This enrollment guide has been designed to provide you with information about each plan in the benefit package

and to help guide you through the choices you have. Reviewing the information contained in this guide will help

you to choose the benefits that fit your needs and lifestyle.

What You Will Find Inside…

Important Information .............................................. 2

Plan Eligibility ............................................................ 2

Fees ......................................................................... 2

Medical Plans ........................................................... 3

Dental - Standard .................................................... 4

Vision – Vision Service Plan ....................................... 4

Hearing Aid Discounts – TruHearing .......................... 5

Life Insurance - Unum ............................................... 6

Accident Insurance ................................................. 7

Critical Illness Insurance ............................................ 7

Individual/Small Group Plans .................................... 8

Available Discounts .................................................. 9

Instructions for the 2018 Open Enrollment............... 10

Women’s Health and Cancer Rights Act -

-Notice of Rights ..................................................... 12

Medicare Part D ..................................................... 12

ACA Notice ............................................................ 15

FORMS 18

The information in this brochure is intended to explain the process for enrolling in Financial Network Group Health Plan’s

benefits program. The benefits described apply to regular full-time employees. As always, the terms and conditions of any

benefit plan are determined by official plan documents. In the event of any discrepancy between the information

provided in this Enrollment Guide and the official plan documents, the official plan documents will govern. None of this

information should be interpreted as a guarantee of employment. The Financial Network Group Health Plan reserves the

right to amend, modify, or terminate any benefit plan at any time.

During open enrollment, you have the opportunity to

change, add or cancel any of your benefits. In

addition, you may add or change the dependents

you cover under your benefits. For medical, dental

and life coverage’s, changes you make during open

enrollment are effective January 1, 2018. Open

enrollment runs from October 16 through October 31.

Confirmations will be sent by November 3. After

November 7 you will not be able to make changes to

your benefit elections for another year, unless you

have a Qualified Change in Status. All elections are

for the calendar year. There is no midyear termination

allowed. This is an ERISA Plan. All premiums listed are

MONTHLY -_ NOT ANNUALLY.

Please review this brochure, and then complete the

enrollment form. A confirmation statement and

invoice will be emailed to you on November 3, 2017.

For 2018, all changes must be documented during

open enrollment with an updated form and an

updated ACH Debit/Credit Card forms. Changes will

be updated and confirmed with Statements sent on

November 3, 2017. All plans finalized with

elections/corrections to the carriers on 11/11/17

Questions: amy.ahrens@ahrensnaefconsulting.com

FAX: 866-817-3969,

Telephone: 770-966-9247,

Financial Network Group Health Plan,

3226 Citation Avenue, NW,

Kennesaw, GA 30144

Financial Network -2018 Benefits Enrollment

Important Dates: For 2018 Plan Year

Enrollment: October 16 thru

October 31

Confirms E-mailed: November 3

Final Changes Due: November 7

Annual Fees Drafted: November

2018 Premiums Begin: December

2

January 22, 2018

Important Information All Financial Network Plan participants must

complete the forms attached and submit either

electronically, via fax or mail within 31 days of their

hire date. All participants who do not complete

the forms, as requested, will have a delay in

receiving new cards and plan information.

Please Review all documents in this e mail and

review the plan designs available to each plan

participant.

1. ACH , Authorization for Debit –is

required for all premium payments

2. Invoices are sent out annually with a

monthly breakdown of premiums and

plans participated in.

3. All participants are required to pay the

initial enrollment fee the month the

benefit begins

4. Existing participants are required to pay

the annual enrollment fee and the

monthly administrative fee.

5. all plan contracts are available for

review on our plan website. Plan

language and forms needed.

Contracts and documents will not be

sent out; all are available electronically

Plan Eligibility If you are a full-time employee (exempt and non-

exempt), scheduled to work at least 20 hours per

week, you are eligible for health and welfare

benefits on the first day of hire. You may also cover

eligible dependents, including:

• Your legal spouse or domestic partner,

• Your unmarried dependent child(ren) until

his or her 26th birthday,

• Natural and legally adopted children,

children placed with you for adoption, or

any other children for whom you or your

spouse is named legal guardian,

according to a letter of guardianship,

• Biological or legally adopted children for

whom the plan is obligated under a

Qualified Medical Child Support Order

(QMCSO) to provide medical coverage.

Fees

Annual Enrollment Fee: $450.00 per participant

Monthly fees: Amount reflected on

Confirmation Statement

The annual fee is drafted at the time of initial

enrollment and each year in November.

3

January 22, 2018

Medical Plans We recognize your health care needs are unique. What you and your family need in a health plan may not

be the same as the family next door; therefore, for 2017, we continue to offer you a choice of medical plans.

The medical options offered by BCBS/GA - Anthem (Blue Cross/Blue Shield of Georgia) and Anthem under a

national plan:

Medical ID Cards

If you elect medical coverage, you will be receiving a new medical identification card prior to January 1.

