NURSESFORNEWBORNS V€¦ · BasicCare Fillings 90% 80% SimpleExtractions 90% 80% MajorCare...

The

Guardian

LifeInsurance

Com

panyofA

merica,N

ewY

ork,NY

Group

Num

ber:00495175

NU

RSES

FOR

NEW

BOR

NS

ALL

ELIGIBLE

EMPLO

YEES

Here

you'llfindinform

ationaboutyour

following

employee

benefit(s).Be

sureto

reviewthe

enclosed-itprovides

everythingyou

needto

signup

foryour

Guardian

benefits.

PLA

NH

IGH

LIGH

TS

•D

ental•

Vision•

Life

key* 00495175 0001 E V36.0

THISPAGE

INTENTIONALLYLEFT

BLANK

2

Benefitinform

ationillustrated

within

thism

aterialreflectsthe

plancovered

byG

uardianas

of12/04/2018N

URSES

FOR

NEW

BORN

SA

LLELIG

IBLEEM

PLOYEES

BenefitSum

mary

TheG

uardianLife

InsuranceC

ompany

ofAm

erica,New

York,NY

DentalB

enefitSum

mary

NU

RSE

SFO

RN

EW

BO

RN

S

Group

Num

ber:00495175

About

Your

Benefits:

Taking

careofyour

teethcan

beexpensive.That’s

why

theright

dentalinsuranceis

soim

portant—

itnot

onlypays

forpreventive

carethat

cankeep

youand

yourfam

ilyhealthy,but

italso

helpspay

form

oreextensive,costly

andoften

unexpectedexpenses

—such

asfillings,crow

nsand

rootcanals.Plus,you

savem

oneyand

havethe

assurancethat

youare

gettingthe

rightcare

when

youuse

oneofour

contracteddentists.G

uardianhas

beenproviding

outstandingdentalplans

tom

illionsofA

mericans

form

orethan

50years.W

henyou

enrollwith

Guardian,you

haveaccess

toone

ofthenation’s

largestdentalnetw

orksoffering

significantdiscounts

soyou

knowthere’s

always

high-quality,affordabledentalcare

closeby.

Frompreventive

checkupsand

cleanings,tocom

prehensiveoralcare

treatments,w

ehave

youcovered.

With

yourP

PO

plan,youcan

visitany

dentist;butyou

payless

out-of-pocketw

henyou

choosea

PPOdentist.

Out-of-netw

orkbenefits

arebased

ona

percentileofthe

prevailingfee

datafor

thedentist's

zipcode.

Your

DentalP

lanP

PO

Your

Netw

orkis

DentalG

uardPreferred

Calendar

yeardeductible

In-Netw

orkO

ut-of-Netw

orkIndividual

$50$50

Family

limit

3per

family

Waived

forPreventive

PreventiveC

hargescovered

foryou

(co-insurance)In-N

etwork

Out-of-N

etwork

PreventiveC

are100%

100%Basic

Care

90%80%

Major

Care

60%50%

Orthodontia

Not

Covered

(appliesto

alllevels)A

nnualMaxim

umB

enefit$1000

$1000P

reventiveServices

Exem

ptfrom

Maxim

umY

esM

aximum

Rollover

Yes

Rollover

Threshold

$500R

olloverA

mount

$250R

olloverIn-netw

orkA

mount

$350R

olloverA

ccountLim

it$1000

Lifetime

Orthodontia

Maxim

umN

otA

pplicableD

ependentA

geLim

its26

3

ASam

pleofServices

Covered

byY

ourP

lan:

NU

RSESFO

RN

EWBO

RNS

ALL

ELIGIBLE

EMPLO

YEESBenefit

Summ

aryThe

Guardian

LifeInsurance

Com

panyofA

merica,N

ewYork,N

Y

PP

OPlan

pays(on

average)In-netw

orkO

ut-of-network

PreventiveC

areC

leaning(prophylaxis)

100%100%

Frequency:O

nceEvery

6M

onthsFluoride

Treatm

ents100%

100%Lim

its:U

nderAge

14O

ralExams

100%100%

Sealants(per

tooth)100%

100%X

-rays100%

100%X

-raysother

thanbitew

ingsin

Basic90%

BasicC

areFillings ‡

90%80%

Simple

Extractions90%

80%

Major

Care

Anesthesia*

60%50%

Bridgesand

Dentures

60%50%

Inlays,Onlays,V

eneers**60%

50%Perio

Surgery60%

50%PeriodontalM

aintenance60%

50%Frequency:

Once

Every6

Months

Repair

&M

aintenanceof

Crow

ns,Bridges&

Dentures

60%50%

Root

Canal

60%50%

Scaling&

RootPlaning(per

quadrant)60%

50%Single

Crow

ns60%

50%SurgicalExtractions

60%50%

This

isonly

apartiallist

ofdentalservices.Your

certificateofbenefits

willshow

exactlyw

hatis

coveredand

excluded.**ForPPO

andor

Indemnity

mem

bers,Crow

ns,Inlays,Onlays

andLabialV

eneersare

coveredonly

when

neededbecause

ofdecayor

injuryor

otherpathology

when

thetooth

cannotbe

restoredw

itham

algamor

composite

filingm

aterial.When

Orthodontia

coverageis

for"C

hild(ren)"only,the

orthodonticappliance

must

beplaced

priorto

theage

limit

setby

yourplan;Iffull-tim

estatus

isrequired

byyour

planin

orderto

remain

insuredafter

acertain

age;thenorthodontic

maintenance

may

continueas

longas

full-time

studentstatus

ism

aintained.IfOrthodontia

coverageis

for"A

dultsand

Child(ren)"

thislim

itationdoes

notapply.

*GeneralA

nesthesia–

restrictionsapply.

‡ForPPO

andor

Indemnity

mem

bers,Fillings–

restrictionsm

ayapply

tocom

positefillings.

This

document

isa

summ

aryof

them

ajorfeatures

ofthe

referencedinsurance

coverage. Itis

intendedfor

illustrativepurposes

onlyand

doesnot

constitutea

contract.The

insuranceplan

documents,including

thepolicy

andcertificate,

comprise

thecontract

forcoverage.T

hefullplan

description,includingthe

benefitsand

allterms,lim

itationsand

exclusionsthat

applyw

illbecontained

inyour

insurancecertificate.T

heplan

documents

arethe

finalarbiterof

coverage. Coverage

terms

may

varyby

stateand

actualsoldplan.T

heprem

iumam

ountsreflected

inthis

summ

aryare

anapproxim

ation;ifthere

isa

discrepancybetw

eenthis

amount

andthe

premium

actuallybilled,the

latterprevails.

Manage

Your

Benefits:

Go

tow

ww

.GuardianA

nytime.com

toaccess

secureinform

ationabout

yourG

uardianbenefits

includingaccess

toan

image

ofyourID

Card.Your

on-lineaccount

willbe

setup

within

30days

afteryour

planeffective

date..

