Common use of BENEFIT ELECTIONS Clause in Contracts

BENEFIT ELECTIONS. See marketing materials for benefit options available by group size. ❑ Health Connections Medical - ConnectiCare HealthEquity HRA/HSA Integrated Accounts [indicate your choice(s)] ❑ Employee HSA Accounts ❑ Employee HRA Accounts ❑ Other: please specify If HealthEquity HRA or HSA services are selected, you or your broker must complete the HealthEquity HRA/HSA ❑ Group Basic Life ❑ Supplemental Life (2 to 9 eligible employees) ❑ Voluntary Life ❑ Group Dental Prior dental coverage? ❑ Yes ❑ No ❑ 10+ eligible employees; with orthodontia? ❑ Yes ❑ No ❑ 3 to 9 eligible employees (orthodontia not available) ❑ Voluntary Dental ❑ Voluntary Accident & Illness Benefits ❑ Voluntary Vision - select one ❑ 12/12/12 ❑ 12/12/24 ❑ Other ConnectiCare Medical Plans (can be offered with Health Connections medical above) ❑ Short-term Disability* select one ❑ Group ❑ Voluntary ❑ Long-term Disability* select one ❑ Group ❑ Voluntary Note: LTD is not available to employees who work fewer than 30 hours per week. The following are ConnectiCare-direct plans, underwritten by ConnectiCare Benefits, Inc. (CBI), and are not part of the CBIA Service Corporation (CBIASC) policy: Passage Gold POS PCP, Choice Silver POS, Choice Silver POS HSA, Choice Bronze POS HSA, Choice Bronze POS. These plans may be purchased by Health Connections * If electing STD or LTD coverage an original completed Tax Service Agreement must be submitted. Separate Tax Service Agreements are required if electing both STD and LTD coverage. ❑ Identity Theft Protection program participants with aggregated billing and administration. Note: These plans are not integrated with HealthEquity HRA or HSA services. If you choose to include these CBI plans in your medical product offering, a separate 2021 CT CBI Small Group Employer Application must be completed and submitted at time of new-business installation or renewal. ❑ Employer paid ❑ Gold ❑ Platinum ❑ Employee only ❑ Employee & family ❑ Employee paid ❑ CBIA COBRA/State Continuation Administration Separate form required Are you selecting retiree coverage? ❑ Yes ❑ No Check the retiree group you are selecting coverage for: ❑ Existing and future retired employees ❑ Existing only ❑ Future only Check all the retiree coverages you are applying for: ❑ Medical ❑ Dental ❑ Group Basic Life (AD&D discontinued at retirement) ❑ Voluntary Dental ❑ Voluntary Vision Retirees are only eligible for coverage in Medicare plans offered in CBIA Health Connections. I designate Agent of Record as: Address (Street) Address (City, State, ZIP Code) Agency The undersigned agent attests they are individually, and the applicable commissionable agent, are duly licensed and have the required training and appointments with the appropriate government agency, authority, and carrier(s) to solicit enrollment of qualified employees or former employees of an employer participating in CBIA Health Connections and also specifically into a Medicare Advantage with Prescription Drug “MAPD” Plan. The agent of record represents that he/she is authorized to execute this Agreement on behalf of the commissionable agent. Commissions payable to: Address (if different from above) Tax Identification number (if commissions are being paid to the agency) Social Security Number (if commissions are being paid to the agent) Telephone The undersigned agent of record and/or commissionable agent agrees that commissions shall only be paid to agents of records/commissionable agents that are properly licensed with government authorities and appointed with applicable carrier(s). In the event CBIA Service Corporation is assigned commissions due to lack of proper license/appointment all relevant parties acknowledge and agree the relationship is strictly limited to commission and no advice regarding any product was provided. Agent of Record: Print Name Agent of Record: Signature

BENEFIT ELECTIONS. See marketing materials for benefit options available by group size. ❑ Health Connections Medical - ConnectiCare HealthEquity HRA/HSA Integrated Accounts [indicate your choice(s)] ❑ Employee HSA Accounts ❑ Employee HRA Accounts ❑ Other: please specify If HealthEquity HRA or HSA services are selected, you or your broker must complete the HealthEquity HRA/HSA ❑ Group Basic Life ❑ Supplemental Life (2 to 9 eligible employees) ❑ Voluntary Life ❑ Dental ❑ Group Dental Prior dental coverage? ❑ Yes ❑ No ❑ 10+ eligible employees; with orthodontia? ❑ Yes ❑ No ❑ 3 to 9 eligible employees (orthodontia not available) ❑ Voluntary Dental ❑ Voluntary Accident & Illness Benefits ❑ Voluntary Vision - select one ❑ 12/12/12 ❑ 12/12/24 ❑ Other ConnectiCare Medical Plans (can be offered with Health Connections medical above) ❑ Short-term Disability* select one ❑ Group ❑ Voluntary ❑ Long-term Disability* select one ❑ Group ❑ Voluntary Note: LTD is not available to employees who work fewer than 30 hours per week. The following are ConnectiCare-direct plans, underwritten by ConnectiCare