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Benefits Guide
2020
1
Because our employees are important to us and the success of our business, QCR Holdings, Inc. offers you and your eligible family members a comprehensive and valuable benefits package. We encourage you to take the time to educate yourself about your options and choose the best coverage for you and your family.
Elections you make during the annual enrollment period will become effective January 1, 2020.
Elections you make during the new hire enrollment period will become effective 1st of the month following 60 days of hire.
DisclaimerThe information in this Enrollment Guide is presented for illustrative purposes and is based on information provided by the employer. The text contained in this Guide 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 Guide 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 your Guide, contact Human Resources.
The information provided in this summary is for comparative purposes only. Actual claims paid are subject to the specific terms and conditions of each contract. This benefit summary does not constitute a contract.
The information in this booklet is proprietary. Please do not copy or distribute to others.
Created by TrueNorth® for
QCR Holdings, Inc.2
Who is Eligible?Part of your total compensation at QCR Holdings, Inc. includes a comprehensive benefits package. To be eligible for benefits you must work at least 24 hours per week.
If you have a status change of Not Benefits Eligible to Benefits Eligible, benefits are effective first of the month following 60 days of status change effective date.
We have an annual enrollment and new hire enrollment for the employee benefits insurance. If you do not elect at annual enrollment or new hire enrollment you will be required to have a qualifying event in order to come on to the plan.
How to Enroll/Re-EnrollEnrollment is completed electronically through Enterprise Benefits by logging into www.paylocity.com. This is your annual/new hire opportunity to elect Medical, Dental, Vision and Voluntary benefits for the 2020 plan year. Voluntary Life and Voluntary Long Term Disability are available, but will require evidence of insurability if you are coming on as a late entrant.
Once you have made your elections, you will not be able to change them until the next annual enrollment, unless you have a qualified life event change in status.
Qualified Life Event Changes Qualified changes in status include: marriage, divorce, legal separation, birth or adoption of a child, change in child’s dependent status, death of spouse, child or other qualified dependent, change in residence due to an employment transfer for you, or termination of adoption proceedings, or change in spouse’s benefits or employment status.
When you decide to enroll in the plan
with a life event change, you will
be required to do so within 30
calendar days of the event.
3
CO
NTA
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INFO
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NRefer to this list when you need to contact one of your benefit vendors. For general information contact Human Resources. See contact information below.
M E D I C A L page 5-8UMR1-800-826-9781www.umr.com
P R E S C R I P T I O N D R U G S page 5-8MedOne1-888-884-6331www.medone-rx.com
V I R T U A L M E D I C I N E page 9Teladoc1-800-TELADOCwww.teladoc.com
W E L L N E S S P R O G R A M page 10Rock Valley Health1-563-324-0008
H E A L T H S A V I N G S A C C O U N T page 11Health Equity1-866-346-5800www.healthequity.com
D E N T A L page 12Health Alliance 1-866-247-3296www.healthalliance.org
V I S I O N page 13-14EyeMed 1-866-939-3633www.eyemedvisioncare.comORAvesis1-855-214-6777www.avesis.com
F L E X S P E N D I N G A C C O U N T page 15UMR 1-800-826-9781 www.umr.comORPRIME Benefit Systems – (CRBT & CB&T employees only)1-319-393-2005
L I F E & D I S A B I L I T Y page 16-17The Standard1-888-937-4783www.standard.com
V O L U N T A R Y P R O D U C T S page 18Supplemental Insurance Services563-652-6813supins@supinsurance.com
H U M A N R E S O U R C E S C O N T A C T SChristina Back – Benefits Administrator1-309-743-7721cback@qcrh.com T R U E N O R T H ® C O N T A C T S
TrueAdvocate Team – for questions regarding:Deductibles, Copays, ID Cards, Claims Issues1-888-655-99804
MED
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H O W T O F I N D A N I N - N E T W O R K P R O V I D E R
Phone Number 800-826-9781Provider Search www.umr.com
To search for a provider, visit the site above and click “Find a Provider” found in a box below the picture on the homepage. Make sure the radio button next to “Medical” is marked. Then select the letter “U” from the alphabet, which will jump the screen down to the United Health Care networks. Select the “United Health Choice Plus Network”. Finally click on the View providers button below and from here you will be able to find health care by a variety of categories.
P P O T R A D I T I O N A L P L A N
Please refer to the complete Summary of Benefits and Coverage for further details on each plan.
I n - N e t w o r k O u t - o f - N e t w o r k
Deductible $1,500/$3,000 $1,750/$3,500
Coinsurance 30% 50%
Out of Pocket Maximum $5,500/$9,000 $6,250/$10,000
Office Visit $30 copay (Primary Care Provider)$50 copay (Specialist)
Subject to deductible/coinsurance
Virtual Visit (Teladoc – more information on page 9)
$20 copay Subject to deductible/coinsurance
Preventive Services $0 copay $0 copay
Urgent Care $50 copay Subject to deductible/coinsurance
Emergency Room $300 copay + 30% coinsurance $300 copay + 30% coinsurance
Prescription Drugs(Retail 30 Days)
Deductible: $150/$300(Deductible is waived for Tier 1)
Not CoveredTier 1 Generic $5 CopayTier 2 Preferred $50 CopayTier 3 Non-preferred $85 Copay
Specialty 30% Coins
5
H O W T O F I N D A N I N - N E T W O R K P R O V I D E R
Phone Number 800-826-9781Provider Search www.umr.com
To search for a provider, visit the site above and click “Find a Provider” found in a box below the picture on the homepage. Make sure the radio button next to “Medical” is marked. Then select the letter “U” from the alphabet, which will jump the screen down to the United Health Care networks. Select the “United Health Choice Plus Network”. Finally click on the View providers button below and from here you will be able to find health care by a variety of categories.
H I G H D E D U C T I B L E H E A L T H P L A N
Please refer to the complete Summary of Benefits and Coverage for further details on each plan.
I n - N e t w o r k O u t - o f - N e t w o r k
Deductible $2,000/$4,000 $2,250/$4,500
Coinsurance 0% 20% coinsurance
Out of Pocket Maximum $2,000/$4,000 $3,000/$5,000
Office Visit Subject to deductible Subject to deductible/coinsurance
Virtual Visit (Teladoc – more information on page 9)
$49 $49
Preventive Services $0 $0
Urgent Care Subject to deductible Subject to deductible/coinsurance
Emergency Room Subject to deductible Subject to deductible/coinsurance
Prescription Drugs Subject to deductible Not covered
Health Savings Account Contribution
If you make a contribution to your HSA via payroll deduction, QCRH will match this contribution $1 for $1, up
to $500 annually
MED
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MED
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E M P L O Y E E C O S T S : P P O T R A D I T I O N A L P L A N
Costs listed above are per pay period, taken 24 times per year.
For the EE/Spouse & Family plans, there is a $25 surcharge per pay period added to the above premiums if your spouse has the option to elect coverage from his or her employer and has declined the coverage.
C o v e r a g e L e v e l Platinum Tier Gold Tier Silver Tier Bronze Tier
*Employee participates & earns Platinum Tier
*Employee participates & earns Gold Tier
*Employee does not participate
**Employee & Spouse participate and both earn Platinum Tier
**Employee & Spouse participate and one or both earn the Gold Tier
**Either the Employee orthe Spouse does not participate if both are enrolled in the medical plan
**Neither the Employee nor the Spouse participates when enrolled in the medical plan
*Employee Only $66.10 $79.38 $252.20
*EE/Child(ren) $174.78 $209.95 $479.85
**EE/Spouse $194.35 $233.40 $324.88 $562.48
**Family $318.90 $383.05 $533.18 $844.30
MED
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PRE
SCRI
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E M P L O Y E E C O S T S : H I G H D E D U C T I B L E H E A L T H P L A N
Costs listed above are per pay period, taken 24 times per year.
For the EE/Spouse & Family plans, there is a $25 surcharge per pay period added to the above premiums if your spouse has the option to elect coverage from his or her employer and has declined the coverage.
C o v e r a g e L e v e l Platinum Tier Gold Tier Silver Tier Bronze Tier
*Employee participates & earns Platinum Tier
*Employee participates & earns Gold Tier
*Employee does not participate
**Employee & Spouse participate and both earn Platinum Tier
**Employee & Spouse participate and one or both earn the Gold Tier
**Either the Employee orthe Spouse does not participate if both are enrolled in the medical plan
**Neither the Employee nor the Spouse participates when enrolled in the medical plan
*Employee Only $32.35 $39.25 $122.03
*EE/Child(ren) $104.25 $126.43 $249.60
**EE/Spouse $115.00 $139.50 $208.33 $291.50
**Family $180.60 $219.00 $327.08 $417.75
8
VIRTU
AL M
EDIC
INE
T E L A D O C
Teladoc offers 24/7 access to a doctor via online video, phone call or mobile app. We know you don’t get sick on a schedule and it’s not always convenient to leave home or work to visit a doctor. Teladoc gives you access to convenient, quality healthcare, anytime, from anywhere.
That means a physician is always just a call, click or swipe away when you:
• Wake up at 2 AM with flu-like symptoms• Get a scratchy throat at work but can’t afford to leave• Feel under the weather during a vacation, on a business trip, or away from
home
There are three ways to register your account for use:
• Online: Go to Teladoc.com and click “set up account”• Mobile App: Download the Teladoc app to your smart phone and click
“Activate Account”• Call Teladoc at 1-800-TELADOC – they can help your register your account
over the phone
Once you have registered your account, accessing care is easy.
1. Provide medical historyHealth information is provided during account setup, which is reviewed by the physician prior to a consult
2. Request a consultYou can connect with the first available physician or schedule an appointment for a convenient time
3. Talk with the physicianWithin minutes, a physician will call back, listen, diagnose the issue and prescribe medication, if medically necessary
4. Pick up the prescriptionThe prescription is sent electronically to a local pharmacy selected by you
Teladoc doctors can diagnose many health issues like cold and flu symptoms, allergies, ear infections, rash and skin problems:
• Abdominal Pain• Cough• Dizziness• Blood Pressure Issues• Bronchitis• Sinusitis• Sore Throat
• Skin Injury• Sprains & Strains• Headache/Migraine• Cold• Flu• Fever• Pink Eye
• Urinary Tract Infection• Laryngitis• Strep• Poison Ivy/Oak• Yeast Infection• Joint Pain/Swelling• Backache
9
WEL
LNES
S PR
OG
RAM
W E L L N E S S P R O G R A M
QCRH has partnered with Rock Valley Health to provide its employees with a Wellness Program to achieve the goal of helping employees and their families adopt and maintain healthy lifestyle behaviors. The Wellness Program is paid by QCRH and is at no cost to the employee unless otherwise indicated by * below.
The Wellness Program is an Outcomes Based Incentive Program. Participation in the program and the outcome of your health screening or nonparticipation will determine which of the four premium tiers you fall into-Platinum, Gold, Silver, or Bronze. See pages 7 and 8 for tier descriptions and rates per medical plan.
Eligible participants include employees and spouses enrolled in the QCRH medical plan.
Rock Valley Health will distribute via email to eligible participants detailed instructions for signing up and completing the health screening process.
Annual Health Screening Process
• Schedule on-site biometric screening appointment*Off-site health forms are available to be completed by your Primary
Care Physician
• Attend on-site biometric screening or submit *off-site health form
• Complete online Health Risk Assessment
• Attend private one-on-one consultation to review health report either on site or by phone
• If applicable attend private one-on-one Health Coaching sessions designed to assist with health lifestyle changes
Wellness Program Disclosure
Your health plan is committed to helping you achieve your best health. Rewards for participating in a wellness program are available to all employees. If you think you might be unable to meet a standard for a reward under this wellness program, you might qualify for an opportunity to earn the same reward by different means. Contact us and we will work with you (and, if you wish, with your doctor) to find a wellness program with the same reward that is right for you in light of your health status. If you have questions regarding the Wellness program, contact:
Christina Back Benefits Administrator309-743-7721cback@qcrh.com.
10
HEA
LTH SA
VIN
GS A
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H E A L T H S A V I N G S A C C O U N T
A Health Savings Account (HSA) is an account funded to help you save for future medical expenses. There are certain advantages to putting money into these accounts, including favorable tax treatment.
WHO CAN HAVE AN HSA?Any adult can have an HSA if you:
• Have coverage under a qualified High Deductible Health Plan (HDHP)• Have no other first-dollar medical coverage• Are not enrolled in Medicare or Medicaid• Cannot be claimed as a dependent on someone else’s tax return
HSA CONTRIBUTIONSContributions to your HSA can be made by you, your employer, or both. You can make contributions to your HSA each year that you are eligible. Your total contribution for 2020 can be no more than:
• Single Coverage: $3,550• Family Coverage: $7,100• If you are 55+: additional $1,000 catch-up contribution
EMPLOYER HSA CONTRIBUTIONIf you make a contribution to your HSA in 2020 via payroll deduction QCRH will match your contribution, dollar for dollar, up to $500.
HSA OPTIONSHealth Equity HSA – if elected, an account will be set up for you and you will receive a packet mailed to your home address.CRBT/CB&T locations – option to elect Health Equity HSA or can elect a CRBT/CB&T HSA If electing CRBT/CB&T will need to see an Account Executive to set up your account.
ADVANTAGES OF HSA:• Security: your HSA can provide a buffer for unexpected medical bills
• Affordability: your monthly medical insurance premiums may be less on this plan
• Flexibility: you can use your HSA to pay for current medical expenses or save your funds for future needs
• Savings: you can save the money in your HSA and grow your account through investment earnings
• Portability: the money in your HSA is always yours, even if you change jobs, change medical coverage, become unemployed, or move to another state
• Ownership: funds remain in the account from year to year. There are no “use it or lose it” rules for these accounts.
11
DEN
TAL
INSU
RAN
CE
H O W T O F I N D A N I N - N E T W O R K P R O V I D E R
There is no network associated with the dental plan. You can seek care from any dentist of your choice. Charges are subject to Usual, Customary and Reasonable (UC&R) rates in the geographic area in which you seek care to determine the amount allowed for each procedure.
Benefits Dental Plan
Deductible Applies to basic and major services only – $25 Single / $50 Family
AnnualMaximum Benefit
$1,200
Preventive Services Covered at 100%; 2 per calendar year
Basic Services Routine & Restorative – 80% coinsurance
Major ServicesEndodontics/Periodontics; gum and bone diseases, high cost restorations – cast restorations, crowns, onlays, posts and cores – 50% coinsurance
Orthodontic Services for proper alignment of teeth – 50% coinsurance to a lifetime maximum of $1,500No age limit applies
2020 Dental Costs (Per Pay Period, taken 24 times per year)
Employee Only Employee & Child(ren) Employee & Spouse Employee & Family
$6.39 $14.05 $11.95 $19.35
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VISIO
N IN
SURA
NC
E
H O W T O F I N D A N I N N E T W O R K P R O V I D E R
Phone Number 1-866-939-3633Provider Search www.eyemedvisioncare.com
To search for a provider, visit the site above, click on ”Find a Provider.” Then select your zip code, network, or provider to load list of providers in your network.
eyeMedServices Amount You Pay
Exam $10 copay (1 covered exam subject to copay every 12 months)
Contacts(in lieu of spectacle lenses and frames)
Conventional: $0 copay, $135 allowance, 15% off balance over $135 Disposable: $0 copay, $135 allowanceMedically Necessary: $0 copay, paid in full Copay of up to $40 may apply for Fit and Follow-Up visit
Frames Member receives any frame with an approximate retail value of $120 every 24 months; $0 copay and 20% off balance over $120
LensesLenses covered in full every 12 months include: $25 copay for singlevision, bifocal, and trifocal lenses. $25 copay, 20% off balance over $120
Laser Vision Correction
Save 15% off the retail price or 5% off the promotional price for Lasik or PRK procedure
2020 Vision Costs (Per Pay Period, taken 24 times per year)
Employee Only Employee & Child(ren) Employee & Spouse Employee & Family
$3.36 $6.72 $6.39 $9.87
13
VIS
ION
INSU
RAN
CE
H O W T O F I N D A N I N N E T W O R K P R O V I D E R
Phone Number 1-800-828-9341Provider Search www.avesis.com
To search for a provider, visit the site above, click on “Vision.” Then select “Search for Providers” in the orange box on the upper right hand side of the page. Then search by provider type, zip code, and other location details to find covered providers in your area.
Services Amount You Pay
Exam $10 copay (1 covered exam subject to copay every 12 months)
Contacts (in lieu of spectacle lenses and frames)
Member receives a contact lens allowance of $130 which can be used for materials and services
Frames
$15 materials copay appliesMember receives a $50 wholesale allowance for frames – up to a $150 retail value At participating Walmart locations, retail pricing for your plan is $68 At participating Costco locations, retail pricing for your plan is $54.99
Lenses
Single vision, bifocal, trifocal & lenticular lenses are covered in full after $15 materials copayStandard progressives are covered up to $50, plus 20% off retail priceOther lens options are discount up to 20% off retail prices
Laser Vision Correction Provider discount up to 25%; One-time/Lifetime allowance of $150
2020 Vision Costs (Per Pay Period, taken 24 times per year)
Employee Only Employee & Child(ren) Employee & Spouse Employee & Family
$5.45 $11.43 $10.48 $14.69
14
FLEXIBLE SPEND
ING
AC
CO
UN
T
Benefit Amount
Medical Reimbursement Account
Allows you to pay for unreimbursed medical, dental or vision expenses with tax-free dollars
Out of pocket health care expenses include: deductible, copays and coinsurance
Doctor prescribed prescription drugs and insulin are eligible
Dependent Care Reimbursement Account
Allows you to pay for dependent care expenses with tax free dollars
Care during working hours for children under age 13
Care during working hours for disabled spouse, child or parent living with you.
Plan year Runs from January 1, 2020 through December 31, 2020
Medical Reimbursement Account Election
Maximum $2,750Up to $500 of unused funds from the prior year can be carried over into 2020
Dependent Care Reimbursement Account Election
Maximum $5,000
Claims
Are reimbursed bi-weekly
Grace period to incur 2020 claims will be from January, 1, 2020 through April 30, 2021The grace period applies to Dependent Care only
Claim filing deadline is April 30, 2021
F L E X I B L E S P E N D I N G A C C O U N T
15
LIFE
AN
D A
D&
D IN
SURA
NC
E
B A S I C L I F E A N D A D & D – S T A N D A R D I N S U R A N C E
QCRH provides full-time employees with a life insurance policy and accidental death and dismemberment (AD&D) insurance. QCRH pays the full cost of this benefit which is provided by The Standard. Update your beneficiary in Enterprise Benefits. If you need assistance with accessing Enterprise Benefits, please contact Human Resources.
Benefit Amount
Life 2 times Annual Earnings up to $500,000
Accidental Death & Dismemberment 2 times Annual Earnings up to $500,000
Age Reduction 65% at age 65; 50% at age 70: 35% at age 75
V O L U N T A R Y L I F E A N D A D & D
QCRH understands that each employee has unique financial planning needs. Some employees may want additional life insurance protection for themselves and their family and we are offering an affordable solution. Employees have the option of electing additional life and accidental death and dismemberment (AD&D) insurance for themselves and eligible family members. You can elect the amount that best meets your individual needs and budget up to $500,000. Your combined Basic & Additional Life amounts may not exceed 6 times your Annual Earnings. You will be responsible for the cost of this benefit which is administered by The Standard.
Voluntary Life and Voluntary AD&D costs are calculated for you in Enterprise Benefits.
Benefit Amount
Employee Increments of $10,000 up to $500,000 or 6 times Annual Earnings.Guarantee Issue up to $150,000
Spouse Increments of $10,000 up to $250,000 or 100% of employee benefit.Guarantee Issue up to $50,000
Children Increments of $2,500 for children from live birth through age 25 up to$10,000
Guarantee Issue amount applies to new hire enrollment only.
Evidence of Insurability is required if:
• You decline coverage during your initial enrollment and then elect coverage at a later date• You elect coverage in excess of the Guarantee Issue during your initial enrollment• Late entrants and increases
If Evidence of Insurability is required, coverage is not effective until approved by The Standard.
16
DISA
BIILITY INSU
RAN
CE
D I S A B I L I T Y I N C O M E B E N E F I T S
QCRH provides full-time employees with Short Term Disability and Voluntary Long-Term Disability income benefits through The Standard. In the event you are injured or become ill, disability income benefits are provided as a source of income. You are not eligible to receive Short-Term Disability benefits if you are receiving Workers’ Compensation benefits.
Short-Term Disability Voluntary Long-Term Disability
Benefits Begin 7 day Elimination Period 90 day Elimination Period
Benefits Payable For 90 days Social Security Normal Retirement Age (SSNRA)
Percentage of Income Replaced 60% 60%
Maximum Benefit Weekly Maximum of $1,300 Monthly Maximum of $10,000
Paid 100% by QCRH Paid 100% by Employee
To offset the Short Term Disability elimination period a benefit called Bank Paid Disability is paid one time in a 12 month period.
17
VO
LUN
TARY
PRO
DU
CTS V O L U N T A R Y A C C I D E N T I N S U R A N C E
QCRH offers a Voluntary Accident Plan through Assurity that gives you a cushion to help cover medical expenses and living costs when you get hurt unexpectedly. This insurance will work in addition to other insurance you may have.
This policy covers benefits for fractures, dislocations, lacerations, concussions, burns, emergency dental work, eye injuries, and surgical procedures. There is also coverage for x-rays, diagnostic exams, follow-up treatments (including physical, speech and occupational therapy) and for hospitalizations.
V O L U N T A R Y C R I T I C A L I L L N E S S I N S U R A N C E
Employees may also purchase a Critical Illness policy through Kemper Health.
The Critical Illness policy pays a lump sum benefit to you upon diagnosis of covered conditions to help cover out of pocket expenses and time off work. Some of the covered conditions are Heart Attack, Stroke, Cancer, and Major Organ Transplant.
V O L U N T A R Y C A N C E R C A R E I N S U R A N C E
This plan pays a cash benefit upon initial diagnosis of a covered cancer, with a variety of other benefits payable throughout cancer treatment. You can use the cash benefit to pay for your medical expenses, rent/mortgage, groceries or other bills – the choice is yours.
For more information on these plans, refer to the employee benefits portal, or contact Supplemental Insurance Services directly.
Supplemental Insurance Services563-652-6813supins@supinsurance.com
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BENEFITS &
CO
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UNIC
ATIO
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E M P L O Y E E B E N E F I T S P O R T A L
Introducing your Benefits Portal!
By accessing your Benefits Portal, you will have access to:• Benefit plan details, rates and forms• Links to provider resources• HR required notices and employee documents• Contact information when you need help
Find Answers to Questions Such As...“What benefits are offered by my employer?”“What is my deductible and copay?”“How to add a spouse or child to my plan?”“How do I enroll in my benefits?”
V I S I T T H E S I T E A T :
www.thebenefitportal.comLogin Name: qcrholdingsPassword: benefits
Here is a snapshot of the login screen:
And the homepage once you log in:
19
ENTE
RPRI
SE B
ENEF
ITS
ENRO
LLM
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A C C E S S I N G A N D C O M P L E T I N G Y O U R B E N E F I T S E N R O L L M E N T
To access your online benefits enrollment, follow the steps listed below:
- Go to www.paylocity.com and log in
- Click on the menu button in the top left corner
- Click on Enterprise Benefits
- Welcome to the Enterprise Benefits home page
To complete your online benefits enrollment, follow the steps listed below:
- From the Enterprise Benefits home page, click on Start Your Enrollment
- Complete each of the following 4 sections of the enrollment:
If you need assistance with your online enrollment or have any questions, contact the following HR Representative:
1. Your Info Review employee information, add/edit family information
2. Your Benefits Enroll or waive coverage for each benefit listed
3. Enroll Review/add/edit your beneficiaries, review and confirm your elections
4. Complete Enrollment completed confirmation, save/print for your records
Christina Back, Benefits Administrator cback@qcrh.com or 309-743-7721
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IMPORTANT NOTICES FROM QCR HOLDINGS, INC. REGARDING THE HEALTH & WELFARE BENEFIT PLAN
The following notices provide important information about the group health plan provided by your employer. Please read the attached notices carefully and keep a copy for your records. If you have any questions regarding any of these notices, please contact: General Contact: Christina Back Phone: 309-743-7721 Email: cback@qcrh.com Mailing Address: 3551 7th Street Moline, IL 61265
Distribution Date: November 2019 or upon hire
These notices are available online at www.thebenefitportal.com or via paper, free of charge, upon request to the Plan Administrator.
Please note this is not a legal document and should not be construed as legal advice.
Women’s Health and Cancer Rights Act Notice Do you know that your plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedema? Call your plan administrator for more information. If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:
• 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;
• Prostheses; and
• Treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. If you would like more information on WHCRA benefits, call your plan administrator.
Newborns’ and Mothers’ Health Protection Act
Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
Premium Assistance under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a state listed below, contact your state Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your state Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the state if it has a program that might help you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you are not already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, you can contact the Department of Labor electronically at www.askebsa.dol.gov or by calling toll-free 1-866-444-EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2019. Contact your State for more information on eligibility.
