Pavement Restoration 2019 (Arizona)

Arizona

CONTENTS & CONTACT INFORMATION

Refer to this list when you need to contact one of your benefit vendors. For general information contact Human Resources.

BROKER Provider Name Broker Contact

M.E. Wilson Company

Amanda Sands

Provider Phone Number Provider Email Address

813-229-8021 Ext. 139 asands@mewilson.com

MEDICAL

page 3

Provider Name

United Healthcare

Provider Phone Number Provider Web Address

866-633-2446

www.myuhc.com.com

DENTAL

page 5

Provider Name

Mutual of Omaha

Provider Phone Number Provider Web Address

877-999-2330

www.mutualofomaha.com

VISION

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Provider Name

Mutual of Omaha

Provider Phone Number Provider Web Address

877-999-2330

www.mutualofomaha.com

BASIC AND VOLUNTARY LIFE

_____________ Mutual of Omaha

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Provider Name

Provider Phone Number Provider Web Address

877-999-2330

www.mutualofomaha.com

SUPPLEMENTAL BENEFITS

___________________

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Provider Name

Aflac – Jay Diaz 800-992-3522 www.aflac.com

Provider Phone Number Provider Web Address

DISCLOSURE NOTICES

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BENEFIT INFORMATION

Benefit

Who pays the cost?

Pavement Restoration pays the majority of the employee portion of the medical plan. You may enroll your eligible dependents for an additional cost.

Medical Insurance

YOUR BENEFITS PLAN

You may elect dental coverage for yourself and your eligible dependents on a voluntary basis and you will be responsible for the cost.

Pavement Restoration offers a variety of benefits allowing you the opportunity to customize a benefits package that meets your personal needs. In the following pages, you’ll learn more about the benefits offered. You’ll also see how choosing the right combination of benefits can help protect you and your family’s health and finances – and your family’s future .

Dental Insurance

You may elect vision coverage for yourself and your eligible dependents on a voluntary basis and you will be responsible for the cost.

Vision Insurance

You may elect voluntary life coverage for yourself and your eligible dependents on a voluntary basis and you will be responsible for the cost.

Voluntary Life Insurance

Pavement Restoration pays the entire cost for employee coverage.

Basic Life

Voluntary Supplemental Benefits

The employee pays the entire cost.

ELIGIBILITY

All Regular full-time employees are eligible to join the Pavement Restoration Benefits Plan on the 1st of the month following 60- Days. “Regular Full-Time Employees” must be regularly scheduled and working at least 30 hours per week.

You may also enroll your dependents in the Benefits Plan when you enroll.

Eligible dependents include:

Your legal spouse

•

• Your married or unmarried natural children, step-children living with you, legally adopted children and any other children for whom you have legal guardianship, who are:

WHEN CAN YOU ENROLL?

► Under 26 years of age;

► A dependent who is older than 26 years of age, but less than 30 years of age may be eligible for medical benefits. To be eligible, a Dependent must: • Be unmarried and not have dependents of his or her own; AND

You can sign up for Benefits at any of the following times:

• After completing your initial eligibility period; • During the annual open enrollment period; • Within 30 days of a qualified family-status change.

Be a resident of Florida or a student; AND

•

• Not have coverage of their own, or covered under any other plan, including Medicare

If you do not enroll at one of the above times, you may enroll during the next annual open enrollment period.

BENEFIT INFORMATION

CHOOSING YOUR BENEFITS

You must actively choose any benefit that you pay for, or share in the cost with Pavement Restoration . Your part of the cost is automatically taken out of your paycheck. There are two ways that the money can be taken out:

WHY DO I PAY FOR BENEFITS WITH BEFORE-TAX MONEY?

There is a definite advantage to paying for some benefits with before-tax money: Taking the money out before your taxes are calculated lowers the amount of your pay that is taxable. Therefore, you pay less in taxes.

• BEFORE YOUR TAXES ARE CALCULATED – medical, dental, and vision

• AFTER YOUR TAXES ARE CALCULATED – voluntary life and accidental death & dismemberment, supplemental benefits

MAKING CHANGES

Generally, you can only change your benefit choices during the annual benefits enrollment period. However, you may be able to change your benefit choices during the plan year if you have a change in status including:

If you fail to notify Human Resources within 30 days of a family status change, you will be required to wait until the next annual enrollment period to make benefit changes unless you have another family status change.

