Sterling Estates - 2023 Benefits Guide

BENEFITS GUIDE 2023 PLAN YEAR

Sterling Estates is proud to offer you a comprehensive benefits package for the 2023 plan year. Keep in mind that new enrollment and changes will become effective January 1 st , 2023. Sterling Estates will be changing Health Insurance Carriers from Healthgram / Cigna to Anthem Blue Cross Blue Shield of Georgia. Anthem Blue Cross Blue Shield has the largest network in Georgia. Each employee will be enrolled with Anthem for the same level of coverage that they currently have with Healthgram. If you want to make any changes to your coverage, please let HR know by January 31 st , 2023. The benefits and costs will not be changing and you can access your providers by visiting anthem.com Select - Find Care Select - Basic Search as Guest Select – Medical Plan or Network Select – Georgia Select – Medical (Employer Sponsored) Select – Blue Open Access POS

About Deductions

Premiums for medical, dental and vision plans are all deducted on a pre-tax basis because they are covered under Section 125 of the Internal Revenue Code. Once you elect benefits you will not be approved to make changes to your election or drop coverage until the next Open Enrollment period, unless you have a qualifying event.

Voluntary life and short-term disability insurance premiums are deducted on a post-tax basis and may be changed outside of the Open Enrollment period.

In preparation of your enrollment, please have the following information readily available for you and your dependent(s): • Date(s) of birth: Mandatory • Social Security Number(s): Mandatory • Full name, relationship, and Social Security Number(s) for Life Beneficiary(ies). (Beneficiaries must be at least 18 years old or you will be required to name a guardian for him/her.) Information Needed for Enrollment

Eligibility Information

Qualifying Life Events

As an employee of Sterling Estates you may be eligible for enrollment in a variety of insurance products. Full-time employees may participate in the benefits package upon the 90th day from date of hire. You may enroll your eligible dependents for coverage once you are eligible. Your eligible dependents include:

Qualifying events are events that cause an individual to lose his or her group health coverage. The type of qualifying event determines who the qualified beneficiaries are for that event and the period of time that a plan must offer continuation of coverage.

Qualifying events include:

• Marriage • Divorce or legal separation • Birth or adoption of a child • Death of spouse or dependent child • Change in employment status • Loss of other coverage • Entitlement to Medicare or Medicaid • Child turning 26 years old

• Your legal spouse • Your children up to age 26 (as identified in the plan document)

*Once your elections are effective, they will remain in effect through the plan year.

You must notify Human Resources within 30 days of the qualifying life event. Depending on the type of event, you may be asked to provide proof of the event. If you do not contact Human Resources within 30 days of the qualifying event, you will have to wait until the next annual enrollment period to make changes.

STERLING ESTATES 2023 BENEFITS GUIDE

Medical and Pharmacy Coverage

Sterling Estates offers the following Medical plans through Anthem BlueCross BlueShield and offers “In and Out-of-Network” benefits. Insurance Carrier:

Anthem BlueCross BlueShield Medical Insurance

Medical Plan:

$1,500 / 20% Coinsurance Plan

In-Network: Office Visit Copay - Primary Care Office Visit Copay - Specialist Care

$30 $60 $75

Urgent Care Copay Emergency Room Care Preventative Visit Copay

$350; then 20% Coinsurance

Diagnostic Testing & Blood Work (Office)

$60

Imaging

Deductible; then 20% Coinsurance

Coinsurance

80%

Employee Deductible Family Deductible

$1,500 $4,500 $4,500 $9,000

Employee Out-of-Pocket Max Family Out-of-Pocket Max

Inpatient Hospital

Deductible; then 20% Coinsurance Deductible; then 20% Coinsurance

Outpatient Hospital or Facility

Out-of-Network: Coinsurance Employee Deductible

50%

$4,500 $13,500 $13,500 $27,000

Family Deductible

Employee Out-of-Pocket Max Family Out-of-Pocket Max

Prescription Drugs: ( 30 Day Supply) Tier 1 - Typically Generic Tier 2 - Typically Preferred Brand Tier 3 - Typically Non-Preferred Brand

$15 $35 $60

Tier 4 - Typically Specialty

25% Coinsurance up to $350

Employee Semi-Monthly Deduction Employee Only

$68.75 $247.50 $178.75 $247.50

Employee + Spouse Employee + Child(ren)

Family

STERLING ESTATES 2023 BENEFITS GUIDE

Dental Coverage

Good dental care is critical to your overall well-being. With Sun Life Dental Insurance, you can get the attention your teeth need - at a cost you can afford. To get the most from your benefits and reduce out-of-pocket costs, choose an In-Network provider by utilizing our large national network. These providers have agreed to file your claims and uphold the highest quality standards. You can find In-Network providers at member.sunlifeconnect. com

Insurance Carrier:

Sun Life Dental Insurance

Plan Type:

Basic Plan

Enhanced Plan

Calendar Year Deductible Calendar Year Maximum

$50 Individual / $150 Family

$750 100%

$1,000

Preventive Services

100%

Basic Services Major Services

80% 10%

80% 50%

Employee Semi-Monthly Deduction Employee Only

$8.05

$17.65 $34.29 $45.44 $62.08

Employee + Spouse Employee + Child(ren)

$15.44 $24.08 $31.47

Family

STERLING ESTATES 2023 BENEFITS GUIDE

Vision Coverage

You can help protect your eyesight by visiting an eye doctor regularly. Vision insurance includes an annual comprehensive eye exam with an eye care doctor. Taking care of your eyes today can lead to a better quality of life later. Your vision plan is through Sun Life and offers “In and Out-of-Network” benefits. You can find vision providers at vsp.com/eye-doctor

Insurance Carrier:

Sun Life Vision Insurance

Plan Type:

In-Network $10 Copay $25 Copay $25 Copay $25 Copay

Exam Copay

Lenses - Single lined Lenses - Bifocal lined

Lenses - Trifocal

Frames

$ 130 Allowance

Elective Contact Lenses (in place of lenses & frame)

$130 Allowance

Frequency for Exam / Lenses / Frames Employee Semi-Monthly Deduction Employee Only

12 months / 12 months / 24 months

$4.68 $9.36

Employee + Spouse Employee + Child(ren)

$10.30 $14.97

Family

STERLING ESTATES 2023 BENEFITS GUIDE

Basic Life and AD&D Insurance Coverage

Sterling Estates provides all Full Time employees with Basic Life AD&D (Accidental Death & Dismemberment) at no cost when electing medical coverage.

Insurance Carrier: Basic Life AD&D Eligibility Requirement Life Insurance Benefit

Anthem Basic Life AD&D Insurance

Full Time Employees (electing medical coverage)

$15,000

Guarantee Issue

Yes

Accidental Death & Dismemberment Benefit (AD&D)

$15,000

Voluntary Term Life Insurance Coverage

As a supplemental benefit, Sterling Estates allows eligible employees to purchase additional life insurance coverage for yourself and your dependents. Employee must be enrolled to purchase coverage for your family. This coverage is paid for by you and is offered through Sun Life. Rates for the voluntary term life insurance are based on age, and volume, and benefits are subject to applicable age reductions.

Insurance Carrier: Voluntary Life AD&D Eligibility Requirement Employee Benefit Amounts Employee

Sun Life Voluntary Life AD&D Insurance

All Eligible Employees

Minimum of $20k up to $250k in increments of $10k

Spouse

Minimum of $5k up to $125k in increments of $5k

Child(ren)

Flat $10k

STERLING ESTATES 2023 BENEFITS GUIDE

Disability Coverage

The goal of Sterling Estates Disability Insurance Plan is to provide you with income replacement should you be unable to work due to a non-work-related illness or injury. The company provides all eligible employees with the option to purchase voluntary “Short-Term Disability” income benefits.

Short-Term Disability coverage is offered through Sun Life.

Insurance Carrier:

Sun Life Short-Term Disability Insurance

Plan Type:

Voluntary

Eligibility Requirement Benefit Percentage Waiting Period - Accident Waiting Period - Sickness Maximum Weekly Benefit

All Eligible Employees

60%

8 Days 8 Days $1,000

Executive Directors - 12 Weeks All Other Eligible Employees - 52 Weeks

Benefit Duration

Pre-Existing Condition

3 / 12

STERLING ESTATES 2023 BENEFITS GUIDE

Frequently Asked Questions

What is included in the Medical Out-of-Pocket maximum? What is included in the Pharmacy Out- of-Pocket maximum? The Medical Out-of-Pocket maximum is the maximum amount a member must pay during the policy year for covered essential health benefits. The OOP includes a member’s deductible and any coinsurance member responsibility. The Pharmacy OOP includes only pharmacy co-pays. The Medical OOP does NOT include monthly premiums, or billing from out-of-network providers. What is an in-network vs out-of-network provider? Anthem Blue Cross Blue Shield contracts with a wide range of doctors, as well as specialists, hospitals, labs, radiology facilities and pharmacies. These are the providers that are considered “in your network”. Specifically, each of these providers has agreed to accept Anthem Blue Cross Blue Shield’s contracted rate for your medical care and services rendered. The contracted rate includes both Anthem Blue Cross Blue Shield’s share of the cost, and the member’s. Your share may be in the form of a co-payment, deductible, or co-insurance. For example, Anthem Blue Cross Blue Shield’s contracted rate for a primary care visit might be $125. The Plan has a $25 co-payment for the visit; the member will pay $25 of the cost and your insurance plan will pay the remaining $100. An “out-of-network” provider is a medical doctor or facility that is not in contract with Anthem Blue Cross Blue Shield. This means that the provider may charge members higher rates for medical services and care, outside of the standard “in-network” rates. For example, a out-of-network provider may charge $200 for a primary care visit. Anthem Blue Cross Blue Shield may pay an adjustment of an out-of-network benefit of $80 dollars to the provider, so the member may be balance-billed for the remaining $120 cost of the visit. When can I change my beneficiary information for my Basic Life Insurance? Any time! It is important that all beneficiary information be kept up-to-date. You may need to change it after a marriage, divorce, or birth of a child. You can contact ADP anytime to update your beneficiary.

