IV. ELIGIBILITY NumberofEligible Employees/Members: 338 Will this plan replace any existing vision coverage? XYes No AnthemBlueViewVision Eligible Class(es) of Employees/Members (please check all that apply): X Active employees X Retiree / Leave of Absence X COBRA eligible employees Other: Arethefollowing covered under the plan: Domestic Partners:* Yes X No If Yes, Same Sex:* Yes No Opposite Sex:* Yes No Dependent Children Covered to Age*: 26** Other Dependent Children who are full-time students covered to age*: 27 XOther 26 Dependent Child Age Termination based on: DayAgeisattained EndofMonthAgeisattained X Endof Year Age is attained MEMBERSHIPINFORMATION Whowill send enrollment for Active Employees/Members? X Group TPA If TPA, TPA Name: Group/TPAContact Name: Irene Taylor PhoneNumber: ( )260-726-9341 E-Mail Address: itaylor@jayschools.k12.in.us Membership will be an electronic membership file? X Yes No Whowill send enrollment for COBRA Employees/Members? X Group TPA If TPA, TPA Name: Group/TPAContact Name: Irene Taylor PhoneNumber: ( ) 260-726-9341 E-Mail Address: itaylor@jayschools.k12.in.us Membership will be an electronic membership file? X Yes No PROBATIONARYPERIOD For New Employees/Members: 30days 60days 90days 180days Other 1stmo.after hire Probationary Period is waived for present Employees/Members: Yes No NumberofEmployees/Memberswhohavenot yet completedthe probationary period: 0 V. PLANSELECTION Please refer to the attached proposal page. Services are provided by EyeMed Vision Care. A-01224IN 2