Your marriage

•

Your divorce or legal separation

•

Birth or adoption of an eligible child

•

Death of your spouse or covered child

•

• Change in your spouse’s work status that affects his or her benefits

• Change in your work status that affects your benefits

WHEN COVERAGE ENDS

• Change in residence or work site that affects your eligibility for coverage

Coverage will stop on the last day of the month in which employment with the company ends.

• Change in your child’s eligibility for benefits

• Receiving Qualified Medical Child Support Order (QMCSO)

KEY BENEFIT TERMS

Copayment – A flat fee that you pay for medical services, regardless of the actual amount charged by your doctor or another provider. This generally applies to physicians’ office visits and prescription drugs. Deductible – The amount you pay toward medical and dental expenses each year before the plan begins paying benefits. Out of Pocket Maximum – The maximum amount you will pay in deductibles, coinsurance and copayments during the year.

MEDICAL INSURANCE

Pavement Restoration offers two medical plans through United Healthcare. To find participating providers go to www.myuhc.com and click on “Find a Doctor”, then follow the prompts to complete the search. The chart below provides a brief overview of the medical plans. This chart is intended only to highlight the benefits available and should not be relied upon to fully determine your coverage.

If the below illustration of benefits conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your exact description of services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage .

ChoicePlus AQOQ

IN-NETWORK:

Plan Year April 1, 2019 – March 30, 2020

Plan Year or Calendar Year Basis

Deductible (Individual / Family)

$1,500 / $4,500

Coinsurance

80% / 20%

Maximum Out-of-Pocket (Individual/Family)

$4,500 / $9,000

Maximum Out-of-Pocket Includes

Deductible, Coinsurance & Copayments

Lifetime Maximum PREVENTIVE CARE:

Unlimited

Wellness Immunizations Mammography/Colonoscopy COPAYMENTS: Referral Required

Covered 100%

Office Visits Consultations for Illness/Injury

$25 Copayment

Specialist Visits

$50 Copayment

Inpatient Hospital

Deductible & Coinsurance Deductible & Coinsurance

Outpatient Surgery Emergency Room Urgent Care

$250 Copayment $75 Copay

OUTPATIENT DIAGNOSTIC SERVICES: Independent/Freestanding Lab Complex Diagnostic (MRI, CT, PET, Etc.) – Freestanding Facility

Covered 100%

Deductible & Coinsurance

PRESCRIPTIONS:

Tier 1: $10 Copay Tier 2: $60 Copay Tier 3: $100 Copay

Retail (30 day supply)

OUT-OF-NETWORK Deductible

$3,000 / $9,000

(Individual / Family)

Maximum Out-of-Pocket (Individual/Family)

$6,250 / $12,500

Coinsurance

60% / 40%

MEDICAL CONTRIBUTION SCHEDULE

Employee Pays (Weekly)

ChoicePlus AQOQ

Employee Only

$ 55.93 $217.82 $157.41 $300.59

Employee + Spouse Employee + Child(ren)

Family

DENTAL INSURANCE

Pavement Restoration offers two dental plans through Mutual of Omaha. The Dental PPO Plan allows you to use in-network or out-of- network benefits. If out-of-network dentists are used, you will be responsible for pay the difference between Mutual of Omaha’s allowed amount and what the dentist may charge, also known as “balance billing”. The chart below provides a brief overview of the plan.

Low Dental PPO Plan (Option 1)

High Dental PPO Plan (Option 2)

Out-of Network 1

In-Network

Out-of Network 1

Calendar Year Deductible Individual

$50

$100 $300

$50

Family

$150

Annual Maximum

$1,000

$1,500 $1,000

Diagnostic & Preventive Exams Cleanings Fluoride X-Rays Sealants Regular Restorative Services Fillings Extractions - Single Tooth Periodontics (Gum Disease) Endodontics (Root Canal) Major Services Crowns

Covered in full

Covered 80% after deductible

Covered 50% after deductible

Covered 80% after deductible

Covered 50% after deductible

Covered 25% after deductible

Covered 50% after deductible

Covered 25% after deductible

Bridges Dentures Orthodontia Child Only

Not Available

1 Subject to balance billing. Please refer to your plan document for specific details.

Low PPO Dental Plan (Option 1)

High PPO Dental Plan (Option 2)

Employee Contributions (Weekly)

Employee Only

$ 3.92 $ 9.00 $ 9.92 $14.54

$ 6.23 $14.31 $15.69 $23.08

Employee + Spouse Employee + Child(ren)

Family

VISION INSURANCE

Pavement Restoration offers vision coverage through Mutual of Omaha. The Vision Plan allows you to use in-network (EyeMed Providers) or out-of-network benefits. If out-of-network vision providers are used, you will be responsible for pay the difference between Mutual of Omaha’s allowed amount and what the provider may charge, also known as “balance billing”.