ALABAMA – Medicaid FLORIDA – Medicaid Website: http://myalhipp.com/ Phone: 1-855-692-5447
Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268
ALASKA – Medicaid GEORGIA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx
Website: https://medicaid.georgia.gov/health-insurance-premium-payment-program-hipp Phone: 678-564-1162 ext 2131
ARKANSAS – Medicaid INDIANA – Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone 1-800-403-0864
COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health
Plan Plus (CHP+) IOWA – Medicaid
Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: https://www.colorado.gov/pacific/hcpf/child-health-plan-plus CHP+ Customer Service: 1-800-359-1991/State Relay 711
Website: http://dhs.iowa.gov/Hawki Phone: 1-800-257-8563
KANSAS – Medicaid NEW HAMPSHIRE – Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512
Website: https://www.dhhs.nh.gov/oii/hipp.htm Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852- 3345, ext. 5218
KENTUCKY – Medicaid NEW JERSEY – Medicaid and CHIP Website: http://chfs.ky.gov Phone: 1-800-635-2570
Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392
CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710
LOUISIANA – Medicaid NEW YORK – Medicaid
Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-695-2447
Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831
MAINE – Medicaid NORTH CAROLINA – Medicaid Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-442-6003 TTY: Maine relay 711
Website: https://dma.ncdhhs.gov/ Phone: 919-855-4100
MASSACHUSETTS – Medicaid and CHIP NORTH DAKOTA – Medicaid Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1-800-862-4840
Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825
MINNESOTA – Medicaid OKLAHOMA – Medicaid and CHIP Website: http://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/medical-assistance.jsp Phone: 1-800-657-3739
Website: http://www.insureoklahoma.org Phone: 1-888-365-3742
MISSOURI – Medicaid OREGON – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005
Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075
MONTANA – Medicaid PENNSYLVANIA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084
Website: http://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthippprogram/index.htm Phone: 1-800-692-7462
NEBRASKA – Medicaid RHODE ISLAND – Medicaid
Website: http://www.ACCESSNebraska.ne.gov Phone: (855) 632-7633 Lincoln: (402) 473-7000 Omaha: (402) 595-1178
Website: http://www.eohhs.ri.gov/ Phone: 855-697-4347, or 401-462-0311 (Direct RIte Share Line)
NEVADA – Medicaid SOUTH CAROLINA – Medicaid Medicaid Website: https://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900
Website: https://www.scdhhs.gov Phone: 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid Website: http://dss.sd.gov Phone: 1-888-828-0059
Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022 ext. 15473
TEXAS – Medicaid WEST VIRGINIA – Medicaid
Website: http://gethipptexas.com/ Phone: 1-800-440-0493
Website: http://mywvhipp.com/ Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)
UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP
Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669
Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 1-800-362-3002
VERMONT– Medicaid WYOMING – Medicaid
Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427
Website: https://wyequalitycare.acs-inc.com/ Phone: 307-777-7531
VIRGINIA – Medicaid and CHIP
Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm CHIP Phone: 1-855-242-8282
To see if any other states have added a premium assistance program since July 31, 2019, or for more information on special enrollment rights, contact either:
U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/agencies/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137. Sample Open Enrollment Notice OMB Control Number 1210-0137 (expires 12/31/2019)
Wellness Program – Notice of Reasonable Alternatives Your health plan is committed to helping you achieve your best health. Rewards for participating in a wellness program are available to all employees. If you think you might be unable to meet a standard for a reward under this wellness program, you might qualify for an opportunity to earn the same reward by different means. Contact us and we will work with you (and, if you wish, with your doctor) to find a wellness program with the same reward that is right for you in light of your health status.
Notice Regarding Wellness Program
The QCRH Wellness Program is a voluntary wellness program available to all employees. The program is administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease, including the Americans with Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act, as applicable, among others. If you choose to participate in the wellness program you will be asked to complete a voluntary health risk assessment or "HRA" that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (e.g., cancer, diabetes, or heart disease). You will also be asked to complete a biometric screening, which will include a blood test for cholesterol and blood sugar. You are not required to complete the HRA or to participate in the blood test or other medical examinations.
However, employees who choose to participate in the wellness program will receive an incentive of reduced medical premiums. Although you are not required to complete the HRA or participate in the biometric screening, only employees who do so will receive the incentive.
The information from your HRA and the results from your biometric screening will be used to provide you with information to help you understand your current health and potential risks, and may also be used to offer you services through the wellness program, such as health coaching. You also are encouraged to share your results or concerns with your own doctor.
Protections from Disclosure of Medical Information
We are required by law to maintain the privacy and security of your personally identifiable health information. Although the wellness program and QCR Holdings may use aggregate information it collects to design a program based on identified health risks in the workplace, we will never disclose any of your personal information either publicly or to the employer, except as necessary to respond to a request from you for a reasonable accommodation needed to participate in the wellness program, or as expressly permitted by law. Medical information that personally identifies you that is provided in connection with the wellness program will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment.
Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the wellness program, and you will not be asked or required to waive the confidentiality of your health information as a condition of participating in the wellness program or receiving an incentive. Anyone who receives your information for purposes of providing you services as part of the wellness program will abide by the same confidentiality requirements. The only individual(s) who will receive your personally identifiable health information are your doctor or health coach in order to provide you with services under the wellness program.
In addition, all medical information obtained through the wellness program will be maintained separate from your personnel records, information stored electronically will be encrypted, and no information you provide as part of the wellness program will be used in making any employment decision. Appropriate precautions will be taken to avoid any data breach, and in the event a data breach occurs involving information you provide in connection with the wellness program, we will notify you immediately.
You may not be discriminated against in employment because of the medical information you provide as part of participating in the wellness program, nor may you be subjected to retaliation if you choose not to participate.
If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact Human Resources.
HIPAA Notice of Privacy Practices
The Health Insurance Portability and Accountability Act of 1996 ("HIPAA") requires that we maintain the privacy of protected health information, give notice of our legal duties and privacy practices regarding health information about you and follow the terms of our notice currently in effect.
If not attached to this document, you may request a copy of the current Privacy Practices, explaining how medical information about you may be used and disclosed and how you can get access to this information.
As Required by Law. We will disclose Health Information when required to do so by international, federal, state or local law.
You have the right to inspect and copy, right to an electronic copy of electronic medical records, right to get notice of a breach, right to amend, right to an accounting of disclosures, right to request restrictions, right to request confidential communications, right to a paper copy of this notice and the right to file a complaint if you believe your privacy rights have been violated.
Notice of Special Enrollment Rights
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. If you are declining enrollment for yourself or your dependents (including your spouse) while coverage under Medicaid or a state Children’s Health Insurance Program (CHIP) is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage. However, you must request enrollment within 60 days after your or your dependents’ Medicaid or CHIP coverage ends. If you or your dependents (including your spouse) become eligible for a state premium assistance subsidy from Medicaid or a CHIP program with respect to coverage under this plan, you may be able to enroll yourself and your dependents (including your spouse) in this plan. However, you must request enrollment within 60 days after you or your dependents become eligible for the premium assistance. To request special enrollment or obtain more information, contact Human Resources.
** Continuation Coverage Rights Under COBRA **
Introduction You’re getting this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees. What is COBRA continuation coverage?
COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage are required to pay for COBRA continuation coverage. If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:
• Your hours of employment are reduced, or • Your employment ends for any reason other than your gross misconduct.
If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:
• Your spouse dies; • Your spouse’s hours of employment are reduced; • Your spouse’s employment ends for any reason other than his or her gross misconduct; • Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or • You become divorced or legally separated from your spouse.
Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events:
• The parent-employee dies; • The parent-employee’s hours of employment are reduced; • The parent-employee’s employment ends for any reason other than his or her gross misconduct;
• The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); • The parents become divorced or legally separated; or • The child stops being eligible for coverage under the Plan as a “dependent child.”
When is COBRA continuation coverage available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events:
• The end of employment or reduction of hours of employment; • Death of the employee; or • The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).
For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to Human Resources. How is COBRA continuation coverage provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. There are also ways in which this 18-month period of COBRA continuation coverage can be extended: Disability extension of 18-month period of COBRA continuation coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. Are there other coverage options besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options
(such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov. If you have questions
Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov. Keep your Plan informed of address changes To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.
New Health Insurance Marketplace Coverage Options and Your Health Coverage
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 employmentbased 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 Human Resources.
.
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.
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.
Form Approved OMB No. 1210-0149
(expires 5-31-2020)
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 QCR Holdings, Inc. 4. Employer Identification Number (EIN) 42-
1397595
5. Employer address 3551 7th Street 6. Employer phone number 609-743-7721
7. City Moline 8. State IL 9. ZIP Code 61265
10. Who can we contact about employee health coverage at this job? Christina Back
11. Phone number (if different from above) 12. Email address cback@qcrh.com
Here is some basic information about health coverage offered by this employer:
• As your employer, we offer a health plan to:
Some employees. Eligible employees are: All employees averaging 30 hours or more per week.
• With respect to dependents:
We do offer coverage. Eligible dependents are: spouses and dependent children up to age 26
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.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020 – 12/31/2020 UMR: QCR HOLDINGS INC: 7670-00-411103 002 003 ($2,000) Coverage for: Individual + Family | Plan Type: HDHP
Page 1 of 6
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.umr.com or by calling 1-800-826-9781. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.umr.com or call 1-800-826-9781 to request a copy.
Important Questions Answers Why this Matters:
What is the overall deductible?
$2,000 person / $4,000 family In-network $2,250 person / $4,500 family Out-of-network
Generally, you must pay all the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, the overall family deductible must be met before the plan begins to pay.
Are there services covered before you meet your deductible?
Yes. Preventive care services are covered before you meet your deductible.
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/
Are there other deductibles for specific services?
No. You don’t have to meet deductibles for specific services.
What is the out–of–pocket limit for this plan?
$2,000 person / $4,000 family In-network $3,000 person / $5,000 family Out-of-network
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, the overall family out-of-pocket limit must be met.
What is not included in the out–of–pocket limit?
Penalties, premiums, balance billing charges, and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Will you pay less if you use a network provider?
Yes. See www.umr.com or call 1-800-826-9781 for a list of network providers.
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (a balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral.
Page 2 of 6
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Common Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other Important Information In-network
(You will pay the least) Out-of-network
(You will pay the most)
If you visit a health care provider’s office or clinic
Primary care visit to treat an injury or illness No charge 20% Coinsurance None
Specialist visit No charge 20% Coinsurance None
Preventive care/screening/ immunization
No charge; Deductible Waived
20% Coinsurance; Deductible Waived Preventive care & screenings from age 7 & Immunizations; 20% Coinsurance Preventive care & screenings from age 7
You may have to pay for services that aren't preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for.
If you have a test
Diagnostic test (x-ray, blood work) No charge 20% Coinsurance None
Imaging (CT/PET scans, MRIs) No charge 20% Coinsurance None
If you need drugs to treat your illness or condition. More information about prescription drug coverage is available at www.MedOne-rx.com
Generic drugs Deductible Applies NA
Non-Embedded Rx + Medical Deductibles and Maximums:
Individual Deductible: $2,000 Individual Out of Pocket Max: $2,000 Family Deductible: $4,000 Family Out of Pocket Max: $4,000
Preferred brand drugs Deductible Applies NA
Non-preferred brand drugs Deductible Applies NA
Specialty drugs Deductible Applies NA
Page 3 of 6
Common Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other Important Information In-network
(You will pay the least) Out-of-network
(You will pay the most)
If you have outpatient surgery
Facility fee (e.g., ambulatory surgery center) No charge 20% Coinsurance None
Physician/surgeon fees No charge 20% Coinsurance None
If you need immediate medical attention
Emergency room care No charge 20% Coinsurance None
Emergency medical transportation No charge 20% Coinsurance None
Urgent care No charge 20% Coinsurance None
If you have a hospital stay
Facility fee (e.g., hospital room) No charge 20% Coinsurance
Preauthorization is required. If you don’t get preauthorization, benefits could be reduced by 50% not to exceed $500 of the total cost of the service.
Physician/surgeon fee No charge 20% Coinsurance None
If you have mental health, behavioral health, or substance abuse needs
Outpatient services No charge 20% Coinsurance None
Inpatient services No charge 20% Coinsurance
Preauthorization is required. If you don’t get preauthorization, benefits could be reduced by 50% not to exceed $500 of the total cost of the service.
If you are pregnant
Office visits No charge; Deductible Waived 20% Coinsurance Cost sharing does not apply to certain
preventive services. Depending on the type of services, deductible, copayment or coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
Childbirth/delivery professional services No charge 20% Coinsurance
Childbirth/delivery facility services No charge 20% Coinsurance
Page 4 of 6
Common Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other Important Information In-network
(You will pay the least) Out-of-network
(You will pay the most)
If you need help recovering or have other special health needs
Home health care No charge 20% Coinsurance
Preauthorization is required. If you don’t get preauthorization, benefits could be reduced by 50% not to exceed $500 of the total cost of the service.
Rehabilitation services No charge 20% Coinsurance 60 Maximum visits per calendar year
Habilitation services Not covered Not covered None
Skilled nursing care No charge 20% Coinsurance
100 Maximum days per calendar year; Preauthorization is required. If you don’t get preauthorization, benefits could be reduced by 50% not to exceed $500 of the total cost of the service.
Durable medical equipment No charge Not covered
Preauthorization is required for DME in excess of $500 for rentals or $1,500 for purchases. If you don’t get preauthorization, benefits could be reduced by 50% not to exceed $500 per claim.
Hospice service No charge 20% Coinsurance None
If your child needs dental or eye care
Children’s eye exam Not covered Not covered None
Children’s glasses Not covered Not covered None
Children’s dental check-up Not covered Not covered None
Page 5 of 6
Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Infertility treatment • Routine foot care • Cosmetic surgery • Long-term care • Weight loss programs • Dental care (Adult) • Routine eye care (Adult)
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric surgery • Hearing aids (In-network only) • Private-duty nursing (if medically necessary) • Chiropractic care • Non-emergency care when traveling outside the U.S. Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.HealthCare.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.HealthCare.gov. Additionally, a consumer assistance program may help you file your appeal. A list of states with Consumer Assistance Programs is available at www.HealthCare.gov and http://cciio.cms.gov/programs/consumer/capgrants/index.html. Does this plan Provide Minimum Essential Coverage? Yes If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan Meet the Minimum Value Standard? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-800-826-9781. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-826-9781.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-826-9781.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
The plan would be responsible for the other costs of these EXAMPLE covered services. Page 6 of 6
Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well-
controlled condition)
Peg is Having a Baby (9 months of in-network pre-natal care and a
hospital delivery)
Mia’s Simple Fracture (in-network emergency room visit and follow up
care)
About these Coverage Examples: The plan's overall deductible $2,000 Specialist coinsurance 0% Hospital (facility) coinsurance 0% Other coinsurance 0% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,800
In this example, Peg would pay:
Cost Sharing Deductibles $2,000 Copayments $0 Coinsurance $0
What isn’t covered Limits or exclusions $0 The total Peg would pay is $2,000
The plan's overall deductible $2,000 Specialist coinsurance 0% Hospital (facility) coinsurance 0% Other coinsurance 0% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,400
In this example, Joe would pay:
Cost Sharing Deductibles* $2,000 Copayments $0 Coinsurance $0
What isn’t covered Limits or exclusions $0 The total Joe would pay is $2,000
The plan's overall deductible $2,000 Specialist coinsurance 0% Hospital (facility) coinsurance 0% Other coinsurance 0% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic tests (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $1,900
In this example, Mia would pay:
Cost Sharing Deductibles* $1,325 Copayments $0 Coinsurance $675
What isn’t covered Limits or exclusions $0 The total Mia would pay is $2,000
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
Note: These numbers assume the patient does not participate in the plan’s wellness program. If you participate in the plan’s wellness program, you may be able to reduce your costs. For more information about the wellness program, please contact: www.umr.com or call 1-800-826-9781. *Note: This plan has other deductibles for specific services included in this coverage example. See "Are there other deductibles for specific services?”" row above.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020 – 12/31/2020 UMR: QCR HOLDINGS INC: 7670-00-411103 001 ($1,500) Coverage for: Individual + Family | Plan Type: PPO
Page 1 of 6
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.umr.com or by calling 1-800-826-9781. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.umr.com or call 1-800-826-9781 to request a copy.
Important Questions Answers Why this Matters:
What is the overall deductible?
$1,500 person / $3,000 family In-network $1,750 person / $3,500 family Out-of-network
Generally, you must pay all the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
Are there services covered before you meet your deductible?
Yes. Preventive care services are covered before you meet your deductible.
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/
Are there other deductibles for specific services?
Yes, Rx. You don’t have to meet deductibles for specific services.
What is the out–of–pocket limit for this plan?
$5,500 person / $9,000 family In-network $6,250 person / $10,000 family Out-of-network
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
What is not included in the out–of–pocket limit?
Copayments for out-of-network services, penalties, premiums, balance billing charges, and health care this plan doesn’t cover.
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Will you pay less if you use a network provider?
Yes. See www.umr.com or call 1-800-826-9781 for a list of network providers.
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (a balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral.
Page 2 of 6
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Common Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other Important Information In-network
(You will pay the least) Out-of-network
(You will pay the most)
If you visit a health care provider’s office or clinic
Primary care visit to treat an injury or illness
$30 Copay per visit; Deductible Waived 50% Coinsurance None
Specialist visit $50 Copay per visit; Deductible Waived 50% Coinsurance None
Preventive care/screening/ immunization
No charge; Deductible Waived
50% Coinsurance; Deductible Waived Preventive care & screenings to age 7 & Immunizations; 50% Coinsurance from age 7 Preventive care & screenings
You may have to pay for services that aren't preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for.
If you have a test
Diagnostic test (x-ray, blood work)
30% Coinsurance; Deductible Waived office setting; 30% Coinsurance outpatient setting
50% Coinsurance None
Imaging (CT/PET scans, MRIs)
20% Coinsurance; Deductible Waived office setting; 30% Coinsurance outpatient setting
50% Coinsurance None
If you need drugs to treat your illness or condition. More information about prescription drug coverage is available at www.MedOne-rx.com
Retail 30-Day Supply
Generic: $5 Preferred Brand: $50 Non-Preferred Brand: $85
NA
Deductible: Individual Rx Deductible: $150 Family Rx Deductible $300 Embedded RX Out of Pocket Maximum: Individual: $5,500 Family: $9,000
Retail 90-Day Supply
Generic: $15 Preferred Brand: $150 Non-Preferred Brand: $255
NA
Mail Order 90-Day Supply
Generic: $10 Preferred Brand: $100 Non-Preferred Brand: $170
NA
Specialty drugs 30-Day Supply 30% of drug cost NA
Page 3 of 6
Common Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other Important Information In-network
(You will pay the least) Out-of-network
(You will pay the most)
If you have outpatient surgery
Facility fee (e.g., ambulatory surgery center) 30% Coinsurance 50% Coinsurance None
Physician/surgeon fees 30% Coinsurance 50% Coinsurance None
If you need immediate medical attention
Emergency room care $300 Copay per visit Facility; 30% Coinsurance Physician; Deductible Waived
$300 Copay per visit Facility; 30% Coinsurance Physician; Deductible Waived
Copay may be waived if admitted
Emergency medical transportation
No charge; Deductible Waived
No charge; Deductible Waived None
Urgent care $50 Copay per visit; Deductible Waived 50% Coinsurance None
If you have a hospital stay
Facility fee (e.g., hospital room) 30% Coinsurance 50% Coinsurance
Preauthorization is required. If you don’t get preauthorization, benefits could be reduced by 50% not to exceed $500 of the total cost of the service.
Physician/surgeon fee 30% Coinsurance 50% Coinsurance None
If you have mental health, behavioral health, or substance abuse needs
Outpatient services $30 Copay per visit; Deductible Waived office visit; 30% Coinsurance other outpatient services
50% Coinsurance None
Inpatient services 30% Coinsurance 50% Coinsurance
Preauthorization is required. If you don’t get preauthorization, benefits could be reduced by 50% not to exceed $500 of the total cost of the service.
If you are pregnant
Office visits No charge; Deductible Waived 50% Coinsurance Cost sharing does not apply to certain
preventive services. Depending on the type of services, deductible, copayment or coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
Childbirth/delivery professional services 30% Coinsurance 50% Coinsurance
Childbirth/delivery facility services 30% Coinsurance 50% Coinsurance
Page 4 of 6
Common Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other Important Information In-network
(You will pay the least) Out-of-network
(You will pay the most)
If you need help recovering or have other special health needs
Home health care 30% Coinsurance Not covered
Preauthorization is required. If you don’t get preauthorization, benefits could be reduced by 50% not to exceed $500 of the total cost of the service.
Rehabilitation services 30% Coinsurance 50% Coinsurance 60 Maximum visits per calendar year
Habilitation services Not covered Not covered None
Skilled nursing care 30% Coinsurance 50% Coinsurance
100 Maximum days per calendar year; Preauthorization is required. If you don’t get preauthorization, benefits could be reduced by 50% not to exceed $500 of the total cost of the service.
Durable medical equipment 30% Coinsurance Not covered
Preauthorization is required for DME in excess of $500 for rentals or $1,500 for purchases. If you don’t get preauthorization, benefits could be reduced by 50% not to exceed $500 per claim.
Hospice service 30% Coinsurance 50% Coinsurance None
If your child needs dental or eye care
Children’s eye exam Not covered Not covered None
Children’s glasses Not covered Not covered None
Children’s dental check-up Not covered Not covered None
Page 5 of 6
Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Infertility treatment • Routine foot care • Cosmetic surgery • Long-term care • Weight loss programs • Dental care (Adult) • Routine eye care (Adult)
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric surgery • Hearing aids (In-network only) • Private-duty nursing (if medically necessary) • Chiropractic care • Non-emergency care when traveling outside the U.S. Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.HealthCare.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.HealthCare.gov. Additionally, a consumer assistance program may help you file your appeal. A list of states with Consumer Assistance Programs is available at www.HealthCare.gov and http://cciio.cms.gov/programs/consumer/capgrants/index.html. Does this plan Provide Minimum Essential Coverage? Yes If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan Meet the Minimum Value Standard? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-800-826-9781. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-826-9781.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-826-9781.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
The plan would be responsible for the other costs of these EXAMPLE covered services. Page 6 of 6
Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well-
controlled condition)
Peg is Having a Baby (9 months of in-network pre-natal care and a
hospital delivery)
Mia’s Simple Fracture (in-network emergency room visit and follow up
care)
About these Coverage Examples: The plan's overall deductible $1,500 Specialist copayment $50 Hospital (facility) coinsurance 30% Other coinsurance 30% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,800
In this example, Peg would pay:
Cost Sharing Deductibles $1,500 Copayments $20 Coinsurance $3,300
What isn’t covered Limits or exclusions $0 The total Peg would pay is $4,820
The plan's overall deductible $1,500 Specialist copayment $50 Hospital (facility) coinsurance 30% Other coinsurance 30% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,400
In this example, Joe would pay:
Cost Sharing Deductibles* $1,500 Copayments $320 Coinsurance $360
What isn’t covered Limits or exclusions $0 The total Joe would pay is $2,180
The plan's overall deductible $1,500 Specialist copayment $50 Hospital (facility) coinsurance 30% Other coinsurance 30% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic tests (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $1,900
In this example, Mia would pay:
Cost Sharing Deductibles* $1,230 Copayments $450 Coinsurance $110
What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,790
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
Note: These numbers assume the patient does not participate in the plan’s wellness program. If you participate in the plan’s wellness program, you may be able to reduce your costs. For more information about the wellness program, please contact: www.umr.com or call 1-800-826-9781. *Note: This plan has other deductibles for specific services included in this coverage example. See "Are there other deductibles for specific services?”" row above.
KH-EG-C (04/19)
EMPLOYEE GUIDE
Cancer Insurance
If you’ve known anyone who has dealt with cancer, you’ve probably seen the financial impact it can cause — even for those with good medical coverage.
How does it work?Employees select coverage that best suits their needs.
Multiple plan options are available with a First Diagnosis Benefit from $2,500 - $5,000.
Kemper Health Cancer Insurance provides a one-time lump-sum benefit for first diagnosis.
Employees and covered family members may receive a one-time lump-sum benefit upon diagnosis of cancer, or specified disease if included.
It also provides benefits for a positive diagnosis test, second and third surgical opinions, drugs and medicines, lodging and transportation, new or experimental treatment and more.
Employees are paid directly with no restrictions on how the cash benefit can be used.
The Kemper Health Cancer Insurance benefit is paid directly to the insured, not the medical provider, and can be used for medical and non-medical costs such as child care, housing costs or even groceries.
1 Benefits pays for charges up to amount listed
2 Disability of primary insured only
• First diagnosis benefit with Second and Third
opinions covered
• Drugs and Medicine, including outpatient anti-
nausea drugs
• Private nursing services
• National Cancer Institute Designated
Comprehensive Cancer Treatment Center
Evaluation/Consultation Benefit
• Breast Prosthesis
• New or experimental therapy
• Hospice care
• Hairpieces and rental of durable goods
• Specified disease coverage
• Radiation/chemotherapy/immunotherapy
• Surgery
• Wellness
• At home nursing
Our cancer insurance provides fixed benefits for early detection and treatment of certain types of cancer. It also includes benefits for other related expenses such as drugs and medicine, new or experimental treatment, hair pieces, hospital confinement, radiation, surgery and an evaluation/consultation at a National Cancer Institute Designated Comprehensive Cancer Treatment Center. There are no restrictions on how you spend the money. You can use it to pay monthly bills, loss of income, child care or anything else you need.
Financial help when you need it most: • Benefits will be paid directly to you, not the hospital
• Coverage can be purchased for you and your entire family
• Waiver of premium after 60 days of disability due to cancer for as long as your disability lasts2
• Portable coverage if you leave your current job, at the same premium
• Includes coverage for 32 other specified diseases
Kemper Health Cancer insurance plan highlights:
PRODUCT FEATURES AND BENEFITSDiagnosis and Related Benefits Plan 1 (Low) Plan 2 (Mid) Plan 2 (High)
First Diagnosis Benefit $2,500 $2,500 $5,000
Positive Diagnosis Test1 $300 $300 $300
Non-Melanoma Skin Cancer Diagnosis Benefit (yearly) $100 $100 $100
National Comprehensive Cancer Treatment Center Evaluation/Consultation1 $750 $750 $750
Hospital and Related Benefits
Hospital Confinement Benefit (daily) $100 $200 $300
Extended Benefits (daily) $300 $600 $900
Government or Charity Hospital (daily)1 $200 $200 $200
Physician's Attendance (daily)1 $35 $35 $35
Private Duty Nursing Services (daily)1 $100 $100 $100
Extended Care Facility (daily)1 $50 $50 $50
At Home Nursing (daily) 1 $100 $100 $100
Hospice Care (daily) 1 $50 $50 $50
See the certificate and any attached rider(s) for details on benefit requirements, provisions, terms, conditions, limitations and exclusions.
