Having the financial support you may need when the time comes means less worry for you and your family.

How it works

Rob bought a new bike so he could lose a few pounds — but he lost his balance instead. He was diagnosed with a torn knee ligament and a broken toe. Rob had one lucky break — his accident insurance paid him $1,875!

Covered Event

Ambulance (ground) $400

Emergency Care $150

Fractured Toe $75

Benefit Amount

Follow-up Visits $150

Knee Ligament Repair $1,100

Total Benefit $1,875

Premiums Monthly Premiums Employee $17.66

Employee + Spouse $30.07

Employee + Child (ren) $32.03

Family $44.44

Plan Details

Eligibility Employee: must be actively at work Spouse: age 17 to 64 Child(ren): Dependent children from birth until their 26th birthday, regardless of marital or student status

Coverage 24-hour Coverage (on- and off-job); A summary of covered injuries is included on the next page.

Sickness Hospital Confinement

This optional rider pays you, your spouse or child(ren) a daily benefit if he or she is in the hospital for a covered illness. The benefit amount is $100 per day for you and spouse, children receive 75% of your benefit amount. Benefits may be paid for up to 30 days per covered sickness.

Evidence of Insurability (EOI) At initial enrollment, health questions are not required when first eligible

Schedule of Benefits A summary of benefits is included on the next page; a full schedule of benefits can be found in the Certificate of Coverage.

Additional FeaturesHealth Screening Benefit: $75 annual benefit for each person on the plan when you have a specified health screening test performed. Portability: You can keep your coverage if your employment status changes.

Exclusions and LimitationsGenerally, benefits will not be paid for a claim incurred in hazardous or illegal occupations, hobbies, or activities. For a full listing of exclusions and limitations, including state-specific exclusions, please refer to your plan document. This plan does not cover sickness / illness.


by 12

x 12

/ (26 or 52)* $

For Additional Information, see page 47

22 | Magnum, LTD.

Be Sure to Review this Summary of Benefits - It shows the many ways this coverage can pay a benefit if you are injured

Voluntary Accident Benefits Covered Injuries and Surgical Procedures Benefit Amount

Skull (except bones of face or nose), depressed Skull (except bones of face or nose), non-depressed Hip, Thigh (femur) Face or Nose (except mandible or maxilla) Rib Finger, Toe

$3,750 / $7,500 $1,500 / $3,000 $2,250 / $4,500 $525 / $1,050 $375 / $750 $75 / $150

$450 / $900

Hip Ankle Collarbone (sternoclavicular) Rib Elbow, Wrist Collarbone (acromioclavicular and separation)

$3,000 / $6,000 $1,200 / $2,400 $750 / $1,500 $450 / $900 $450 / $900 $150 / $300 $150 / $300

35 or more square inches of the body surface

At least 10 square inches, but less than 20 square inches; or At least 20 square inches, but less than 35 square inches; or 35 or more square inches of the body surface

for 2nd or 3rd degree burns

At least 10 square inches, but less than 20 square inches; or At least 20 square inches, but less than 35 square inches; or 35 or more square inches of the body surface

$1,000

$2,500 $5,000

$10,000

50%

$150 $250 $500

Coma Concussion Dental (emergency) - crown / extraction Eye Injury Laceration

$10,000

$150 $300 / $100

$300 $25 to $600

Ambulance Ground / Air

$400 / $1,500

Emergency Room Treatment Emergency Treatment in Physician Office/Urgent Care Physician Follow-up Visit (2 visits per accident)

$150 $75 $75

Travel - Lodging (per day up to 30 days per accident) Travel - Transportation (maximum of $1,440)

$150 $0.40

Basic Accidental Death Benefit AD Common Carrier Benefit**

$50,000 / $20,000 / $10,000 $150,000 / $60,000 / $30,000

Initial Accidental Dismemberment Catastrophic Accidental Dismemberment

Up to $15,000

Up to $100,000

* For a full listing, review your Certificate of Coverage. ** Common Carrier refers to airplanes, trains, buses, trolleys, subways and boats. Certain conditions apply. See your Disclosure Statement or Outline of Coverage/Disclosure Document for specific details.

23 | Magnum, LTD.

UNUM’s $75 Annual Wellness Benefit Administered by UNUM

Your UNUM Voluntary Accident and Critical Illness plans pays a Wellness Benefit for one wellness test each year. With UNUM’s Wellness Benefit, you and other covered family members can receive a valuable incentive for important tests and screenings. Many of these tests are routinely performed, so it’s easy to take advantage of this benefit. Only one health screening benefit will be paid per covered person per calendar year. This means UNUM will pay a total of $150 ($75 per eligible wellness test) each calendar year per covered member, if the member is enrolled in both the Accident and Critical Illness plans

Most Common Tests and Screenings Include

Blood test for triglycerides

Fasting blood glucose test

Mammography

Pap Smear

Serum cholesterol test to determine HLD and LDL levels

Bone marrow aspiration or biopsy

CA 15-3 (blood test for breast cancer)

CA-125 (blood test for ovarian cancer)

CEA (blood test for colon cancer)

Carotid Doppler

Chest X-ray

Colonoscopy

Electrocardiogram

Fasting plasma glucose (FPG)

Flexible Sigmoidoscopy

Hemoglobin A1C (HbA1c)

Hemoccult stool analysis

PSA (blood test for prostate cancer)

Serum protein electrophoresis (blood test for myeloma)

Skin cancer biopsy

Stress test on a bicycle or treadmill

Thermography

Thin prep pap test

Two-hour post-load plasma glucose

Virtual colonoscopy

Other Tests and Screenings Include

How do you Receive the Wellness Benefit?

1. Submit proof that a health screening measure was taken.

You can file your claim online with a one-time registration on unum.com, by mail or over the phone. Simply call 800.635.5597 for more information.

2. You will need to provide the following information:

» First and last name of the employee and claimant (the employee might not be the claimant)

» Employee’s Social Security number or policy number

» Name and date of the test

» Physician’s name and the facility name where the test was performed

24 | Magnum, LTD.

Voluntary Whole Life Administered by UNUM

Why Might I Purchase Whole Life Insurance on Top of My Term Life Insurance? Like Term Life Insurance, Whole Life Insurance is cheaper when you first purchase a policy. While Term Life Insurance gets more expensive as you age and renew your policies, Whole Life Insurance premiums are locked-in for the life of the policy at the issue-age rate. Why wait? Lock in a lower premium TODAY! Your Whole Life Insurance can also build cash value over time, which you can use later in life to buy a smaller “paid-up” policy with no more premiums due.

