Fixed Indemnity Medical Insurance Plan, Ancillary Products,

and Self-Funded Minimum Essential Coverage (MEC) Enrollment Guide

Complete the Enrollment Form to Elect or Decline Coverage

IMPORTANT PLAN INFORMATION: You have one medical plan option. Additional benefits are available to add if you enroll
in the Fixed Indemnity Medical Insurance Plan.
1. You MUST complete the Enrollment Form as part of your New Hire Process.
2. Elect or decline all benefits on the Enrollment Form.
3. You MUST Sign and Date the bottom of the form, even if you decline coverage.
4. Return the Enrollment Form to your Branch Manager.
5. Keep the Summary of Benefits pages for your records.

Not available in all states. Some provisions, benefits, exclusions or limitations herein may vary by state.

The Essential StaffCARE Fixed Indemnity Medical Insurance Plan, Prescription Drug, Dental, Vision, and Term Life
Plans are underwritten by Fidelity Security Life Insurance Company®, Kansas City, MO; Policy/Form Numbers:
LM-162, DT-239, VC-151, TL-149, SD-36.

THE FIXED INDEMNITY MEDICAL INSURANCE PLAN IS A SUPPLEMENT TO HEALTH INSURANCE. IT IS NOT A
SUBSTITUTE FOR ESSENTIAL HEALTH BENEFITS COVERAGE AS DEFINED IN FEDERAL HEALTH LAW.

The MEC Wellness/Preventive Plan is an employer-sponsored, self-funded plan that has been deemed to be in compliance
with ACA rules and regulations. More information about Preventive Services may be found on the government website
at: [Link] For questions or assistance, please call
Essential StaffCARE Customer Service at 1-888-208-1998.

Voluntary Electronic Availability of Summary Health Information for MEC/Wellness Preventive Plan
Copies of the Summary of Benefits and Coverage (“SBC”) and Summary Plan Description (“SPD”) from Essential
StaffCARE (“ESC”) are available at the following link: [Link]/mec-sbc-spd
While you may have other health plans, this is the link for your MEC plan SPD with ESC. These important documents
explain the terms and conditions of your Health Plan, including eligibility, coverage amounts and exclusions along
with your rights and responsibilities. At any time, you may request paper copies or revoke your consent to electronic
delivery, free of charge, by calling 1-888-208-1998.

For questions or assistance, please call Essential StaffCARE Customer Service at 1-888-208-1998.

BUA2 F-ESC/MEC 4USDVTW P2M v3.0

 VSI 3126902-BUA2 OFFICE USE ONLY LOCATION ____________ Rehire Date __ __ /__ __ /__ __ __ __

BENEFIT ELECTION FORM F-ESC/MEC 4USDVTW P2M v3.0

A. REQUIRED EMPLOYEE INFORMATION D. E
 NROLL IN LIMITED BENEFIT PLANS
PRINT USING BLACK or BLUE INK (Must Be Filled Out) You MUST select a coverage level before any benefits.
Your coverage level for all the benefits will be identical.
Name
Employee Only
Phone
SELECT Employee + Child(ren)
Social Security Number
COVERAGE LEVEL Employee + Spouse
Date of Birth / / Gender M F Weekly Payroll Employee + Family
Deducted Rates
Address Apt. NO to ALL Benefits
City State Zip
FIXED INDEMNITY Weekly Payroll
B. MEDICARE INFORMATION MEDICAL INSURANCE PLAN¹ Deducted Rates

Do you or any of your dependents receive Medicare Benefits? $20.91 Employee Only
YES $34.71 Employee + Child(ren)
Yes No If Yes, fill out the remainder of this section.
$39.73 Employee + Spouse
NO
Medicare Health Insurance Claim Number (HICN): $52.90 Employee + Family
1
This coverage is not available to residents of NH, HI, or PR
Medicare Effective Date:
Coverage Level DENTAL VISION TERM LIFE

E $1.68
Name of Covered Person(s): $5.40 $0.60
Employee Only
Employee + Child(ren) $14.58 $4.53 $0.90
1.
$10.80 $3.36 $0.90
PL
Employee + Spouse
Employee + Family $20.52 $6.37 $1.80
2.
Yes Yes Yes
3.
No No No
M

C. REQUIRED DEPENDENT INFORMATION E. BENEFICIARY INFORMATION

Name DOB / / If you have selected the Benefit Bundle, please write in your
SA

beneficiary information for the Term Life Benefit.

