ASSOCIATES Welcome - Agent Benefitsdocs.agentbenefits.net/homeservices/CT_2013Enrollment.pdfUnited Concordia Dental Basic Plan Monthly Rates $157.66 $100,000 Benefit Amount Monthly

Welcome to the Agent

care Program

DergalisASSOCIATES

In order to ensure proper processing of your applications, please read the following instructions carefully.

1) Once you have selected the plan(s) in which you wish to enroll, complete the corresponding application(s).

2) Make sure you have signed and completed the application(s) in their entirety. Check them for any errors or missing information.

3) Review, complete and sign the Automatic Deduction Agreement form.

4) Make a photocopy of your voided check for the account from which you would like the premium deduction to take place and include it with your forms. Remember, all bank account deductions will take place on the 1st business day of each month. If we are unable to draft your account on this day, you may be subject to fees as outlined in the Automatic Deduction Agreement.

5) Fax your application with the Automatic Deduction Agreement and the voided check to the Insurance Department fax number shown below. We MUST have all applications by the posted due date or coverage cannot become effective!

DergalisASSOCIATES

Please call us with any questions you have during the enrollment process.

Insurance Department P: (888) 564-0300 | F: (856) 396-3193 | claire@agentbenefi ts.net

DEADLINE: 03.30.2013 COVERAGE BEGINS: 05.01.2013

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OPENENROLLMENT

OPEN

helping you protect...

your FUTURE

Retirement Savings Plan through the Automatic Contribution Program

Rollover from Previous Employer Retirement Account

Investment Strategies through a FREE Financial Needs Analysis

College Savings Plan

Tax Savings Plan through the Automatic Contribution Program1

Life Insurance2

Group or Individual

Disability Insurance2

Group or Individual

Long-Term Care Insurance2

Health InsuranceConnecticut only

Dental Insurance

Vision Insurance

your INCOME your HEALTH

Agent Care Program

DERGALISASSOCIATES DERGALIS

Peter Dizdar P: (212) 541-1965 | E: [email protected] | W: agentbenefi ts.net/connecticut

1) The automatic contribution portion of the tax savings plan is not provided through AXA Advisors or AXA Network. All contributed funds are invested in a money market mutual fund through AXA Advisors, LLC. An Investment in the fund is not insured or guaranteed by the Federal Deposit Insurance Corporation (FDIC) or any government agency. Although the Fund seeks to preserve the value of your investment at $1.00 per share, it is possible to lose money by investing in the Fund.Please consider the charges, risks, expenses, and investment objectives carefully before purchasing a mutual fund. For a prospectus containing this and other information, please contact a fi nancial professional. Read it carefully before you invest or send money. 2) These Insurance products are made available through third party carriers and are offered through an insurance brokerage, AXA Network, LLC and its subsidiaries.All group life, disability income, health, dental and vision insurance coverage is offered entirely outside of AXA Network, LLC, AXA Network Insurance Agency of California, LLC, AXA Network Insurance Agency of Utah, LLC or any of their affi liates. AXA Advisors and AXA Network do not provide tax advice. Please consult your own tax advisor regarding your particular circumstances and appropriate course of action. The Retirement Savings Plan is not an employer-sponsored qualifi ed retirement plan.

Financial Professionals with Dergalis Associates offer securities through AXA Advisors LLC, 1290 Avenue of the Americas, New York, NY (212) 314-4600, and offers insurance and annuity products through AXA Network, LLC. Prudential Connecticut Realty and its affi liate companies do not offer investments or insurance. Prudential Connecticut Realty and its affi liate compa-nies are not affi liated with AXA Advisors or AXA Network. Dergalis Associates in not owned or operated by AXA Advisors or AXA Network. PPG 67479 (3/12) (Exp. 3/14)

We’re a team of professionals focusing on fi nancial services, health insurance and benefi t administration. The team works together to help you create customized fi nancial strategies and benefi t plans.

Guaranteed Issue Group Insurance

DergalisASSOCIATES

Frequently Asked Questions

DergalisASSOCIATES

Q: Must I take all of the benefits? A: No, each benefit can be purchased individually.

Q: Will I get another opportunity to enroll if I decline to take coverage now? A: Once a year, the Group Dental and Vision plans will have an Open Enrollment period. However, the Group

Disability and Life Insurance will NEVER be offered again on a Guaranteed-Issue basis. While you can apply at a later date, limited medical underwriting will be required and the carrier will have the right to decline you coverage based on the results.

Q: I currently have other coverage for Dental and Vision. If I lose that coverage, could I participate in your program?

A: Yes, you will have the opportunity to enroll in the Dental or Vision plan within 30 days of a qualifying life event such as birth, death, divorce or loss of coverage. For more information on what constitutes a qualifying life event, please contact our office.

Q: Is the Automatic Deduction from my checking account the only way to pay? A: We also accept Visa or MasterCard for premium payments. Please contact our office at (888) 564-0300 for

more information. Additionally, you can use a savings account as long as you provide a deposit slip imprinted with your name, bank account number and bank routing number.

Q: When and how will I receive confirmation of my coverage? A: You should receive an email from our office within three weeks, as well as confirmation in the mail which will

arrive at the address listed on your application.

Q: What if I have an emergency before I receive proof of coverage? A: In the event of an emergency situation, you should contact Lynn Barry at (800) 265-2876 x 11373. Lynn will

help you in the transition period.

Prudential Connecticut Realty and Prudential Rhode Island RealtyPrudential Connecticut Realty and Prudential Rhode Island RealtyPrudential Connecticut Realty and Prudential Rhode Island RealtyPrudential Connecticut Realty and Prudential Rhode Island Realty

Group Insurance RatesGroup Insurance RatesGroup Insurance RatesGroup Insurance Rates

Single Single $7.55

Husband/Wife Husband/Wife $15.10

Parent/Child Parent & Child $15.10

Parent/Children Parent & Children $22.65

Family Family $22.65

Age Age Rate

< 30 < 30 $25.48

30-34 30-34 $23.92

35-39 35-39 $22.36

40-44 40-44 $21.84

45-49 45-49 $23.92

50-54 50-54 $26.00

55-59 55-59 $30.68

Dependent Child Life 60-64 $36.40

$5,000 65-69 $41.60

70-74 $45.76

75-99 $49.92

Age RateAge < 30 $2.81 60-64* 30-34 $3.64

35-39 $4.58 40-44 $5.62

65-69** 45-49 $10.19 50-54 $14.98 55-59 $26.21 60-64 $38.69 65-69 $40.56 70-74 $24.23 75-99 $26.10

Monthly Rates

Monthly Rates

Davis Vision

Lincoln Financial Group

Monthly Rates Per$500 Weekly Benefit Amount

Short-Term Disability

Monthly Rates

Rates are effective through 4/30/15


Rates are effective through 4/30/14

$17.68

$9.36

$12.48

All rates include an administrative fee. These rates are for illustrative purposes

and are subject to change without notice. For more specific information refer to

the highlight sheets.

$11.96

• Require Evidence of Insurability Paperwork

Spousal rates are based on the agent’s date of birth.

United Concordia DentalBasic Plan Monthly Rates

$157.66

$100,000 Benefit AmountMonthly Rates

$143.90

$200.64

$200.64

$65.22

Life Insurance

Rates

$52.00

$1.04

$10,000 Guarantee Issue Amount

Amounts over $100,000

• Require Evidence of Insurability Paperwork

• Subject to underwriting requirements and you may be denied.


Rate

$7.28

$30.16

$78.00

Life Insurance Over Age 60

Spousal rates are based on the agent’s date of birth

*Max benefit of $250,000 **Max benefit of $162,500

$6,500 Guarantee Issue Amount$15.22

Amounts over $10,000

• Are subject to underwriting requirements and

you may be denied.