Keep the new card with you at all times so that you will have it available when you need medical services.

The card identifies your medical plan and gives instructions for providers on where to send claim information.

BCBS

HSAOAP3 5.5K/0 5.5K

Medical Plan Comparison

What you Pay:

In-Network Out-of-Network

Calendar Year Deductible

Individual $5,500 $16,500

, Family $11,000 $33,000

Out-of-Pocket Expense Max

Individual $5,500 $19,650

Family $11,000 39,300

Lifetime Maximum unlimited

Coverage Levels

Preventive Care Office Visits plan pays 100% 50% after Ded.

Physician Office Visits 0% after ded 50% after Ded.

Specialist Office Visits 0% after ded 50% after Ded.

Inpatient Hospital Care (Daily room, board and general nursing care at semi-private room rate) 0% after ded 50% after Ded.

Inpatient Physician Care (surgeon, anesthesiologist, radiologist, pathologist, etc.) 0% after ded 50% after Ded.

Outpatient Facility/hospital charges 0% after ded 50% after Ded.

Pharmacy

Retail (31-day supply)

Preferred Generic Plan pays 100% after ded

Preferred Brand Plan pays 100% after ded

Non-Preferred Brand Plan pays 100% after ded

Specialty Drug Plan pays 100% after ded

Mail Order (Maintenance Only, 90-day supply) $15/$70/$180/20% coin after Deductible

Cost/mo Monthly Premium

Member Only $1,353.49

Member + Spouse $2,842.32

Member + Child $2,639.30

Member + Family $4,128.14

4

January 22, 2018

Dental - Standard By providing coverage for routine preventive

care, a comprehensive dental plan

encourages employees to maintain a

healthy lifestyle and good oral hygiene by

seeking dental check-ups on a regular basis.

This chart provides a brief summary of the

benefits provided by Standard.

All contracts and certificates are available

on our benefits website.

Vision – Vision Service Plan VSP is the provider of your vision coverage.

The chart details the benefits available.

You may also access www.vsp.com for more

information.

Benefit Provisions Plan 1 Plan 2b

Deductibles:

Single $50 $50

Family $150 $150

Preventive 100% 100%

Basic 80% after ded 80% after ded

Major 50% after ded. 50% after ded.

Orthodontia 50% after ded. 50% after ded.

Annual Maximum $1,250 $2,500

Orthodontia Lifetime

Maximum $1,250 $2,000

Rollover $250 $400

PPO Bonus $100 $100

Orthodontia Limiting Age

19 Adults and Children

Coverage Level

Employee Only 46.12/mo 62.09/mo

Employee + Spouse 90.58/mo 121.86/mo

Employee + Child(ren) 123.34/mo 164.84/mo

Employee + Family 167.80/mo 224.61/mo

VISION SERVICE PLAN BENEFITS

Eye Exam $0 copay

Material Copay $0 copay

Frames Covered once

every 24 months

Lenses Covered once every

12 months

Contact Lenses- in lieu of frame $180 Allowance

Monthly Premium

Single $10.68

Employee+1 $19.80

Family $30.20

5

January 22, 2018

Hearing Aid Discounts – TruHearing If you have elected vision coverage, you and your

dependents are also eligible for Hearing Aid

Discounts.

VSP participants and dependents can save up to

$2,400 on a pair of hearing aids.

Learn more at vsp.truhearing.com or call 877-396-

7194 and mention VSP.

TruHearing provides members with:

• 3 provider visits for fitting, adjustments and

cleanings

• A 45 day money back guarantee

• 3 yr manufacturer’s warranty for repairs ;

onetime loss/damage

• 48 free batteries per hearing aid.

6

January 22, 2018

Life Insurance - Unum You may purchase coverage of up to 3 times your

base salary. You may also purchase Dependent Life

Insurance for your spouse, and/or children.

Accidental Death and Dismemberment is also

available.

For new participants after January 1, Evidence of

Insurability (EOI) is required for coverage in excess of

$300,000. Existing participants are grandfathered

with their current elections. Spouse coverage equal

to 100% of the Employee is available up to $500,000.

EOI is also required if you are increasing your current

amount.

Coverage

Employee Life/Accidental Death and

Dismemberment

Basic Life of $25,000 11.90/mo. - mandatory

Voluntary life 1,2 or 3 times up to $750,000.

Those with coverage currently in excess of

$750,000 will be grandfathered. Life elections for

both Employee and Spouse Coverage will be

based on the following premium chart

Age Mo. Prem/$1,000

15-24 0.11

25-29 0.11

30-34 0.13

35-39 0.14

40-44 0.19

45-49 0.25

50-54 0.37

55-59 0.58

60-64 0.82

65-69 1.32

70-74 2.11

75+ 6.42

Benefit reduces to 50% at age 70.

Spousal Life

Coverage equal to 100% of employee life up to

$500,000.