Plan Details

Employee: Choose $10,000, $20,000, $30,000 or $40,000.

Child(ren): Choose $10,000 or $20,000. Either employee or spouse has the option of choosing a standalone policy for

Child: $10,000 For amounts over Guarantee Issue amount, you must complete an Evidence of Insurability form and be approved for the

The Paid-Up Option is 120/70. This Policy is guaranteed renewable to age 120, at which point the policy will mature. If enrolling between the ages of 15 and 50, you have the option to purchase a Paid-Up Option. If you choose the Paid-Up option, your premiums are due until age 70, at which point your policy will be paid up with no additional premiums due for the remaining life of the policy. Rates are different if choosing the Paid-Up Option.

Long Term Care (LTC)

You can use your Life Insurance benefit to help pay for Long Term Care (LTC) received at home, in a nursing home or assisted living facility, or adult day care. LTC payments reduce the death benefit until exhausted. Long Term Care (LTC) coverage is not included on policies with Face Amounts less than $10,000 ($18,000 in Oregon). Coverage is not available in HI, NY, and UT. For new coverage (not increased/stacked), employee may choose the LTC Restoration Rider (subject to

Portability: This an individually owned policy; you can keep your coverage if your employment status changes. Living Benefits / Terminal Illness: This policy features a living benefit that will pay out if you are diagnosed with a terminal illness. Any payout of a living benefit in case of terminal illness with reduce the sum of the death benefit.

Premiums Your monthly cost varies based on a variety of factors, including your issue age, tobacco use, amount of benefit being applied for, optional purchase of the Long Term Care Rider or Paid-Up at Age 70 Option. This is a sampling of premiums only, please consult the plan documents for exact pricing based on your situation.

SAMPLE Monthly Premiums for $30,000 Final Expense Benefit Non-Tobacco Tobacco

Monthly Premium Cash Value at 65 Monthly Premium Cash Value at 65 20 $18.59 $12,205 $32.33 $13,894

30 $26.74 $11,295 $44.20 $12,822

40 $42.99 $9,736 $71.76 $10,979

50 $75.71 $7,020 $125.37 $7,760

Issue Age

What might it cost you per pay period based on the SAMPLE premiums above? A 20-year-old employee elects $30,000 of Whole Life coverage as a Non-Tobacco User (assuming 52 pay periods).

$18.59 x 12 = $223.08 / 52 $4.29

25 | Magnum, LTD.

Employee Assistance Program (EAP) Administered by UNUM

This program is available to you even if you do not elect benefits through Magnum’s benefits package.

Turn to us, when you don’t know where to turn. Everyone grapples with personal and work-related issues from time to time. Don’t do it alone. Take advantage of your Employee Assistance Program and Work/Life Balance services, included free of charge with your Unum benefits. You and your family can call the Employee Assistance Program for things like:

Personal, family and work issues:

Stress, anxiety and depression

Relationship issues, divorce

Anger, grief and loss

Addiction, eating disorders, mental illness

And more

Unlimited help over the phone

Talk to a Licensed Professional Counselor or Work/Life Specialist over the phone. Compassionate professionals are there to listen, help you define your issues, and put you in touch with expert resources in your community for additional support. Just call 800.854.1446. Three free in-person counseling sessions When phone support isn’t enough, you can take advantage of three in-person visits with a Licensed Professional Counselor, included at no additional charge with your EAP. Your counselor will provide short-term support and advice, and help you find local resources for ongoing care, if necessary. Other valuable benefits Monthly webinars

Educational materials

Provider search tool Who’s covered You

Your spouse

Your dependent children

Your parents and parents-in-law If you experienced a medical emergency while traveling, would you know who to call?

Whenever you travel 100 miles or more from home — to another country or just another city — be sure to pack your worldwide emergency travel assistance phone number! Travel assistance speaks your language, helping you locate hospitals, embassies and other “unexpected” travel destinations. Add the number to your cell phone contacts, so it’s always close at hand! Just one phone call connects you and your family to medical and other important services 24 hours a day. Download the Assist America app.

Assist America Within the U.S.: 1-800-872-1414 Outside the U.S.: 609-986-1234 Via e-mail: [email protected] Reference number: 01-AA-UN-762490

Work / Life balance issues:

Finding childcare

Accessing legal help

Locating eldercare services

Managing your finances

Reducing medical bills (ask about out medical Bill Saver service)

And more

26 | Magnum, LTD.

Annual Notices

1. HIPAA Special Enrollment Rights

2. Women’s Health & Cancer Rights Act

3. HIPAA Notice of Privacy Practices Reminder

4. Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)

5. COBRA General Notice

6. Notice of Creditable Coverage

LTD. plan(s), please make sure they also have the opportunity to review this information.

HIPAA Special Enrollment Rights

Magnum, LTD. Health Plan Notice of Your HIPAA Special Enrollment Rights

Our records show that you are eligible to participate in the Magnum, LTD. Health Plan (to actually participate, you must complete an enrollment form and pay part of the premium through payroll deduction).

A federal law called HIPAA requires that we notify you about an important provision in the plan - your right to enroll in the plan under its “special enrollment provision” if you acquire a new dependent, or if you decline coverage under this plan for yourself or an eligible dependent while other coverage is in effect and later lose that other coverage for certain qualifying reasons.

Loss of Other Coverage (Excluding Medicaid or a State Children’s Health Insurance Program). If you decline enrollment for yourself or for an eligible dependent (including your spouse) while other health insurance or group health plan coverage is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 31 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

Loss of Coverage for Medicaid or a State Children’s Health Insurance Program. If you decline enrollment for yourself or for an eligible dependent (including your spouse) while Medicaid coverage or coverage under a state children’s health insurance program is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage. However, you must request enrollment within 60 days after your or your dependents’ coverage ends under Medicaid or a state children’s health insurance program.

New Dependent by Marriage, Birth, Adoption, or Placement for Adoption. If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your new dependents. However, you must request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.