Social Security # Gender M F Name
Relationship
Relationship: Spouse Child Domestic Partner
Name DOB / / F. ENROLL IN MEC WELLNESS/PREVENTIVE BENEFIT
Social Security # Gender M F $14.46 Employee Only
MEC PLAN 1
Relationship: Spouse Child Domestic Partner $20.48 Employee + Child(ren)
Weekly Payroll
Name DOB $19.17 Employee + Spouse
/ / Deducted Rates
$25.18 Employee + Family
Social Security # Gender M F 83126902-M-BUA2
NO to MEC Plan
Relationship: Spouse Child Domestic Partner
1
This coverage is not available to residents of HI or PR

G. REQUIRED SIGNATURE YOU MUST SIGN AND DATE EVEN IF YOU DECLINE COVERAGE
By signing below, I confirm I have read the Benefits Summary and the Limitations and Exclusions for the recommended benefit plans;
I’ve been offered self-funded ACA compliant coverage (MEC Wellness/Preventive) and open enrollment is only available for a limited
time. I also understand that making no benefit selection is a declination of benefit coverage and benefit coverage is only available to
employees who are over the age of 18 with a valid SSN.
DATE __ __ /__ __ /__ __ __ __ SIGNATURE
 SUMMARY OF BENEFITS
Fixed Indemnity Medical Insurance Plan
Group Number: 3126902-BUA2
The Fixed Indemnity Medical Insurance Plan pays a flat amount for a covered event caused by an accident or illness. If the covered
event costs more, you pay the difference. But if the covered event costs less, you keep the difference.
Plan Year Per Plan Year
Outpatient Benefits Per Day Inpatient Benefits
Maximum Day Maximum
Physician Office visit $105 8 days Hospital Admission $250 1 day
Outpatient Surgery 1
$500 1 day Daily Hospital Confinement $500 3x (unlimited days)
Anesthesia $125 — Intensive Care Unit Maximum9 $600 30 days
Diagnostic Labs2 $75 6 days Skilled Nursing Facility10 $100 60 days (no lifetime max)
Diagnostic Tests 3
$200 3 days Inpatient Surgery $3,000 1 day
Ambulance Services 4
$300 / $900
5 6
1 day Anesthesia $750 —
Emergency Room (Injuries)7 $500 2 days Wellness Care11
Emergency Room (Sickness) $200 2 days Persons age 1+ $100 1 Day
Prescription Drugs 8
$20 30 days Persons under age 1 $100 4 Days
Telemedicine Services* No Cost Unlimited
*You will have access to a national Telemedicine program called 1.800MD. This program connects members to board certified physicians around
the clock (24/7/365) via telephone or secure video. 1.800MD doctors can answer questions, give advice, and even diagnose and treat illnesses
by calling 1-800-530-8666.

MEC Wellness/Preventive Plan

Group Number: 83126902-M-BUA2
Your second option for medical coverage is the MEC Wellness/Preventive Plan. This plan provides coverage for preventive
services such as immunizations and routine health screenings.
Preventive Services Benefit In-Network Non-Network

Preventive Services for Adults 100% 40%

Preventive Services for Women 100% 40%
Preventive Services for Children 100% 40%

Fixed Indemnity Medical

MEC Plan
PREMIUM Insurance Plan
(Weekly)
(Weekly)
Employee Only $20.91 $14.46
Employee + Child(ren) $34.71 $20.48
Employee + Spouse $39.73 $19.17
Employee + Family $52.90 $25.18
1
benefits are not payable for surgical operations performed in a Physician’s office 2 routine or wellness lab screens and tests are not covered
3
laboratory tests and routine wellness screens and tests not covered 4 transportation must occur within 72 hours of the accident or onset of
the sickness 5 benefit is for ground/water services 6 benefit is for air services 7 treatment must be within 72 hours of the accident 8 To file a
claim for reimbursement, save your receipt and remit to Planned Administrators, Inc. 9 pays in addition to daily hospital confinement 10 must
be under age 65 and admitted to the Skilled Nursing Facility within 14 days following a Hospital stay of at least three consecutive days
11
benefit is payable for each day an insured person has any one of the health screenings, exams, or tests listed in the policy
 SUMMARY OF BENEFITS
Dental
Benefits are payable for dental treatment services and supplies performed by or prescribed by a Dentist or Dental Hygienist.
Waiting Period/
Benefits Annual Maximum Benefits: $750 Deductible: $50 (per insured person)
Coinsurance
Coverage A None / 80% Exams, Cleanings, Fluoride, Bitewings, Tests & Labs, Space Maintainers, and Sealants
Coverage B 3 Months / 60% Fillings, Oral Surgery, Anesthesia, and Repairs for Crowns, Bridges and Dentures
Coverage C 12 Months / 50% Periodontics and Endodontics Including Root Canal, Crowns, Bridges, and Dentures

Vision
Helps offset the cost of covered procedures performed by an optometrist.

