Medical Benefits Package

Year 2017

eTeam Inc.
 Welcome to Benefit Enrollment.

Please be sure to fill out the election form and

the medical enrollment application in its entirety
(even if waiving).

Eligibility: Employees must work an average of 30 hours/week or

130 hours/month to be eligible to participate in the
employer offered health plan. Individuals can begin
participation in the plan or make changes to existing
plan participation during open enrollment periods OR
when a qualifying life event occurs.
The enrollment will be effective 1st of the month after
completing 30 days.

Questions? Call Kistler Tiffany Benefits at 866-KTB-SERV

MEC Avoid Penalties- Preventative Minimum Essential Coverage: covers 64
points of preventative care includes Physical. Mammogram, Colonoscopy

26 Covered Services for Children

1. Alcohol and Drug Use assessments
2:. Autism screening for chiidren limited to two screenmgs up to 24 months
3. Behavioral assessments for children limited to 5 assessments up to age 17.
4. Blood Pressure screening
5. Cervical Dysplasia screening
6. Congenital Hypothyroidism screening for newborns
7. Depression screening for adolescents age 12 and older
8. Developmental screening for children under age 3, and surveillance throughout childhood
9. Dysiipidemia screening for chiidren
10. Fluoride Chemoprevention supplements for children without fluoride in their water source when prescribed by a physician
11. Gonorrhea preventive medication for the eyes of all newborns
12. Hearing screening for all newborns
13. Height, Weight and Body Mass Index measurements for children.
14. Hematocrit or Hemoglobin screening for children
15. Hemoglobinopathles or sickle cell screening for newborns
16. HIV screening for adolescents
17. Immunization vaccines for children from birth to age 18 -doses, recommended ages, and recommended populations vary:
Diphtheria, Tetanus, Pertussis
18. Iron supplements for children up to 12 months when prescribed by a physician
19. Lead screening for children
20. Medical History for all children throughout development Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
21. Obesity screening and counseling
22. Oral Health risk assessment for young children up to age 10
23. Phcnylkctonuria (PKU) screening in newborns
24. Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents
25. Tuberculin testing for children
26. Vision screening for all children under the age of 5
15 Covered Preventive Services for Adults (ages 18 and older/
1. Abdominal Aortic Aneurysm one time screening for age 65-75
2. Al!:oho! Misuse screening and counseling
3. Aspirin use for men ages 45-79 and women ages 55-79to prevent CVD when prescribed by a physician
4. Blood Pressure screening for all adults
5. Cholesterol screening for adults
6. Colorectal Cancer screening for adults starting at age 50 limited to one every 5 years
7. Depression screening for adults
8. Type 2 Diabetes screening for adults
9. Diet counseling for adults
10. HIV screening for adults
11. Immunizations vaccines for adults (Hepatitis A & 8, Herpes Zoster, Human Papillomavirus, Influenza (flu shot), Measles, Mumps Rubella, Meningococcal, Pneumococcal,
Tetanus, Diptheria, Pertussis)
12. Obesity screening and counseling for all adults
13. Sexually Transmitted Infection (STI) prevention counseling for adults
14. Tobacco Use screening for all adults and cessation interventions
15. Syphilis screening for all adults
23 Covered Preventative Services for Women, Including Pregnant Women
1. Anemia screening on a routine basis for pregnant women
2. Bacteriuria urinary tract or other infection screening for pregnant women
3. BRCA counseling and genetic testing for women at higher risk
4. Breast Cancer Mammography screenings every year for women age 40 and over
5. Breast Cancer Chemoprevention counseling for women
6. Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women. Non-network
services will be payable as network services.
7. Cervical Cancer screening
8. Chlamydia Infection screening
9. Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient
drugs
10. Domestic and interpersonal violence screening and counseling for all women
11. Felic Acid supplements for women who may become pregnant when prescribed by a physician
12. Gestational diabetes screening
13. Gonorrhea screening for all women
14. Hepatitis B screening for pregnant women
15. Human Immunodeficiency Virus (HIV) screening and counseling
16. Human Papillomavlrus (HPV) DNA Test: HPV DNA testing every three years for women with normal cytology results who are 30 or older
17. Osteoporosis screening over age 60
18. Routine prenatal visits for pregnant women
19. Rh Incompatibility screening for all pregnant women and follow-up testing
20, Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users
21. Sexually Transmitted Infections (STI} counseling
22. Syphilis screening
23. Well-woman visits to obtain recommended preventive services

Rates (Biweekly)
Employee 28.81
Employee+ Spouse 62.82
Employee+ Child (ren) 44.08
Employee+ Family 78.08

Questions? Call Kistler Tiffany Benefits at 866-KTB-SERV

ETEAM : Health Benefit Plan SM87575E Coverage Period: Beginning on or after 01/01/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Family Plan Type: High-deductible

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan
document at www.starmarkinc.com or by calling 1-800-522-1246, ext. 26300.

