DESCRIPTION PAGE

Website and Contacts 2

Health InsuranceBenefit Overview 4 Employee & Dependent Bi-Weekly Rates 5Calculating Your Rate Worksheet 6OPTIMA VANTAGE 1250/20/80 Summary of Benefits 7-8 Dental InsuranceDental Rates 9Dental Benefit Details 10-11 Vision InsuranceVision Rates 14Vision Benefit Details 15-16

Flex & Dependent CareBenefit Overview 18-21

TABLE OF CONTENTS

© 2015 Choctaw Pension Actuaries, LLC

Guy’s Upholstery Employee BenefitsPage 2 © 2015 Choctaw Pension Actuaries, LLC

WEBSITE AND CONTACTS

PresidentW. Brandon BeaversCell: 757-288-8282Office: Extension 110brandon@bladebc.com

CONTACTS

National HeadquartersPO Box 1472Virginia Beach, VA 23451Ph. 866-495-4015F. 757-425-8666www.bladebc.com

Director of BenefitsAmy ThompsonDirect: 757-544-9130Office: Extension 112amy@bladebc.com

To view this booklet as well, claim forms, provider lookups and the MANDATORY SUMMARY OF BENEFITS

AND COVERAGE go to

www.bladebc.com/guysWe have also created a new ticket system, allowing you to create a support ticket on our website. This system can be used for things like claims problems, provider direc-tories, address changes, etc.

Once the ticket is created, you will automatically be assigned a ticket number and login credentials to view the status of your ticket 24 hours a day. This system is SSL secured and allows for documents to be scanned and uploaded.

To create a support ticket, go to www.bladebc.com/support

Guy’s Upholstery Employee Benefits

HEALTH INSURANCE

HEALTH BENEFIT COMPARISON

HEALTH BENEFIT DETAILS

HEALTH BENEFIT OVERVIEW

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BENEFITS AND FEATURES

© 2015 Choctaw Pension Actuaries, LLC

For a complete list of Limitations and Exclusions, as well as the ACA Mandated Summary of Coverage and Benefits go to:

www.bladebc.com/guys

OptimaBENEFITS AND FEATURES

Vantage$1250/20/80%

Annual deductibles (indiv/family) In-network $1,250 / $2,500 Out-of-network N/ACoinsurance (plan pays)

In-network Covered at 80 % (AD)

Out-of-network N/AOut of pocket maximum (indiv/family)In-network $3,250 / $6,500Out-of-network N/APhysician ServicesPrimary Care Visit $20 copaySpecialist Visit $40 copayHospital ServicesInpatient hospitalization Covered at 80% (AD)Outpatient Surgery Covered at 80% (AD)Emergency/Urgent Care Svcs.

Emergency care (true emergency) Covered at 80% (AD)

Urgent care centers (non-ER level of care)

$40 copay

Prescription Coverage

Retail Pharmacy $10/40/50 or 20%/ 20%; Max $250/script

90-day Mail Order $25/100/150 or 20%; N/A; Max $750

Preventive Vision 1 exam every 12 months: no cost

(AD) = After Deductible(ND) = Not Applied to Deductible

(CYD) = Calendar Year Deductible

Optima Vantage 1250/20/80Bi Weekly Payroll DeductionAge Non Smoker Smoker

< 20 $60.42 $60.4221 $95.16 $114.1922 $95.16 $114.1923 $95.16 $114.1924 $95.16 $114.1925 $95.54 $114.6526 $97.44 $116.9327 $99.72 $119.6728 $103.44 $124.1229 $106.48 $127.7830 $108.00 $129.6031 $110.29 $132.3532 $112.57 $135.0933 $114.00 $136.8034 $115.52 $138.6335 $116.28 $139.5436 $117.04 $140.4537 $117.81 $141.3738 $118.57 $142.2839 $120.09 $144.1140 $121.61 $145.9341 $123.90 $148.6842 $126.08 $151.3043 $129.13 $154.9544 $132.93 $159.5245 $137.41 $164.8946 $142.74 $171.2847 $148.73 $178.4848 $155.58 $186.7049 $162.34 $194.8150 $169.95 $203.9451 $177.47 $212.9652 $185.75 $222.9053 $194.12 $232.9554 $203.16 $243.7955 $212.20 $254.6456 $222.00 $266.4057 $231.90 $278.2858 $242.46 $290.9559 $247.70 $297.2460 $258.26 $309.9161 $267.39 $320.8762 $273.39 $328.0763 $280.91 $337.0964 $285.47 $342.57