FindA

Dentist:

Visitw

ww

.GuardianA

nytime.com

Click

on“Find

AProvider”;You

willneed

toknow

yourplan,

which

canbe

foundon

thefirst

pageofyour

dentalbenefitsum

mary.

EX

CLU

SION

SA

ND

LIMIT

AT

ION

Sn

ImportantInform

ationaboutG

uardian’sD

entalGuard

Indemnity

andD

entalGuard

PreferredN

etwork

PPOplans:T

hispolicy

providesdental

insuranceonly.C

overageis

limited

tothose

chargesthat

arenecessary

toprevent,diagnose

ortreat

dentaldisease,defect,orinjury.D

eductiblesapply.

Theplan

doesnotpay

for:oralhygieneservices

(exceptas

coveredunder

preventiveservices),orthodontia

(unlessexpressly

providedfor),cosm

eticor

experimentaltreatm

ents(unless

theyare

expresslyprovided

for),anytreatm

entsto

theextentbenefits

arepayable

byany

otherpayor

orfor

which

nocharge

ism

ade,prostheticdevices

unlesscertain

conditionsare

met,and

servicesancillary

tosurgicaltreatm

ent.The

planlim

itsbenefits

fordiagnostic

consultationsand

forpreventive,restorative,endodontic,periodontic,and

prosthodonticservices.The

services,exclusionsand

limitations

listedabove

donotconstitute

acontractand

area

summ

aryonly.T

heG

uardianplan

documents

arethe

finalarbiterofcoverage.C

ontract#G

P-1-DG

2000etal.

nP

PO

andor

Indemnity

SpecialLimitation:Teeth

lostormissing

beforea

coveredperson

becomes

insuredby

thisplan.A

coveredperson

may

haveone

orm

orecongenitally

missing

teethorhave

lostoneor

more

teethbefore

hebecam

einsured

bythisplan.

We

won’tpay

foraprosthetic

devicew

hichreplaces

suchteeth

unlessthe

devicealso

replacesoneor

more

naturalteethlostorextracted

afterthecovered

personbecam

einsured

bythisplan.R3-D

G2000

4

Dental Maxim

um Rollover ®

Save Your Unused C

laims D

ollars For When You N

eed Them M

ost

Guardian w

ill roll over a portion of your unused annual maxim

um into your personal M

aximum

Rollover Account

(MR

A). If you reach your Plan Annual Maxim

um in future years, you can use m

oney from your M

RA. To qualify for an

MR

A, you must have a paid claim

(not just a visit) and must not have exceeded the paid claim

s threshold during the benefit year. Your M

RA m

ay not exceed the MR

A limit. You can view

your annual MR

A statement detailing your

account and those of your dependents on ww

w.G

uardianAnytime.com

. Please note that actual m

aximum

limitations and thresholds vary by plan. Your plan m

ay vary from the one used below

as an example to illustrate how the M

aximum

Rollover functions. Plan A

nnual M

aximum

* Threshold

Maxim

um R

ollover Am

ount In-N

etwork O

nly Rollover

Am

ount M

aximum

Rollover

Account Lim

it

$1000 $500

$250 $350

$1000

Maxim

um claim

s reim

bursement

Claim

s amount that

determines rollover

eligibility

Additional dollars added to Plan Annual M

aximum

for future years

Additional dollars added to Plan Annual M

aximum

for future years if only in-netw

ork providers w

ere used during the benefit year

Plan Annual Maxim

um

plus Maxim

um R

ollover cannot exceed $2,000 in

total

* If a plan has a different annual maxim

um for PPO

benefits vs. non-PPO benefits, ($1500 PPO

/$1000 non-PPO for exam

ple) the non-PPO m

aximum

determines the M

aximum

R

ollover plan.

Here’s how

the benefits work:

YEAR

ON

E: Jane starts with a $1,000 Plan Annual M

aximum

. She subm

its $150 in dental claims. Since she did not reach the $500

Threshold, she receives a $250 rollover that will be applied to Year

Two.

YEAR

TWO

: Jane now has an increased Plan Annual M

aximum

of $1,250. This year, she subm

its $50 in claims and receives an

additional $250 rollover added to her Plan Annual Maxim

um.

YEAR

THR

EE: Jane now has an increased Plan Annual M

aximum

of $1,500. This year, she subm

its $1,200 in claims. All claim

s are paid due to the am

ount accumulated in her M

aximum

Rollover Account.

YEAR

FOU

R: Jane’s Plan Annual M

aximum

is $1,300 ($1,000 Plan Annual M

aximum

+ $300 remaining in her M

aximum

Rollover

Account). For Overview

of your Dental Benefits, please see About Your Benefit Section of this Enrollm

ent Booklet. N

OTES:

You and your insured dependents maintain separate M

RAs based on your ow

n claim activity. Each M

RA m

ay not exceed the MR

A limit.

Cases on either a calendar year or policy year accum

ulation basis qualify for the Maxim

um R

ollover feature. For calendar year cases with an effective date in O

ctober, Novem

ber or D

ecember, the M

aximum

Rollover feature starts as of the first full benefit year. For exam

ple, if a plan starts in Novem

ber of 2013, the claim activity in 2014 w

ill be used and applied to M

RAs for use in 2015.

Under either benefit year set up (calendar year or policy year), M

aximum

Rollover for new

entrants joining with 3 m

onths or less remaining in the benefit year, w

ill not begin until the start of the next full benefit year. M

aximum

Rollover is deferred for m

embers w

ho have coverage of Major services deferred. For these m

embers, M

aximum

Rollover starts

when coverage of M

ajor services starts, or the start of the next benefit year if 3 months or less rem

ain until the next benefit year. (Actual eligibility timefram

e may vary. See your

Plan Details for the m

ost accurate information.)

Guardian's D

ental Insurance is underwritten and issued by The G

uardian Life Insurance Com

pany of America or its subsidiaries, N

ew York, N

Y. Products are not available in all states. Policy lim

itations and exclusions apply.

Optional riders and/or features m

ay incur additional costs. Plan documents are the final arbiter of coverage.

Policy Form #G

P-1-DG

2000, et al. 5

PreventiveAdvantage

–AdditionalDetails

Enjoypreventivedentalcare,withno

deductionfrom

yourplan’sannualmaxim

um.

WithPreventiveAdvantage,youcanreceiveallpreventivecare,includingexams,cleanings,x-raysandfluoride

treatments,withouthavingthebenefitexpensesdeductedfromyourannualmaximum.Thatmeansyoucanstretch

yourbenefitevenfurtherforevenmoresavingstoyou.•

Simplypaytheapplicableco-insuranceand

deductibleforPreventivecare(ifany)•

Theentireannualmaxim

umam

ountispreservedforotherdentalneeds

•Preventivecarewillcontinueto

becoveredeven

aftertheannualmaxim

umism

et

Dentistsrecommendoralexamsandcleaningseverysixmonths.Nowyoucantakegoodcareofyouroralhealth

withouthavingtobalancetheneedfordentalprocedures.