Term

Definition

Network Office Visit (PCP) The “per visit” co-pay cost for a primary care or standard network doctor.

The “per visit” co-pay cost for a specialized doctor (cardiologist, OB/GYN,

Specialist Office Visit

orthopedic, gastrointestinal, etc.)

The amount of money a member owes for any In-network health care services before co-insurance coverage begins. These are generally services that are NOT covered under a standard co-pay (inpatient surgery, outpatient surgery, MRI, etc.) Deductibles run on a calendar year basis. After any applicable deductible is met, the remaining cost of any in-network health care service is divided between the insurance carrier and the member. A 70% / 30% network co-insurance would divide the cost of a service with 70% paid by the insurance carrier and 30% paid by the member. These are generally services that are NOT covered under a standard co-pay (inpatient surgery, outpatient surgery, MRI, etc.) The maximum amount a member must pay during the policy year for covered essential health benefits. The OOP includes a member’s deductible, any co-insurance member responsibility, primary care and specialist office visit co-pays, ER or Urgent Care co-pays, and prescription co-pays / costs. The OOP does NOT include monthly premiums, billing from out-of-network providers, or spending for non-essential health benefits. The cost of a one month supply of a prescription drug. All covered drugs are designated into tiered levels based on drug usage, cost, and clinical effectiveness. Tier 1 usually includes generics, while Tier 2 generally includes preferred brand name medications. Tier 3 typically includes non-preferred brand name medications, Tier 4 usually includes higher cost drugs and Specialty Drugs are covered under a separate tier.

Network Deductible

Co-Insurance

Network Out-of-Pocket Maximum (OOP)

Prescription Drug Tiers and Monthly Co-Pays

STERLING ESTATES 2023 BENEFITS GUIDE

Anthem Enrollment Application

Employee Enrollment Application For 51+ Employee Groups Georgia

You, the employee, must complete this application. You are solely responsible for its accuracy and completeness. To avoid the possibility of delay, answer all questions and be sure to sign and date your application.

Please complete electronically or in blue or black ink only. Employer name S t e r l ing Estates

Group no.

Subsection

L 0 7 5 5 8

Section A: Employee information Last name

First name

M.I.

Social Security no.* (required)

Birthdate (MMDDYYYY)

Home address

City

County

State ZIP code

Marital status Single

Primary phone no.

Sex

Male

Female

Married

Domestic Partner

Employee email address

Hire date (MMDDYYYY)

No. of hours worked per week

Employment status Full time

Part time

Disabled

Retired

Primary Care Physician (PCP) name

PCP ID no.

Existing patient? Yes No

Section B: Application type Select one

New enrollment Open enrollment

COBRA — (not applicable to life and disability) Select qualifying event

Qualifying event date

Left employment

Reduction in hours

Death

Loss of dependent child status

Divorce or legal separation

Medicare (not applicable to life and disability) Covered employee’s Medicare entitlement (not applicable to life and disability)

Additional qualifying events for Life and Disability: Marriage/Domestic Partnership/Civil Union Birth, adoption of child, legal guardianship of child

Divorce/terminate Domestic Partnership/Civil Union

Death of spouse

Death of child

Spouse left employment and lost group life insurance — applicable only for Life Change in class from full–time to part–time/part–time to full–time Qualifying event date: (MMDDYY) * Anthem Blue Cross and Blue Shield (Anthem) is required by the Internal Revenue Service to collect this information.

Reset Form

Save and Print

10 STERLING ESTATES 2023 BENEFITS GUIDE

Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Life and Disability products are underwritten by Greater Georgia Life Insurance Company using the trade name Anthem Life. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

F0301.EE – 01012023

46697GAMENMUB Rev. 7/22 1 of 9

5837861 46697GAMENMUB LG 2023 Employee Prt FR 07 22

Anthem Enrollment Application

Social Security no.* (required)

Section C: Type of coverage 1. Medical coverage

OAP5/72LF

HMO

PPO

POS

EPO

Enter product name: __________________________________________________

Select network:

✔

Add HRA Wrap (Administered by Anthem) Member medical coverage — select one:

Employee only

Employee + Spouse/Domestic Partner

Employee + child(ren)

Family

2. Flexible Spending Account (FSA) coverage — Multiple plans can be selected. Healthcare FSA (excluded if you have an HSA plan) Limited-Purpose FSA (for dental and vision services) Dependent Care FSA

Commuter Parking Commuter Transit No FSA coverage at this time

3. Dental coverage

Enter product selected: ________________________________________________________ Member dental coverage — select one: Employee only Employee + Spouse/Domestic Partner 4. Vision coverage Enter product selected: ________________________________________________________ Member vision coverage — select one: Employee only Employee + Spouse/Domestic Partner

Employee + child(ren)

Family

Employee + child(ren)

Family

5. Life and disability coverage If you select life and/or disability coverage over the guarantee issue amount or are a late entrant an Evidence of Insurability form may be sent to you to complete. These coverages will become effective on the date established by the provisions of the group contract and certificates issued thereunder. Your employer will advise you of your plan options. These coverages may be subject to medical evidence underwriting and would only become effective upon approval.