Important Questions Answers Why this Matters:

In-network:
$5,000 person/$10,000 family You must pay all the costs up to the deductible amount before this plan begins to pay for
What is the overall Out-of-network: covered services you use. Check your policy or plan document to see when the deductible
deductible? $10,000 person/$20,000 family starts over (usually, but not always, January 1st). See the chart starting on page 2 for how
much you pay for covered services after you meet the deductible.
Does not apply to preventive
care.
Are there other
You don't have to meet deductibles for specific services, but see the chart starting on page
deductibles for specific No
2 for other costs for services this plan covers.
services?
Yes
For in-network: $6,550
Is there an person/$13,100* family The out-of-pocket limit is the most you could pay during a coverage period (usually one
outofpocket limit on *$7,150 maximum per person year) for your share of the cost of covered services. This limit helps you plan for health
my expenses? with family coverage. care expenses.
For out-of-network: $17,500
person/$35,000 family

What is not included in Pre-certification penalties,

premium, balanced-billed
the outofpocket Even though you pay these expenses, they don't count toward the out-of-pocket limit.
charges, and health care this
limit? plan doesn't cover.
Is there an overall
The chart starting on page 2 describes any limits on what the plan will pay for specific
annual limit on what No
covered services, such as office visits.
the plan pays?

Questions: Call 1-800-522-1246, ext. 26300 or visit us at www.starmarkinc.com.

If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.starmarkinc.com or call 1-800-522-1246, ext. 26300 to request a copy.
Important Questions Answers Why this Matters:

Yes. For a list of in-network If you use an in-network doctor or other health care provider, this plan will pay some or all
providers, see of the costs of covered services. Be aware, your in-network doctor or hospital may use an
Does this plan use a
www.starmarkinc.com or call out-of-network provider for some services. Plans use the term in-network, preferred, or
network of providers?
participating for providers in their network. See the chart starting on page 2 for how this
1-800-522-1246, ext. 26300 plan pays different kinds of providers.
Do I need a referral to
No You can see the specialist you choose without permission from this plan
see a specialist?
Some of the services this plan doesnt cover are listed on the Excluded Services & Other
Are there services this
Yes Covered Services section. See your policy or plan document for additional information
plan doesnt cover?
about excluded services.

Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if
the plans allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if
you havent met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and
the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts.
Your Cost If Your Cost If
Common You Use an You Use an
Services You May Need Limitations & Exceptions
Medical Event In-network Out-of-network
Provider Provider
Primary care visit to treat an injury or illness 20% coinsurance 50% coinsurance none
Specialist visit 20% coinsurance 50% coinsurance none
Chiropractor - 20 visits/yr.
If you visit a health Acupuncture, massage, naturopathic
care providers office Other practitioner office visit 20% coinsurance 50% coinsurance med - 12 visits/yr.
or clinic Nutrition counseling - 3 visits while
covered under this plan
Preventive care/screening/immunization No charge 50% coinsurance none
If you have a test Diagnostic test (x-ray, blood work) 20% coinsurance 50% coinsurance none
Imaging (CT/PET scans, MRIs) 20% coinsurance 50% coinsurance $300 penalty for failure to precertify.
If you need drugs to Generic drugs 20% coinsurance Same as in- none
 Your Cost If Your Cost If
Common You Use an You Use an
Services You May Need Limitations & Exceptions
Medical Event In-network Out-of-network
Provider Provider
network
treat your illness or Same as in-
Preferred brand drugs 20% coinsurance none
condition network
More information Same as in-
Non-preferred brand drugs 20% coinsurance none
about prescription network
drug coverage is
Use specialty pharmacy for in-network
available at Specialty drugs 20% coinsurance Not covered
benefit.
www.starmarkinc.com
If you have Facility fee (e.g., ambulatory surgery center) 20% coinsurance 50% coinsurance none
outpatient surgery Physician/surgeon fees 20% coinsurance 50% coinsurance none
Same as in-
Emergency room services 20% coinsurance none
If you need network
immediate medical Same as in-
Emergency medical transportation 20% coinsurance none
attention network
Urgent care 20% coinsurance 50% coinsurance none
If you have a Facility fee (e.g., hospital room) 20% coinsurance 50% coinsurance $300 penalty for failure to precertify.
hospital stay Physician/surgeon fee 20% coinsurance 50% coinsurance $300 penalty for failure to precertify.
Mental/Behavioral health outpatient services 20% coinsurance 50% coinsurance none
If you have mental
Mental/Behavioral health inpatient services 20% coinsurance 50% coinsurance $300 penalty for failure to precertify.
health, behavioral
health, or substance
Substance use disorder outpatient services 20% coinsurance 50% coinsurance none
abuse needs
Substance use disorder inpatient services 20% coinsurance 50% coinsurance $300 penalty for failure to precertify.
0% coinsurance
routine prenatal
Prenatal and postnatal care office visits, 20% 50% coinsurance none
If you are pregnant
coinsurance other
services
Delivery and all inpatient services 20% coinsurance 50% coinsurance $300 penalty for failure to precertify.
100 days/year. $300 penalty for failure
Home health care 20% coinsurance 50% coinsurance
to precertify.
If you need help 60 visits/year. Inpatient rehabilitation:
Rehabilitation services 20% coinsurance 50% coinsurance
recovering or have $300 penalty for failure to precertify.
other special health Habilitation services 20% coinsurance 50% coinsurance 60 visits/year. Inpatient habilitation:
 Your Cost If Your Cost If
Common You Use an You Use an
Services You May Need Limitations & Exceptions
Medical Event In-network Out-of-network
Provider Provider
needs $300 penalty for failure to precertify.
81 days/year. $300 penalty for failure
Skilled nursing care 20% coinsurance 50% coinsurance
to precertify.
Durable medical equipment 20% coinsurance 50% coinsurance none
6 months while covered under this
Hospice service 20% coinsurance 50% coinsurance plan. $300 penalty for failure to
precertify.
Routine vision
screening - No
charge
Eye exam Other services - Not covered none
including routine
If your child needs eye exam, Not
dental or eye care covered
Glasses Not covered Not covered
Dental check-up Not covered Not covered

