Employee Benefits Guide 2017

2017

E M P L O Y E E B E N E F I T S

2

T A B L E O F C O N T E N T S

In this Guide, we use the term Company to refer to your company.

requirements, enrollment procedures and coverage effective dates for the benefits offered by the Company. It is not a legal plan

document and does not imply a guarantee of employment or a continuation of benefits. While this Guide is a tool to answer most

of your questions, full details of the plans are contained in the Summary Plan Descriptions (SPDs), which govern each plan’s

operation. Whenever an interpretation of a plan benefit is necessary, the actual plan documents will be used.

This Guide is intended to describe the eligibility

y the Company. It is not a legal plan

4 Welcome

5

Survivor Benefits

Income Protection

Retirement Planning

Additional Benefits

Glossary

Required Notices

Important Contacts & Mobile Apps

Eligibility & Enrollment

Medical Benefits

Pharmacy Benefits

Dental Benefits

Vision Benefits

Health Savings Account (HSA)

Flexible Spending Account (FSA)

7

9

1

See page for important

information concerning

Medicare Part D coverage.

31

3

Employee Wellness

Changes in 2017

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13

15

17

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25

27

29

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C H A N G E S I N 2 0 1 7It's no secret that change is inevitable. It's a way of life. Accept it.

The Company wants you to be aware of the following changes going forward in 2017:

Visit Aetna's DocFind® at https://www.aetna.com/individuals-families/find-a-doctor.html

Selected Plan:

What does all this mean to you and your family?

YOUR DOCTOR’S OFFICE IS CLOSED. DO YOU

KNOW WHERE TO GO?

Freestanding ER vs. Urgent Care Centers

What to look for

Hours

Wait time

Who you'll see

Capabilities

Patient load

Cost

■ ■

■ ■ ■ ■ ■

3

Aetna Open Access Managed Choice POS

®

®

The Keystyle Portal extends the Vista by Viewpointprocesses with an easy to use web-based interface foraccelerated review and approval. Reviewers can login tothe portal on any device that supports web viewing tocomplete the review process (iPhone/iPad, Android,PC,etc.)

The portal provides an accessible interface foremployees to simplify common business tasks,including the following:

■ Update Personal Info

■ Open Enrollment/Benefits

■ Submit Timecards

■ Request Time Off

Streamline Processes*Dynamic Systems, Inc. (DSI) ONLY*

Research the options in your area and determine which onesare covered by your insurance plan's network; note thatbalance billing may apply.

Be sure you know which facilities in your area are urgent careand which are freestanding ERs. Lastly, when you needmedical care, determine what level of care you actuallyrequire. Choosing an urgent care center for everyday healthconcerns could save you hundreds of dollars.

*Reminder: Just because a hospital is in your plan's network,doesn't mean that its associated freestanding ER is.

From the App Store on yourmobile device, search for

"QR Reader" and install thetool needed to scan QR codes

seen throughout the guide.

Have a Smartphone?This Benefit Guide is equipped with

mobile-friendly barcodes. These barcodes aremore commonly referred to as QR Codes, or

"Quick Response" codes.

Scanning these codes allows you to instantlynavigate to separate sites on your phone in a

matter of seconds. The content of the sitesmight be a website, video, article, or App

download. A QR Code can essentially take youanywhere - you just have to scan them first.

How Do I Scan Them?

1. Get one of the FREE QR Reader Apps

2. Once downloaded, open the App on your smartphone & follow the directions for scanning QR Codes3. The App reads the codes automatically, then immediately takes you to that code's content

WELCOME

health and well-being. We are proud to provide

you and your family with valuable information

and significant benefits. This Guide is an

overview of the benefits available to you

and their impact on your compensation

as a whole. Please read it carefully in order

to make the best choices for you and your

family in the 2017 Plan Year.

We are committed to our employees and their

4

W E L C O M E

ELIGIBILITY & ENROLLMENTYou and your family have unique needs, which is why benefit plans from which you

may choose. Consider your spouse's benefits eemplmployment and

eligibility when weighing each option.

If you are a 30 hours per week, you are Dental, Vision, Life and Disability Plans, along with the

Flexible Spending Account (FSAs), Health Savings Account (HSA) and additional benefits.

When Does Coverage Begin?

Eligible DependentsDependents eligible for coverage in

Your spouse in states

which recognize common-law marriages).

5

benefits plan include:full-time employee who works at leasteligible to participate in the Medical,

we offer a variety of

through his or her place of employment and your dependent's

legal spouse (or common-law

The elections you make for benefits are effective the first (1st)

day of the month following the date of hire. Field personnel are

eligible for benefits the first (1st) day of the month following

60 days from the date of hire. Due to IRS regulations, once you

have made your choices for the 2017 Plan Year, you won't be

able to change your benefits until the next enrollment period

■ Children up to age 26 (includes birth children, stepchildren, legally adopted children, children placed for adoption, foster children, and children for whom legal guardianship has been awarded to you or your

■spouse.)

■ Dependent children, regardless of age, provided he or she is incapable of self-support due to a mental or physical disability, is fully dependent on you for support as indicated on your federal tax return, and is approved by your Medical Plan to continue coverage past age 26.

Verification of dependent eligibility will be required upon enrollment.

unless you experience a Qualifying Life event.

The choices you made during Open Enrollment will become

effective on January 1, 2017.

You CANNOT change your beneit

selections during the Plan Year

unless you have a Qualifying

Life Event, such as the birth or

adoption of a child.

E L I G I B I L I T Y& E N R O L L M E N T

Eligibility

5

■

CURIOUS

ABOUT

Qualifying Life

Events and how

they may

afect your

coverage?

Qualifying Life EventsWhen one of the following events occurs, you from the date of the event request changes to your coverage.

■ Change in your legal marital status (marriage, divorce or legal separation)

■ Change in the number of your dependents (for example, through birth or adoption, or if a child is no longer an eligible dependent)

■ Change in yourin a loss or gain of coverage)

■ Change in your employment status from full time to part time, or part time to full time, resulting in a gain or loss of coverage

■ Entitlement to Medicare or Medicaid

■ Eligibility for coverage through the Marketplace

■ Change in your address or location that may affect the coverage for which you are eligible

Your change in coverage must be consistent with your change in status. Please direct questions regarding specific life events and your ability to request changes

Preparing to Enroll

any eligible dependent(s) that you plan to enroll. You cannot enroll your dependent(s) without this information.

to Human Resources.

spouse's employment status (resulting

absorbing a significant amount of the costs.

e sure to have the Social S

As a committed partner in your health, the Company will be

have 30 days

Please note that employee contributions for Medical, Dental and Vision depending on the level of coverage you select. In general, the more coverage you have, the higher your employee contribution will be.

coverage vary

that you may select any combination of Medical, Dental and Vision plan coverage categories. For example, you could select Medical coverage for you and your entire family,

but select Dental and Vision coverage only for yourself. The only requirement is that you must elect coverage for yourself in order to elect any dependent have the option to select coverage from the following categories:

coverage. You

■ ■Employee Only

■ Employee + Spouse

■■

Employee + Child(ren)

■ Employee + Family

Keep in mind

Be sure to have the Social Security numbers and birthdatesfor any eligible dependent(s) that you plan to enroll. Youcannot enroll your dependent(s) without this information.

contributions for Medical, Dental, Vision, FSA or HSA benefits

is deducted on a pre-tax basis, which lessens your tax liability.

How to Enroll

1. Understand Your Choices This Guide contains very useful reference material to help you prepare for Annual Enrollment. Keep it handy so you can refer to it throughout the year.

2. Review Your Options with Your Family Make sure you include any other individuals

who will be affected by your elections in the

decision-making process.

5. Conirm Your Personal and Dependent Information

6. Review Your Existing Coverage or Select New Coverage

3.

4.

Things to ConsiderTake the following situations into account before you enroll to make sure you have the right coverage.

■ Does your benefit coverage available through another employer?

■ Did you get married, divorced or have a baby recently? If so, do you need to add or remove any dependent(s) and/or update your beneficiary designation?

■ Did any of your covered children reach theirbirthday this year? If so, they are no longer eligible for benefits unless they meet specific criteria. Additional details can be found in the Eligible Dependents section of this Guide.

spouse or dependents have

26th

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to notify Human Resources to

Your share of the

WELLNESS

From time to time, we all need a little extra advice from a health professional or a gentle nudge

toward wellness. This is why we offer a health management program to all benefits-eligible employees

called Health Management Programs through Aetna. This benefit is provided to you at no cost and is

completely confidential.

Visit www.myaetna.com todayVisit www.myaetna.com today

■ Informative Webinars, Programs, Challenges & Discounts

■ Personalized Coaching and Chronic Condition Management Tools

■ Convenient and Secure Storage of Medical Records

■ Helpful Reminders About Upcoming or Needed Preventive Exams

■ BMI and Weight Management Tools

■ Talk to a Nurse

■ Tele-doc

It serves as a customized guide, much like a road map, tohelp you on your journey to wellness. The Health andWellness Program is full of helpful tools such as:

We want to reward you for taking steps toward goodhealth. The first step is to know your blood work numbers.We provide on-site Biometric Wellness Screenings foremployees and their spouses on a voluntary basis. TheBiometric Screenings will consist of the followingmeasurements: blood pressure, blood lipids (totalcholesterol, HDL cholesterol), glucose, height, weight,body mass index, and waist circumference. Individualtest results will remain confidential; The Company willnot have access to such private health information.

Wellness Discount

If you are not able to participate in the onsite BiometricScreenings, there are additional options available toyou. Contact your Human Resources department tolearn more.

Visit Quest Diagnostics online at

the website below for more

information on your voluntary

Wellness Screening:

www.my.questforhealth.com

Registration Key: FGI

Unique ID: Last Name & Last 4 #'s of SSNSWAP

SUGARY

drinks for water.

Find more tips

here on leading a

healthy lifestyle.

E M P L O Y E EW E L L N E S S

7

90% of lung cancer cases

are linked to smoking. Visit

www.smokefree.gov to learn

how to kick the habit for good.

90% of Lung Cancer cases

are linked to smoking.

Visit www.smokefree.gov to learn

how to kick the habit for GOOD!

N O T E S

__________________________________________

__________________________________________

Tobacco User

In order to help control employee Medical premium

costs, the Company has implemented a Tobacco User

Discount. This Discount is applicable to employees

and eligible household dependents enrolled in the

Medical Plan. You must sign a Tobacco Affidavit as

part of your enrollment for you and your household

If you make the decision to eliminate tobacco use, the

Company offers a variety of programs and information

to support you to quit. Aetna gives you access to a

variety of services, including personal coaching, online

tools, an audio health library, and discounts to wellness

-related products and services. Once a Tobacco

Program is successfully completed, you will be eligible

for the Tobacco User Discount with your plan.

If it is unreasonably difficult for you or your spouse to

complete a Biometric Screening due to a Medical

please call Human Resources to discuss alternatives.

Privacy Reminder: The Company does not have

access to individual health information. The statistics

reference in this communication are aggregate.

Personal health information is always treated

privately and we take this very seriously.

__________________________________________

__________________________________________

Discount

dependents to receive the Discount.