VISION BENEFIT In-Network Out-of-Network

Eye exam with dilation as necessary 1 $10 Copay; plan pays 100% Plan pays $45; you pay remaining
Exam Options
Retinal Imaging You pay up to $39 You pay 100% of the price
Standard Contact Lens Fit 2 You pay up to $55 You pay 100% of the price
Premium Contact Lens Fit 2 10% off retail price; you pay remaining You pay 100% of the price
Frames 3, 4 Plan pays 20% after $110 allowance $90; you pay remaining
Standard Plastic Lenses 1,4, 5
Single Vision $25 Copay Plan pays $40; you pay remaining
Bifocal $25 Copay Plan pays $60; you pay remaining
Trifocal / Lenticular $25 Copay Plan pays $80; you pay remaining
Progressive–Standard $90 Copay Plan pays $60; you pay remaining
Progressive–Premium $90 Copay; plan pays 20% after $120 allowance Plan pays $60; you pay remaining
Lens Options
UV Treatment / Tint (Solid and Gradient) /
$15 You pay 100% of the price
Standard Plastic Scratch Coating
Standard Polycarbonate $40 You pay 100% of the price
Standard Anti-Reflective Coating $45 You pay 100% of the price
Non-Glass Photochromatic /
20% off retail price You pay 100% of the price
Other Add-ons and Services
Contact Lenses 1,6
Conventional Plan pays 15% after $110 allowance Plan pays $90; you pay remaining
Disposable Plan pays 100% after $110 allowance Plan pays $90; you pay remaining
Medically Necessary Plan pays 100% Plan pays $210; you pay remaining
Lasik 7 15% off retail price or 5% off promotional price You pay 100% of the price
1
Per insured; once every 12 months 2Includes follow up; contact lens fit and two follow-up visits are available once a comprehensive eye exam has been completed3once
every 24 months4in lieu of contact lenses540% off additional pairs of glasses and 15% off conventional lenses once funded benefit is used6Contact lens allows
covers materials only; in lieu of regular lenses7Lasik or PRK from US Laser Network

Term Life
Provides coverage to your family in the event of your passing. Don’t forget to name a beneficiary on the enrollment form to receive this benefit.
Benefit Amounts
Employee Amount $10,000 (reduces to $5,000 at 70; $2,500 at 75) Dependent (6 mos +) $2,500
Spouse Amount $5,000 Dependent (14 days to 6 mos) $250
Accidental Death & Dismemberment (AD&D is part of the Term Life Benefit.)
Death / Loss of two limbs / Sight in both eyes /
Employee Only Loss of one limb or sight in one eye ($5,000)
One limb and sight in one eye ($10,000)