Benefits, Inc. (CBI), and are not part of the CBIA Service Corporation (CBIASC) policy: Passage Gold POS PCP, Choice Silver POS, Choice Silver POS HSA, Choice Bronze POS HSA, Choice Bronze POS. These plans may be purchased by Health Connections * If electing STD or LTD coverage an original completed Tax Service Agreement must be submitted. Separate Tax Service Agreements are required if electing both STD and LTD coverage. ❑ Identity Theft Protection program participants with aggregated billing and administration. Note: These plans are not integrated with HealthEquity HRA or HSA services. If you choose to include these CBI plans in your medical product offering, a separate 2021 CT CBI Small Group Employer Application must be completed and submitted at time of new-business installation or renewal. ❑ Employer paid ❑ Gold ❑ Platinum ❑ Employee only ❑ Employee & family ❑ Employee paid ❑ CBIA COBRA/State Continuation Administration Separate form required Are you selecting retiree coverage? ❑ Yes ❑ No Check the retiree group you are selecting coverage for: ❑ Existing and future retired employees ❑ Existing only ❑ Future only Check all the retiree coverages you are applying for: ❑ Medical ❑ Dental ❑ Group Basic Life (AD&D discontinued at retirement) ❑ Voluntary Dental ❑ Voluntary Vision Retirees are only eligible for coverage in Medicare plans offered in CBIA Health Connections. I designate Agent of Record as: Address (Street) Address (City, State, ZIP Code) Agency The undersigned agent attests they are individually, and the applicable commissionable agent, are duly licensed and have the required training and appointments with the appropriate government agency, authority, and carrier(s) to solicit enrollment of qualified employees or former employees of an employer participating in CBIA Health Connections and also specifically into a Medicare Advantage with Prescription Drug “MAPD” Plan. The agent of record represents that he/she is authorized to execute this Agreement on behalf of the commissionable agent. Commissions payable to: Address (if different from above) Tax Identification number (if commissions are being paid to the agency) Social Security Number (if commissions are being paid to the agent) Telephone The undersigned agent of record and/or commissionable agent agrees that commissions shall only be paid to agents of records/commissionable agents that are properly licensed with government authorities and appointed with applicable carrier(s). In the event CBIA Service Corporation is assigned commissions due to lack of proper license/appointment all relevant parties acknowledge and agree the relationship is strictly limited to commission and no advice regarding any product was provided. Agent of Record: Print Name Agent of Record: Signature

BENEFIT ELECTIONS. See marketing materials for benefit options available by group size. ❑ Health Connections Medical - ConnectiCare HealthEquity HRA/HSA Integrated Accounts [indicate your choice(s)] ❑ Employee HSA Accounts ❑ Employee HRA Accounts ❑ Other: please specify If HealthEquity HRA or HSA services are selected, you or your broker must complete the HealthEquity HRA/HSA ❑ Group Basic Life ❑ Supplemental Life (2 to 9 eligible employees) ❑ Voluntary Life ❑ Group Dental Prior dental coverage? ❑ Yes ❑ No ❑ 10+ eligible employees; with orthodontia? ❑ Yes ❑ No ❑ 3 2 to 9 eligible employees (orthodontia not available) ❑ Voluntary Dental ❑ Voluntary Accident & Illness Benefits ❑ Voluntary Vision - select one ❑ 12/12/12 ❑ 12/12/24 ❑ Other ConnectiCare Medical Plans Voluntary Life (can be offered with Health Connections medical above10+ eligible employees) ❑ Voluntary Dependent Life (10+ eligible employees) Additional No-cost Services Separate forms are required to set up each of these services. ❑ CBIA COBRA Administration ❑ CBIA HRA Administration ❑ Voluntary Dental ❑ Short-term Disability* - select one ❑ Group ❑ Voluntary ❑ Voluntary Accident & Illness Benefits ❑ Long-term Disability* - select one ❑ Group ❑ Voluntary Note: LTD is not available to employees who work fewer than 30 hours per week. The following are ConnectiCare-direct plans, underwritten by ConnectiCare Benefits, Inc. (CBI), and are not part of the CBIA Service Corporation (CBIASC) policy: Passage Gold POS PCP, Choice Silver POS, Choice Silver POS HSA, Choice Bronze POS HSA, Choice Bronze POS. These plans may be purchased by Health Connections * If electing STD or LTD coverage an original completed Tax Service Agreement must be submitted. Separate Tax Service Agreements are required if electing both STD and LTD coverage. ❑ Identity Theft Protection program participants with aggregated billing and administration. Note: These plans are not integrated with HealthEquity HRA or HSA services. If you choose to include these CBI plans in your medical product offering, a separate 2021 CT CBI Small Group Employer Application must be completed and submitted at time of new-business installation or renewal. ❑ Employer paid ❑ Gold ❑ Platinum ❑ Employee only ❑ Employee & family ❑ Employee paid ❑ CBIA COBRA/State Continuation Administration Separate form required Are you selecting retiree coverage? ❑ Yes ❑ No Check the retiree group you are selecting coverage for: ❑ Existing and future retired employees ❑ Existing only ❑ Future only Check all the retiree coverages you are applying for: ❑ Medical ❑ Dental ❑ Group Basic Life (AD&D discontinued at retirement) ❑ Voluntary Dental ❑ Voluntary Vision Retirees are only eligible for coverage in Medicare plans offered in CBIA Health Connections. I designate Agent of Record as: Address (Street) Address (City, State, ZIP Code) Agency The undersigned agent attests they are individually, and the applicable commissionable agent, are duly licensed and have the required training and appointments with the appropriate government agency, authority, and carrier(s) to solicit enrollment of qualified employees or former employees of an employer participating in CBIA Health Connections and also specifically into a Medicare Advantage with Prescription Drug “MAPD” Plan. The agent of record represents that he/she is authorized to execute this Agreement on behalf of the commissionable agent. Commissions payable to: Address (if different from above) Tax Identification number (if commissions are being paid to the agency) Social Security Number (if commissions are being paid to the agent) Telephone The undersigned agent of record and/or commissionable agent agrees that commissions shall only be paid to agents of records/commissionable agents that are properly licensed with government authorities and appointed with applicable carrier(s). In the event CBIA Service Corporation is assigned commissions due to lack of proper license/appointment all relevant parties acknowledge and agree the relationship is strictly limited to commission and no advice regarding any product was provided. Agent of Record: Print Name Agent of Record: SignatureSignature The undersigned employer attests that it meets and will abide by all of the following participation requirements: • The undersigned employer is a small employer as defined in Connecticut Public Act 90-134. • The undersigned employer is a member of the Connecticut Business & Industry Association (CBIA) and will renew membership annually. • The undersigned employer is a firm, corporation, partnership or association that has been actively engaged in business for at least three consecutive months. • The undersigned employer acknowledges that an active eligible employee is an employee who works more than 30 hours per week. Some employers may also wish to provide coverage to employees who work 20 - 29 hours per week. • A minimum of 50 of the full-time eligible employees enrolling in the CBIA Health Connections program work/reside in Connecticut. • The undersigned employer employs a minimum of two (2) full-time active eligible employees and not more than 50 full-time equivalent employees. • The undersigned employer must maintain a minimum of two (2) active full-time eligible employees participating in all offered Group lines of coverage at all times. If there are fewer than two (2) active full-time employees enrolled in any Group line of coverage, that line of coverage will not be renewed. • The undersigned employer must meet a minimum of 75 participation of eligible employees. Valid waivers can be excluded from the calculation for medical and dental coverage. • The undersigned employer must meet a minimum of 100 participation for all coverages that are non-contributory, whereby the employer pays 100 of the premiums. • The undersigned employer understands that there are separate participation requirements for voluntary coverages: Employers with 2-9 employees: • Voluntary Life, Short Term Disability and Long Term Disability have a minimum participation requirement of three (3) enrolled employees. • Voluntary Dental, Vision & Accident and Illness have a requirement of two (2) lines of coverage offered by CBIA Health Connections and two (2) employees enrolled in one line of coverage. • Supplemental Life does not have a minimum participation requirement; The employee must be also be enrolled in basic life coverage. Employers with 10 or more employees: • Voluntary Life, Short Term Disability and Long Term Disability have a minimum participation requirement of three (3) enrolled employees. • Voluntary Dental, Vision, and Accident and Illness have a requirement of one (1) line of coverage and two (2) enrolled employees. • Supplemental Life is not available. • The undersigned employer has a place of business in Connecticut. • The undersigned Employer agrees to provide annual certification of continued adherence to the Program participation requirements listed here. • One hundred percent (100 ) of the eligible employees enrolling in the Program are covered by Workers’ Compensation insurance, except those eligible employees who are not legally required to be covered by Workers’ Compensation insurance. • The undersigned employer will contribute an amount equal