Employee Bi-Weekly Payroll Deduction

Optima Vantage 1250/20/80Bi Weekly Payroll DeductionAge Non Smoker Smoker

< 20 $88.61 $88.6121 $139.55 $167.4622 $139.55 $167.4623 $139.55 $167.4624 $139.55 $167.4625 $140.10 $168.1226 $142.90 $171.4827 $146.24 $175.4928 $151.68 $182.0229 $156.15 $187.3830 $158.39 $190.0631 $161.73 $194.0832 $165.08 $198.1033 $167.17 $200.6134 $169.41 $203.2935 $170.52 $204.6336 $171.64 $205.9737 $172.76 $207.3138 $173.88 $208.6539 $176.11 $211.3340 $178.34 $214.0141 $181.69 $218.0342 $184.90 $221.8843 $189.36 $227.2444 $194.94 $233.9445 $201.50 $241.8046 $209.32 $251.1847 $218.11 $261.7348 $228.16 $273.7949 $238.07 $285.6850 $249.23 $299.0851 $260.25 $312.3052 $272.40 $326.8753 $284.67 $341.6154 $297.93 $357.5255 $311.19 $373.4356 $325.56 $390.6757 $340.08 $408.0958 $355.56 $426.6759 $363.24 $435.8960 $378.73 $454.4761 $392.12 $470.5562 $400.92 $481.1063 $411.94 $494.3364 $418.64 $502.37

Dependent Bi-Weekly Payroll Deduction

OPTIMA VANTAGE 1250/20/80 BENEFIT DETAILS

Guy’s Upholstery Employee Benefits Page 5 © 2015 Choctaw Pension Actuaries, LLC

Guy’s Upholstery Employee BenefitsPage 6 © 2015 Choctaw Pension Actuaries, LLC

CALCULATING YOUR PAYROLL DEDUCTION

Each person in the family has their own rate. Due to ACA, you have to find each person’s age in your family and add them up to find your total bi-weekly rate.

Please use the calculator below as a guide:

Employee Rate: _______________+

Spouse Rate: _______________+

Child 1 Rate: _______________+

Child 2 Rate: _______________+

Child 3 Rate: _______________=

Total Bi-Weekly Rate: _______________

**All rates shown are bi-weekly. Optima charges for the first three children ONLY. Any additional children have no cost. If your deduction is $0 or less, there will be no deduction from payroll.

OPTIMA VANTAGE 1250/20/80 BENEFIT DETAILS

Guy’s Upholstery Employee Benefits Guy’s Upholstery Employee Benefits Page 7© 2015 Choctaw Pension Actuaries, LLC

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OPTIMA VANTAGE 1250/20/80 BENEFIT DETAILS

© 2015 Choctaw Pension Actuaries, LLC

DENTAL INSURANCE

DENTAL RATES

DENTAL BENEFIT PLAN

DENTAL INSURANCE RATES

Guy’s Upholstery Employee BenefitsPage 10

DENTAL RATES

Effective MAY 1, 2015

Bi-Weekly Payroll Deduction

Guardian PPO

Employee Only $20.08

Employee + Spouse $40.75

Employee + Child(ren) $49.19

Family $71.96

© 2015 Choctaw Pension Actuaries, LLC

Guardian PPO

Employee Only $20.08

Employee + Spouse $40.75

Employee + Child(ren) $49.19

Family $71.96

DENTAL PPO BENEFIT DETAIL

Guy’s Upholstery Employee Benefits Page 11© 2015 Choctaw Pension Actuaries, LLC

DENTAL BENEFITS FOR

GUY’S UPHOLSTERY

Dental Plan WD

THE FOLLOWING IS A BRIEF OUTLINE OF BENEFITS BEING PROVIDED BY THE GUARDIAN. IT IS NOT MEANT TO SERVE AS A FORMAL DOCUMENT OR TO REPLACE THE CERTIFICATE BOOKLET. REFER TO YOUR BOOKLET FOR COVERAGE INFORMATION.