Eligibility for Premium Assistance Under Medicaid or a State Children’s Health Insurance Program – If you or your dependents (including your spouse) become eligible for a state premium assistance subsidy from Medicaid or through a state children’s health insurance program with respect to coverage under this plan, you may be able to enroll yourself and your dependents in this plan. However, you must request enrollment within 60 days after your or your dependents’ determination of eligibility for such assistance.

To request special enrollment or to obtain more information about the plan’s special enrollment provisions, contact Jennifer Moran - Human Resource Coordinator at 701.451.6492 or [email protected].

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Important Warning

If you decline enrollment for yourself or for an eligible dependent, you must complete our form to decline coverage. On the form, you are required to state that coverage under another group health plan or other health insurance coverage (including Medicaid or a state children’s health insurance program) is the reason for declining enrollment, and you are asked to identify that coverage. If you do not complete the form, you and your dependents will not be entitled to special enrollment rights upon a loss of other coverage as described above, but you will still have special enrollment rights when you have a new dependent by marriage, birth, adoption, or placement for adoption, or by virtue of gaining eligibility for a state premium assistance subsidy from Medicaid or through a state children’s health insurance program with respect to coverage under this plan, as described above. If you do not gain special enrollment rights upon a loss of other coverage, you cannot enroll yourself or your dependents in the plan at any time other than the plan’s annual open enrollment period, unless special enrollment rights apply because of a new dependent by marriage, birth, adoption, or placement for adoption, or by virtue of gaining eligibility for a state premium assistance subsidy from Medicaid or through a state children’s health insurance program with respect to coverage under this plan.

Women’s Health & Cancer Rights Act If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (“WHCRA”). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:

All stages of reconstruction of the breast on which the mastectomy was performed;

Surgery and reconstruction of the other breast to produce a symmetrical appearance;

Prostheses; and

Treatment of physical complications of the mastectomy, including lymphedema.

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under the plan. Therefore, the following deductibles and coinsurance apply:

Plan 1: $3,000-0% HSA Plan (Individual: 0% coinsurance and $3,000 deductible; Family: 0% coinsurance and $6,000 deductible)



If you would like more information on WHCRA benefits, please call your Plan Administrator at 701.451.6492 or [email protected].

HIPAA Notice of Privacy Practices Reminder Protecting Your Health Information Privacy Rights

Magnum, LTD. is committed to the privacy of your health information. The administrators of the Magnum, LTD. Health Plan (the “Plan”) use strict privacy standards to protect your health information from unauthorized use or disclosure.

The Plan’s policies protecting your privacy rights and your rights under the law are described in the Plan’s Notice of Privacy Practices. You may receive a copy of the Notice of Privacy Practices by contacting Jennifer Moran - Human Resource Coordinator at 701.451.6492 or [email protected].

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Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2021. Contact your State for more information on eligibility –

ALABAMA – Medicaid CALIFORNIA – Medicaid

Website: http://myalhipp.com/ Phone: 1-855-692-5447

Website: Health Insurance Premium Payment (HIPP) Program http://dhcs.ca.gov/hipp Phone: 916-445-8322 Email: [email protected]

ALASKA – Medicaid COLORADO – Health First Colorado (Colorado’s

Medicaid Program) & Child Health Plan Plus (CHP+)

The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: [email protected] Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: https://www.colorado.gov/pacific/hcpf/child-health-plan-plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711 Health Insurance Buy-In Program (HIBI): https://www.colorado.gov/pacific/hcpf/health-insurance-buy-program HIBI Customer Service: 1-855-692-6442

ARKANSAS – Medicaid FLORIDA – Medicaid

Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/hipp/index.html Phone: 1-877-357-3268

GEORGIA – Medicaid MASSACHUSETTS – Medicaid and CHIP

Website: https://medicaid.georgia.gov\health-insurance-premium-payment-program-hipp Phone: 678-564-1162 ext 2131

Website: https://www.mass.gov/info-details/masshealth-premium-assistance-pa Phone: 1-800-862-4840

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INDIANA – Medicaid MINNESOTA – Medicaid

Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: https://www.in.gov/medicaid/ Phone 1-800-457-4584

Website: https://mn.gov/dhs/people-we-serve/children-and- families/health-care/health-care-programs/programs-and- services/other-insurance.jsp Phone: 1-800-657-3739

IOWA – Medicaid and CHIP (Hawki) MISSOURI – Medicaid

Medicaid Website: https://dhs.iowa.gov/ime/members Medicaid Phone: 1-800-338-8366 Hawki Website: http://dhs.iowa.gov/Hawki Hawki Phone: 1-800-257-8563 HIPP Website: https://dhs.iowa.gov/ime/members/medicaid-a-to-z/hipp HIPP Phone: 1-888-346-9562

Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005

KANSAS – Medicaid MONTANA – Medicaid

Website: https://www.kancare.ks.gov/ Phone: 1-800-792-4884

Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084

KENTUCKY – Medicaid NEBRASKA – Medicaid

Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: 1-855-459-6328 Email: [email protected]

KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx Phone: 1-877-524-4718

Kentucky Medicaid Website: https://chfs.ky.gov

Website: http://www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178

LOUISIANA – Medicaid NEVADA – Medicaid

Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP)

Medicaid Website: http://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900

MAINE – Medicaid NEW HAMPSHIRE – Medicaid

Enrollment Website: https://www.maine.gov/dhhs/ofi/applications-forms Phone: 1-800-442-6003 TTY: Maine relay 711 Private Health Insurance Premium Webpage: https://www.maine.gov/dhhs/ofi/applications-forms Phone: -800-977-6740. TTY: Maine relay 711

Website: https://www.dhhs.nh.gov/oii/hipp.htm Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345, ext 5218

NEW JERSEY – Medicaid and CHIP SOUTH DAKOTA – Medicaid

Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710

Website: http://dss.sd.gov Phone: 1-888-828-0059

NEW YORK – Medicaid TEXAS – Medicaid

Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831

Website: http://gethipptexas.com/ Phone: 1-800-440-0493

NORTH CAROLINA – Medicaid UTAH – Medicaid and CHIP

Website: https://medicaid.ncdhhs.gov/ Phone: 919-855-4100

Medicaid Website: https://medicaid.utah.gov/CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669

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NORTH DAKOTA – Medicaid VERMONT – Medicaid

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825

Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427

OKLAHOMA – Medicaid and CHIP VIRGINIA – Medicaid and CHIP

Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

Website: https://www.coverva.org/en/famis-select https://www.coverva.org/en/hipp Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-800-432-5924