Please contact Human Resources to complete or enroll

in a tobacco cessation program or to submit

confirmation of being under a physician's care for

tobacco or nicotine use.

Cessation

8

condition,

Our Medical coverage helps you maintain your well-being through preventive care and access to an

extensive network of providers, as well as affordable prescription medication. It is up to you to choose the

Plan that best option you elect will be in place for all of

the 2017 Plan Year, unless you have a Qualifying Life Event.

Medical PremiumsPremium contributions for Medical will be deducted from your paycheck on a pre-tax basis. Your level of coverage will determine

How to Find a Provider

SCAN HERE TO LEARN ABOUT

A VARIETY OF

TOPICS, INCLUDING

HEART HEALTH.

MEDICAL BENEFITS

10

matches your needs. Please keep in mind that the

your semi-monthly contributions.

EMPLOYEEONLY

EMPLOYEE + SPOUSE

EMPLOYEE + CHILD(REN)

EMPLOYEE + FAMILY

$1,500 MEDICAL PLAN $5,000 MEDICAL PLAN HSA MEDICAL PLAN

8

To see a current list of Medical providers online, go to The provider

directory, DocFind, allows you to search for medical professionals within the network.

If you do not have internet access, please call Member Services at 1-888-416-2277.

The phone number is also provided on the back of your Aetna ID card.

If you do not have an ID card or internet access, call Aetna's Corporate Contact Center at

1-800-US-AETNA (1-800-872-3862). This is not a Member Services phone number. You will

be transferred to the Member Services group that handles your Aetna coverage. The Corporate

Contact Center is staffed Mon-Fri, 7 a.m. to 7 p.m. ET.

SEMI-MONTHLY DEDUCTIONS

NON-SMOKER

NON-SMOKER

NON-SMOKER

SMOKER SMOKER SMOKER

NON-SMOKERW/SPOUSE

SURCHARGE

NON-SMOKERW/SPOUSE

SURCHARGE

NON-SMOKERW/SPOUSE

SURCHARGE

SMOKERW/SPOUSE

SURCHARGE

SMOKERW/SPOUSE

SURCHARGE

SMOKERW/SPOUSE

SURCHARGE

WITH CREDITAPPLIED

WITH CREDITAPPLIED

WITH CREDITAPPLIED

WITHOUT CREDITAPPLIED



$ 65.63

$ 279.51

$ 165.69

$ 393.75

$ 120.63

$ 334.51

$ 220.69

$ 448.75

$ 22.24

$ 192.58

$ 87.45

$ 245.81

$ 77.24

$ 247.58

$ 300.81

$ 65.63

$ 279.51

$ 165.69

$ 393.75

$ 120.63

$ 334.51

$ 220.69

$ 448.75

$ 142.45

www.myaetna.com.

M E D I C A L B E N E F I T S

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Each covered individual is not required to meet the individual deductible. The HSA has an aggregate deductible, meaning the

family deductible amount will include all combined eligible expenses that you and your covered dependents incur. The family

deductible amount may be satisfied by one member or a combination of two or more members covered under your medical plan.

Health Care Cost Transparency

Urgent Care Centers vs. Freestanding Emergency RoomsFreestanding emergency rooms look a lot like the urgent care centers you are likely used to, but the costs and services are

drastically different. In general, consider an urgent care center as an extension of your primary care physician, while freestanding

emergency rooms should be used for health conditions that require a high level of care. Research the options in your area and

determine which ones are covered by your insurance plan's network; note that balance billing may apply. Choosing an urgent care

center for everyday health concerns could save you hundreds of dollars.

Save Money by Seeing In Network

Physicians and Taking Advantage

of Preventive Care Services

Ofered by Your Plan.

FAMILY

IN-NETWORK OUT-OF-NETWORK OUT-OF-NETWORK OUT-OF-NETWORKIN-NETWORK IN-NETWORKIN-NETWORK IN-NETWORKOUT-OF-NETWORK

INDIVIDUAL


ANNUAL DEDUCTIBLE

ANNUAL OUT-OF-POCKET MAXIMUM (Includes Deductible and ALL Medical Copays)

$1,500

$3,000

$3,000

$6,000

$5,000

$10,000

$10,000

$20,000

$4,000

$8,000

$8,000

$16,000

$6,350

$12,700

$12,500

$25,000

80% 80%50% 50%

$2,600 *

$5,200 *

100%

$5,000

$10,000

N/A

N/A

N/A

N/A

N/A

$5,000*

$10,000*

70%

$10,000

$20,000

LIFETIME MAXIMUM Unlimited Unlimited Unlimited

PREVENTIVE CARE

URGENT CARE

EMERGENCY ROOM

COPAYS / COINSURANCE

SPECIALIST

PRIMARY CARE $25 copay 50% after deductible $30 copay 50% after deductible 100% after deductible

50% after deductible 50% after deductible$50 copay $60 copay

50% after deductible 50% after deductible

$50 copay 50% after deductible $75 copay 50% after deductible

$250 copay $250 copay $250 copay $250 copay

100% after deductible








N/A

N/A

N/A

N/A

N/A70% after deductible





Medical Plan SummaryThe chart below gives a summary of Medical coverage provided

necessity as determined by the Plan. Please be aware that all out-of-network services are subject to Reasonable and Customary

(R&C) limitations.

the 2017 by Aetna. All covered services are subject to Medical

No Charge No Charge No Charge

Consumer-Driven Health Plans and tools, such as Flexible Spending Accounts and Health Savings Accounts, have helped putthe power of health care spending in consumers' hands. This means you have control over how your health care dollars arespent. But with the cost of services varying widely even within the same network and geographic area, how can you be sureyou're getting the most bang for your health care buck? Health Care Cost Transparency tools are available through Aetna.These online tools allow consumers to compare costs for everything from prescription drugs to major surgeries. For moreinformation, visit www.myaetna.com.

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$250 copay after deductible$250 copay after deductible$250 copayAFTER deductible

$250 copayAFTER deductible



100% after deductible 70% after deductible

* The Company has elected to fund the HSA Account in 2017 for the employee $500or $1,000 for family. This is a discretionary amount that will be reviewed annually.

INDIVIDUAL

FAMILY

COINSURANCE (PLAN PAYS)

Prescription Drug Coverage for Medical Plans

PHARMACY BENEFITS

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Our Prescription Drug Program is coordinated through Aetna.

You may find information on your benefits coverage and search for network pharmacies by logging on to www.myaetna.com

or by calling the Customer Care number on your ID Card.

Your cost is determined by the tier assigned to the prescription drug product. All products on the list are assigned as Generic,

Preferred, Non-Preferred or Specialty.


IN-NETWORKOUT-OF-

NETWORKIN-NETWORK

OUT-OF-NETWORK

IN-NETWORKOUT-OF-

NETWORK

RETAIL RX

$10 copay $15 copay80% after

applicable copay

$30 copay $35 copay

$50 copay $60 copay

80% afterapplicable copay




(30-DAY SUPPLY)

MAIL ORDER RX (90-DAY SUPPLY)

$25 copay

$75 copay

$125 copay

In-Networkcoverage only


$37.50 copay

$87.50 copay

$150 copay




?

?

80% afterapplicable

copay

80% afterapplicable

copay

In-Networkcoverage

only

RETAIL PHARMACY (30-day supply)

(90-day supply)

In-Networkcoverage

only

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(Tier 1)GENERIC

PREFERRED

NON-PREFERRED

(Tier 2)

(Tier 3)

(Tier 1)GENERIC

PREFERRED

NON-PREFERRED

(Tier 2)

(Tier 3)

70% afterapplicable

copay

In-Networkcoverage

only

In-Networkcoverage

only

$30 copay after deductible






P H A R M A C Y B E N E F I T S

Individual spending on prescription drugs is skyrocketing, especially for those requiring specialty medications - those that treatcomplex conditions such as cancer and rheumatoid arthritis. Go to GoodRX.com to compare costs at local and mail-orderpharmacies and find coupons for your prescription drug needs.

You should also take advantage of tax breaks, such as withdrawing money tax-free from a Health Savings Account or FlexibleSpending Account when paying for medications.

Raising Prescription Drug Costs

11

Premier RX with Step Therapy will require Pre-certification.

NEED ADDITIONAL

GENERIC DRUG FACTS?

Q & A: GENERIC DRUGSWhat is a generic drug?When a new, FDA-approved drug goes on the market, it may have patent or exclusivity protection that enables the manufacturer to sell the drug exclusively for a period of time. When those expire or no longer serve as a barrier to approval, other companies can make it in generic form.

Are generic drugs as efective as brand-name drugs?Yes. A generic drug is the same as a brand-name drug in dosage, safety, strength, quality, the way it works, the way it is taken and the way it should be used. he FDA requires generic drugs have the same high quality, strength, purity and stability as brand-name drugs.

Are generic drugs as safe as brand-name drugs?Yes. he FDA must approve the generic drug before it can be marketed.

Are generic drugs that much cheaper than brand-name medications?Yes. On average, the cost of a generic drug is 80% to 85% lower than the brand-name equivalent.

Is there a generic equivalent for my brand-name drug?To ind out if there is a generic equivalent for your brand-name drug, visit www.fda.gov to view a catalog of FDA-approved drug products, as well as drug labeling information.

131112

DENTAL BENEFITSRoutine preventive care such as regular Dental checkups can help lower your risk of stroke and heart

disease. coverage will provide you and your family affordable options for

overall health. Coverage is available from

1414

United HealthCare.

The Company's Dental

12

Dental PremiumsPremium contributions for Dental will be deducted from your paycheck on a pre-tax basis. Your tier of coverage will determine your semi-monthly


DENTAL PLAN - United Health Care (UHC)

EMPLOYEE ONLY

EMPLOYEE + SPOUSE

EMPLOYEE + CHILD

EMPLOYEE + FAMILY


Company-Paid

$9.08

$26.06

$33.88

ELECTION OPTIONS:

(UHC).

To find a network dentist,

visit www.myuhc.com.

BRUSH UP

ON CARING

FOR YOUR TEETH.

Network DentistsYour Plan's In-Network dentists have agreed to charge lower

fees, which helps keep money in your pocket. If you choose to

use a dentist who doesn't participate in your Plan's network,

your out-of-pocket costs will be higher, and you are subject to

any charges beyond the Reasonable and Customary (R&C).

premium.

D E N T A L B E N E F I T S

13

1513

Flossing isn’t fun,

but it can go a long way toward

preventing gum disease.

14

Dental Plan benefits are available to you as a Company benefit. The chartbelow gives a summary of the 2017 Dental coverage provided by UnitedHealthCare (UHC). All out-of-network services are subject to Reasonableand Customary (R&C) limitations.