TakeadvantageofPreventiveCareforgood

oralhealth…

andsavetheannualm

aximum

forotherdentalcareneeds,such

as:

Oralexams

Cleaning

X-Rays

Fluoridetreatments

Fillings

Rootcanal

Crowns

Oralsurgery

Denturesandbridgework

Here’showthisbenefitworksforyou:

Joevisitsthedentistforhisannualcleaning.Hisdeductibleis$25.Thecleaningcosts$125.Allexpensesabovethedeductiblearecoveredand,withthePreventiveAdvantageplanoption,willnotreducetheAnnualMaximum.

ForOverviewofyourDentalBenefits,pleaseseeAboutYourBenefitSectionofthisEnrollmentBooklet.

Guardian'sDentalInsuranceisunderwrittenandissuedbyTheGuardianLifeInsuranceCompanyofAmericaoritssubsidiaries,NewYork,

NY.Productsarenotavailableinallstates.Policylimitationsandexclusionsapply.Optionalridersand/orfeaturesmayincuradditionalcosts.Plandocumentsarethefinalarbiterofcoverage."

PolicyForm#GP-1-DG2000,etal.

6

About

Your

Benefits:

Eyecare

isa

vitalcomponent

ofahealthy

lifestyle.With

visioninsurance,having

regularexam

sand

purchasingcontacts

orglasses

issim

pleand

affordable.Thecoverage

isinexpensive,yet

thebenefits

canbe

significant!Guardian

providesrich,flexible

plansthat

allowyou

tosafeguard

yourhealth

while

savingyou

money.Review

yourplan

optionsand

seew

hyvision

insurancem

aybe

agreat

benefitfor

you.

Visitany

doctorw

ithyour

FullFeatureplan,but

saveby

visitingany

ofthe50,000+

locationsin

thenation's

largestvision

network.

Vision

Benefit

Summ

aryG

roupN

umber:00495175

NU

RSESFO

RN

EWBO

RNS

ALL

ELIGIBLE

EMPLO

YEESBenefit

Summ

aryThe

Guardian

LifeInsurance

Com

panyofA

merica,N

ewYork,N

Y

NU

RSE

SFO

RN

EW

BO

RN

S

Benefitinform

ationillustrated

within

thism

aterialreflectsthe

plancovered

byG

uardianas

of12/04/2018

Your

Vision

Plan

FullFeature

Your

Netw

orkis

VSP

Netw

orkSignature

Plan

Copay

Exams

Copay

$10

Materials

Copay

(waived

forelective

contactlenses)$

25

Sample

ofCovered

ServicesYou

pay(after

copayifapplicable):

In-network

Out-of-netw

ork

EyeExam

s$0

Am

ountover

$46

SingleV

isionLenses

$0A

mount

over$47

LinedBifocalLenses

$0A

mount

over$66

LinedT

rifocalLenses$0

Am

ountover

$85

LenticularLenses

$0A

mount

over$125

Frames

80%ofam

ountover

$120¹A

mount

over$47

Contact

Lenses(Elective)

Am

ountover

$120A

mount

over$120

Contact

Lenses(M

edicallyN

ecessary)$0

Am

ountover

$210

Contact

Lenses(Evaluation

andfitting)

15%offU

CR

No

discounts

Cosm

eticExtras

Avg.30%

offretailpriceN

odiscounts

Glasses

(Additionalpairoffram

esand

lenses)20%

offretailprice^N

odiscounts

LaserC

orrectionSurgery

Discount

Up

to15%

offtheusualcharge

or5%

offpromotionalprice

No

discounts

ServiceFrequencies

Exams

Every12

months

Lenses(for

glassesor

contactlenses)‡‡Every

12m

onths

Frames

Every24

months‡‡‡

Netw

orkdiscounts

(glassesand

contactlensprofessionalservice)

Limitless

within

12m

onthsofexam

.

Dependent

Age

Limits

26Visit

ww

w.G

uardianAnytim

e.comand

clickon

“Finda

Provider”

VSP

•‡‡Benefitincludes

coveragefor

glassesor

contactlenses,notboth.

•^

Forthe

discountto

applyyour

purchasem

ustbe

made

within

12m

onthsofthe

eyeexam

.Inaddition

Full-Featureplans

offer30%

offadditionalprescriptionglasses

andnonprescription

sunglasses,includinglens

options,ifpurchasedon

thesam

eday

asthe

eyeexam

fromthe

same

VSPdoctor

who

providedthe

exam.

•C

hargesfor

aninitialpurchase

canbe

usedtow

ardthe

materialallow

ance.Any

unusedbalance

remaining

afterthe

initialpurchasecannot

bebanked

forfuture

use.Theonly

exceptionw

ouldbe

ifam

ember

purchasescontactlenses

froman

outofnetwork

provider,mem

berscan

usethe

balancetow

ardsadditionalcontactlenses

within

thesam

ebenefitperiod.

•1Extra

$20on

selectbrands

•‡‡‡.The

VSPsystem

considerscontactlenses

tobe

theequivalentofa

fullpairofeyeglasses(lenses

andfram

es)sowhile

them

embercan

obtaincontactlenses

oneyearand

standardeyeglass

lensesthe

nextyear,thefram

esbenefitwould

notbeavailable

until24m

onthsortwo

calendaryears,dependingon

theplan

design,afterthedate

them

emberobtained

thecontactlenses.

7

NU

RSESFO

RN

EWBO

RNS

ALL

ELIGIBLE

EMPLO

YEESBenefit

Summ

aryThe

Guardian

LifeInsurance

Com

panyofA

merica,N

ewYork,N

Y

Thisdocum

entis

asum

mary

ofthem

ajorfeatures

ofthereferenced

insurancecoverage. It

isintended

forillustrative

purposesonly

anddoes

notconstitute

acontract.The

insuranceplan

documents,including

thepolicy

andcertificate,com

prisethe

contractfor

coverage.Thefullplan


benefitsand

allterms,lim

itationsand

exclusionsthat

applyw

illbecontained

inyour

insurancecertificate.The

plandocum

entsare

thefinalarbiter

ofcoverage. C

overageterm

sm

ayvary

bystate

andactualsold

plan.Theprem

iumam

ountsreflected

inthis

summ

aryare

anapproxim

ation;ifthereis

adiscrepancy

between

thisam

ountand

theprem

iumactually

billed,thelatter

prevails.

Manage

Your

Benefits:

Go

tow

ww

.GuardianA

nytime.com

toaccess

secureinform

ationabout

yourG

uardianbenefits

includingaccess

toan

image

ofyourID

Card.Your

on-lineaccount

willbe

setup

within

30days

afteryour

planeffective

date.

EX

CLU

SION

SA

ND

LIMIT

AT

ION

SIm

portantInformation:This

policyprovides

visioncare

limited

benefitshealth

insuranceonly.

Itdoesnotprovide

basichospital,basic

medicalor

major

medicalinsurance

asdefined

bythe

New

YorkState

InsuranceD

epartment.

Coverage

islim

itedto

thosecharges

thatarenecessary

fora

routinevision

examination.C

o-paysapply.

