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Blue Shield of California Life & Health Insurance Company

Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance Benefit Summary Effective January 1, 2021 Basic Group Term Life Insurance is an important part of a complete benefits package. It provides protection to you and your beneficiaries. Below is information about how our coverage can meet your needs.

Age Reduction Schedule

Your Benefit will reduce to 65% of the original amount when you turn 65 and to 50% of the original amount when you reach 70.

Waiver of Premium Provision

If you become totally disabled, as defined in the certificate, you can continue your Life Insurance coverage without any premium payments. The amount of coverage will be the coverage in effect at the time you become disabled. This waiver is subject to age limitations, reductions and terminations.

Accelerated Death Benefit

If you become terminally ill, you may elect an advanced payment of up to 50% of the death benefit to a maximum of $250,000.

Conversion

You may convert your Basic Group Term Life Insurance coverage to a Whole Life policy if your employment ends. You must apply for conversion within 31 days after your termination of employment. Rates are based on your age at the time of conversion.

Employee Basic Group Term AD&D Benefit Type of Loss

Portion of Principal Sum

Loss of Life

100%

Loss of a hand, foot, complete loss of sight in one eye or hearing in one ear

50%

Loss of an arm or leg

75%

Complete loss of sight in both eyes or hearing in both ears

100%

Loss of the thumb and index finger or all 4 fingers on the same hand

25%

Loss of all toes on one foot

25%

Loss of speech

50%

Loss of speech and hearing

100%

Paralysis of both upper and lower limbs (Quadriplegia)

100%

Paralysis of both lower limbs or both upper limbs (Paraplegia)

75%

Paralysis of upper and lower limb one side (Hemiplegia)

50%

Paralysis of one arm or leg

25%

A17764 (1/21)

$25,000

Blue Shield of California is an Independent Licensee of the Blue Shield Association

Employee Basic Group Term Life Benefit

Employee Basic Group Term AD&D Benefit

Additional Provisions when an AD&D Benefit is Payable

Seat Belt and Air Bag Benefit

An additional benefit of 10% up to a maximum of $25,000 will be paid if you lose your life in an automobile accident (either driving or riding in a car) while properly wearing a seat belt and the airbag is deployed at the time of the accident.

Special Education Benefit Spouse/Domestic Partner and Children

Your Spouse/Domestic Partner is eligible for a one-time benefit up to a maximum of $5,000 when enrolled as a full-time student. Each of your children is eligible for a benefit of $2,500/year (4 consecutive years) when enrolled, before the age of 26 and within 1 year after your date of death, as a full time in an accredited college, university, or vocational school. Maximum benefit payable per child is $10,000.

Repatriation Benefit

An additional benefit up to a maximum of $2,000, for the purposes defined in the certificate, if you lose your life at least 100 miles away from your permanent place of residence.

Comatose Benefit

An additional benefit of 50% if you become comatose as a direct result of an accident and remain continuously so for 60 days.

Felonious Assault Benefit

An additional benefit of 10% if you incur a loss as the result of a Violent Criminal Act or Felonious Assault. The Felonious Assault must be inflicted by someone other than a fellow employee or a member of your family or household and must occur while you are working for or on your Employer's premises.

Common Carrier Benefit

An additional benefit is payable if you die as a result of an Accident which occurs while you are a fare-paying passenger of a Public Conveyance.

Surgical Reattachment Benefit

An additional benefit for a loss incurred if a part is dismembered as a result of an injury and the surgical reattachment is not successful within a period of 365 days.

This Benefit Summary is an overview of Blue Shield of California Life & Health Insurance Company (Blue Shield Life) Basic Group Term Life Insurance available for eligible employees. Please refer to your Certificate for a complete description of benefits, limitations, exclusions and other terms and conditions of coverage. In the event of a discrepancy between the English and Spanish versions of this Benefit Summary, the English version prevails. Basic Group Term Life and AD&D insurance is underwritten by Blue Shield of California Life & Health Insurance Company.

Blue Shield of California Life & Health Insurance Company Notice Informing Individuals about Nondiscrimination and Accessibility Requirements

• Provides aids and services at no cost to people with disabilities to communicate effectively with us such as: - Qualified sign language interpreters - Written information in other formats (including large print, audio, accessible electronic formats, and other formats) • Provides language services at no cost to people whose primary language is not English such as: - Qualified interpreters - Information written in other languages If you need these services, contact the Blue Shield Life Civil Rights Coordinator. If you believe that Blue Shield Life has failed to provide these services or discriminated in another way on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability, you can file a grievance with: Blue Shield of California Life & Health Insurance Company Civil Rights Coordinator P.O. Box 629007 El Dorado Hills, CA 95762-9007 Phone: (844) 831-4133 (TTY: 711) Fax: (844) 696-6070 Email: BlueShieldCivilRightsCoordinator@ blueshieldca.com Blue Shield of California Life & Health Insurance Company 601 12th Street, Oakland CA 94607

You may also contact the California Department of Insurance if you believe that Blue Shield of California Life & Health Insurance Company has failed to provide these services or discriminated in another way on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability. You can file a grievance with: California Department of Insurance Consumer Communications Bureau 300 S. Spring Street, South Tower Los Angeles, CA 90013 Phone: 1-800-927-HELP (4357) or TDD 1-800-482-4833

Complaint forms are available at www.insurance.ca.gov/01-consumers/101-help If you believe that you have not been provided these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW. Room 509F, HHH Building Washington, DC 20201 (800) 368-1019; TTY: (800) 537-7697

Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.