Vision

Routine Eye Exams

$10 Copay

Lenses* Single

$25 Copay $25 Copay $25 Copay $25 Copay

Bifocal Trifocal Lenticular

Frames

$100 allowance, less applicable copay

Contact Lenses

$100 allowance, less applicable copay

Frequency Exam

Once every 12 months

Lenses or contact lenses

Once every 12 months

Frame

Once every 24 months

• Lenses, Frames & Contacts are limited to either one pair of contacts or frames/lenses per calendar year.

Employee Contributions (Weekly)

Vision

Employee Only

$1.51 $2.54 $2.59 $4.10

Employee + Spouse Employee + Child(ren)

Family

BASIC LIFE AND AD&D & VOLUNTARY LIFE INSURANCE

BASIC LIFE INSURANCE Pavement Restoration provides life insurance to all active full time employees at no cost to the employee. The chart below provides an overview of the plan.

Basic Life Insurance

Employee Benefit Amount

$15,000

35% at age 65 60% at age 70 75% at age 75

Age Reduction Schedule

Included Equal to basic life

Accidental Death & Dismemberment (AD&D)

VOLUNTARY LIFE INSURANCE

Pavement Restoration provides all active employees working 30 or more hours per week the option to purchase life insurance coverage through a group plan, at the employee’s cost. The chart below provides an overview of the plan. Please note that anyone enrolling outside of their initial open enrollment period is considered a late entrant and will be subject to medical underwriting.

Voluntary Life Insurance

Employee Life

Increments of $25,000 up to $200,000

Employee Guarantee Issue

$100,000 for timely entrants

Spouse Life

Increments of $5,000 up to 100% of employee's amount or $100,000

Spouse Guarantee Issue

$25,000 for timely entrants

10% of employee’s amount not to exceed $10,000 (Coverage limits based on child age.)

Dependent Life

VOLUNTARY LIFE - Weekly

$50,000 Policy (Employee) Election Amount

$75,000 Policy (Employee) Election Amount

$100,000 Policy (Employee) Election Amount

$25,000 Policy (Employee) Election Amount

Age

Employee

Spouse

Child

Employee

Spouse

Child

Employee

Spouse

Child

Employee

Spouse

Child

<30

$0.64

$0.32

$0.09

$1.27

$.64

$.19

$1.90

$.95

$.28

$2.54

$1.27

$.37

30-34

$0.69

$0.35

$0.09

$1.39

$.69

$.19

$2.08

$1.04

$.28

$2.77

$1.39

$.37

35-39

$0.75

$0.38

$0.09

$1.50

$.75

$.19

$2.25

$1.13

$.28

$3.00

$1.50

$.37

40-44

$1.21

$0.61

$0.09

$2.42

$1.21

$.19

$3.64

$1.82

$.28

$4.85

$2.42

$.37

45-49

$2.02

$1.01

$0.09

$4.04

$2.02

$.19

$6.06

$3.03

$.28

$8.08

$4.04

$.37

50-54

$3.12

$1.56

$0.09

$6.23

$3.12

$.19

$9.35

$4.67

$.28

$12.46

$6.23

$.37

55-59

$4.79

$2.39

$0.09

$9.58

$4.79

$.19

$14.37

$7.18

$.28

$19.15

$9.58

$.37

60-64

$6.92

$3.46

$0.09

$13.85

$6.92

$.19

$20.77

$10.39

$.28

$27.69

$13.85

$.37

65-69

$10.96

$5.48

$0.09

$21.92

$10.96

$.19

$32.89

$16.44

$.28

$43.85

$21.92

$.37

SUPPLEMENTAL BENEFITS

Plan Summaries

- First Occurrence benefits of $5,000 or $7,000 for children - Hospital Confinement Benefits for: - Heart Attack - Coronary Artery Bypass Surgery - Stroke

Voluntary Health Event Plan

- End Stage Renal Failure - Human Organ Transplant - Major Third Degree Burns - Coma, and so much more!