to at least fifty percent (50 ) of the lowest monthly employee-only medical rate for each employee based on age. • The undersigned employer will maintain Basic Group Life insurance through CBIA Health Connections for all medical enrollees. • The undersigned employer agrees to give a minimum 15-days advance written notification to CBIA Service Corporation if it wants to cancel any coverages. Otherwise, it will be liable for the premium until the termination of its participation in the Program. • The undersigned employer agrees that reinstatement after cancellation for non-payment (including NSF payments) can only occur two (2) times during a rolling twelve (12) month period. • Employers with two (2) to nine (9) eligible employees must enroll and maintain a minimum of two (2) lines of coverage. To disenroll individual(s) from an employer/union sponsored Medicare Advantage plan and convert them to Original Medicare, the employer or union must provide the following. • The employer/union will provide CBIA a timely notice of contract termination or the ineligibility of an individual to participate in the employer or union group sponsored Medicare Advantage plan. Such notice must be prospective, not retroactive. • The employer/union must provide a prospective notice to its members alerting them of the termination event and of other insurance options available to them through their employer/union.

BENEFIT ELECTIONS. See marketing materials for benefit options available by group size. ❑ Health Connections Medical - ConnectiCare HealthEquity HRA/HSA Integrated Accounts [indicate your choice(s)] ❑ Employee HSA Accounts ❑ Employee HRA Accounts ❑ Other: please specify If HealthEquity HRA or HSA services are selected, you or your broker must complete the HealthEquity HRA/HSA ❑ Group Basic Life ❑ Supplemental Life (2 to 9 eligible employees) ❑ Voluntary Life (10+ eligible employees) ❑ Voluntary Dependent Life (10+ eligible employees) ❑ Group Dental Prior dental coverage? ❑ Yes ❑ No ❑ 10+ eligible employees; with orthodontia? ❑ Yes ❑ No ❑ 3 to 9 eligible employees (orthodontia not available) ❑ Voluntary Dental ❑ Voluntary Accident & Illness Benefits ❑ Voluntary Vision - select one ❑ 12/12/12 ❑ 12/12/24 ❑ Other ConnectiCare Medical Plans (can be offered with Health Connections medical above) Voluntary Accident & Illness Benefits Additional No-cost Services Separate forms are required to set up each of these services. ❑ Short-term Disability* - select one ❑ Group ❑ Voluntary ❑ Long-term Disability* - select one ❑ Group ❑ Voluntary Note: LTD is not available to employees who work fewer than 30 hours per week. The following are ConnectiCare-direct plans, underwritten by ConnectiCare Benefits, Inc. (CBI), and are not part of the ❑ CBIA Service Corporation (CBIASC) policy: Passage Gold POS PCP, Choice Silver POS, Choice Silver POS HSA, Choice Bronze POS HSA, Choice Bronze POS. These plans may be purchased by Health Connections COBRA Administration ❑ CBIA HRA Administration * If electing STD or LTD coverage an original completed Tax Service Agreement must be submitted. Separate Tax Service Agreements are required if electing both STD and LTD coverage. ❑ Identity Theft Protection program participants with aggregated billing and administration. Note: These plans are not integrated with HealthEquity HRA or HSA services. If you choose to include these CBI plans in your medical product offering, a separate 2021 CT CBI Small Group Employer Application must be completed and submitted at time of new-business installation or renewal. ❑ Employer paid ❑ Gold ❑ Platinum ❑ Employee only ❑ Employee & family ❑ Employee paid ❑ CBIA COBRA/State Continuation Administration Separate form required Are you selecting retiree coverage? ❑ Yes ❑ No Check the retiree group you are selecting coverage for: ❑ Existing and future retired employees ❑ Existing only ❑ Future only Check all the retiree coverages you are applying for: ❑ Medical ❑ Dental ❑ Group Basic Life (AD&D discontinued at retirement) ❑ Voluntary Dental ❑ Voluntary Vision Retirees are only eligible for coverage in Medicare plans offered in CBIA Health Connections. I designate Agent of Record as: Address (Street) Address (City, State, ZIP Code) Agency The undersigned agent attests they are individually, and the applicable commissionable agent, are duly licensed and have the required training and appointments with the appropriate government agency, authority, and carrier(s) to solicit enrollment of qualified employees or former employees of an employer participating in CBIA Health Connections and also specifically into a Medicare Advantage with Prescription Drug “MAPD” Plan. The agent of record represents that he/she is authorized to execute this Agreement on behalf of the commissionable agent. Commissions payable to: Address (if different from above) Tax Identification number (if commissions are being paid to the agency) Social Security Number (if commissions are being paid to the agent) Telephone The undersigned agent of record