OREGON – Medicaid WASHINGTON – Medicaid

Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075

Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022

PENNSYLVANIA – Medicaid WEST VIRGINIA – Medicaid

Website: https://www.dhs.pa.gov/providers/Providers/Pages/Medical/HIPP-Program.aspx Phone: 1-800-692-7462

Website: http://mywvhipp.com/ Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

RHODE ISLAND – Medicaid and CHIP WISCONSIN – Medicaid and CHIP

Website: http://www.eohhs.ri.gov/ Phone: 1-855-697-4347, or 401-462-0311 (Direct Rite Share Line)

Website: https://www.dhs.wisconsin.gov/badgercareplus/p- 10095.htm Phone: 1-800-362-3002

SOUTH CAROLINA – Medicaid WYOMING – Medicaid

Website: https://www.scdhhs.gov Phone: 1-888-549-0820

Website: https://health.wyo.gov/healthcarefin/medicaid/programs- and-eligibility/ Phone: 1-800-251-1269

To see if any other states have added a premium assistance program since July 31, 2021, or for more information on special enrollment rights, contact either:

U.S. Department of Labor U.S. Department of Health and Human Services

Employee Benefits Security Administration Centers for Medicare & Medicaid Services

www.dol.gov/agencies/ebsa www.cms.hhs.gov

1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email [email protected] and reference the OMB Control Number 1210-0137.

OMB Control Number 1210-0137 (expires 1/31/2023)

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COBRA General Notice

Model General Notice of COBRA Continuation Coverage Rights (For use by single-employer group health plans)

** Continuation Coverage Rights Under COBRA**

Introduction

You’re getting this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage.

The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.

You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.

What is COBRA continuation coverage?

COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.

If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:

Your hours of employment are reduced, or

Your employment ends for any reason other than your gross misconduct.

If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:

Your spouse dies;

Your spouse’s hours of employment are reduced;

Your spouse’s employment ends for any reason other than his or her gross misconduct;

Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or

You become divorced or legally separated from your spouse.

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Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events:

The parent-employee dies;

The parent-employee’s hours of employment are reduced;

The parent-employee’s employment ends for any reason other than his or her gross misconduct;

The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);

The parents become divorced or legally separated; or

The child stops being eligible for coverage under the Plan as a “dependent child.”

When is COBRA continuation coverage available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events:

The end of employment or reduction of hours of employment;

Death of the employee; or

The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).

For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to: Jennifer Moran. How is COBRA continuation coverage provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. There are also ways in which this 18-month period of COBRA continuation coverage can be extended:

Disability extension of 18-month period of COBRA continuation coverage

If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage.

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Second qualifying event extension of 18-month period of continuation coverage

If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.

Are there other coverage options besides COBRA Continuation Coverage?

Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicare, Medicaid, Children’s Health Insurance Program (CHIP), or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov/.

Can I enroll in Medicare instead of COBRA continuation coverage after my group health plan coverage ends?

In general, if you don’t enroll in Medicare Part A or B when you are first eligible because you are still employed, after the Medicare initial enrollment period, you have an 8-month special enrollment period1 to sign up for Medicare Part A or B, beginning on the earlier of

The month after your employment ends; or

The month after group health plan coverage based on current employment ends.

If you don’t enroll in Medicare and elect COBRA continuation coverage instead, you may have to pay a Part B late enrollment penalty and you may have a gap in coverage if you decide you want Part B later. If you elect COBRA continuation coverage and later enroll in Medicare Part A or B before the COBRA continuation coverage ends, the Plan may terminate your continuation coverage. However, if Medicare Part A or B is effective on or before the date of the COBRA election, COBRA coverage may not be discontinued on account of Medicare entitlement, even if you enroll in the other part of Medicare after the date of the election of COBRA coverage.

If you are enrolled in both COBRA continuation coverage and Medicare, Medicare will generally pay first (primary payer) and COBRA continuation coverage will pay second. Certain plans may pay as if secondary to Medicare, even if you are not enrolled in Medicare.

For more information visit https://www.medicare.gov/medicare-and-you.

If you have questions

Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.healthcare.gov.

1https://www.medicare.gov/sign-up-change-plans/how-do-i-get-parts-a-b/part-a-part-b-sign-up-periods.

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Keep your Plan informed of address changes

To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.

Plan contact information

Magnum, LTD.

Jennifer Moran - Human Resource Coordinator

3000 7th Avenue N PO Box 2023

Fargo, North Dakota 58103

United States

701.451.6492

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Annual Medicare Part D Certification Important Information Applies if you or one of your dependents is on Medicare or becomes covered under Medicare while you remain an active employee. Medicare offers insurance coverage for prescription drugs through Medicare Part D. MAGNUM, LTD. Medical Plan will continue to offer prescription drug coverage as a benefit under these plans for active employees and their covered dependents. Magnum’s coverage is considered ‘creditable coverage’, which means Magnum’s Medical Plans’ prescription drug benefits provide coverage at least as good as or better than Medicare Part D. If you or one of your dependents is on Medicare or becomes covered under Medicare while you remain an active employee, please print the Certificate of Creditable Coverage, and keep it in your records. This Certificate of Creditable Coverage will allow you and your dependents to join Medicare Part D in the future without paying late enrollment fees.

During your employment, you have the option to choose to continue your prescription drug coverage through Magnum’s Medical Plan or to elect Medicare Part D. However, if you choose to elect Medicare Part D, you will not be eligible to participate in Magnum’s Medical Plan that provide both medical and prescription drug coverage. Please read materials sent to you from Medicare or other Medicare Part D providers carefully before making your decision.

Notice of Creditable Coverage

Important Notice from Magnum, LTD.

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 Magnum, LTD. 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:

1. 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.

2. Magnum, LTD. has determined that the prescription drug coverage offered by the medical plan 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.

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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 Magnum, LTD. coverage will not be affected. The $3,000-0% HSA, $5,000-0% HSA, and the $6,350-0% HSA plans offer the following prescription drug coverage for a 1-month supply: 100% coverage after the deductible. Members may keep this coverage if they elect part D and this plan will coordinate with Part D coverage. See pages 7- 9 of the CMS Disclosure of Creditable Coverage To Medicare Part D Eligible Individuals Guidance (available at http://www.cms.hhs.gov/CreditableCoverage/), which outlines the prescription drug plan provisions/ options that Medicare eligible individuals may have available to them when they become eligible for Medicare Part D.