Lincoln Financial GroupLong-Term Disability

Monthly Rates Per$1000 Monthly Benefit Amount

Revised 1/23/2013

Dental Benefits Summary for Homeservices of America

EEM-0142-0712

Effective Date: 5/1/2013 Network: Advantage PlusBenefit Category1 CONCORDIA FLEX PLAN

In-Network2 Non-Network2

Class I – Diagnostic/Preventive ServicesExams

100% 100%

Bitewing X-raysAll Other X-raysCleanings & Fluoride Treatments SealantsPalliative Treatment

Class II – Basic ServicesBasic Restorative (Fillings)

100% 100%

Simple ExtractionsSpace MaintainersRepairs of Crowns, Inlays, Onlays, Bridges & DenturesEndodonticsComplex Oral Surgery General Anesthesia Nonsurgical Periodontics 70% 70%Surgical Periodontics

Class III – Major Services Inlays, Onlays, Crowns 50% 50%Prosthetics (Bridges, Dentures)

Orthodontics for all membersDiagnostic, Active, Retention Treatment 50% 50%

Included Plan FeaturesSmile for Health® Maternity Benefit Covers 1 additional cleaning during pregnancy

Maximums & Deductibles (applies to the combination of services received from network and non-network dentists)

Annual Program Deductible (per person/per family) $50/$150Excludes Class I & Orthodontics

Annual Program Maximum (per person) $2,000Excludes Orthodontics

Lifetime Orthodontic Maximum (per person) $1,500Reimbursement Advantage Plus Advantage

Representative listing of covered services – certificate of coverage provides a detailed description of benefits.1. Unmarried dependent children covered to age 19. Unmarried dependent students covered to age 25.2. Reimbursement is based on our schedule of maximum allowable charges (MACs). Network dentists agree to accept our allowances as payment in full for covered services. Non-network dentists may bill the member for any difference between our allowance and their fee (also known as balance billing). United Concordia Dental’s standard exclusions and limitations apply.

UnitedConcordia.com • 1-800-332-0366

HomeServices of America Concordia Flex

HUFF REALTY

*Deductible is waived on Diagnostic and Preventive services, when performed by a Participating Provider*

• All coinsurance percentages are of United Concordia's Maximum Allowable Charge (MAC).

Coinsurances and deductibles are based upon on the maximum allowance. • Standard United Concordia policies and procedures apply. • Provider information available at www.ucci.com. The network of participating providers for this

program is Advantage Plus. • Rates are effective until April 30, 2013 and include a 4% administration fee.

Revised 2/1/2012

Diagnostic & Preventive

Routine Examinations X-rays Fluoride Treatments Cleanings Sealants Palliative Treatment

100%

Basic Basic Restorative Endodontics Complex Oral Surgery Repairs Simple Extractions

100%

Major Crowns, Inlays, Onlays Prosthetics 50%

Surgical Periodontics Non-Surgical Periodontics 70%

Orthodontics Diagnostic, Active, Retention Treatment 50%

Deductibles & Maximums Deductible* $50 per person/$150 per familyCalendar Year Maximum $2,000 per person Orthodontic Lifetime Maximum $1,500 Monthly Rates Effective 5/1/2011 to 4/30/2013

Single $41.07 Husband/Wife $90.60Parent/Child $99.26Parent/Children $126.39 Family $126.39

Dental Insurance Information

Prudential Connecticut Realty and Prudential Rhode Island Realty

*Representative listing of covered services – certificate of coverage provides a detailed description of benefits.

1) Unmarried dependent children covered to age 19. Unmarried dependent stu-dents covered to age 25.

2) Reimbursement is based on our schedule of maximum allowable charges (MACs). Network dentists agree to accept our allowances as payment in full for covered services. Non-network dentists may bill the member for any difference between our allowance and their fee (also known as balance billing). United Concordia Dental’s standard exclusions and limitations apply.

— Provider information available at www.ucci.com. The network of particpating providers for this program is Advantage Plus.

— Rates are effective until April 30, 2014 and include a 4% administration fee.

Revised 1/23/2013

Single $65.22

Husband/Wife $143.90

Parent/Child $157.66

Parent/Children $200.64

Family $200.64

Monthly Rates Effective until 4/30/2014

Vision Rates and Benefit Summary

Services In-Network Out-of-NetworkReimbursement

Eye Examinations . . . . . . . . . . . . . . . . . . . . . . . . . . . .Every 12 months $0.00 copayment up to $32.00•Including dilation as professionally indicated.

Frames . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Every 12 months $0.00 copayment up to $30.00•You may choose from the Fashion Selection from the “The Collection” for Fashionavailable in most network provider offices. A $60.00 credit will be selectionapplied toward a network provider’s own frame. Employees who seekservices through a participating retail location will be given a $60.00allowance toward the purchase of a frame. If you choose a frame with aprice that exceeds the credit or allowance, you will be responsible forany balance.

Spectacle lenses (per pair) . . . . . . . . . . . . . . . . . . . .Every 12 months $0.00 copayment•Single Vision up to $25.00•Bifocal up to $36.00•Trifocal up to $46.00•Lenticular up to $72.00 Optional lens types, or coatings may be available at discounted fees.

Contact Lenses (per dispense) . . . . . . . . . . . . . . . .Every 12 months $0.00 copayment• Standard, soft daily-wear, disposable contact lenses may be selected in for plan supplied

lieu of eyeglasses. Contact lens fitting and evaluation will be covered in contact lensesfull. A $75.00 credit will be applied toward disposable or non disposable contact lenses; standard hard daily-wear contact lenses will be covered infull from the provider’s own supply. Members who seek servicesthrough a participating retail location will also receive an allowance of $75.00 to be applied toward the cost of contact lenses from the retail location’s supply.

• Medically necessary contact lenses (prior approval required) covered in full up to $225.00Please Note: Contact lenses can be worn by most people. Once the contact lens option isselected and the lenses are fitted, they may not be exchanged for eyeglasses.

How do I receive services from a provider in the network?• Call the network provider of your choice and schedule an appointment.• Identify yourself as Davis Vision plan participant.• Provide the office with the employee’s ID number and the date of birth of any covered children needing services.It’s that easy! The provider’s office will verify your eligibility for services, and no claim forms or ID cards are required!Who are the network providers?They are licensed providers who are extensively reviewed and credentialed to ensure that stringent standards for quality service are maintained. Please call 1-800-999-5431 to access the Interactive Voice Response (IVR) Unit, which will supply you with the names andaddresses of the network providers nearest you, or you may access our website at www.davisvision.com and utilize our “Find a Doctor”feature.

For information prior to enrolling, call Dergalis Associates at (888) 564-0300 (toll free) orvisit Davis Vision’s Website at: www.davisvision.com and enter client control code 4196.

Single Parent/Child Husband/Wife Parent/Children Family

$7.55 $15.10 $15.10 $22.65 $22.65

Realtors Vision Benefits

Fitting and Evaluations:$20.00 - daily-wear$30.00 - extended wear

Contact Lenses:$48.00 - conventional$75.00 - disposable

To enroll for Vison Care:Submit your application to DergalisAssociates as instructed.

HomeServices of America, Inc. / 2/1/2012

Rates Effective to 4/30/2013

Vision Rates and Benefit Summary

How do I receive services from a provider in the network? — Call the network provider of your choice and schedule an appointment. — Identify yourself as Davis Vision plan participant. — Provide the office with the employee’s ID number and the date of birth of any covered children needing services.

It’s that easy! The provider’s office will verify your eligibility for services, and no claim forms or ID cards are required!

Who are the network providers?They are licensed providers who are extensively reviewed and credentialed to ensure that stringent standards for quality service are main-tained. Please call 1-800-999-5431 to access the Interactive Voice Response (IVR) Unit, which will supply you with the names and address-es of the network providers nearest you, or you may access our website at www.davisvision.com and utilize our “Find a Doctor” feature.