1 Benefits pays for charges up to amount listed 2 Based on procedure up to maximum shown 3 Subject to a calender year maximum 4 Subject to a lifetime maximum
PRODUCT FEATURES AND BENEFITSRadiation, Chemotherapy and Related Benefits Plan 1 (Low) Plan 2 (Mid) Plan 2 (High)
Radiation/Chemotherapy/Immunotherapy (monthly) $2,500 $5,000 $10,000
Blood, Plasma and Platelets (daily)1 $200 $200 $200
Colony Stimulating Factors (monthly)1 $500 $500 $1,000
Surgery and Related Benefits
Surgical 1 $1,500 $1,500 $3,000
Second and Third Surgical Opinions Charges Charges Charges
Bone Marrow and Peripheral Stem Cell Transplant (lifetime)2,4 $15,000 $15,000 $15,000
Anesthesia ( % of surgery) 25% 25% 25%
Ambulatory Surgical Center (daily) 1 $250 $250 $250
Donor Benefit Bone Marrow and Stem Cell Transplant (daily)1 $50 $50 $50
- 2X Hospital Confinement Benefit $200 $400 $600
- round trip coach fair Charges Charges Charges
- transportation personal vehicle $.50/mile $.50/mile $.50/mile
- donor lodging and meals Charges Charges Charges
Miscellaneous Benefits
Drugs and Medicine (daily) 1,3 $25 $25 $25
Outpatient Anti-Nausea Drugs (yearly)1,3 $250 $250 $250
Self-Administering Drugs (monthly)1 $4,000 $4,000 $4,000
New or Experimental Treatment (yearly)1,3 $7,500 $7,500 $7,500
Miscellaneous Therapy Charges (lifetime)1,4 $10,000 $10,000 $10,000
Physical Therapy or Speech Therapy (per session)1 $35 $35 $35
Ambulance Charges Charges Charges
Non-Local Transportation Coach Fare or $.50/mile
Coach Fare or $.50/mile
Coach Fare or $.50/mile
Adult Companion Lodging (daily)1 $ 75/day $ 75/day $ 75/day
Adult Companion Transportation Coach Fare or $.50/mile
Coach Fare or $.50/mile
Coach Fare or $.50/mile
Artificial Limb or Prosthesis (lifetime)1,4 $1,500 $1,500 $1,500
Breast Prosthesis Charges Charges Charges
Hair Piece (lifetime) 1,4 $150 $150 $150
Rental or Purchase of Durable Goods (yearly) 1,3 $1,500 $1,500 $1,500
Additional Benefits
Wellness (yearly) 1,3 $50 $50 $75
Intensive Care Unit (daily) - ICU confinement for treatment other than
cancer or a specified disease $325 $325 $325
- For confinement in a step down unit $162.50 $162.50 $162.50 - For confinement in a an ICU for treatment of
cancer or specified disease $650 $650 $650
- For confinement in an ICU for treatment of common carrier $650 $650 $650
Cancer Insurance Plan – Benefits*The following is a summary of the benefits included in the Kemper Health Cancer insurance plan. This is a brief description and does not replace or modify the comprehensive description of all benefits, limitations and exclusions contained in the policy/certificate and riders that are subject to the laws of the state having jurisdiction. Benefits, limitations, exclusions and rates may vary by state; plans not available in all states.
First Diagnosis BenefitPays a one-time benefit per insured when first diagnosed with cancer (or specified disease, if selected). The first diagnosis must occur after the certificate effective date.
Positive Diagnosis TestPays a one-time benefit per insured person for one diagnostic test that leads to positive diagnosis of cancer (or a specified disease) up to a maximum of $300 per calendar year. This benefit is not payable if the same cancer (or specified disease, if selected) recurs.
Second and Third Surgical OpinionsPays an insured’s expense incurred for a written second or third surgical opinion as to the need for a surgical procedure.
Non-Local TransportationPays an insured’s expenses for non-local travel to a hospital (inpatient or outpatient); radiation therapy center; chemotherapy or oncology clinic; or any other specialized treatment either at a common carrier fare; or 50 cents per mile for up to 700 miles per treatment for round-trip personal vehicle transportation for round trips over 60 miles. This benefit is payable if the insured’s treatment is not available locally and is available non-locally.
Adult Companion Lodging and TransportationPays for the insured’s one adult companion lodging and transportation expenses if the insured is confined in a non-local hospital for cancer (or specified disease) treatment. This benefit is payable for up to $75 per day for a single room in a motel, hotel or other accommodations up to a maximum stay of 60 days. This benefit is not payable for lodging expenses incurred more than 24 hours before the treatment nor for lodging expenses incurred more than 24 hours following treatment. This benefit pays a common carrier fare or 50 cents per mile round-trip personal vehicle transportation for round trips over 60 miles up to 700 miles per hospital stay for treatment. If we pay for personal vehicle mileage under the non-local transportation benefit we will pay personal vehicle mileage under this benefit only if the adult companion lives in another town other than where the insured lives.
AmbulancePays an insured’s expenses for ambulance service if the insured is taken to the hospital by a licensed or hospital-owned ambulance and is admitted as an inpatient.
Bone Marrow and Peripheral Stem Cell TransplantPays for an insured’s expenses for surgical and anesthetic charges associated with bone marrow transplant and/or peripheral stem cell transplant up to a combined lifetime maximum of $15,000.
*Some provisions and benefits may not be available in all states or may vary by state. See each state’s policy/certificate for details.
CANCER INSURANCE SEMI-MONTHLY RATESEmployee Employee + Spouse Employee + Children Employee + Family
Plan 1 (Low) $11.24 $21.94 $15.29 $24.55
Plan 2 (Mid) $14.42 $28.11 $19.42 $31.33
Plan 3 (High) $18.21 $35.48 $24.22 $39.36
Rates are for sample purposes and based on Iowa state rates.
AnesthesiaPays an insured’s expenses incurred for the services of an anesthesiologist in connection with surgery up to 25% of the amount paid for such surgery. For anesthesia in connection with the treatment of skin cancer, the benefit is limited to $100.
Ambulatory Surgical CenterPays an Insured’s expenses incurred for surgery performed at an ambulatory surgical center up to a maximum of $250 per day.
Drugs and MedicinesPays an insured’s expenses for drugs and medicine while confined in a hospital up to a maximum of $25 for each day of confinement, subject to a calendar year maximum of $600.
Outpatient Anti-Nausea DrugsPays an insured’s expenses for drugs prescribed by a physician and used for suppressing nausea during cancer (or specified disease, if selected) treatment up to a maximum of $250 per calendar year.
Miscellaneous Therapy Charges Pays an insured’s expenses up to a lifetime maximum of $10,000 for laboratory work and its interpretation and routine or diagnostic x-rays, scans and their interpretations. Service must be performed while receiving treatment(s) in radiation therapy, radioactive isotopes therapy; chemotherapy or immunotherapy or within 30 days following a covered treatment.
Self-Administering Drugs Pays an insured’s expenses up to $4,000 per month for self-administered chemotherapy, including hormone therapy, or immunotherapy agents.
Blood, Plasma and Platelets Pays for an insured person’s expenses incurred up to a maximum of $200 per day for: 1. Blood, plasma and platelets; 2. Transfusions; 3. The administration of 1 and 2 above; 4. Processing and procurement costs; and 5. Cross matching.Will not pay for blood replaced by donors.
Physician’s AttendancePays an insured’s expenses up to a maximum of $35 per day for one visit per day by a physician while the insured is confined in a hospital.
Private Duty Nursing ServicesPays an insured’s expenses up to a maximum of $100 per day for private nursing care by a nurse required and ordered by the attending physician, and while the insured is confined in a hospital.
National Cancer Institute Designated Comprehensive Cancer Treatment Center Evaluation/Consultation BenefitPays an insured’s expenses up to a lifetime maximum of $750 for evaluation if diagnosed with cancer and seeking evaluation or consultation from a National Cancer Institute Designated Comprehensive Cancer Treatment Center. If the Comprehensive Cancer Treatment Center is located more than 30 miles from the insured’s place of residence, it also pays for transportation and lodging expenses up to a lifetime maximum of up to $350.
This benefit is not payable on the same day a second or third surgical opinion benefit is payable and is in lieu of the non-local transportation benefits of the policy.
Cancer Insurance Plan – Benefits (continued)*
*Some provisions and benefits may not be available in all states or may vary by state. See each state’s policy/certificate for details.
Breast ProsthesisPays an insured’s expenses for a breast prosthesis to restore body contour lost due to breast cancer and the implantation of the prosthesis.
Artificial Limb or Prosthesis Pays an insured’s expenses incurred when an amputation is performed up to a lifetime maximum of $1,500 per insured person for amputation per an artificial limb or prosthesis and the procedure to affix or implant it.
Physical Therapy or Speech TherapyPays an insured’s expenses up to $35 per therapy session for physical or speech therapy for restoration of normal bodily function.
New or Experimental TreatmentPays an insured’s expenses up to a maximum of $7,500 per calendar year for new or experimental treatment, which is judged necessary by the attending physician and received in the United States or in its territories.
Hospice CarePays an insured’s expenses up to $50 per day for care received in a free standing hospice care center or at home if diagnosed as terminally ill. The attending physician must approve the stay or care, and the stay or care must begin within 14 days after a hospital stay. Admission or benefits payable for hospice centers that are designated areas of hospitals will be paid the same as inpatient hospital stays. We will not pay for food services or meals other than dietary counseling; services related to well-baby care; services provided by volunteers; or support for the family after the death of the Insured Person.
Government or Charity HospitalPays an insured up to $200 per day for confinement in a hospital operated by or for the United States Government (including the Veteran’s Administration) or a hospital that does not charge for the services it provides (charity). The daily benefit is paid in lieu of all other benefits provided in the policy.
HairpiecePays for an insured’s expenses up to a lifetime maximum of $150 for a hairpiece when hair loss is the result of cancer treatment.
Rental or Purchase of Durable GoodsPays for an insured’s expenses up to $1,500 per calendar year for the rental or purchase of the following pieces of durable medical equipment: 1. A respirator or similar mechanical device; 2. Brace; 3. Crutches; 4. Hospital bed; and 5. Wheelchair.
Waiver of Premium Premiums are waived following a 60-day period of disability due to cancer (or specified disease, if selected). An insured must be receiving treatment for such cancer (or specified disease, if selected) for which benefits are payable under the policy and remain disabled for 60 consecutive days. Premiums are waived for the period of disability.
*Some provisions and benefits may not be available in all states or may vary by state. See each state’s policy/certificate for details.
Cancer Insurance Plan – Benefits (continued)*
Cancer Insurance Plan – Benefits (continued)*
*Some provisions and benefits may not be available in all states or may vary by state. See each state’s policy/certificate for details.
Specified Disease - Plan 1 (Low), Plan 2 (Mid), Plan 3 (High)Specified disease means any of the following: Addison’s Disease, Amyotrophic Lateral Sclerosis, Cystic Fibrosis, Diphtheria, Encephalitis, Epilepsy, Hansen’s Disease, Legionnaire’s Disease, Lupus Erythematosus, Lyme Disease, Malaria, Meningitis(epidemic cerebrospinal), Multiple Sclerosis, Muscular Dystrophy, Myasthenia Gravis, Niemann-Pick Disease, Osteomyelitis, Poliomyelitis, Rabies, Reye’s Syndrome, Rheumatic Fever, Rocky Mountain Spotted Fever, Scarlet Fever, Sickle Cell Anemia, Tay-Sachs Disease, Tetanus, Toxic Epidermal Necrolysis, Tuberculosis, Tularemia, Typhoid Fever, Undulant Fever, Whipple’s Disease
Hospital Confinement Benefit - Plan 1 (Low), Plan 2 (Mid), Plan 3 (High)Pays a daily benefit for each day an insured is charged the daily room rate by a hospital. This benefit is payable up to 60 days for one period of continuous stay. For covered dependent child(ren) under the age of 21, the benefit is two times the daily benefit for Hospital Confinement shown in the policy’s Schedule of Benefits.
Colony Stimulating Factors - Plan 1 (Low), Plan 2 (Mid), Plan 3 (High)Pays the insured’s expense incurred up to the selected monthly maximum benefit for the cost of chemical substances and their administration to stimulate the production of blood cells.
Radiation/Chemotherapy/Immunotherapy - Plan 1 (Low), Plan 2 (Mid), Plan 3 (High)Pays a daily or monthly benefit for expenses incurred for covered treatment to modify or destroy cancerous tissue.
Surgery - Plan 1 (Low), Plan 2 (Mid), Plan 3 (High)Pays the insured’s expense incurred for a surgeon’s fee up to the amount shown in the policy’s Surgical Schedule for an operation and for care by the surgeon after the operation. Payment will not include charges by an assistant or co-surgeons. Benefits for surgery performed on an outpatient basis will be 150% of the scheduled amount shown on the surgical schedule not to exceed the actual surgeon’s fees for the surgery.
Non-Melanoma Skin Cancer Diagnosis Benefit - 1 (Low), Plan 2 (Mid), Plan 3 (High)Pays an annual benefit per insured when diagnosed with non-melanoma skin cancer. This benefit is not payable for a diagnosis of malignant melanoma or any other type of cancer. No other benefits are payable for the diagnosis or treatment of any non-melanoma skin cancer.
Extended Benefits - Plan 1 (Low), Plan 2 (Mid) This benefit is only available if the Hospital Confinement Benefit is included. It pays a benefit of three times the Hospital Confinement Benefit if the insured is confined in a hospital for more than 60 continuous days. Payment will begin on the 61st day of continuous hospital confinement. This benefit is payable in lieu of the Hospital Confinement Benefit.
Extended Care Facility - 1 (Low), Plan 2 (Mid), Plan 3 (High)This benefit is only available if the Hospital Confinement Benefit is included. It pays an insured’s expenses incurred for confinement in an extended care facility for a maximum of $50 per day, up to the number of days that the Hospital Confinement Benefit was paid. The confinement in the extended care facility must be at the direction of the attending physician and must begin within 14 days after a hospital confinement.
At Home Nursing - 1 (Low), Plan 2 (Mid), Plan 3 (High)This benefit is only available if the Hospital Confinement Benefit is included. It pays an insured’s expenses incurred for a private duty nurse at home up to $100 per day and up to the number of days that the Hospital Confinement Benefit was paid. The nursing services
must be required and authorized by the attending physician and must begin immediately following a hospital confinement.
Cancer Insurance Plan – Benefits (continued)*
*Some provisions and benefits may not be available in all states or may vary by state. See each state’s policy/certificate for details.
Donor Benefit Bone Marrow and Stem Cell Transplant - 1 (Low), Plan 2 (Mid), Plan 3 (High)This benefit is only available if the Hospital Confinement Benefit is included. It pays for the expenses incurred, up to $50 per day, by an insured and his or her live donor. Also pays: (a) two times the Hospital Confinement Benefit for medical expenses, (b) charges for round trip coach fare on a common carrier to the city where the transplant is performed, (c) 50 cents per mile personal vehicle transportation from the insured’s or donor’s home to the hospital in which the insured is staying up to 700 miles per hospital stay and (d) for lodging and meals expenses for donor to remain near hospital.
Wellness - 1 (Low), Plan 2 (Mid), Plan 3 (High)Pays an insured’s expenses incurred up to the selected benefit amount for cancer screening, including, but not limited to, the following:
Abdominal aortic aneurysm ultrasound EKG
Blood test for triglycerides Double contrast barium enema
Bone marrow testing Fasting blood glucose test
Bone density screening Flexible sigmoidoscopy
Breast ultrasound Hemoccult stool analysis
Cancer Antigen 125 blood test Mammography
Cancer Antigen 15-3 blood test Pap test
Carcinoembryonic antigen (CEA) blood test Prostate Specific Antigen (PSA) blood test
Carotid ultrasound Serum cholesterol test to determine HDL/LDL level
CEA (blood test for colon cancer) Serum Protein Electrophoresis (SPEP) blood test
Chest X-ray Stress test
Colonoscopy Thermography
CT Angiography
Intensive Care Unit (ICU) Benefit - 1 (Low), Plan 2 (Mid), Plan 3 (High)Pays a daily benefit per insured’s period of confinement in an intensive care unit (ICU). The period of confinement must be due to sickness or injury. Benefits are payable from the first day of intensive care unit (ICU) confinement. A day is defined as a 24-hour period. If an Insured is confined to an intensive care unit (ICU) for only part of a day, a pro-rata portion of the daily benefit will be paid.
INTENSIVE CARE UNIT BENEFITS CONFINEMENT AMOUNTSFor confinement in an intensive care unit (ICU) for treatment other than for cancer (or specified disease, if selected) or common carrier injury
Plan 1 (Low) $325 Plan 2 (Mid) $325 Plan 3 (High) $325
For confinement in a step down unit One-half the daily benefit amount elected for intensive care unit (ICU) confinement
For confinement in an intensive care unit (ICU) for treatment of cancer (or specified disease, if selected)
2 times the daily benefit amount elected for intensive care unit (ICU) confinement
For confinement in an intensive care unit (ICU) for treatment of common carrier injury
2 times the daily benefit amount elected for intensive care unit (ICU) confinement
Maximum payment period 45 days per period of confinement
Cancer Insurance Plan Limitations and ExclusionsLimitationsDuring the first 1 month, following the effective date of coverage for an insured person, losses incurred for pre-existing conditions are not covered. After this 1 month period, benefits for such conditions will be payable unless specifically excluded from coverage. We will give credit for any time the insured person was covered under a similar policy immediately prior to the certificate effective date.
This pre-existing condition limitation does not apply to the Wellness Benefit.
The pre-existing condition exclusion period will be reduced for each insured person to the extent the pre-existing condition exclusion period was previously satisfied by similar coverage in force immediately prior to the insured’s effective date of coverage under the policy.
Pre-Existing Conditions means Cancer or a specified disease for which an insured person has received medical consultation, treatment, care, services, or for which diagnostic test(s) have been recommended for which medication has been prescribed during the 1 month immediately preceding the effective date of coverage for the insured person.
ExclusionsBenefits under the policy and any attached rider(s) will only be payable for diagnosis resulting from cancer (or specified diseases, if included). Benefits are not payable for any loss caused in whole or in part by or resulting in whole or part from the following:
1. Any other disease or sickness;
2. Injuries;
3. Any disease, condition, or incapacity that has been caused, complicated, worsened, or affected by:
a. Specified disease or specified disease treatment (if included); or
b. Cancer or cancer treatment, or unless otherwise defined in the policy;
4. Care and treatment received outside the United States or its territories; or
5. New and experimental treatment by any program that does not qualify as new and experimental treatment under the Policy.
Some provisions, exclusions or limitations may vary by state. See the certificate for details.
Policy Form Series KB-EC-POL-0117 and KB-MC-0117
Intensive Care Unit (ICU) Rider ExclusionsExclusions This rider does not cover intensive care unit (ICU) or step down unit confinements that occur during a period of confinement that began before the rider effective date or resulting from intentionally self-inflicted injury or suicide attempt.
This rider does not cover any loss as a result of the insured person’s being intoxicated or under the influence of alcohol, drugs or any narcotic unless administered on the advice of a physician and taken according to the physician’s advice. The term “intoxicated” refers to that condition as defined by law or the legal decisions of the jurisdiction in which the accident or the cause of the loss or losses occurred.
Some provisions, exclusions or limitations may vary by state. See the certificate for details.
Rider Form Series KB-EC-ICU-0117 and KB-MC-ICU-0117
Policies issued by: Reserve National Insurance Company A Kemper Health Company Oklahoma City, Oklahoma
Policy Form Number Series KB-EC-POL-0117 and KB-MC-0117, with Rider Form Series KB-EC-HASFDB and KB-MC-HASFDB-0117, KB-EC-ICU-0117 and KB-MC-ICU-0117, and KB-EC-BER-0117 and KB-MC-BER-0117. Form numbers may vary by state.
Kemper Health, kemperbenefits.com, is part of Kemper Corporation (NYSE: KMPR), a diversified insurance holding company, with subsidiaries that provide an array of products to the individual and business markets. Kemper’s underwriting companies are rated “A-” (Excellent) for financial strength and ability to meet policyowner obligations by A.M. Best Company, a leading insurance rating authority.
Kemper Corporation’s underwriting company for the Kemper Health voluntary worksite life, accident and health insurance products is Reserve National Insurance Company, which is responsible for the underwriting risks, financial and contractual obligations and support functions associated with the products it issues. Kemper Corporation is not responsible for the products of any of its underwriting companies.
This is only a summary of products and services offered. Actual offerings may vary by group size and other underwriting considerations, and are subject to state insurance law, and the benefits/provisions as described may vary due to such law. All products are subject to the terms, conditions, limitations and exclusions of the specific policy. Please see the specific policy and certificate for details. Policies are not available in all states.
The Kemper Health insurance plans, either separately or in combination with each other, are not “minimum essential coverage” under the federal Affordable Care Act. Lack of minimum essential coverage may result in an additional tax payment.
IMPORTANT: If an individual is insured under the Kemper Health Cancer Insurance Policy and is also covered by Medicaid or a state variation of Medicaid, most benefits are automatically assigned according to state regulations. This means that instead of paying the benefits to the insured individual, we must pay the benefits to Medicaid or the medical provider to reduce the charges billed to Medicaid. Please consider your circumstances before enrolling in Kemper Health coverage.
©2019. All rights reserved.
kemperbenefits.com
Affordable protection in an ever-changing world. At Kemper Health we understand the changes that affect our
customers’ lives and their need for affordable insurance. Our
voluntary benefits play a critical role in employees’ financial well-
being by helping fill the gaps in major medical plans, preparing for
retirement and providing financial protection from the unexpected.
Contact Kemper Health today to discover how easy it is to offer
your clients the best solutions.
KH-RS-C (05/19)
BENEFIT SNAPSHOTLow Mid High
First Diagnosis Benefit $2,500 $2,500 $5,000
Hospital Confinement $100/day $200/day $300/day
Colony Stimulating Factors
$500/month $500/month $1,000/month
Radiation/Chemotherapy
$2,500/month $5,000/month $10,000/month
Surgical Benefit $1,500 $1,500 $3,000
Non-Melanoma/Skin Cancer Diagnosis
$100 $100 $100
Wellness $50 $50 $75
New or Experimental Treatment
Up to $7,500 per calendar year
Specified Disease 32 additional illnesses
See the certificate and any attached rider(s) for details on benefit requirements provisions, terms, conditions, limitations and exclusions.
Cash benefits are paid directly to the insured with no restrictions on how the funds can be used.
Cancer Insurance
Help when you need it most When you or a loved one is diagnosed with cancer, the financial burden can be overwhelming. While primary health insurance is there to cover the medical bills, many patients face challenges due to time away from work and expenses not covered by other insurance.
Stay focused on getting well A Kemper Health Cancer insurance plan gives you an extra layer of financial security during these tough times—providing cash benefits that you can use to help keep the bills paid and protect your savings. That way, your focus can be on getting better.
How it Works 1. Select one of three plan options.
2. The plan pays a one-time, lump-sum first cancer diagnosis benefit.
3. As treatment begins, the plan pays additional benefits including:
• Radiation/chemotherapy/immunotherapy.
• New or Experimental Treatment.
• Second and third surgical opinions, drugs and medicines, lodging and transportation, and other expenses.
Features & Extras • No medical questions during initial enrollment.
• Coverage is portable.
• Wellness benefit for screenings like mammograms, PSA or Triglyceride blood tests.
• Skin cancer diagnosis (non-melanoma) benefit.
Policies issued by: Reserve National Insurance Company A Kemper Health Company Oklahoma City, Oklahoma Policy Form Number Series KB-EC-POL-0117 and KB-MC-0117. Form numbers and benefit availability may vary by state.
Kemper Health is part of Kemper Corporation (NYSE: KMPR), a diversified insurance holding company, with subsidiaries that provide an array of products to the individual and business markets. For more information about the Kemper Health voluntary worksite life, accident and health insurance products, see kemperbenefits.com.
Kemper Corporation’s underwriting company for the Kemper Health voluntary worksite life, accident and health insurance products is Reserve National Insurance Company, which is responsible for the underwriting risks, financial and contractual obligations and support functions associated with the products it issues. Reserve National Insurance Company is rated “A-” (Excellent) for financial strength and ability to meet policyowner obligations by A.M. Best Company, a leading insurance rating authority. Rating refers to the overall financial status of the Company and is not a recommendation of the specific policy previsions or practices. Kemper Corporation is not responsible for the products of any of its underwriting companies.
This is only a summary of products and services offered. Actual offerings may vary by group size and other underwriting considerations, and are subject to the requirements of state insurance laws and regulations, and the benefits/provisions as described may vary due to such requirements. All products are subject to the terms, conditions, limitations and exclusions of the specific policy. Please see the specific policy and certificate for details. Policies are not available in all states.
The Kemper Health insurance plans, either alone or in combination with each other, are not “minimum essential coverage” under the federal Affordable Care Act.
IMPORTANT: If an individual is insured under one or more Kemper Health insurance plans, and is also covered by Medicaid or a state variation of Medicaid, most non-disability benefits are automatically assigned according to state regulations. This means that instead of paying the benefits to the insured individual, we must pay the benefits to Medicaid or the medical provider to reduce the charges billed to Medicaid. Proposed insureds should consider their circumstances before enrolling in Kemper Health coverage.
If you are an employer offering one or more of these insurance products to your employees, the product(s) may constitute a part of an employee benefit plan under the Employee Retirement Income Security Act of 1974 (“ERISA”). An employer offering an ERISA employee benefit plan will be responsible for a number of obligations applicable under ERISA, including, without limitation, the obligation to make required disclosures to employees and file reports with the federal government. You should consult with an experienced attorney concerning the requirements for compliance with ERISA.