EOI is required for $25,000 or greater.

Child(ren) Life

Coverage 5,000 10,000

Mo. Premium 2.70 5.40

Disability - Unum Short-Term Disability (STD) The Financial Network Group Health Plan will

continue insuring the Short-Term Disability plan with

Aetna. Benefits begin on the 15th calendar day of

disability. Benefits may then continue for up to 11

weeks. Max annual salary covered is $300,000.

Note: All state mandated disability (short term

disability) plans are coordinated in conjunction

with the appropriate state law and max benefit

limits.

Long-Term Disability (LTD) You are also eligible for Long-Term Disability

Insurance. Benefits begin after 90 consecutive

calendar days of disability. Max annual salary

covered is $300,000.

To help you determine your specific

coverage needs, ask yourself

questions such as:

▪Does my family depend on me as a sole

source of income?

▪What other financial resources will my

family have?

▪Will my insurance be enough to cover my

family’s expenses?

STD ▪ Benefits Begin After 15 days

▪ 60% of Base Income

▪ $3,500/week Max Benefit

▪ .26/$10 weekly covered benefit

LTD ▪ Benefits Begin After 90 Days

▪ 60% of Base Income.

▪ $15,000/month Max Benefit

▪ .60/$100monthly covered payroll.

7

January 22, 2018

Accident Insurance

Accident Insurance pays a set benefit amount

based on

the type of injury you have and the type of

treatment you

need. It covers accidents that occur on and off

the job. And it

includes a range of incidents, from common

injuries to more

serious events.

Why is this coverage so valuable? • It can help you with out-of-pocket costs

that your medical plan doesn’t cover, like

co-pays and deductibles.

• You’re guaranteed base coverage, without

answering health questions.

• The cost is conveniently deducted from your

paycheck.

• You can keep your coverage if you change

jobs or retire. You’ll be billed directly

Who can get coverage?

You If you’re actively at work

Your Spouse Ages 17-64

Your Children Dependent children from birth

until their 26th birthday,

regardless of marital or

student status

How much does it cost? Monthly Premium

You $22.35

You and your spouse $38.46

You and your child(ren) $41.62

You, your spouse and

child(ren)

$57.73

Critical Illness Insurance

How does it work? If you’re diagnosed with an illness that is

covered by this insurance, you’ll receive a

benefit payment in one lump sum. You can use

the money however you want.

Why is this coverage so valuable? • The money can help you pay out-of-pocket

medical expenses, like co-pays and

deductibles.

• You can use this coverage more than once.

Even after you receive a payout for one

illness, you’re still covered for the remaining

conditions. If you have a different condition

later, you can receive another benefit.

• This insurance pays you once for each

eligible illness. However, the diagnoses must

be at least 90 days apart, and the

conditions can’t be related to each other.

Can I buy coverage now?

• It’s more affordable when you buy it

through your employer.

• The cost is conveniently deducted from your

paycheck.

• You can keep coverage if you leave the

company or retire. You’ll be billed at home.

Monthly Premium per $1,000 of Coverage

Age Non-Tobacco Tobacco 0-24 $0.58 $0.87

25-29 $0.63 $1.05

30-34 $0.83 $1.48

35-39 $1.13 $2.17

40-44 $1.60 $3.19

45-49 $2.20 $4.40

50-54 $2.90 $5.88

55-59 $3.82 $7.49

60-64 $4.89 $8.97

65-69 $5.50 $9.35

70-99 $9.86 $15.07

Monthly Premium for Wellness Benefit Employee and Children $1.60

Spouse $1.60

.

Enrollment Packages for these two

benefits will be mailed directly to

your home October 16, 2017.

Enrollment forms must be completed

and returned to Unum directly by

October 31, 2017.

8

January 22, 2018

Individual/Small Group Plans

In today’s busy world, we have so many needs that many groups in and of themselves can’t solve or meet

your individual or family specific needs. In light of these changes, the changes within our individual area, we

are now offering a variety of individual tools that will help you provide solutions for your family. We have

access to a variety of services and products that will enhance your personal financial plan. These could be

of great benefit to you, your family and your business.

If you are interested in any of these options listed in the chart below, complete the information request that

is labeled individual enrollment plans and submit to us as quickly as possible. These will be available

throughout the year, as these are not defined under the ERISA guidelines.

Personal Needs Business Needs Family Protection

◦Health Insurance

◦Life Insurance

◦Long Term Care Insurance

Business Continuation Strategies

◦Business Loan Protection

◦Business Overhead Insurance

◦Disability Buyout

◦Buy-Sell Arrangements

◦Key Employee Insurance

◦Corporate Owned Life Insurance Options

Don’t delay in researching any or all of these items. Please keep in mind that you will be asked health

questions for many of these plans. You will have to complete the basic information form in this packet, as

well as be available for further evidence of insurability. Our group plan does not make these decisions; the

individual carriers will determine the rates and the amounts to be covered by.