Dental Plan Summary

IN-NETWO F-NETWORK

INDIVIDUAL $25 $35

FAMILY $50 $65

ANNUAL DEDUCTIBLE

$50

$150

$1,500 $1,000$1,500

$50

$150

CALENDAR YEAR MAXIMUM

COVERED SERVICES

MAJOR SERVICES

85%* 79%*

ORTHODONTICS85%* N/A

ORTHODONTIC LIFETIME MAXIMUM

$1,000

CrownsDentures

Bridges

Dependent Child(ren) (up to age 19)50%

DENTAL PLAN(UHC)

50% afterdeductible

100% 85%*Amalgam Filling

Root Canal TherapyPeriodontal ScalingRoutine Extractions

BASIC SERVICES

80% afterdeductible

95%* 80%*CleaningsX-Rays

PREVENTIVE SERVICES100%

Vision PremiumsPremium contributions for Vision will be deducted from your paycheck on a pre-tax basis. Your tier of coverage will determine

VISION BENEFITS

1616

your

If you wear glasses or contacts, chances are you already have a steady appointment with an eye doctor.

But even those with perfect eyesight should have their Vision checked on a regular basis. To ensure that

you and your family have access to quality Vision care, The Company offers a comprehensive Vision

benefit provided by United HealthCare (UHC).

14

SET YOUR

EYES ON A FEW

WAYS TO MAINTAIN

YOUR VISION.

vision

semi-monthly premium.

V I S I O N B E N E F I T S

15


- United Health Care (UHC)

EMPLOYEE ONLY

EMPLOYEE + SPOUSE

EMPLOYEE + CHILD

EMPLOYEE + FAMILY


Company-Paid

VISION PLAN

ELECTION OPTIONS:

$2.32

$2.48

$4.96

1715

According to the Centers for

Disease Control and Prevention,

approximately 14 million

Americans 12 and older have

self-reported visual impairment

(deined as 20/50 or worse).

VISION PLAN (UHC)

COVERED MATERIALS

LENSES

IN-NETWORK OUT-OF-NETWORK

LENTICULAR

SINGLE VISION

BIFOCAL

TRIFOCAL

$25 copay

$25 copay

$25 copay

$25 copay

Up to $40

Up to $60

Up to $80

Up to $80

FRAMES

RETAIL FRAME EQUIVALENT

CONTACT LENSES

NECESSARY

ELECTIVE

COPAYS

*

BENEFIT FREQUENCY

EXAMINATION

LENSES

FRAMES

CONTACTS (in lieu of Lenses and Frames)

Once every 12 months




* Allows for 4 boxes of disposable contact lenses from a network provider

$130 allowance

$25 copay

$105 allowance

$10 copay

Up to $45

Up to $210

Up to $105

Up to $40EXAMINATION / SCREENING

VISION PLAN - (UHC)

Vision Plan Summary

)

16

Vision Plan benefits are available to you as a Company benefit. Premium contributions for Vision will be deducted fromyour paycheck on a pre-tax basis. Your tier of coverage will determine your semi-monthly premium.

HEALTH SAVINGS ACCOUNTTake charge of your health care spending with a Health Savings Account (HSA). Contributions to an

HSA are tax-free, and no matter what, the money in the account is yours. Use the account to pay for eligible

Medical expenses when you are enrolled in a qualified consumer-driven health plan with HSA.

Your HSA can be used for qualified expenses, including those of your spouse or dependent(s), even if they are not covered by your Plan.

a debit card, giving you direct accessto your account balance. When you have a qualified medicalexpense, you can use your debit card to pay. You must have abalance to use your debit card. There are no receipts to submitfor reimbursement.

EligibilityYou are eligible to open and fund an HSA if:

■ You are enrolled in an HSA-eligible Consumer-Driven Health Plan.

■ You are not covered by care flexible spending account or health reimbursementaccount.

■ You are not eligible to be claimed as a dependent on someone else’s tax return.

■ You are not enrolled in Medicare, Medicaid or TRICARE for Life insurance.

■ You have not received Department of Veterans Affairs Medical benefits in the past 90 days.

Individually Owned AccountYou own and manage your

Health Savings Account. You

determine how much you'll

contribute to the account, when

to use the money to pay for

qualified medical expenses,

and when to reimburse yourself.

HSAs allow you save and roll

over money if you do not spend

it in the calendar year. The money

in this account is portable, even

if you change plans or jobs. There

are no vesting requirements or

forfeiture provisions.

18

CALCULATE

YOUR TAX SAVINGS

FROM AN HSA.

18

HSA Bank will issue you

your spouse's health plan, health

Eligible expenses include doctors' office visits, eye exams, prescription expenses and LASIK surgery. IRS Publication 502 provides a complete list of eligible expenses and can be found on www.irs.gov.

16

H E A L T HS A V I N G S A C C O U N T

17

1917

Funds in your HSA will roll over

from year to year, allowing you

to save money for future

Medical expenses.

N O T E S

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

18

How to EnrollYou must elect HSA. You will all HSA

enrollment materials and designate the amount to contribute on

a pre-tax basis. The Company will establish an HSA account

need to complete

in your name and send in your contribution once bank accountinformation has been provided and verified.

Maximize Your Tax SavingsContributions to an HSA are

through payroll deduction on a pre-tax basis when you open

an account with in this account

(including interest and investment earnings) grows

As long as the funds are used to pay for qualified

medical expenses, they are spent

HSA Bank. The money

TAX-FREE.

TAX-FREE.

TAX-FREE

HSA Funding LimitsEach year, the IRS places a limit on the maximum amount that

can be contributed to HSA accounts.

HSA FUNDING LIMITS

EMPLOYEE

FAMILY

$3,400

$6,$6,750

HSA FUNDING LIMITS

$3,400

HSA CATCH-UP CONTRIBUTIONS

HSA FUNDING LIMITS

AGE 55 OR OLDER $1,000

an HSA employer contribution

that will be deposited on a quarterly basis.

EMPLOYER HSA CONTRIBUTION

EMPLOYEE

FAMILY

The Company also

$500

$1,000

provides

EMPLOYER HSA CONTRIBUTION

The Company HSA Plan is established with HSA Bank.You may be able to roll over funds from another HSA.For more enrollment information, visit online atwww.hsabank.com.

, so they can be made

that include any employer contribution are limited to thefollowing:

For 2017, contributions

FLEXIBLE SPENDING ACCOUNT

222218

Flexible Spending Accounts (FSAs) allow you to set aside pre-tax payroll deductions to pay for

out-of-pocket health care expenses such as deductibles, copays and coinsurance, as well as dependent

care expense.

You can contribute up to $2,600 for qualified medicalexpenses with pre-tax dollars, which will reduce theamount of your taxable income and increase yourtake-home pay.

Please note: Over-the-Counter (OTC) drugs are noteligible for reimbursement through an FSA without adoctor's prescription.

Please note: If you elect for a Health Savings Account(HSA) for medical, you are NOT eligible for a HealthCare FSA.

Health Care Flexible Spending Account

Please note: ALL employees are eligible for a Dependent CareFSA, regardless of which medical plan you are enrolled in.

In addition to the Health Care FSA, you may opt to participatein the Dependent Care FSA as well - whether or not you electany other benefits. The Dependent Care FSA allows you to setaside pre-tax funds to help pay for expenses associated withcaring for elder or child dependents. Unlike the Health CareFSA, reimbursement from your Dependent Care FSA islimited to the total amount that is deposited in your account atthat time.

Dependent Care Flexible Spending Account

With the Dependent Care FSA, you are allowed toset aside up to $5,000 to pay for child or elder careexpenses on a pre-tax basis.

Eligible dependents include children younger thanthe age of 13 and dependents of any age who areincapable of caring for themselves.

Expenses are reimbursable as long as the provider isnot anyone considered your dependent for incometax purposes.

In order to be reimbursed, you must provide the taxidentification number or Social Security number ofthe party providing care.

■

■

■

■

F L E X I B L ES P E N D I N G A C C O U N T

19

2319

You cannot use FSA funds

to pay for insurance premiums.

Once you incur an eligible expense, submit a claim formalong with the required documentation. If you have aquestion about a reimbursement, contact P&A Group.Should you need to submit a receipt, P&A Group willmail or email you a receipt notification. You shouldalways retain a receipt for your records.

How to Use the Account

Please check with your tax advisor to determine if any

exceptions apply to you.

This account covers dependent day care expenses that are

necessary for you and your spouse to work or attend school

full time. The dependent must be a child younger than the age

of 13 and claimed as a dependent on your federal income tax

return or a disabled dependent who spends at least eight hours

a day in your home.

Eligible Dependent Care Flexible Spending Account Expenses

Examples of eligible dependent care expenses include:

In-Home Baby-Sitting Services ■

Care of a Preschool Child by a Licensed Nursery ■ (not by an individual you claim as a dependent)

Before and After-School Care ■Day Camp ■In-House Dependent Day Care ■

or Day Care Provider

General Rules and Restrictions

■Your expenses must be incurred during ■

the 2017 Plan Year.

Your dollars cannot be transferred from ■ one FSA to another.

You cannot participate in Dependent Care FSA ■ and claim a dependent care tax deductionat the same time.

In exchange for the tax advantages that FSAs offer, the IRShas imposed the following rules and restrictions for bothHealth Care and Dependent Care FSAs:

G

I

H

LEARN

MORE ABOUT

FSA LIMITS, GRACE

PERIODS AND

ROLLOVERS.

exceptions apply to you.

20

Health Care FSAs.

Up to may be rolled over to the next ■ $250

You cannot change your FSA election

in the middle of the Plan Year unless

■

a Qualifying Life Event occurs, such asmarriage, birth of a child, or divorce.

Please note that failure to provide proof that an expensewas valid can result in your expense being deemedtaxable.

Plan Year at the end of 2017 for

For example:

SURVIVOR BENEFITS

242420

Discussing what might happen to your family if you were not around to provide for them isn't always the

easiest conversation, but it is necessary. Survivor benefits provide financial assistance in an absence, and

can help you plan for the unexpected. If you have life insurance now, chances are you can take comfort

in knowing that those who depend on you will be provided for.

Dependents who are eligible must be listed on the benefit forms

turned into Human Resources for processing.

Beneficiary DesignationA beneficiary is the person you designate to receive your life

insurance benefits in the event of your death. This includes any

benefits payable under Group Term Life offered by The Company.

Benefits payable for a dependent’s death under the

insurance are payable to you.

It is important that your beneficiary designation is clear so there

is no question as to your intentions. It is also important that you

name a primary and contingent beneficiary. When naming your

beneficiary(ies), please indicate their full name, address, Social

Security number, relationship, date of birth and distribution

percentage. If the beneficiary is not legally related, insert the

words “Not Related” in the relationship field.

If you name more than one beneficiary with unequal shares,

please show the amount of insurance to be paid to each

beneficiary in percentages.

Life Provider Co.

Basic Term Life and Accidental Death & Dismemberment(AD&D) Insurance

Life and AD&D benefits are essential to the financial security ofyou and your family. As such, it is important to understand howyour Plan works and what benefits you will receive.

Dependents who are elig

NEED HELP

CHOOSING THE RIGHT

LIFE INSURANCE PLAN?

Basic Term Life and AD&D benefits are provided to you as apart of your basic coverage. The Company provides employeeswith Life and AD&D insurance through Aetna, whichguarantees that loved ones, such as a spouse or other designatedsurvivor(s), continue to receive part of an employee's benefitsafter death.

automatically receive life insurance even if you elect to waive

other medical, dental, or vision coverage. Your Basic AD&D

benefit is and is also provided by this Company at no

cost to you.