If you do decide to join a Medicare drug plan and drop your current Magnum, LTD. coverage, be aware that you and your dependents may be able to get this coverage back.

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 Magnum, LTD. 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 Magnum, LTD. 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).

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Date: January 01, 2022

Name of Entity/Sender: Magnum, LTD.

Contact—Position/Office: Jennifer Moran - Human Resource Coordinator

Office Address: 3000 7th Avenue N PO Box 2023

Fargo, North Dakota 58103

United States

Phone Number: 701.451.6492

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).

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FAQs about Health Savings Accounts (HSAs)

A Health Savings Account is a tax-advantaged account that helps you to save money on health care expenses. You must be enrolled in a high deductible healthcare plan to enroll in an HSA. The questions and answers provide more information about HSAs.

16. What expenses are not covered under an HSA?

17. What happens if I use HSA funds to pay for an ineligible expense?

18. Can I use HSA funds toward medical expenses incurred before I established my HSA?

19. Can I delay enrollment in Medicare so that I can remain HSA-eligible?

20. Can I transfer funds from an Individual Retirement Account (IRA) to my HSA?

21. If I elect the HDHP mid-year, how much can I contribute to my HSA?

22. If I have a family status change mid-year and drop the HDHP, what is the maximum amount I can contribute to my HSA?

23. If I have a family status change and my HDHP coverage changes from single to family coverage, what is the maximum amount I can contribute to my HSA?

24. If I have a family status change that changes my HDHP coverage from family to single, what is the maximum amount I can contribute to my HSA?

25. What happens to my HSA if I get a job at a new company that doesn’t have an HSA-qualified option?

1. What is a health savings account (HSA)?

2. Why is it a good idea to have an HSA?

3. Who can establish an HSA?

4. What is a qualified high deductible health plan (HDHP)?

5. What is the 2022 IRS HSA contribution limit?

6. Will Magnum, LTD. contribute to my HSA?

7. How do I make HSA contributions?

8. If my spouse and I have separate HSAs, can we each contribute to the IRS maximum?

9. What happens if I contribute more than the annual IRS limit?

10. Can I pay for the medical expenses of my spouse and/or children with my HSA even if they’re not covered under my HSA-qualified coverage?

11. Does my HSA earn interest?

12. When can I use my HSA funds?

13. What are eligible HSA expenses?

14. Are over-the-counter (OTC) medicines eligible expenses?

15. What OTC items are eligible expenses?

*This information being provided is for general educational purposes only. If you have specific questions about your benefits, please contact the human resources department.

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FAQs about Health Savings Accounts (HSAs) 1. What is a health savings account (HSA)?

A health savings account is a healthcare bank account. The main purpose of this account is to offset the cost of a qualified high deductible health plan (HDHP) and provide savings for your out-of-pocket eligible healthcare expenses.

You own your HSA! It’s yours to keep, even if you change jobs, change benefit plans or retire.

Once your HSA is established, money that is deposited in your account can be used tax-free to pay for eligible healthcare expenses. You save money on expenses you’re already paying for, like doctor office visits, prescription drugs, and much more. Best of all, you decide how and when to use your HSA dolars.

3. Who can establish an HSA?

IRS guidelines govern HSA eligibility, and not everyone can set up an HSA. Eligibility requirements for establishing an HSA are:

You must have coverage under a qualified HDHP You can’t participate in another health plan that’s not a qualified HDHP, such as your spouse’s plan or a general-

purpose healthcare FSA You cannot be enrolled in Medicare You cannot be claimed as a dependent on someone else’s

tax return

2. Why is it a good idea to have an HSA? By participating in a qualified HDHP, you will be responsible for most first-dollar medical expenses. An HSA benefits you by allowing you to offset those costs while saving money on taxes in three ways:

Tax-free deposits – The money you contribute to your HSA

isn’t taxed (up to the annual IRS contribution limit) Tax-free earnings – Your interest and any investment earnings

grow tax-free Tax-free withdrawals – The money used toward eligible

healthcare expenses isn’t taxed – now or in the future By allocating pre-tax dollars to your HSA, you pay less in taxes. This allows you to save money on eligible expenses that you are paying for out of your pocket. The amount you save depends on your tax bracket. For example, if you are in the 30 percent tax bracket, you can save $30 on every $100 spent on eligible healthcare expenses. HSA funds accumulate in your account just like with a personal savings account. There is no “use-it-or-lose-it” rule with an HSA, and you decide how and when to use your HSA funds -- for eligible expenses you have now, in the future, or during retirement. And when you reach a certain balance in your HSA, investment opportunities are available.

4. What is a qualified high deductible health plan (HDHP)?

A qualified HDHP is a type of health plan that meets certain IRS requirements for minimum annual deductibles and maximum out-of-pocket expense limits. These IRS requirements are set on an annual basis.

5. What is the 2022 IRS HSA contribution limit? The IRS contribution limit for 2022 is $3,650 for single coverage and $7,300 for family coverage (regardless of number of dependents covered on the medical plan). The IRS allows for an additional $1,000 in annual contributions on both self-only and family coverage for account holders age 55 and over. These additional permissible contributions are known as “catch up contributions.”

6. Will Magnum, LTD. contribute to my HSA? Magnum, LTD. will contribute the following to our employee HSA’s:

Non-OTR employees—$299 annually ($11.50 over 26 pay periods)

OTR drivers—$299 annually ($11.50 over 26 pay periods or $5.75 over 52 pay periods)

7. How do I make HSA contributions?

Magnum, LTD. makes deposits to employees’ HSA’s and encourages employees to make additional contributions through payroll deduction or direct deposit. Please Note: To continue to make HSA contributions, you must maintain the eligibility requirements. If you lose your eligibility, for example you change jobs and are no longer enrolled in an HSA compatible health plan, you can no longer add money to the account, but you can still use your HSA funds at any time.


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8. If my spouse and I have separate HSAs, can we each contribute to the IRS maximum?

The maximum a married couple can contribute to an HSA (or HSAs) is a combined total equaling the IRS annual HSA contribution limit for a family, which is $7,300 for 2022.