Basic Life and AD&D Basic Dependent Life Supplemental/Voluntary Life and AD&D ($15,000)

Short Term Disability Long Term Disability

✔

$_____________ (employee amount) Supplemental/Voluntary Dependent Life Spouse $_____________ (spouse amount) Supplemental/Voluntary Dependent Life Child $_____________ (child amount)

Voluntary Short Term Disability Voluntary Long Term Disability Voluntary AD&D

Current annual income $_____________

Life and disability class no.

If choosing medical please select beneficiary for included $15,000 life insurance policy

Beneficiary designation — Attach a separate sheet if necessary. Beneficiary type Primary Contingent Name of beneficiary

Percentage

Social Security no.*

Relationship to applicant Date of birth

Street address

City

State ZIP code

Phone no.

Beneficiary type Primary Contingent

Name of beneficiary

Percentage

Social Security no.*

Relationship to applicant Date of birth

Street address

City

State ZIP code

Phone no.

Beneficiary type Primary Contingent

Name of beneficiary

Percentage

Social Security no.*

Relationship to applicant Date of birth

Street address

City

State ZIP code

Phone no.

Beneficiary type Primary Contingent

Name of beneficiary

Percentage

Social Security no.*

Relationship to applicant Date of birth

Street address

City

State ZIP code

Phone no.

Total percentages should add up to 100%. If the total percentages add up to less than 100%, the remaining percentage will be paid in equal shares to all named beneficiaries to total 100%. If the total percentages add up to more than 100%, each named beneficiary’s share will be reduced equally to total 100%. If no percentages are indicated, the proceeds will be divided equally. If no primary beneficiary survives, the proceeds will be paid to the contingent beneficiary(ies) listed above. Beneficiaries may be changed by the insured’s written notice to his or her employer.

STERLING ESTATES 2023 BENEFITS GUIDE

* Anthem is required by the Internal Revenue Service to collect this information.

2 of 9

Anthem Enrollment Application

Social Security no.* (required)

If you live in AZ, CA, ID, LA, NM, NV, TX, WA, WI and your spouse is not 50% or more beneficiary, your spouse needs to sign below. In CA, NV, and WA, Spouse also includes your registered Domestic Partner. Spousal consent for community property states only (Note: The insurance company is not responsible for the validity of a spouse’s consent for designation.) If you live in a community property state (AZ, CA, ID, LA, NM, NV, TX, WA, and WI), your state may require you to obtain the signature of your spouse if your spouse will not be named as a primary beneficiary for 50% or more of your benefit amount. Please have your spouse read and sign the following. I am aware that my spouse, the Employee/Retiree named above, has designated someone other than me to be the beneficiary of group life insurance under the above policy. Spouse authorization, if applicable I hereby consent to such designation and waive any rights I may have to the proceeds of such insurance under applicable community property laws. I understand that this consent and waiver supersedes any prior spousal consent or waiver under this plan.

Spouse/Domestic Partner name

Date (MMDDYYYY)

Spouse/Domestic Partner signature X

Spouse sign here to waive community property rights

6. Group Supplemental Health plans — Refer to the summary of benefits for coverage options offered. Select all that apply. Accident Member accident coverage — select one: Employee only Employee + Spouse/Domestic Partner Employee + child(ren) Family Complete the following if there is more than one Voluntary Accident plan design offered: Contract code for plan elected: ________________ Critical Illness Member critical illness coverage — select one: Employee only Employee + Spouse/Domestic Partner Employee + child(ren) Family Contract code for plan elected: ________________ Employee coverage amount: ________________ Will all eligible individuals applying for Critical Illness coverage, when such coverage is to become effective, be enrolled in comprehensive health benefits from an individual or group health insurance policy or an HMO or employer plan providing for essential health benefits? Yes No Complete the following if you or your spouse smoked or used tobacco products in the last 12 months: (tobacco product explanation) Employee smoker — select one: Yes No If yes, type of tobacco product: __________________________________ Spouse smoker — select one: Yes No If yes, type of tobacco product: __________________________________ Hospital Indemnity Member hospital indemnity coverage — select one: Employee only Employee + Spouse/Domestic Partner Employee + child(ren) Family Will all eligible individuals applying for Hospital Indemnity coverage, when such coverage is to become effective, be enrolled in comprehensive health benefits from an individual or group health insurance policy or an HMO or employer plan providing for essential health benefits? Yes No Complete the following if there is more than one Voluntary Hospital Indemnity plan design offered: Contract code for plan elected: ________________ Group Accident, Critical Illness, and Hospital Indemnity Insurance beneficiary designation — Attach a separate sheet if necessary. Beneficiary type Primary Contingent Name of beneficiary Percentage % Social Security no.* Relationship to applicant Date of birth Street address City State ZIP code Phone no.