A49727-DOI (12/19)

Blue Shield Life:

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our Civil Rights Coordinator is available to help you.

Blue Shield of California Life & Health Insurance Company is an independent licensee of the Blue Shield Association

Discrimination is against the law Blue Shield of California Life & Health Insurance Company complies with applicable state laws and federal civil rights laws, and does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability. Blue Shield of California Life & Health Insurance Company does not exclude people or treat them differently because of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability.

Notice of the Availability of Language Assistance Services Blue Shield of California Life & Health Insurance Company

No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help call the CA Dept. of Insurance at 1-800-927-4357. English Servicios de idiomas sin costo. Puede obtener un intérprete. Le pueden leer documentos y que le envíen algunos en español. Para obtener ayuda, llámenos al número que figura en su tarjeta de identificación o al 1-866-346-7198. Para obtener más ayuda, llame al Departamento de Seguros de CA al 1-800-927-4357. Spanish 免費語言服務。您可獲得口譯員服務。可以用中文把文件唸給您聽，有些文件有中文的版本，也可以把這些文 件寄給您。欲取得協助，請致電您的保險卡所列的電話號碼，或撥打 1-866-346-7198 與我們聯絡。欲取得其他 協助，請致電 1-800-927-4357 與加州保險部聯絡。Chinese

Các Dịch Vụ Trợ Giúp Ngôn Ngữ Miễn Phí. Quý vị có thể được nhận dịch vụ thông dịch. Quý vị có thể được người khác đọc giúp các tài liệu và nhận một số tài liệu bằng tiếng Việt. Để được giúp đỡ, hãy gọi cho chúng tôi tại số điện thoại ghi trên thẻ hội viên của quý vị hoặc 1-866-346-7198. Để được trợ giúp thêm, xin gọi Sở Bảo Hiểm California tại số 1-800-927-4357. Vietnamese 무료 통역 서비스. 귀하는 한국어 통역 서비스를 받으실 수 있으며 한국어로 서류를 낭독해주는 서비스를 받으실 수 있습니다. 도움이 필요하신 분은 귀하의 ID 카드에 나와있는 안내 전화: 1-866-346-7198번으로 문의해 주십시오. 보다 자세한 사항을 문의하실 분은 캘리포니아 주 보험국, 안내 전화 1-800-927-4357번으로 연락해 주십시오. Korean

Walang Gastos na mga Serbisyo sa Wika. Makakakuha ka ng interpreter o tagasalin at maipababasa mo sa Tagalog ang mga dokumento. Para makakuha ng tulong, tawagan kami sa numerong nakalista sa iyong ID card o sa 1-866-346-7198. Para sa karagdagang tulong, tawagan ang CA Dept. of Insurance sa 1-800-927-4357 Tagalog Անվճար Լեզվական Ծառայություններ։ Դուք կարող եք թարգման ձեռք բերել և փաստաթղթերը ընթերցել տալ ձեզ համար հայերեն լեզվով։ Օգնության համար մեզ զանգահարեք ձեր ինքնության (ID) տոմսի վրա նշված կամ 1-866-346-7198 համարով։ Լրացուցիչ օգնության համար 1-800-927-4357 համարով զանգահարեք Կալիֆորնիայի Ապահովագրության Բաժանմունք։ Armenian Беслпатные услуги перевода. Вы можете воспользоваться услугами переводчика, и ваши документы прочтут для вас на русском языке. Если вам требуется помощь, звоните нам по номеру, указанному на вашей идентификационной карте, или 1-866-346-7198. Если вам требуется дополнительная помощь, звоните в Департамент страхования штата Калифорния (Department of Insurance), по телефону 1-800-927-4357. Russian 無料の言語サービス 日本語で通訳をご提供し、書類をお読みします。サービスをご希望の方は、ＩＤカー ド記載の番号または1-866-346-7198までお問い合わせください。更なるお問い合わせは、カリフォルニア州 保険庁、1-800-927-4357までご連絡ください。Japanese