The

plandoes

notpayfor:orthoptics

orvision

trainingand

anyassociated

supplementaltesting;m

edicalorsurgicaltreatm

entofthe

eye;andeye

examination

orcorrective

eyewear

requiredby

anem

ployeras

acondition

ofemploym

ent;replacementoflenses

andfram

esthat

arefurnished

underthis

plan,which

arelostor

broken(except

atnorm

alintervals

when

servicesare

otherwise

availableor

aw

arrantyexists).The

planlim

itsbenefits

forblended

lenses,oversizedlenses,photochrom

iclenses,

tintedlenses,progressive

multifocallenses,coated

orlam

inatedlenses,a

frame

thatexceedsplan

allowance,cosm

eticlenses;U

-Vprotected

lensesand

optionalcosmetic

processes.

Theservices,

exclusionsand

limitations

listedabove

donot

constitutea

contractand

area

summ

aryonly.

TheG

uardianplan

documents

arethe

finalarbiter

ofcoverage.Contract

#GP-1-V

SN-96-VIS

etal.

LaserC

orrectionSurgery:

Discounts

onaverage

of10-20%offusualand

customary

chargeor

5%off

promotionalprice

forvision

laserSurgery.M

embers

out-of-pocketcostsare

limited

to$1,800

pereye

forLA

SIKor

$1,500per

eyefor

PRK

or$2300

pereye

forC

ustomLA

SIK,C

ustomPR

K,or

BladelessLA

SIK.

Lasersurgery

isnot

aninsured

benefit.The

surgeryis

availableata

discountedfee.

Thecovered

personm

ustpay

theentire

discountedfee.In

addition,thelaser

surgerydiscountm

aynot

beavailable

inallstates.

8

The

Gu

ar dia

n Life

Insu

r an

ce C

om

pa

ny of A

m e

rica, 7

Han

o v

er Sq

uare, N

ew

Yo

rk, NY

G

G-014346 (4/16)

NO

TIC

E O

F PR

IVA

CY

P R A C

TIC

ES

T

HIS N

OT

ICE

DE

SCR

IBE

S HO

W H

EALT

H IN

FOR

MA

TIO

N A

BO

UT

YO

U M

AY

BE

USE

D

AN

D D

ISCL

OSE

D A

ND

HO

W Y

OU

CA

N G

ET

AC

CE

SS TO

TH

IS INFO

RM

AT

ION

.

PLEA

SE R

EV

IEW

IT C

AR

EFU

LL

Y.

E

ffective: 05/01/2016

This Notice of Privacy Practices describes how

Guardian and its subsidiaries m

ay use and disclose your Protected H

ealth Information (PH

I) in order to carry out treatment, paym

ent and health care operations and for other purposes perm

itted or required by law.

G

uardian is required by law to m

aintain the privacy of PHI and to provide you w

ith notice of our legal duties and privacy practices concerning PH

I. We are required to abide by the term

s of this Notice so long as it rem

ains in effect. We reserve

the right to change the terms of this N

otice of Privacy Practices as necessary and to make the new

Notice effective for all

PHI m

aintained by us. If we m

ake material changes to our privacy practices, copies of revised notices w

ill be made

available on request and circulated as required by law. C

opies of our current Notice m

ay be obtained by contacting G

uardian (using the information supplied below

), or on our Web site at w

ww

.guardianlife.com/privacy-policy.

W

hat is Protected Health Inform

ation (PHI):

PH

I is individually identifiable information (including dem

ographic information) relating to your health, to the health care

provided to you or to payment for health care. PH

I refers particularly to information acquired or m

aintained by us as a result of your having health coverage (including m

edical, dental, vision and long term care coverage).

In W

hat Ways m

ay Guardian U

se and Disclose your Protected H

ealth Information (PH

I):

Guardian has the right to use or disclose your PH

I without your w

ritten authorization to assist in your treatment, to

facilitate payment and for health care operations purposes. There are certain circum

stances where w

e are required by law

to use or disclose your PHI. A

nd there are other purposes, listed below, w

here we are perm

itted to use or disclose your PH

I without further authorization from

you. Please note that examples are provided for illustrative purpo ses only and are

not intended to indicate every use or disclosure that may be m

ade for a particular purpose.

Guardian has the right to use or disclose your PH

I for the following purposes:

Treatm

ent. Guardian m

ay use and disclose your PHI to assist your health care providers in your diagnosis and

treatment. For exam

ple, we m

ay disclose your PHI to providers to supply inform

ation about alternative treatm

ents.

Payment. G

uardian may use and disclose your PH

I in order to pay for the services and resources you may receive.

For example, w

e may disclose your PH

I for payment purposes to a health care provider or a health plan. Such

purposes may include: ascertaining your range of benefits; certifying that you received treatm

ent; requesting details regarding your treatm

ent to determine if your benefits w

ill cover, or pay for, your treatment.

H

ealth Care O

perations. Guardian m

ay use and disclose your PHI to perform

health care operations, such as adm

inistrative or business functions. For example, w

e may use your PH

I for underwriting and prem

ium rating

purposes. How

ever, we w

ill not use or disclose your genetic information for underw

riting purposes and are prohibited by law

from doing so.

A

ppointment Rem

inders. Guardian m

ay use and disclose your PHI to contact you and rem

ind you of appointments.

H

ealth Related Benefits and Services. Guardian m

ay use and disclose PHI to inform

you of health related benefits or services that m

ay be of interest to you.

Plan Sponsors. Guardian m

ay use or disclose PHI to the plan sponsor of your group health plan to perm

it the plan sponsor to perform

plan administration functions. For exam

ple, a plan may contact us regarding benefits, service or

coverage issues. We m

ay also disclose summ

ary health information about the enrollees in your group health plan

to the plan sponsor so that the sponsor can obtain premium

bids for health insurance coverage, or to decide whether

to modify, am

end or terminate your group health plan.

9

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G-014346 (4/16)

Guardian is required to use or disclose your PH

I:

• To you or your personal representative (som

eone with the legal right to m

ake health care decisions for you); •

To the Secretary of the Departm

ent of Health and H

uman Services, w

hen conducting a compliance

investigation, review or enforcem

ent action related to health information privacy or security; and

• W

here otherwise required by law

.

Guardian is R

equired to Notify Y

ou of any Breaches of Your U

nsecured PHI.

A

lthough Guardian takes reasonable, industry-standard m

easures to protect your PHI, should a breach occur, G

uardian is required by law

to notify affected individuals. Under federal m

edical privacy law, a breach m

eans the acquisition, access, use, or disclosure of unsecured PH

I in a manner not perm

itted by law that com

promises the security or privacy of

the PHI.

O

ther Uses and D

isclosures.

Gu

ardian m

ay also use and disclose you

r PHI for th

e followin

g purposes with

out your au

thorization:

•

We m

ay disclose your PHI to persons involved in your care or paym

ent for care, such as a family m

ember or

close personal friend, when you are present and do not object, w

hen you are incapacitated, under certain circum

stances during an emergency or w

hen otherwise perm

itted by law.