9. What happens if I contribute more than the annual IRS limit? Contributions made in excess of the annual IRS limit (known as “excess contributions”) can be taxed.

10. Can I pay for the medical expenses of my spouse and/ or children with my HSA even if they’re not covered under my HSA-qualified coverage? Yes, the money in your HSA can be used to pay for any tax dependent family member’s qualified medical expenses, even if they’re not covered under your HSA-qualified plan.

11. Does my HSA earn interest?

HSA’s are interest-bearing accounts. See your bank’s account details for more information.

12. When can I use my HSA funds? You can begin using your dollars as soon as funds are available in your account.

13. What are eligible HSA expenses? You can only use HSA dollars toward eligible expenses – those you pay for out of your pocket for health care-related goods and services for you, your spouse, and eligible tax dependents. IRS rules govern expense eligibility, and generally, these rules state that eligible expenses include items and services that are meant to diagnose, cure, mitigate, treat, or prevent illness or disease. Transportation that is primarily for medical care is also included. Here are some other examples:

Your health plan deductible (the amount you pay before your plan starts paying a share of your costs)Your share of the cost for doctor office visits and prescription drugs

Your share of the cost for eligible dental care, including exams, X-rays, cleanings, and orthodontia

Your share of the cost for eligible vision care, including exams, eyeglasses, contact lenses, and laser eye surgery

Keep in mind that there’s no double-dipping. Expenses reim-bursed under your HSA cannot be reimbursed under any other plan or program. Only your out-of-pocket healthcare expenses are eligible for reimbursement. Plus, expenses reimbursed under an HSA can’t be deducted when you file your tax return.

14. Are over-the-counter (OTC) medicines eligible expenses?

Yes, but they require a written or electronic prescription to be an eligible HSA expense. IRS rules state that OTC medicines are only eligible for reimbursement under your HSA if prescribed by a doctor (or another person who can issue a prescription) in the state where you purchase the OTC medicines. If your doctor suggests an OTC medicine, just ask for a prescription. These rules do not apply to insulin (including OTC insulin). Here are some of the many examples of OTC medicines and drugs requiring a prescription:

Allergy and sinus: Actifed, Benadryl, Claritin, Sudafed Antacids: Mylanta, Pepcid AC, Prilosec, TUMS Aspirin and pain relievers: Advil, Excedrin, Motrin, Tylenol Cold and flu: Nyquil, Theraflu, Tylenol Cold & Flu Diaper rash ointments: Balmex, Desitin First aid creams, sprays, and ointments: Bactine, Neosporin Sleep aids: Sominex, Tylenol PM, Unisom SleepTabs

You can use your HSA funds to purchase OTC medicines only if you present a doctor’s prescription for an OTC medicine to a pharmacist. The pharmacist will then dispense the medicine just like a traditional pre-scription and assign an Rx number. If you cannot give the pharmacist an OTC prescription before paying for the OTC medicine, you must purchase the medicine out of your pocket and then reimburse yourself from your HSA. In case you are audited by the IRS, retain one of these documents:

A written or electronic OTC prescription along with an itemized cash register receipt that includes the merchant name, name of the OTC medicine or drug, purchase date, and amount

A printed pharmacy statement or receipt from a pharmacy that includes the patient’s name, the Rx number, the date the prescription was filled, and the amount


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17. What happens if I use HSA funds to pay for an ineligible expense? You will have to pay taxes on the ineligible expense, and if you are under age 65, you must pay a 20 percent penalty. At age 65 or older, you may use your HSA funds to pay for anything you want without being penalized. You only have to pay taxes on ineligible items purchased with HSA funds.

21. If I elect the HDHP mid-year, how much can I contribute to my HSA? If you enroll mid-year, in general your contributions are limited by the 1/12 rule. Single Coverage: For each full calendar month of qualified coverage, you may contribute up to 1/12 of the $3,550 annual limit. Family Coverage: For each full calendar month of qualified coverage, you may contribute up to 1/12 of the $7,100 annual limit.

However, you can contribute more than is permitted by the 1/12 rule if you stay enrolled for the next year, which is known as the “testing period.” The testing period requires you to maintain the HDHP through the entire month of December of the current tax year and all twelve (12) months of the next tax year. The type of HDHP coverage (single or family) you have on December 1 governs the amount that you can contribute for the year. Examples : If enrolled in single coverage on December 1, you may contribute up to $3,550. If you are enrolled in family coverage on December 1, you may contribute up to $7,100. In each instance, if you are at least age 55, you can also make a $1,000 catch up contribution.

These higher contributions will be taxed and subject to an additional 10% penalty tax if you fail to stay enrolled in the

18. Can I use HSA funds toward medical expenses incurred before I established my HSA? No, you may only use HSA dollars toward eligible expenses incurred after your HSA has been established. Once you have your HSA set up, you may reimburse yourself for out-of-pocket medical expenses at any time if funds are available in your account.

19. Can I delay enrollment in Medicare so that I can remain HSA-eligible? Yes. Those who are actively employed over age 65 may enroll in Medicare Part A and Part B during the eight months following the month group health plan coverage ends or when their employment ends, whichever is first, and will avoid incurring a Medicare Part B late enrollment premium penalty. There is no penalty for delaying to enroll in Medi-care Part A.

20. Can I transfer funds from an Individual Retirement Account (IRA) to my HSA? Individuals can make a one-time, tax-free trustee-to- trustee transfer from an IRA to an HSA. The individual must remain enrolled in an HSA-qualified plan and eligible for an HSA for at least the next 12 months following the fund transfer. Note that these transfer amounts do count against the statutory contribution limits outlined above.

15. What OTC items are eligible expenses?

Many OTC healthcare-related items are eligible under your HSA, such as:

Bandages, Band-Aids, gauze, and first aid kits

Batteries for hearing aids, blood glucose monitors, etc.

Diabetic supplies and test kits

High blood pressure monitors

Thermometers

16. What expenses are not covered under an HSA?Expenses that are not approved to be paid with HSA funds are called “ineligible expenses.” Ineligible HSA expenses include:

Cosmetic surgery and procedures, including teeth whit-

ening Herbs, vitamins, and supplements used for general

health OTC medicines that you don’t have a prescription for

(except insulin) Insurance premiums Family or marriage counseling Personal use items such as toothpaste, shaving cream,

and makeup Prescription drugs imported from another country


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22. If I have a family status change mid-year and drop the HDHP, what is the maximum amount I can contribute to my HSA? If you drop the HDHP mid-year, your contributions are limited by the 1/12 rule. Single Coverage: For each full month of coverage, you may contribute up to 1/12 of the $3,550 annual limit, plus 1/12 of any catch-up contribution. Family Coverage: For each full month of coverage, you may contribute up to 1/12 of the $7,100 annual limit, plus 1/12 of any catch-up contribution.