‫ﺑﺮای‬.‫ ﻣﯿﺘﻮاﻧﯿﺪ از ﺧﺪﻣﺎت ﯾﮏ ﻣﺘﺮﺟﻢ ﺷﻔﺎھﯽ اﺳﺘﻔﺎده ﮐﻨﯿﺪ و ﺑﮕﻮﺋﯿﺪ ﻣﺪارک ﺑﮫ زﺑﺎن ﻓﺎرﺳﯽ ﺑﺮاﯾﺘﺎن ﺧﻮاﻧﺪه ﺷﻮﻧﺪ‬.‫ﺧﺪﻣﺎت ﻣﺠﺎﻧﯽ ﻣﺮﺑﻮط ﺑﮫ زﺑﺎن‬ ‫ﺑﺮای‬.‫ ﺗﻤﺎس ﺑﮕﯿﺮﯾﺪ‬1-866-346-7198 ‫ﺑﺎ ﻣﺎ از طﺮﯾﻖ ﺷﻤﺎره ﺗﻠﻔﻨﯽ ﮐﮫ روی ﮐﺎرت ﺷﻨﺎﺳﺎﺋﯽ ﺷﻤﺎ ﻗﯿﺪ ﺷﺪه اﺳﺖ و ﯾﺎ اﯾﻦ ﺷﻤﺎره‬،‫درﯾﺎﻓﺖ ﮐﻤﮏ‬ Persian.‫ ﺗﻠﻔﻦ ﮐﻨﯿﺪ‬1-800-927-4357 ‫)اداره ﺑﯿﻤﮫ ﮐﺎﻟﯿﻔﺮﻧﯿﺎ( ﺑﮫ ﺷﻤﺎره‬CA Dept. of Insurance ‫ ﺑﮫ‬،‫درﯾﺎﻓﺖ ﮐﻤﮏ ﺑﯿﺸﺘﺮ‬

blueshieldca.com

ਮੁਫ਼ਤ ਭਾਸ਼ਾ ਸੇਵਾਵਾਂ: ਤੁ ਸੀ ਂ ਦੁਭਾਸ਼ੀਏ ਦੀਆਂ ਸੇਵਾਵਾਂ ਹਾਸਲ ਕਰ ਸਕਦੇ ਹੋ ਅਤੇ ਦਸਤਾਵੇਜ਼ਾਂ ਨੂੰ ਪੰਜਾਬੀ ਿਵੱਚ ਸੁ ਣ ਸਕਦੇ ਹੋ। ਕੁਝ ਦਸਤਾਵੇਜ਼ ਤੁ ਹਾਨੂੰ ਪੰਜਾਬੀ ਿਵੱਚ ਭੇਜੇ ਜਾ ਸਕਦੇ ਹਨ। ਮਦਦ ਲਈ ਤੁ ਹਾਡੇ ਆਈਡੀ (ID) ਕਾਰਡ 'ਤੇ ਿਦੱਤੇ ਨੰਬਰ 'ਤੇ ਜਾਂ 1-866-346-7198 'ਤੇ ' ਸਾਨੂੰ ਫ਼ੋਨ ਕਰੋ। ਵਧੇਰੇ ਮਦਦ ਲਈ ਕੈਲੀਫ਼ੋਰਨੀਆ ਿਡਪਾਰਟਮ�ਟ ਆਫ਼ ਇਨਸ਼ੋਰ�ਸ ਨੂੰ 1-800-927-4357 'ਤੇ ਫ਼ੋਨ ਕਰੋ। Punjabi េស�កម� ��ឥតគិតៃថ�។ អ� ក�ចទទួ ល�នអ� កបកែ្រប�� និង�នឯក�រជូ នអ� ក� ��ែខ� រ ។ ស្រ�ប់ជំនួយ សូ មទូ រស័ព�មកេយើងខ��ំ�មេលខែដល�នប��ញេលើប័ណ�សំ�ល់ខ� �នរបស់អ�ក ឬេលខ 1-866-346-7198 ។ ស្រ�ប់ជំនួយបែន� មេទៀត សូ មទូ រស័ព�េ�្រកសួ ង����ប់រងរដ� �លីហ��រ�៉ �មេលខ 1-800-927-4357 Khmer