Should you decide to pursue the individual plans, you will have a direct contract with the individual carriers.

If you have any questions surrounding these options, please don’t hesitate to contact Amy Ahrens for further

information – amy.ahrens@ahrensnaefconsulting.com; 770-966-9247.

9

January 22, 2018

Available Discounts The Financial Network Benefit Program offers many discounts.

• 15% off Brooks Brothers regularly priced merchandise every day

• Amusement park tickets

• Broadway theatre tickets, movie tickets

• Sporting events

• Car Rentals (Alamo, Avis etc.)

• Hotels (Hilton, IHG etc.)

• Zoos, Aquariums and Museums

• Travel websites (Expedia, Orbitz etc.)

• Merchant gift certificates

• Online shopping and service discounts with select partners

• For pet insurance discounts go to www.petinsurance.com/nbg and sign up through the online enrollment. Rates given will reflect discount

See Enrollment Instructions Below

Register for your free account today!

1. Go to: www.workingadvantage.com or To order by phone, call (800) 565-3712. 2. Click on Register in the orange box at the top of the page 3. Click Employee Click Here 4. Enter Member ID# 381749710 and create your account with your e-mail address and password of your choice. 5. Take advantage of online offers immediately!

• You will receive a 15% when you enroll online at: membership.BrooksBrothers.com and follow the enrollment instructions. Enter the following information:

Organization ID #: 13401 Organization Enrollment PIN #: 49085

• Print out a temporary shopping pass.

• You will receive your personalized Corporate Membership Card in approximately 3-5 business days.

Corporate Perks

1. Go to: http://ahrensnaefconsulting.corporateperks.com 2. Login/Register at Ahrens Naef Consulting Perks 3. Register with your email address and use the company code ahrensnaefconsulting12

SAVE SAVE SAVE

10

January 22, 2018

Instructions for the 2018 Open Enrollment After you have reviewed this guide and your benefit options, if you wish to make changes, you are ready to

enroll. If you do not wish to make any changes, your plan will continue as is for 2018, based on your 2017

elections. A confirmation of your 2018 elections will be sent by November 3, 2017. Corrections will be sent

out by November 7, 2017. All new premiums will be taken beginning in December and the annual fee will be

taken in November 2017.

1. Complete the applicable enrollment form in your enrollment packet or on line. Follow the instructions

carefully.

• You will need to provide Social Security Numbers and birth dates for your spouse and eligible

dependent children if you plan to cover them.

• You will need to designate a beneficiary for the life insurance coverage. It is helpful but not required

to provide Social Security numbers for beneficiaries. By providing a Social Security Number, you help

to ensure that the person making a claim against your life insurance policy is indeed your intended

beneficiary.

2. Keep a copy of your form for your records.

3. Return your signed enrollment form to Human Resources/Amy Ahrens - no later than October 31, 2017.

Forms may be submitted

amy.ahrens@ahrensnaefconsulting.com

Fax: 866-817-3969, Telephone: 770-966-9247

Financial Network Group Health Plan

3226 Citation Avenue, NW

Kennesaw, GA 30144.

REMEMBER

Open enrollment runs until October 31, 2017.

Don’t wait until the last day to enroll.

If you have not enrolled and submitted your paperwork by October 31,

2017, you will not be able to make changes to your benefits until the

2018 enrollment period, unless you have a qualified change of status.

11

January 22, 2018

12

January 22, 2018

Women’s Health and Cancer Rights Act - -Notice of Rights The Women’s Health and Cancer Rights Act of 1998 was enacted on October 21, 1998. It provides certain

protections for breast cancer patients who elect breast reconstruction in connection with a mastectomy.

Specifically, the Act requires that health plans cover post-mastectomy reconstructive breast surgery if they

provide medical and surgical coverage for mastectomies. Coverage must be provided for:

1. Reconstruction of the breast on which the mastectomy has been performed;

2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; and

3. Prostheses and physical complications of all stages of mastectomy, including lymphedemas.

The benefits required under the Women’s Health and Cancer Rights Act must be provided in a manner

determined in consultation with the attending physician and the patient.

These benefits are subject to the health plan’s regular co-payments and deductibles.

Medicare Part D Important Notice from the Financial Network Benefits Plan About Your Prescription Drug

Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about

your current prescription drug coverage with The Financial Network Benefit Plan and about your options

under Medicare’s prescription drug coverage. This information can help you decide whether or not you

want to join a Medicare drug plan. If you are considering joining, you should compare your current

coverage, including which drugs are covered at what cost, with the coverage and costs of the plans

offering Medicare prescription drug coverage in your area. Information about where you can get help

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

There are two important things you need to know about your current coverage and Medicare’s

prescription drug coverage:

Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get

this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an

HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard

level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly

premium.