You may use any dentist you choose. However, if you use a provider within the PPO network, you will receive a higher level of benefits as indicated below, and will not be balanced billed. If you choose to use a provider that is out of the network The Guardian will pay the percentage of the usual and customary amount, and you could be subject to balance billing.

The following list of items will give you an approximate idea of the procedures that are covered and their corresponding level of reimbursement:

In-Network Out-of-Network

Deductible $50 $50 (Waived for Preventative Services)

Family Deductible 3X Per Family 3X Per Family

Annual Maximum $1,000 $1,000

DENTAL PPO BENEFIT DETAILS

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In-Network Out-of-Network

Preventive & Diagnostic Services 100% 100% a) Teeth cleaning b) Fluoride treatment c) Space maintainers d) Oral examinations e) X-rays f) Emergency Treatment g) Topical Sealants

Basic Services 90% 80% a) Laboratory Testing b) Fillings c) Root canals d) Repair & maintenance of bridgework & dentures e) Periodontic services f) Extractions & other basic oral surgery g) Anesthesia h) Stainless steel & acrylic crowns I) Injectable antibiotics needed solely for treatment of a dental condition

Major Services 60% 50% a) Inlays b) Onlays c) Crowns & posts d) Installation of bridgework e) Dentures

When the expected cost of a proposed course of treatment is $300 or more, the dentist must send a pre-treatment plan to The Guardian. The claim office will review the pre-treatment plan and advise what we will pay, based upon usual and customary fee schedules.

LATE ENTRANT PENALTY: (10 Plus Groups) Six month waiting period for Basic Services, 12 month waiting period for Major Services.

DEPENDENT ELIGIBILITY: The Guardian covers your unmarried children to age 26.

DENTAL CLAIMS OFFICE: 1-800-541-7846 (PO Box 2459 Spokane, WA, 99210-2459)

DENTAL DIRECTORY: www.glic.com – Network is DentalGuard Preferred

Vision Insurance

Vision Rates

Vision Benefits

VISION RATES

VISION INSURANCE RATES

Effective MAY 1, 2015

Bi-Weekly premium deduction from paycheck

Weekly

Employee Only $3.09

Employee + Spouse $5.21

Employee + Child(ren) $5.31

Family $8.41

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VISION BENEFIT DETAILS

Guy’s Upholstery Employee Benefits Page 15Guy’s Upholstery Employee Benefits © 2015 Choctaw Pension Actuaries, LLC

The Guardian Life Insurance of America 7 Hanover Square, New York, New York 10004

1

GUY’S UPHOLSTERY Vision Service Plan (Davis Network) Full Feature Program

Plan Features:Copayment: Exam $10.00

Materials $25.00

Copayment: $10.00 (Copay Applies to 1st Service Performed)

Benefit Details In-network Out-of-network

Eye Exams Covered in Full after Copay $ 46.00 Maximum after Copay

Frequency: Every 12 Months

LensesFrequency: Every 12 Months

Single Vision Covered in Full after Copay $ 47.00 Maximum after Copay

Bifocal Covered in Full after Copay $ 66.00 Maximum after Copay

Trifocal Covered in Full after Copay $ 85.00 Maximum after Copay

Lenticular Covered in Full after Copay $125.00 Maximum after Copay

Contact Lenses* Frequency: Every 12 Months

Medically Necessary Covered in Full after Copay $210.00 Maximum after Copay

Elective $120.00 Maximum (Copay Does Not Apply)

Frames $120.00 Retail Allowance** $ 47.00 Maximum after Copay

Frequency: Every 24 Months

*If you choose contact lenses, you will not be eligible to receive lenses for 12 months and a frame for 24 months following the date contacts were obtained. For elective and necessary contact lenses, we will pay up to the benefit limits towards, the contact lens evaluation fee, fitting costs and materials. Note, the contact lens evaluation fee and fitting costs are separate from the comprehensive vision care exam.