©2019. All rights reserved.
First Diagnosis Benefit
Positive Diagnosis Test
Second and Third Surgical Opinions
Non-Local Transportation
Adult Companion Lodging and Transportation
Ambulance
Bone Marrow and Peripheral Stem Cell Transplant
Anesthesia
Ambulatory Surgical Center
Drugs and Medicines
Outpatient Anti-Nausea Drugs
Miscellaneous Therapy Charges
Self-Administering Drugs
Blood, Plasma and Platelets
Physician’s Attendance
Private Duty Nursing Services
National Cancer Institute Designated Comprehensive Cancer Treatment Center Evaluation/Consultation Benefit
Breast Prosthesis
Artificial Limb or Prosthesis
Physical Therapy or Speech Therapy
New or Experimental Treatment
Hospice Care
Government or Charity Hospital Hairpiece
Rental or Purchase of Durable Goods
Waiver of Premium
Specified Disease
Hospital Confinement
Colony Stimulating Factors
Radiation/Chemotherapy/Immunotherapy Surgery
Non-Melanoma Skin Cancer Diagnosis Benefit
Extended Benefits
Extended Care Facility
At Home Nursing
Donor Benefit Bone Marrow and Stem Cell Transplant
Wellness
GROUP VOLUNTARY CANCER SEMI-MONTHLY RATES LOW Employee Employee/Spouse Employee/Children Family
$11.24 $21.94 $15.29 $24.55
MID
$14.42 $28.11 $19.42 $31.33
HIGH
$18.21 $35.48 $24.22 $39.36
Benefits Summary
The Kemper Health voluntary Critical Illness insurance plan gives peace of mind by reducing the financial burden and stress associated with a critical illness. Offering this type of insurance as part of a progressive group benefits plan can help attract and retain employees, support employee health and inspire loyalty in the workplace.
Policy Form Series KB-MCI-1805 and KB-ECI-1805, and Rider Form Series KB-MCI-CT-1805 and KB-ECI-CT-1805. 1Vise, Sharlotte. “At-A-Glance Heart Disease and Stroke Statistics 2018.” Health Metrics, American Heart Association, 31 Jan. 2018, healthmetrics.heart.org/at-a-glance-heart-disease-and-stroke-statistics-2018/.
KH-VP-CI (01/19)
How does it work?Kemper Health Critical Illness insurance provides a lump-sum benefit payment upon diagnosis of a covered illness, paid directly to the insured.
The insured may receive a lump-sum benefit for each covered critical illness diagnosis.
The insured person is paid directly with no restrictions on how the cash benefit can be used.
The Kemper Health Critical Illness benefit is paid directly to the insured and can be used for medical and non-medical costs, like child care, rent or even groceries.
Every 40 seconds, approximately one person
in the United States will have a heart attack1
Critical Illness Insurance
PRODUCT FEATURES AND BENEFITSPREMIER PLAN (Without Cancer)
100% Benefits Heart Attack, Stroke, Sudden Cardiac Arrest, Pulmonary Embolism, End Stage Renal (Kidney) Failure, Major Organ Failure, Coma, Severe Burns, Complete Loss of Hearing, Complete Loss of Sight, Complete Loss of Speech, Type 1 Diabetes, Multiple Sclerosis (MS), Muscular Dystrophy, Myasthenia Gravis, Occupational HIV, Occupational Hepatitis, Sickle Cell Anemia, Paralysis, Amyotrophic Lateral Sclerosis (ALS), Pulmonary Fibrosis, Lyme Disease
50% Benefits Advanced Alzheimer’s Disease, Advanced Parkinson’s Disease, Ruptured Aneurysm, Coronary Artery Disease (Bypass Surgery)
25% Benefits Diphtheria, Encephalitis, Heart Valve Surgery, Huntington’s Disease, Rabies, Rocky Mountain Spotted Fever, Tay-Sachs Disease, Tetanus, Tuberculosis
10% Benefits Heart Catheterization, Transient Ischemic Attack (TIA), Coronary Artery Disease (Angioplasty or Atherectomy)
Dependent Coverage Spouse/Children covered at 50% of employee’s benefit amount
Additional Occurrence Benefit 100% after 6 months
Reoccurrence Benefit 100% after 12 months
Childhood Conditions 100% Cerebral Palsy, Cleft Lip or Cleft Palate, Down Syndrome, Spina Bifida, 25% Cystic Fibrosis
Wellness Benefit $50
Second Opinion $250
Non Local Transportation and Lodging Benefits
Yes
Elimination or Waiting Periods No
Pre-Existing Conditions N/A
Plan Termination None
Portability Yes
Rate Guarantee 1 year
Exclusions and LimitationsExclusionsBenefits under the policy and any attached rider(s) will not be payable for any loss caused in whole or in part by or resulting in whole or part from the following:
1. A specified health event occurring prior to the effective date of coverage for an Insured Person.
2. Suicide or attempt at suicide, or intentional self-inflicted injury or sickness.
3. Participation in any activity or event, including the operation of a vehicle, while under the influence of a controlled substance (unless administered by a physician or taken according to the physician’s instructions) or while intoxicated as defined by the law of the jurisdiction in which the cause of the loss occurs.
4. Participating in any sport or sporting activity for wage, compensation or profit.
5. Commission of or attempt to commit an assault or felony.
6. Engaging in an illegal activity or occupation.
7. Declared war or any act of declared war.
8. Travel in or descent from an aircraft, except while a fare-paying passenger.
9. An experimental major human organ transplant.
EMPLOYEE: NON-TOBACCOAge 5,000 10,000 15,000 20,000 25,000 30,000
18-25 $1.36 $1.99 $2.61 $3.23 $3.85 $4.4726-30 $1.76 $2.62 $3.49 $4.35 $5.22 $6.0831-35 $2.43 $3.81 $5.20 $6.58 $7.97 $9.3536-40 $3.45 $5.68 $7.91 $10.13 $12.36 $14.5941-45 $4.71 $8.00 $11.29 $14.57 $17.86 $21.1546-50 $6.16 $10.69 $15.21 $19.74 $24.26 $28.7951-55 $7.53 $13.29 $19.04 $24.79 $30.55 $36.3056-60 $9.39 $16.81 $24.23 $31.65 $39.07 $46.4961-65 $12.32 $22.42 $32.53 $42.63 $52.74 $62.8466-70 $15.94 $29.45 $42.96 $56.48 $69.99 $83.5071+ $22.79 $43.06 $63.33 $83.60 $103.86 $124.13
EMPLOYEE + SPOUSE: NON-TOBACCOAge 5,000 10,000 15,000 20,000 25,000 30,000
18-25 $2.33 $3.28 $4.23 $5.18 $6.14 $7.0926-30 $2.94 $4.27 $5.60 $6.93 $8.26 $9.6031-35 $3.99 $6.12 $8.25 $10.39 $12.52 $14.6636-40 $5.59 $9.02 $12.45 $15.88 $19.32 $22.7541-45 $7.55 $12.61 $17.67 $22.73 $27.79 $32.8546-50 $9.79 $16.75 $23.71 $30.67 $37.62 $44.5851-55 $11.91 $20.75 $29.59 $38.42 $47.26 $56.1056-60 $14.76 $26.14 $37.51 $48.89 $60.26 $71.6461-65 $19.26 $34.72 $50.17 $65.63 $81.08 $96.5366-70 $24.79 $45.40 $66.02 $86.64 $107.25 $127.8771+ $35.05 $65.77 $96.48 $127.19 $157.90 $188.62
EMPLOYEE + CHILD: NON-TOBACCOAge 5,000 10,000 15,000 20,000 25,000 30,000
18-25 $2.48 $3.64 $4.80 $5.97 $7.13 $8.2926-30 $2.87 $4.28 $5.68 $7.09 $8.50 $9.9031-35 $3.54 $5.47 $7.39 $9.32 $11.25 $13.1736-40 $4.57 $7.34 $10.10 $12.87 $15.64 $18.4141-45 $5.83 $9.66 $13.48 $17.31 $21.14 $24.9746-50 $7.28 $12.34 $17.41 $22.48 $27.54 $32.6151-55 $8.65 $14.94 $21.24 $27.53 $33.83 $40.1256-60 $10.50 $18.46 $26.43 $34.39 $42.35 $50.3161-65 $13.44 $24.08 $34.73 $45.37 $56.02 $66.6666-70 $17.06 $31.11 $45.16 $59.22 $73.27 $87.3271+ $23.91 $44.72 $65.53 $86.34 $107.15 $127.95
FAMILY: NON-TOBACCOAge 5,000 10,000 15,000 20,000 25,000 30,000
18-25 $3.71 $5.34 $6.97 $8.59 $10.22 $11.8426-30 $4.33 $6.34 $8.34 $10.34 $12.35 $14.3531-35 $5.38 $8.18 $10.99 $13.80 $16.60 $19.4136-40 $6.97 $11.08 $15.19 $19.29 $23.40 $27.5041-45 $8.93 $14.67 $20.40 $26.13 $31.87 $37.6046-50 $11.18 $18.81 $26.44 $34.07 $41.70 $49.3451-55 $13.30 $22.81 $32.32 $41.83 $51.34 $60.8556-60 $16.15 $28.20 $40.25 $52.30 $64.34 $76.3961-65 $20.65 $36.78 $52.91 $69.03 $85.16 $101.2966-70 $26.18 $47.46 $68.75 $90.04 $111.33 $132.6271+ $36.44 $67.83 $99.21 $130.60 $161.98 $193.37
Critical Illness -Issue Age Premier (without Cancer) Plan - Semi-Monthly Rates EMPLOYEE: TOBACCOAge 5,000 10,000 15,000 20,000 25,000 30,000
18-25 $1.60 $2.43 $3.26 $4.09 $4.92 $5.7526-30 $2.26 $3.57 $4.88 $6.18 $7.49 $8.8031-35 $3.46 $5.75 $8.03 $10.31 $12.59 $14.8736-40 $5.38 $9.26 $13.15 $17.03 $20.92 $24.8041-45 $7.79 $13.71 $19.62 $25.54 $31.45 $37.3746-50 $10.52 $18.75 $26.97 $35.19 $43.41 $51.6351-55 $13.19 $23.64 $34.10 $44.55 $55.00 $65.4656-60 $16.66 $30.09 $43.52 $56.95 $70.38 $83.8161-65 $22.08 $40.29 $58.51 $76.72 $94.93 $113.1566-70 $28.50 $52.71 $76.92 $101.13 $125.34 $149.5571+ $39.45 $74.81 $110.18 $145.54 $180.90 $216.27
EMPLOYEE + SPOUSE: TOBACCOAge 5,000 10,000 15,000 20,000 25,000 30,000
18-25 $2.70 $3.98 $5.26 $6.54 $7.82 $9.1026-30 $3.74 $5.77 $7.79 $9.82 $11.85 $13.8831-35 $5.62 $9.17 $12.72 $16.28 $19.83 $23.3836-40 $8.62 $14.67 $20.72 $26.78 $32.83 $38.8941-45 $12.38 $21.60 $30.81 $40.02 $49.23 $58.4446-50 $16.64 $29.43 $42.22 $55.01 $67.79 $80.5851-55 $20.78 $37.02 $53.26 $69.50 $85.74 $101.9856-60 $26.16 $46.98 $67.80 $88.62 $109.44 $130.2661-65 $34.52 $62.70 $90.80 $119.05 $147.23 $175.4166-70 $44.40 $81.76 $119.12 $156.48 $193.84 $231.2171+ $60.95 $115.15 $169.35 $223.55 $277.75 $331.95
EMPLOYEE + CHILD: TOBACCOAge 5,000 10,000 15,000 20,000 25,000 30,000
18-25 $2.72 $4.09 $5.46 $6.83 $8.20 $9.5726-30 $3.38 $5.23 $7.07 $8.92 $10.77 $12.6231-35 $4.58 $7.40 $10.23 $13.05 $15.87 $18.6936-40 $6.49 $10.92 $15.35 $19.77 $24.20 $28.6241-45 $8.91 $15.36 $21.82 $28.27 $34.73 $41.1946-50 $11.64 $20.40 $29.17 $37.93 $46.69 $55.4551-55 $14.30 $25.30 $36.29 $47.29 $58.29 $69.2856-60 $17.78 $31.75 $45.72 $59.69 $73.66 $87.6361-65 $23.20 $41.95 $60.71 $79.46 $98.21 $116.9766-70 $29.62 $54.37 $79.12 $103.87 $128.62 $153.3871+ $40.57 $76.47 $112.37 $148.28 $184.18 $220.09
FAMILY: TOBACCOAge 5,000 10,000 15,000 20,000 25,000 30,000
18-25 $4.09 $6.04 $7.99 $9.95 $11.90 $13.8526-30 $5.13 $7.83 $10.53 $13.23 $15.93 $18.6331-35 $7.01 $11.23 $15.46 $19.68 $23.91 $28.1336-40 $10.01 $16.73 $23.46 $30.19 $36.91 $43.6441-45 $13.77 $23.66 $33.54 $43.42 $53.31 $63.1946-50 $18.03 $31.49 $44.95 $58.41 $71.87 $85.3351-55 $22.17 $39.08 $55.99 $72.91 $89.82 $106.7356-60 $27.55 $49.04 $70.53 $92.03 $113.52 $135.0161-65 $35.91 $64.76 $93.61 $122.46 $151.31 $180.1666-70 $45.79 $83.82 $121.86 $159.89 $197.92 $235.9671+ $62.34 $117.21 $172.09 $226.96 $281.83 $336.70
kemperbenefits.com
Policies issued by: Reserve National Insurance Company A Kemper Health Company, Oklahoma City, Oklahoma
Policy Form Series KB-MCI and KB-ECI. Form numbers may vary by state.
Kemper Health, kemperbenefits.com, is part of Kemper Corporation (NYSE: KMPR), a diversified insurance holding company, with subsidiaries that provide an array of products to the individual and business markets.
Kemper Corporation’s underwriting company for the Kemper Health voluntary worksite life, accident and health insurance products is Reserve National Insurance Company, which is responsible for the underwriting risks, financial and contractual obligations and support functions associated with the products it issues. Reserve National Insurance Company is rated “A-” (Excellent) for financial strength and ability to meet policyowner obligations by A.M. Best Company, a leading insurance rating authority. Rating refers to the overall financial status of the Company and is not a recommendation of the specific policy previsions or practices. Kemper Corporation is not responsible for the products of any of its underwriting companies.
This is only a summary of products and services offered. Actual offerings may vary by group size and other underwriting considerations, and are subject to the requirements of state insurance laws and regulations, and the benefits/provisions as described may vary due to such requirements. All products are subject to the terms, conditions, limitations and exclusions of the specific policy. Please see the specific policy and certificate for details. Policies are not available in all states.
The Kemper Health voluntary insurance plans, either alone or in combination with each other, are not “minimum essential coverage” under the federal Affordable Care Act.
IMPORTANT: If an individual is insured under one or more Kemper Health voluntary insurance plans, and is also covered by Medicaid or a state variation of Medicaid, most non-disability benefits are automatically assigned according to state regulations. This means that instead of paying the benefits to the insured individual, we must pay the benefits to Medicaid or the medical provider to reduce the charges billed to Medicaid. Proposed insureds should consider their circumstances before enrolling in Kemper Health coverage.
If you are an employer offering one or more of these insurance products to your employees, the product(s) may constitute a part of an employee benefit plan under the Employee Retirement Income Security Act of 1974 (“ERISA”). An employer offering an ERISA employee benefit plan will be responsible for a number of obligations applicable under ERISA, including, without limitation, the obligation to make required disclosures to employees and file reports with the federal government. You should consult with an experienced attorney concerning the requirements for compliance with ERISA.
©2019. All rights reserved.
Affordable protection in an ever-changing world. At Kemper Health we understand the changes that affect our
customers’ lives and their need for affordable insurance. Our
voluntary benefits play a critical role in employees’ financial well-
being by helping fill the gaps in major medical plans, preparing for
retirement and providing financial protection from the unexpected.
Contact Kemper Health today to discover how easy it is to offer
your clients the best solutions.
Group Accident Expense Insurance POLICY FORM G H1708/G H1708C
PREPARED FOR
QCR Holdings Inc.
Group Accident Expense Insurance
Accident Expense Benefits - 24 Hour Coverage
$100 Physician Office $150 Physician Office $100 Urgent Care $150 Urgent Care
$200 Emergency Room $300 Emergency Room
$200 Ground $300 Ground$600 Air $900 Air
$50 Held 4-20 hrs. $75 Held 4-20 hrs.$100 Held 20+ hrs. $150 Held 20+ hrs.
$1,000 Single $1,500 Single$2,000 Multiple $3,000 Multiple
$200 Ground $300 Ground
$500 Air $750 Air
Blood, Plasma or Platelets
Two per accidentFollow-Up Treatment
$100
For companion accompanying an insured traveling 100+ miles from residence for treatment; up to 30 days per accident
TIER 2
Lodging$200
Medical Supplies
ApplianceRented or purchased, such as crutches or wheelchair
$250.00
$150
$375.00
Other than while confined in hospital or nursing home; six per calendar year$10.00 $15.00
Prescription Medication
TIER 3Supportive Care - Payable only if Initial Accident Treatment benefit was paid for the same injury
Physical, Occupational or Speech TherapySix per accident
$60 $90
$150
Chiropractic or Acupuncture Treatment
Over-the-counter: once per accident:three per calendar year$10.00 $15.00
TIER 3
$600 $900
Emergency Room Observation UnitHeld in hospital, without addmission, after ER treatment
Transport to or from hospital; one ground or air per accident Ambulance
Telemedicine Treatment $40
Initial Accident Treatment
$60
X-Ray $200 $300
One physician's office, urgent care or ER visit per accident
$100 $150 Diagnostic ExamsCT, CAT, MRI or EEG
Processing or transfusion
For physician treatement 50+ miles from residence; up tp three round trips per accident
Transportation
Prosthetic DevicesNot including hearing or dental aids, eyeglasses or cosmetic devices
Residence or Vehicle Modification $1,000 $1,500
Six per accident$60 $90
Epidural Pain Management $100
$300
Key features
Emergency Care TIER 2
Assurity's Group Accident Expense insurance plan includes the benefits listed in the schedule below for a covered accident. All treatment must be provided or prescribed by a physician and maximum benefits per insured person are one per accident unless otherwise noted. Each benefit is subject to conditions for payments as detailed in the certificate.
• Coverage is guaranteed issue; there are no medical exams or tests to take.
• Family-friendly benefits covering ChildOrganized Sports, Hospital Confinement-Child Care and Accidental Death-Children Education.
• Employee and family coverage - Coverage is available for employees, plus their spouse/domestic partner and children.
$200 Crown $300 Crown$60 Extraction $90 Extraction
$4,000 Open Reduction $6,000 Open Reduction
$2,000 Closed Reduction $3,000 Closed Reduction
$4,000 Open Reduction $6,000 Open Reduction
$2,000 Closed Reduction $3,000 Closed Reduction
$30,000 Quadriplegia $45,000 Quadriplegia $15,000 Paraplegia $22,500 Paraplegia
Dental Emergency
Eye InjuryRequiring surgery or removal of foreign object
$200
Payable percent of benefit shown varies by length of lacerationLaceration
FracturePayable percent of benefit shown varies based on joint or bone,open or closed reduction, or chip
Gunshot WoundRequires hospitalization and surgery
$1,000
TIER 3
BurnsPayable percent of benefit shown varies by degree of burn and percentage of body affected
$1,000 $1,500
ComaNot medically induced or the result of drug or alcohol use
$20,000
Specific Injury Care TIER 2
$300
Natural tooth treatment provided by a dentistDislocation
Payable percent of benefit shown varies by joint or bone and degree of dislocation
Resulting in hearing loss greater than 60%; once per lifetimeEar Injury
$300 $200
$30,000
ConcussionNot payable if tramatic brain injury benefit is paid
$50.00 $75.00
Burns – Skin GraftPercentage of burn benefits
50% 50%
Child Organized SportsPercentage of all other payable benefits for dependent child if injured during amateur organized athletic competition or supervised practice for such; up to $1,000
10% 10%
$1,500
$100 $150
Not available with off-the-job coverageOccupational HIV
$600 $900
$75.00
Post-Traumatic Stress Disorder $400 $600
ParalysisLasting 90+ days, diagnosed permanent; one quadriplegia or paraplegia benefit per lifetime
Poisoning $50.00
$450 Sub-Acute Intensive Care Unit
Up to 365 days per accident$200
$900
Hospital Care - Daily benefits unless otherwise noted TIER 2 TIER 3
$300
Up to 30 days per accidentIntensive Care Unit
$400 $600
$1,500
Hospital Confinement
Hospital Admission
Once per accident; once per calendar year$1,000
Traumatic Brain InjuryDiagnosed by CT, CAT, MRI, EEG, PET, or X-Ray
$600
$300
Hospital Confinment - Child CareFor all dependent children, by licensed provider, while insured is confined to hospital; up to 30 days per accident
$40 $60
Rehabilitation Unit
Up to 30 days per accident; 60 days per calendar year$200
Up to 30 days per accident$300
Does not include hernia$2,000 $3,000
Surgical Care TIER 2 TIER 3
Open Abdominal, Thoracic or Cranial Surgery
$1,500
Hernia Surgery $500 $750
Exploratory SurgeryDiagnostic arthroscopic or laparoscopic and not payable if any other surgery benefit is paid
$500 $750
Tendon, Ligament, Rotator Cuff or Knee Cartilage Surgery $1,000 $1,500
Accidental Death and Dismemberment Rider (Form R G1712C) TIER 2 TIER 3
Accidental Death and unless otherwise noted below 50% spouse/25% child; not payable if Accidental Death-Common Carrier benefit is paid
Miscellaneous Outpatient SurgeryRequires anesthesia and not payable if any other surgery benefit is paid
$200 $300
AnesthesiaAdministered for a payable surgery benefit
$200 $300
$1,500
Accidental DismembermentPercent of benefit shown varies by body part; 50% spouse/25% child
$40,000 $60,000
Accidental Death – SeatbeltAdditional benefit if seatbelt in use; 50% spouse/25% child
$40,000 $60,000
$15,000 $10,000
Accidental Death – Common CarrierIf fare-paying passenger on common carrier; 50% spouse/25% childAccidental Death – Children Education
$100,000 $150,000
Additional benefit for dependent children enrolled in post-secondary educationalinstitution; one per accidental death, per qualifying dependent child
$1,000
Ruptured Disc Surgery $1,000
Group Accident Expense InsurancePOLICY FORM G H1708/G H1708C
Employer: QCR Holdings Inc. Issue State: ILCoverage Type: 24 Hour
Plan Type: TIER 2 (2 units)Rider(s): None
Semi-Monthly Premium Rates
Coverage RateEmployee $5.68Employee and Spouse $9.80Employee and Children $9.92Family $15.06
Plan Type: TIER 3 (3 units)Rider(s): None
Semi-Monthly Premium Rates
Coverage EmployeeEmployee $8.52Employee and Spouse $14.70Employee and Children $14.88Family $22.59
EM2,SU2-6,SP2,HA2,SG2,AD2- 5
EM3,SU3-6,SP3,HA3,SG3,AD3- 5
Ver 5.3July 2, 2019
Group Accident Expense InsurancePOLICY FORM G H1708/G H1708C
GROUP ACCIDENT EXPENSE INSURANCE PROVIDES LIMITED BENEFIT COVERAGE.
Actively Employed - The employee must be actively employed to be eligible for coverage.
Right to Cancel - The contract contains a 30-day free look period.
Termination - Coverage will terminate the earliest of the following: the date policy terminates for any reason; the dateemployee is no longer an employee (portability available); when premiums are not paid by the end of the grace period;the date Assurity receives written notice to terminate; when the employee establishes residence in a foreign country; orupon the employee's death.
Exclusions - Assurity will not pay benefits for losses that are caused by or are the result of any insured person(s):
- operating, learning to operate, or serving as a crew member of any aircraft;- having a sickness independent of the Covered Accident, including physical or mental infirmity (sickness means any
illness, infection (except infection which results from an Accidental Injury, or from accidental, involuntary or unintentional ingestion of a contaminated substance), disease or any other abnormal physical condition which is not caused by an Injury);
- being exposed to war or any act of war, declared or undeclared;- actively serving in any of the armed forces, or units auxiliary thereto, including the National Guard or Army Reserve,
except during active duty training of less than 60 days;- suffering from a Mental and Nervous Disorder (except for Post-Traumatic Stress Disorder as described in
this Certificate);- having a substance use disorder;- being under the influence of an excitant, depressant, hallucinogen, narcotic, or any other drug, including
those prescribed by a Physician that are misused;- being intoxicated (as determined by the laws governing the operation of motor vehicles in the jurisdiction where loss
occurs) or under the influence of an illegal substance or a narcotic (except for narcotics used as prescribed to the Insured Person by a Physician);
- having cosmetic surgery or other elective procedures that are not medically necessary;- having an inguinal, ventral, femoral, umbilical, epigastric, hiatal or congenital hernia, except as paid by the
Hernia Surgery Benefit;- commission of or attempting to commit a felony;- being incarcerated in a penal institution or government detention facility;- participating in a riot, insurrection or rebellion;- intentionally self-inflicting an Injury; or- committing or attempting to commit suicide, while sane or insane.
No benefits, except the Initial Accident Treatment benefit, will be payable for services provided outside of the United States.
This is a proposal, not a contract nor an offer to contract. Availability of this product, along with all benefits and premiums as presented,is subject to the approval of Assurity. All benefits, premiums, conditions, exclusions and limitations are governed only by the actual contractas approved by Assurity and not this proposal. Policy availability, features and rates may vary by state.
Assurity is a marketing name for the mutual holding company, Assurity Group, Inc. and its subsidiaries. Those subsidiaries include, but arenot limited to, Assurity Life Insurance Company and Assurity Life Insurance Company of New York. Insurance products and services areoffered by Assurity Life Insurance Company in all states except New York. In New York, insurance products and services are offered byAssurity Life Insurance Company of New York, Albany, NY. Product availability, features and rates may vary by state.