• W

e may use or disclose your PH

I for public health activities, such as reporting of disease, injury, birth and death, and for public health investigations.

• W


I in an emergency, directly to or through a disaster relief entity, to find and tell

those close to you of your location or condition •

We m

ay disclose your PHI to the proper authorities if w

e suspect child abuse or neglect; we m

ay also disclose your PH

I if we believe you to be a victim

of abuse, neglect, or domestic violence.

• W


I to a government oversight agency authorized by law

to conducting audits, investigations, or civil or crim

inal proceedings. •

We m

ay use or disclose your PHI in the course of a judicial or adm

inistrative proceeding (e.g., to respond to a subpoena or discovery request).

• W


I to the proper authorities for law enforcem

ent purposes. •

We m

ay disclose your PHI to coroners, m

edical examiners, and/or funeral directors consistent w

ith law.

• W


I for organ or tissue donation. •

We m

ay use or disclose your PHI for research purposes, but only as perm

itted by law.

• W

e may use or disclose PH

I to avert a serious threat to health or safety. •

We m

ay use or disclose your PHI if you are a m

ember of the m

ilitary as required by armed forces services.

• W


I to comply w

ith workers' com

pensation and other similar program

s. •

We m

ay disclose your PHI to third party business associates that perform

services for us, or on our behalf (e.g. vendors).

• W

e may use and disclose your PH

I to federal officials for intelligence and national security activities authorized by law

. We also m

ay disclose your PHI to authorized federal officials in order to protect the

President, other officials or foreign heads of state, or to conduct investigations authorized by law.

• W


I to correctional institutions or law enforcem

ent officials if you are an inmate or under

the custody of a law enforcem

ent official (e.g., for the institution to provide you with health care services, for the

safety and security of the institution, and/or to protect your health and safety or the health and safety of other individuals).

• W


I to your employer under lim

ited circumstances related prim

arily to w

orkplace injury or illness or medical surveillance.

W

e generally will not sell your PH

I, or use or disclose PHI about you for m

arketing purposes without your

authorization unless otherwise perm

itted by law.

Y

our Rights w

ith Regard to Y

our Protected Health Inform

ation (PHI):

Y

our Authorization for O

ther Uses and D

isclosures. Other than for the purposes described above, or as otherw

ise perm

itted by law, G

uardian must obtain your w

ritten authorization to use or disclosure your PHI. Y

ou have the right to revoke that authorization in w

riting except to the extent that: (i) we have taken action in reliance upon the authorization

prior to your written revocation, or (ii) you w

ere required to give us your authorization as a condition of obtaining coverage, and w

e have the right, under other law, to contest a claim

under the coverage or the coverage itse lf.

10

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G-014346 (4/16)

Under federal and state law

, certain kinds of PHI m

ay require enhanced privacy protections. These forms of PH

I include inform

ation pertaining to: •

HIV

/AID

S testing, diagnosis or treatment

• V

enereal and /or comm

unicable Disease(s)

• G

enetic Testing •

Alcohol and drug abuse prevention, treatm

ent and referral •

Psychotherapy notes

We w

ill only disclose these types of delineated information w

hen permitted or required by law

or upon your prior written

authorization.

Your R

ight to an Accounting of D

isclosures. An ‘accounting of disclosures’ is a list of certain disclosures w

e have m

ade, if any, of your PHI. Y

ou have the right to receive an accounting of certain disclosures of your PHI that w

ere made

by us. This right applies to disclosures for purposes other than those made to carry out treatm

ent, payment and health care

operations as described in this notice. It excludes disclosures made to you, or those m

ade for notification purposes.

We ask that you subm

it your request in writing by com

pleting our form. Y

our request may state a requested tim

e period not m

ore than six years prior to the date when you m

ake your request. Your request should indicate in w

hat form

you want the list (e.g., paper, electronically). O

ur form for A

ccounting of Disclosure requests is available at

ww

w.guardianlife.com

/privacy-policy .

Your R

ight to Obtain a Paper C

opy of This Notice. Y

ou have a right to request a paper copy of this notice even if you have previously agreed to accept this notice electronically. Y

ou may obtain a paper copy of this notice by sending

a request to the contact information listed at the end of this notice.

Y

our Right to File a C

omplaint. If you believe your privacy rights have been violated, you m

ay file a complaint w

ith G

uardian or the Secretary of U.S. D

epartment of H

ealth and Hum

an Services. If you wish to file a com

plaint with

Guardian, you m

ay do so using the contact information below

. You w

ill not be penalized for filing a complaint.

Please subm

it any exercise of the Rights designated below

to Guardian in w

riting using the contact information listed

below. For som

e requests, Guardian m

ay charge for reasonable costs associated with com

plying with your requests; in

such a case, we w

ill notify you of the cost involved and provide you the opportunity to modify your request before any

costs are incurred.

Your R

ight to Request Restrictions. Y

ou have the right to request a restriction on the PHI w

e use or disclose about you for treatm

ent, payment or health care operations as described in this notice. Y

ou also have the right to request a restriction on the m

edical information w

e disclose about you to someone w

ho is involved in your care or the payment for your care.

G

uardian is not required to agree to your request; however, if w

e do agree, we w

ill comply w

ith your request until we

receive notice from you that you no longer w

ant the restriction to apply (except as required by law or in em

ergency situations). Y

our request must describe in a clear and concise m

anner: (a) the information you w

ish restricted; (b) whether

you are requesting to limit G

uardian's use, disclosure or both; and (c) to whom

you want the lim

its to apply.

Your R

ight to Request Confidential Com

munications. Y

ou have the right to request that Guardian com

municate w

ith you about your PH

I be in a particular manner or at a certain location. For exam

ple, you may ask that w

e contact you at w

ork rather than at home. W

e are required to accomm

odate all reasonable requests made in w

riting, when such requests

clearly state that your life could be endangered by the disclosure of all or part of your PHI.

Y

our Right to A

mend Y

our PHI If you feel that any PH

I about you, which is m

aintained by Guardian, is inaccurate or

incomplete, you have the right to request that such PH

I be amended or corrected. W

ithin your written request, you m

ust provide a reason in support of your request. G

uardian reserves the right to deny your request if: (i) the PHI w

as not created by G

uardian, unless the person or entity that created the information is no longer available to am

end it (ii) if we

do not maintain the PH

I at issue (iii) if you would not be perm

itted to inspect and copy the PHI at i ssue or (iv) if the PH

I w

e maintain about you is accurate and com

plete. If we deny your request, you m

ay submit a w

ritten statement of your

disagreement to us, and w

e will record it w

ith your health information.

Y

our Right to A

ccess to Your PH

I. You have the right to inspect and obtain a copy of your PH

I that we m

aintain in designated record sets. U

nder certain circumstances, w

e may deny your request to inspect and copy your PH

I. In an instance w

here you are denied access and have a right to have that determination review

ed, a licensed health care professional chosen by G

uardian will review

your request and the denial. The person conducting the review w

ill not be the person w

ho denied your request. Guardian prom

ises to comply w

ith the outcome of the review

.