and/or commissionable agent agrees that commissions shall only be paid to agents of records/commissionable agents that are properly licensed with government authorities and appointed with applicable carrier(s). In the event CBIA Service Corporation is assigned commissions due to lack of proper license/appointment all relevant parties acknowledge and agree the relationship is strictly limited to commission and no advice regarding any product was provided. Agent of Record: Print Name Agent of Record: SignatureSignature The undersigned employer attests that it meets and will abide by all of the following participation requirements: • The undersigned employer is a small employer as defined in Connecticut Public Act 90-134. • The undersigned employer is a member of the Connecticut Business & Industry Association (CBIA) and will renew membership annually. • The undersigned employer is a firm, corporation, partnership or association that has been actively engaged in business for at least three consecutive months. • The undersigned employer acknowledges that an active eligible employee is an employee who works more than 30 hours per week. Some employers may also wish to provide coverage to employees who work 20 - 29 hours per week. • A minimum of 50 of the full-time eligible employees enrolling in the CBIA Health Connections program work/reside in Connecticut. • The undersigned employer employs a minimum of two (2) full-time active eligible employees and not more than 50 full-time equivalent employees. • The undersigned employer must maintain a minimum of two (2) active full-time eligible employees participating in all offered Group lines of coverage at all times. If there are fewer than two (2) active full-time employees enrolled in any Group line of coverage, that line of coverage will not be renewed. • The undersigned employer must meet a minimum of 75 participation of eligible employees. Valid waivers can be excluded from the calculation for medical and dental coverage. • The undersigned employer must meet a minimum of 100 participation for all coverages that are non-contributory, whereby the employer pays 100 of the premiums. • The undersigned employer understands that there are separate participation requirements for voluntary coverages: Employers with 2-9 employees: • Voluntary Life, Short Term Disability and Long Term Disability have a minimum participation requirement of three (3) enrolled employees. • Voluntary Dental, Vision & Accident and Illness have a requirement of two (2) lines of coverage offered by CBIA Health Connections and two (2) employees enrolled in one line of coverage. • Supplemental Life does not have a minimum participation requirement; The employee must be also be enrolled in basic life coverage. Employers with 10 or more employees: • Voluntary Life, Short Term Disability and Long Term Disability have a minimum participation requirement of three (3) enrolled employees. • Voluntary Dental, Vision, and Accident and Illness have a requirement of one (1) line of coverage and two (2) enrolled employees. • Supplemental Life is not available. • The undersigned employer has a place of business in Connecticut. • The undersigned Employer agrees to provide annual certification of continued adherence to the Program participation requirements listed here. • One hundred percent (100 ) of the eligible employees enrolling in the Program are covered by Workers’ Compensation insurance, except those eligible employees who are not legally required to be covered by Workers’ Compensation insurance. • The undersigned employer will contribute an amount equal to at least fifty percent (50 ) of the lowest monthly employee-only medical rate for each employee based on age. • The undersigned employer will maintain Basic Group Life insurance through CBIA Health Connections for all medical enrollees. • The undersigned employer agrees to give a minimum 15-days advance written notification to CBIA Service Corporation if it wants to cancel any coverages. Otherwise, it will be liable for the premium until the termination of its participation in the Program. • The undersigned employer agrees that reinstatement after cancellation for non-payment (including NSF payments) can only occur two (2) times during a rolling twelve (12) month period. • Employers with two (2) to nine (9) eligible employees must enroll and maintain a minimum of two (2) lines of coverage. To disenroll individual(s) from an employer/union sponsored Medicare Advantage plan and convert them to Original Medicare, the employer or union must provide the following. • The employer/union will provide CBIA a timely notice of contract termination or the ineligibility of an individual to participate in the employer or union group sponsored Medicare Advantage plan. Such notice must be prospective, not retroactive. • The employer/union must provide a prospective notice to its members alerting them of the termination event and of other insurance options available to them through their employer/union.