The Financial Network Benefit Plan has determined that the prescription drug coverage offered by the Basic

PPO and Security PPO is, on average for all plan participants, expected to pay out as much as standard

Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your

existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a

penalty) if you later decide to join a Medicare drug plan.

13

January 22, 2018

When Can You Join A Medicare Drug Plan?

You can join a Medicare drug plan when you first become eligible for Medicare and each year from

November 25th through December 31st.

However, if you lose your current creditable prescription drug coverage, through no fault of your own, you

will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?

If you decide to join a Medicare drug plan, your current Financial Network Benefit Plan

coverage will be affected. You can retain your existing coverage and choose not to enroll in

a Part D plan; or you can enroll in a Part D plan as primary.

If you do decide to join a Medicare drug plan and drop your current Financial Network Benefit Plan

coverage, be aware that you and your dependents will not be able to get this coverage back until

open enrollment or due to a change in family status.

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?

You should also know that if you drop or lose your current coverage with The Financial Network Benefit Plan

and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may

pay a higher premium (a penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly

premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month

that you did not have that coverage. For example, if you go nineteen months without creditable coverage,

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

may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug

coverage. In addition, you may have to wait until the following November to join.

For More Information About This Notice Or Your Current Prescription Drug Coverage…

Contact the person listed below for further information:

NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare

drug plan, and if this coverage through The Financial Network Benefit Plan changes. You also may

request a copy of this notice at any time

14

January 22, 2018

For More Information About Your Options Under Medicare Prescription Drug Coverage…

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare

& You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also

be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage:

Visit www.medicare.gov

Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the

“Medicare & You” handbook for their telephone number) for personalized help

Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is

available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov,

or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Remember: Keep this notice. If you enroll in one of the new plans approved by Medicare which offer

prescription drug coverage, you may be required to provide a copy of this notice when you join to show that

you are not required to pay a higher premium amount.

Date: October 26, 2017

Name of Entity/Sender: Financial Network Group Health Plan

Contact--Position/Office: Amy Ahrens /Nikki Hale

Address: 3226 Citation Ave NW

Kennesaw, GA 30144

Phone Number: 770-966-9247

ACA Notice

New Health Insurance Marketplace Coverage Options and Your Health Coverage

PART A: General Information Whe n ke y pa rts of the hea lth c a re la w ta ke e ffec t in 2 0 1 4 , the re w ill be a new wa y to buy hea lth ins ura nc e : the H ea lth

Ins ura nc e Ma rke tp la c e . T o a s s is t you a s you eva lua te options for you a nd your fa m ily, th is no tic e provide s s om e ba s ic

inform a tion a bout the new Ma rke tp la c e a nd em ploym ent­ ba s e d hea lth c ove ra ge offe re d by your em ploye r.

What is the Health Insurance Marketplace?

T he Ma rke tp la c e is de s igned to he lp you f ind hea lth ins ura nc e tha t m ee ts your needs a nd f its your budge t. T he Ma rke tp la c e

offe rs "one - s top s hopping" to f ind a nd c om pa re priva te hea lth ins ura nc e options . Y ou m a y a ls o be e lig ib le for a new k ind

of ta x c red it tha t lowers your m onthly prem ium right a wa y. O pen enro llm e nt for hea lth ins ura nc e c ove ra ge through the

Ma rke tp la c e beg ins in Oc tobe r 2 0 1 3 for c ove ra ge s ta rting a s ea rly a s J a nua ry 1 , 2 0 1 4 .

Can I Save Money on my Health Insurance Premiums in the Marketplace?

Y ou m a y qua lify to s a ve m oney a nd lower your m onthly prem ium , but only if your em ploye r doe s not offe r c ove ra ge , or

offe rs c ove ra ge tha t does n't m ee t c e rta in s ta nda rds . T he s a vings on your prem ium tha t you're e lig ib le for depe nds on your

hous eho ld inc om e .

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?

Y e s . If you ha ve a n offe r of hea lth c ove ra ge from your em ploye r tha t m ee ts c e rta in s ta nda rds , you w ill no t be e lig ib le for a

ta x c re d it through the Ma rketp la c e a nd m a y w is h to e nro ll in your e m ploye r's hea lth p la n. H oweve r, you m a y be e lig ib le for a

ta x c re d it tha t lowers your m onthly prem ium , or a reduc tion in c e rta in c os t- s ha ring if your em ploye r does not offe r c ove ra ge

to you a t a ll or does not offe r c ove ra ge tha t m ee ts c e rta in s ta nda rds . If the c os t of a p la n from your em ploye r tha t would

c ove r you ( a nd not a ny othe r m em bers of your fa m ily) is m ore tha n 9 . 5 % of your hous eho ld inc om e for the yea r, or if the

c ove ra ge your em ploye r provides doe s not m ee t the "m inim um va lue " s ta nda rd s e t by the A fforda b le C a re Ac t, you m a y be

e lig ib le for a ta x c red it.1

No te : If you purc ha s e a hea lth p la n through the Ma rke tp la c e ins tea d of a c c epting hea lth c ove ra ge offe red by your em ploye r,

then you m a y los e the em ploye r c ontribution ( if a n y) to the em ploye r- offe re d c ove ra ge . A ls o , th is em ploye r c ontribution - a s

we ll a s your em ployee c ontribution to e m ploye r- offe red c ove ra ge - is often exc luded from inc om e for F e de ra l a nd S ta te

inc om e ta x purpos es . Y our pa ym e nts fo r c ove ra ge through the Ma rke tp la c e a re m a de on a n a fte r- ta x ba s is .