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isnt a complete list. Check your policy or plan document for other excluded services.)

Bariatric surgery Cosmetic surgery Dental Care (Adult)

Dental Care (Children) Hearing aids Infertility treatment
Most coverage provided outside of the United Non-emergency care when traveling outside
Long-term care
States of the United States
Routine eye care (Children) - excluding
Routine eye care (Adult) Routine Foot Care
routine vision screening
Weight loss programs

Other Covered Services (This isnt a complete list. Check your policy or plan document for other covered services and your costs for these
services.)
 Acupuncture (if prescribed for rehabilitation
Chiropractic care Private-duty nursing
purpose)

Your Rights to Continue Coverage:

If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health
coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay
while covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-800-522-1246, ext. 26300. You may also contact your state insurance
department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of
Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For
questions about your rights, this notice, or assistance, you can contact us at 1-800-522-1246, ext. 26300.
If your plan is subject to ERISA you may contact the Department of Labors Employee Benefits Security Administration at 1-866-444-EBSA (3272) or
www.dol.gov/ebsa/healthreform.

Does this Coverage Provide Minimum Essential Coverage?

The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does
provide minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard?

The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This
health coverage does meet the minimum value standard for the benefits it provides.

Language Access Services:

Spanish (Espaol): Para obtener asistencia en Espaol, llame al 1-800-522-1246, ext. 26300.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-522-1246, ext. 26300.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-522-1246, ext. 26300.

Chinese (): 1-800-522-1246, ext. 26300.

To see examples of how this plan might cover costs for a sample medical situation, see the next page.
About these Coverage Having a baby Managing type 2 diabetes
(normal delivery) (routine maintenance of
Examples: a well-controlled condition)

These examples show how this plan might cover n Amount owed to providers: $7,540 n Amount owed to providers: $5,400
medical care in given situations. Use these n Plan pays $140 n Plan pays $340
examples to see, in general, how much financial n Patient pays $7,400 n Patient pays $5,060
protection a sample patient might get if they are
covered under different plans. Sample care costs: Sample care costs:
Hospital charges (mother) $2,700 Prescriptions $2,900
Routine obstetric care $2,100 Medical Equipment and Supplies $1,300
Hospital charges (baby) $900 Office Visits and Procedures $700
Anesthesia $900 Education $300
Laboratory tests $500 Laboratory tests $100
Prescriptions $200 Vaccines, other preventive $100
Radiology $200 Total $5,400
Vaccines, other preventive $40
Total $7,540 Patient pays:
Deductibles $5,000
Patient pays: Copays $0
Deductibles $7,200 Coinsurance $0
Copays $0 Limits or exclusions $60
Coinsurance $0 Total $5,060
Limits or exclusions $200
Total $7,400

BIWEEKLY PLAN COST(based on pay-rate):