Your Basic Life benefit is

Company at no cost to you. If you are a full-time employee, you

$150,000,

For just $1 per month, you may elect

life insurance for your dependent(s) as

follows:

SupplementalDependent Life

$5,000 for spouse

$100 for children (14 days - 6 mo.)

$2,000 for children (6 mo. - 19) OR

age 25 if a full-time student.

■ ■ ■

and is provided by this

e a full-time employee, y

$50,000

PRIMARY CONTINGENT

Mary J. Doe,

Wife (34%)

Jane Doe,

Daughter (33%)

John Doe,

Son (33%)

Joseph W. Doe, Son (50%) Jane Doe,

Daughter (50%) OR

Estate of the Insured (100%)

If there is insufficient space for your beneficiary designations,

leave it blank and attach a separate sheet of paper indicating

your designations and share percentages. If you need assistance,

contact or your own legal counsel.Human Resources

S U R V I V O RB E N E F I T S

21

2521

BASIC LIFE

COVERAGE AMOUNT

WHO PAYS Sample Company

BENEFITS PAYABLE Upon employee’s death

MAXIMUM BENEFIT $5,000

EVIDENCE OF INSURABILITY (EOI) REQUIRED N/A

BASIC DEPENDENT LIFE

COVERAGE AMOUNT

WHO PAYS Sample Company

BENEFITS PAYABLE Upon dependent’s death

MAXIMUM BENEFIT $1,000 per family

EVIDENCE OF INSURABILITY (EOI) REQUIRED

COVERAGE AMOUNT Increments of $1,000

WHO PAYS Employee

BENEFITS PAYABLE Upon your death

MAXIMUM BENEFIT The lesser of five times your annual salary or $500,000

EVIDENCE OF INSURABILITY (EOI) REQUIRED When making elections greater than $100,000

COVERAGE AMOUNT Increments of $5,000

WHO PAYS Employee

BENEFITS PAYABLE Upon dependent’s death

MAXIMUM BENEFIT The lesser of two times employee’s annual salary or $250,000 fo spouse; $25,000 per child

SUPPLEMENTAL DEPENDENT LIFE

SUPPLEMENTAL EMPLOYEE LIFE

$150,000

FGI Services, LLC. (the Company)

Upon employees death

$150,000

N/A

$5,000 $100 $2,000

Employee - $1.00 per month

$5,000 $100 $2,000

Upon dependent's death

Subject to EOI

Subject to EOI

$100,000

Upon employee's death

$100,000

increments of $5,000

must be less than50% of the

employee's amountor $250,000

must be less than50% of the

employees amountor $10,000

increments of $2,000

$100

$100

Upon dependent's death

* You must purchase Supplemental Life insurance for yourself if you wish to purchase Supplemental Life insurance for your spouse and/or children

EVIDENCE OF INSURABILITY (EOI) REQUIRED When making elections greater than $50,000Subject to EOI

Employee

Employee

*

*

Life Insurance

may Life insurance for themselves and their families. Premiums are paid through

post-tax payroll deductions.Eligible employees purchase Supplemental

Guarantee Issue

Employees are allowed $100,000 of Supplemental Term Life insurance without providing proof of good health, which is also

known as Evidence of Insurability (EOI). Spouses are allowed $25,000 of Supplemental Term Life insurance without providing

proof of good health.

The Guarantee Issue is available to those new hires, employees, and their dependents who enroll

mu

when they are first eligible for

coverage.

,

You st also ciary t. must also designate a beneficiary to receive payment.

22

262622

AGE (AS OF JANUARY 1)

SP STIC

Younger than 20 Younger than 25

21-23 26-28

24-26 29-31

27-29 32-34

30-33 35-37

34-36 38-41

37-39 42-44

40-43 45-47

44-46 48-50

47-50 51-53

51-55 54-57

SUPPLEMENTAL LIFE INSURANCE

AGE(as of January 1st)

EMPLOYEEEMPLOYEEPOUSE/DOMES

PARTNERSPOUSE(per $5k)(Non-Tobacco per $10k) (Tobacco per $10k)

EMPLOYEE

$0.86

$1.00

$1.31

$1.84

$3.02

$5.08

$7.78

$10.52

$20.66

$38.59

$76.42

$1.39

$1.76

$2.65

$4.43

$7.57

$12.23

$17.07

$21.03

$37.10

$61.66

$99.43

Under 30

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

$0.54

$0.59

$0.75

$1.18

$2.11

$3.46

$5.01

$7.68

$14.16

$23.39

$47.39

M O N T L Y R A T E S

Be sure to check state-speciic

rules if you designate someone

other than your spouse as your

Life insurance beneiciary.

M O N T H L Y R A T E S

l

SUPPLEMENTAL CHILD(REN) LIFE INSURANCE

One or more Children $0.49

PREMIUM RATES - PER $2,000 MONTLYMONTHLY

$ ÷ 1,000 = $ x Age Based Rate = $

Benefit Elected Monthly Premium

TO CALCULATE HOW MUCH YOUR SUPPLEMENTAL LIFE COVERAGE WILL COST :

23

Disability insurance can replace

up to of your income

if you are unable to work.

Sample Company ofers disability coverage to protect you against an unfortunate or debilitating

injury. This insurance protects a portion of your income until you can return t u reach

retirement age.

INCOME PROTECTION

Short Term Disability (STD) Insurance

Long Term Disability (LTD) Insurance

27

for deta

Short Term Disability (STD) benefits are available to you as

a company benefit. STD insurance protects a portion of your

income if you become partially or totally disabled for a short

period of time. It replaces 60% of your income, up to a

maximum weekly benefit of $2,250, depending on your

current annual earnings. You must be sick or disabled for at

least 30 days before you can receive a benefit payment.

Payments may last up to 180 days. Certain exclusions and

any pre-existing condition limitations may apply. Please refer

to your Summary Plan Description for details or contact

Human Resources for specifics.

23

Your Company offers disability coverage to protect you against an unfortunate or debilitating

injury. This insurance protects a portion of your income until you can return to

reach retirement age.

60%

work or until you

DISCOVER

FREE RESOURCES,

TIPS AND DATA ON

DISABILITIES HERE.

I N C O M EP R O T E C T I O N

24

Long Term Disability (LTD) benefits are available to youas a company benefit. LTD insurance protects a portion ofyour income if you become partially or totally disabled foran extended period of time. This insurance replaces 60%of your income, up to a maximum of $9,750 per month,depending on your current annual earnings. You must besick or disabled for at least 902 days before you canreceive a benefit payment. Payments will last for as longas you are disabled or until you reach your Social SecurityNormal Retirement Age, whichever is sooner. Certainexclusions and any pre-existing condition limitations mayapply. Please refer to your Summary Plan Description fordetails or contact Human Resources for specifics.

RETIREMENT PLANNING

N O T E S

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

2924

Don’t forget to account for future

health care costs when you are

considering how much money you

will need during retirement.

Contributing to the PlanDeferred contributions are based on a to exceed Plan limits set by the IRS. The limit for 2017

Catch-up ContributionsIf you are or will be age 50 or older during and you already contribute the maximum allowed to your 401(k) account, you may also make a catch-up contribution. This additional deposit of funds accelerates your progress toward your retirement goals. The maximum catch-up contribution is $6,000 for 2017.

It's never too early - or too late - to start planning for your retirement. Making contributions to a 401(k)

account is the first step toward achieving financial security later in life. The FGI Group 401(k) Plan provides

you with the tools and flexibility you will need to retire comfortably and securely.

flat dollar amount not

2017 calendar year

can invest for retirement while receiving certain tax advantages. The Company will match 25% of your

contribution with no cap.

Eligible employees

, in 2017.

All employees are eligible for 401k benefits the first of the month,

following or coinciding with date of hire and will be enrolled

automatically with a deferral rate of 6%. Instructions on how to

change your contributions/opting-out will be mailed to you

directly from Fidelity.

EligibilityYou may start mak

R E T I R E M E N TP L A N N I N G

25

is $18,000.

303025

N O T E S

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

SET

RETIREMENT GOALS.

NEED MORE ADVICE?

26

Consolidating Your Retirement SavingsIf you have an existing qualified retirement plan (pre-taxor post-tax) with a previous employer, you may transferor rollover that account in to the Plan at any time. Toinitiate a rollover into your Plan, please refer to theSummary Plan Description or contact Human Resourcesfor further instruction.

You may change the amount of your contributions any time.All changes will become effective as soon as administrativelyfeasible and will remain in effect until you modify them. Youmay also discontinue your contributions any time. Once youstop making contributions, you may start again at any time.Ask Fidelity about their Fidelity Advisory Service that canassist you in managing your accounts. Fees for this service isrequired.

Changing or Stopping Your Contributions

VESTING SCHEDULE

YEARS OF SERVICE PERCENTAGE VESTED

0-2 years 20%

45%

6 years 100%

3-5 years

less than 2 years

2 years

0%

20%

3 years 40%

60%4 years

5 years 80%

6 years or more 100%

Investing in the PlanYou decide how to invest the assets in your account.

for you to choose from. This includes the traditional (pre-tax)

401(k) and the Roth (post-tax) 401(k). You may change your

investment choices any time. For more information, please

refer to your 401(k) Enrollment Guide.

The FGI 401(k) Plan offers a selection of investment options

You ma

ADDITIONAL BENEFITS

31

Emotional Health and Well-Being

■ Alcohol or Drug Dependency

■ Marriage or Family Relationship Problems

■ Job Pressures

■ Stress, Anxiety, Depression

■ Grief and Loss

■ Financial or Legal Advice

EAP provides referrals to help with:

■ Unlimited phone contact for grief counseling, financial planning and legal advice up to one year from the date of your claim’s approval

■ Assessment and action planning to help you develop an individualized course of action

■ Up to three sessions per problem per member with the appropriate EAP counselor for any combination of emotional, legal, or financial advising

■ Referrals to additional resources outside of the Beneficiary Assist Program to support specific situations like long-term grief counseling or complex probate and estate planning

Services Include:

The Company cares about you and your family's total health management - mental, emotional and physical. For that reason, the

Company provides an Employee Assistance Program (EAP) to all staff members at no co

This service connects you with the best mental health and counseling services. Whether you are interested in work/life resources,mental health assistance, or legal and financial advice, the EAP service can connect you and members of your household with avariety of professionals. With just one phone call, at any hour of the day or night, you have access to helpful resources. The EAPbenefit includes three counseling sessions per problem per member with a qualified licensed professional. All services are 100%

confidential and will not be shared with the Company.

For more information, visit online at www.aetnaeap.com/login.aspx or by calling 1-800-492-4357.

26

■

Employee Assistance Program (EAP)

Your Company knows the value of having healthy, well-rounded, and balanced employees, which is why

we offer additional benefits to help you manage your life.

(EAP) at no cost to you.

A D D I T I O N A LB E N E F I T S

27

Username: FGI Group Password: 8004924357

33

Talk to a NurseThe "Ask a Nurse" program offered through Aetna can giveyou a peace of mind knowing that there is a medicalprofessional available by phone or email 24-hours a day.Registered nurses can help you:

Understand medical procedures and treatment options

Medication counseling and side effect explainations

Improve how you talk with your doctor/medical provider

Describe your symptoms better

Ask the right questions

Avoid trips to the doctor's office or hospital

■ ■ ■ ■ ■ ■

Do you prefer to read? Healthwise solutions shares it's tools

and illustrations to help you make more informed health care

decisions. Find information about health conditions, tests and

procedures, and treatment options. Insights provided include

Healthwise Blogs, Patient Responses, health care news and

events, and more.