HDHP during the entire testing period. Please see IRS Publication 969 and IRA Form 8889 at www.IRS.gov for examples and for a testing period worksheet.

23. If I have a family status change and my HDHP coverage changes from single to family coverage, what is the maximum amount I can contribute to my HSA? If your status changes from single to family on or before December, you may make a full family contribution, including any catch-up contribution. If you make your contribution for the full year based on enrollment in family coverage, you will be subject to the testing period escribed in question 20.

24. If I have a family status change that changes my HDHP coverage from family to single, what is the maximum amount I can contribute to my HSA? You are permitted to contribute 1/12th of the family annual maximum for each full month you are covered by a family HDHP, plus 1/12th of the single annual maximum for each full month you are covered by a single HDHP. You may also contribute 1/12 of any catch-up contribution

25. What happens to my HSA if I get a job at a new company that doesn’t have an HSA-qualified option? Your HSA is your money, so it goes with you from job to job. If your new employer has an HSA-qualified plan and you enroll in that plan, you can continue contributing funds to your existing HSA. If not, you can continue to spend the money in your account to meet your family’s expenses tax-free. You can also choose to let the money sit in the account until you need it later on in life. You cannot, however, contribute to the account or have contributions made on your behalf if you do not have HSA-qualified insurance.


WHEN TO CALL UNUM

• If you are injured at work notify your manager or supervisor immediately. Do not use thistoll-free number for work-related injuries.

• When your health care provider has determined you are unable to work due to illness,injury or pregnancy.

• Thirty days before a disability based on the expected delivery date of a child orprescheduled medical treatment.

WHAT TO DO NEXT

• Notify your manager or supervisor of your absence from work.

• To submit your claim via telephone, call the toll-free number listed to the left. Please beprepared with the information requested on page 2 of this brochure.

• To submit your claim via the Unum website, go to www.unum.com and follow the claimsubmission instructions.

• Provide your health care provider with a signed and dated copy of the disabilityauthorization form (last page of brochure). This form authorizes the release of medicalinformation needed to evaluate your disability claim.

• Fax a copy of the signed and dated disability authorization to the Unum Benefits Centerat the following toll-free fax number, 800-447-2498. If you prefer, you may mail acopy to the address at the top of the authorization, or you may sign and submit yourauthorization electronically at www.unum.com/claims.

OUR COMMITMENT TO YOU

We understand that a disabling illness or injury creates emotional, physical and financial challenges and we want to do whatever we can to help you. You have our commitment to provide you with responsive service and to be understanding and sensitive to your circumstances during the claim process.

Filinga Short Term Disability Claimby Telephone or on the Unum Website

Short Term Disability Policy #: 472379

www.unum.com

Telephone: (866) 779-1054 Fax: 800-447-2498

Monday-Friday

7:00 a.m. to 7:00 p.m.

Central

G-73647-WEB (09/18)

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Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries. Services provided by subsidiaries of Unum Group.

Unum Group, 1 Fountain Square, Chattanooga, TN 37402

INFORMATION NEEDED TO SUBMIT A SHORT TERM DISABILITY CLAIM

Please be prepared to provide the following information when you call to submit your claim. If someone else makes the call on your behalf, he/she may need to provide this information.

• Name of the company where you work

• Policy number: 472379

• Your name and Social Security number or employee ID number

• Complete address and phone number

• Date of birth

• Marital status

• Occupation (or job title)

• Supervisor’s name and telephone number

• Your last day worked and your first day absent from work due to your claim

• The date you expect to return to work (if you know), or the actual date if you have already returned to work at the timeyou call

In addition, the following information will be needed when submitting a disability claim.

• Healthcare provider’s name, address, fax and telephone number

• A brief description of your medical condition including cause of condition (illness or injury), date of injury or beginningof illness, and whether it’s work-related

• The dates of your first visit, your most recent visit, and your next scheduled visit with your healthcare provider forthis condition

• Work restrictions or limitations stated by your healthcare provider, if any.

Prompt and complete information from you and your healthcare provider will help assure a timely decision and payment if you are eligible.

Unum may require additional medical information to better understand your claim. The timing of the decision depends on how quickly the information is received.

Unum will partner with you to gather all required information for the duration of your claim.

Check your claim status, correspondence, and updates online – anytime.

Unum has developed a secure and easy way for you to manage your disability claim online at www.unum.com/claims. Our secure web services allow you to access and make changes to your open claims, as well as view updates and correspondence when they become available.

Our secure site helps eliminate delays and is simple to use. Here are a few main features:

• Sign and submit your electronic disability authorization form.

• Upload documents for disability claims from your personal computer.

• Register for direct deposit of your claim payment, when applicable.

• Check claim status, correspondence, and most recent payment information.

• Verify and change personal information and monitor your claim progress.

You may also manage your claim with the Unum Customer App. The Unum Customer App is available for Apple and Android devices.