Beneficiary type Primary Contingent

Name of beneficiary

Percentage

Social Security no.*

Relationship to applicant Date of birth

Street address

City

State ZIP code

Phone no.

Beneficiary type Primary Contingent

Name of beneficiary

Percentage

Social Security no.*

Relationship to applicant Date of birth

Street address

City

State ZIP code

Phone no.

Beneficiary type Primary Contingent

Name of beneficiary

Percentage

Social Security no.*

Relationship to applicant Date of birth

Street address

City

State ZIP code

Phone no.

12 STERLING ESTATES 2023 BENEFITS GUIDE

* Anthem is required by the Internal Revenue Service to collect this information.

3 of 9

Anthem Enrollment Application

Social Security no.* (required)

Section D: Coverage information — All fields required. Attach a separate sheet if necessary. Dependent information must be completed for all additional dependents (if any) to be covered under this coverage. An eligible dependent may be your spouse or domestic partner, your children, or your spouse’s or domestic partner’s children (to the end of the calendar month in which they turn age 26 unless they qualify as a disabled person). List all dependents beginning with the eldest. Spouse/Domestic Partner last name First name M.I. Social Security no.* (required)

Disabled Yes

Birthdate (MMDDYYYY)

Relationship to applicant Spouse

Sex

Male

Female

Domestic Partner

PCP name

PCP ID no.

Existing patient? Yes No

Dependent last name

First name

M.I.

Social Security no.* (required)

Sex

Disabled Yes

Birthdate (MMDDYYYY)

Relationship to applicant Biological child of applicant/spouse/domestic partner Other If other, what is relationship? _______________________________

Male

Female

PCP name

PCP ID no.

Existing patient? Yes No

Does this dependent have a different address? No If yes, please enter: ____________________________________________________________________________________________ Dependent last name First name M.I. Social Security no.* (required) Yes

Disabled Yes

Birthdate (MMDDYYYY)

Relationship to applicant Biological child of applicant/spouse/domestic partner Other If other, what is relationship? _______________________________

Sex

Male

Female

PCP name

PCP ID no.

Existing patient? Yes No

Disabled Yes

Birthdate (MMDDYYYY)

Relationship to applicant Biological child of applicant/spouse/domestic partner Other If other, what is relationship? _______________________________

Sex

Male

Female

PCP name

PCP ID no.

Existing patient? Yes No

Does this dependent have a different address? No If yes, please enter: ____________________________________________________________________________________________ Yes

13 STERLING ESTATES 2023 BENEFITS GUIDE

Anthem Enrollment Application

Social Security no.* (required)

Section E: Medical information 1. Has anyone listed on this application ever had medical advice, treatment or do you know, or have reasons to know, of health problems in regard to the following? Check Yes or No. a. Cancer, tumor, or neoplasm † Yes No b. Organ transplantation Yes No c. Disorders of the heart or circulatory system Yes No d. Hepatitis Yes No 2. Is anyone listed on this application pregnant? Yes No If yes, when is the expected due date? 3. Has any applicant been advised to undergo a surgical operation or procedure within the last six months? Yes No 4. Is any applicant currently taking prescription drugs? Yes No If yes, please list on a separate sheet and attach. 5. Has anyone applying for coverage been treated for a serious illness (For example: cancer, diabetes, heart disease, cardiovascular disease, AIDS or AIDS– related disease, pregnancy, mental/nervous disorder, substance abuse, or any illnesses related to a major body organ) been hospitalized, had surgery, OR incurred healthcare claims in excess of $7,500 in the last 12 months? Yes No This section MUST be completed if you answered “Yes” to any questions 1–5 above. Person treated Name of illness or disorder Type of treatment received Treatment dates From:

To:

From:

To:

From:

To:

From:

To:

From:

To:

14 STERLING ESTATES 2023 BENEFITS GUIDE

Anthem Enrollment Application

Social Security no.* (required)

Section F: Prior and other group coverage Are you or anyone applying for coverage currently eligible for Medicare?

Yes No If yes, give name: _____________________________________________________________________________________________ Medicare ID no. Part A effective date Part B effective date Medicare eligibility reason (check all that apply) Age Disability ESRD: Onset date: Medicare Part D ID no. Medicare Part D carrier Part D effective date

Are you or a family member previously or currently covered by a Medicare, health, and/or dental plan? Yes No If yes, please provide the following:

Coverage (check all that apply)

Name of person covered (Last name, first, M.I.)

Type (check one)

Policyholder name

Dates (if applicable)

Carrier name Carrier phone no.

Policy ID no.