Visit the program online at:

https://www.healthwise.net/aetna/Content/CustDocument.

aspx?XML=STUB.XML&XSL=CD.FRONTPAGE.XSL

Healthwise Knowledgebase

27

Travel Assistance With Aetna's Travel Assistance Program, toll-free emergency

assistance is available to you and any dependent(s) 24 hours

a day, seven days a week, when traveling 100 or more miles

from your primary home for 90 days or less.

Paid Time OfThe purpose of Paid Time Off (PTO) is to

with flexible, paid time off from work that can be used for

needs such as vacation, personal or family illness, doctor

appointments, school, volunteering and other activities of the

choice. The Company's goal is to reduce unscheduled

absences and the need for supervisory oversight.

The PTO days you acquire replace all existing vacation, sick time

and personal business days that you have been allotted under

prior policies.

provide employees

employee's

Tuition Assistance to helping its full-time

pursue professional growth and development

by offering tuition assistance for eligible courses at the

undergraduate level.

The Company is committedemployees

Courses must be work related.

TelemedicineTelemedicine through

on-demand access to board-certified doctors and pediatricians by

online video, phone, or secure email. For a copay of

consultation, you can be treated for various health and general

pediatric care issues without leaving the comfort of your home.

This service can be utilized for after-hours non-emergency care,

when your primary care physician is not available, make requests

TelaDoc is an additional benefit available

to employees and their dependents. With TelaDoc, you have

for prescriptions or refills, or if you are traveling and need

general medical care. Examples of items that can be treated

include allergies, asthma, headache, pink eye, respiratory

infections, ear infections, and much more. Please note thatsome states do not allow physicians to prescribe medications

via telemedicine.

To access a board certified physician via phone or onlinevideo consultation, please visit www.teladoc.com/aetna

or call 855-835-2362.

$40 per

AVISO: El programa tambien esta disponible en espanol.

To speak with a nurse at anytime

call 1-800-556-1555

28

GLOSSARY

Coinsurance – Your share of the cost of a covered health

care service, calculated as a percent (for example, 20%) of the

allowed amount for the service, typically after you meet your

deductible. For instance, if your plan’s allowed amount for an

office visit is $100 and you’ve met your deductible (but haven't

yet met your out-of-pocket maximum), your coinsurance

payment of 20% would be $20. Your plan sponsor or employer

would pay the rest of the allowed amount.

Flexible Spending Accounts (FSAs) – An option

that allows participants to set aside pre-tax dollars to pay for

certain qualified expenses during a specific time period (usually a

12-month period). There are two types of FSAs: the Health Care

FSA and the Dependent Care FSA.

■ Health Care FSA – With the Health Care

FSA, participants can use their accounts to cover

eligible medical expenses such as copays, eye exams,

prescriptions and more. All expenses must be qualified

as defined in Section 213(d) of the Internal Revenue

Code. Please note that over-the-counter medications

are not eligible for reimbursement without a doctor’s

prescription with the Health Care FSA.

343428

Health Care Cost Transparency – Also known as

Market Transparency or Medical Transparency. Health care

provider costs can vary widely, even within the same geographic

area. To make it easier for you to get the most cost-effective

health care products and services, online cost transparency

tools, which are typically available through health insurance

carriers, allow you to search an extensive national database

to compare costs for everything from prescription drugs and

office visits to MRIs and major surgeries. cription

Explanation of Beneits (EOB)– A statement sent

by your insurance carrier that explains which procedures and

services were provided, how much they cost, what portion of the

claim was paid by the plan, and what portion is your liability,

in addition to how you can appeal the insurer’s decision. These

statements are also posted on the carrier's website.

Employee Contribution – The amount

you pay for your insurance coverage.

semi-monthly

Deductible – The amount you owe for health care services

before your health insurance or plan sponsor (employer) begins

to pay its portion. For example, if your deductible is $1,000,

your plan does not pay anything until you’ve met your $1,000

deductible for covered health care services. This deductible

may not apply to all services, including preventive care.

Copay – The fixed amount, as determined by your insurance

plan, you pay for health care services received.

Consumer-Driven Health Planthat provides choice, flexibility and control when it comes to

spending money on health care. Preventive care is covered at

100% with in network providers, there are no copays, and all

qualified employee-paid Medical expenses count toward your

deductible and your out-of-pocket maximum.

(HSA) - Plan option

G L O S S A R Y

29

Both accounts are "use it or lose it" -meaning that funds that are NOT used by

the end of the plan year will be lost.

Up to $250.00 may be rolled over tothe next Plan Year at the end of

2017 for Health Care FSAs.

■ Dependent Care FSA– A Dependent Care FSA –

helps to reimburse participants for eligible expenses associated

with caring for a qualified dependent, such as a dependent

younger than age 13 or another dependent that may be

incapable of self-care. For additional information on eligible

expenses, refer to Publication 503 on the IRS website.

Prescription Medications – Medications prescribed

to you by a doctor. Cost of these medications is determined

by their assigned

■ Drugs – Drugs approved by the U.S. Food

and Drug Administration (FDA) to be chemically

identical to

■ Drugs – Brand-name drugs on your

provider’s list of approved drugs. You can check online

with your provider to see this list.

■ Drugs – Brand-name drugs not on

your provider’s list of approved drugs. These drugs are

typically newer and have higher co-payments.

■ Drugs – Prescription medications used to

treat complex, chronic and often costly conditions such as

multiple sclerosis, rheumatoid arthritis, hepatitis C, and

hemophilia. Because of the high cost of these specialty

drugs, many insurers require that specific criteria be

met before a drug is covered. These requirements often

include:

• Performing a prior authorization to request coverage

of the medication

• Having a specific disease that the drug is FDA-approved

to treat

• Having a history of trying and failing cheaper

medications

• Creating high out-of-pocket costs when purchasing

the medication

• Restricting what pharmacy can dispense these

medications

Reasonable and Customary Allowance (R&C) – Also known as an eligible expense or the Usual and Customary

(U&C). The amount your insurance company will pay for

a Medical service in a geographic region based on what

providers in the area usually charge for the same or similar

Medical service.

Summary of Beneits and Coverage (SBC) – Mandated by health care reform, your insurance carrier or

plan sponsor will provide you with a clear and easy to follow

summary of your benefits and plan coverage.

35

tier: Generic, Preferred, Non-Preferred or

Specialty.

corresponding Preferred or Non-Preferred

Generic

Preferred

Non-Preferred

Specialty

cription

N O T E S

Health Savings Account (HSA) – A personal health

care bank account funded by you or your employer’s tax-free

dollars to pay for qualified medical expenses. You must be

enrolled in a CDHP to open an HSA. Funds contributed to an

HSA roll over from year to year and the account is portable,

meaning if you change jobs your account goes with you.

Out-of-Network – Out-of-network providers are doctors,

hospitals and other providers that are not contracted with your

insurance company. If you choose an out-of-network doctor,

services will not be provided at a discounted rate.

Out-of-Pocket Maximum – The most you pay during

a policy period (usually a 12-month period) before your health

insurance or plan begins to pay 100% of the allowed amount.

This limit does not include your premium, charges beyond

the Reasonable & Customary, or health care your plan doesn’t

cover. Check with your health insurance carrier to confirm what

payments apply to the out-of-pocket maximum.

Over-the-Counter (OTC) Medications – Medications

typically made available without a prescription.

29

versions. The color or flavor of a Generic medicine may be

different, but the active ingredient in the drugs are usually

the most cost-effective version of any medication.

__________________________________________

__________________________________________

__________________________________________

30

Required NoticesImportant Notice from FGI Services, LLC About Your

Prescription Drug Coverage and Medicare under the

AetnaPlan(s)

Please read this notice carefully and keep it where you can ind it. This

notice has information about your current prescription drug coverage with

FGI Services, LLC and about your options under Medicare’s prescription drug

coverage. This information can help you decide whether or not you want to

join a Medicare drug plan. If you are considering joining, you should compare

your current coverage, including which drugs are covered at what cost, with

the coverage and costs of the plans offering Medicare prescription drug

coverage in your area. Information about where you can get help to make

decisions about your prescription drug coverage is at the end of this notice.

There are two important things you need to know about your current coverage

and Medicare’s prescription drug coverage:

1. Medicare prescription drug coverage became available in 2006

to everyone with Medicare. You can get this coverage if you join a

Medicare Prescription Drug Plan or join a Medicare Advantage Plan

(like an HMO or PPO) that offers prescription drug coverage. All

Medicare drug plans provide at least a standard level of coverage set

by Medicare. Some plans may also offer more coverage for a higher

monthly premium.

2. FGI Services, LLC has determined that the prescription drug coverage

offered by the Aetna plan(s) is, on average for all plan participants,

expected to pay out as much as standard Medicare prescription drug

coverage pays and is therefore considered Creditable Coverage.

Because your existing coverage is Creditable Coverage, you can keep

this coverage and not pay a higher premium (a penalty) if you later

decide to join a Medicare drug plan.

When Can You Join A Medicare Drug Plan?

You can join a Medicare drug plan when you irst become eligible for Medicare

during a seven-month initial enrollment period. That period begins three

months prior to your 65th birthday, includes the month you turn 65, and

continues for the ensuing three months. You may also enroll each year from

October 15th through December 7th.

However, if you lose your current creditable prescription drug coverage,

through no fault of your own, you will also be eligible for a two (2) month

Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens To Your Current Coverage If You Decide to

Join A Medicare Drug Plan?

If you decide to join a Medicare drug plan, your current FGI Services, LLC

coverage will not be affected. For most persons covered under the Plan, the

Plan will pay prescription drug beneits irst, and Medicare will determine its

payments second. For more information about this issue of what program

pays irst and what program pays second, see the Plan’s summary plan

description or contact Medicare at the telephone number or web address

listed herein.

If you do decide to join a Medicare drug plan and drop your current

FGI Services, LLC coverage, be aware that you and your dependents will not

be able to get this coverage back.

When Will You Pay A Higher Premium (Penalty) To Join A

Medicare Drug Plan?

You should also know that if you drop or lose your current coverage with

FGI Services, LLC and don’t join a Medicare drug plan within 63 continuous

days after your current coverage ends, you may pay a higher premium (a

penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without creditable prescription drug

coverage, your monthly premium may go up by at least 1% of the Medicare

base beneiciary premium per month for every month that you did not have that

coverage. For example, if you go nineteen months without creditable coverage,

your premium may consistently be at least 19% higher than the Medicare base

beneiciary premium. You may have to pay this higher premium (a penalty) as

long as you have Medicare prescription drug coverage. In addition, you may

have to wait until the following October to join.

For More Information about This Notice or Your Current

Prescription Drug Coverage…

Contact the person listed at the end of these notices for further information.