The following represents some policy conditions, limitations and exclusions. For complete details of the coverage, please contact your agent, Assurity or ask to review the policy for more information. Provisions may vary by state.
Supplemental Insurance Services Claims Assistant: Stacy Martin, Shiela Marlowe
General Information: Rhonda Pape Please contact us for all your Assurity and Kemper Insurance needs. We will be happy to assist you with claims, service requests, general questions, etc. Our contact information is as follows: 115 East Platt Street Maquoketa, IA 52060 Phone: (563) 652-6813 Fax: (563) 652-9736 supins@supinsurance.com
Assurity Home Office PO Box 82533 Lincoln, NE 68501 Phone: (800) 869-0355 Ext 4484 Fax: (800) 869-0368
To file a Claim with Kemper; 1-844-613-6245
401(K) RETIREMENT PLAN
QCRH offers employees a 401(k) retirement plan. Employees are eligible for the 401(k) plan beginning on their date of hire. The 2020 annual maximum contributions are as follows: if you are under the age of 50 your maximum contribution is $19,500 per year into the 401(k). If you are over the age of 50 or will be during the calendar year, your maximum contribution is $26,000 per year into the 401(k).
QCRH matches* at the following: 100% match of first 3% of salary deferred / 50% match of next 3% of salary deferred
*Match given if you have completed at least 1000 Hours of Service during the Plan Year and are actively employed on the last day of the Plan Year. Future employer contributions are at the discretion of QCR Holdings, Inc.
Vesting schedule for Matching Contributions:
Years of Service Percentage Vested
Less than 1 0%
1 20%
2 40%
3 60%
4 80%
5 + 100%
Automatic Deferral Percentage
Thirty days after your hire date, QCRH will automatically withhold 6 % of your compensation from your pay each payroll period and contribute that amount to the Plan as a pre-tax 401(k) deferral unless you make a contrary election. To make a contrary election, please see “Activate your account” below.
Automatic Increase Plan
On January 1st of each year, your deferral percentage will automatically increase by 1%, unless elected otherwise. The increase will stop when your deferral percentage reaches 15%. To elect otherwise, log into your account and update the Automatic Increase Contribution.
401(K) RETIREMENT PLAN – Access Instructions – First Time Users
1. Go to www.principal.com. On the home page, select Login and choose Personal.2. Click on the Create an Account link.3. On the Create an Account screen, enter your First name, Last name, Date of birth, Social Security Number, Zip code and select I consent
to doing business electronically, then click Continue.4. Answer the Security Questions and click Continue.5. Create a unique username, set a secure password and your email address.6. Select and answer two security questions.7. You will receive a message that you have logged in successfully.8. The first time you log in, you will need to choose where to send the verification codes (text message or email) and how often you want to
use them.For assistance setting up your account, please contact Principal at 1-800-547-7754. If you have questions concerning your 401(k) please contact Christina Back or Shellee Showalter.
Investment Help Is Available Quad Cities Investment Center (QCIC) can provide investment help on a variety of products and services and is familiar with the 401(k) i nvestment choices under that program. Please feel free to contact one of the QCIC Investment Representatives with questions or concerns. QCIC offers this service free to all QCRH employees. You may find that your individual broker can provide guidance as well.
Dave Howell, Utica dhowell@qcbt.com 563-468-4407
Blake Schaeffer, Brady St bschaeffer@qcbt.com 563-468-6272
Amber Brummit, Moline abrummit@qcbt.com 309-743-7794 815-963-2173
Deb Gertsen, Cedar Rapids dgertsen@crbt.com 319-743-7133
Laurel Thompson, Waterloo lthompson@communitybt.com 319-433-6121
Ken Wilson, Ankeny kwilson@bankcsb.com 515-252-1278
Lee Kazma, Ankeny lkazma@bankcsb.com 515-252-1154
Welcome!
principal.com/Welcome
We're so glad you're here.There's a retirement plan waiting foryou! In just a few steps, you'll be onyour way. Here's what to expect.
Review your contributionYour organization has set a contribution ratefor you. Log in, take a look and make changesto your contribution rate if you want, or visit principal.com/MatchEnrollmentWebinar.
*The plan’s participant level default is: Vanguard Target Retirement Fund. See Investment Option Summary for important information. If thedefault is a target date fund series, the applicable target date fund will be based on the plan’s normal retirement date.
Get your account set upVisit principal.com/Welcome to get started.
Begin by:• Setting security preferences• Reading important plan notices
Check out the plan'sinvestmentsEach one is different and you canchoose based on your goals and howyou feel about risk. You can also pickfrom the plan's investment optionslater. But by picking it later, youunderstand that until you make a newinvestment selection, you're directingcontributions to the plan's default.*
For a full listing, refer to the Investment Option Summary.
The subject matter in this communication is educational only and provided with the understanding that Principal® is not rendering legal, accounting, investment advice or tax advice. You should consult with appropriate counsel or other advisors on all matters pertaining to legal, tax, investment or accounting obligations and requirements.
Investing involves risk, including possible loss of principal.
Asset allocation and diversification does not ensure a profit or protect against a loss. Equity investment options involve greater risk, including heightened volatility, than fixed-income investment options. Fixed-income investments are subject to interest rate risk; as interest rates rise their value will decline. International and global investing involves greater risks such as currency fluctuations, political/social instability and differing accounting standards. These risks are magnified in emerging markets.
Insurance products and plan administrative services provided through Principal Life Insurance Co. Principal Funds, Inc. is distributed by Principal Funds Distributor, Inc. Securities offered through Principal Securities, Inc., 800-547-7754, member SIPC and/or independent broker-dealers. Principal Life, Principal Funds Distributor, Inc. and Principal Securities are members of the Principal Financial Group®, Des Moines, IA 50392. Certain investment options and contract riders may not be available in all states or U.S. commonwealths.
Principal, Principal and symbol design and Principal Financial Group are trademarks and service marks of Principal Financial Services, Inc., a member of the Principal Financial Group.
PQ12087-01 | © 2018 Principal Financial Services, Inc. | 10/2018 | 621222-102018
See your retirement savings in one placeWe’ll help you roll eligible outside retirement savings into your retirement account.
Keep in touchStaying in the know when it comes to retirement planning is a pretty good idea. We’ll send you educational information about what’s important to you.
Designate a beneficiaryDon’t leave the decision up to someone else if something happens to you before retirement. Always designate a beneficiary to ensure the money in your account goes to a loved one.
Keep going!You've got this and we've got your back when it comes to educational resources.
Visit principal.com/Welcome to learn more.
443 principal.com 44334-65623/QCR HOLDINGS, INC. 401(k) PLAN
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Principal Life Insurance Company
Des Moines, IA 50306-9394
Plan Summary
4-65623 / QCR Holdings, Inc. 401(k) Plan
07.01.2019 021931 Plan Summary - Page 1 of 5
.
Am I eligible for QCR Holdings, Inc. 401(k) Plan?
You are eligible to join the plan unless you are an employee who is:
· a nonresident alien
· an independent contractor or employee of an independent contractor
· represented by a bargaining unit that has bargained with us in good faith on the subject of retirement benefits
If you meet the above requirements, you are eligible to join the plan if you:
· are at least age 18
You enter the plan on any date on or after you meet the eligibility requirements.
.
Are there limits to my contributions?
The retirement plan includes an automatic contribution arrangement. Please refer to the notice provided to you
by your plan sponsor for details.
You may choose to contribute from 1% to 100% of your total pay.
Your taxable income is reduced by the amount you contribute pre-tax through salary deferral. This lets you
reduce your taxable income.
Your maximum contribution percentage and/or dollar amount may also be limited by Internal Revenue Service
regulations. Current employee contribution limits may be found by searching for 401(k) contribution limits on the
Internal Revenue Service’s website at www.irs.gov.
If you are 50 years old or older during the plan year and you have met the annual IRS deferral limit (or the
specified plan limit for deferrals), you may contribute a catch-up deferral. If you qualify and are interested in
making catch-up contributions, the current limit may be found on the Internal Revenue Service’s website at
www.irs.gov.
.
Can I make after-tax, Roth salary deferral contributions?
Roth salary deferral contributions are another option to designate your salary deferral contributions.
445 4455
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07.01.2019 021931 Plan Summary - Page 2 of 5
4-65623 / QCR Holdings, Inc. 401(k) Plan
Plan Summary
.
Roth salary deferral contributions are made on an after-tax basis. You may designate any amount of the available
salary deferral limit for a plan calendar year as Roth salary deferral contributions.
Roth salary deferral contributions plus your pre-tax salary deferral contributions are counted toward the annual
salary deferral contribution amount and salary deferral contribution percentage mentioned above.
Distributions from your Roth salary deferral contribution account will generally be tax-free if the distribution
meets the qualified distribution requirements, death or disability and you have maintained the Roth salary
deferral account for at least 5 taxable years.
.
Can I change my contributions to my employer's retirement plan?
You may stop making salary deferral contributions at any time. You may change your salary deferral amount
daily. Changes will be implemented as soon as administratively feasible.
.
Employer contributions
Your employer may match part of the pay you contribute to the plan through salary deferral.
If a matching contribution is made to the plan, it will be calculated based on salary deferrals and pay as of the end
of the plan year.
The conditions you have to meet may include an hours requirement and/or require you to be an active participant
during or at the end of the plan year.
Your employer may make a discretionary contribution at the end of the plan year if you meet the requirements
below.
You will receive contributions if you are an active participant on the last day of the plan year and you earned at
least 1,000 hours during the latest accrual service period ending on or before that date.
Participants who retire, become totally disabled or die during the plan year will also receive these contributions
as specified in the Summary Plan Description booklet.
Employer contributions may change in the future.
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07.01.2019 021931 Plan Summary - Page 3 of 5
4-65623 / QCR Holdings, Inc. 401(k) Plan
Plan Summary
.
.
I have a retirement account with a previous employer. Can I combine the two?
You may be allowed to roll over into this plan all or a portion of the retirement funds you have outside this plan.
You may then withdraw all or a portion of your rollover contributions. The number of withdrawals may be limited.
Refer to your Summary Plan Description for more details.
To receive additional information, contact your Plan Administrator, visit us at principal.com or call
1-800-547-7754.
.
When am I vested in the retirement plan funds?
You are always 100% vested in the contributions you choose to defer. You cannot forfeit these contributions.
You are vested in employer contributions based on years of vesting service in which you worked at least 1,000
hours as shown below.
The vesting schedule is:
.
5 Years Graded Custom
< 1 Years
0%
1 Years
20%
2 Years
40%
3 Years
60%
4 Years
80%
5 Years
100%
The vesting schedule applies to the following contribution(s):
Employer Match
in M
Employer
Discretionary
.
How can I access my account information, including fees and investment
information?
You may obtain account information through:
· Our automated phone system at 1-800-547-7754
· Principal.com
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07.01.2019 021931 Plan Summary - Page 4 of 5
4-65623 / QCR Holdings, Inc. 401(k) Plan
Plan Summary
.
.
Can I take money from the plan?
Yes, you may receive funds from your account for the following reasons:
· Retirement (the older of age 60 or your age on the earlier of the date 5 year(s) after your hire date or the date 5
years after the first day of the plan year when your entry date occurred)
· Age 59-1/2 and still working
· Qualified reservist
· Death
· Disability*
· Termination of employment
· Financial hardship
Please refer to the participant notice or Summary Plan Description provided to you by your plan sponsor about
withdrawal benefits.
*You must have ceased employment to receive this benefit.
.
If I need to take a loan from the plan, what are the guidelines?
You may borrow up to 50% of the vested account balance or $50,000.00 (whichever is less). Amount available is
reduced by an outstanding balance or by the highest outstanding balance in the past 12 months. This includes all
loans (new loans taken in the past 12 months, loans paid off in the last 12 months, and all defaulted loan
balances, no matter how old the loan).
The minimum loan amount is $1,000.00.
You may have 5 loan(s) outstanding at anytime.
The interest rate will be determined when you apply for your loan. You pay back both the principal and interest
directly to the account held for you in the plan through payroll deduction.
Loans must be repaid within a 5-year period. However, if the loan is for the purchase of your primary residence,
the repayment period can be up to 10-year(s). See your loan administrator for additional details.
Refer to your Summary Plan Description for more details on contributions available for a plan loan.
.
Other Information
Your salary deferral contributions are included in the wages used to determine your Social Security tax.
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07.01.2019 021931 Plan Summary - Page 5 of 5
4-65623 / QCR Holdings, Inc. 401(k) Plan
Plan Summary
.
This plan summary includes a brief description of your employer's retirement plan features. While this plan
summary outlines many of the major provisions of your employer's retirement plan, this summary does not
provide you with every plan detail. The legal plan document, which governs this plan, provides full details. If there
are any discrepancies between this plan summary and the legal plan document, the legal plan document will
govern.
From time to time, your employer may elect to amend the retirement plan provisions. This plan summary may be
updated to reflect proposed amendments to the plan document provisions. Until a plan amendment is adopted,
however, the legal plan document will govern. Contact your plan sponsor if you would like more details regarding
applicable retirement plan provisions.
Most withdrawals/distributions are subject to taxation and required withholding. Check with your financial/tax
advisor on how this may affect you.
The Principal® is required by the IRS to withhold 20% of the portion of a distribution that is eligible for rollover if
it is not directly rolled over to another eligible retirement plan, including an IRA, or used to purchase an annuity
to be paid over a minimum period of the lesser of 10 years or the participant's life expectancy. This withholding
will offset a portion of federal income taxes you owe on the distribution.
The retirement account may be affected differently by individual state taxation rules. Contact your tax advisor
with questions.
If you have questions about the retirement plan call 1-800-547-7754 Monday through Friday, 7 a.m. - 9 p.m.
(Central time), to speak to a retirement specialist at The Principal®.
To learn more about The Principal®, visit principal.com.
Insurance products and plan administrative services are provided by Principal Life Insurance Company, a member of the Principal
Financial Group® (The Principal®), Des Moines, IA 50392.
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Important Participant Notice Regarding Qualified Default Investment Alternative and Automatic Contribution Arrangement
QCR HOLDINGS, INC. 3551 7TH STREET MOLINE, IL 61265-6156 (309) 743-7760 www.qcrh.com
You have the right to direct the investment of retirement plan contributions among the investment options offered under the retirement plan. Properly investing retirement contributions is important for planning your future retirement income. You should consider your investment direction decision carefully. This notice provides information regarding where contributions submitted to the retirement plan for your benefit will be directed in the absence of your investment election. You may direct the investment of the retirement funds by visiting www.principal.com.
Automatic Enrollment
This retirement plan includes an automatic contribution arrangement that applies to new participants or re-hired participants as they enter the plan. If you are a new participant, you will be automatically enrolled in the retirement plan, meaning 6% of your pay will be deducted from paychecks and contributed to the retirement plan on your behalf unless you elect a different salary deferral percentage. If you are currently eligible for the plan, you will maintain your current salary deferral amount unless you elect a different salary deferral percentage.
The retirement plan also includes an automatic salary deferral increase provision. Salary deferral contributions for automatically enrolled participants will automatically be increased by 1% every 1/1 up to 15%.
If you do not wish to be automatically enrolled, you may elect not to defer or to defer another percentage. If you affirmatively elect to make salary deferral contributions, or if you are automatically enrolled, and you do not provide an investment direction as to how contributions made on your behalf should be directed, then the contributions will be directed to the plan's investment option default discussed below.
Investment Option Default
If you have not provided complete, up-to-date direction as to how the account set up for you under the retirement plan is to be invested, the account will be invested under automatic rules. You need to understand these rules and make sure that you are comfortable with them or that you take action to direct the investment of the account according to your preferences. These rules state that, if we do not have complete investment directions from you, the retirement funds in the account and new contributions for which we do not have direction will be directed to Vanguard Target Retirement Fund, sub advised by Vanguard Group. Your directions must be received at the Corporate Center of Principal Life Insurance Company.
See the table below to identify the Vanguard Target Retirement Fund that will apply based on your current age and when you will reach the plan's normal retirement date. For information on how you may make an investment direction election, please see the "Right to Direct" section below.
Normal Retirement Date Vanguard Target Retirement Fund
2012 or earlier Vanguard Target Retirement Income Inv Fund
Between 2013 and end of 2017 Vanguard Target Retirement 2015 Inv Fund
Between 2018 and end of 2022 Vanguard Target Retirement 2020 Inv Fund
Between 2023 and end of 2027 Vanguard Target Retirement 2025 Inv Fund
Between 2028 and end of 2032 Vanguard Target Retirement 2030 Inv Fund
Between 2033 and end of 2037 Vanguard Target Retirement 2035 Inv Fund
Between 2038 and end of 2042 Vanguard Target Retirement 2040 Inv Fund
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4-65623 2018-10-06 02:37:36 Page 2 of 2
Between 2043 and end of 2047 Vanguard Target Retirement 2045 Inv Fund
Between 2048 and end of 2052 Vanguard Target Retirement 2050 Inv Fund
Between 2053 and end of 2057 Vanguard Target Retirement 2055 Inv Fund
Between 2058 and end of 2062 Vanguard Target Retirement 2060 Inv Fund
2063 or later Vanguard Target Retirement 2065 Inv Fund
Note: Neither the principal nor the underlying assets of the Vanguard Target Retirement Fund are guaranteed at any time, including the target date. Investment risk remains at all times.
To learn about the retirement plan's default investment option and related objectives, risk and return characteristics, and associated fees and expenses, please see the following description and attached investment information or Investment Option Summary included in the enrollment workbook for the Vanguard Target Retirement Fund that will apply.
Target Date portfolios are managed toward a particular target date, or the approximate date the investor is expected to start withdrawing money from the portfolio. As each target date portfolio approaches its target date, the investment mix becomes more conservative by increasing exposure to generally more conservative investments and reducing exposure to typically more aggressive investments. Neither the principal nor the underlying assets of target date portfolios are guaranteed at any time, including the target date. Investment risk remains at all times. Neither asset allocation nor diversification can assure a profit or protect against a loss in down markets. Be sure to see the relevant prospectus or offering document for full discussion of a target date investment option including determination of when the portfolio achieves its most conservative allocation.
Right to Direct
If you do not want retirement funds to be directed as indicated above, then you may elect to direct the retirement funds to investment options under the retirement plan by visiting The Principal Web site at www.principal.com and logging into the account or by calling 1-800-547-7754.
You may make changes to your investment direction as allowed under the retirement plan. This includes transferring any contributions from the applicable investment option default to another investment option. Transfers out of the investment option default are not subject to restrictions, fees or expenses1 for a 90-day period, unless the fees and expenses are charged on an ongoing basis for the operation of the investment2. See the attached investment information for information regarding restrictions, fees or expenses after the 90-day period.
Additional Information
For additional information about the investment option default or other investment alternatives under the plan please visit www.principal.com or contact:
SHELLEE SHOWALTER, SENIOR VICE PRESIDENT 3551 7TH STREET MOLINE, IL 61265-6156 (309)743-7760 SShowalter@qcrh.com
test row 1 Includes surrender charges, liquidation or exchange fees, redemption fees and similar expenses charged in connection with the liquidation of, or transfer from, the investment option default. 2 Includes investment management fees, distribution and/or service fees, "12b-1" fees, or legal, accounting, transfer agent and similar administrative expenses.
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QCR HOLDINGS, INC. 401(k) PLAN Contract/Plan ID Number: 4-65623
ERISA 404 retirement plan andinvestment informationsupplementOctober 14, 2019
In addition to the Fees and Expenses identified in the QCR HOLDINGS, INC. 401(k) PLAN ERISA 404 retirementplan and investment information notice (Notice), fees for services provided by another service provider may alsoapply.
RAYMOND JAMES & ASSOCIATES, INC. charges an annual fee for Education and Plan Services pursuant to the terms and conditions of the agreement between RAYMOND JAMES & ASSOCIATES, INC. and the plan sponsor. One fourth of the annual fee to the Plan for this service will be deducted on a quarterly basis from the plan and each participant will pay a proportion of the expenses. The amount deducted from each participant’s account is determined by prorating the amount based on your account balance.
You can view the dollar amount of any Plan administrative expenses taken from your account at principal.com and on your statements.
This concludes information about the above-named firm's services and fees. No person or entity affiliated with Principal is responsible for any part of the content of this supplement and it is provided solely as an accommodation to the plan and at the request of the Plan Administrator.
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10.20.2019 070909 Plan Information - Page 1 of 3
QCR HOLDINGS, INC. 401(k) PLAN Contract/Plan ID Number: 4-65623
ERISA 404 retirement plan andinvestment information10/20/2019
The retirement savings plan offered by QCR HOLDINGS, INC is a great way to help you save for the life you wantin retirement. QCR HOLDINGS, INC. 401(k) PLAN (the Plan) has fees associated with the services and resourcesprovided by the Plan.
Plan FiduciaryThe Plan Fiduciary is the individual(s) who has authority over the operation and administration of the Plan and itsretirement funds. The Plan Fiduciary is typically your employer, and may also be called the Plan Sponsor.
Plan Administrator
The Plan Administrator, who is also a Plan Fiduciary, has the authority over the operation and administration of thePlan. If you have questions about the investment options available under the Plan or would like paper copies ofadditional investment information, you can obtain this information on principal.com or by contacting the PlanAdministrator:
QCR HOLDINGS, INC.3551 7TH STREETMOLINE, IL 61265-6156309-743-7760
Information about ERISA Section 404(c)
The Employee Retirement Income Security Act (ERISA) provides rules on the investment of retirement funds. QCRHOLDINGS, INC has chosen to qualify the Plan as an ERISA 404(c) plan and intends to comply by providinginformation for you to make educated investment decisions and by letting you:
• Direct the investment of individual retirement accounts
• Choose from at least three diverse investment options
• Change investment choices at least quarterly
This means the Plan Fiduciary should not be liable for any investment losses that result from a participant'sinvestment control.
Your future, your choiceThe Plan Fiduciary makes certain investment options available to you under the Plan. But you are responsible fordirecting the retirement funds to the options available in the Plan that work best for you. You can make changes toyour investment mix by logging into your account at principal.com. Learn more about the investment optionsavailable under the Plan online and in the Investment Option Summary.
Directing or transferring between investment optionsCertain investment options may have restrictions. See the Investment Option Summary for details.
If the Plan includes employer securities, further trading restrictions may apply if you are subject to your company'sinsider trading policy.
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10.20.2019 070909 Plan Information - Page 2 of 3
QCR HOLDINGS, INC. 401(k) PLAN Contract/Plan ID Number: 4-65623
You can direct or transfer retirement funds between the different investment options at least quarterly, but the Planmay allow for more frequent transfers and changes. To update investment elections for your current balance orfuture contributions, log in to your account at principal.com or call us at 800.547.7754.
Voting rights
A description of the exercise of voting, tender and similar rights for an investment alternative and any restrictions onthese rights can be found in the relevant Plan document or trustee powers section of the trust agreement. If youwould like copies of these documents, contact the Plan Administrator, if applicable.
Fees and expenses+
For the current year, an annual Plan administrative expense of 0.11% applies to your account balance.One-twelfth of the total amount will be deducted from your account balance each month.
A portion of the total investment expense of the Plan's investment options may contain revenue sharing. Anyrevenue sharing received from the Plan's investment options will be credited back in full to the impactedparticipant as a Fee Adjustment on a monthly basis. Please refer to the enclosed Investment Option Summary toreview information about revenue sharing (if applicable) included in the Total Investment Expense of eachinvestment.
Plan administrative expenses typically cover items such as recordkeeping, participant website access, participantstatements, Plan compliance services and financial professional services.
Occasionally, there may be additional Plan expenses during normal Plan operation for services such as legal,auditing, other service provider, consulting or investment advice. The Plan Fiduciary determines how these expensesare allocated at the time the expenses are paid. These expenses are typically allocated among participants based onparticipant account balance, but may be allocated by dividing the total expenses to be deducted by the totalnumber of participants in the Plan. You can view the dollar amount of applicable expenses under your account atprincipal.com and on your statement.
Participant-level feesParticipant transaction fees will be charged to your account balance for the services you choose to use. Participanttransaction fees for the Plan include:
• Distribution fee: $40.00• Distribution in-kind fee: $40.00• Distribution installment fee: $10.00 per quarter• Enhanced Hardship Withdrawal Service fee: $80.00• Loan maintenance fee for new loans: $12.00 per quarter• Loan setup fee: $50.00• Qualified Domestic Relations Order fee: $220.00 Per hour for each Domestic Relations Order reviewed. The
fee is divided between the participant and the alternate payee involved unless specified differently within theDomestic Relations Order or the Plan's administrative procedures.
• Qualified Domestic Relations Order processing fee: $350.00 for each Domestic Relations Order processed.The fee is divided equally between the participant and the alternate payee involved unless specified differentlywithin the Domestic Relations Order or the Plan's Administrative Procedures.
A charge of $0.05 per share applies when employer securities are traded and is paid directly to the stock broker. Inaddition, the Securities and Exchange Commission collects a minimal fee per each trade. Please see SEC.gov formore details regarding the fee. These charges will be reflected in the share price used in the transaction and willnot be reflected as a dollar amount.
+ If you have a balance in an investment that is excluded from the collection of expenses, we will collect the expense from the balances in otherinvestments, beginning with the investment with the largest balance.