Pay rate $15 &below I $16-20 Abgve $20
Employee 163 200.72 335.76
-
Employee + Spouse
. :hild (ren)
709.43
457.6
774.43
522.6
839.43
587.6
Employee + Family 961.27 1026.27 1091.27
Questions and answers about the Coverage Examples:
What are some of the
assumptions behind the Coverage
Examples?
Costs dont include premiums.
Sample care costs are based on national
averages supplied by the U.S.
Department of Health and Human
Services, and arent specific to a
particular geographic area or health plan.
The patients condition was not an
excluded or preexisting condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for
any member covered under this plan.
Out-of-pocket expenses are based only
on treating the condition in the example.
The patient received all care from in-
network providers. If the patient had
received care from out-of-network
providers, costs would have been higher.
Questions: Call 1-800-522-1246, ext. 26300 or visit us at www.starmarkinc.com.
If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.starmarkinc.com or call 1-800-522-1246, ext. 26300 to request a copy.
What does a Coverage Example
show?
For each treatment situation, the Coverage
Example helps you see how deductibles,
copayments, and coinsurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isnt covered or payment is limited.
Does the Coverage Example
predict my own care needs?
No. Treatments shown are just examples.
The care you would receive for this
condition could be different based on your
doctors advice, your age, how serious your
condition is, and many other factors.
Does the Coverage Example
predict my future expenses?
No. Coverage Examples are not cost
estimators. You cant use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on
the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.
Can I use Coverage Examples to
compare plans?
Yes. When you look at the Summary of
Benefits and Coverage for other plans,
youll find the same Coverage Examples.
When you compare plans, check the
Patient Pays box in each example. The
smaller that number, the more coverage
the plan provides.
Are there other costs I should
consider when comparing
plans?
Yes. An important cost is the premium
you pay. Generally, the lower your
premium, the more youll pay in out-of-
pocket costs, such as copayments,
deductibles, and coinsurance. You
should also consider contributions to
accounts such as health savings accounts
(HSAs), flexible spending arrangements
(FSAs) or health reimbursement accounts
(HRAs) that help you pay out-of-pocket
expenses.
 Policyholder: ETEAM INC

Voluntary Dental PPO Benefit

Summary
Effective Date: 01/01/2017

Predetermination of Benefits: Before treatment begins for inlays, onlays, single crowns, prosthetics,
periodontics and oral surgery, you may file a dental treatment plan with Principal Life Insurance Company.
Principal Life will provide a written response indicating benefits that may be payable for the proposed treatment.

This chart provides you a brief summary of the key benefits of the dental coverage available from Principal Life
Insurance Company. Following the chart, you will find additional information to answer questions you may have.
For a complete list of all your dental coverage benefits and restrictions, please refer to your booklet or contact your
employer.

Eligibility
Job Class CONSULTANTS

Benefits Payable
Network Dental Preferred Provider Organization (PPO)
Calendar Year Deductible Coinsurance (Policy Pays)
In-Network Non-Network In-Network Non-Network
Unit 1 Preventive $0 $50 100% 100%
Unit 2 Basic $50 $50 80% 80%
Unit 3 Major $50 $50 50% 50%
Family Deductible Maximum 3 times the per person deductible amount

Combined Deductible
Combined Maximums
Maximum Accumulation
Emergency Services
In-network deductibles for basic and major procedures are combined. Non-network deductibles
for preventive, basic, and major procedures are combined.
Maximums for preventive, basic, and major procedures are combined. In-network Calendar year
maximums are $1,500 per person. Non-network Calendar year maximums are $1,500 per
person.
This allows for a portion of unused maximum benefit to carry over to next year's maximum
benefit amount. To qualify, you must have had a dental service performed within the Calendar
year and used less than the maximum threshold. The threshold is equal to the lesser of 50% of
the maximum benefit or $1000. If qualification is met, 50% of the threshold is carried over to
next year's maximum benefit. You can accumulate no more than four times the carry over
amount.
If a member requires treatment or service for an emergency dental condition and cannot reach a
preferred dental provider without unreasonable delay, benefits for such treatment or service
received from a non-preferred dental provider will be paid as if the treatment or service had
been provided by a preferred dental provider. The member must provide information either
with the claim or during an appeal that identifies the situation as an emergency.

Additional Benefits

Lifetime Deductible Coinsurance (Policy Pays)

In-Network Non-Network In-Network Non-Network
Unit 4 - Orthodontia $0 $0 50% 50%
Child
Lifetime Maximum:
In-Network: $1,500
Non-Network: $1,500
 VOLUNTARY DENTAL

How Are Dental Procedures Covered?

The list of common procedures shows what unit the procedure is included in and how often they are covered.

Unit 1 Routine exams - one per six months

Preventive Routine cleaning (prophylaxis) - one per six months (Expectant mothers, diabetics and
Procedures those with heart disease receive one additional routine or periodontal cleaning within a
calendar year.)
Second Opinion Consultation
Fluoride one treatment each calendar year (covered only for dependent children under
age 14)
X-rays - Bitewing (one set every calendar year), occlusal, periapical
X-rays Full mouth survey (one every 60 months), extraoral