NOTE: You’ll get this notice each year. You will also get it before the next

period you can join a Medicare drug plan, and if this coverage through

FGI Services, LLC changes. You also may request a copy of this notice at any

time.

For More Information about Your Options under Medicare

Prescription Drug Coverage…

More detailed information about Medicare plans that offer prescription drug

coverage is in the “Medicare & You” handbook. You’ll get a copy of the

handbook in the mail every year from Medicare. You may also be contacted

directly by Medicare drug plans.

For more information about Medicare prescription drug coverage:

» Visit www.medicare.gov

» Call your State Health Insurance Assistance Program (see the inside

back cover of your copy of the “Medicare & You” handbook for their

telephone number) for personalized help

» Call 1-800-MEDICARE (1-800-633-4227).

TTY users should call 1-877-486-2048

If you have limited income and resources, extra help paying for Medicare

prescription drug coverage is available. For information about this extra help,

visit Social Security on the web at www.socialsecurity.gov, or call them at

1-800-772-1213 (TTY 1-800-325-0778).

Remember: Keep this Medicare Part D notice. If you decide to join one

of the Medicare drug plans, you may be required to provide a copy of

this notice when you join to show whether or not you have maintained

creditable coverage and, therefore, whether or not you are required to

pay a higher premium (a penalty).

Date: January 1, 2017

Name of Entity/Sender: FGI Services, LLC

Contact—Position/Ofice: Human Resources

Address: P.O. Box 585

Austin, TX 78767

Phone Number: 512-443-4848

31

Women’s Health and Cancer Rights Act

The Women’s Health and Cancer Rights Act of 1998 was signed into law

on October 21, 1998. The Act requires that all group health plans providing

medical and surgical beneits with respect to a mastectomy must provide

coverage for all of the following:

» Reconstruction of the breast on which a mastectomy has been

performed

» Surgery and reconstruction of the other breast to produce a

symmetrical appearance

» Prostheses

» Treatment of physical complications of all stages of mastectomy,

including lymphedema

This coverage will be provided in consultation with the attending physician

and the patient, and will be subject to the same annual deductibles and

coinsurance provisions which apply for the mastectomy. For deductibles and

coinsurance information applicable to the plan in which you enroll, please

refer to the summary plan description or contact Human Resources at

512-443-4848.

HIPAA Privacy and Security

The Health Insurance Portability and Accountability Act of 1996 deals with how

an employer can enforce eligibility and enrollment for health care beneits, as

well as ensuring that protected health information which identiies you is kept

private. You have the right to inspect and copy protected health information

that is maintained by and for the plan for enrollment, payment, claims and

case management. If you feel that protected health information about you is

incorrect or incomplete, you may ask your beneits administrator to amend

the information. The Notice of Privacy Practices has been recently updated.

For a full copy of the Notice of Privacy Practices, describing how protected

health information about you may be used and disclosed and how you can get

access to the information, contact Human Resources at 512-443-4848.

HIPAA Special Enrollment Rights

If you are declining enrollment for yourself or your dependents (including your

spouse) because of other health insurance or group health plan coverage, you

may be able to later enroll yourself and your dependents in this plan if you

or your dependents lose eligibility for that other coverage (or if the employer

stops contributing towards your or your dependents’ other coverage).

Loss of eligibility includes but is not limited to:

» Loss of eligibility for coverage as a result of ceasing to meet the plan’s

eligibility requirements (i.e. legal separation, divorce, cessation of

dependent status, death of an employee, termination of employment,

reduction in the number of hours of employment);

» Loss of HMO coverage because the person no longer resides or works

in the HMO service area and no other coverage option is available

through the HMO plan sponsor;

» Elimination of the coverage option a person was enrolled in, and

another option is not offered in its place;

» Failing to return from an FMLA leave of absence; and

» Loss of coverage under Medicaid or the Children’s Health Insurance

Program (CHIP).

Unless the event giving rise to your special enrollment right is a loss of

coverage under Medicaid or CHIP, you must request enrollment within 30 days

after your or your dependent’s(s’) other coverage ends (or after the employer

that sponsors that coverage stops contributing toward the coverage).

If the event giving rise to your special enrollment right is a loss of coverage

under Medicaid or the CHIP, you may request enrollment under this plan

within 60 days of the date you or your dependent(s) lose such coverage under

Medicaid or CHIP. Similarly, if you or your dependent(s) become eligible for a

state-granted premium subsidy towards this plan, you may request enrollment

under this plan within 60 days after the date Medicaid or CHIP determine that

you or the dependent(s) qualify for the subsidy.

In addition, if you have a new dependent as a result of marriage, birth,

adoption, or placement for adoption, you may be able to enroll yourself and

your dependents. However, you must request enrollment within 30 days after

the marriage, birth, adoption, or placement for adoption.

To request special enrollment or obtain more information, contact Human

Resources at 512-443-4848.

32

Premium Assistance Under Medicaid and the

Children’s Health Insurance Program (CHIP)If you or your children are eligible for Medicaid or CHIP and you’re eligible

for health coverage from your employer, your state may have a premium

assistance program that can help pay for coverage, using funds from their

Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid

or CHIP, you won’t be eligible for these premium assistance programs but

you may be able to buy individual insurance coverage through the Health

Insurance Marketplace. For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you

live in a State listed below, contact your State Medicaid or CHIP office to find

out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and

you think you or any of your dependents might be eligible for either of these

programs, contact your State Medicaid or CHIP office or dial

1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If

you qualify, ask your state if it has a program that might help you pay the

premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid

or CHIP, as well as eligible under your employer plan, your employer must

allow you to enroll in your employer plan if you aren’t already enrolled. This

is called a “special enrollment” opportunity, and you must request coverage

within 60 days of being determined eligible for premium assistance.

If you have questions about enrolling in your employer plan, contact the

Department of Labor at www.askebsa.dol.gov or call

1-866-444-EBSA (3272).

If you live in one of the following states, you may be

eligible for assistance paying your employer health plan

premiums. The following list of states is current as of

July 31, 2016. Contact your State for more information

on eligibility –

ALABAMA – Medicaid

WEBSITE http://myalhipp.com/

PHONE 1-855-692-5447

ALASKA – Medicaid

WEBSITE The AK Health Insurance Premium Payment Program

http://myakhipp.com/

PHONE 1-866-251-4861

EMAIL [email protected]

MEDICAID

ELIGIBILITY: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

ARKANSAS – Medicaid

WEBSITE http://myarhipp.com/

PHONE 1-855-MyARHIPP (855-692-7447)

COLORADO – Medicaid

WEBSITE http://www.colorado.gov/hcpf

PHONE Medicaid Customer Contact Center: 1-800-221-3943

FLORIDA – Medicaid

WEBSITE http://flmedicaidtplrecovery.com/hipp/

PHONE 1-877-357-3268

GEORGIA – Medicaid

WEBSITE http://dch.georgia.gov/medicaid

- Click on Health Insurance Premium Payment (HIPP)

PHONE 404-656-4507

INDIANA – Medicaid

WEBSITE Healthy Indiana Plan for low-income adults 19-64

http://www.hip.in.gov

PHONE 1-877-438-4479

WEBSITE All other Medicaid

http://www.indianamedicaid.com

PHONE 1-800-403-0864

IOWA – Medicaid

WEBSITE http://www.dhs.state.ia.us/hipp/

PHONE 1-888-346-9562

KANSAS – Medicaid

WEBSITE http://www.kdheks.gov/hcf/

PHONE 1-785-296-3512

KENTUCKY – Medicaid

WEBSITE http://chfs.ky.gov/dms/default.htm

PHONE 1-800-635-2570

LOUISIANA – Medicaid

WEBSITE http://dhh.louisiana.gov/index.cfm/subhome/1/n/331

PHONE 1-888-695-2447

MAINE – Medicaid

WEBSITE http://www.maine.gov/dhhs/ofi/public-assistance/index.html

PHONE 1-800-442-6003

TTY: Maine relay 711

MASSACHUSETTS – Medicaid and CHIP

WEBSITE http://www.mass.gov/MassHealth

PHONE 1-800-462-1120

MINNESOTA – Medicaid

WEBSITE http://mn.gov/dhs/ma/

PHONE 1-800-657-3739

MISSOURI – Medicaid

WEBSITE http://www.dss.mo.gov/mhd/participants/pages/hipp.htm

PHONE 573-751-2005

MONTANA – Medicaid

WEBSITE http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP

PHONE 1-800-694-3084

NEBRASKA – Medicaid

WEBSITE http://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Pages/

accessnebraska_index.aspx

PHONE 1-855-632-7633

NEVADA – Medicaid

WEBSITE Medicaid Website: http://dwss.nv.gov/

PHONE Medicaid Phone: 1-800-992-0900

NEW HAMPSHIRE – Medicaid

WEBSITE http://www.dhhs.nh.gov/oii/documents/hippapp.pdf

PHONE 603-271-5218

33

NEW JERSEY – Medicaid and CHIP

WEBSITE Medicaid Website:

http://www.state.nj.us/humanservices/

dmahs/clients/medicaid/

PHONE Medicaid Phone: 609-631-2392

WEBSITE CHIP Website: http://www.njfamilycare.org/index.html

PHONE CHIP Phone: 1-800-701-0710

NEW YORK – Medicaid

WEBSITE http://www.nyhealth.gov/health_care/medicaid/

PHONE 1-800-541-2831

NORTH CAROLINA – Medicaid

WEBSITE http://www.ncdhhs.gov/dma

PHONE 919-855-4100

NORTH DAKOTA – Medicaid

WEBSITE http://www.nd.gov/dhs/services/medicalserv/medicaid/

PHONE 1-844-854-4825

OKLAHOMA – Medicaid and CHIP

WEBSITE http://www.insureoklahoma.org

PHONE 1-888-365-3742

OREGON – Medicaid

WEBSITE http://healthcare.oregon.gov/Pages/index.aspx

http://www.oregonhealthcare.gov/index-es.html

PHONE 1-800-699-9075

PENNSYLVANIA – Medicaid

WEBSITE http://www.dhs.pa.gov/hipp

PHONE 1-800-692-7462

RHODE ISLAND – Medicaid

WEBSITE http://www.eohhs.ri.gov/

PHONE 401-462-5300

SOUTH CAROLINA – Medicaid

WEBSITE http://www.scdhhs.gov

PHONE 1-888-549-0820

SOUTH DAKOTA - Medicaid

WEBSITE http://dss.sd.gov

PHONE 1-888-828-0059

TEXAS – Medicaid

WEBSITE http://gethipptexas.com/

PHONE 1-800-440-0493

UTAH – Medicaid and CHIP

WEBSITE Medicaid: http://health.utah.gov/medicaid

CHIP: http://health.utah.gov/chip

PHONE 1-877-543-7669

VERMONT– Medicaid

WEBSITE http://www.greenmountaincare.org/

PHONE 1-800-250-8427

VIRGINIA – MEDICAID AND CHIP

WEBSITE Medicaid Website: http://www.coverva.org/programs_premium_

assistance.cfm

PHONE Medicaid Phone: 1-800-432-5924

WEBSITE CHIP Website: http://www.coverva.org/programs_premium_

assistance.cfm

PHONE CHIP Phone: 1-855-242-8282

WASHINGTON – Medicaid

WEBSITE http://www.hca.wa.gov/free-or-low-cost-health-care/program-

administration/premium-payment-program

PHONE 1-800-562-3022 ext. 15473

WEST VIRGINIA – Medicaid

WEBSITE http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/default.aspx

PHONE 1-877-598-5820, HMS Third Party Liability

WISCONSIN – Medicaid and CHIP

WEBSITE https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf

PHONE 1-800-362-3002

WYOMING – Medicaid

WEBSITE https://wyequalitycare.acs-inc.com/

PHONE 307-777-7531

To see if any other states have added a premium assistance program since

July 31, 2016, or for more information on special enrollment rights, contact

either:

U.S. Department of Labor

Employee Benefits Security Administration

www.dol.gov/ebsa

1-866-444-EBSA (3272)

U.S. Department of Health and Human Services

Centers for Medicare & Medicaid Services

www.cms.hhs.gov

1-877-267-2323, Menu Option 4, Ext. 61565

OMB Control Number 1210-0137 (expires 10/31/2016)

34

N O T E S

____ ___

____ ___

__________

___________________________________

___________________________________

___________________________________

_______________________ _

____________________________

_____

_____ _

___________________________________

___________________________________

Directly benefit

information with the Lockton BeneftLink

Mobile App. You’ll be immediately connected to

provider websites and phone numbers. You can

even capture and

store important

information like ID

cards, your group

numbers, doctors’

names and more!