How Can I Get More Information?

For more information about your coverage offered by your employer, please check your summary plan description or contact

Amy M. Ahrens, MRC Ahrens-Naef Consulting 3226 Citation Ave, NW Kennesaw, GA 30144

w - 770-966-9247 f - 770-529-9063

amy.ahrens@ahrensnaefconsulting.com ahrensnaef@mindspring.com

T he Ma rke tp la c e c a n he lp you eva lua te your c ove ra ge options , inc lud ing your e lig ib ility for c ove ra ge through the Ma rke tp la c e

a nd its c os t. P lea s e vis it H e a lthC a re . go v for m ore inform a tion, inc lud ing a n online a pp lic a tion for hea lth ins ura n c e c ove ra ge

a nd c onta c t inform a tion for a H ea lth Ins ura nc e Ma rke tp la c e in your a rea .

Form Approved

OMB No. 1210-0149 (expires 11-30-2013)

f- 866-817-3969

PART B: Information About Health Coverage Offered by Your Employer T his s ec tion c onta ins info rm a tion a bout a ny hea lth c ove ra ge offe red by your em ploye r. If you dec ide to c om ple te a n

a pp lic a tion for c ove ra ge in the Ma rke tp la c e , you w ill be a s ked to provide this info rm a tion. T his inform a tion is num bered

to c orre s pond to the Ma rke tp la c e a pp lic a tion.

3. Employer name

4. Employer Identification Number (EIN)

Financial Advisors Network LTD 27-0638127

5. Employer address 6. Employer phone number

3226 Citation Ave. NW 770-966-9247

7. City 8. State 9. ZIP code Kennesaw GA 30144

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

11. Phone number (if different from above) 12. Email address

Amy. ahrens@ahrensnaefconsulting. com

H ere is s om e ba s ic inform a tion a bout hea lth c ove ra ge offe re d by this em ploye r:

• A s your em ploye r, we offe r a hea lth p la n to :

A ll em ployee s . E lig ib le em ployee s a re :

full- tim e em ployee (e xem pt a nd non- e xem pt) ,

s c he duled to work a t lea s t 2 0 hours pe r week

S om e em ployee s . E lig ib le em ployee s a re :

• With re s pec t to de pendents :

We do offe r c ove ra ge . E lig ib le depe nde nts a re : Y our lega l s pous e or dom es tic pa rtne r, Y our

unm a rried depe nde nt c hild ( re n) until h is or he r 2 6 th b irthda y, Na tura l a nd lega lly a dopted c hildre n,

c hildren p la c ed w ith you fo r a doption, o r a ny o the r c hild ren for whom you or your s pous e is na m ed

lega l g ua rd ia n, a c c ord ing to a le tte r of gua rd ia ns hip , B io log ic a l or lega lly a dopted c hildre n for

whom the p la n is ob liga te d under a Q ua lif ied Med ic a l C hild S upport Orde r (QMC S O) to provide

m e d ic a l c ove ra ge .

We do not offe r c ove ra ge .

If c hec ked, th is c ove ra ge m ee ts the m inim um va lue s ta nda rd , a nd the c os t of th is c ove ra ge to you is inte nded

to be a ffo rda b le , ba s e d on em ployee wa ges .

* * E ven if your em ploye r inte nds your c ove ra ge to be a fforda b le , you m a y s till be e lig ib le for a p rem ium

d is c ount through the Ma rke tp la c e . T he Ma rke tp la c e w ill us e your hous eho ld inc om e , a long w ith othe r fa c to rs ,

to de te rm ine whe the r you m a y be e lig ib le for a prem ium d is c ount. If , for e xa m ple , your wa ges va ry from

week to week (pe rha ps you a re a n hourly em ployee or you work on a c om m is s ion ba s is ) , if you a re new ly

em ploye d m id- yea r, or if you ha ve othe r inc om e los s es , you m a y s till qua lify for a prem ium d is c ount.

If you dec ide to s hop for c ove ra ge in the Ma rke tp la c e , H e a lthC a re . go v w ill guide you through the proc es s . H e re 's the

em ploye r inform a tion you' ll e nte r when you vis it H e a lthC a re . go v to f ind out if you c a n ge t a ta x c re dit to lower your

m onthly prem ium s .