**Approximately 15,000 frames are covered in full. Frames not fully covered are offered at a discounted cost. If you select a frame that exceeds the retail allowance, the plan will cover 20% of the amount above the allowance. You must pay the rest.

VISION BENEFIT DETAILS

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The Guardian Life Insurance of America 7 Hanover Square, New York, New York 10004

2

Dependent Age Limits: Children are covered up to age 26.

Important Information: This policy provides vision care limited benefits health insurance only. It does not provide basic hospital, basic medical or major medical insurance as defined by the New York State Insurance Department. Coverage is limited to those charges that are necessary for a routine vision examination. Co-pays apply. The plan does not pay for: orthoptics or vision training and any associated supplemental testing; medical or surgical treatment of the eye; and eye examination or corrective eyewear required by an employer as a condition of employment; replacement of lenses and frames that are furnished under this plan, which are lost or broken (except at normal intervals when services are otherwise available or a warranty exists). The plan limits benefits for blended lenses, oversized lenses, photochromic lenses, tinted lenses, progressive multifocal lenses, coated or laminated lenses, a frame that exceeds plan allowance, cosmetic lenses; U-V protected lenses and optional cosmetic processes. The services, exclusions and limitations listed above do not constitute a contract and are a summary only. The Guardian plan documents are the final arbiter of coverage. Contract #GP-1-VSN-96-VIS et al.

This handout is for illustrative purposes. You will receive benefit booklets when your enrollment application is processed. If there is a discrepancy between this handout and your benefit booklet,

the benefit booklet prevails.

FLEX PLAN

HOW IT WORKS

COMMONLY ASKED QUESTIONS

YOUR OPTIONS

DETERMINING YOUR REIMBURSABLE EXPENSES

EXAMPLES OF ELIGIBLE HEALTH CARE EXPENSES

EXAMPLES OF INELIGIBLE EXPENSES

FLEX PLAN DETAILS

Sometimes referred to as a cafeteria plan, flex plan, or a Section 125 Plan – a Flexible benefits Plan lets you set aside a certain amount of your paycheck into an account before paying income taxes. During the year you have access to this account for reimbursement of expenses you regularly pay for, such as healthcare and dependent daycare.

Reimbursable expenses can include:P DeductiblesP Co-paysP Prescription DrugsP Some Over–the-Counter Medicine (OTC) (Such as antacids, allergy medicine, pain relievers, and cold medicines)P Dental CareP Eyewear & Contact LensesP Laser Vision SurgeryP Adult/Child Care ServicesP And More!!

HERE’S HOW IT WORKS …

Example: An employee makes $2,000 each pay period and decides to participate in her employer’s Flexible Benefits Plan. As a result, her insurance premiums and health and daycare expenses are paid with tax-free dollars, giving her an additional $100 each pay period!

Gross Earnings $2,000 FICA, Federal, State Taxes - $500 Insurance Premium - $100 Health/Daycare Expenses - $300 NET EARNINGS $1,100

Gross Earnings $2,000 Insurance Premium - $100 Health/Daycare Expenses - $300 Adjust Gross Earnings $1,600 FICA, Federal, State Taxes - $400 NET EARNINGS $1,200

Guy’s Upholstery Helps your paycheck buy more with a Flexible Benefits Plan!

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1 3 2 Complete the form provided in the enrollment kit.

Determine how much you expect to spend out of pocket during the plan year. Remember, do not over estimate.

Carefully read this material and choose which plan(s) you wish to enroll in.

With the Plan

Without the Plan

© 2015 Choctaw Pension Actuaries, LLC Guy’s Upholstery Employee Benefits

FLEX PLAN DETAILS

COMMONLY ASKED QUESTIONS

What is a Flexible Benefits Plan? A benefit provided by your employer that lets you set aside a certain amount of your paycheck into an account before paying income taxes. During the year you can be directly reimbursed from your account for qualified healthcare and daycare expenses.