Dental Vision Term Life

PREMIUM
(Weekly) (Weekly) (Weekly)
Employee Only $5.40 $1.68 $0.60
Employee + Child(ren) $14.58 $4.53 $0.90
Employee + Spouse $10.80 $3.36 $0.90
Employee + Family $20.52 $6.37 $1.80
FIXED INDEMNITY MEDICAL INSURANCE PLAN the same benefits for the duration of any Hospital Confinement or 90
LIMITATIONS AND EXCLUSIONS days, whichever occurs first. No further premium payment is required
Limitations to qualify for this extension of benefits.
Recurrent Confinements. If the Company pays benefits for a period of
Confinement, and the Insured Person is readmitted within 30 days of DENTAL BENEFIT
that Confinement for the same condition, the later Confinement will The Policy does not provide any benefits for the following charges,
be treated as a continuation of the prior Confinement. If more than services or supplies:
30 days have passed between periods of Confinement for the same 1. that, in the absence of insurance, the Insured Person would not be
condition or the successive Confinement is for an unrelated cause, required to pay;
the Company will treat the later Confinement as a new Confinement.
2. related to self-inflicted injuries (in Colorado, Missouri or Montana,
Exclusions while sane);
The Policy does not provide any benefits for the following: 3. related to war or an act of war, whether or not declared;
1. suicide or any attempt of suicide, while sane or insane (in Colorado, 4. related to the Insured Person’s commission of a felony or an assault
Missouri or Montana, while sane); on another person;
2. any intentionally self-inflicted Injury or Sickness or any attempt 5. related to a riot, nuclear accident or a major disaster;
thereat (in Colorado, Missouri or Montana, while sane);
6. caused by, related to, or as a condition of employment, including
3. rest care or rehabilitative care and treatment, except as specifically self-employment. This exclusion applies even if charges are not
provided in the Skilled Nursing Facility Confinement benefit; covered under any Workers’ Compensation, Occupational Disease,
4. dependent child Pregnancy, except Complications of Pregnancy; group, group-type and individual automobile “No-Fault” coverage
5. routine newborn care, except as specifically provided for in the or similar law;
Wellness benefit; 7. that are more than Usual and Customary Charges;
6. voluntary abortion, except where Medically Necessary to save the 8. that are incurred, or for which treatment began, before the Insured
Insured Person’s life; Person’s effective date of coverage or after the Insured Person’s
7. participation in a Riot, insurrection, rebellion, civil commotion, civil termination of coverage;
disobedience or unlawful assembly. For purposes of this exclusion, 9. related to congenital or development malformations existing when
“Participation” means to take an active part in common with the Insured Person’s coverage became effective under the Policy
others; “Riot” means any use or threat to use force or violence or (unless the procedure is performed on an Insured Person who was
disturbance by three or more persons without authority of law. This covered immediately following birth;
does not include a loss that occurs while acting in a lawful manner 10. that are Experimental/Investigational;
within the scope of authority;
11. appliances, services or procedures relating (i) the change
8. committing, attempting to commit or taking part in a felony, battery, ormaintenance of vertical dimension; (ii) restoration of occlusion (iv)
assault or engaging in an illegal occupation; correction of attrition or abrasion; or (vi) bite analysis or registration;
9. any Injury occurring while the Insured Person is intoxicated occlusion (iv) correction of attrition or abrasion; or (vi) bite analysis
(where the blood alcohol content meets the legal presumption of or registration;
intoxication under the law of the state where the Injury took place); 12. related to orthognathic surgery;
10. treatment for the voluntary taking of any poison or inhalation of 13. for replacement of bridges unless the bridge cannot be made
gas, or voluntary taking of any drug, sedative or narcotic, unless serviceable;
prescribed by a Physician and taken according to the prescribed
dosage; 14. for replacement of partial or full dentures unless the prosthetic
appliance is more than five years old and cannot be made
11. dental care or treatment, except: serviceable;
12. care or treatment due to an Injury to sound, natural teeth treated 15. for replacement of crowns, inlays or onlays unless the prior placement
within 12 months of the Accident; is more than seven years old and cannot be made serviceable;}
13. treatment necessary due to congenital defects or birth abnormalities; 16. related to lost, stolen, missing or duplicate dentures, bridges or
14. excision of impacted third molars, or space maintainers;
15. closed or open reduction of fractures or dislocation of the jaw; 17. charges for implants of any type, and all related procedures, removal
16. sex changes; of implants, precision or semi-precision attachments, denture
17. the reversal of tubal ligation or the reversal of vasectomies; duplication, overdentures and any associated surgery, or other
18. flying or descending from any aircraft or air conveyance, except customized services or attachments;
as a fare-paying passenger in any regularly scheduled commercial 18. related to fixed or removable bridgework involving replacement of
aircraft flying between established airports on a regularly scheduled a natural tooth or teeth that were lost prior to the Insured Person’s
route; effective date of coverage under the Policy. Benefits may be payable
19. accidental bodily Injury occurring while serving on full-time active for bridgework required for loss of teeth while insured under the
duty in any Armed Forces of any country or international authority Policy, if such bridgework is not an abutment for non-covered
(any premium paid will be returned by the Company pro rata for bridgework;
any period of active duty); 19. related to prescription drugs and analgesia pre-medication;
20. declared or undeclared war or acts thereof; 20. related to charges for telephone consultations, failure to keep a
21. injury or Sickness arising out of or in the course of any occupation scheduled appointment, to complete claim forms or attending