‫ اﺗﺼﻞ ﺑﻨﺎ‬،‫ ﻟﻠﺤﺼﻮل ﻋﻠﻲ اﻟﻤﺴﺎﻋﺪة‬.‫ ﯾﻤﻜﻨﻚ اﻟﺤﺼﻮل ﻋﻠﻲ ﻣﺘﺮﺟﻢ و ﻗﺮاءة اﻟﻮﺛﺎﺋﻖ ﻟﻚ ﺑﺎﻟﻠﻐﺔ اﻟﻌﺮﺑﯿﺔ‬.‫ﺧﺪﻣﺎت ﺗﺮﺟﻤﺔ ﺑﺪون ﺗﻜﻠﻘﺔ‬ ‫ اﺗﺼﻞ‬،‫ ﻟﻠﺤﺼﻮل ﻋﻠﻲ اﻟﻤﺰﯾﺪ ﻣﻦ اﻟﻤﻌﻠﻮﻣﺎت‬.1-866-346-7198 ‫ﻋﻠﻲ اﻟﺮﻗﻢ اﻟﻤﺒﯿﻦ ﻋﻠﻲ ﺑﻄﺎﻗﺔ ﻋﻀﻮﯾﺘﻚ أو ﻋﻠﻲ اﻟﺮﻗﻢ‬ Arabic .1-800-927-4357 ‫ﺑﺈدارة اﻟﺘﺄﻣﯿﻦ ﻟﻮﻻﯾﺔ ﻛﺎﻟﯿﻔﻮرﻧﯿﺎ ﻋﻠﻲ اﻟﺮﻗﻢ‬ Cov Kev Pab Txhais Lus Tsis Them Nqi. Koj yuav thov tau kom muaj neeg los txhais lus rau koj thiab kom neeg nyeem cov ntawv ua lus Hmoob. Yog xav tau kev pab, hu rau peb ntawm tus xov tooj nyob hauv koj daim yuaj ID los sis 1-866-346-7198. Yog xav tau kev pab ntxiv hu rau CA lub Caj Meem Fai Muab Kev Tuav Pov Hwm ntawm 1-800-927-4357 Hmong ่ านเอกสารใหค้ ณ บริการทางภาษาอย่างไม่เสียค่าใช ้จ่าย คุณสามารถรบั บริการจากล่าม รวมถึงให ้เจ ้าหน้าทีอ่ ุ ฟัง หรือส่งเอกสารบางส่วนในภาษาของคุณไปหาคุณได ้ หากต ้องการความช่วยเหลือ ่ อยู่ด ้านหลังบัตรประจําตัวของคุณ หรือ ทีหมายเลข ่ 1-866-346-7198 กรุณาโทรศัพท ์ตามหมายเลขทีระบุ ่ ่ ่ 1-800-927-4357 Thai หากต ้องการความช่วยเหลือเพิมเติม โปรดโทรมาที กรมการประกันภัยแห่งมลร ัฐแคลิฟอร ์เนี ยทีหมายเลข िनःशु � भाषा सेवाएँ । आप एक दु भािषया की सेवा प्रा� कर सकते ह� । आप द�ावेजों को पढ़वा के सुन सकते ह� और कुछ को अपनी भाषा म� �यं को िभजवा सकते ह� । सहायता के िलए, अपने ID काड� पर िदए गए नं बर पर, या 1-866-346-7198 पर हम� फ़ोन कर� । अिधक सहायता के िलए कैलीफोिन�या बीमा िवभाग (CA Dept. of Insurance) को 1-800-927-4357 पर फ़ोन कर� । Hindi

Doo b11h 7l7n7g0 saad bee y1t’i’ bee an1’1wo’. D77 sh1 ata’halne’doo7g7 h0l=-doo n7n7zingo 47 b7ighah. Naaltsoos naanin1h1jeeh7g7 shich’8’ y7idooltah 47 doodag0 [a’ shich’8’ 1dooln77[ n7n7zingo b7ighah. Sh7k1 a’doowo[ n7n7zingo nihich’8’ b44sh bee hod7ilnih d00 n1mboo 47 d77 ninaaltsoos doot[‘7zh7g7 bee n47ho’d7lzin7g7 bine’d44’ bik11’ 47 doodag0 47 (866)346-7198j8’ hod77lnih. H0zh= sh7k1 an11’doowo[ n7n7zingo 47 d77 b4eso 1ch’22h naa’nil bi[ haz’32j8’ 1-800-927-4357j8’ hod77lnih. Navajo ບໍລິການແປພາສາໂດຍບ່ໍ ເສຍຄ່ າ. ທ່ ານສາມາດຂໍເອົາຜູ້ ແປພາສາໄດ້ . ທ່ ານສາມາດຂໍໃຫ້ ອ່ານເອກະສານໃຫ້ ທ່ານຟັງ ແລະ ສົ່ງເອກະສານບາງຢ່ າງທີ່ເປັນພາສາຂອງທ່ ານ. ສໍາລັບຄວາມຊ່ ວຍເຫື ຼ ອ, ໃຫ້ ໂທຫາພວກເຮົາຕາມເບີໂທລະສັບທີ່ມີໃນບັດປະຈໍາຕົວຂອງທ່ ານ ຫື ຼ ໂທຫາເບີ1-866-346-7198. ສໍາລັບຄວາມຊ່ ວຍເຫື ຼ ອເພ່ີ ມເຕີມໂທຫາ ພະແນກ ປະກັນໄພຂອງລັດຄາລີຟໍເນຍໄດ້ ທີ່ເບີ1-800-927-4357. Laotian

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