BeneftLinkUsername: fgi

Password: benefits

IMPORTANT CONTACTS

COVERAGE CONTACT

MEDICAL

PHARMACY

WELLNESS

DENTAL

VISION

LIFE AND AD&D

DISABILITY

EMPLOYEE ASSISTANCE

PROGRAM

BENEFICIARY ASSISTANCE

401(K) PLAN

HEALTH SAVINGS ACCOUNT

FLEXIBLE SPENDING ACCOUNTS

P&A Group800-688-2611Claims Fax: 716-855-7105 or 877-855-7105www.padin.com

Aetna888-416-2277

Lockton

access, FGI Services, LLC.

34

AetnaPlan #835875888-416-2277www.aetna.com/individuals-families/ pharmacy.html

AetnaPlan #835875888-416-2277 or 1-800-US-AETNAwww.aetna.com

United HealthCare (UHC)Plan #743533877-816-3596www.myuhc.com/member/prewelcome

United HealthCare (UHC)Plan #743533800-638-3120www.myuhc.com/member/prewelcom

Human Resources512-443-4848

Aetna Resources for Living800-492-4357www.mylifevalues.com


Fidelity InvestmentsPlan #487074800-835-5097www.401k.com or www.netbenefits.com

AetnaPlan #835875866-326-1380www.aetna.com

HSA BankClient Assistance Center800-357-6246www.hsabank.com

AetnaPlan #835875866-326-1380www.aetna.com

www.aetna.com/insurance-producer/health-wellness-programs.html

______________________________

______________________________

______________________________

____________________________

____________________________

______

______________

______________

#80840

www.aetna.com/individuals-families/pharmacy.html

www.aetna.com/insurance-producer/health-wellness-tools.html

www.myuhc.com/member/

www.myuhc.com/member/

https://www.padmin.com/employee-participants/account-login/index.php3

P&A Group800-688-2611Claims Fax: 716-855-7105 or 877-855-7105

www.hsabank.com/hsabank/members

https://www.aetna.com/individuals-families/member-plans-benefits/disability-insurance.html


https://www.aetna.com/insurance-producer/life-insurance.html

I M P O R T A N T C O N T A C T S

35

IMPORTANT CONTACTSCONTINUED

404040

_

_

_

_

_

35

_____ ________________

HSA BankMobile

______________________ __

_____________

______________

_____________

______________

_

__

__ __

_ _

________________

https://itunes.apple.com/us/app/hsa-bank-mobile/id867117986?mt=8

https://play.google.com/store/apps/details?id=com.lighthouse1.mobilebenefits.hbkbp&hl=en

Get Away Inc. 214-632-9988 www.getaway.com

AetnaAXA Assistance USA's Alert Center312-935-3704 (direct) or 877-935-3704 (toll-free)

If outside the U.S., call 312-935-3704.All collect calls are accepted.

TRAVEL ASSISTANCE

TELEMEDICINETelaDoc855-835-2362www.teladoc.com/aetna

HUMANRESOURCES

512-443-48483901 S. LamarSuite 100Austin, TX 78704

HUMANRESOURCES

512-443-48483901 S. LamarSuite 100Austin, TX 78704

WELLNESS

SCREENING

Quest DiagnosticsFGI Group Plan Specialist: Katie Birkenfeld

913-895-2536www.my.questforhealth.com

____________________________

____________________________

______Scan the codes belownow to access apps thatsave you time & money

_

__

__

_

__ ___

______________ __

____________________________

______________

______________

UnitedHealthCare

(UHC)

__

_______________ ___

_______________ __

____________________________

______________

______________

AetnaMedical

__ __

______________ _

___________________________

______________

______________

FidelityNet Benefits

__ __

______________ __

____________________________

______________

______________

iTriage

_

_Medwatcher

______________________ __

_____________

______________

_____________

______________

_

__

__ __

_ _

________________

___________________________________________

______________________ __

_____________

______________

_____________

______________

_

__

__ __

_ _

________________

https://itunes.apple.com/us/app/teladoc-member-24-7-access/id656872607?mt=8&ign-mpt=uo%3D4

https://play.google.com/store/apps/details?id=com.teladoc.members

_

___ ___

__

__________________________________________

__ ___

______________ __

____________________________

______________

______________

InstantHeart Rate

https://itunes.apple.com/us/app/medwatcher-for-drugs-vaccines/id391767048?mt=8

https://play.google.com/store/apps/details?id=org.medwatcher&hl=en

_

I M P O R T A N T C O N T A C T S

36

In today’s uncertain economic times, it’s more important than ever to ensure your retirement plan is on track—and The Clift Group at Morgan Stanley is here to help. As a participant in the FGI Group Inc 401(k) Plan, you can receive one-on-one financial planning. And best of all, this service is available at no additional cost to you.

Take charge of your retirement planning

We can help you:

• Build a Customized Financial Plan for

you and your family

• Understand your plan’s features and

investment options

• Review the importance of

diversification and other asset

allocation strategies

• Discuss Non-Qualified and Self-Directed

Brokerage Accounts

• Complete a Pre-Retirement Checklist

• Assist retiring employees with

retirement plan distribution strategies

Meet your retirement

plan consulting team:

Kevin Clift, CIMA

Financial Advisor

214-661-7101

[email protected]

31 years of experience

Matt Sheldahl, CFA

Consulting Group Analyst

214-661-7103

[email protected]


Kyle Clift, CRPS

Financial Advisor

214-661-7102

[email protected]


http://www.morganstanleyfa.com

/thecliftgroup/

200 Crescent Court, Suite 900

Dallas, TX 75201

Planning for retirement is important. To reach your goals, you need to know how much

to save and which investment options are right for you. We’re here to help. The Clift

Group has over 50 years of experience serving 401(k) Plans like yours.

Tax laws are complex and subject to change. Morgan Stanley Smith Barney LLC (“Morgan Stanley”) , its affiliates and Morgan Stanley

Financial Advisors and Private Wealth Advisors do not provide tax or legal advice and are not “fiduciaries” (under ERISA, the Internal

Revenue Code or otherwise) with respect to the services or activities described herein except as otherwise agreed to in writing by Morgan

Stanley. Individuals are encouraged to consult their tax and legal advisors (a) before establishing a retirement plan or account, and (b)

regarding any potential tax, ERISA and related consequences of any investments made under such plan or account.

Investments and services offered through Morgan Stanley Smith Barney LLC. Member SIPC.

N O T E S

37

2017

PAYROLL DEDUCTION AUTHORIZATION FORM

PRE-TAXABLE BENEFITS

F

O

R

P

A

Y

R

O

L

L

U

S

E

O

N

L

Y

DEPENDENT (DAY CARE) SPENDING ACCOUNT: MAXIMUM $5,000.00

ANNUAL (CALENDAR YEAR) CONTRIBUTION AMOUNT: $ DECLINE

FLEXIBLE SPENDING ACCOUNT: MAXIMUM

ANNUAL (CALENDAR YEAR) CONTRIBUTION AMOUNT: $ DECLINE

HEALTH PLAN COVERAGE OPTIONS – CHOOSE ONE

Aetna Deductible Options: $1,500 (Standard) OR $5,000 (HDHP) OR Health Savings Account (HSA)

Employee Only Employee & Spouse

Employee & Children Employee & Family DECLINE

DENTAL COVERAGE

Employee Only (Company Pays) Employee & Spouse


VISION COVERAGE

Employee Only (Company Pays) Employee & Spouse


VOLUNTARY BENEFITS

DEPENDENT LIFE ($1.00 A MONTH) EMPLOYEE PAYS DECLINE

SUPPLEMENTAL LIFE INS. (Aetna APPLICATION REQUIRED) EMPLOYEE PAYS DECLINE

If you are electing to participate in FSA Medical and/or Dependent Day Care, please complete the requested information below

Spouse Name Date of Birth Dependent Name Date of Birth

Dependent Name Date of Birth Dependent Name Date of Birth

I hereby elect the benefits indicated above. I have read and understand the enrollment materials contained within the employee benefit guide and I authorize

my employer to adjust my pay as required by my election(s). I understand that this election is binding and cannot be revoked or modified until the next plan

year, except under the limited circumstances that are described in detail in the SPD that I have received from my employer (i.e. marriage, divorce, birth). I also

understand if participating in an FSA account (Health/Dependent Day Care) any funds not used for eligible expenses incurred during the period of coverage will

be forfeited in accordance with the current plan provisions and tax laws.

I hereby, elect to make a CHANGE to my current "pre-tax" benefits (as allowed by my employer’s plan do u e t), due to the followi g “family status change"

which was effective on / / 2017

Marriage Divorce Legal Separation Birth/Adoption of child Change in job status

Death in immediate family My depe de t’s eligi ility for e efits has ha ged My (spousal) eligibility for benefits has changed

EMPLOYEE SIGNATURE___________________________________________ DATE________________________________

FOR HR USE ONLY

EFFECTIVE DATE:

EMPLOYER/DIVISION

FGI Services, LLC Dynamic Systems, Inc. Dynamic Manufacturing Solutions, LLC TAB Technologies, Inc.

EMPLOYEE LAST NAME

FIRST NAME, MIDDLE INITIAL

DATE OF BIRTH

MARITAL STATUS

Single Married

EMPLOYEE MAILING ADDRESS

CITY, STATE & ZIP

CONTACT PHONE NUMBER

PRIMARY EMAIL

BACKUP EMAIL

$2,600.00

HR 2017

ENROLLMENT / CHANGE / CANCELLATION FORM

ENROLL CHANGE

A. Employee Information

FIRST NAME M.I. LAST NAME SOCIAL SECURITY NO.