X

X

46-6604828

T he inform a tion be low c orre s ponds to the Ma rke tp la c e E m ploye r C ove ra ge T oo l. C om ple ting this s ec tion is optiona l for

em ploye rs , but w ill he lp ens ure em ploye rs unde rs ta nd the ir c ove ra ge c ho ic e s but w ill he lp e ns ure em ployees unde rs ta nd

the ir c ove ra ge c ho ic es .

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

Yes (Continue)

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

No (STOP and return this form to employee)

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

Yes (Go to question 15) No (STOP and return form to employee) 15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't include

family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and didn't receive any other discounts based on wellness programs. a. How much would the employee have to pay in premiums for this plan? $ b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly

If the p la n yea r w ill e nd s oon a nd you know tha t the hea lth p la ns offe red w ill c ha nge , go to que s tion 1 6 . If you don' t

know, S T OP a nd re turn form to em ployee .

16. What change will the employer make for the new plan year? Employer won't offer health coverage Employer will start offering health coverage to employees or change the premium for the lowest-cost plan

available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.)

a. How much would the employee have to pay in premiums for this plan? $ b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly

• A n e m p lo ye r- s p o ns o re d he a lth p la n m e e ts the "m in im um va lue s ta n d a rd " if the p la n ' s s ha re o f the to ta l a llo w e d b e n e fit c o s ts c o ve re d b y

the p la n is no le s s tha n 6 0 p e rc e n t o f s uc h c o s ts ( S e c tio n 3 6 B ( c ) ( 2 ) ( C ) ( ii) o f the In te rna l R e ve nue C o d e o f 1 9 8 6 )

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FORMS

Financial Network Group Health Plan

2018 Annual Enrollment Form (01/01/2018)

Employee Information Last Name:

First Name:

MI:

Address:

City:

St:

Zip:

Date of

Birth:

Social Security

Number:

Phone:

Coverage Effective

Date:

Email Address:

Annual Salary $

(or prior yr earnings)

Full-Time

Part-time Hours/Wk

Marital Status:

Single Married

Divorced Widow(er)

Gender:

Male

Female

Does your spouse work?

Yes No

Do you have coverage elsewhere (such as your

spouse’s employer)?

Yes (complete box D) No

(A) Medical

Choose One Employee

Only

Employee &

Spouse

Employee &

Child(ren)

Employee &

Family

HSA

Request Individual Quote

Waive Coverage

$2,041.98/mo

$4,288.19/mo

$3,981.87

$6,228.06

(A) Dental

Choose One Employee

Only

Employee &

Spouse

Employee &

Child(ren)

Employee &

Family

Dental Plan- Plan A

Dental Plan- Plan B

Waive Coverage

$46.12/mo

$62.09/mo

$ 90.58/mo

$121.86/mo

$123.34/mo

$164.84/mo

$167.80/mo

$224.61/mo

(B) Vision

Choose One Employee

Only

Employee &

One

Employee &

Family

Vision Plan

Waive Coverage

$10.68/m

o $19.80/mo $30.20/mo

(C) List All Eligible Family Members Enrolled For Dental, Vision

Name (Last, First, MI): Gender Birth Date) Social Security #. Relationship

(D) Information About Other Group Dental Coverage you will continue

Name (Last, First, MI): Dental Other Employer Name and Number of Plan

(E) Disability (Salary must equal amount entered on page one) Note: EOI required if increasing coverage

Short Term Disability

Waive

(Enter Salary Amount)

$

• Benefit equals 60% of weekly salary up to a $3,500 benefit.

• Rate is $0.26 per $10 of weekly benefit covered.

Long Term Disability

Waive

(Enter Salary Amount)

$

• Benefit equals 60% up to a $15,000 maximum monthly benefit)

• Rate is $0.60 per $100 of monthly covered payroll

IMPORTANT: Complete both pages of this form

(F) Life Insurance/Accidental Death & Dismemberment (Salary equals amount entered on page one) If life amount is greater

than $300,000 Evidence of Insurability form is required) Basic Life $25,000: List Your Beneficiaries For Life and AD&D Insurance

Primary (Last/First/MI): Relationship:

Contingent (Last/First/MI): Relationship:

Age Mo. Rate/$1,000 Age Mo. Rate/$1,000

15-24 .11 50-54 .37

25-29 .11 55-59 .58

30-34 .13 60-64 .82

35-39 .14 65-69 1.32

40-44 .19 70-74 2.11

45-49 .25 75+ 6.42

1. Employee Life/AD&D) 1 X Salary 2 X Salary 3 X Salary WAIVE

List Your Beneficiaries For Life and AD&D Insurance for the above elected coverage.