Unit 2 Periodontal prophylaxis - if three months have elapsed after active surgical periodontal
Basic treatment; subject to Routine cleaning frequency limit (Expectant mothers, diabetics and
Procedures those with heart disease receive one additional routine or periodontal cleaning within a
calendar year.)
Emergency exams subject to Routine exam frequency limit
Space maintainers - covered only for dependent children under age 14; repairs not
covered
Sealants on first and second permanent molars for dependent children under age 14;
one each tooth each 36 months
Harmful Habit Appliance - covered only for dependent children under age 14
Fillings and stainless steel crowns
General Anesthesia (covered only for specific procedures)/IV Sedation
Simple Oral Surgery
Complex Oral Surgical Procedures
Non-surgical Periodontics, including scaling and root planing - once each quadrant each
24 months (For expectant mothers, diabetics and those with heart disease, this procedure
is provided with no deductible and 100% coinsurance.)
Periodontal Surgical Procedures one each quadrant each 36 months
Simple Endodontics (root canal therapy for anterior teeth)
Complex Endodontics (root canal therapy for molar teeth)

Unit 3 Repairs to Partial Denture, Bridge, Crown, Relines, Rebasing, Tissue Conditioning and
Major Adjustment to Bridge/Denture, within policy limitations
Procedures Crowns each 120 months per tooth if tooth cannot be restored by a filling.
Inlays, Onlays, Cast Post and Core, Core Buildup - each 120 months per tooth
Bridges - Initial placement / Replacement of bridges 120 months old.
Dentures - Initial placement of complete or partial dentures / Replacement of complete or
partial dentures over 60 months old

Unit 4 - Orthodontic X-rays and other diagnostic procedures, fixed and removable appliances
Procedures

There is Coordination of Benefits, which is a procedure for limiting benefits from two or more carriers to 100% of
the claimant's covered expenses.
 VOLUNTARY DENTAL

Understanding Your Dental Benefits

Am I Eligible For Coverage?

To be eligible for coverage, you must qualify as an eligible member and be considered actively at work.

You must be enrolled for dental coverage before it can be offered to your dependents. Eligible dependents
include your spouse, qualified domestic partner and children, including those of your qualified domestic partner.
Additional eligibility requirements may apply.

An annual enrollment applies. Members can enroll for dental coverage during the annual enrollment period and
not be subject to the late entrant waiting period. Certain restrictions apply.

How Do I Find A Participating Provider?

Use the Provider Directory on www.principal.com to locate nearby dentists or see if your dentist participates in
your network.

1 Visit www.principal.com/dentist.

2 Begin your search by picking the state where you would like to find a provider. Next, specify a network. Depending
on the network chosen, you may be transferred to a partner site.

3 Enter the name of the provider you are looking for (if known). If you are looking for a nearby dentist, enter the city
and state and/or ZIP code. Be sure to indicate how far you are willing to travel.

4 Select the desired specialty or use the No Specialty Preference default. Click Continue.

5 Select a language if your preference is other than English. Click Continue.

You may nominate your dentist for inclusion in our network. Please submit the dentist's name, address, phone
and specialty by calling 1-800-832-4450, or submit through www.principal.com/refer-dental-provider.

What Are The Restrictions Of My Coverage?

This Benefit Summary is a summary only. For a complete list of benefit restrictions, please refer to your booklet.
 VOLUNTARY DENTAL

Limitations & Exclusions

Late Entrant Provision Those members enrolling more than 31 days after becoming eligible will be subject to an
individual benefit waiting period, subject to policy guidelines.
Missing Tooth Benefits for the initial placement of bridges, partials and dentures are not covered if those teeth
were missing prior to becoming insured under the Principal Life policy. When the policy
replaces coverage under a prior plan, continuous coverage under the prior plan may be
applied to the missing tooth provision requirement.
Orthodontia If there is orthodontia (ortho) treatment in progress on the coverage effective date and you are
covered under any prior group coverage for ortho, there will be immediate coverage for
treatment if proof is submitted that shows:
1) Ortho treatment was started and bands or appliances were inserted while insured under
any prior group coverage, and
2) Ortho treatment has been continued while insured under this policy.

You will not be covered if ortho treatment is in progress prior to the effective date with
Principal Life and you are not covered under any prior group coverage for ortho.
Scheduled/MAC Design Claim payments for both in-network and non-network services are based on the provider fee
schedule amounts.
Other Limitations There are additional limitations to your coverage. A complete list is included in your booklet.

WELL GIVE YOU AN EDGE

Principal Life Insurance Company, Des Moines, Iowa 50392-0002, www.principal.com

This is a summary of dental coverage underwritten by or with administrative services provided by Principal Life Insurance Company. This
benefit summary is for administrative purposes and is not a complete statement of benefits and restrictions. Youll receive a benefit booklet
with details about your coverage. If there is a discrepancy between this summary and your benefit booklet, the benefit booklet prevails.

GP55773-18 | 09/2016 | 2017 Principal Financial Services, Inc.

 Policyholder: ETEAM INC

Voluntary Vision Benefit Summary

Effective Date: 01/01/2017

This chart provides you a brief summary of the key benefits of the vision coverage available from Principal
Life Insurance Company. Following the chart, you will find additional information to answer questions
you may have. For a complete list of all your vision coverage benefits and restrictions, please refer to your
booklet or contact your employer.