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10.20.2019 070909 Plan Information - Page 3 of 3
QCR HOLDINGS, INC. 401(k) PLAN Contract/Plan ID Number: 4-65623
The following information is available upon request from the Plan Administrator (at no charge):
• Copies of prospectuses (or any short-form or summary prospectuses) for the investment options
• Copies of any financial statements or reports, such as statements of additional information and shareholderreports, and of any other similar materials relating to the Plan's designated investment options
• A statement of the value of a share or unit of each designated investment option and the date of the valuation
• A list of the assets comprising the portfolio of each investment option which constitute Plan assets and the valueof each asset (or the proportion of the investment which it comprises)
• The following information about each investment option (including fixed-return investment options) availableunder the Plan: issuer name, investment objective, principal strategies and risks, turnover rate, performance, andfee and expense information
• To the extent a group annuity contract under the Plan permits you to select an annuity guaranteed by aninsurance company, a statement that the guarantee provided by the insurance company is subject to its long-termfinancial strength and claims-paying ability
To help you make informed investment choices and for more information aboutthe investment options available to you, including investment objectives,performance and fees, please review the enclosed materials or visitprincipal.com.
Delivery of statements
This is a notice that your benefit statements are provided quarterly and are available by logging in to your account atprincipal.com. The statement includes any fees deducted on your retirement account and is being deliveredelectronically based on your continuous access to the website. You have the right to receive paper statements, freeof charge, which you can elect that preference under your account, or by calling 800.547.7754 Monday throughFriday, 7 a.m.-9 p.m. CT.
For important information on the plan’s investment options, see the Investment Option Summary.Insurance products and plan administrative services provided through Principal Life Insurance Co. Securities are offered throughPrincipal Securities, Inc, 800-547-7754, member SIPC and/or independent brokerdealers. Securities sold by a Principal SecuritiesRegistered Representative are offered through Principal Securities, Inc., Principal Securities and Principal Life are members of thePrincipal Financial Group, Des Moines, Iowa, 50392. Certain investment options may not be available in all states or U.S.commonwealths.
PT249H | 449412-052018 | 6/2018
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Investment Option Summary
This document provides important information to help you compare the investment options available to you under the retirement plan.
Investment results shown represent historical performance and do not guarantee future results. Investment returns and principalvalues fluctuate with changes in interest rates and other market conditions so the value, when redeemed, may be worth more or lessthan original costs. Current performance may be lower or higher than the performance data shown. For additional information on theinvestment options, including most recent month-end performance, log in to the Principal Financial Group® website at principal.com orcall our automated phone system at 1-800-547-7754.
Additional information available online includes, if applicable, the name of the investment option's issuer; the investment option'sobjectives or goals; the investment option's principal strategies, including a general description of the types of assets held by theinvestment option; the portfolio turnover rate; and the investment option's performance data and fee and expense information.
In situations where the net and gross total investment expense figures are different, the mutual fund or the underlying fund in which aSeparate Account invests has waived/capped a portion of its management fees through the date displayed in the waiver expirationdate or contractual cap expiration date column. Differences may also be shown due to the fund family choosing to pay certainexpenses that would normally be payable by the fund. Returns displayed are based on total investment expense net.
Total Investment Expense - Gross is the current maximum expense ratio, as a percentage of assets that can be applied to thisinvestment option.
Total Investment Expense - Net; you will be responsible for this expense and it will be automatically taken prior to calculatingperformance. Total Investment Expense Net is the Total Investment Expense Gross expense ratio less any fee waivers,reimbursements or caps, if applicable. The expenses ratio, as a percentage of net assets, includes applicable operating expenses,management fees, including 12b-1 fees, and administrative fees.
Fees and expenses are only one of several factors that participants and beneficiaries should consider when making investmentdecisions. Some or all of the Plan administrative expenses are paid from the total investment expense of one or more of the Plan'sinvestment options. The cumulative effect of fees and expenses can substantially reduce the growth of a participant's orbeneficiary's retirement account. Participants and beneficiaries can visit the Employee Benefit Security Administration's website foran example demonstrating the long-term effect of fees and expenses.
For a glossary of terms to assist you in understanding the designated investment options, log in to your account at principal.com.
10.20.2019 070914 Investment Option Summary - Page 1 of 23
Contract/Plan ID Number: 4-65623
As of 09/30/2019
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Investment Option Summary - Page 2 of 23 10.20.2019 070914
Contract/Plan ID Number: 4-65623Asset Class: Short-Term Fixed Income
This asset class is generally composed of short-term, fixed-income investment options that are largely liquid and are designed tonot lose much value. These investment options may include stable value, money market, short-term bond, and guaranteed interestaccounts. They are considered to be among the least risky forms of investment options. However, they typically have a lower rateof return than equities or longer-term fixed income investment options over long periods of time. Depending on the objectives ofthe investment options, they may experience price fluctuations and may lose value.
Investment Category: Stable Value
Inv Manager or Sub-Advisor: KeyBank
Investment Option Name Average Annual Total Return
KeyBank EB Managed GuaranteedInvestment Contract 4 (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)
YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
1.42 1.84 1.51 1.45 1.56 4.47 1.50 1.33 1.60 4.53 1/1976
Benchmark: Bloomberg Barclays US Government1-3 Year Index 3.07 4.42 1.54 1.34 1.21 - 1.58 0.82 1.03 - -
Description: This investment option is made available especially for your plan. For more information on it, please refer to the Principal RetirementService Center® at www. principal.com.
Composition (% of Assets) as of N/A Fees & Expenses # of Transfers Allowed/Time Period
N/A Total Inv Exp Net % 0.76 -
Contractual Cap Expiration Date N/A
Waiver Expiration Date N/A
Total Inv Exp Gross % 0.76
Total Inv Exp Gross Per $1,000 Invested $7.60
Redemption Fee -
Revenue Sharing % 0.35
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Contract/Plan ID Number: 4-65623
10.20.2019 070914 Investment Option Summary - Page 3 of 23
Asset Class: Fixed Income
This asset class is generally composed of investment options that invest in bonds, or debt of a company or government entity(including U.S. and Non- U.S.). It may also include real estate investment options that directly own property. These investmentoptions typically carry more risk than short-term fixed income investment options (including, for real estate investment options,liquidity risk), but less overall risk than equities. All investment options in this category have the potential to lose value.
Investment Category: Intermediate Core Bond
Inv Manager or Sub-Advisor: Vanguard Group
Investment Option Name Average Annual Total Return
Vanguard Intermediate-Term Bond IndexAdmiral Fund 8,F (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)
YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
10.28 12.43 3.10 3.93 4.78 5.15 -0.17 2.92 4.45 4.78 11/2001
Benchmark: Bloomberg Barclays Aggregate BondIndex 8.52 10.30 2.92 3.38 3.75 - 0.01 2.52 3.48 - -
Description: The investment seeks the performance of the Bloomberg Barclays U.S. 5-10 Year Government/Credit Float Adjusted Index. BloombergBarclays U.S. 5-10 Year Government/Credit Float Adjusted Index includes all medium and larger issues of U.S. government, investment-gradecorporate and investment-grade international dollar-denominated bonds that have maturities between 5 and 10 years and are publicly issued. All of itsinvestments will be selected through the sampling process, and at least 80% of its assets will be invested in bonds held in the index.
Composition (% of Assets) as of 08/31/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 0.63 Non-U.S. Bonds 8.79 Total Inv Exp Net % 0.07 1/30 day period
Convertibles 1.20 U.S. Bonds 89.38 Contractual Cap Expiration Date N/A
Waiver Expiration Date N/A
Total Inv Exp Gross % 0.07
Total Inv Exp Gross Per $1,000 Invested $0.70
Redemption Fee -
Revenue Sharing % 0.00
Investment Category: Intermediate Core-Plus Bond
Inv Manager or Sub-Advisor: Western Asset Management Co.
Investment Option Name Average Annual Total Return
Western Asset Core Plus Bond I Fund 8,10,E (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
10.79 11.75 4.48 4.69 5.89 6.11 -1.49 3.82 6.91 5.81 7/1998
Benchmark: Bloomberg Barclays U.S. UniversalIndex 8.80 10.07 3.23 3.62 4.14 - -0.25 2.72 4.06 - -
Description: The investment seeks to maximize total return, consistent with prudent investment management and liquidity needs. The fund invests in aportfolio of fixed income securities of various maturities and, under normal market conditions, will invest at least 80% of its net assets in debt and fixedincome securities. Although the fund may invest in securities of any maturity, it will normally maintain a dollar-weighted average effective durationwithin 30% of the average duration of the domestic bond market as a whole as estimated by the fund's subadvisers. The fund may invest up to 20% ofits total assets in non-U.S. dollar denominated securities.
Composition (% of Assets) as of 06/30/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 1.31 U.S. Stocks 0.06 Total Inv Exp Net % 0.45 1/30 day period
Non-U.S. Bonds 16.65 Convertibles 1.06 Contractual Cap Expiration Date N/A
Preferred 0.07 U.S. Bonds 80.86 Waiver Expiration Date 12/31/2020
Total Inv Exp Gross % 0.52
Total Inv Exp Gross Per $1,000 Invested $5.20
Redemption Fee -
Revenue Sharing % 0.15
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Investment Option Summary - Page 4 of 23 10.20.2019 070914
Contract/Plan ID Number: 4-65623Asset Class: Fixed Income
This asset class is generally composed of investment options that invest in bonds, or debt of a company or government entity(including U.S. and Non- U.S.). It may also include real estate investment options that directly own property. These investmentoptions typically carry more risk than short-term fixed income investment options (including, for real estate investment options,liquidity risk), but less overall risk than equities. All investment options in this category have the potential to lose value.
Investment Category: Nontraditional Bond
Inv Manager or Sub-Advisor: Franklin Templeton Investments
Investment Option Name Average Annual Total Return
Templeton Global Bond R6 Fund 3,11 (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
-0.58 1.16 3.99 0.94 3.82 1.18 1.57 1.78 5.41 1.44 5/2013
Benchmark: ICE BofAML U.S. LIBOR 3 MonthIndex 2.06 2.64 1.81 1.24 0.78 - 2.08 0.86 0.67 - -
Description: The investment seeks current income with capital appreciation and growth of income. Under normal market conditions, the fund invests atleast 80% of its net assets in "bonds." Bonds include debt obligations of any maturity, such as bonds, notes, bills and debentures. It investspredominantly in bonds issued by governments, government-related entities and government agencies located around the world. The fund may investup to 25% of its total assets in bonds that are rated below investment grade or, if unrated determined by the investment manager to be of comparablequality. It is non-diversified.
Composition (% of Assets) as of 06/30/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 41.64 U.S. Stocks -1.32 Total Inv Exp Net % 0.57 -
Non-U.S. Bonds 53.32 U.S. Bonds 6.36 Contractual Cap Expiration Date N/A
Waiver Expiration Date 04/30/2020
Total Inv Exp Gross % 0.67
Total Inv Exp Gross Per $1,000 Invested $6.70
Redemption Fee -
Revenue Sharing % 0.00
Inv Manager or Sub-Advisor: PGIM Investments, LLC
Investment Option Name Average Annual Total Return
PGIM Absolute Return Bond Z Fund 8,11,E (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
5.52 4.83 4.49 3.35 - 3.06 0.69 2.66 - 2.65 3/2011
Benchmark: ICE BofAML U.S. LIBOR 3 MonthIndex 2.06 2.64 1.81 1.24 0.78 - 2.08 0.86 0.67 0.68 -
Description: The investment seeks positive returns over the long term, regardless of market conditions. The fund invests at least 80% of its investableassets (net assets plus borrowings for investment purposes, if any) in debt securities (generally referred to as "bonds") and/or investments that provideexposure to bonds. It may invest up to 50% of its total assets in debt securities that are rated below investment grade (which are sometimes referred toas "junk bonds") or, if unrated, of comparable quality at the time of purchase.
Composition (% of Assets) as of 08/31/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 12.65 U.S. Stocks -1.91 Total Inv Exp Net % 0.73 2/90 day period
Non-U.S. Bonds 29.35 Convertibles 0.31 Contractual Cap Expiration Date N/A
Preferred 0.51 U.S. Bonds 59.08 Waiver Expiration Date 02/29/2020
Total Inv Exp Gross % 0.79
Total Inv Exp Gross Per $1,000 Invested $7.90
Redemption Fee -
Revenue Sharing % 0.25
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Contract/Plan ID Number: 4-65623
10.20.2019 070914 Investment Option Summary - Page 5 of 23
Asset Class: Balanced/Asset Allocation
This asset class is generally composed of a combination of fixed income and equity investment options. These investment optionsmay include balanced, asset allocation, target-date, and target-risk investment options. Although typically lower risk thaninvestment options that invest solely in equities, all investment options in this category have the potential to lose value.
Investment Category: Allocation--30% to 50% Equity
Inv Manager or Sub-Advisor: T. Rowe Price Associates, Inc.
Investment Option Name Average Annual Total Return
T. Rowe Price Personal Strategy Income IFund 6,7,10,11,G (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)
YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
11.08 5.87 6.55 5.51 7.07 7.40 -2.91 4.03 8.05 5.42 3/2016
Benchmark: Morningstar Moderately ConservativeTarget Risk Index 11.19 6.64 5.94 5.00 6.09 - -2.87 3.46 6.26 - -
Description: The investment seeks the highest total return over time consistent with a primary emphasis on income and a secondary emphasis oncapital growth. The fund invests in a diversified portfolio typically consisting of approximately 40% stocks; 55% bonds, money market securities, andcash reserves; and 5% alternative investments, including through hedge funds. Under normal conditions, its allocation to the broad asset classes will bewithin the following ranges: stocks (30-50%), bonds and money markets (45-65%), and alternative investments (0-10%).
Composition (% of Assets) as of 06/30/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 9.51 U.S. Stocks 24.61 Total Inv Exp Net % 0.52 1/30 day period
Non-U.S. Stocks 14.03 Non-U.S. Bonds 19.08 Contractual Cap Expiration Date N/A
Convertibles 0.29 Preferred 0.19 Waiver Expiration Date N/A
U.S. Bonds 27.45 Other 4.83 Total Inv Exp Gross % 0.68
Total Inv Exp Gross Per $1,000 Invested $6.80
Redemption Fee -
Revenue Sharing % 0.00
Investment Category: Allocation--50% to 70% Equity
Inv Manager or Sub-Advisor: T. Rowe Price Associates, Inc.
Investment Option Name Average Annual Total Return
T. Rowe Price Personal Strategy BalancedI Fund 6,7,10,11,G (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)
YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
13.82 5.56 8.48 6.80 8.80 9.34 -4.42 4.88 10.04 6.90 3/2016
Benchmark: Morningstar Moderate Target RiskIndex 13.11 5.41 7.43 5.91 7.51 - -4.76 4.08 7.97 - -
Description: The investment seeks the highest total return over time consistent with an emphasis on both capital growth and income. The fund investsin a diversified portfolio typically consisting of approximately 60% stocks; 35% bonds, money market securities, and cash reserves; and 5% alternativeinvestments, including through hedge funds. Under normal conditions, its allocation to the broad asset classes will be within the following ranges:stocks (50-70%), bonds and money markets (25-45%), and alternative investments (0-10%).
Composition (% of Assets) as of 06/30/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 3.27 U.S. Stocks 37.04 Total Inv Exp Net % 0.62 1/30 day period
Non-U.S. Stocks 20.90 Non-U.S. Bonds 12.65 Contractual Cap Expiration Date N/A
Convertibles 0.20 Preferred 0.18 Waiver Expiration Date N/A
U.S. Bonds 20.98 Other 4.79 Total Inv Exp Gross % 0.75
Total Inv Exp Gross Per $1,000 Invested $7.50
Redemption Fee -
Revenue Sharing % 0.00
4423 442323
Investment Option Summary - Page 6 of 23 10.20.2019 070914
Contract/Plan ID Number: 4-65623Asset Class: Balanced/Asset Allocation
This asset class is generally composed of a combination of fixed income and equity investment options. These investment optionsmay include balanced, asset allocation, target-date, and target-risk investment options. Although typically lower risk thaninvestment options that invest solely in equities, all investment options in this category have the potential to lose value.
Investment Category: Allocation--70% to 85% Equity
Inv Manager or Sub-Advisor: T. Rowe Price Associates, Inc.
Investment Option Name Average Annual Total Return
T. Rowe Price Personal Strategy Growth IFund 6,7,10,11,G (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)
YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
16.00 4.63 10.19 7.83 10.21 11.03 -5.95 5.49 11.56 8.26 3/2016
Benchmark: Morningstar Moderately AggressiveTarget Risk Index 15.04 3.91 8.95 6.79 8.80 - -6.74 4.60 9.48 - -
Description: The investment seeks the highest total return over time consistent with a primary emphasis on capital growth and a secondary emphasison income. The fund invests in a diversified portfolio typically consisting of approximately 80% stocks; 16% bonds, money market securities, and cashreserves; and 4% alternative investments, including through hedge funds. Under normal conditions, its allocation to the broad asset classes will bewithin the following ranges: stocks (70-90%), bonds and money markets (5-25%), and alternative investments (0-10%).
Composition (% of Assets) as of 06/30/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 1.39 U.S. Stocks 49.71 Total Inv Exp Net % 0.66 1/30 day period
Non-U.S. Stocks 28.41 Non-U.S. Bonds 5.18 Contractual Cap Expiration Date N/A
Convertibles 0.08 Preferred 0.16 Waiver Expiration Date N/A
U.S. Bonds 11.05 Other 4.00 Total Inv Exp Gross % 0.75
Total Inv Exp Gross Per $1,000 Invested $7.50
Redemption Fee -
Revenue Sharing % 0.00
Investment Category: Target-Date Retirement
Inv Manager or Sub-Advisor: Vanguard Group
Investment Option Name Average Annual Total Return
Vanguard Target Retirement Income InvFund 6,7,9,10,F (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)
YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
10.29 6.75 5.10 4.57 5.76 5.29 -1.99 3.35 5.92 4.88 10/2003
Benchmark: Morningstar Lifetime ModerateIncome Index 9.73 5.21 4.99 4.18 5.61 - -2.20 2.94 5.88 - -
Description: The investment seeks to provide current income and some capital appreciation. The fund invests in other Vanguard mutual fundsaccording to an asset allocation strategy designed for investors currently in retirement. Its indirect bond holdings are a diversified mix of short-,intermediate-, and long-term U.S. government, U.S. agency, and investment-grade U.S. corporate bonds; inflation-protected public obligations issuedby the U.S. Treasury; mortgage-backed and asset-backed securities; and government, agency, corporate, and securitized investment-grade foreignbonds issued in currencies other than the U.S. dollar.
Composition (% of Assets) as of 08/31/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 1.75 U.S. Stocks 18.19 Total Inv Exp Net % 0.12 1/30 day period
Non-U.S. Stocks 11.30 Non-U.S. Bonds 18.27 Contractual Cap Expiration Date N/A
Convertibles 0.22 U.S. Bonds 50.21 Waiver Expiration Date N/A
Other 0.07 Total Inv Exp Gross % 0.12
Total Inv Exp Gross Per $1,000 Invested $1.20
Redemption Fee -
Revenue Sharing % 0.00
244424 4424
Contract/Plan ID Number: 4-65623
10.20.2019 070914 Investment Option Summary - Page 7 of 23
Asset Class: Balanced/Asset Allocation
This asset class is generally composed of a combination of fixed income and equity investment options. These investment optionsmay include balanced, asset allocation, target-date, and target-risk investment options. Although typically lower risk thaninvestment options that invest solely in equities, all investment options in this category have the potential to lose value.
Investment Category: Target-Date 2015
Inv Manager or Sub-Advisor: Vanguard Group
Investment Option Name Average Annual Total Return
Vanguard Target Retirement 2015 InvFund 6,7,9,10,F (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)
YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
11.26 6.08 6.18 5.33 7.26 6.15 -2.97 4.03 7.84 5.71 10/2003
Benchmark: Morningstar Lifetime Moderate 2015Index 12.28 6.45 6.19 5.15 7.05 - -3.54 3.61 7.55 - -
Description: The investment seeks to provide capital appreciation and current income consistent with its current asset allocation. The fund invests inother Vanguard mutual funds according to an asset allocation strategy designed for investors planning to retire and leave the workforce in or within afew years of 2015 (the target year). The fund's asset allocation will become more conservative over time, meaning that the percentage of assetsallocated to stocks will decrease while the percentage of assets allocated to bonds and other fixed income investments will increase.
Composition (% of Assets) as of 08/31/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 1.68 U.S. Stocks 22.88 Total Inv Exp Net % 0.13 1/30 day period
Non-U.S. Stocks 14.41 Non-U.S. Bonds 16.94 Contractual Cap Expiration Date N/A
Convertibles 0.20 Preferred 0.01 Waiver Expiration Date N/A
U.S. Bonds 43.80 Other 0.08 Total Inv Exp Gross % 0.13
Total Inv Exp Gross Per $1,000 Invested $1.30
Redemption Fee -
Revenue Sharing % 0.00
Investment Category: Target-Date 2020
Inv Manager or Sub-Advisor: Vanguard Group
Investment Option Name Average Annual Total Return
Vanguard Target Retirement 2020 InvFund 6,7,9,10,F (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)
YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
12.61 5.29 7.08 5.97 7.96 6.25 -4.24 4.44 8.53 5.63 6/2006
Benchmark: Morningstar Lifetime Moderate 2020Index 13.28 6.53 6.78 5.57 7.64 - -4.16 3.87 8.27 - -
Description: The investment seeks to provide capital appreciation and current income consistent with its current asset allocation. The fund invests inother Vanguard mutual funds according to an asset allocation strategy designed for investors planning to retire and leave the workforce in or within afew years of 2020 (the target year). The fund's asset allocation will become more conservative over time, meaning that the percentage of assetsallocated to stocks will decrease while the percentage of assets allocated to bonds and other fixed income investments will increase.
Composition (% of Assets) as of 08/31/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 1.56 U.S. Stocks 31.04 Total Inv Exp Net % 0.13 1/30 day period
Non-U.S. Stocks 19.72 Non-U.S. Bonds 14.50 Contractual Cap Expiration Date N/A
Convertibles 0.17 Preferred 0.01 Waiver Expiration Date N/A
U.S. Bonds 32.90 Other 0.10 Total Inv Exp Gross % 0.13
Total Inv Exp Gross Per $1,000 Invested $1.30
Redemption Fee -
Revenue Sharing % 0.00
4425 442525
Investment Option Summary - Page 8 of 23 10.20.2019 070914
Contract/Plan ID Number: 4-65623Asset Class: Balanced/Asset Allocation
This asset class is generally composed of a combination of fixed income and equity investment options. These investment optionsmay include balanced, asset allocation, target-date, and target-risk investment options. Although typically lower risk thaninvestment options that invest solely in equities, all investment options in this category have the potential to lose value.
Investment Category: Target-Date 2025
Inv Manager or Sub-Advisor: Vanguard Group
Investment Option Name Average Annual Total Return
Vanguard Target Retirement 2025 InvFund 6,7,9,10,F (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)
YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
13.70 4.89 7.77 6.39 8.48 6.75 -5.15 4.66 9.06 6.19 10/2003
Benchmark: Morningstar Lifetime Moderate 2025Index 14.23 6.22 7.51 6.04 8.31 - -4.90 4.16 9.05 - -
Description: The investment seeks to provide capital appreciation and current income consistent with its current asset allocation. The fund invests inother Vanguard mutual funds according to an asset allocation strategy designed for investors planning to retire and leave the workforce in or within afew years of 2025 (the target year). The fund's asset allocation will become more conservative over time, meaning that the percentage of assetsallocated to stocks will decrease while the percentage of assets allocated to bonds and other fixed income investments will increase.
Composition (% of Assets) as of 08/31/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 1.56 U.S. Stocks 36.65 Total Inv Exp Net % 0.13 1/30 day period
Non-U.S. Stocks 23.49 Non-U.S. Bonds 13.22 Contractual Cap Expiration Date N/A
Convertibles 0.16 Preferred 0.01 Waiver Expiration Date N/A
U.S. Bonds 24.80 Other 0.11 Total Inv Exp Gross % 0.13
Total Inv Exp Gross Per $1,000 Invested $1.30
Redemption Fee -
Revenue Sharing % 0.00
Investment Category: Target-Date 2030
Inv Manager or Sub-Advisor: Vanguard Group
Investment Option Name Average Annual Total Return
Vanguard Target Retirement 2030 InvFund 6,7,9,10,F (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)
YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
14.28 4.15 8.29 6.67 8.92 6.58 -5.86 4.82 9.57 5.86 6/2006
Benchmark: Morningstar Lifetime Moderate 2030Index 15.11 5.40 8.31 6.50 8.90 - -5.82 4.44 9.74 - -
Description: The investment seeks to provide capital appreciation and current income consistent with its current asset allocation. The fund invests inother Vanguard mutual funds according to an asset allocation strategy designed for investors planning to retire and leave the workforce in or within afew years of 2030 (the target year). The fund's asset allocation will become more conservative over time, meaning that the percentage of assetsallocated to stocks will decrease while the percentage of assets allocated to bonds and other fixed income investments will increase.
Composition (% of Assets) as of 08/31/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 1.50 U.S. Stocks 41.09 Total Inv Exp Net % 0.14 1/30 day period
Non-U.S. Stocks 26.40 Non-U.S. Bonds 10.75 Contractual Cap Expiration Date N/A
Convertibles 0.13 Preferred 0.01 Waiver Expiration Date N/A
U.S. Bonds 19.99 Other 0.12 Total Inv Exp Gross % 0.14
Total Inv Exp Gross Per $1,000 Invested $1.40
Redemption Fee -
Revenue Sharing % 0.00
264426 4426
Contract/Plan ID Number: 4-65623
10.20.2019 070914 Investment Option Summary - Page 9 of 23
Asset Class: Balanced/Asset Allocation
This asset class is generally composed of a combination of fixed income and equity investment options. These investment optionsmay include balanced, asset allocation, target-date, and target-risk investment options. Although typically lower risk thaninvestment options that invest solely in equities, all investment options in this category have the potential to lose value.