11

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G-014346 (4/16)

How

to Contact U

s:

If you have any questions about this Notice or need further inform

ation about matters covered in this N

otice, please call the toll-free num

ber on the back of your Guardian ID

card. If you are a broker please call 800-627-4200. All others

please contact us at 800-541-7846. You can also w

rite to us with your questions, or to exercise any of your rights, at the

address below:

A

ttention: Guardian C

orporate Privacy Officer

National O

perations

Address: The G

uardian Life Insurance Com

pany of Am

erica G

roup Quality A

ssurance - Northeast

P.O. Box 2457

Spokane, WA

99210-2457

12

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14

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Election

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$6.15$10.80

$17.85$28.50

$40,000$1.00

$1.40$2.00

$3.40$5.20

$8.20$14.40

$23.80$38.00

$50,000$1.25

$1.75$2.50

$4.25$6.50

$10.25$18.00

$29.75$47.50

$60,000$1.50

$2.10$3.00

$5.10$7.80

$12.30$21.60

$35.70$57.00

$70,000$1.75

$2.45$3.50

$5.95$9.10

$14.35$25.20

$41.65$66.50

$80,000$2.00

$2.80$4.00

$6.80$10.40

$16.40$28.80

$47.60$76.00

$90,000$2.25

$3.15$4.50

$7.65$11.70

$18.45$32.40

$53.55$85.50

$100,000$2.50

$3.50$5.00

$8.50$13.00

$20.50$36.00

$59.50$95.00

Policy

Election

Am

ount

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$4.75

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$2.05$3.60

$5.95$9.50

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$8.93$14.25

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Policy

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$0.51$0.51

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$7,000$0.60

$0.60$0.60

$0.60$0.60

$0.60$0.60

$0.60$0.60

15

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YEESBenefit

Summ

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Guardian

LifeInsurance

Com

panyofA

merica,N

ewYork,N

Y

Voluntary

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ostIllustration

continued

<30

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ofcoveragefor

fullplandescription.

Dependentlife

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Thisdocum

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ajorfeatures

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documents,including

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andcertificate,com

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benefitsand

allterms,lim

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16

NU

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ALL

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Summ

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$10,000$0.13

$2,000$0.03

$30,000$0.39

$15,000$0.20

$3,000$0.04

$40,000$0.52

$20,000$0.26

$4,000$0.05

$50,000$0.65

$25,000$0.33

$5,000$0.07

$60,000$0.78

$30,000$0.39

$6,000$0.08

$70,000$0.91

$35,000$0.46

$7,000$0.09

$80,000$1.04

$40,000$0.52

$8,000$0.10

$90,000$1.17

$45,000$0.59

$9,000$0.12

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Manage

Your

Benefits:

Go

tow

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nytime.com

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secureinform

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on-lineaccount

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planeffective

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LIMIT

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Statesin

orderto

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coveragefor

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ontem

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ent:(a)exceedingone

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anarea

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arningby

theU

SD

epartmentofState.Subject

tostate

specificvariations.T

hisproposalis

hedgedsubjectto

satisfactoryfinancialevaluation.Please

referto

policybookletfor

fullplandescription.

Dependentlife

insurancew

illnottakeeffectifa

dependent,otherthan

anew

born,is

confinedto

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otherhealth

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oris

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We

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seecontractfor

specificdefinition;definition

oflossm

ayvary

dependingon

thebenefit

payable.Enhanced

AD

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:Aloss

may

bedefined

asdeath,quadriplegia,loss

ofspeechand

hearing,lossofcognitive

function,comatose

statein

excessofone

month,

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orparaplegia.T

heloss

mustoccur

within

aspecified

periodoftim

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definition;definitionofloss

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benefitpayable.

This

document

isa

summ

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them

ajorfeatures

ofthe

referencedinsurance

coverage. Itis

intendedfor

illustrativepurposes

onlyand

doesnot

constitutea

contract.The

insuranceplan

documents,including

thepolicy

andcertificate,com

prisethe

contractfor

coverage.The

fullplandescription,including

thebenefits

andallterm

s,limitations

andexclusions

thatapply

willbe

containedin

yourinsurance

certificate.The

plandocum

entsare

thefinalarbiter

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overageterm

sm

ayvary

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premium

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17

WillPrep

ServicesSpecialbonusforparticipantsin

voluntarylifeplan

YouremployerhasworkedwithGuardiantomakeWillPrepServicesavailabletoeligiblememberswithVoluntaryLife

plans.Keepinganup-to-datewillisessentialtoensuringthatyourassetsaredistributedasyouintended,nomatterthesizeofyourestate.Youmaybeavoidingcreatingawillbecauseyoubelieveyoucan’taffordthetimeorlegalexpense.Now

youcanwithWillPrepServices.

WillPrepServicesoffersupportandguidancetohelpyouproperlypreparethedocumentsnecessarytopreserveyour

family’sfinancialsecurity.WillPrephasarangeofservicesincludingonlineplanningdocuments,aresourcelibraryand

accesstoprofessionals*tohelpwithissuesrelatedto:

AdvancedHealthCareDirectives

FinancialPowerofAttorney

W

illsandLivingWills

EstateTaxes

GuardianshipandConservatorship

ResourceLibrary

Executors&

Probate

HealthcarePowerofAttorney

Trusts

FormoreinformationaboutWillPrepServices,gotowww.ibhwillprep.com;Username:W

illPrep;Password:GLIC09orcall1-877-433-6789

*TheOptionofanattorneypreparedwillisavailableforasmallfee.W

illPrepServicesareprovidedbyIntegratedBehavioralHealth,Inc.,anditscontractors.TheGuardianLifeInsuranceCompanyofAmerica

(Guardian)doesnotprovideanypartofWillPrep

Services.Guardianisnotresponsibleorliableforcareoradvicegivenbyanyproviderorresourceundertheprogram.Thisinformationisforillustrativepurposesonly.Itisnotacontract.OnlytheAdministrationAgreementcanprovidetheactualterms,services,limitationsandexclusions.GuardianandIBH

reservetherighttodiscontinuetheW

illPrepServicesatanytimewithoutnotice.Legal

serviceswillnotbeprovidedinconnectionwithorpreparationforanyactionagainstGuardian,IBH,oryouremployer.

18

Welcom

eto

theC

ollegeTuition

BenefitsRew

ardsprogram

!YourPlan

Sponsorhas

worked

with

Guardian

tom

akeC

ollegeTuition

Benefitservicesavailable

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ewards

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ompany

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19

EvidenceofInsurability—GuardianLife,Short

TermDisabilityandLongTerm

Disability

OnlineEvidenceofInsurabilityGotoguardiananytime.com/eoi

TheGuardianLifeInsuranceCompanyofAmericaguardiananytime.com

NewYork,NY

2017-44837(08/19)

ADDITIONALNOTES:ApplicabletocoveragerequiringfullEvidenceofInsurability(notapplicabletoconditionalissueamounts.ElectronicEOIisnotavailableinthefollowingstates:NewYork,NewHampshire,VirginiaandMontanaElectronicEOIisavailableusingmostinternetbrowsers.