Eligibility
Job Class CONSULTANTS

Benefits Payable
Providers Any provider can be used for your vision care

Covered Charges Scheduled Benefit Amount* Frequency

Exams $50 One exam every 12 months

Frames $100 One set every 24 months

Lenses $50 for single vision Two lenses (one pair) every 12 months
Includes progressive $75 for bifocal
lenses $100 for trifocal
$150 for lenticular

Contact Lenses $150 Contact lenses are in lieu of frames and lenses. (The
Includes disposable contact lens benefit is equal to the Frames plus Single
lenses Vision Lens benefit. Therefore, the full benefit allowance
may not be available every 12 months.)

Limitations & Exclusions

Late Entrant Waiting Those members enrolling more than 31 days after becoming eligible will be subject to an
Period individual benefit waiting period, subject to plan guidelines.

Non-Medically The coverage does not pay for visual analysis or vision aids that are not medically
Necessary Services necessary.

Other Limitations There are additional limitations to your coverage. A complete list is included in your
booklet.

*No deductible or coinsurance applies with this vision benefit.

There is Coordination of Benefits, which is a procedure for limiting benefits from two or more carriers to
100% of the claimant's covered expenses.
 VOLUNTARY VISION

Understanding Your Vision Benefits

Am I Eligible For Coverage?

To be eligible for coverage, you must qualify as an eligible member and be considered actively at work.

You must be enrolled for vision coverage before it can be offered to your dependents. Eligible dependents
include your spouse and children. Additional eligibility requirements may apply.

How Do I Submit A Claim?

No claim form is needed. Send the provider's itemized statement* and a photocopy of the front and back
of your vision ID card to Principal Life Insurance Company, PO Box 10357, Des Moines, IA 50306-0357.
For further assistance, call the Principal Financial Group at (800) 247-4695.

*The itemized statement shows what services and treatments were provided. A receipt showing the amount paid or bill showing the
amount due is not sufficient.

WELL GIVE YOU AN EDGE

Principal Life Insurance Company, Des Moines, Iowa 50392-0002, www.principal.com

This is a summary of vision coverage underwritten by or with administrative services provided by Principal Life Insurance Company. This
benefit summary is for administrative purposes and is not a complete statement of benefits and restrictions. Youll receive a benefit
booklet with details about your coverage. If there is a discrepancy between this summary and your benefit booklet, the benefit booklet
prevails.

GP 55899-4 | 08/2013 | 2013 Principal Financial Services, Inc.

 Accident
Insurance
Accident 1.0 - Premier - NJ

Accidents happen in places

where you and your family
spend the most time at
work, in the home and on the
playgroundand theyre
unexpected. How you care
for them shouldnt be.
coloniallife.com
Colonial Lifes Accident Insurance is designed to help you fill some Children ages 5 to 14
account for nearly 40
of the gaps caused by increasing deductibles, co-payments and percent of all sports-
out-of-pocket costs related to an accidental injury. related injuries treated
in hospital emergency
Benefits listed are for each covered person per covered accident departments. The rate and
unless otherwise specified. See the attached outline of coverage for severity of sports-related
complete details. injury increases with a
childs age.
2009 National Center for Sports Safety
Initial Care When an accident happens, you dont want to worry about how you will pay for
the initial care, especially if you have to go to a doctors office, urgent care
facility or the emergency room for x-rays or ride in an ambulance.
Accident Emergency Treatment $125
X-ray Benefit $40
Ambulance $200
Air Ambulance $2,000

Common Fractures and dislocations are frequent injuries common in both adults and children.
Closed Open
Accidental Dislocations (Separated Joint) Reduction Reduction
(Non-Surgical) (Surgical)
Injuries Hip $2,400 $4,800
Knee (except patella) $1,200 $2,400
Ankle Bone or Bones of the Foot (other than Toes) $960 $1,920
Collarbone (Sternoclavicular) $600 $1,200
In the U.S., a disabling
Lower Jaw, Shoulder, Elbow, Wrist $360 $720 injury takes place every
Bone or Bones of the Hand $360 $720 second. The economic
Collarbone (Acromioclavicular and Separation) $120 $240 impact of these
One Toe or Finger $120 $240 unintentional injuries
amounted to $684.4 billion
Closed Open in 2007. This is equivalent
Fracture Reduction Reduction to about $2,300 per capita.
(Non-Surgical) (Surgical)
Depressed Skull $3,000 $6,000 Injury Facts, National Safety Council,
2009 Edition
Non-Depressed Skull $1,200 $2,400
Hip, Thigh $1,800 $3,600
Body of Vertebrae, Pelvis, Leg $900 $1,800 Features of
Bones of Face or Nose (except mandible or maxilla) $420 $840
Colonial Lifes
Upper Jaw, Maxilla $420 $840
Upper Arm between Elbow and Shoulder $420 $840
Accident Insurance:
Lower Jaw, Mandible, Kneecap, Ankle, Foot $360 $720 Family coverage is
Shoulder Blade, Collarbone, Vertebral Process $360 $720 available for your spouse
Forearm, Wrist, Hand $360 $720 and children.
Rib $300 $600
Coccyx $240 $480 Your benefits are paid
Finger, Toe $120 $240 directly to you, unless
specified otherwise.
Your Colonial Life policy also provides benefits for the following injuries received
as a result of a covered accident. Youre covered
Burn $1,000 to $12,000 Tendon/Ligament/ $750 - one worldwide.
(based on size and degree) Rotator Cuff $1,500 - two or
more This plan is portable;
you can take it with you
Coma $12,500 Lacerations $30 to $500
(based on size) if you change jobs or
Concussion $60 retire.
Emergency Dental $100 Extraction Ruptured Disc $750
Work $400 Crown, Implant, You are paid benefits
or Denture regardless of any other
Eye Injury $300 Torn Knee Cartilage $750 insurance you may have.
Surgical If your covered accidental injury is serious enough to require surgical care or a transfusion, your
Colonial Life policy can provide the following benefits:
Care
Surgery (cranial, open abdominal or thoracic) $1,500
Surgery (hernia) $150
Surgery (arthroscopic or exploratory) $200
Blood/Plasma/Platelets $300