Investment Category: Target-Date 2035
Inv Manager or Sub-Advisor: Vanguard Group
Investment Option Name Average Annual Total Return
Vanguard Target Retirement 2035 InvFund 6,7,9,10,F (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)
YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
14.77 3.37 8.78 6.92 9.35 7.32 -6.58 4.99 10.04 6.72 10/2003
Benchmark: Morningstar Lifetime Moderate 2035Index 15.76 4.24 8.96 6.84 9.29 - -6.82 4.61 10.17 - -
Description: The investment seeks to provide capital appreciation and current income consistent with its current asset allocation. The fund invests inother Vanguard mutual funds according to an asset allocation strategy designed for investors planning to retire and leave the workforce in or within afew years of 2035 (the target year). The fund's asset allocation will become more conservative over time, meaning that the percentage of assetsallocated to stocks will decrease while the percentage of assets allocated to bonds and other fixed income investments will increase.
Composition (% of Assets) as of 08/31/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 1.48 U.S. Stocks 45.48 Total Inv Exp Net % 0.14 1/30 day period
Non-U.S. Stocks 29.29 Non-U.S. Bonds 8.32 Contractual Cap Expiration Date N/A
Convertibles 0.10 Preferred 0.01 Waiver Expiration Date N/A
U.S. Bonds 15.18 Other 0.13 Total Inv Exp Gross % 0.14
Total Inv Exp Gross Per $1,000 Invested $1.40
Redemption Fee -
Revenue Sharing % 0.00
Investment Category: Target-Date 2040
Inv Manager or Sub-Advisor: Vanguard Group
Investment Option Name Average Annual Total Return
Vanguard Target Retirement 2040 InvFund 6,7,9,10,F (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)
YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
15.35 2.63 9.28 7.15 9.61 6.93 -7.32 5.10 10.26 6.14 6/2006
Benchmark: Morningstar Lifetime Moderate 2040Index 16.11 3.23 9.30 6.98 9.42 - -7.65 4.65 10.32 - -
Description: The investment seeks to provide capital appreciation and current income consistent with its current asset allocation. The fund invests inother Vanguard mutual funds according to an asset allocation strategy designed for investors planning to retire and leave the workforce in or within afew years of 2040 (the target year). The fund's asset allocation will become more conservative over time, meaning that the percentage of assetsallocated to stocks will decrease while the percentage of assets allocated to bonds and other fixed income investments will increase.
Composition (% of Assets) as of 08/31/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 1.43 U.S. Stocks 49.87 Total Inv Exp Net % 0.14 1/30 day period
Non-U.S. Stocks 32.24 Non-U.S. Bonds 5.72 Contractual Cap Expiration Date N/A
Convertibles 0.07 Preferred 0.01 Waiver Expiration Date N/A
U.S. Bonds 10.53 Other 0.14 Total Inv Exp Gross % 0.14
Total Inv Exp Gross Per $1,000 Invested $1.40
Redemption Fee -
Revenue Sharing % 0.00
4427 442727
Investment Option Summary - Page 10 of 23 10.20.2019 070914
Contract/Plan ID Number: 4-65623Asset Class: Balanced/Asset Allocation
This asset class is generally composed of a combination of fixed income and equity investment options. These investment optionsmay include balanced, asset allocation, target-date, and target-risk investment options. Although typically lower risk thaninvestment options that invest solely in equities, all investment options in this category have the potential to lose value.
Investment Category: Target-Date 2045
Inv Manager or Sub-Advisor: Vanguard Group
Investment Option Name Average Annual Total Return
Vanguard Target Retirement 2045 InvFund 6,7,9,10,F (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)
YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
15.69 2.06 9.41 7.23 9.66 7.71 -7.90 5.13 10.26 7.07 10/2003
Benchmark: Morningstar Lifetime Moderate 2045Index 16.18 2.62 9.37 6.97 9.38 - -8.17 4.60 10.32 - -
Description: The investment seeks to provide capital appreciation and current income consistent with its current asset allocation. The fund invests inother Vanguard mutual funds according to an asset allocation strategy designed for investors planning to retire and leave the workforce in or within afew years of 2045 (the target year). The fund's asset allocation will become more conservative over time, meaning that the percentage of assetsallocated to stocks will decrease while the percentage of assets allocated to bonds and other fixed income investments will increase.
Composition (% of Assets) as of 08/31/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 1.40 U.S. Stocks 53.46 Total Inv Exp Net % 0.15 1/30 day period
Non-U.S. Stocks 34.71 Non-U.S. Bonds 3.52 Contractual Cap Expiration Date N/A
Convertibles 0.04 Preferred 0.01 Waiver Expiration Date N/A
U.S. Bonds 6.71 Other 0.15 Total Inv Exp Gross % 0.15
Total Inv Exp Gross Per $1,000 Invested $1.50
Redemption Fee -
Revenue Sharing % 0.00
Investment Category: Target-Date 2050
Inv Manager or Sub-Advisor: Vanguard Group
Investment Option Name Average Annual Total Return
Vanguard Target Retirement 2050 InvFund 6,7,9,10,F (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)
YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
15.71 2.07 9.42 7.24 9.65 6.99 -7.90 5.12 10.27 6.19 6/2006
Benchmark: Morningstar Lifetime Moderate 2050Index 16.11 2.39 9.32 6.89 9.28 - -8.41 4.51 10.27 - -
Description: The investment seeks to provide capital appreciation and current income consistent with its current asset allocation. The fund invests inother Vanguard mutual funds according to an asset allocation strategy designed for investors planning to retire and leave the workforce in or within afew years of 2050 (the target year). The fund's asset allocation will become more conservative over time, meaning that the percentage of assetsallocated to stocks will decrease while the percentage of assets allocated to bonds and other fixed income investments will increase.
Composition (% of Assets) as of 08/31/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 1.42 U.S. Stocks 53.40 Total Inv Exp Net % 0.15 1/30 day period
Non-U.S. Stocks 34.75 Non-U.S. Bonds 3.51 Contractual Cap Expiration Date N/A
Convertibles 0.04 Preferred 0.01 Waiver Expiration Date N/A
U.S. Bonds 6.72 Other 0.15 Total Inv Exp Gross % 0.15
Total Inv Exp Gross Per $1,000 Invested $1.50
Redemption Fee -
Revenue Sharing % 0.00
284428 4428
Contract/Plan ID Number: 4-65623
10.20.2019 070914 Investment Option Summary - Page 11 of 23
Asset Class: Balanced/Asset Allocation
This asset class is generally composed of a combination of fixed income and equity investment options. These investment optionsmay include balanced, asset allocation, target-date, and target-risk investment options. Although typically lower risk thaninvestment options that invest solely in equities, all investment options in this category have the potential to lose value.
Investment Category: Target-Date 2055
Inv Manager or Sub-Advisor: Vanguard Group
Investment Option Name Average Annual Total Return
Vanguard Target Retirement 2055 InvFund 6,7,10,F (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)
YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
15.69 2.09 9.41 7.21 - 10.06 -7.89 5.10 - 9.09 8/2010
Benchmark: Morningstar Lifetime Moderate 2055Index 16.02 2.29 9.26 6.81 9.17 - -8.57 4.42 10.19 8.47 -
Description: The investment seeks to provide capital appreciation and current income consistent with its current asset allocation. The fund invests inother Vanguard mutual funds according to an asset allocation strategy designed for investors planning to retire and leave the workforce in or within afew years of 2055 (the target year). The fund's asset allocation will become more conservative over time, meaning that the percentage of assetsallocated to stocks will decrease while the percentage of assets allocated to bonds and other fixed income investments will increase.
Composition (% of Assets) as of 08/31/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 1.43 U.S. Stocks 53.34 Total Inv Exp Net % 0.15 1/30 day period
Non-U.S. Stocks 34.90 Non-U.S. Bonds 3.48 Contractual Cap Expiration Date N/A
Convertibles 0.04 Preferred 0.01 Waiver Expiration Date N/A
U.S. Bonds 6.64 Other 0.15 Total Inv Exp Gross % 0.15
Total Inv Exp Gross Per $1,000 Invested $1.50
Redemption Fee -
Revenue Sharing % 0.00
Investment Category: Target-Date 2060+
Inv Manager or Sub-Advisor: Vanguard Group
Investment Option Name Average Annual Total Return
Vanguard Target Retirement 2060 InvFund 6,7,10,F (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)
YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
15.68 2.07 9.41 7.20 - 9.72 -7.87 5.10 - 8.52 1/2012
Benchmark: Morningstar Lifetime Moderate 2060Index 15.91 2.22 9.18 6.71 9.11 - -8.69 4.34 10.22 7.71 -
Description: The investment seeks to provide capital appreciation and current income consistent with its current asset allocation. The fund invests inother Vanguard mutual funds according to an asset allocation strategy designed for investors planning to retire and leave the workforce in or within afew years of 2060 (the target year). The fund's asset allocation will become more conservative over time, meaning that the percentage of assetsallocated to stocks will decrease while the percentage of assets allocated to bonds and other fixed income investments will increase.
Composition (% of Assets) as of 08/31/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 1.41 U.S. Stocks 53.36 Total Inv Exp Net % 0.15 1/30 day period
Non-U.S. Stocks 34.89 Non-U.S. Bonds 3.47 Contractual Cap Expiration Date N/A
Convertibles 0.04 Preferred 0.01 Waiver Expiration Date N/A
U.S. Bonds 6.66 Other 0.15 Total Inv Exp Gross % 0.15
Total Inv Exp Gross Per $1,000 Invested $1.50
Redemption Fee -
Revenue Sharing % 0.00
4429 442929
Investment Option Summary - Page 12 of 23 10.20.2019 070914
Contract/Plan ID Number: 4-65623Asset Class: Balanced/Asset Allocation
This asset class is generally composed of a combination of fixed income and equity investment options. These investment optionsmay include balanced, asset allocation, target-date, and target-risk investment options. Although typically lower risk thaninvestment options that invest solely in equities, all investment options in this category have the potential to lose value.
Investment Category: Target-Date 2060+
Inv Manager or Sub-Advisor: Vanguard Group
Investment Option Name Average Annual Total Return
Vanguard Target Retirement 2065 InvFund 6,7,10,F (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)
YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
15.71 2.09 - - - 7.12 -7.95 - - 0.45 7/2017
Benchmark: Morningstar Lifetime Moderate 2060Index 15.91 2.22 9.18 6.71 9.11 - -8.69 4.34 10.22 0.21 -
Description: The investment seeks to provide capital appreciation and current income consistent with its current asset allocation. The fund invests inother Vanguard mutual funds according to an asset allocation strategy designed for investors planning to retire and leave the workforce in or within afew years of 2065 (the target year). The fund's asset allocation will become more conservative over time, meaning that the percentage of assetsallocated to stocks will decrease while the percentage of assets allocated to bonds and other fixed income investments will increase.
Composition (% of Assets) as of 08/31/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 1.42 U.S. Stocks 53.39 Total Inv Exp Net % 0.15 1/30 day period
Non-U.S. Stocks 35.21 Non-U.S. Bonds 3.39 Contractual Cap Expiration Date N/A
Convertibles 0.04 Preferred 0.01 Waiver Expiration Date N/A
U.S. Bonds 6.39 Other 0.15 Total Inv Exp Gross % 0.15
Total Inv Exp Gross Per $1,000 Invested $1.50
Redemption Fee -
Revenue Sharing % 0.00
Asset Class: Large U.S. Equity
This asset class is generally composed of investment options that invest in stocks, or shares of ownership in large, well-established,U.S. companies. These investment options typically carry more risk than fixed income investment options but have the potential forhigher returns over longer time periods. They may be an appropriate choice for long-term investors who are seeking the potentialfor growth. All investment options in this category have the potential to lose value.
Investment Category: Large Value
Inv Manager or Sub-Advisor: Vanguard Group
Investment Option Name Average Annual Total Return
Vanguard Windsor II Adm Fund 11,F (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
18.11 1.73 10.10 7.53 11.09 6.82 -8.53 5.51 11.20 6.11 5/2001
Benchmark: Russell 1000 Value Index 17.81 4.00 9.43 7.79 11.46 - -8.27 5.95 11.18 - -
Description: The investment seeks to provide long-term capital appreciation and income. The fund invests mainly in large- and mid-capitalizationcompanies whose stocks are considered by an advisor to be undervalued. Undervalued stocks are generally those that are out of favor with investorsand that the advisor believes are trading at prices that are below average in relation to measures such as earnings and book value. These stocks oftenhave above-average dividend yields. It uses multiple investment advisors.
Composition (% of Assets) as of 06/30/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 4.12 U.S. Stocks 89.21 Total Inv Exp Net % 0.25 1/30 day period
Non-U.S. Stocks 6.64 U.S. Bonds 0.03 Contractual Cap Expiration Date N/A
Waiver Expiration Date N/A
Total Inv Exp Gross % 0.25
Total Inv Exp Gross Per $1,000 Invested $2.50
Redemption Fee -
Revenue Sharing % 0.00
304430 4430
Contract/Plan ID Number: 4-65623
10.20.2019 070914 Investment Option Summary - Page 13 of 23
Asset Class: Large U.S. Equity
This asset class is generally composed of investment options that invest in stocks, or shares of ownership in large, well-established,U.S. companies. These investment options typically carry more risk than fixed income investment options but have the potential forhigher returns over longer time periods. They may be an appropriate choice for long-term investors who are seeking the potentialfor growth. All investment options in this category have the potential to lose value.
Investment Category: Large Blend
Inv Manager or Sub-Advisor: Vanguard Group
Investment Option Name Average Annual Total Return
Vanguard Total Stock Market IndexAdmiral Fund F (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)
YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
20.00 2.88 12.81 10.42 13.09 6.78 -5.17 7.90 13.25 6.00 11/2000
Benchmark: Russell 1000 Index 20.53 3.87 13.19 10.62 13.23 - -4.78 8.21 13.28 - -
Description: The investment seeks to track the performance of a benchmark index that measures the investment return of the overall stock market.The fund employs an indexing investment approach designed to track the performance of the CRSP US Total Market Index, which representsapproximately 100% of the investable U.S. stock market and includes large-, mid-, small-, and micro-cap stocks regularly traded on the New York StockExchange and Nasdaq. It invests by sampling the index, meaning that it holds a broadly diversified collection of securities that, in the aggregate,approximates the full index in terms of key characteristics.
Composition (% of Assets) as of 08/31/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 0.75 U.S. Stocks 98.34 Total Inv Exp Net % 0.04 1/30 day period
Non-U.S. Stocks 0.91 Contractual Cap Expiration Date N/A
Waiver Expiration Date N/A
Total Inv Exp Gross % 0.04
Total Inv Exp Gross Per $1,000 Invested $0.40
Redemption Fee -
Revenue Sharing % 0.00
Inv Manager or Sub-Advisor: Vanguard Group
Investment Option Name Average Annual Total Return
Vanguard 500 Index Admiral Fund 2,F (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
20.54 4.22 13.36 10.80 13.21 6.33 -4.43 8.46 13.10 5.51 11/2000
Benchmark: Russell 1000 Index 20.53 3.87 13.19 10.62 13.23 - -4.78 8.21 13.28 - -
Description: The investment seeks to track the performance of a benchmark index that measures the investment return of large-capitalization stocks.The fund employs an indexing investment approach designed to track the performance of the Standard & Poor's 500 Index, a widely recognizedbenchmark of U.S. stock market performance that is dominated by the stocks of large U.S. companies. The advisor attempts to replicate the targetindex by investing all, or substantially all, of its assets in the stocks that make up the index, holding each stock in approximately the same proportion asits weighting in the index.
Composition (% of Assets) as of 08/31/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 0.16 U.S. Stocks 98.87 Total Inv Exp Net % 0.04 1/30 day period
Non-U.S. Stocks 0.97 Contractual Cap Expiration Date N/A
Waiver Expiration Date N/A
Total Inv Exp Gross % 0.04
Total Inv Exp Gross Per $1,000 Invested $0.40
Redemption Fee -
Revenue Sharing % 0.00
4431 443131
Investment Option Summary - Page 14 of 23 10.20.2019 070914
Contract/Plan ID Number: 4-65623Asset Class: Large U.S. Equity
This asset class is generally composed of investment options that invest in stocks, or shares of ownership in large, well-established,U.S. companies. These investment options typically carry more risk than fixed income investment options but have the potential forhigher returns over longer time periods. They may be an appropriate choice for long-term investors who are seeking the potentialfor growth. All investment options in this category have the potential to lose value.
Investment Category: Large Growth
Inv Manager or Sub-Advisor: Capital Research and Mgmt Co
Investment Option Name Average Annual Total Return
American Funds AMCAP R6 Fund 11,G (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
13.96 -2.38 11.81 9.46 12.80 14.37 -1.58 8.43 14.39 14.02 5/2009
Benchmark: Russell 1000 Growth Index 23.30 3.71 16.89 13.39 14.94 - -1.51 10.40 15.29 - -
Description: The investment seeks long-term growth of capital. The fund invests primarily in common stocks of U.S. companies that have solidlong-term growth records and the potential for good future growth. The basic investment philosophy of the investment adviser is to seek to invest inattractively valued companies that, in its opinion, represent good, long-term investment opportunities.
Composition (% of Assets) as of 06/30/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 9.99 U.S. Stocks 83.77 Total Inv Exp Net % 0.36 1/30 day period
Non-U.S. Stocks 6.24 Contractual Cap Expiration Date N/A
Waiver Expiration Date N/A
Total Inv Exp Gross % 0.36
Total Inv Exp Gross Per $1,000 Invested $3.60
Redemption Fee -
Revenue Sharing % 0.00
Asset Class: Small/Mid U.S. Equity
This asset class is generally composed of investment options that invest in stocks, or shares of ownership in small- to medium-sizedU.S. companies. These investment options typically carry more risk than larger U.S. equity investment options but have thepotential for higher returns. They may be an appropriate choice for long-term investors who are seeking the potential for growth.All investment options in this category have the potential to lose value.
Investment Category: Mid Cap Value
Inv Manager or Sub-Advisor: AB LP
Investment Option Name Average Annual Total Return
AB Discovery Value Z Fund 1,11,E (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
12.97 -7.66 6.17 6.60 10.89 7.10 -14.98 4.33 12.82 5.66 10/2013
Benchmark: Russell Midcap Value Index 19.47 1.60 7.82 7.55 12.29 - -12.29 5.44 13.03 - -
Description: The investment seeks long-term growth of capital. The fund invests primarily in a diversified portfolio of equity securities of small- tomid-capitalization U.S. companies. Under normal circumstances, it invests at least 80% of its net assets in securities of small- to mid-capitalizationcompanies. For purposes of this policy, small- to mid-capitalization companies are those that, at the time of investment, fall within the capitalizationrange between the smallest company in the Russell 2500(R) Value Index and the greater of $5 billion or the market capitalization of the largestcompany in the Russell 2500(R) Value Index.
Composition (% of Assets) as of 08/31/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 1.34 U.S. Stocks 93.10 Total Inv Exp Net % 0.78 2/60 day period
Non-U.S. Stocks 5.57 Contractual Cap Expiration Date N/A
Waiver Expiration Date N/A
Total Inv Exp Gross % 0.78
Total Inv Exp Gross Per $1,000 Invested $7.80
Redemption Fee -
Revenue Sharing % 0.00
324432 4432
Contract/Plan ID Number: 4-65623
10.20.2019 070914 Investment Option Summary - Page 15 of 23
Asset Class: Small/Mid U.S. Equity
This asset class is generally composed of investment options that invest in stocks, or shares of ownership in small- to medium-sizedU.S. companies. These investment options typically carry more risk than larger U.S. equity investment options but have thepotential for higher returns. They may be an appropriate choice for long-term investors who are seeking the potential for growth.All investment options in this category have the potential to lose value.
Investment Category: Mid Cap Blend
Inv Manager or Sub-Advisor: Vanguard Group
Investment Option Name Average Annual Total Return
Vanguard Mid Cap Index Admiral Fund 1,F (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
22.60 3.65 10.67 9.20 13.05 9.86 -9.23 6.21 13.87 9.01 11/2001
Benchmark: Russell Midcap Index 21.93 3.19 10.69 9.10 13.07 - -9.06 6.26 14.03 - -
Description: The investment seeks to track the performance of a benchmark index that measures the investment return of mid-capitalization stocks.The fund employs an indexing investment approach designed to track the performance of the CRSP US Mid Cap Index, a broadly diversified index ofstocks of mid-size U.S. companies. The advisor attempts to replicate the target index by investing all, or substantially all, of its assets in the stocks thatmake up the index, holding each stock in approximately the same proportion as its weighting in the index.
Composition (% of Assets) as of 08/31/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 0.85 U.S. Stocks 97.36 Total Inv Exp Net % 0.05 1/30 day period
Non-U.S. Stocks 1.79 Contractual Cap Expiration Date N/A
Waiver Expiration Date N/A
Total Inv Exp Gross % 0.05
Total Inv Exp Gross Per $1,000 Invested $0.50
Redemption Fee -
Revenue Sharing % 0.00
Investment Category: Mid Cap Growth
Inv Manager or Sub-Advisor: Dreyfus
Investment Option Name Average Annual Total Return
BNY Mellon Small/Mid Cap Growth I Fund 1,E (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)
YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
21.82 -4.95 15.56 11.60 13.93 12.16 -1.57 7.00 13.87 11.75 8/1990
Benchmark: Russell Midcap Growth Index 25.23 5.20 14.50 11.12 14.08 - -4.75 7.42 15.12 - -
Description: The investment seeks long-term growth of capital. To pursue its goal, the fund normally invests at least 80% of its net assets, plus anyborrowings for investment purposes, in equity securities of small-cap and mid-cap U.S. companies. The adviser currently considers small-cap andmid-cap companies to be those with total market capitalizations that are equal to or less than the total market capitalization of the largest companyincluded in the Russell 2500(TM) Growth Index (the index), the fund's benchmark index. The fund is non-diversified.
Composition (% of Assets) as of 08/31/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 0.40 U.S. Stocks 93.41 Total Inv Exp Net % 0.74 4/12 month period
Non-U.S. Stocks 6.19 Contractual Cap Expiration Date N/A
Waiver Expiration Date N/A
Total Inv Exp Gross % 0.74
Total Inv Exp Gross Per $1,000 Invested $7.40
Redemption Fee -
Revenue Sharing % 0.25
4433 443333
Investment Option Summary - Page 16 of 23 10.20.2019 070914
Contract/Plan ID Number: 4-65623Asset Class: Small/Mid U.S. Equity
This asset class is generally composed of investment options that invest in stocks, or shares of ownership in small- to medium-sizedU.S. companies. These investment options typically carry more risk than larger U.S. equity investment options but have thepotential for higher returns. They may be an appropriate choice for long-term investors who are seeking the potential for growth.All investment options in this category have the potential to lose value.
Investment Category: Small Blend
Inv Manager or Sub-Advisor: Vanguard Group
Investment Option Name Average Annual Total Return
Vanguard Small Cap Index Admiral Fund 1,2,11,F (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)
YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
17.78 -3.81 9.62 8.62 12.38 8.88 -9.31 5.25 13.57 8.29 11/2000
Benchmark: Russell 2000 Index 14.18 -8.89 8.23 8.19 11.19 - -11.01 4.41 11.97 - -
Description: The investment seeks to track the performance of a benchmark index that measures the investment return of small-capitalization stocks.The fund employs an indexing investment approach designed to track the performance of the CRSP US Small Cap Index, a broadly diversified index ofstocks of small U.S. companies. The advisor attempts to replicate the target index by investing all, or substantially all, of its assets in the stocks thatmake up the index, holding each stock in approximately the same proportion as its weighting in the index.
Composition (% of Assets) as of 08/31/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 2.31 U.S. Stocks 96.90 Total Inv Exp Net % 0.05 1/30 day period
Non-U.S. Stocks 0.76 U.S. Bonds 0.04 Contractual Cap Expiration Date N/A
Waiver Expiration Date N/A
Total Inv Exp Gross % 0.05
Total Inv Exp Gross Per $1,000 Invested $0.50
Redemption Fee -
Revenue Sharing % 0.00
344434 4434
Contract/Plan ID Number: 4-65623
10.20.2019 070914 Investment Option Summary - Page 17 of 23
Asset Class: International Equity
This asset class is composed of investment options that invest in stocks, or shares of ownership in companies with their principalplace of business or office outside the United States. These investment options often carry more risk than U.S. equity investmentoptions but may have the potential for higher returns. They may be an appropriate choice for long-term investors who are seekingthe potential for growth. All investment options in this category have the potential to lose value.
Investment Category: Diversified Emerging Markets
Inv Manager or Sub-Advisor: Invesco
Investment Option Name Average Annual Total Return
Invesco Oppenheimer Developing MarketsR6 Fund 3,11,E (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)
YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
11.31 2.65 8.05 2.83 5.86 5.91 -11.79 1.13 10.21 4.94 12/2011
Benchmark: MSCI Emerging Markets NR Index 5.89 -2.02 5.97 2.33 3.37 - -14.58 1.65 8.02 - -
Description: The investment seeks capital appreciation. The fund mainly invests in common stocks of issuers in developing and emerging marketsthroughout the world and at times it may invest up to 100% of its total assets in foreign securities. Under normal market conditions, it will invest atleast 80% of its net assets, plus borrowings for investment purposes, in equity securities of issuers whose principal activities are in a developing market,i.e. are in a developing market or are economically tied to a developing market country, and in derivatives and other instruments that have economiccharacteristics similar to such securities.