HomeServices of America, Inc. 4/16/2012

Vision Insurance Information

For information prior to enrolling, call Dergalis Associates at (888) 564-0300 (toll free) or visit Davis Vision’s website at www.davisvision.com and enter client code 4196

Not for distribution outside of Davis Vision and group/broker/consultant relationship

Proposed Benefits In-Network Benefits Plan Design Frequency – Once Every: Designer 2 Eye Examination inclusive of Dilation (when professionally indicated) 12 Months Spectacle Lenses 12 Months Frame 12 Months Contact Lens Evaluation, Fitting & Follow-Up Care 12 Months Contact Lenses (in lieu of eyeglasses) 12 Months Copayments Eye Examination $10Spectacle Lenses $25Contact Lens Evaluation, Fitting & Follow-Up Care $25Eyeglass Benefit - Frame Average Retail Value

Non-Collection Frame Allowance (Retail): Up to $130 Up to $130

Plus a 20% discount on any overage/1

Davis Vision Frame Collection/2 (in lieu of Allowance):

Fashion / Designer level Up to $175 IncludedPremier level Up to $225 $25 copayment

Eyeglass Benefit - Spectacle Lenses Average Retail Value Member Charges Clear plastic single-vision, lined bifocal or trifocal lenses (any Rx) $60-$120 IncludedOversize Lenses $20 IncludedTinting of Plastic Lenses $20 IncludedScratch-Resistant Coating $25-$40 IncludedPolycarbonate Lenses/3 $60-$75 $0 or $30/3

Ultraviolet Coating $25-$30 $12Standard Anti-Reflective (AR) Coating $50-$70 $35Premium AR Coating $65-$90 $48Ultra AR Coating $100-$125 $60Standard Progressive Lenses $150-$195 $50Premium Progressives (Varilux®, etc.) $195-$300 $90Intermediate-Vision Lenses $150-$175 $30High-Index Lenses $90-$150 $55Polarized Lenses $95-$110 $75Plastic Photosensitive Lenses $95-$150 $65Scratch Protection Plan: Single Vision | Multifocal Lenses $20|$40 Contact Lens Benefit (in lieu of eyeglasses)

Non-Collection Contact Lenses: Materials AllowanceUp to $130

Plus a 15% discount on any overage/1

- Evaluation, Fitting & Follow-Up Care – Standard Lens Types Included

- Evaluation, Fitting & Follow-Up Care – Specialty Lens TypesUp to $60 allowance

Plus a 15% discount on any overage Collection Contact Lenses/2 (in lieu of Allowance): Materials- Disposable - Planned Replacement

8 boxes/multi-packs 4 boxes/multi-packs

- Evaluation, Fitting & Follow-up Care IncludedMedically Necessary Contact Lenses (with prior approval)- Materials, Evaluation, Fitting & Follow-Up Care Included

Out-of-Network Reimbursement Schedule: up to Eye Examination: $40 Single Vision Lenses: $40 Trifocal Lenses: $80 Elective Contact Lenses: $105Frame: $50 Bifocal Lenses: $60 Lenticular Lenses: $100 Medically Necessary CL: $225

1/Additional discounts not applicable at Walmart or Sam’s Club locations.2/Collection is available at most participating independent provider offices. Collection is subject to change. Collection is inclusive of select torics and multifocals.3/Polycarbonate lenses are covered in full for dependent children, monocular patients and patients with prescriptions +/- 6.00 diopters or greater.

One-year eyeglass breakage warranty included Single Husband/Wife Parent/Child Parent/Children Family

$7.55 $15.10 $15.10 $22.65 $22.65

Monthly Rates Effective until 4/30/2015

Information about Laser Vision Correction Services:Davis Vision is pleased to provide you and your eligible dependents with the opportunity to receive Laser Vision Correction Servicesat significant discounts through a network of experienced, credentialed surgeons (please note that some providers have flat feesequivalent to these discounts). For more information, please visit our website at www.davisvision.com or call 1-800-999-5431.Information about Low Vision Services:You and your covered dependents are entitled to a comprehensive low vision evaluation once every five years and low vision aids upto the plan maximum. Up to four follow-up care visits will be covered during the five year period.What about out-of-network provider benefits?You may receive services from an out-of-network provider, although you will receive the greatest value and maximize your benefitdollars if you select a provider who participates in the network. If you choose an out-of-network provider, you must pay the providerdirectly for all charges and then submit a claim for reimbursement to:

Vision Care Processing UnitP.O. Box 1525

Latham, NY 12110To request claim forms, please visit the Davis Vision website at www.davisvision.com or call 1-800-999-5431.What lenses/coatings are included? • Plastic or glass single vision, bifocal or trifocal lenses, in any prescription range.• Oversize lenses.• Post-cataract lenses.• Polycarbonate lenses for dependent children, monocular patients and patients with prescriptions +/- 6.00 diopters or greater.Are there any optional frames, lens types or coatings available?Yes, you can pay the low, discounted fixed fees indicated and receive these exciting optional items:• $20.00 for a Designer frame from “The Collection”.• $40.00 for a Premier frame from “The Collection”.• $35.00 for polycarbonate lenses.• $20.00 for scratch-resistant coating.• $20.00 for Photogrey Extra® (photosensitive) glass lenses.• $15.00 for glass grey #3 prescription lenses.• $15.00 for fashion, sun or gradient tinted plastic lenses.• $15.00 for ultraviolet (UV) coating.• $40.00 for standard ARC (anti-reflective coating). Premium ARC is $55.00.• $75.00 for polarized lenses.• $30.00 for intermediate vision lenses.• $20.00 for blended invisible bifocals.• $70.00 for plastic photosensitive lenses. • $60.00 for high-index (thinner and lighter) lenses.• $65.00 for standard progressive addition multifocal lenses. Premium progressive additional lenses are $105.00. **** Progressive addition multifocals can be worn by most people. Conventional bifocals will be supplied at no additional charge for anyone who is unable to adapt to

progressive addition lenses; however, the copayment will not be refunded.

Information about Mail Order Contact Lenses:Free membership and access to a mail order replacement contact lens service, Lens 123, providing a fast and convenient way to purchase replacement contact lenses at significant savings. For more information, please call 1-800-LENS-123 (1-800-536-7123) or visit theLens 123 website at www.Lens123.com.For additional information:Please call Davis Vision at 1-800-999-5431 with questions or visit our website: www.davisvision.com. Member ServiceRepresentatives are available: Monday through Friday, 8:00 AM to 8:00 PM, Eastern Time, and; Saturday, 9:00 AM to 4:00 PM EasternTime. Participants who use a TTY (Teletypewriter) because of a hearing or speech disability may access TTY services by calling 1-800-523-2847.Your rights as a patient:Davis Vision recognizes that all patients have specific rights, including, but not limited to:• The right to complete information about their healthcare options and consequences.• The right to participate in all treatment decisions.• The right to dignity, privacy, confidentiality and non-discrimination.• The right to complain or appeal any decision.Patients also have the responsibility: • To provide complete and accurate information. • To follow care instructions.For a complete copy of Your Rights and Responsibilities As a Patient, please visit our website at: www.davisvision.com or call 1-800-999-5431.

HomeServices of America, Inc. / 2/1/2012

Vision Insurance Informationcontinued

Voluntary Life Program Specifications

Coverage Underwritten By Lincoln Financial Group, 8801 Indian Hills Drive, Omaha, NE 68114

VOLUNTARY LIFE INSURANCE

Sales Associate ∙ Excellent opportunity to purchase group term life insurance. ∙ You Choose The Protection You Want! ∙ $5,000 increments up to $250,000 ∙ $100,000 Guarantee Issue for Realtors under age 60 ∙ $10,000 Guarantee Issue for Realtors age 60-64 $6500 Guarantee Issue for Realtors age 65-69 ∙ No Guarantee Issue for Realtors age 70 and over – maximum

coverage is $50,000. Subject to Evidence of Insurability and underwriting requirements

Your Benefits Will Reduce ∙ 35% upon the attainment of age 65 ∙ An additional 15% of the original amount at age 70 ∙ An additional 20% of the original amount at age 75 ∙ Benefits will terminate upon retirement Spouse Benefit Amount ∙ You choose the protection you want! ∙ $2,500 increments up to a maximum of $50,000 ∙ $25,000 Guarantee Issue for a spouse up to realtor’s age 59! ∙ No Guarantee Issue for spouses age 60 and over. • Agent must elect coverage in order for your spouse to be eligible • Subject to a maximum of 50% of the agent’s elected life benefit Your Spouse’s Benefit Will Reduce ∙ 35% upon the attainment of the Realtor’s age 65 • Benefits will terminate at Realtor’s age 70

Dependent Children Benefit Amount ∙ You must elect coverage for yourself in order to be eligible for this benefit. ∙ You Choose: $5,000 or $10,000 for children age 6 months to 19 years (up to 25 years if unmarried and a full-time student) ∙ $250 for children age 14 days to 6 months; newborn children to age 14 days are not eligible for a benefit Other Benefits Include ∙ Waiver of Premium ∙ Accelerated Death Benefit ∙ Portable after 12 months ∙ Conversion Program Eligibility All Sales Associates. You must be a licensed Real Estate Sales Associate with your realty company who: 1) is currently in business of listing and selling real estate for

your realty company or through one of its affiliated real estate companies;

2) has met the minimum eligibility requirements set by your realty company; 3) has a Real Estate license current with the State; 4) is a member in good standing with the Local Board of Realtors, and; 5) is current on the Release of Liability Plan with the Policyholder. Sales Associates must be actively at work on the day coverage takes effect. Dependents must not be in a period of limited activity on the day coverage takes effect.