Transportation/ If a covered person must travel more than 50 miles to receive special treatment and confinement in
a hospital for injuries received as the result of a covered accident, your Colonial Life policy provides
Lodging benefits to help with transportation other than ambulance. Colonial Life will pay lodging costs for a
Assistance hotel/motel for a family member or companion to accompany the covered person who is confined
to a hospital that is more than 50 miles from his or her residence.
Transportation $600 per round trip up to 3 round trips
Lodging (family member or companion) $150 per night up to 30 days

Accident Traditional health insurance policies may have per admission deductibles and co-payments that
must be satisfied prior to covering benefits related to hospital stays. Your Colonial Life policy
Hospital Care provides benefits to help with these costs.
Hospital Admission* $1,500 per accident
Hospital Confinement $275 per day up to 365 days
Hospital ICU Admission* $3,000 per accident
Hospital ICU Confinement $550 per day up to 15 days per accident
* We will pay either the Hospital Admission or Hospital Intensive Care Unit (ICU) Admission, but not both.

Accident You may require follow-up care once you are discharged from the emergency room, hospital or
doctors office. You may have to undergo physical therapy, use crutches or a wheelchair or even
Follow-Up Care require the use of an artificial limb. If so, your Colonial Life policy provides the following benefits:
Accident Follow-Up Doctor Visit $50 (up to 4 visits per accident)
Medical Imaging Study $200 per accident (limit 1 per covered accident and 1 per
calendar year)
Occupational or Physical Therapy $35 per treatment up to 10 days
Appliances $100 (such as wheelchair, crutches)
Prosthetic Devices/Artificial Limb $750 - one, $1,500 - more than 1
Rehabilitation Unit $150 per day up to 15 days per covered accident, and 30 days
per calendar year. Maximum of 30 days per calendar year

Accidental For injuries received as a result of a covered accident that lead to an accidental dismemberment or
death, this plan provides benefits
benefits that can help see you and your family through the loss.
Dismemberment
and Accidental Accidental Dismemberment
Death Loss of Finger/Toe $1,200 one, $2,400 two or more
Loss of Hand/Foot/Sight of Eye $12,000 one, $24,000 two or more

Accidental Death Accidental Death Common Carrier

Named Insured $50,000 $200,000
Spouse $50,000 $200,000
Child(ren) $10,000 $40,000
Benefit Worksheet
For use by Colonial Life Benefits Counselor
Flexible Benefit (Pre-tax)
Coverage: (check one)
Employee Only Spouse Only One Child Only Employee/Spouse
One-Parent Family, Employee One-Parent Family, Spouse Two-Parent Family
Plan: (check one) On and Off -Job Benefits Off -Job Only Benefits
Premium Per Pay Period $__________________ The premium will vary based on benefits selected.

Learn more about these and all of the personal insurance products and services that Colonial Life offers at
coloniallife.com.

This coverage has exclusions and limitations that may affect benefits payable. Coverage type and benefits vary by state
and may not be available in all states. See the Outline of Coverage within for complete details.

Applicable to policy form Accident 1.0-NS-NJ. This brochure is not complete without the corresponding Outline of
Coverage form Accident 1.0-NS-O-NJ.

Accident 1.0 - Premier- NJ

Colonial Life
1200 Colonial Life Boulevard
Columbia, South Carolina 29210 Colonial Life products are underwritten by Colonial Life & Accident
coloniallife.com Insurance Company, for which Colonial Life is the marketing brand.

02/10 74515
 Hospital Confinement Indemnity Insurance
Plan 1

Our Individual Medical BridgeSM insurance can help with medical costs that your
health insurance may not cover. These benefits are available for you, your spouse
and eligible dependent children.