Start:

Individual Group Medicare

Health Dental Orthodontia

End:

Start:

Individual Group Medicare

Health Dental Orthodontia

End:

Start:

Individual Group Medicare

Health Dental Orthodontia

End:

Start:

Individual Group Medicare

Health Dental Orthodontia

End:

Start:

Individual Group Medicare

Health Dental Orthodontia

End:

15 STERLING ESTATES 2023 BENEFITS GUIDE

Anthem Enrollment Application

Social Security no.* (required)

Section G: Terms, Conditions and Authorizations Please read this section carefully before signing the application. Eligible employee:

£ An active employee of the Employer who works the number of hours per week to be eligible for benefits as defined by the Employer and approved by Anthem Blue Cross and Blue Shield (Anthem) as of the effective date. Employment must be verifiable from state or federal wage tax reports. £ An employee, as defined above, who enters into employment after the coverage effective date and who completes the group imposed waiting period for eligibility (if any) and applies for coverage within 30 days. £ Any other class of persons identified by the Employer, provided that written approval of their eligibility is obtained from the Company(ies); or £ Employees eligible for continuous coverage under state or federal laws. Eligible employee does not include independent contractors (whose compensation is reported on IRS Form 1099) and directors and officers of the Group Policyholder if they do not work the required number of hours per week described above. Eligible dependent: £ Employee’s spouse, or children age 26 or younger, which includes a newborn, natural child, or a child placed with the employee for adoption, a stepchild, or any other child for whom the employee has legal guardianship or court ordered custody. The age limit for enrolling a child is age 26. Coverage for children will end on the last day of the month in which the children reach age 26. For life coverage, only employee’s Spouse/Domestic Partner or children age 26 or younger, legally adopted children, and stepchildren are eligible. £ The age limit of 26 does not apply for the initial enrollment or maintaining enrollment of an unmarried child who cannot support himself or herself because of mental retardation, mental illness, or physical incapacity that began prior to the child reaching the age limit. Coverage may be obtained for the child who is beyond the age limit at the initial enrollment if the employee provides proof of handicap and dependence at the time of enrollment. (The employee may be asked to provide a physician’s certification of the dependent’s condition.) £ Dependents eligible for continuous coverage under state or federal laws. As an eligible employee, I am requesting coverage for myself and all eligible dependents listed and authorize my employer to deduct any required contributions for this insurance from my earnings. All statements and answers I have given are true and complete. I understand it is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. I understand all benefits are subject to conditions stated in the Group Contract and coverage document. In signing this application I represent that: I have read or have had read to me the completed application, and I realize any false statement or misrepresentation in the application may result in loss of coverage. I certify each Social Security number listed on this application is correct. For Health Savings Account enrollees: Except as otherwise provided in any agreement between me and the financial custodian, the custodian of my Health Savings Account (HSA), I understand that my authorization is required before the financial custodian may provide Anthem with information regarding my HSA. I hereby authorize the financial custodian to provide Anthem with information about my HSA, including account number, account balance, and information regarding account activity. I also understand that I may provide Anthem with a written request to revoke my authorization at any time. Coverage option: If your employer/group offers HMO coverage which does not permit you to receive the full range of covered services from the provider of your choice, you will also have the option at the time of your initial enrollment and at each renewal to choose a health care plan allowing you to access care from the provider of your choice (“point-of-service” plan). This point-of-service plan may be offered by the HMO, Anthem or by another carrier. Abbreviated Notice of Insurance Information Practices Privacy Act. Georgia state law establishes standards for the collection, use, and disclosure of information gathered in connection with insurance transactions. The application attached to this notice contains specific personal questions about you and your dependents. We are required to advise you that personal information may be collected from persons other than you or other individuals proposed for coverage. An investigative consumer report may be made to help us obtain additional medical data from physicians or hospitals. All data confidential. O.C.G.A. section 33-39-5, subsection (c) (1 through 4) requires that: 1. Personal information may be collected from persons other than the individual or individuals proposed for coverage; 2. Such information as well as other personal or privileged information subsequently collected by the insurance institution or agent may in certain circumstances be disclosed to third parties without authorization; 3. A right of access and correction exists with respect to all personal information collected; 4. The notice prescribed in subsection (b) of the above referenced Code section will be furnished to the applicant or policyholder upon request. Access to your data. You have the right to see or obtain a photocopy of your personal information which we have. You also have the right to send us a written request if you want any of your personal information to be amended, corrected, or deleted. If you wish to have a more detailed explanation of our information practices, please contact Anthem Blue Cross and Blue Shield Customer Service Department, Post Office Box 7368, Columbus, Georgia 31908-7368. I’m signing here because I WANT TO GET INFORMATION ABOUT MY BENEFITS BY EMAIL OR ELECTRONICALLY. SUCH ELECTRONIC MAILINGS OR COMMUNICATIONS MAY EVEN INCLUDE CANCELLATION OR NONRENEWAL NOTICES. This may include my certificate or evidence of coverage, explanation of benefits statements, required notices and helpful or personalized information to get the most out of my plan, so I will make sure Anthem has my most up to date email. These electronic communications may include specific details about me and my plan. I know I can change my mind at any time or request a free copy of specific materials by mail. I’ll just contact Anthem to do either.