Composition (% of Assets) as of 08/31/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 4.67 U.S. Stocks 0.69 Total Inv Exp Net % 0.85 1/30 day period
Non-U.S. Stocks 88.04 Preferred 0.04 Contractual Cap Expiration Date N/A
Other 6.57 Waiver Expiration Date N/A
Total Inv Exp Gross % 0.85
Total Inv Exp Gross Per $1,000 Invested $8.50
Redemption Fee -
Revenue Sharing % 0.00
Inv Manager or Sub-Advisor: Vanguard Group
Investment Option Name Average Annual Total Return
Vanguard Emerging Markets Stock IndexAdmiral Fund 3,11,F (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)
YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
8.07 1.27 5.26 2.01 3.16 4.94 -14.58 1.32 7.47 4.59 6/2006
Benchmark: MSCI Emerging Markets NR Index 5.89 -2.02 5.97 2.33 3.37 - -14.58 1.65 8.02 - -
Description: The investment seeks to track the performance of a benchmark index that measures the investment return of stocks issued by companieslocated in emerging market countries. The fund employs an indexing investment approach designed to track the performance of the FTSE EmergingMarkets All Cap China A Inclusion Index. It invests by sampling the index, meaning that it holds a broadly diversified collection of securities that, in theaggregate, approximates the index in terms of key characteristics.
Composition (% of Assets) as of 08/31/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 2.95 U.S. Stocks 0.22 Total Inv Exp Net % 0.14 1/30 day period
Non-U.S. Stocks 96.14 Preferred 0.14 Contractual Cap Expiration Date N/A
U.S. Bonds 0.02 Other 0.53 Waiver Expiration Date N/A
Total Inv Exp Gross % 0.14
Total Inv Exp Gross Per $1,000 Invested $1.40
Redemption Fee -
Revenue Sharing % 0.00
4435 443535
Investment Option Summary - Page 18 of 23 10.20.2019 070914
Contract/Plan ID Number: 4-65623Asset Class: International Equity
This asset class is composed of investment options that invest in stocks, or shares of ownership in companies with their principalplace of business or office outside the United States. These investment options often carry more risk than U.S. equity investmentoptions but may have the potential for higher returns. They may be an appropriate choice for long-term investors who are seekingthe potential for growth. All investment options in this category have the potential to lose value.
Investment Category: Foreign Large Blend
Inv Manager or Sub-Advisor: Vanguard Group
Investment Option Name Average Annual Total Return
Vanguard Developed Markets IndexAdmiral Fund 3,11,F (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)
YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
12.63 -2.08 6.28 3.62 5.07 3.97 -14.46 0.85 6.26 3.49 8/1999
Benchmark: MSCI ACWI Ex USA Index 11.56 -1.23 6.33 2.90 4.45 - -14.20 0.68 6.57 - -
Description: The investment seeks to track the performance of the FTSE Developed All Cap ex US Index. The fund employs an indexing investmentapproach designed to track the performance of the FTSE Developed All Cap ex US Index, a market-capitalization-weighted index that is made up ofapproximately 3,885 common stocks of large-, mid-, and small-cap companies located in Canada and the major markets of Europe and the Pacificregion. The adviser attempts to replicate the target index by investing all, or substantially all, of its assets in the stocks that make up the index, holdingeach stock in approximately the same proportion as its weighting in the index.
Composition (% of Assets) as of 08/31/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 2.59 U.S. Stocks 1.23 Total Inv Exp Net % 0.07 1/30 day period
Non-U.S. Stocks 96.12 Preferred 0.01 Contractual Cap Expiration Date N/A
Other 0.05 Waiver Expiration Date N/A
Total Inv Exp Gross % 0.07
Total Inv Exp Gross Per $1,000 Invested $0.70
Redemption Fee -
Revenue Sharing % 0.00
Investment Category: Foreign Large Growth
Inv Manager or Sub-Advisor: Capital Research and Mgmt Co
Investment Option Name Average Annual Total Return
American Funds EuroPacific Growth R6Fund 3,11,G (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)
YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
15.72 1.14 7.38 5.02 6.07 8.66 -14.91 1.86 7.69 7.72 5/2009
Benchmark: MSCI ACWI Ex USA Growth Index 16.21 2.03 7.37 4.86 5.82 - -14.43 1.69 7.15 - -
Description: The investment seeks long-term growth of capital. The fund invests primarily in common stocks of issuers in Europe and the Pacific Basinthat the investment adviser believes have the potential for growth. Growth stocks are stocks that the investment adviser believes have the potential forabove-average capital appreciation. It normally will invest at least 80% of its net assets in securities of issuers in Europe and the Pacific Basin. The fundmay invest a portion of its assets in common stocks and other securities of companies in emerging markets.
Composition (% of Assets) as of 06/30/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 6.88 U.S. Stocks 1.58 Total Inv Exp Net % 0.49 1/30 day period
Non-U.S. Stocks 91.28 Non-U.S. Bonds 0.17 Contractual Cap Expiration Date N/A
Convertibles 0.03 U.S. Bonds 0.06 Waiver Expiration Date N/A
Total Inv Exp Gross % 0.49
Total Inv Exp Gross Per $1,000 Invested $4.90
Redemption Fee -
Revenue Sharing % 0.00
364436 4436
Contract/Plan ID Number: 4-65623
10.20.2019 070914 Investment Option Summary - Page 19 of 23
Asset Class: International Equity
This asset class is composed of investment options that invest in stocks, or shares of ownership in companies with their principalplace of business or office outside the United States. These investment options often carry more risk than U.S. equity investmentoptions but may have the potential for higher returns. They may be an appropriate choice for long-term investors who are seekingthe potential for growth. All investment options in this category have the potential to lose value.
Investment Category: Foreign Small/Mid Value
Inv Manager or Sub-Advisor: Dimensional Fund Advisors
Investment Option Name Average Annual Total Return
DFA International Small Cap Value I Fund 1,3,E (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)
YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
8.21 -11.17 2.61 2.75 5.77 6.84 -23.31 0.93 8.71 6.71 12/1994
Benchmark: MSCI World Ex USA SMID Index 13.20 -4.60 5.63 4.79 6.35 - -17.34 1.95 8.77 - -
Description: The investment seeks long-term capital appreciation. The advisor intends to purchase securities of small value companies associated withdeveloped market countries that the Advisor has designated as approved markets. As a non-fundamental policy, under normal circumstances, the fundwill invest at least 80% of its net assets in securities of small companies in the particular markets in which it invests. It may gain exposure to companiesassociated with approved markets by purchasing equity securities in the form of depositary receipts, which may be listed or traded outside the issuer'sdomicile country.
Composition (% of Assets) as of 07/31/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 0.81 U.S. Stocks 1.33 Total Inv Exp Net % 0.68 1/30 day period
Non-U.S. Stocks 97.73 Other 0.14 Contractual Cap Expiration Date N/A
Waiver Expiration Date N/A
Total Inv Exp Gross % 0.68
Total Inv Exp Gross Per $1,000 Invested $6.80
Redemption Fee -
Revenue Sharing % 0.00
Investment Category: World Large Stock
Inv Manager or Sub-Advisor: Capital Research and Mgmt Co
Investment Option Name Average Annual Total Return
American Funds Capital World Growthand Income R6 Fund 3,11,G (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)
YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
14.98 1.64 8.94 6.31 8.28 10.61 -9.97 4.26 9.39 9.88 5/2009
Benchmark: MSCI ACWI Large Cap NR Index 16.15 1.82 10.11 6.75 8.29 - -8.63 4.41 9.28 - -
Description: The investment seeks long-term growth of capital while providing current income. The fund invests primarily in common stocks ofwell-established companies located around the world, many of which have the potential to pay dividends. It invests, on a global basis, in commonstocks that are denominated in U.S. dollars or other currencies. Under normal market circumstances, the fund will invest a significant portion of itsassets in securities of issuers domiciled outside the United States, including those based in developing countries.
Composition (% of Assets) as of 06/30/2019 Fees & Expenses # of Transfers Allowed/Time Period
Cash 6.38 U.S. Stocks 44.46 Total Inv Exp Net % 0.44 1/30 day period
Non-U.S. Stocks 48.17 Non-U.S. Bonds 0.53 Contractual Cap Expiration Date N/A
Preferred 0.28 U.S. Bonds 0.13 Waiver Expiration Date N/A
Other 0.04 Total Inv Exp Gross % 0.44
Total Inv Exp Gross Per $1,000 Invested $4.40
Redemption Fee -
Revenue Sharing % 0.00
4437 443737
Investment Option Summary - Page 20 of 23 10.20.2019 070914
Contract/Plan ID Number: 4-65623Asset Class: Employer Security
This investment type includes the company stock that is held in trust for your benefit. This stock is public and readily traded in thepublic marketplace. There are risks and rewards associated with company stock. The returns can be a higher rate of return thanother asset classes but do have the potential to lose value. The risks can be greater because returns are dependent on a single stockand a number of reasons, such as economic factors, the market or the company's performance, could result in a pronouncedfluctuation in the stock price in a given period.
Investment Category: N/A
Inv Manager or Sub-Advisor:
Investment Option Name Average Annual Total Return
QCR Holdings, Inc. Common Stock 5,T (as of 09/30/2019 quarter end) (as of 12/31/2018 year end)YTD Ret 1-Year 3-Year 5-Year 10-Year Since
Incept 1-Year 5-Year 10-Year SinceIncept
InceptDate
18.92 -6.44 6.78 17.10 14.43 9.02 -24.55 14.04 12.77 8.55 10/1993
Benchmark: Standard & Poor's 500 Index 20.55 4.25 13.39 10.84 13.24 - -4.38 8.49 13.12 - -
Description: QCR Holdings Inc is a United States based multi-bank holding company. It provides bank and bank-related services through its bankingsubsidiaries. The company, through its subsidiaries, is also engaged in offering direct financing lease contracts and wealth management services. Itsprimary business segment is Commercial banking. The company's principal business consists of attracting deposits and investing deposits inloans/leases and securities. It offers a broad range of commercial and retail lending/leasing and investment services to corporations, partnerships,individuals, and government agencies.
Composition (% of Assets) as of N/A Fees & Expenses # of Transfers Allowed/Time Period
N/A Total Inv Exp Net % 0.00 -
Contractual Cap Expiration Date N/A
Waiver Expiration Date N/A
Total Inv Exp Gross % 0.00
Total Inv Exp Gross Per $1,000 Invested $0.00
Redemption Fee -
Revenue Sharing % 0.00
Investors should carefully consider a mutual fund's investment objectives, risks, charges, and expenses prior to investing. Aprospectus, or summary prospectus if available, containing this and other information can be obtained by contacting a financialprofessional, visiting principal.com, or calling 1-800-547-7754. Read the prospectus carefully before investing.
The value of the investment options will fluctuate so that when redeemed, shares or units may be worth more or less than theoriginal cost.
An investment's past performance is not necessarily an indication of how the investment will perform in the future.
Since inception benchmark returns are displayed on the Investment Option Summary for investments that are less than 10 years old. The benchmarkreflecting the Since Inception return is the Morningstar Category index. For some Sub-Advised investment options, two benchmarks will be displayedon the Investment Option Summary and the secondary index reflecting the Since Inception Return is the Morningstar Category index.
Investment Options may charge a short-term trading or redemption fee to protect the interests of long-term Contractholders.
Returns shown for periods of less than one year are not annualized. All returns displayed here are after net Total Investment Expense of theinvestment option.
For a Mutual Fund investment option, Total Investment Expense gross equals the sum of (a) the total fund operating expenses plus (b) if the mutualfund invests in other mutual funds, the weighted-average management fee of those other mutual funds, as listed in the most recent prospectus. Theactual Total Investment Expense may change if the mutual fund investment option's allocation of assets to other mutual funds changes.
© 2019 Morningstar, Inc. All Rights Reserved. Part of the mutual fund data contained herein: (1) is proprietary to Morningstar and/or its contentproviders; (2) may not be copied or distributed; and (3) is not warranted to be accurate, complete, or timely. Neither Morningstar nor its contentproviders are responsible for any damages or losses arising from any use of this information.
384438 4438
Contract/Plan ID Number: 4-65623
10.20.2019 070914 Investment Option Summary - Page 21 of 23
Insurance products and plan administrative services are provided by Principal Life Insurance Company. Principal mutual funds are part of the PrincipalFunds, Inc. series. Principal Funds, Inc. is distributed by Principal Funds Distributor, Inc. Securities are offered through Principal Securities, Inc.,1-800-547-7754, member SIPC and/or independent broker/dealers. Securities sold by a Principal Securities, Inc. Registered Representative are offeredthrough Principal Securities, Inc. Principal Funds Distributor, Principal Securities, Inc. and Principal Life are members of the Principal Financial Group®(The Principal®), Des Moines, IA 50392.
As allowed by their prospectuses several mutual fund companies have decided to impose redemption fees and/or transfer restrictions on certain planand/or participant transactions. One or more of the investment options in your employer's retirement plan may be impacted. For more information,visit The Principal Web site at principal.com.
Any operating expenses of a mutual fund or underlying mutual fund that are part of net Total Investment Expense are obtained from the mutualfund's most recent prospectus. The operating expenses shown as part of net Total Investment Expense include voluntary expense limits and feecredit.
This report includes investment options that contain information from a variety of sources. Morningstar generally provides holdings information,operations data, and rankings or statistics proprietary to Morningstar. Morningstar is also the source of information on certain mutual funds.
These results are for the investment options available through your Plan Sponsor's retirement plan, and may be different from the results for otherretirement plans. Past performance is not a guarantee of future results. Principal values and investment returns will fluctuate so that values uponredemption may be worth more or less than original costs. Total returns illustrated are net of investment expenses and management fees.
Since inception returns are only shown for funds/accounts in existence for less than 10 years.
1 Small-cap and mid-cap investment options are subject to more fluctuation in value and may have additional risks than other investment options withstocks of larger, more stable companies.
2 Each index based investment option is invested in the stocks or bonds of the index it tracks. Performance of indexes reflects the unmanaged resultsfor the market segment the selected stocks or bonds represent. There is no assurance an index based investment option will match the performanceof the index tracked.
3 International and global investment options are subject to additional risk due to fluctuating exchange rates, foreign accounting and financial policies,and other economic and political environments.
4 Performance prior to December 31, 2005, was gross of fees.
5 This investment option is not a pooled investment. It may experience greater volatility and should not be directly compared to investment optionsthat have a more diversified investment mix.
6 Equity investment options involve greater risk, including heightened volatility, than fixed-income investment options. Fixed-income investmentoptions are subject to interest rate risk, and their value will decline as interest rates rise.
7 Asset allocation does not guarantee a profit or protect against a loss. Investing in real estate, small-cap, international, and high-yield investmentoptions involves additional risks.
8 Fixed-income investment options are subject to interest rate risk, and their value will decline as interest rates rise. Neither the principal of bondinvestment options nor their yields are guaranteed by the U.S. government.
9 This fund indirectly bears its pro rata share of the management fees incurred by the underlying funds in which it invests. The operating expenses ofthe underlying mutual funds are part of total investment expense. Performance results reflect the application of these expenses.
10 Fixed-income and asset allocation investment options that invest in mortgage securities are subject to increased risk due to real estate exposure.
11 For investment options, returns for all time periods, except the Since Inception time frame, may include the historical performance of the oldest shareclass of the investment, adjusted to reflect a portion of the fees and expenses of this share class. Since Inception returns display the actual return ofthis share class and do not reflect the adjusted returns of the oldest share class. Please see the fund's prospectus or if CIT, the offering document formore information on specific expenses, and the investment options most recent shareholder report for actual date of first sale. For a CIT, you mayneed to contact the plan sponsor or plan advisor, if applicable. Expenses are deducted from income earned by the investment option. As a result,dividends and investment results will differ for each share class.
E Investment option limits the number of transfers allowed into the investment option. All participant investment transfers and non-scheduledrebalancing activity are counted toward the number of transfers allowed. When the number of allowed transfers into the investment option is met,no additional investment transfers into the investment option will be allowed until the holding period elapses. Contributions into the investmentoption are not impacted.
F Investment option limits transfer activity. Once the number of allowed transfers is met, participants are not allowed to transfer back into aninvestment option which they have transferred out of until the holding period elapses. All participant investment transfers and non-scheduledrebalancing activity are counted toward the number of transfers allowed. Contributions into the investment option are not impacted. Participantsmay still transfer out to different investment options or to money market or Guaranteed options.
G Investment option limits transfer activity. Once the number of allowed transfers is met, participants are not allowed to transfer amounts valued atthe threshold amount or more back into the investment option which they have transferred out of until the holding period elapses. All participantinvestment transfers and non-scheduled rebalancing activity valued at the threshold amount or more are counted toward the number of transfersallowed. Contributions into the investment option are not impacted. Participant transfers made for less than the threshold amount do not count andare not limited.
T The since inception return is calculated based on the date when the stock first started pricing on an exchange, as reported to us by Morningstar, Inc.
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Investment Option Summary - Page 22 of 23 10.20.2019 070914
Contract/Plan ID Number: 4-65623-- Principal Life works with each fund family to implement each funds' policy and establish frequent trading guidelines that best mirror Prospectus
language. Mutual Fund Network investment managers have the ability to monitor for excessive trading and may enforce frequent purchaselimitations in addition to or in lieu of policy monitored by Principal Life Insurance Company. Please refer to the Prospectus for verification.
Benchmark Descriptions
MSCI Emerging Markets NR Index measures equity market performance in the global emerging markets. It consists of 26 emerging market countriesin Europe, Latin America and the Pacific Basin.
Russell Midcap Growth Index is a market-weighted total return index that measures the performance of companies within the Russell Midcap Indexhaving higher price-to-book ratios and higher forecasted growth values.
Russell Midcap Index includes firms 201 through 1000, based on market capitalization, from the Russell 3000 Index.
Russell 2000 Index consists of the smallest 2000 companies in the Russell 3000 Index, representing approximately 10% of the Russell 3000 totalmarket capitalization.
Russell Midcap Value Index is a market-weighted total return index that measures the performance of companies within the Russell Midcap indexhaving lower price-to-book ratios and lower forecasted growth values.
Morningstar Lifetime Moderate 2060 Index represents a portfolio of global equities, bonds and traditional inflation hedges such as commodities andTIPS. This portfolio is held in proportions appropriate for a U.S. investor who is about 50 years away from retirement.
MSCI ACWI Ex USA Index is a free float-adjusted market capitalization index that is designed to measure the combined equity market performance ofdeveloped and emerging market countries excluding the US.
Standard & Poor's 500 Index is a market capitalization-weighted index of 500 widely held stocks often used as a proxy for the stock market.
Bloomberg Barclays Aggregate Bond Index represents securities that are domestic, taxable, and dollar denominated. The index covers the U.S.investment grade fixed rate bond market, with index components for government and corporate securities, mortgage pass-through securities, andasset-backed securities. These major sectors are subdivided into more specific indices that are calculated and reported on a regular basis.
Morningstar Moderately Conservative Target Risk Index represents a portfolio of global equities, bonds and traditional inflation hedges such ascommodities and TIPS. This portfolio is held in a static allocation appropriate for U.S. investors who seek a slightly below-average exposure to equitymarket risk and returns.
Morningstar Moderately Aggressive Target Risk Index represents a portfolio of global equities, bonds and traditional inflation hedges such ascommodities and TIPS. This portfolio is held in a static allocation appropriate for U.S. investors who seek a slightly above-average exposure to equitymarket risk and returns.
Morningstar Lifetime Moderate Income Index represents a portfolio of global equities, bonds and traditional inflation hedges such as commoditiesand TIPS. This portfolio is held in proportions appropriate for a U.S. investor who is at least ten years into retirement.
Morningstar Lifetime Moderate 2015 Index represents a portfolio of global equities, bonds and traditional inflation hedges such as commodities andTIPS. This portfolio is held in proportions appropriate for a U.S. investor who is about five years away from retirement.
Russell 1000 Index consists of the 1000 largest companies within the Russell 3000 index. Also known as the Market-Oriented Index, because itrepresents the group of stocks from which most active money managers choose.
MCSI ACWI Ex USA Growth Index captures large and mid-cap secuities exhibiting overall growth style characteristics across 22 Developed Marketscountries and 23 Emerging Markets countries.
Morningstar Lifetime Moderate 2020 Index represents a portfolio of global equities, bonds and traditional inflation hedges such as commodities andTIPS. This portfolio is held in proportions appropriate for a U.S. investor who is about ten years away from retirement.
Morningstar Lifetime Moderate 2025 Index represents a portfolio of global equities, bonds and traditional inflation hedges such as commodities andTIPS. This portfolio is held in proportions appropriate for a U.S. investor who is about 15 years away from retirement.
Morningstar Lifetime Moderate 2030 Index represents a portfolio of global equities, bonds and traditional inflation hedges such as commodities andTIPS. This portfolio is held in proportions appropriate for a U.S. investor who is about 20 years away from retirement.
Morningstar Lifetime Moderate 2035 Index represents a portfolio of global equities, bonds and traditional inflation hedges such as commodities andTIPS. This portfolio is held in proportions appropriate for a U.S. investor who is about 25 years away from retirement.
Bloomberg Barclays 1-3 Yr Government Index is comprised of both the Treasury Bond Index and the Agency Bond Index.
Russell 1000 Growth Index is a market-capitalization weighted index of those firms in the Russell 1000 with higher price-to-book ratios and higherforecasted growth values.
Morningstar Lifetime Moderate 2040 Index represents a portfolio of global equities, bonds and traditional inflation hedges such as commodities andTIPS. This portfolio is held in proportions appropriate for a U.S. investor who is about 30 years away from retirement.
Bloomberg Barclays U.S. Universal Index represents the union of the U.S. Aggregate Bond Index, the U.S. High Yield Corporate Index, the 144A Index,the Eurodollar Index, the Emerging Markets Index, the non-ERISA portion of the CMBS Index, and the CMBS High Yield Index.
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10.20.2019 070914 Investment Option Summary - Page 23 of 23
Russell 1000 Value Index is a market-capitalization weighted index of those firms in the Russell 1000 with lower price-to-book ratios and lowerforecasted growth values.
Morningstar Lifetime Moderate 2045 Index represents a portfolio of global equities, bonds and traditional inflation hedges such as commodities andTIPS. This portfolio is held in proportions appropriate for a U.S. investor who is about 35 years away from retirement.
Morningstar Lifetime Moderate 2050 Index represents a portfolio of global equities, bonds and traditional inflation hedges such as commodities andTIPS. This portfolio is held in proportions appropriate for a U.S. investor who is about 40 years away from retirement.
ICE BofAML U.S. LIBOR 3 Month Index is an average of the interest rate for U.S. dollar deposits, known as Eurodollars, of a stated maturity. LIBOR isan abbreviation for the London Interbank Offered Rate.
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PQ12087-01 | © 2018 Principal Financial Services, Inc. | 10/2018 | 621222-102018
4-65623/QCR HOLDINGS, INC. 401(k) PLAN
10/30/2019
QCR Holdings, Inc. | Additional Benefits 1
ADDITIONAL BENEFITS
Employee Assistance Program (EAP)
EAP is an employer-sponsored benefit that provides confidential assessment, short-term counseling, referral (when
necessary), and follow-up services for employees and their immediate family members.
Employee Stock Purchase Plan (ESPP)
All employees of QCRH, QCBT, CRBT/CBT, CSB, SFC, Bates and M2 are eligible to contribute up to 15% of their bi-
weekly pay, up to a maximum value of $25,000 per calendar year through regular payroll deductions for the purchase of the
QCR Holdings, Inc. Common Stock at a 15% discounted rate. There are two offering periods; January 1 – June 30 and July
1 – December 31. Employees can enroll before January 1 each year for the first offering period starting January 1 and
before July 1 each year for the second offering period starting July 1.
Personal Day Buy-Up
QCRH realizes that employees have occasional “time away from work” needs during the course of the year that exceed the
Personal Day policy. Employees will be able to purchase up to two (2) additional personal days per calendar year. The cost
of additional personal days will be calculated using the rate of pay at the time of the request and payroll deducted over the
remaining pay periods of the calendar year. Find the Personal Day Buy-Up form out on QNews.
Sabbatical Program
All full-time employees (32-40 hours per week) with 10, 18, 25, and 30 years of service and have satisfactory performance
are eligible for 4 consecutive weeks paid time off in addition to personal time. The time off can be used for education
purposes, service or community involvement or personal reasons.
Education Assistance
QCRH encourages the professional development of its employees through formal education and thus provides tuition
assistance for courses taken at an accredited secondary school, college, or university. This policy covers tuition only, books
and fees are the responsibility of the employee. All employees working at least 24 hours per week are eligible. See QNews
for the full policy and request form.
Clothing Advance
In order to help our employees comply with the personal appearance policy – QCR Holdings, Inc. has a clothing advance in
place. An employee* may apply for a clothing advance up to $300.00. Requests will be taken at the start of each new quarter
– January, April, July and October. The funds must be used for business attire. Please see QNews for the full policy and
procedure.
*Executive Officers are excluded from this program
Family of Friends – QCRH/QCBT employees working in the Quad Cities
The Family of Friends is a program to help QCRH/QCBT employees who are going through a difficult period. The program
provides funds or personal time for emergencies.
CYBER COUCH The Cyber Couch is the place togo for tips on self improvement.
The Cyber Couch also offers:�� News features�� Tests and Quizzes�� Medication Information�� A psychological self-help
book�� a list of helpful telephone
numbers�� AND MUCH MORE....
www.genesishealth.com/couch Username: QCRPassword: genesis
FINANCIAL RESOURCESLearn how to better manage your purchases and finances.�� Managing Your Money�� Credit�� Credit History
www.genesishealth.com/eapUser-name: smartmoneypassword: genesis
LEGAL RESOURCESFree phone consultation to assist with personal legal matters such as:�� Family Law�� Housing and Real Estate�� Creditor Concerns�� Consumer Rights�� Criminal�� Contracts
COUNSELINGGenesis EAP provides free, confidential professional counseling to help you, or someone in your immediate family, resolve personal problems including:
�� Marital/relationship�� Emotional/stress�� Alcohol/drug abuse�� Family illness�� Family conflict�� Financial�� Legal�� Job/personal stress�� Addictions
Take advantage of your EAP It’s free.
It’s confidential.
It’s a job benefit.
It’s available for you, your spouse and your dependents.
www.genesishealth.com/EAP
Call us at 563.386.4004 or 800.475.1641 for more information.
Use of all Genesis EAP services are held in complete confidence. Your privacy is assured.
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