Why should I participate in the Healthcare Reimbursement Account when I already have health insurance? This account is used to pay for expenses not covered by insurance. For example - annual physicals, co-payments, eye exams, glasses, orthodontics, prescription drugs, some non-prescription drugs and hospital care to name a few.

If I set aside part of my pay, won’t I make less money? Your net take-home pay will increase by the amount of taxes you did not pay. An example of how it may work for you is detailed on the first page of this brochure.

Can I change my contributions during the year? Only if you have a change in status such as: marriage, birth, adoption, or a change in your, your spouse’s, or your dependent’s employment status.

What if I currently take the dependent care credit on my annual tax return? If your family income is over $20,000, you will most likely benefit from this plan rather than taking advantage of the current in-come tax credit. The amount you deposit in your Dependent Care Reimbursement Account reduces the amount, dollar for dollar, that you can claim as a credit on your tax return.

How do I get reimbursed for my expenses? Once you have completed the enclosed enrollment form, a debit card will be issued to you. You can also submit paper claims by completing a claim form. If you need a claim form, contact CPActuaries at 1-866-495-4015. Once you receive the claim form, sim-ply complete it, attach a copy of the healthcare or dependent care bill/receipt, and mail or fax the form and receipts to CPActuaries at 757-425-8666. Within a short time, you will receive your reimbursement by ACH Direct Deposit or mail. When using your debit card, please hold on to all your receipts. You may still need to submit these receipts for claim substantiation.

Do I have to wait for the money to be deposited in my account in order to make a claim for reimbursement? The annual amount you have allocated for the Medical Reimbursement Account is available to you at any time throughout the plan year. The amount available from your Dependent Care Reimbursement Account is the amount you have contributed to date.

How do I know how much is available in my accounts? Each time you are reimbursed you will receive a statement attached to your ACH Direct Deposit email notification or reimburse-ment check that shows the dollar amount you have set aside as well as the amount you have been paid to date. You may call CPAc-tuaries at (757) 422-8880 ext 112 or (866) 495-4015 ext 112. You will also be able to check your balances online.

What happens to my accounts if I terminate my employment? You will be able to request reimbursement for healthcare and daycare expenses for services provided prior to your termination, unless COBRA is available under your plan and is elected.

What if I don’t use all of the money I set aside in my accounts? Carefully review your estimated expenses before making the decision to participate. Any contributions that are not used during the plan year are forfeited. You will have 90 days to submit expenses after the plan year ends.

What if I am not covered under my company’s health insurance plan? Good news! You and your family can still participate in the Medical Care or Dependent Care Reimbursement Accounts.

How do I benefit by participating? Your biggest advantage is the tax savings. Every dollar you set aside in your account reduces your income taxes, and you can be reimbursed for qualified expenses that you are already paying for!

Are there any negatives that I should know about? Yes, because you are not paying any social security tax on that portion of your income that has been redirected, your social secu-rity benefits may be slightly reduced.

Page 19© 2015 Choctaw Pension Actuaries, LLCGuy’s Upholstery Employee Benefits

FLEX PLAN DETAILS

YOUR OPTIONS

1. Medical Expense Reimbursement AccountThis account reimburses you for medical expenses not covered by insurance. You set aside money, tax-free, through regular payroll deductions. During the year, you can be reimbursed directly from your account for those qualified medical services provided which are not covered by insurance.

Common expenses that qualify for reimbursement are-doctor visits, deductibles, co-payments, prescriptions, mental health care, dental services and orthodontics, chiropractor services, eye exams, glasses and contacts. For a more complete listing, contact CPActuaries or your Human Resource Department.

2. Dependent Care Reimbursement AccountThis account reimburses you for daycare expenses for eligible children and adults. Through regular payroll deductions, you set aside part of your income to pay for these expenses on a tax-free basis. To qualify, your dependents must be: •Achildundertheageof13,or •Achild,spouseorotherdependentwhoisphysicallyormentallyincapableofself-careandspendatleast8 hours day in your household.