- True 24 hour Protection for both on and off-the-job injuries. - Provides cash for medical expenses (even if covered by medical insurance), income for lost wages, hospital stays, and fracture benefit, and accidental death and dismemberment. - Pays directly to you over-and-above any other coverage in force. Benefit is portable, (you can take it with you) with no change in price even if you change jobs. dislocations

Voluntary Accident Insurance Plan

- Provides cash for hospital confinements due to injury, illnesses, or pregnancies. - Pays directly to you over-and-above any other coverage. - Benefit is portable (you can take it with you) with no change in price even if you change jobs.

Voluntary Hospital Insurance Plan

- Pays a cash benefit directly to you, over-and-above any other coverage presently in force to help offset the high costs associated with the treatment of cancer. - Provides money for hospital stays, surgeries, experimental treatments, travel and lodging costs. - Benefit is portable (you can take it with you) with no change in price even if you change jobs.

Voluntary Cancer Insurance Plan

REQUIRED ANNUAL EMPLOYEE DISCLOSURE NOTICES

Required Annual Employee Disclosure Notices

THE NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT OF 1996

WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998 The Women’s Health and Cancer Rights Act of 1998 requires Service Works Commercial Roofing to notify you, as a participant or beneficiary of the Service Works Commercial Roofing Health and Welfare Plan, of your rights related to benefits provided through the plan in connection with a mastectomy. You, as a participant or beneficiary, have rights to coverage to be provided in a manner determined in consultation with your attending physician for: 1. All stages of reconstruction of the breast on which the mastectomy was performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; and

The Newborns’ and Mothers’ Health Protection Act of 1996 prohibits group and individual health insurance policies from restricting benefits for any hospital length of stay for the mother or newborn child in connection with childbirth; (1) following a normal vaginal delivery, to less than 48 hours, and (2) following a cesarean section, to less then 96 hours. Health insurance policies may not require that a provider obtain authorization from the health insurance plan or the issuer for prescribing any such length of stay. Regardless of these standards an attending health care provider may, in consultation with the mother, discharge the mother or newborn child prior to the expiration of such minimum length of stay. 1. Deny to the mother or newborn child eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan, solely to avoid providing such length of stay coverage; 2. Provide monetary payments or rebates to mothers to encourage such mothers to accept less than the minimum coverage; 3. Provide monetary incentives to an attending medical provider to induce such provider to provide care inconsistent with such length of stay coverage; 5. Restrict benefits for any portion of a period within a hospital length of stay described in this notice. These benefits are subject to the plan’s regular deductible and co-pay. For further details, refer to your Summary Plan Description. Keep this notice for your records and call Human Resources for more information. Effective January 1, 2009 group health plans are required by Federal government to comply with Section 111 of the Medicare, Medicaid, and SCHIP Extensions of 2007’s new Medicare Secondary Payer regulations. The mandate is designed to assist in establishing financial liability of claims assignments. In other words, it will help establish who pays first. The mandate requires group health plans to collect additional information, more specifically Social Security numbers for all enrollees, including dependents 6 months of age or older. Please be prepared to provide this information on your benefits enrollment form when enrolling into benefits. Further, a health insurer or health maintenance organization may not: 4. Require a mother to give birth in a hospital; or SECTION 111

2. Prostheses and treatment of physical compilations of the mastectomy, including lymphedema.

These benefits are subject to the plan’s regular deductible and co-pay. For further details, refer to your Summary Plan Description. Keep this notice for your records and call Human Resources for more information.

MICHELLE’S LAW

The law allows for continued coverage for dependent children who are covered under your group health plan as a student if they lose their student status because of a medically necessary leave of absence from school. This law applies to medically necessary leaves of absence that begin on or after January 1, 2010 If your child is no longer a student, as defined in your Certificate of Coverage, because he or she is on a medically necessary leave of absence, your child may continue to be covered under the plan for up to one year from the beginning of the leave of absence. This continued coverage applies if your child was (1) covered under the plan and (2) enrolled as at student at a post-secondary educational institution (includes colleges, universities, some trade schools and certain other post-secondary institutions). Your employer will require a written certification from the child’s physician that states that the child is suffering from a serious illness or injury and that the leave of absence is medically necessary.