Hospital confinement. ..................................................................... $__________________

1000
Maximum of one benefit per covered person per calendar year

Daily Hospital Confinement............................................................ $_____________

50 per day
Maximum of 60 days per covered person per confinement
Re-confinement for the same or related condition within 90 days of discharge is considered a continuation of
a previous confinement. If more than 90 days have passed between the periods of hospital confinement, we
will treat this later confinement as a new and separate confinement.

Health savings account (HSA) compatible

This plan is compatible with HSA guidelines. This plan may also be offered to employees
who do not have HSAs.

Colonial Life & Accident Insurance Companys Individual Medical Bridge offers an HSA
For more information, compatible plan in most states.
talk with your
benefits counselor.

ColonialLife.com THIS POLICY PROVIDES LIMITED BENEFITS.

EXCLUSIONS
We will not pay benefits for losses which are caused by: cosmetic surgery, dental procedures, illegal occupations, intoxication
or drug addiction, mental or emotional disease or disorder, suicide or injuries which any covered person intentionally does to
himself or herself, or war. We will not pay benefits for hospital confinement or daily hospital confinement of a newborn
who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a
pre-existing condition. A pre-existing condition is a sickness or physical condition for which a covered person was treated,
had medical testing, received medical advice or had taken medication within the 12 months before the effective date of
the policy.
For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000-NJ. This is
not an insurance contract and only the actual policy provisions will control.

2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are
underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

IMB7000 PLAN 1 | 101576-NJ

EVERYONE
Delete Grouping
rivets: each-range
17 - 49 Edit Delete Band
Coverage
Level Monthly Rate
rivets: each-rate
Employee 13.8
Employee + 27.35
Spouse
Employee + 20.2
Child(ren)
Employee + 33.75
Family

50 - 59 Edit Delete Band

Coverage
Level Monthly Rate
rivets: each-rate
Employee 19.35
Employee + 38.05
Spouse
Employee + 25.75
Child(ren)
Employee + 44.45
Family

60 - 64 Edit Delete Band

Coverage
Level Monthly Rate
rivets: each-rate
Employee 26.95
Employee + 53.15
Spouse
Employee + 33.35
Child(ren)
Employee + 59.55
Family

65 - 75 Edit Delete Band

Coverage
Level Monthly Rate
rivets: each-rate
Employee 36.5
Employee + 71.9
Spouse
Employee + 42.9
Child(ren)
Employee + 78.3
Family
Employee Enrollment/Waiver Form

eTeam Inc.
Employer : ______________

Enrollee Information
Last Name: _______________________________ First Name: _________________________________ M.I.: _____________________
Street/Apt#: __________________________________ City: _______________________________ State/Zip: _____________________
Phone: __ __ __ - __ __ __ - __ __ __ __ Phone (Alt): __ __ __ - __ __ __ - __ __ __ __ Marital Status: Single Married
Email: ______________________________________Job Title: ___________________________Full Time Hire Date ___ / ___ / ___
Annual Salary / Pay Rate: $________________

Waiver ( if WAIVING, all other sections should be left blank )

I WAIVE medical coverage in the companys health plan for: Employee (Self) Spouse Child(dren)
Reason for waiving coverage (circle one): Covered under spouse/parent employers group plan / Medicare / Military Service / Individual
Policy / Other If Other, provide explanation: _________________________________________________________________________

Enrollee Signature X________________________________________________ Date (required) ______________________________

Applicant Enrollment Information (Ignore if Waiving)

The table below should contain ALL family members applying for coverage. mm/dd/yyyy
Last Name First Name M.I. Gender Date of Birth Social Security No.

Employee:

Spouse:

Child:

Child:

Child:

Child:

Questions? Call Kistler Tiffany Benefits at 866-KTB-SERV

1
 Employee Enrollment/Waiver Form
I Elect Medical Coverage
Mark an X for plan selection and coverage type

MEC HSA

Employee

Employee + Spouse:

Employee + Child:

Employee + Family:

I Elect Dental Coverage I Elect Vision Coverage

Mark an X for plan selection and coverage type Mark an X for plan selection and coverage type

Dental Plan Vision Plan

Employee Employee
: :
Employee + Spouse: Employee + Spouse:
Employee + Child: Employee + Child:

Employee + Family: Employee + Family:

I Elect Hospital Bridge Coverage I Elect Accident Coverage

Mark an X for plan selection and coverage type Mark an X for plan selection and coverage type

Hospital Bridge Plan Accident Plan

Employee Employee
: :
Employee + Spouse: Employee + Spouse:
Employee + Child: Employee + Child:

Employee + Family: Employee + Family:

I agree to the payroll deduction. I understand I no longer qualify for the subsidy on Healthcare.gov

Signed: ______________________ Dated: ______________________

Questions? Call Kistler Tiffany Benefits at 866-KTB-SERV