Qualified expenses for reimbursement include-adult and child daycare centers, preschool and before/after school care.

*Please note: If your family’s annual income is over $20,000, this reimbursement option will most likely save you more money than the dependent care tax credit you take on your tax return. You will also receive your tax savings throughout the year, rather than once a year when you file your tax return.

DETERMINING YOUR REIMBURSABLE EXPENSE

By completing the following information, you can calculate your annual reimbursable expenses. Take into consideration the services to be provided during the upcoming plan year for you and your dependents.

Medical Care ExpensesMedical (1) Dental (2) Vision (3) Deductibles $________ Routine Care $________ Exams $________Co-payments $________ Fillings/Crowns $________ Eye Surgery $________Office Visits $________ Orthodontics $________ Lenses/Frames $________Prescriptions/OTC $________ Others $________ Contacts $________Other $________ Total $________ Solutions $________Total $________ Other $________ Total $________Dependent Care ExpensesChildren $________________Adults $________________Total $________________

Estimated Annual ExpensesTotal Medical Expenses (add 1+2+3) $_________________Total Dependent Care Expenses $_________________

Total Expenses $_________________

Using the information calculated, complete the enclosed form and return it to CPActuaries.

Page 20 © 2015 Choctaw Pension Actuaries, LLC Guy’s Upholstery Employee Benefits

EXAMPLES OF ELIGIBLE HEALTH CARE EXPENSES

Acupuncture Alcohol & drug dependency inpatientAmbulance usageAnesthesia Artificial limbs Birth control BracesBraille books and magazinesChiropractic servicesChristian Science practitioner servicesContact lenses and solutionCrutchesDental expensesDenturesDermatology services** Diagnostic feesDoctor feesEyeglasses, including exam fees

Guide dogs Hearing aids and batteriesHospital feesHypnosis (for treatment of an illness)InsulinIn vitro fertilization Laboratory feesMaternity expenses Neurological expensesNursing home expensesNursing home expensesNursing servicesObstetric servicesOpthalmologic treatmentOptometry servicesOrgan transplantsOrthodontia** Orthopedic services and shoesOsteopathic services

OTC medical care items*Pediatric servicesPhysiotherapyPodiatry servicesPrescription drugsPsychiatric carePsychotherapySmoking cessation programsSpeech therapy Sterilization feesSubstance abuse treatment Surgical feesTransportation for treatment Vaccinations and immunizationsVasectomy Vision expenses Wheelchairs X-Rays

EXAMPLES OF INELIGIBLE EXPENSESBath products, cleansers, soap Cosmetic services and supplies Cream, lip balms, lipstick, lotionsDental BleachingDeodorants and anti-perspirants

Feminine hygiene productsFoot care productsHair care productsHair removal productsMedicine dispensers

Shaving and grooming products Stimulants (to stay awake)Sunscreen, sunless tanning

* For a list of common over-the-counter items visit www. fsaandyou.com** Excludes procedures for cosmetic purposes

If you enroll during the Health Care FSA annual open enroll-ment period for coverage beginning MAY 1, your coverage under the plan for the plan year will be equal to monthly election multiplied by 52, up to $2,500. Your corresponding salary reductions will begin on the first pay date of the plan year

The pay period reduction amount may vary depending on any changes in pay frequency, available compensation, leave of absence, or employment termination

Unused FundsWhen deciding how much to contribute, you should make sure that you carefully estimate enough to cover your eligible health care expenses, but not too much, because any unused amount at the end of the year for which a valid claim has not been filed in a timely manner will be forfeited, according to IRS regulations. However, new guidance allows for up to $500 of unused funds to rollover to the next plan year.

You have up to 90 days immediately following the plan year in which the expense was incurred by a Health Care FSA participant to request reimbursement of eligible health and dependant care expenses.

FLEX PLAN DETAILS

© 2015 Choctaw Pension Actuaries, LLCGuy’s Upholstery Employee Benefits Page 21