Required Annual Employee Disclosure Notices continued REQUIRED ANNUAL EMPLOYEE DISCLOSURE NOTICES continued

HIPAA PRIVACY POLICY FOR FULLY-INSURED PLANS WITH NO ACCESS TO PHI

PATIENT PROTECTION: If the Group Health Plan generally requires the designation of a primary care provider who participates in the network and who is available to accept you or your family members. For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from the carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology. The health care professionals, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, or for information on how to select a primary care provider, and for a list of the participating primary care providers, contact the Plan Administrator or refer to the carrier website. It is your responsibility to ensure that the information provided on your application is accurate and complete. Any omissions or incorrect statements made by you on your application may invalidate your coverage. The carrier has the right to rescind coverage on the basis of fraud or misrepresentation . CHILDREN’S HEALTH INSURANCE PROGRAM REAUTHORIZATION ACT (CHIPRA) OF 2009 Effective April 1, 2009, a special enrollment period provision is added to comply with the requirements of the Children’s Health Insurance Program Reauthorization Act (CHIPRA) of 2009. If you or a dependent is covered under a Medicaid or CHIP plan and coverage is terminated as a result of the loss of eligibility for Medicaid or CHIP coverage, you may be able to enroll yourself and/or your dependent(s). However, you must enroll within 60 days after the date eligibility is lost. If you or a dependent becomes eligible for premium assistance under an applicable State Medicaid or CHIP plan to purchase coverage under the group health plan, you may be able to enroll yourself and/or your dependent(s). However, you must enroll within 60 days after you or your dependent is determined to be eligible for State premium assistance. Please note that premium assistance is not available in all states.

I. No access to protected health information (PHI) except for summary health information for limited purpose and enrollment / dis-enrollment information. Neither the group health plan nor the plan sponsor (or any member of the plan sponsor’s workforce) shall create or receive protected health information (PHI) as defined in 45 C.F.R. § 160.103 except for (1) summary health information for purpose of (a) obtaining premium bids or (b) modifying, amending, or terminating the group health plan, and (2) enrollment and dis- enrollment information. The insurer for the group health plan will provide the group health plan’s notice of privacy practices and will satisfy the other requirements under HIPAA related to the group health plan’s PHI. The notice of privacy practices will notify participants of the potential disclosure of summary health information and enrollment / dis-enrollment information to the group health plan and the plan sponsor. The group health plan is a fully-insured group health plan sponsored by the “Plan Sponsor”. The group health plan and the plan sponsor intend to comply with the requirements of 45 C.F.R. § 164.530 (k) so that the group health plan is not subject to most of HIPAA’s privacy requirements. II. Insurer for group health plan will provide privacy notice The group health plan shall not intimidate, threaten, coerce, discriminate against, or take other retaliatory action against individuals for exercising their rights , filing a complaint, participating in an investigation, or opposing any improper practice under HIPAAA. The group health plan shall not require an individual to waive his or her privacy rights under HIPAA as a condition of treatment, payment, enrollment or eligibility. If such an action should occur by one of the plan sponsor’s employees, the action shall not be attributed to the group health plan. IV. No Waiver III. No intimidating or retaliatory acts

Required Annual Employee Disclosure Notices - Continued REQUIRED ANNUAL EMPLOYEE DISCLOSURE NOTICES continued

MEDICARE PART D

This notice applies to employees and covered dependents who are eligible for Medicare Part D. Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with United Healthcare and about your options under Medicare’s prescription 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. 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare through Medicare prescription drug plans and Medicare Advantage Plan (like an HMO or PPO) that offer prescription drug coverage. All Medicare prescription 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. United Healthcare has determined that the prescription drug coverage offered by the Welfare Plan for Employees of Service Works Commercial Roofing under the United Healthcare option are, on average for all plan participants, expected to pay out as much as the 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. You should also know that if you drop or lose your coverage with United Healthcare and don’t enroll in Medicare prescription drug coverage after your current coverage ends, you may pay more (a penalty) to enroll in Medicare prescription drug coverage later. _______________________________________________________ You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 th to December 7 th . 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 United Healthcare coverage will not be affected. You can keep this coverage if you elect part D and this plan will coordinate with Part D coverage. If you decide to join a Medicare drug plan and drop your current United Healthcare coverage, be aware that you and your dependents will be able to get this coverage back. When can you join a Medicare Drug Plan?

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 United Healthcare 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 at least 1% of the Medicare base beneficiary 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 beneficiary 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 our office for further information (see contact information below). 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 United Healthcare 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: • Call your State Health Insurance Assistance Program (see 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). • Visit www.medicare.gov

Remember: Keep this notice. If you enroll in one of the new plans approved by Medicare which offer prescription drug coverage, you may be required to provide a copy of this notice when you join to show that you are not required to pay a higher premium amount.

