Retiree Medical Plan Election Form

RETIREE MEDICAL PLAN ELECTION FORM CW DePauw University Underwritten by: United American Insurance Company Dental Plan is underwritten by: Delta Dental Vision Plan is underwritten by: Anthem You must return your election form to put your coverage in force! Retiree Information (Please print) Name Date of Birth Address Social Security Number City Sex Phone Number State Zip Code Medicare ID# (From Medicare Id card): Hospital (Part A) effective date (from Medicare ID card): Medical (Part B) effective date (from Medicare ID card): Email Address Date of Retirement Spouse Information (if enrolling) Name Date of Birth Sex Social Security Number Date of Retirement Medicare ID# (From Medicare Id card): Hospital (Part A) effective date (from Medicare ID card): Medical (Part B) effective date (from Medicare ID card): Please Choose Type of Coverage Effective Date: {effective_date} Check Desired Coverage: Retiree Only Retiree & Spouse Surviving Spouse Medical Plan Delta Dental Plan Anthem Vision Plan Please Check box for VEBA Payment, if Applicable: I would like my monthly premium to be deducted from my VEBA account: ☐Yes ☐No (continue to next page)

RETIREE MEDICAL PLAN ELECTION FORM CW Please sign and date below: Date: Retiree Signature: Date: Spouse/Surviving Spouse Signature: If you are an authorized representative, you must sign above and provide the following information: Name: _______________________________________________ Address: ______________________________________________ Phone Number: ________________________________________ Relationship to Retiree: _________________________________ Please return signed election form to: Amwins Group Benefits 50 Whitecap Drive, North Kingstown, RI 02852 For Customer Service, please call: 1-888-883-3757 Monday through Friday, 8:00 AM to 8:00 PM EST

MEDICARE PRESCRIPTION DRUG PLAN INDIVIDUAL ENROLLMENT FORM SPONSORED GROUP PLAN To enroll in Express Scripts Medicare® (PDP) please provide the following information: Group Name: DePauw University Desired Effective Date: {effective_date} Retiree Last Name: First Name: Middle Initial:  Mr.  Mrs.  Ms. Birth Date: (__ __/__ __/__ __ __ __) (M M / D D / Y Y Y Y) Sex:  M  F Social Security Number: Home Phone Number: ( ) E-Mail Address: Permanent Resident Street Address: City: State: ZIP Code: Mailing Address (only if different from your Permanent Residence Address): Street Address: City: State: ZIP Code: Spouse or Surviving Spouse Last Name: First Name: Middle Initial:  Mr.  Mrs.  Ms. Birth Date: (__ __/__ __/__ __ __ __) (M M / D D / Y Y Y Y) Sex:  M  F Social Security Number: Home Phone Number: ( ) E-Mail Address: Permanent Resident Street Address: City: State: ZIP Code: Mailing Address (only if different from your Permanent Residence Address): Street Address: City: State: ZIP Code: Emergency Contact: (Optional) Name: Phone Number: Relationship to you: E-Mail Address: Continued next page