Date (MMDDYYYY)

Applicant signature X

Sign here

16 STERLING ESTATES 2023 BENEFITS GUIDE

* Anthem is required by the Internal Revenue Service to collect this information.

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Anthem Enrollment Application

Social Security no.* (required)

Section H: Waiver/Declining coverage Medical coverage Medical coverage declined for — check all that apply: Reason for declining coverage — check all that apply:

Myself

Spouse/domestic partner

Dependent(s)

Covered by spouse’s/domestic partner’s group coverage Enrolled in other insurance — Please provide company name and plan: __________________________________________________ Enrolled in individual coverage Spouse covered by employer’s group medical coverage Medicare/Medicaid/VA Other — please explain: ___________________________________ No coverage

Dental coverage Dental coverage declined for — check all that apply: Reason for declining coverage — check all that apply:

Myself

Spouse/domestic partner

Dependent(s)

Vision coverage Vision coverage declined for — check all that apply: Reason for declining coverage — check all that apply:

Myself

Spouse/domestic partner

Dependent(s)

Life coverage † Life/AD&D coverage declined for:

Myself Spouse, Domestic Partner and dependent coverage not available if life coverage is waived/declined. Dependent Life coverage declined for:

Spouse/domestic partner and dependents

Short Term Disability coverage declined for: Long Term Disability coverage declined for: Supplemental/Voluntary coverage declined for:

Myself Myself Myself

Supplemental/Voluntary Dependent Life coverage declined for: Voluntary Short Term Disability coverage declined for: Voluntary Long Term Disability coverage declined for: Reason for declining coverage — check all that apply:

Spouse/domestic partner and dependents

Myself Myself

Life/AD&D declined for religious reasons Do not elect to enroll in Dependent Life Do not elect to enroll in Supplemental/Voluntary coverage Do not elect to enroll in Supplemental/Voluntary Dependent Life coverage

Do not elect to enroll in Voluntary Short Term Disability Do not elect to enroll in Voluntary Long Term Disability

† I hereby certify that I have been given the opportunity to apply for the available group life benefits offered by my employer, the benefits have been explained to me, and I and/or my dependent(s) decline to participate. Neither I nor my dependent(s) were induced or pressured by my employer, agent, or life carrier, into declining this coverage, but elected of my (our) own accord to decline coverage. I understand that if I wish to apply for such coverage in the future, I may be required to provide evidence of insurability at my expense. Sign here only if you are declining coverage. Signature of applicant X Printed name Social Security no. Date (MMDDYYYY)

17 STERLING ESTATES 2023 BENEFITS GUIDE

* Anthem is required by the Internal Revenue Service to collect this information.

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Anthem Enrollment Application

Social Security no.* (required)

Special enrollment rights If you declined enrollment for yourself or your dependent(s) (including a spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependent(s) in this plan if you or your dependent(s) lose eligibility for the other health insurance or group health plan coverage (or if the employer stops contribution towards your coverage or your dependent’s other coverage). However, you must request enrollment within 31 days after coverage ends (or after the employer stops contribution toward the other coverage). In addition, if you have a dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your dependent(s) provided that you request enrollment within 31 days after the marriage, birth, adoption or placement for adoption. I also understand that my dependents and I may enroll under two additional circumstances: £ Either your or your dependent’s Medicaid or Children’s Health Insurance Program (CHIP) coverage is terminated as a result of loss of eligibility; or £ You or your dependent becomes eligible for a subsidy (state premium assistance program). In these cases, you may be able to enroll yourself and your dependents provided that you request enrollment within 60 days of the loss of Medicaid/CHIP or of the eligibility determination.

* Anthem is required by the Internal Revenue Service to collect this information.

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18 STERLING ESTATES 2023 BENEFITS GUIDE

Sun Life Enrollment Application

SunLife One Sun Life Executive Park, Wellesley Hills, MA 02481 Group Enrollment Form

Sun Life Assurance Company of Canada One Sun Life Executive Park Wellesley Hills, MA 02481

New employee

Change

COBRA

Employer use (check one):

1. General Information Employer Name Sterling Estates Sterling Estates

Account / Policy Number 925592

Location

2. Employee Information Employee's Full Legal Name (First, M.I., Last)

Date of Birth

Male Female

Street Address

City

State

Zip Code

Occupation

Eligibility Class (if applicable) Social Security Number Phone Number

Date employed:

Full-Time Part-Time

Date: Date:

Return from layoff Date:

Rehire

Current Active Employment Type # of hours Full-Time

Earnings $ Hourly

Part-Time

Weekly

Monthly

Annually

Other:

3. Dependent Information Please complete this entire section if you are selecting dependent coverage. No employee can be insured as a dependent when he/she is also insured as an employee for any benefit under the same policy. If more space is needed, please add additional pages. Relationship Full legal name (First, M.I., Last) Gender Social Security number Date of birth Student Y/N Spouse Children

19 STERLING ESTATES 2023 BENEFITS GUIDE

GVMPEM-5627 (Rev 4/20)

Sun Life Enrollment Application

4. Benefit Elections You need to complete all sections of the enrollment form including electing or refusing insurance coverage below and sign it. This must be done either during the enrollment period or within 31 days of your eligibility date. Benefits completely paid by your employer ("non-contributory benefits") cannot be refused. Not all of the benefit options listed below will be necessarily available to you. Your employer will tell you which benefits are available and what your Maximum Guaranteed Issue amount is.