Date:

4/1/19

Name of Entity/Sender:

Pavement Restoration Contact--

Position/Office:

Krystal Willis 5423 N. 59 th Street Tampa, FL 33610

Phone Number:

813-626-4287

COBRA NOTICE

COBRA

Consolidated Omnibus Budget Reconciliation Act (COBRA) provides terminated employees and their covered dependents the opportunity for a temporary extension of health coverage at group rates (plus 2% service fee) in certain instances where coverage under the plan would otherwise end. You and your covered dependents have the right to choose continuation coverage if group health coverage is lost under the health plan for any of the following reasons: (1) death of the employee; (2) a termination of the employee’s employment (for reasons other than gross misconduct) or a reduction in the employee’s hours of employment; (3) divorce or legal separation from employee; (4) employee becomes entitled to Medicare; or (5) the dependent child ceases to be a “dependent child” by definition under the plan. Under the law, you or the covered dependent has the responsibility to inform us, as the employer, within 30 days of a qualifying event such as divorce, legal separation, or a child losing dependent status under the plan. We, as the employer, have the responsibility to notify you and your covered dependents of the right to continue coverage should coverage end due to death, employment termination, reduction in hours of employment, or Medicare entitlement.

New Health Insurance Marketplace Coverage Options and Your Health Coverage

Form Approved OMB No. 1210-0149 Expires: 5-31-2020

PART A: General Information When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance : the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment-based health coverage offered by your employer. What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.

Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit. 1 Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis.

How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or contact:

Krystal Willis

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.

PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application.

3. Employer Name

4. Employer Identification Number (EIN)

Pavement Restoration, Inc.

59-3713047

5. Employer Address

6. Employer Phone Number

5423 N. 59 th Street

813-626-4287

7. City

8. State

9. Zip Code

Tampa

33610

10. Who can we contact about employee health coverage at this job?

Krystal Willis

11. Phone Number (if different from above)

12. E-mail address

Krystal@palmettoprime.com

1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs

Here is some basic information about health coverage offered by this employer: • As your employer, we offer a health plan to:

X All Employees. Eligible employees are:

All Full Time Employees working at least 30 hours.

Some employees. Eligible employees are:

With respect to dependents:

•

X We do offer coverage. Eligible Dependents are:

Your Legal Spouse. Your married or unmarried natural children, step-children living with you, legally adopted children and any other children for whom you have legal guardianship, who are under 26 years of age. A dependent who is older than 26 years of age, but less than 30 years of age may be eligible for medical benefits if the dependent is: • unmarried and not have dependents of his or her own; AND • Be a resident of Florida or a student; AND • Not have coverage of their own, or covered under any other plan; AND • Not entitled to benefits under Medicare

We do not offer coverage.

X If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages.

**Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount.

If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your monthly premiums.

The information below corresponds to the Marketplace Employer Coverage Tool. Completing this section is optional for employers, but will help ensure employees understand their coverage choices.

13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months?

Yes (Continue)

13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? (mm/dd/yyyy) (Continue)

No (STOP and return this form to employee)

14. Does the employer offer a health plan that meets the minimum value standard*?

Yes (Go to question 15)

No (STOP and return form to employee)

15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and didn't receive any other discounts based on wellness programs.

a. How much would the employee have to pay in premiums for this plan?

$ 36.51

b. How often?

Weekly

Every 2 weeks

Twice a month

Monthly

Quarterly

Yearly

If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don’t know, STOP and return form to employee.

16. What change will the employer make for the new plan year?

Employer won’t offer health coverage

Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15)

a. How much would the employee have to pay in premiums for this plan?

_________________________

b. How often?

Weekly

Every 2 weeks

Twice a month

Monthly

Quarterly

Yearly

1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36(c)(2)(C)(ii) of the Internal Revenue Code of 1986)

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NOTES

________________________________________________________________________________________________________________________

The information in this Benefits Summary is presented for illustrative purposes and is based on information provided by your employer. The text contained in this Summary was taken from various summary plan descriptions and benefit information. While every effort was taken to accurately report your benefits, discrepancies or errors are always possible. In case of discrepancy between the Benefits Summary and the actual plan documents, the actual plan documents will prevail. All information is confidential, pursuant to the Health Insurance Portability and Accountability Act of 1996. If you have any questions about this summary, contact Human Resources.

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