This is only a summary and is subject to the terms and conditions of the contract. If there is a discrepancy between this summary and the contract, the contract is considered correct. Revised 10/15/08 GI Group Plan

Voluntary Life Insurance

Life Insurance Information

Coverage Underwritten by Lincoln Financial Group, 8801 Indian Hills Drive, Omaha, NE 68114

Revised 10/15/08 GI Group Plan

VOLUNTARY LONG TERM DISABILITY PROGRAM SPECIFICATIONS


Realtor Benefit Amount Excellent opportunity to purchase group long-term disability insurance on an automatic deduction basis.

Coverage may be elected in $100 increments, minimum $500. Up to 60% of your monthly earnings (rounded down to the next lower $100 increment) to a maximum of

$5,000 $5,000 guaranteed issue

Elimination Period

This is the number of days you must be disabled due to the same or related sickness or injury before benefit payments start:

180 Days

Maximum Benefit Duration This is the maximum period of time that benefits will continue to be paid to you during a period of disability:

2 Years (Note: After age 70, the benefit period is reduced by 50%)

Pre-Existing Exclusion

“Pre-existing condition” means any sickness or injury for which you have received medical treatment, consultation, care or services (including diagnostic measures or the taking of prescribed drugs or medicines) during the 12 months prior to the coverage effective date. A disability arising from any “pre-existing condition” will not be covered for 24 months after your effective date, if you continue to be treated for the condition during the first 12 months after your coverage begins. If you receive NO treatment for that condition during the first 12 months, coverage will begin after 12 months.

Other Benefits Included

Pregnancy and Mental and Nervous conditions are covered Partial Disability Benefits

Family Income Benefit Waiver of Premium

Portability coverage is available for up to 12 months after your employment ends, provided the policy has been in effect for 12 months

(For reasons other than disability, leave, or retirement)

Program Eligibility All Sales Associates.* Sales Associates must be actively at work on the day coverage takes effect.

*See Eligibility wording on definitions page

Program Effective Date See your company open enrollment information for your effective date.

All Late Entrants are required to complete satisfactory Evidence of Insurability information.

Long-Term Disability Insurance Information



SUMMARY OF VOLUNTARY LONG TERM DISABILITY INSURANCE BENEFITS

ELIGIBILITY All Sales Associates. You must be a licensed Real Estate Associate with your affiliated realty company who:

1. Is currently in the business of listing and selling real estate for your realty company or through an affiliated real estate company;

2. Has met the minimum eligibility requirements set by your realty company; 3. Has a real estate license current with the sate; 4. Is a member in good standing with the local Board of Realtors; and 5. Is currently on the Release of Liability Plan with the policyholder

Sales Associates must be actively at work on the day coverage takes effect. A delayed effective date will apply if the Realtor is not actively at work on the date that the insurance would otherwise take effect.

DEFINITION OF TOTAL DISABILITY

Total Disability is defined as the inability to perform each of the main duties of a Realtor due to injury or sickness, and supported by medical information from your physician. Your “own” occupation is covered for 24 months.

ELIMINATION PERIOD Elimination Period is the number of days you must be totally disabled before benefit payments

start. The Elimination Period is waived on Recurrent Disabilities. You can return to your regular occupation for up to six months without having to satisfy a new Elimination Period if there is a recurrence of the prior disability.

BENEFIT DURATION Maximum Benefit Duration is the longest period of time that benefits will continue to be paid to

you during a period of disability. PARTIAL DISABILITY BENEFITS

Partial Disability means that you are unable to perform one or more of the main duties of a Realtor or are unable to perform such duties on a full-time basis. Lincoln Financial does not require that the Realtor be totally disabled prior to receiving partial benefits. To qualify for the benefit you must satisfy the elimination period. Partial disability benefits are reduced by earnings from any form of employment and end on the earliest of the date you cease to be partially disabled, the date your earnings exceed 85% of your pre-disability income or the date the maximum benefit duration ends.

EXCLUSIONS Lincoln Financial does not pay Long Term Disability benefits for any period of disability:

Which is the result of self-inflicted injury or attempted suicide; During which you are not under the regular care of a doctor; Due to active participation in a riot or in the commission of a felony; Due to war, declared or undeclared, or any act of armed aggression; or

When a disability is due to mental illness, Lincoln Financial’s standard contract considers benefits payable for up to a maximum period of 24 months. However, if the insured Realtor is confined to a hospital at the end of the 24-month period, benefits will continue up to the specified maximum benefit duration.

GUARANTEE ISSUE This coverage is extended to you without requiring evidence of insurability as long as you

meet eligibility requirements and enroll during your eligibility period. If you do not apply for this coverage when you are initially eligible and you choose to apply at a later date, you will be responsible for any expenses associated with obtaining further medical information.

Long-Term Disability Insurance Informationcontinued


SUMMARY OF VOLUNTARY LONG TERM DISABILITY INSURANCE BENEFITS (continued)

MAXIMUM BENEFIT DURATION

The Maximum Benefit Period is the longest period of time that benefits will continue to be paid as long as you are disabled in accordance with the contract. The Maximum Benefit Period is 2 Years.

PREGNANCY Pregnancy is treated as an illness. The definition of disability must be satisfied and the

elimination period completed before benefits would begin. BENEFIT INTEGRATION The Long Term Disability benefits are reduced by any other income you are eligible for under:

Primary & Family Social Security Disability or Retirement or any similar plan or act; Worker’s Compensation Law, occupational disease law or any similar law; State Disability Plans or any compulsory benefit act or law;

Other group disability plans Disability or retirement benefits through your employer; and Any form of employment (full or part-time).

PORTABILITY You may be able to extend your current coverage at the same rates for up to 12 months after

leaving your realty company, if coverage has been in-force for at least 12 months prior to termination and you are not disabled, on leave of absence, or retired.

FAMILY INCOME BENEFIT

A family Income Benefit is paid in the event of your untimely death. A lump sum benefit equal to 3 times your last monthly long term disability benefit is paid to your surviving spouse or children if you should die. To qualify, you must have been disabled for 180 days and have been receiving long-term disability benefits under terms of the policy.

WAIVER OF PREMIUM Premiums due during a total or partial disability period are waived after benefits become

payable and for as long as they continue. This is only a summary of coverage and is not a binding contract. A certificate of coverage will be made available to you, which describes the benefits in greater details. Should there be a difference between this summary and the contract, the contract will govern.

Coverage Underwritten by Lincoln Financial Group

8801 Indian Hills Drive, Omaha, NE 68114

Long-Term Disability Insurance Informationcontinued


VOLUNTARY SHORT TERM DISABILITY PROGRAM


BENEFITS

Sales Associate ∙ Excellent opportunity to purchase group short term disability insurance on an automatic deduction basis. ∙ 60% of your salary, rounded to the nearest dollar, up to $500. ∙$500 Guarantee Issue Elimination Period ∙ This is the number of continuous days you must be totally disabled before benefit payments start. ∙ 31st Day Accident / 31st Day Sickness Maximum Benefit Duration ∙ This is the longest period of time that benefits will continue to be paid to you during a period of disability. ∙ 26 Weeks (Benefit is reduced by 50% at age 70, and terminates at retirement) Pre-Existing Exclusion ∙ “Pre-existing condition” means any sickness or injury for which you have received medical treatment,

consultation, care or services (including diagnostic measures or the taking of prescribed drugs or medicines) during the 12 months prior to the coverage effective date. A disability arising from any such sickness or injury will be covered only if it begins after you have performed your duties as a realtor for 12 months following the coverage effective date.

Other Benefits Included ∙ Pregnancy, Alcoholism, Drug Addiction and Mental and Nervous conditions are treated the same as any

other sickness. ∙ Partial Disability Benefits Program Eligibility ∙ All Sales Associates.* Sales Associates must be actively at work on the day coverage takes effect. *see definitions page.

• All Late Entrants are required to complete satisfactory Evidence of Insurability information.