1.Click“Yes,IhavereadandagreetotheDisclosureStatement.”

IfyouremployerislocatedinastatewhereonlineEOIisnotavailable(NY,NH,VAandMT)pleasedownloadtheEOIformfrom

GuardianAnytime.2.EnterGroupID#shownaboveandclick“Enter”3.Selectthecoveragesyouareapplyingforandfillin

yourcurrentandnewelectionamountsHELPFULTIP:Enter“0”forcurrentamountifthisisanewelectionorifthisisarequesttoincreaseyourshorttermdisabilityorlongterm

disabilitycoverage.Click“Continue”.Onthefollowingscreen,youwill:•

Inputyourpersonalinformation•

Answerthehealthquestions•

Reviewyouranswers,electronicallyprovideyoursignatureandclick“Submit”toreceiveconfirmation(PDF)

•Guardianwillsooncontactyoudirectlyregardingyourapplication.

12

3

20

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$25,000q

$30,000q

$35,000q

$40,000q

$45,000q

$50,000

*GuaranteeIssue

Amount

*Theam

ountmay

notbem

orethan

50%ofthe

employee

amountforVoluntary

Life.

qIdo

notwantthis

coverage

AddVoluntary

LifeforDependent/Child(ren)

PolicyAm

ountq

$1,000q

$2,000q

$3,000q

$4,000q

$5,000q

$6,000q

$7,000q

$8,000q

$9,000q

$10,000*

*GuaranteeIssue

Amount

*Theam

ountmay

notbem

orethan

10%ofthe

employee

amountforVoluntary

Life.

qIdo

notwantthis

coverage

AddVoluntary

AD&D

Youm

ustenrollforvoluntaryterm

lifeto

beeligible

forthiscoverage.

Yourelectedam

ountofcoveragew

illbe1

time(s)the

coverageelected

forvoluntarylife.

Youm

ustbeenrolled


qEm

ployeeq

Idonotw

antthiscoverage

qSpouse

qIdo

notwantthis

coverageq

Child(ren)q

Idonotw

antthiscoverage

4 LIFEINSURANCE

continued

ImportantNotes:

�Based

onyourplan

benefitsand

age,youm

aybe

requiredto

complete

anevidence

ofinsurabilityform

forVoluntaryLife.

Name

yourbeneficiaries:(Primary

beneficiarypercentages

musttotal100%

)Ifelectingdifferentbeneficiaries

thatarenotthe

same

asthose

named

forBasicLife,

pleasenam

ebelow

.

Primary

Beneficiaries:

Name:

SocialSecurityNum

ber:______

___-______-___

______

___%

DateofBirth

(mm

-dd-yy):____-____-____Address/City/State/Zip:

Phone:()

-Relationship

toEm

ployee:_

Name:

SocialSecurityNum

ber:______

___-______-___

______

___%

DateofBirth

(mm


Phone:()

-Relationship

toEm

ployee:_

ContingentBeneficiary:SocialSecurity

Number:___

______-___

___-______

______

DateofBirth

(mm


Phone:()

-Relationship

toEm

ployee:_

(Inthe

eventtheprim

arybeneficiaries

aredeceased,the

contingentbeneficiaryw

illreceivethe

benefit.Employerm

aintainsbeneficiary

information.)

Spouseand

dependent/child(ren)�Ifthe

intendedbeneficiary

isto

besom

eoneotherthan

theem

ployee,pleasecom

pletethe

BeneficiaryDesignation

form.

Signature

lAn

employee's

decisionto

electVisionornotelectVision

mustbe

retaineduntilthe

nextplan'sOpen

Enrollmentperiod.Ifthe

employee

electsnotto

enrollinvision

coverage,theyare

noteligibleto

enrolluntiltheplan's

nextOpenEnrollm

entperiod.

lIunderstand

thatlifeinsurance

coveragefora

dependent,otherthana

newborn

child,willnottake

effectifthatdependentisconfined

toa

hospitalorotherhealthcare

facility,orishom

econfined,oris

unableto

performtw

oorm

oreActivities

ofDailyLiving

(ADL's).

lIunderstand

thatmy

dependent(s)cannotbeenrolled

foracoverage

ifIamnotenrolled

forthatcoverage.

lIunderstand

thattheprem

iumam

ountsshow

nabove

areestim

ationsand

areforillustrative

purposesonly.

lSubm

issionofthis

formdoes

notguaranteecoverage.Am

ongotherthings,coverage

iscontingentupon

underwriting

approvalandm

eetingthe

applicableeligibility

requirements

assetforth

inthe

applicablebenefitbooklet.

lIunderstand

thatImustbe

activelyatw

orkorm

yelected

coveragew

illnottakeeffectuntilIhave

metthe

eligibilityrequirem

ents(as

definedin

thebenefitbooklet.)This

doesnotapply

toeligible

retirees.

lIfcoverage

isw

aivedand

youlaterdecide

toenroll,late

entrantpenaltiesm

ayapply.You

may

alsohave

toprovide,atyourow

nexpense,proofofeach

person'sinsurability.Guardian

oritsdesignee

hasthe

righttorejectyourrequest.

lPlan

designlim

itationsand

exclusionsm

ayapply.Forcom

pletedetails

ofcoverage,pleasereferto

yourbenefitbooklet.Statelim

itationsm

ayapply.

lIhereby

applyforthe

groupbenefit(s)thatIhave

chosenabove.

lIunderstand

thatImustm

eeteligibilityrequirem

entsforallcoverages

thatIhavechosen

above.

lIagree

thatmy

employerm

aydeductprem

iums

fromm

ypay

iftheyare

requiredforthe

coverageIhave

chosenabove.

lIacknow

ledgeand

consenttoreceiving

electroniccopies

ofapplicableinsurance

relateddocum

ents,inlieu

ofpapercopies,tothe

extentpermitted

byapplicable

law.I

may

changethis

electiononly

byproviding

thirty(30)day

priorwritten

notice.

lIattestthatthe

information

providedabove

istrue

andcorrectto

thebestofm

yknow

ledge.

Anyperson

who

with

intenttodefraud

anyinsurance

company

orotherpersonfiles

anapplication

forinsuranceorstatem

entsofclaim

containingany

knowingly,false

information,orconceals

forpurposeofm

isleadinginform

ationconcerning

anyfactm

aterialhereto,comm

itsa

fraudulentinsuranceact,w

hichis

acrim

e,andm

ayalso

besubjectto

civilpenalties,ordenialofinsurancebenefits.

GuardianGroup

PlanNum

ber:00495175Please

printemployee

name:

DE

TAC

HE

NTIR

EFO

RM

AN

DR

ETU

RN

TOY

OU

RE

MP

LOY

ER

ww

w.gu

ardianlife.com

5

Thestate

inw

hichyou

residem

ayhave

aspecific

statefraud

warning.Please

refertothe

attachedFraud

Warning

Statements

page.