INFORMATION THAT MAY BE IMPORTANT TO YOU

unum.com

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Claim Fraud StatementsFraud WarningFor your protection, the laws of several states, including Alaska, Arizona, Arkansas, Delaware, Idaho, Indiana, Louisiana, Maine, Maryland, New Mexico, Ohio, Oklahoma, Rhode Island, Tennessee, Texas, Virginia, Washington, and West Virginia require the following statement to appear on this claim form:Any person who knowingly and with the intent to injure, defraud or deceive an insurance company 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.Fraud Warning for Alabama Residents For your protection, Alabama law requires the following to appear on this claim form:Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.Fraud Warning for California ResidentsFor your protection, California law requires the following to appear on this claim form:Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.Fraud Warning for Colorado ResidentsFor your protection, Colorado law requires the following to appear on this claim form: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 claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.Fraud Warning for District of Columbia ResidentsFor your protection, the District of Columbia requires the following to appear on this claim form:WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant.Fraud Warning for Florida ResidentsFor your protection, Florida law requires the following to appear on this claim form:Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a statement of claim or an application containing false, incomplete or misleading information is guilty of a felony of the third degree.Fraud Warning for Kentucky ResidentsFor your protection, Kentucky law requires the following to appear on this claim form:Any person who knowingly and with intent to defraud any insurance company or other person files a 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.Fraud Warning for Minnesota ResidentsFor your protection, Minnesota law requires the following to appear on this claim form:A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.Fraud Warning for New Hampshire ResidentsFor your protection, New Hampshire law requires the following to appear on this claim form:Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638.20.Fraud Warning for New Jersey ResidentsFor your protection, New Jersey law requires the following to appear on this claim form:Any person who knowingly and with intent to defraud any insurance company or other persons, files a 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, subject to criminal prosecution and civil penalties. Fraud Warning for New York ResidentsFor your protection, New York law requires the following to appear on this claim form:Any person who knowingly and with the 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 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.Fraud Warning for Pennsylvania ResidentsFor your protection, Pennsylvania law requires the following to appear on this claim form: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 penalties.Fraud Warning for Puerto Rico ResidentsFor your protection, Puerto Rico law requires the following to appear on this claim form:Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation with the penalty of a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. If aggravating circumstances are present, the penalty thus established may be increased to a maximum of five (5) years; if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.45 | Magnum, LTD

The Benefits CenterP.O. Box 100158Columbia, SC 29202-3158Toll-free: 1-800-858-6843 Fax: 1-800-447-2498Monday through Friday, 8 a.m. to 8 p.m. (Eastern Time)

Please sign and return this authorization to The Benefits Center at the address above. You are entitled to receive a copy of this authorization. This authorization is designed to comply with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.

Authorization to Collect and Disclose Information(Not for FMLA Requests)

I authorize the following persons: health care professionals, hospitals, clinics, laboratories, pharmacies and all other medical or medically related providers, facilities or services, rehabilitation professionals, vocational evaluators, health plans, insurance companies, third party administrators, insurance producers, insurance service providers, consumer reporting agencies including credit bureaus, GENEX Services, LLC, The Advocator Group and other Social Security advocacy vendors, professional licensing bodies, employers, attorneys, financial institutions and/or banks, and governmental entities;To disclose information, whether from before, during or after the date of this authorization, about my health, including HIV, AIDS or other disorders of the immune system, use of drugs or alcohol, mental or physical history, condition, advice or treatment (except this authorization does not authorize release of psychotherapy notes), prescription drug history, earnings, financial or credit history, professional licenses, employment history, insurance claims and benefits, and all other claims and benefits, including Social Security claims and benefits (“My Information”);To Unum Group and its subsidiaries, Unum Life Insurance Company of America, Provident Life and Accident Insurance Company, The Paul Revere Life Insurance Company, and persons who evaluate claims for any of those companies (“Unum”);So that Unum may evaluate and administer my claims, including providing assistance with return to work. For such evaluation and administration of claims, this authorization is valid for two years, or the duration of my claim for benefits (to include any subsequent financial management and/or benefit recovery review), whichever is shorter. I understand that once My Information is disclosed to Unum, any privacy protections established by HIPAA may not apply to the information, but other privacy laws continue to apply. Unum may then disclose My Information only as permitted by law, including, state fraud reporting laws or as authorized by me. I also authorize Unum to disclose My Information to the following persons (for the purpose of reporting claim status or experience, or so that the recipient may carry out health care operations, claims payment, administrative or audit functions related to any benefit, plan or claim): any employee benefit plan sponsored by my employer; any person providing services or insurance benefits to (or on behalf of) my employer, any such plan or claim, or any benefit offered by Unum; or, the Social Security Administration. Unum will not condition the payment of insurance benefits on whether I authorize the disclosures described in this paragraph. For the purposes of these disclosures by Unum, this authorization is valid for one year or for the length of time otherwise permitted by law. If I do not sign this authorization or if I alter or revoke it, except as specified above, Unum may not be able to evaluate or administer my claim(s), which may lead to my claim(s) being denied. I may revoke this authorization at any time by sending written notice to the address above. I understand that revocation will not apply to any information that Unum requests or discloses prior to Unum receiving my revocation request.

____________________________________________________ _________________________Insured’s Signature Date Signed

____________________________________________________ _________________________Printed Name Social Security NumberI signed on behalf of the Insured as _________________________________ (Relationship). If Power of Attorney Designee, Guardian, or Conservator, please attach a copy of the document granting authority.Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.

TELEPHONICG-73647-WEB (09/18)

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Your Unum Benefits Resources

Voluntary benefits include: Accident

Critical Illness

Whole Life

Group Voluntary Life/AD&D

Short Term Disability

Long Term Disability

At Unum, we value your business and want to make it easy for you to manage your insurance benefits. Please keep this list of resources and contacts handy. If you ever have a question, or need to file a claim, we’ll be there to help you every step of the way.

Questions about your policy?

Accident, Critical Illness, Whole Life Call our Customer Contact Center toll-free at 1-800-635-5597Press 1 and a Customer Service Specialist will assist you.

Group Voluntary Term Life/AD&D, Short Term Disability, and Long Term Disability Call our Customer Contact Center toll-free at 1-800-421-0344Press 2 and a Customer Service Specialist will assist you.

Visit www.unum.com/employees The first time you visit, you’ll need to click “Register” at the top of the page and enter your information.

Your policy will be available once we receive, process and approve your application. The Customer Contact Center can also help you if you need to cancel your policy. Unum will notify your Human Resources department at work if you make any changes to your benefits.

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Need to file a claim? Accident, Critical Illness, Whole Life

Call our Customer Contact Center

at 1-800-635-5597

A Customer Service Specialist will email you a claim form or help you download one from the website.

Group Voluntary Term Life/AD&D and Long Term Disability Call your Human Resource Team for more information on how to file a

claim Call (701)-561-7044

Short Term Disability Call (866)-779-1054

For all lines of coverage you have the option of filing a claim directly from our secure website:

www.unum.com/claims

To get started, follow the directions below:

With the Unum Customer App, you can access claim information anytime, anywhere from your mobile phone. Designed for and available in Apple® and Android™ app stores.

Insurance products are underwritten by the subsidiaries of Unum.

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NOTES

health benefits

Documents