Short-Term Disability Insurance Information


LINCOLN FINANCIAL GROUP SUMMARY OF VOLUNTARY SHORT TERM DISABILITY INSURANCE BENEFITS

ELIGIBILITY All Sales Associates. You must be a licensed Real Estate Sales Associate with your realty company who: 1) is currently in business of listing and selling real estate for your realty company or through one of its affiliated real estate companies; 2) has met the minimum eligibility requirements set by your realty company; 3) has a Real Estate license current with the State; 4) is a member in good standing with the Local Board of Realtors, and; 5) is current on the Release of Liability Plan with the Policyholder. Sales Associates must be actively at work on the day coverage takes effect. Dependents must not be in a period of limited activity on the day coverage takes effect. A delayed effective date will apply if the Realtor is not actively at work on the date that the insurance would otherwise take effect, or for a dependent who is confined to a health care facility or in a period of limited activity.

WEEKLY BENEFIT If you are Totally Disabled beyond the elimination period due to a covered injury or sickness, you will be eligible to

receive a weekly benefit of 60% of your basic weekly income to a maximum benefit of $500. This coverage is optional.

DEFINITION OF Total Disability means you are unable to perform each of the main duties of a realtor on a full-time or part-time TOTAL DISABILITY basis due to an injury or sickness.

ELIMINATION PERIOD Elimination Period is the number of continuous days you must be totally disabled before benefit payments start.

BENEFIT DURATION Maximum Benefit Duration is the longest period of time that benefits will continue to be paid to you during a period

of disability.

GUARANTEE ISSUE This coverage is extended to you without requiring evidence of insurability as long as you meet eligibility requirements and enroll during your eligibility period. If you do no apply for this coverage when you are initially eligible and you choose to apply at a later date, you will be responsible for any expenses associated with obtaining further medical information.

PARTIAL DISABILITY Partial Disability means that due to a non-work-related sickness or injury, you are unable to perform one or more of BENEFITS the main duties of your regular occupation or are unable to perform such duties on a full-time basis. You must be

totally disabled prior to receiving partial benefits. To qualify for the benefit you must satisfy the elimination period and be earning less than 80% of your pre-disability salary. Partial disability benefits are reduced by earnings from any form of employment and end on the earliest of the date you cease to be partially disabled, the date your earnings exceed 85% of your pre-disability income or the date the maximum benefit duration ends.

PRE-EXISTING Pre-Existing Condition means any sickness or injury for which you have received medical treatment, consultation, CONDITION care or services (including diagnostic measures or the taking of prescribed drugs or medicines) during the 12

months prior to the coverage effective date. A disability arising from any such injury or sickness will be covered only if it begins after you have been insured for 12 consecutive months.

PREGNANCY Pregnancy is treated as an illness. The definition of disability must be satisfied and the elimination period

completed before benefits would begin. The pre-existing condition exclusion applies as for any illness.

EXCLUSIONS Benefits are not payable while you are not under the regular care of a physician; if disability is due to intentional, self-inflicted injury; if disability is due to an injury or sickness covered by Workers’ Compensation or resulting from employment for wage and profit; or while you receive payment under a salary continuance or retirement plan sponsored by your employer.

BENEFIT REDUCTION The Short-Term Disability benefit duration will reduce by 50% at age 70 and will terminate at retirement. This is only a summary of coverage and is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater details. Should there be a difference between this summary and the contract, the contract will govern.

Coverage Underwritten by Lincoln Financial Group 8801 Indian Hills Drive, Omaha, NE 68114


Short-Term Disability Insurance Informationcontinued

Applications

DergalisASSOCIATES

DergalisASSOCIATES

home address

ss #

email

Name

CompaNy Name offiCe loCatioN

❏ UNited CoNCordia deNtal ❏ davis visioN

A. PleAse check All coverAge(s) you Are APPlying for

PrudentiAl connecticut reAlty

phoNe

City

i represent that all information supplied in the application is true and correct. any person who knowingly, and with intent to defraud any insurance company or other person, files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act which is a crime.

state

birth date

hire date

GeNder

zip

❏ M ❏ f

AdMinistrAtive use only

effeCtive date

❏ applying for single coverage for myself ❏ applying for myself and dependents listed below

b. PleAse indicAte who will be insured under the Policy (check only one)

sPouseCoverage for:❏ dental❏ vision❏ both

child 1Coverage for:❏ dental❏ vision❏ both



c. enrollMent inforMAtion (coMPlete if including coverAge for dePendents)

GeNder

GeNder

GeNder

GeNder

Name

Name

Name

Name

ss#

ss#

ss#

ss#

birth date

birth date

birth date

birth date

siGNatUre date

❏ M ❏ f

❏ M ❏ f

❏ M ❏ f

❏ M ❏ f

dental and vision insurance enrollment formhomeservices of america

Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. GLAD 4 01/12 Please See Last Page/Reverse for Beneficiary and Signature

The Lincoln National Life Insurance Company P.O. Box 2616, Omaha, NE 68103-2616 Phone: (800) 423-2765 Fax: (877) 573-6177

ENROLLMENT FORM FOR GROUP INSURANCE

Please Use Ink or Type

GROUP ID:

CTRE

GROUP POLICY #: Billing Division or Location:

A. Employee Information (Complete for ALL Enrollments) Employer Name/Company Name (Please Print) CTRE, LLC dba Prudential Connecticut Realty

County Employer ZIP State

Employee Last Name First Name Middle Initial

Social Security Number Date of Birth

Spouse Last Name First Name Middle Initial


Street Address City State Zip

Gender: Male Female Marital Status: Married Single Home Phone ( )

Work Phone ( )

Completed By Employer Average Hours Worked Per Week: Occupation:

Earnings: Hourly Monthly Weekly Yearly

$

Date of Full-Time Employment:

Rehire Date:

B. Product Selection (Complete for ALL Enrollments) Basic Coverage NOTE: Please mark the box or boxes for each coverage you are applying for.

All coverage amounts are subject to the limitations and exclusions as stated in the policy.

Voluntary Coverage NOTE: Please mark the box or boxes for each coverage you are applying for. All coverage amounts are subject to the limitations and exclusions as stated in the policy.

TYPE OF COVERAGE AMOUNT OF COVERAGE TOTAL PREMIUM

Voluntary Employee Life Insurance Yes No* $ $

Voluntary Spouse Life Insurance Yes No* $ $

Voluntary Dependent Child Benefit Yes No* $5,000 $10,000 $

Voluntary Short Term Disability Yes No* Weekly Benefit Amount $

$

Voluntary Long Term Disability Yes No* Monthly Benefit Amount $

$

*By selecting No, application for coverage at a later date may require further medical information and/or a physical exam, which will be at my own expense.

--Actual deductions may vary slightly from above illustrations due to rounding--

C. Beneficiary Information (Complete ONLY for Life/AD&D) Primary Beneficiary's Last Name First MI Relationship of Beneficiary Social Security Number


Contingent Beneficiary's Last Name First MI

Relationship of Beneficiary Social Security Number


Note: A Contingent Beneficiary will receive benefits only if the Primary Beneficiary does not survive you. If you wish to designate more than one Primary or Contingent Beneficiary, please attach a separate sheet of paper.

Page 1 of 2

GLAD 4 11/00 Rev. 04/07 WA

The Lincoln National Life Insurance Company

A Stock Company Home Office Location: Fort Wayne, Indiana Group Insurance Service Office: P.O. Box 2616, Omaha, NE 68103-2616

Phone: (800) 423-2765 Fax: (877) 573-6177

ENROLLMENT FORM FOR GROUP INSURANCE Please Use Ink or Type

GROUP ID:HSWPNRA


A. Employee Information (Complete for ALL Enrollments)Employer Name/Company Name (Please Print) Homes Services of Washington dba Prudential Northwest Realty

Associates – State of Washington


Employee Last Name First Name Middle Initial Social Security Number Date of Birth

Spouse Last Name First Name Middle Initial Social Security Number Date of Birth



Work Phone ( )


Earnings: Hourly Monthly Weekly Yearly$

Date of Full-Time Employment: Rehire Date:

B. Product Selection (Complete for ALL Enrollments) Voluntary Coverage NOTE: Please mark the box or boxes for each coverage you are applying for.