Thelaw

sofNew

Yorkrequire

thefollow

ingstatem

entappear:Anyperson

who

knowingly

andw

ithintentto

defraudany

insurancecom

panyorotherperson

filesan

applicationforinsurance

orstatementofclaim

containingany

materially

falseinform

ation,orconcealsforthe

purposeofm

isleading,information

concerningany

factm

aterialthereto,comm

itsa


hichis

acrim

e,andshallalso

besubjectto

acivilpenalty

nottoexceed

fivethousand

dollarsand

thestated

valueofthe

claimforeach

suchviolation.(Does

notapplyto

LifeInsurance.)

SIGNATUREOF

EMPLOYEE

X___________________________________________

DATE______________________

EnrollmentKit

00495175,0001,EN

FraudW

arningStatem

ents

Thelaw

sofseveralstates

requirethe

following

statements

toappearon

theenrollm

entform:

Alabama:Any

personw

hoknow

inglypresents

afalse

orfraudulentclaimforpaym

entofaloss

orbenefitorwho

knowingly

presentsfalse

information

inan

applicationfor

insuranceis

guiltyofa

crime

andm

aybe

subjecttorestitution

finesorconfinem

entinprison,orany

combination

thereof.

Arizona:ForyourprotectionArizona

lawrequires

thefollow

ingstatem

enttoappearon

thisform

.Anyperson

who

knowingly

presentsa

falseorfraudulentclaim

forpayment

ofaloss

issubjectto

criminaland

civilpenalties.

California:ForyourprotectionCalifornia

lawrequires

thefollow

ingto

appearonthis

form:Any

personw

hoknow

inglypresents


forthepaym

entofaloss

isguilty

ofacrim

eand

may

besubjectto

finesand

confinementin

stateprison.

Colorado:Itisunlaw

fultoknow

inglyprovide

false,incomplete,orm

isleadingfacts

orinformation

toan

insurancecom

panyforthe

purposeofdefrauding

orattempting

todefraud

thecom

pany.Penalties

may

includeim

prisonment,fines,denialofinsurance,and

civildamages.

Anyinsurance

company

oragentofaninsurance

company

who

knowingly

providesfalse,incom

plete,ormisleading

factsorinform

ationto

apolicy

holderorclaimantforthe

purposeofdefrauding

orattempting

todefraud

thepolicy

holderorclaimantw

ithregard

toa

settlementoraw

ardpayable

frominsurance

proceedsshallbe

reportedto

theColorado

DivisionofInsurance

within

theDepartm

entofRegulatory

Agencies.

Connecticut,Iowa,Kansas,Nebraska,Oregon,and

Vermont:Any

personw

hoknow

ingly,andw

ithintentto

defraudany

insurancecom

panyorotherperson,files

anapplication

ofinsuranceorstatem

entofclaimcontaining

anym

ateriallyfalse

information

orconceals,forthepurpose

ofmisleading,inform

ationconcerning

anyfactm

aterialthereto,m

aybe

guiltyofa


hichm

aybe

acrim

e,andm

ayalso

besubjectto

civilpenalties.

Delaware,Indiana

andOklahom

a:WARNING:Any

personw

hoknow

ingly,andw

ithintentto

injure,defraudordeceive

anyinsurer,m

akesany

claimforthe

proceedsofan

insurancepolicy

containingany

false,incomplete

ormisleading

information

isguilty

ofafelony.

DistrictofColumbia:W

ARNING:Itisa

crime

toprovide

falseorm

isleadinginform

ationto

aninsurerforthe

purposeofdefrauding

theinsurerorany

otherperson.Penaltiesinclude

imprisonm

entand/orfines.Inaddition,an

insurermay

denyinsurance

benefits,iffalseinform

ationm

ateriallyrelated

toa

claimw

asprovided

bythe

applicant.

Florida:Anyperson

who

knowingly

andw

ithintentto

injure,defraud,ordeceiveany

insurerfilesa

statementofclaim

oranapplication

containingany

false,incomplete,or

misleading

information

isguilty

ofafelony

ofthethird

degree.

Kentucky:Anyperson

who

knowingly

andw

ithintentto

defraudany

insurancecom

panyorotherperson

filesa

statementofclaim

containingany

materially

falseinform

ationorconceals,forthe

purposeofm

isleading,information

concerningany

factmaterialthereto

comm

itsa


hichis

acrim

e.

Louisianaand

Texas:Anyperson

who

knowingly

presentsa


forpaymentofa

lossorbenefitis

guiltyofa

crime

andm

aybe

subjecttofines

andconfinem

entsin

stateprison.

Maine,Tennessee,Virginia

andW

ashington:Itisa

crime

toknow

inglyprovide

false,incomplete

ormisleading

information

toan

insurancecom

panyforthe

purposeof

defraudingthe

company.Penalties

may

includeim

prisonment,fines

oradenialofinsurance

benefits.

Maryland

andRhode

Island:Anyperson

who

knowingly

andw

illfullypresents

afalse

orfraudulentclaimforpaym

entofaloss

orbenefitorknowingly

andw

illfullypresents

falseinform

ationin

anapplication

forinsuranceis

guiltyofa

crime

andm

aybe

subjecttofines

andconfinem

entinprison.

Minnesota:A

personw

hofiles

aclaim

with

intenttodefraud

orhelpscom

mita

fraudagainstan

insurerisguilty

ofacrim

e.

NewHam

pshire:Anyperson

who,w

itha

purposeto

injure,defraudordeceive

anyinsurance

company,files

astatem


anyfalse,incom

pleteor

misleading

information

issubjectto

prosecutionand

punishmentforinsurance

fraud,asprovided

inN.H.Rev.Stat.Ann.§

638:20

NewJersey:Any

personw

hoknow

inglyfiles

astatem


anyfalse

ormisleading

information

issubjectto

criminaland

civilpenalties.

NewM

exico:Anyperson

who

knowingly

presentsa


forpaymentora

lossorbenefitorknow

inglypresents

falseinform

ationin

anapplication

forinsurance

isguilty

ofacrim

eand

may

besubjectto

civilfinesand

criminalpenalties

ordenialofinsurancebenefits.

Ohio:Anyperson

who

with

intenttodefraud

orknowing

thathe/sheis

facilitatinga

fraudagainstan

insurer,submits

anapplication

orfilesa

claimcontaining

afalse

ordeceptive

statementis

guiltyofinsurance

fraud.

Pennsylvania:Anyperson

who

knowingly

andw

ithintentto

defraudany

insurancecom

panyorotherperson

filesan

applicationforinsurance

orstatementofclaim

containingany

materially

falseinform

ationorconceals

forthepurpose

ofmisleading,inform

ationconcerning

anyfactm

aterialtheretocom

mits

afraudulentinsurance

act,w

hichis

acrim

eand

subjectssuch

personto

criminaland

civilpenalties.

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