for compensation, wage or profit or benefits that he Insured Person physician statements and any other services or supplies that are
is entitled to under any Occupational Disease Law or similar law, not part of the direct treatment of the Insured Person;
whether or not application for such benefits have been made; 21. that are not made by a Dentist;
22. medical care, services or supplies provided outside of the United 22. related to counseling on diet and nutrition, oral hygiene or plaque
States of America or its territories; control;
23. treatment of obesity, weight reduction or dietetic control; except 23. received from a provider who is member of the Insured Person’s
morbid obesity or disease etiology; Immediate Family;
24. confinement, care or services incurred prior to the Insured Person’s 24. caused by or related to an Insured Person’s military service, including
Effective Date or that begin after termination of coverage; service in a military reserve unit;
25. confinement, care or services furnished by any agency or program 25. for services and supplies not included in a Covered Procedure;
funded by federal, state or local government. This does not apply 26. related to orthodontia;
to Medicaid or where prohibited by law; 27. any prosthodontic dental appliance installed or delivered more than
26. confinement or treatment that is not Medically Necessary; or 30 days after the Insured Person’s insurance terminates;
27. any Confinement or treatment not specifically covered in the 28. that are payable under any medical insurance;
Schedule of Benefits. 29. made by any government entity unless the Insured Person is
Extension of Benefits. This provision applies if an Insured Person required to pay; or by any public entity from which coverage could
is Hospital Confined on the termination date of the Policy, unless have been obtained by application or enrollment even if application
termination is due to nonpayment of premiums. The Company will pay or enrollment was not actually made;
 30. related to treatment, services or supplies which are not rendered in charges arising from:
accordance with generally accepted standards of dental practice; 1. medical or surgical treatment, services or supplies for the treatment of
31. related to cosmetic dentistry, including but not limited to veneers and the eye, eyes or supporting structures;
teeth whitening or bleaching; 2. Refraction, when not provided as part of a Comprehensive Eye
32. related to cast restorations, inlays, onlays and crowns for teeth that are Examination;
not broken down by extensive decay or accidental injury or for teeth 3. services provided as a result of any Workers’ Compensation law, or
that can be restored by other means (such as an amalgam or composite similar legislation, or required by any governmental agency or program
filling); whether federal, state or subdivisions thereof;
33. for treatment of malignancies, cysts and neoplasms; or 4. orthoptic or vision training, subnormal vision aids and any associated
34. replacement of third molars. supplemental testing; Aniseikonic lenses;
VISION BENEFIT 5. any Vision Examination or any corrective Vision Materials required by a
Fees charged by a provider for services other than a covered benefit Policyholder as a condition of employment;
and any local, state or federal taxes must be paid in full by the insured 6. safety eyewear;
to the provider. Such fees, taxes or materials are not covered under the 7. solutions, cleaning products or frame cases;
policy. Allowances provide no remaining balance for future use within 8. non-prescription sunglasses;
the same benefit frequency.
9. plano (non-prescription) lenses; plano (non-prescription) contact lenses;
The plan does not provide any vision examination or vision materials
benefits for treatment, services or supplies that are for othoptic or vision 10. two pair of glasses in lieu of bifocals;
training, subnormal vision aids and any associated supplemental testing; 11. electronic vision devices;
Aniseikonic lenses; medical and/or surgical treatment of the eye or sup- 12. services rendered after the date an Insured Person ceases to be covered
porting structures (except for the Lasik benefit); safety eyewear; plano under the Policy, except when Vision Materials ordered before coverage
(non-prescription) lenses or contact lenses; non-prescription sunglasses; ended are delivered, and the services rendered to the Insured Person
two pair of glasses in lieu of bifocals or lost, broken lenses, frames or are within 31 days from the date of such order; or
contact lenses. 13. lost or broken lenses, frames, glasses, or contact lenses that are replaced
Some provisions, benefits, exclusions or limitations listed herein may before the next Benefit Frequency when Vision Materials would next
vary by state. become available.
Providers are not required to carry all brands on all tiers. For current
listing of brands by tier, call 866-939-3633.
Exclusions:
No benefits will be paid for services or materials connected with or

Member Services:
For frequently asked questions and network information for the Fixed Indemnity Medical Insurance Plan, visit
[Link]/FSLIND. For questions and a full list of preventive services covered by the MEC Wellness/Preventive Plan,
as well as the MEC SBC, please visit [Link]/FSLMECW. A paper copy is also available, free of charge, by calling
Essential StaffCARE Customer Service 1-888-208-1998.
PLEASE NOTE: To make changes or cancel coverage by telephone call (800) 269-7783. Use pin code 408 + _ _ _ _ (last four digits of your
SSN) for your Fixed Indemnity Medical Insurance Plan (see gray section above for benefits covered). Use pin code 648 + _ _ _ _ (last four
digits of your SSN) for your MEC plan. Your Company has chosen to take your payroll deductions on a Post-Tax basis.
Essential StaffCARE Customer Service: 1-888-208-1998
• Once enrolled, members can call this number for questions regarding plan coverage, ID card, claim status, and policy booklets and to
add, change, or cancel coverage.
• Customer Service Call Center hours are M - F, 8:30 a.m. to 8 p.m. Eastern Standard Time.
Bilingual representatives are available.
• Members can also visit [Link] and click on “Members” and enter your group number.