All coverage amounts are subject to the limitations and exclusions as stated in the policy. TYPE OF COVERAGE AMOUNT OF COVERAGE TOTAL PREMIUM Voluntary Employee Life Insurance Yes No $ $Voluntary Spouse Life Insurance Yes No $ $Voluntary Dependent Child Benefit Yes No 5000 10000 $

Voluntary Short Term Disability Yes No Weekly Benefit Amount $ $

Voluntary Long Term Disability Yes No Monthly Benefit Amount $ $

C. Beneficiary Information (Complete ONLY for Life or AD&D Enrollments)Primary Beneficiary's Last Name First MI Relationship of Beneficiary Social Security Number


Contingent Beneficiary's Last Name First MI Relationship of Beneficiary Social Security Number



Voluntary Employee Life Insurance Yes

Yes

Yes

Yes

Yes

No $25,000 $

$

$

$

$

$5,000

$5,000 $10,000

$50,000

$15,000

$75,000

$25,000

$100,000Other:

Other:

Weekly Benefit Amount $

Monthly Benefit Amount $

$500 Maximum Benefit

$5,000 Maximum Benefit

No

No

No

No

Voluntary Spouse Life Insurance

Voluntary Dependent Child Benefit

Voluntary Short Term Disability

Voluntary LongTerm Disability

Annual Earnings$





GROUP ID:

CTRE










Work Phone ( )



$


Rehire Date:









$


$













GROUP ID:

CTRE










Work Phone ( )



$


Rehire Date:









$


$









GLAD 4 01/12

D. Request for Coverages This coverage has been offered to me and after careful consideration of the benefits, I have decided to:

REQUEST COVERAGE for which I am or may become eligible under the group policies issued by The Lincoln National Life Insurance Company. I hereby enroll for group insurance, for which I am eligible or may become eligible. If contributions are required, I authorize my employer to deduct premiums from my salary.

NOT ENROLL myself in the Program. I understand that if I enroll for coverage at a later date, and if a physical examination or further medical information is required, it will be at my own expense.

NOT ENROLL my dependents in the Program. I understand that if I enroll for coverage for my dependents at a later date, and if a physical examination or further medical information is required, it will be at my own expense.

A PERSON MAY BE COMMITTING INSURANCE FRAUD IF HE OR SHE SUBMITS AN APPLICATION CONTAINING A FALSE OR DECEPTIVE STATEMENT WITH THE INTENT TO DEFRAUD (OR KNOWING THAT HE OR SHE IS HELPING TO DEFRAUD) AN INSURANCE COMPANY, AS DETERMINED BY A COURT OF COMPETENT JURISDICTION. The insurance requested on this enrollment form will not be effective until approved by the Group Insurance Service Office of The Lincoln National Life Insurance Company, or its insurance partners, and the initial premium is paid to The Lincoln National Life Insurance Company. A delayed effective date will apply if the employee is not Actively at Work or an Active Member, or a dependent is in a period of limited activity on the date insurance would otherwise take effect. Employee Full Name: Employee Signature: Date:

Page 2 of 2

GLAD 4 01/12

D. Request for Coverages This coverage has been offered to me and after careful consideration of the benefits, I have decided to:

REQUEST COVERAGE for which I am or may become eligible under the group policies issued by The Lincoln National Life Insurance Company. I hereby enroll for group insurance, for which I am eligible or may become eligible. If contributions are required, I authorize my employer to deduct premiums from my salary.

NOT ENROLL myself in the Program. I understand that if I enroll for coverage at a later date, and if a physical examination or further medical information is required, it will be at my own expense.

NOT ENROLL my dependents in the Program. I understand that if I enroll for coverage for my dependents at a later date, and if a physical examination or further medical information is required, it will be at my own expense.

A PERSON MAY BE COMMITTING INSURANCE FRAUD IF HE OR SHE SUBMITS AN APPLICATION CONTAINING A FALSE OR DECEPTIVE STATEMENT WITH THE INTENT TO DEFRAUD (OR KNOWING THAT HE OR SHE IS HELPING TO DEFRAUD) AN INSURANCE COMPANY, AS DETERMINED BY A COURT OF COMPETENT JURISDICTION. The insurance requested on this enrollment form will not be effective until approved by the Group Insurance Service Office of The Lincoln National Life Insurance Company, or its insurance partners, and the initial premium is paid to The Lincoln National Life Insurance Company. A delayed effective date will apply if the employee is not Actively at Work or an Active Member, or a dependent is in a period of limited activity on the date insurance would otherwise take effect. Employee Full Name: Employee Signature: Date:





GROUP ID:

CTRE










Work Phone ( )



$


Rehire Date:









$


$









Full Name: Signature: Date:

name of insured

signature of account owner*

*note: signature should be that of the owner of the checking account whose name appears on the check used for deductions.

signature of insured

revised 3/19/2012

date

date

Automatic Deduction and Notification AgreementPLEASE READ CAREFULLY. BY SIGNING BELOW, YOU AGREE TO HAVING READ AND UNDERSTOOD THE FOLLOWING:

I hereby authorize Realty Benefit Services, an affiliate of Dergalis Associates, to access my checking and/or savings account solely for the purpose of paying premiums for the insurance benefits that I select. The deductions could include health, dental, vision, life, disability, accident and / or critical illness insurance premiums. I understand that these deductions will be made periodically and I realize that changes in premiums may result in higher or lower deductions. I further understand that I shall incur additional charges in the event this debit is returned for any reason. In the event that Realty Benefits Services is unable to collect my premiums on the first business day of the month, I will be charged $25.00.

social security # email

home phone

home addresscity state zip

cell phone

realty company office location

notificationsI agree to provide signed written notice at least two weeks in advance in the event I wish to cancel, change or amend my current policies. I further agree to indemnify and hold harmless Realty

Benefit Services, an affiliate of Dergalis Associates, for charges assessed on my account from my lending institution due to debits for services rendered. I agree to notify Realty Benefit Services, an affiliate of

Dergalis Associates, in writing of any changes to my bank account. This notice will be at least two weeks in advance of any scheduled payment debits. (You can fax your notice to Dergalis Associates at

(856) 396-3193, ATTN: Claire Juliano).

I understand that these services are being provided solely through arrangements with Realty Benefit

Services, an affiliate of Dergalis Associates, my real estate firm and the insurance carrier. I am aware that I must notify Dergalis Associates in writing if I no longer work as a licensed Realtor with my current Real Estate firm. This notification is my responsibility. If I do NOT notify Dergalis Associates within 30 days of my termination, I realize I may continue to get billed for services and benefits that I am no longer eligible to receive and I may forfeit any benefits received or premiums I paid for these benefits beyond my termination date. NO REFUNDS WILL BE PROVIDED FOR MY FAILURE TO NOTIFY DERGALIS

ASSOCIATES OF TERMINATION OR SEPARATION FROM MY REAL ESTATE COMPANY. I understand that any changes to or termination of my coverage will also affect the coverage I have elected for my dependents.

By signing, I acknowledge that I have read and accept the terms of the above notification agreement.

Attach Voided Check

Attach Your Business Card

DergalisASSOCIATES

Evidence of Insurability Form

You only need to fill out the Evidence of Insurability form if you’re purchasing

morE than the Guaranteed-Issue amount of LIFE InsurancE.

Fill out the form:

— If you are a realtor under age 60 purchasing a Life Insurance policy over $100,000

— If you are a realtor age 60 or over purchasing a Life Insurance policy over $10,000

— If you are purchasing a Life Insurance policy for your spouse* over $25,000

spouse must be under age 60

DergalisASSOCIATES

GL4A 10 CT 08/2012

The Lincoln National Life Insurance Company A Stock Company Home Office Location: Fort Wayne, Indiana

Group Insurance Service Office: P.O. Box 2616, Omaha, NE 68103-2616 Phone: (800) 423-2765 Fax: (877) 573-6177

EVIDENCE OF INSURABILITY INFORMATION Please submit this form to The Lincoln National Life Insurance Company (herein referred to as "the Company"). No coverage for which evidence of insurability is required will be effective until approved in writing by the Company.

Complete all blanks in ink and print clearly. Incomplete forms will cause consideration for coverage to be delayed.

SECTION 1. Group Information: Group Name Group ID

Group Policy No(s). Billing Division/Location

SECTION 2. Employee Information: (Complete even if employee is not applying for coverage.)