Primary (Last/First/MI): Relationship:

Contingent (Last/First/MI): Relationship:

If more than one primary or contingent beneficiary is to be specified, attach beneficiary information on a separate page. Unless otherwise

specified, payment will be shared equally by all primary beneficiaries who survive the Insured; if none, by all contingent beneficiaries who

survive. The right to change the beneficiary is reserved unless otherwise stated. If you are married, but choose someone other than your

spouse as beneficiary, have your spouse sign below to acknowledge the other beneficiary.

Spouse’s Signature: Date:

2. Spouse Life* (Premium Based on Age

Chart above.) Enter Amt $_________________ (must not exceed EE Election)

Amount must be in increments of $1,000. WAIVE

Spouse Name: Sp DOB: Sp SSN:

3. Child Life $5,000 ($2.70/mo) $10,000 ($5.40/mo.) * WAIVE

If child life is elected, please provide dependent information in Section D above

(G) Mid-Year Change Information To add or delete dependents or make a plan change midyear, (1) check the qualifying event allowing the change and (2) indicate the date

of the event below: Event allowing dependent addition and some plan changes (event must have been within the last 31 days): The change in election

must be consistent with the event. Marriage Birth of child Court-ordered custody/support/legal guardianship Adoption/Pre-adoptive

placement. (If dependent has or had other coverage within last 63 days, provide Certificate of Creditable Coverage.) Dependent lost

eligibility for other coverage due to, specify:

The Date of Event is the last date of the other coverage:

Event allowing/requiring dependent deletion and some plan changes: The change in election must be consistent with the event.

(Notify Amy Ahrens when a covered dependent loses eligibility (within no more than 30 days). Notice for COBRA continuation within 60 days.

Death of Dependent Divorce/legal separation Change in support order Other loss of dependent status due to, specify:

The Date of Event is the last date of the other coverage:

(H) Authorization

I have been given the opportunity to enroll in the Financial Network Group Benefit Plan. I authorize Financial Network Group Benefit Plan

to make any necessary deductions from my pay for elected coverages. Medical, and dental and other health and disability deductions

will be deducted pre-tax from my pay unless I contact Human Resources to indicate a different election. I understand that I cannot

change my benefit enrollment elections until the next open enrollment period unless I have a qualified change in status (which must be

reported to Human Resources within 31 days of the event). I authorize payment of medical benefits to preferred providers where

applicable, for those charges covered by my group insurance benefits. I authorize release, for the term of my coverage, to or by my

physician or health care provider of any medical information including copies of medical records, or insurance carrier with information

necessary to establish student eligibility. This authorization will remain valid during my term of coverage under my group insurance plan or

12 months, whichever is less. I or my authorized representative may request a copy of this authorization and a photocopy of this

authorization will be considered valid.

Employee Signature (typed name serves as signature) Date

Forms may be submitted by clicking blue button:

Please remember in addition to your monthly premium there is an annual enrollment fee of $450/participant as well as a

participant administration fee reflected on Confirmation Statement

Financial Network Group Health Plan

AUTHORIZATION AGREEMENT

Direct Withdrawals /Direct Deposits

(ACH Debits/Credits)

I (we) hereby authorize FINANCIAL NETWORK GROUP HEALTH PLAN, hereinafter called COMPANY,

to initiate debit entries and to initiate, if necessary, credit entries and adjustments for any credit

entries in error to my (our) Checking or Savings account (select one) at the financial

institution, hereinafter called BANK, and to credit the same to such account.

BANK

NAME

AMOUNT

CITY, STATE

ROUTING

NUMBER

ACCOUNT NO.

Please remember in addition to your monthly premium there is an annual

enrollment fee of $450/participant as well as a monthly participant

administration fee.

*Any NSF will result in an additional $50 fee. *

**Attach a voided check for verification**

This authorization is to remain in full force and effect until COMPANY has received written

notification from me (or either of us) of its termination in such time and in such manner as

to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.

Printed Name Office Location and Name

Signature (typed name serves as

signature)

Date

Effective Plan Date:

FINANCIAL NETWORK GROUP HEALTH PLAN

Credit Card Processing

I (we) hereby authorize FINANCIAL NETWORK/GROUP HEALTH PLAN, hereinafter called COMPANY,

to initiate debit entries and to initiate, if necessary, credit entries and adjustments for any

credit entries in error to my (our) – credit card. All credit card payments will be charged a

4.5% convenience fee per transaction, for the processing of the premium(s). (Amex is a

charge of 5.0%)

Name – as

printed on the

card

Stated Amount to be

charged, without

Convenience Fee

Type of Card

Visa

MasterCard

Amex (+5% fee)

Expiration of Card

Credit Card

Number

CV(3 or 4 digit code)

Located on back of

card

Zip Code

This authorization is to remain in full force and effect until COMPANY has received written

notification from me (or either of us) of its termination in such time and in such manner as to

afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.

PRINTED NAME (S)________________________________________________________________________________

SIGNED NAME __________________________________________________________________________________

DATE ___________________________________________________________________________________________