Elect Refuse Coverage

Dental:

Basic

Enhanced

Employee

Employee + Spouse

Employee + Child(ren) Employee + Family Were you covered under another dental plan within the last 31 days? .................... Yes No

If "Yes," provide the termination date: Reason for termination of coverage?

Vision:

Employee

Employee + Spouse Employee + Family

Employee + Child(ren) Employee Voluntary Life $

Employee Matching Voluntary Accidental Death & Dismemberment (AD&D)

Spouse Voluntary Life $

Spouse Matching Voluntary Accidental Death & Dismemberment (AD&D)

Child(ren) Voluntary Life $

Child(ren) Matching Voluntary Accidental Death & Dismemberment (AD&D)

Voluntary Short-Term Disability (STD) $

Accident:

Employee

Employee + Spouse Employee + Family

Employee + Child(ren)

5. Beneficiary Designation Information Primary Beneficiary Designation

On the lines below, list the individual(s) who should receive proceeds in the event of your death. You may specify as many individuals as you like, but the total proceeds must equal 100%. This is your primary beneficiary. Attach additional pages if necessary. If you do not name a beneficiary or if no beneficiary is alive at the time of your death, proceeds will be payable in accordance with your Group insurance policy. Designation applies to all coverages for which a beneficiary designation is required. Primary Beneficiary(ies)

Percent share of proceeds*

1 Name (First, M.I., Last)

Relationship to employee Social Security number

Address

Phone number

Date of birth

2 Name (First, M.I., Last)

Relationship to employee Social Security number

Address

Phone number

Date of birth

*Must equal 100%

GVMPEM-5627 (Rev 4/20)

20 STERLING ESTATES 2023 BENEFITS GUIDE

Sun Life Enrollment Application

Secondary Beneficiary Designation On the lines below, list the individual(s) who should receive the proceeds ONLY IF ALL of the individuals listed above are not living at the time of your death. This is your secondary (or contingent) beneficiary. The Secondary beneficiary is not paid if a primary beneficiary is alive at the time of your death. Attach additional pages if necessary. Secondary Beneficiary(ies)

Percent share of proceeds*

1 Name (First, M.I., Last)

Relationship to employee Social Security number

Address

Phone number

Date of birth

2 Name (First, M.I., Last)

Relationship to employee Social Security number

Address

Phone number

Date of birth

*Must equal 100%

6. Signature and authorization information

I understand that:

I am requesting coverage under a Group Insurance policy offered by my employer. This coverage will end when my employment terminates, subject to any portability or continuation provisions available under the Group Insurance policy.

My employer will deduct all or part of the premium for contributory coverage from my pay.

If applying for coverage more than 31 days past my eligibility date, Evidence of Insurability may be required. For Life and Short-Term Disability insurance, Evidence of Insurability may be required for amounts over my Guarantee Issue for this enrollment.

Increases to current Life and Short-Term Disability benefits may require Evidence of Insurability.

If I decline coverage for myself or, if applicable, for my family now and want it at a later date, I/we will have to submit an Evidence of Insurability application, if required for the elected coverage(s), to be approved by Sun Life Assurance Company of Canada (Wellesley, MA). For Dental coverage, I understand that I will not be entitled to benefits until the expiration of any Late Entrant benefit waiting period specified in the certificate of insurance.

For Dental Insurance plans, I have the right to select any dental care provider of my choice.

The dental plan includes a pre-determination provision that will advise me in advance of the benefits I may be eligible for if the procedure is performed. Coverages include benefit waiting periods, limitations, exclusions and a pre-existing conditions provision that may affect my entitlement to benefits. If I am not actively at work due to injury, illness, layoff or leave of absence on the date that any initial or increased coverage is scheduled to start under the plan, such coverage will not start until the date I return to work. When required by the coverage, if my spouse or any of my dependent children are confined due to an injury or illness, as required by the coverage, on the date that any initial or increased coverage is scheduled to start under the plan, such coverage will not start until the date they are no longer confined and are able to perform their normal activities. By signing below, I am representing that the information I have provided is true and correct to the best of my knowledge and belief. X Employee Signature Today's Date To the Employee: Make a copy of this form for your records before submitting it to your employer. To the Employer: This original enrollment form should remain at the employer's site. Family status, coverage, or beneficiary changes should be recorded on another copy of the Enrollment Form.

GVMPEM-5627 (Rev 4/20)

21 STERLING ESTATES 2023 BENEFITS GUIDE

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