First Name Last Name Middle Initial

Social Security No. - - State of Birth Date of Birth / /

Annual Earnings $ Date of Hire/Rehire / /Home Mailing Address:

(Street) (City) (State) (Zip)

Phone No(s): Home ( ) - Work ( ) - Best Time to Call AM/PM

Email Address: Home Work

Beneficiary (for Life or AD&D Insurance) Relationship

SECTION 3. Spouse Information: (Complete only if applying for Dependent coverage.)

First Name Last Name Middle Initial

Social Security No. - - State of Birth Date of Birth / /Home Mailing Address (if different than above):

(Street) (City) (State) (Zip)

Phone No(s): Home ( ) - Work ( ) - Best Time to Call AM/PM

Email Address: Home Work SECTION 4. Plan(s) Applied for: (Only include the amount of coverage in excess of any existing amount or guaranteed issue amount.)

Basic Coverage(s) Requested Basic Coverage Amount

Optional/Voluntary Coverage(s) RequestedOptional/Voluntary Coverage Amount

Life $ Employee Life $ Dependent Life $ Employee Life & AD&D $ STD Spouse Life $ LTD Spouse Life & AD&D $

Short Term Disability (STD) $ Long Term Disability (LTD) $

Critical Illness (Mark Categories below) Enter Principal Sum for: Heart Category

Cancer Category Organ Category Quality of Life Category

Employee $ Spouse $ Child $

Page 1 of 5

CTRE, LLC dba Prudential Connecticut Realty CTRE

GL4A 10 CT CONTINUED ON NEXT PAGE 08/2012

STATEMENT OF HEALTH

SECTION 5. Medical Information - To be completed by applicants applying for ANY coverages. Employee Applicant Gender: Male Female Height: Ft. In. Weight: lbs.

Spouse Applicant Gender: Male Female Height: Ft. In. Weight: lbs. Employee Spouse

YES NO YES NOIn the past 12 months, have you smoked a cigarette, cigar or pipe, chewed tobacco or used tobacco or nicotine in any form? SECTION 6. Medical Information - To be completed if applying for LIFE or DISABILITY coverages.

Employee Spouse YES NO YES NO

1. Within the past 7 years, have you had, or been told by a physician that you had, or been treated for a condition listed below? (FOR CONDITIONS ANSWERED YES, PLEASE PROVIDE DETAILS IN SECTION 7.)

a. Heart or circulatory disorder; liver or kidney disorder; lung or respiratory disorder; mental or nervous disorder; alcoholism, drug or substance abuse; diabetes, cancer, tumor, epilepsy, hepatitis or stroke?

b. High blood pressure? If answered YES, please provide last reading and date of reading: BP Reading (Employee) DateBP Reading (Spouse) Date

c. Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC), or AIDS related conditions?

2. Within the past 5 years, have you been diagnosed with a physical disorder not listed above? (IF ANSWERED YES, PLEASE PROVIDE DETAILS IN SECTION 7.)

3. Are you currently under observation, receiving treatment or taking medication? (IF ANSWERED YES, PLEASE PROVIDE DETAILS IN SECTION 7.)

4. If applying for DISABILITY coverage, please complete these additional questions. a. Are you currently pregnant? b. Within the past 5 years, have you been diagnosed or treated for:

i. Disorder of the back, neck, or spine? ii. Osteoarthritis, Rheumatoid Arthritis, or degenerative joint disease? iii. Knee Disorder, Injury or Surgery?

(FOR CONDITIONS ANSWERED YES, PLEASE PROVIDE DETAILS IN SECTION 7.)

SECTION 7. Provide details for any questions answered YES in SECTION 6. (Attach additional sheet, if needed.) Question Number

Applicant Name Condition/Treatment/Medication Date of Diagnosis

Date of Last Symptom

CurrentStatus or Condition

Attending Physician's Name, Address, and Phone Number

Page 2 of 5

GL4A 10 CT PLEASE COMPLETE THE ATTACHED AUTHORIZATION 08/2012

SECTION 8. Medical Information - To be completed if applying for CRITICAL ILLNESS coverage. Employee Spouse

YES NO YES NO 1. Within the past 7 years, has anyone applying for coverage been diagnosed with or received

treatment for Systemic Lupus, Type I or II Diabetes, Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC), or sarcoidosis?

If applying for the Heart Category, please complete the questions below. 2. Within the past 7 years, has anyone applying for coverage been diagnosed with or received

treatment for Pacemaker, any type of fibrillation, coronary artery disease, atherectomy or any type of heart surgery, heart attack, congestive heart failure, cardiomyopathy, stroke, transient ischemic attack, congenital heart disease, chronic anticoagulation therapy?

3. Is anyone applying for coverage currently taking three or more high blood pressure (HBP) medications or had HBP medications changed or increased within the past six months?

If applying for the Cancer Category, please complete the question below. 4. Within the past 7 years, has anyone applying for coverage been diagnosed with or received

treatment for internal cancer, melanoma, bone marrow or stem cell transplant?

If applying for the Organ Category, please complete the question below. 5. Within the past 7 years, has anyone applying for coverage been diagnosed with or received

treatment for Cystic fibrosis, renal hypertension or any kidney disease or disorder (not including stones), chronic obstructive pulmonary disease, emphysema, pulmonary fibrosis, Hepatitis or liver disease or disorder (not including Hepatitis A), cirrhosis of the liver, any organ transplant, or donor?

If applying for the Quality of Life Category, please complete the question below. 6. Within the past 7 years, has anyone applying for coverage been diagnosed with or received

treatment for glaucoma or retinitis pigmentosa?

FRAUD WARNING: A person may be committing insurance fraud if he or she submits an application containing a false or deceptive statement with the intent to defraud (or knowing that he or she is helping to defraud) an insurance company, as determined by a court of competent jurisdiction.

I HEREBY: 1. request the coverage for which I am (or may become) or my Spouse is (or may become) eligible under group policies issued by

The Lincoln National Life Insurance Company; 2. authorize any required deductions from my earnings; 3. name the above beneficiary to receive any benefits payable in the event of my death; 4. represent to the best of my knowledge and belief that the above Statement of Health is true and complete, and that each item

answered yes is fully disclosed; 5. represent that if the above Statement of Health has been completed to obtain coverage for my Spouse, I have discussed and

reviewed with my Spouse the responses and information supplied on behalf of my Spouse in the Statement of Health, and to the best of our knowledge and belief, the Spouse portion of the Statement of Health is true and complete, and each item answered yes is fully disclosed; and

6. acknowledge that I have read the FRAUD WARNING. I understand that for continued eligibility I must remain an active employee working at least the minimum hours or otherwise continue coverage as outlined in the contract. The attached AUTHORIZATION has been completed and signed by the employee.

Signature of (Employee) Applicant: Date:

Signature of (Spouse) Applicant: Date:

Group Insurance Service Office Use: Self Bill List Bill

Approved Declined

EFFECTIVE DATE:

Page 3 of 5

GL4A 12 AUTH

The Lincoln National Life Insurance Company A Stock Company Home Office Location: Fort Wayne, Indiana

Group Insurance Service Office: P.O. Box 2616, Omaha, NE 68103-2616 Phone: (800) 423-2765 Fax: (877) 573-6177

AUTHORIZATION: I (the undersigned) authorize any physician, medical professional, medical facility, pharmacy benefit manager, insurer, reinsurer, consumer reporting agency or the Medical Information Bureau (MIB) to release information from the records of: 1. Applicant/Patient Name: (Last) (First) (Middle) Date of Birth: Social Security Number: This Authorization covers any periods of medical treatment during the last seven years. 2. Information to be released: My complete medical records including:

information about the diagnosis, treatment or prognosis of my medical condition (including referral documents from other facilities); and

prescription drug records and related information maintained by physicians, pharmacy benefit managers, and other sources. 3. Information is to be released to: EMSI (Examination Management Services Incorporated), The Lincoln National Life Insurance

Company or its reinsurers. 4. I understand that the purpose of disclosing this information is to evaluate my application for insurance. The Company will use the

information obtained with this Authorization to determine eligibility for insurance; and will only release such information: to reinsurance companies, the MIB or providers of a business or legal service concerned with my application; and as otherwise may be required by law or may be further authorized by me.

5. I authorize The Lincoln National Life Insurance Company, or its reinsurers, to disclose Protected Health Information or personal

health information about me to MIB, Inc. in the form of a brief coded report for participation in MIB's fraud prevention and detection programs.