MAILING ADDRESS CITY STATE ZIP

B. Dependents

(If additional space is needed, attach separate sheet)

ACTION NAME/SOCIAL SECURITY NUMBER

SEX

DATE OF BIRTH

RELATIONSHIP

FULL-TIME STUDENT

COVERAGE

Enroll Change Cancel

Spouse:

M

F

Yes

No

Medical Dental Vision SS#


Dependent:

M

F

Yes

No



Dependent:

M

F

Yes

No



Dependent:

M

F

Yes

No



Dependent:

M

F

Yes

No


aa C. Other Insurance

On the day your coverage begins, will you, your spouse, or dependents be covered under any other insurance? If yes, complete the following section: (Use a separate sheet if necessary)

Insurance Company Name Medicare Medicaid Other Insurance Carrier

Name of Person Insured Social Security Number Coverage Start Date Coverage End Date

C. Other Insurance

SIGNATURE: _________________________________________ DATE: __________________________

Health Savings Account (HSA) Application and Eligibility Form

Instructions: Complete all fields below. Mail or fax your application to: HSA Bank, P.O. Box 939, Sheboygan, WI 53082, Fax: 920-803-4184 For assistance, call 800-357-6246, Monday - Friday, 7 a.m. - 9 p.m., or Saturday, 9 a.m. -1 p.m., CT. Para ayuda en Español, por favor llamar 866-357-6232.

PART 1: GENERAL INFORMATION FOR PRIMARY ACCOUNTHOLDER

First Name: MI: Last Name: Date of Birth (must be 18): (mm/dd/yyyy) Social Security Number (Required):

Physical Street Address: (Required) City: State: ZIP Code:

Preferred Mailing Address: Physical Street Address P.O. Box

Email:

P.O. Box: City: State: ZIP Code:

Home Phone: Business Phone:

Citizenship Status: U.S. Citizen Resident Alien Non-resident Alien

If not a U.S. Citizen, enter Country of Citizenship:

Employment: Employed Not Employed Self-Employed Retired

Employer: Title/Profession:

Health Plan Insurance: Single Family

Effective Date of your Health Insurance:

Deductible Amount: $

PART 2: AUTHORIZED SIGNER OPTIONAL: (SUCH AS A SPOUSE OR ANOTHER THIRD PARTY)

By completing all of the fields below, you are authorizing the person designated as “Authorized Signer” to access and initiate transactions on your account as your agent.

HSA Bank will rely upon this designation until HSA Bank receives your written revocation of this authorization and has had a reasonable time to act upon it. You hold harmless

and indemnify HSA Bank against any claims against or losses arising out of HSA Bank’s reliance on this authorization, and release HSA Bank from any liability arising from

such reliance, unless otherwise prohibited by law. You remain solely responsible for any tax consequences that result from any actions taken by the authorized signer

regarding your account.

First Name: MI: Last Name: Date of Birth: (mm/dd/yyyy) Social Security Number:

Address same as accountholder

Street Address:

City: State: ZIP Code: Phone Number:

If you would like to designate a beneficiary for your account, please complete our Designation of Beneficiaries form which is available on our website at:

http://www.hsabank.com/beneficiary.

PART 3: ACCOUNT SELECTIONS

Please select the account options and enter an amount where appropriate.

Primary Accountholder debit card (No Charge)

Authorized Signer debit card (if applicable) (No Charge)

Checks ($7.95 – check must be included to process order) $______________

Initial Contribution $______________ Contribution Year_______________

Transfer: Yes No (If yes, please attach the HSA transfer/rollover form or IRA form)

PART 4: ACCOUNT AUTHORIZATION

By signing below, I certify that:

• I am, or will be covered by a qualified High Deductible Health Plan (HDHP), I am not enrolled in Medicare or covered under other health insurance that is not compatible with an HSA, and I may

not be claimed as a dependent on another person’s tax return (excluding spouses per the IRS).

• HSA Bank is hereby appointed to serve as custodian of my Health Savings Account.

• To help the government fight the funding of terrorism and money laundering activities, Federal Law requires that all financial institutions obtain, verify and record information that identifies each

person who opens an account. What this means to you: when you open an account we will need you and your authorized signer to provide name, street address, date of birth and other

information that will allow us to identify you and your authorized signer. We may also ask to see your driver’s license or other identifying documents.

After your application is processed, you will receive a Welcome Kit by mail in 7-10 business days. The Welcome Kit contains your account number and our disclosures. It also outlines our

services and provides details on how to manage your account. If you don’t receive your Welcome Kit, please contact us.

Accountholder Signature: Date:

For Tracking Purposes (to be completed by employer or insurance/financial representative) Internal Use Only:

Health Plan Code Broker Dealer AIN# SVC Software MGA Marketing Employer Fed ID #

FGI Group Inc

1036743 1036742 1015084 742333173

http://www.hsabank.com/beneficiary

Health Savings Account (HSA)

Contribution Options & Salary Reduction Arrangement

FORM_Contributions_Options_EE_to_ER_030915

By my signature below, I certify that I have enrolled, or plan to enroll, in an HSA-qualified High Deductible Health Plan (HDHP) and

am not covered under any other plan that would disqualify me from opening or contributing to my Health Savings Account. I

understand that this form is provided for convenience purposes and that HSA Bank will not initiate any contributions to my HSA,

but will allow my employer or their authorized agent to initiate contributions to my account.

OPTION ONE

I elect to make contributions to my HSA through a pre-tax salary reduction through my employer’s Section 125 Cafeteria Plan

and authorize my employer deduct the amounts as indicated from my salary and forward the funds to HSA Bank to be deposited

in my HSA.

Deduction Option: Frequency of Pay Period:

$50.00 per pay period Weekly (52 per/year)

$75.00 per pay period Bi-Weekly (26 per/year)

$100.00 per pay period Semi-Monthly (24 per/year)

Maximum Single Contribution

(less employer contribution)

Monthly (12 per/year)

Maximum Family Contribution

(less employer contribution)

Other $_______.____

Total Annual Employee Election: $_______.____

Total Annual Employer Election (if applicable): $_______.____

Note: Your Total Annual Employee Election along with contributions from any other sources, including your employer, may not exceed the Annual Maximum Contribution amount set by the IRS. Contribution limits for the current tax year can be found at: www.hsabank.com or by visiting the IRS site at: www.irs.gov. Additionally, investment accounts are not FDIC insured, may lose value and are not a deposit or other obligation of, or guarantee by the bank.

Date of first HSA contribution: _____________

(Date must be on or after the first day of your HDHP coverage or the first day of opening your HSA, whichever is later. Leaving the date blank will authorize your employer to determine the date on your behalf.)

OPTION TWO

I do not want to make contributions to my HSA through a pre-tax salary reduction. I understand that I may make contributions

to my HSA on an after-tax basis by sending contribution(s) directly to HSA Bank.

EMPLOYEE INFORMATION

Employee Name: SSN:

Employee Address:

City: State: Zip Code:

Employee Signature: Date:

Please return form to your employer.

FGI Group, Inc. Enrollment/Change Request Aetna Life Insurance Company BASIC LIFE INSURANCE

A. Transaction Information

1. Enrollment

New Employee

-Tobacco

Requested Employee Coverage Voluntary Life/AD&D

Requested Dependent Coverage Yes No

Tobacco Non-Tobacco

2. Termination (Cancel) Employee* *Employee must be enrolled for dependent(s) to have coverage.

3. Change (*Provide explanation in Section D, Special Remarks.) Add Dependent(s) Remove Dependent(s) Plan Change Increase/Decrease Benefit Amount* Other*

B. Employer Information

1. Employer Name – Full Name of Business or Organization

FGI Group, Inc.

2. Control No.

835875

Suffix

Account

3. Plan Number

4. SFO

Dallas

5. Employer Address (Street, City, State, ZIP Code) Location of Business or Organization

3901 S. LAMAR BLVD, SUITE 100 AUSTIN TX 78704

6. Claim Office Code

Hartford, CT #174

7. Customer Code (Optional)

N/A

C. Employee Information – Please Print all Information.

1. Employee Social Security No. 2. Employee Name (Last, First, Middle Initial) 3. Birthdate (MM/DD/YYYY)

4. Sex 5. Telephone Numbers

Home ( )

Work ( )

6. Employee Home Address (Number, Street, Apt. No., City, State, ZIP Code) 7. Employee Annual Earnings

$

8. Occupation/Title

9. Employee Coverage Amounts (Based on the requirements of your Plan, you may have to submit evidence of good health.)

Employee Annual Earnings $

Basic Life Amount $150,000

Supplemental Life Amount

$

Basic AD&D Amount

$50,000 10. Beneficiary Designation – If more than one beneficiary, use Special Remarks. Dependent coverage Beneficiary is always the Employee.

Full Beneficiary Name (First, Middle, Last)

Social Security Number of Beneficiary

Relationship to Employee

D. Covered Dependents

Complete only if Dependent Coverage is offered under your Plan. Check this box if you are refusing coverage for your dependents.

(A)dd/New (C)hange (R)emove

Dependent Name (First, Middle Initial, Last)

Social Security Number (If dependent has no SSN, write “None”)

Relat. Code

Birthdate

MM/DD/YYYY

Student Age 19 or Older

Yes No

Supplemental Dependent Life Amount

Supplemental Dependent AD&D Amount

$ $

$ $

$ $

$ $

Special Remarks

E. Certification – Signatures Required Employee E-mail Address:

My signature below signifies my agreement with the statements and authorization under Certification and Authorization on the back of this form.

1. Employee Signature

X _______________________________________________________

Date 2. Employer Signature

X _____________________________________________________

Date

Visit us at www.aetna.com Make a copy for your records. (3-02) B-POD

TOBACCO AFFIDAVIT

To be eligible for the Non-Tobacco Credit, you must select one of the following “Tobacco Free”

requirements:

1. My household and I are “tobacco free”; or

2. My household dependents and I must complete a Tobacco Cessation Program and submit a

Tobacco Cessation Certificate of Completion to the HR Department; or

TOBACCO IS DEFINED AS CIGARETTES, E-CIGARETTES (VAPING), PIPES,

CIGARS, OR CHEWING TOBACCO

Please make your selection below:

□ I and my household dependents are Tobacco Free and will be eligible for the Non-Tobacco Credit

3. I and my household dependents must submit documentation to the HR Department that I/weare under a physician's care for tobacco cessation or are unable to complete the tobaccocessation program due to a medical condition.

□

□ I and my household dependents must submit documentation to the HR Department that I/weare under a physician's care for tobacco cessation or are unable to complete the tobaccocessation program due to a medical condition.

□

I and my household dependents are in the process of completing a Tobacco Cessation Program. I understand that I need to complete an submit proof of completion to HR to receive the TobaccoDiscount.

I and/or my household dependents are NOT Tobacco Free and will not receive TheTobacco Discount.

Providing inaccurate or false information to receive the Non-Tobacco credit may lead to

disciplinary action up to and including separation.

Employee Signature: __________________________________ Date: __________________

Employee Name (Print): _________________________________

Tobacco Discount.

aliciaholmes

Text Box

If you and your eligible household dependents elect to participate in one of FGI's medical plans, you must complete and sign this Tobacco Affidavit Statement before your Enrollment can be processed by the HR Department.

Documents

Employee Benefits Guide 2017