I further understand that refusal to sign this Authorization may result in denial of eligibility for this insurance coverage. 6. I understand the information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and

may no longer be protected by federal law, however, the Company contractually requires the recipient to protect the information. 7. I understand that I may revoke this Authorization in writing at any time, except to the extent: 1) the Company has taken action in

reliance on this Authorization; or 2) the Company is using this Authorization in connection with a contestable claim under my coverage with the Company. If written revocation is not received, this Authorization will be considered valid for a period of time not to exceed 24 months from the date of signing. To initiate revocation of this Authorization, direct all correspondence to the Company at the above address.

8. A photocopy of this Authorization is to be considered as valid as the original. 9. I acknowledge that I have received the attached Notice of Information Practices. 10. I understand that I am entitled to receive a copy of this Authorization. Signature of Applicant: Date:

Page 4 of 5

GL4A 12 MIB NOTICE

NOTICE OF INSURANCE INFORMATION PRACTICES

COLLECTION OF INFORMATION This NOTICE is provided in compliance with your state's Insurance Information and Privacy Protection Act. In order to provide insurance coverage on a fair and equitable basis, we must collect information about you and others for whom coverage may be provided. This information may include age, occupation, physical condition, health history, prescription drug records, general reputation, mode of living and other personal characteristics. You will provide much of the information. We may collect or verify information by personal interviews and by otherwise contacting Medical professionals and institutions, pharmacy benefit managers, employers, business associates, friends, neighbors and other insurance companies. We may ask insurance support organizations to collect information and submit an investigative consumer report. That organization may disclose the contents of the report to others for which it performs such services. You may request a copy of the report or a personal interview in connection with it. DISCLOSURE OF INFORMATION The law allows disclosure of certain information without your authorization in response to a valid administration or judicial order, as permitted or required by law, or to: 1. Persons or organizations performing professional, business or insurance functions for us; 2. Our agents, insurance support organizations or consumer reporting agencies; 3. Medical professionals and medical-care institutions; 4. Persons or organizations conducting bonafide actuarial or scientific research studies, audits or evaluations; 5. Insurance regulatory, law enforcement or other governmental authorities; 6. Persons or organizations involved in any sale, transfer, merger or consolidation of our business; and 7. Group Policyholders, certificate holders, professional peer review organizations, or persons having legal or beneficial interest in a

policy of insurance. We do NOT disclose to our affiliates any information we receive about you from a consumer reporting agency. We do NOT disclose your nonpublic personal information to third parties except as necessary to provide you our products and services. We, or our reinsurers, may also release information in our file to other insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted. MIB, Inc. Information regarding your insurability will be treated as confidential. The Lincoln National Life Insurance Company or its reinsurers may, however, make a brief report thereon to the MIB, Inc. formerly known as Medical Information Bureau, a not-for-profit membership organization of insurance companies, which operates an information exchange on behalf of its members. If you apply to another MIB member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, MIB, upon request, will supply such company with the information about you in its file. Upon receipt of a request from you, MIB will arrange disclosure of any information in your file. Please contact MIB at 866 692-6901 (TTY 866 346-3642). If you question the accuracy of the information in the MIB's file, you may contact the MIB and seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of MIB's information office is 50 Braintree Hill Park, Suite 400, Braintree, Massachusetts 02184-8734. Information for consumers about MIB may be obtained on its website at www.mib.com. PERSONAL DISCLOSURE Also, you have a right to access personal information about you in our files. You may request that we correct, amend or delete information you believe is inaccurate or irrelevant. A description of the appropriate procedures will be sent to you upon written request. TELEPHONE PERSONAL HISTORY REVIEW After your application has been received in the Group Insurance Service Office, you may receive a telephone call from a specially trained Group Insurance Service Office Interviewer who will ask you some questions to obtain verification or additional information. If you have questions about the terms discussed in the NOTICE, please write to: The Lincoln National Life Insurance Company Group Insurance Service Office P. O. Box 2616 Omaha, Nebraska 68103-2616

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Name

email office locatioN

phoNe: office home cell

date start date

Request for More InformationPeter Dizdar p: (212) 541-1965 | e: [email protected] | W: agentbenefits.net/connecticut

FAXBacK (856) 795-1035 | attN: peter dizdar

1) the automatic contribution portion of the tax savings plan is not provided through aXa advisors or aXa Network. all contributed funds are invested in a money market mutual fund through aXa advisors, llc. an investment in the fund is not insured or guaranteed by the federal deposit insurance corporation (fdic) or any government agency. although the fund seeks to preserve the value of your investment at $1.00 per share, it is possible to lose money by investing in the fund.Please consider the charges, risks, expenses, and investment objectives carefully before purchasing a mutual fund. For a prospectus containing this and other information, please contact a financial professional. Read it carefully before you invest or send money. 2) these insurance products are made available through third party carriers and are offered through an insurance brokerage, aXa Network, llc and its subsidiaries.all group life, disability income, health, dental and vision insurance coverage is offered entirely outside of aXa Network, llc, aXa Network insurance agency of california, llc, aXa Network insurance agency of Utah, llc or any of their affiliates. aXa advisors and aXa Network do not provide tax advice. please consult your own tax advisor regarding your particular circumstances and appropriate course of action. the retirement savings plan is not an employer-sponsored qualified retirement plan.

financial professionals with dergalis associates offer securities through aXa advisors llc, 1290 avenue of the americas, New York, NY (212) 314-4600, and offers insurance and an-nuity products through aXa Network, llc. prudential connecticut realty and its affiliate companies do not offer investments or insurance. prudential connecticut realty and its affiliate companies are not affiliated with aXa advisors or aXa Network. dergalis associates in not owned or operated by aXa advisors or aXa Network. ppG 67477 (3/12) (exp. 3/14)

check the products that you are interested in, and a representative will contact you to provide quotes or advice.

tax savings plan through the automatic contribution program1

individual life insurance2

Group life insurance

individual disability income insurance2

Group disability income insurance

long-term care insurance2

helping protect

your IncoMe

health insurance Connecticut Only

Group dental insurance

Group Vision insurance

helping protect

your HealtH

retirement savings plan through the automatic contribution program

rollover from previous employer retirement account

investment strategies through a free financial Needs analysis

college savings plan

helping protect

your FutuRe

Health Insurance Quote Request(Connecticut Only)

FAXBACK (856) 795-1035 | ATTN: Peter Dizdar

DATe Of BirTh

GeNDer (please check) MALe feMALe

Are yOu A TOBACCO uSer? (please check) yeS NO

hOW MANy PreSCriPTiONS Are yOu CurreNTLy TAKiNG? (please circle)

0 1 2 3+

heiGhT

CurreNT WeiGhT

Applicant information

DATe Of BirTh


DO They uSe TOBACCO? (please check) yeS NO

hOW MANy PreSCriPTiONS Are They CurreNTLy TAKiNG? (please circle)

0 1 2 3+

heiGhT

CurreNT WeiGhT

Spouse information

complete only If coveRage Is needed

DATe Of BirTh

DATe Of BirTh

DATe Of BirTh




fuLL TiMe STuDeNT? (please check) yeS NO



Child information

complete only If coveRage Is needed

peter dizdar P: (212) 541-1965 | e: [email protected] | W: agentbenefits.net/connecticut

you can enroll in our individual health Plans at

any tImeindividual health PlansOur Health Insurance professionals can access a wide range of plans and will work directly with you to narrow down the options to find the most cost-effective plan for you and your family.

individual plans are not guaranteed acceptance. you will have to go through a medical underwriting process, and your medical history will be taken into account.

NAMe

eMAiL OffiCe LOCATiON

CiTyhOMe ADDreSS

DATe COVerAGe iS NeeDeD if yeS, DATe COVerAGe eNDS:

DO yOu NeeD MATerNiTy COVerAGe? (please check) yeS NO

DO yOu CurreNTLy hAVe COVerAGe? (please check) yeS NO

hAS COVerAGe PreViOuSLy BeeN DeNieD? (please check) yeS NO

STATe ziP

PhONe: OffiCe hOMe CeLL

TODAy’S DATe

Documents

ASSOCIATES Welcome - Agent Benefitsdocs.agentbenefits.net/homeservices/CT_2013Enrollment.pdfUnited Concordia Dental Basic Plan Monthly Rates $157.66 $100,000 Benefit Amount Monthly