Please Provide Your Medicare Insurance Information Please take out your Medicare Card to complete this section.  Please fill in these blanks so they match your red, white and blue Medicare card. - OR -  Attach a copy of your Medicare card or your letter from the Social Security Administration or Railroad Retirement Board. You must have Medicare Part A or Part B (or both) to join a Medicare prescription drug plan. Retiree: Spouse or Surviving Spouse: Name: ____________________________________ Medicare Number __ __ __ __ - __ __ __ - __ __ __ __ OR Medicare Claim Number __ __ __ - __ __ - __ __ __ __ - __ __ Is Entitled To Effective Date HOSPITAL (Part A) ____________ MEDICAL (Part B) ____________ Name: ____________________________________ Medicare Number __ __ __ __ - __ __ __ - __ __ __ __ OR Medicare Claim Number __ __ __ - __ __ - __ __ __ __ - __ __ Is Entitled To Effective Date HOSPITAL (Part A) ____________ MEDICAL (Part B) ____________ Select Your Enrollment Options Below (Please Check Desired Coverage) Please check which plan you want to enroll in: Retiree:  Option 1  Option 2  Option 3 Spouse or Surviving Spouse:  Option 1  Option 2  Option 3 Important Information About Your Medicare Part D Prescription Drug Plan Express Scripts Medicare® (PDP) is offered by Medco Containment Life Insurance Company, which contracts with the Federal government. This coverage is Medicare Part D coverage and is in addition to your coverage under Medicare Parts A and B. You must keep your Medicare Parts A and/or B coverage in order to qualify for this plan. You must inform your former employer of any other prescription drug coverage you may have. Enrollment Requirements You can be in only one Medicare prescription drug plan at a time. If you are currently in a Medicare prescription drug plan, a Medicare Advantage Plan with prescription drug coverage, or an individual Medicare Advantage Plan, your enrollment in Express Scripts Medicare may end that enrollment. Continued on next page

Important Information About Your Medicare Part D Prescription Drug Plan You must live within the 50 U.S. states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands or American Samoa, and be a U.S. citizen or lawfully present in the United States to participate in this plan. It is your responsibility to inform your former employer of any address changes. You can join a new Medicare prescription drug plan or Medicare health plan from October 15 to December 7. Except in special cases, you cannot join a new plan at any other time of the year. If you leave this plan and don’t have or get other Medicare prescription drug coverage or creditable coverage (as good as Medicare’s), you may be required to pay a late enrollment penalty (LEP) if you go 63 days or more without Medicare Part D coverage or other creditable prescription drug coverage. Some people may have to pay an extra premium amount because of their yearly income. If you have to pay an extra amount, the Social Security Administration – not your Medicare plan – will send you a letter telling you what that extra amount will be and how to pay it. If you have any questions about this extra amount, contact the Social Security Administration at 1.800.772.1213. TTY users call 1.800.325.0778. Medicare beneficiaries with low or limited income and resources may qualify for Extra Help. If you qualify, your Medicare prescription drug plan costs will be less. Once you are enrolled in this drug plan, Medicare will tell the plan how much assistance you will receive and Express Scripts will send you information on the amount you will pay. If you are not currently receiving Extra Help, you can contact 1.800.MEDICARE (1.800.633.4227) to see if you might qualify. TTY users call 1.877.486.2048. Once you are a member of this plan, you have the right to file a grievance or appeal plan decisions about payment or services if you disagree. Read your Evidence of Coverage to know which rules you must follow to receive coverage with this Medicare prescription drug plan. This information is not a complete description of benefits. Contact Express Scripts Medicare for more information. Limitations, copayments and restrictions may apply. Benefits, premium (if applicable) and/or copayments/coinsurance may change on January 1 of each year. The formulary and/or pharmacy network may change at any time. You will receive notice when necessary. Release of Information: By joining this Medicare prescription drug plan, I acknowledge that Express Scripts Medicare can release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Express Scripts Medicare can release my information, including my prescription drug event data, to Medicare, who may release it for research and other purposes that follow all applicable Federal statutes and regulations. Retiree’s Signature: Today’s Date: Spouse or Surviving Spouse’s Signature: Today’s Date: Express Scripts Medicare (PDP) is a prescription drug plan with a Medicare contract. Enrollment in Express Scripts Medicare depends on contract renewal. © 2019 Express Scripts Holding Company. All Rights Reserved

DIRECT PAYMENT AUTHORIZATION FORM Please read, sign and return with your Enrollment Forms Name (Last, First, Middle Initial): Phone: Street Address: City: State: Zip: Type of Account:  Savings  Checking Select Monthly Withdrawal Date:  1st  8th  15th Please fill in the below information: Routing Number: Account Number: Confirm Account Number: Monthly payments are withdrawn on the 1st business day on or after the date you selected above. You will receive a confirmation from Amwins Group Benefits that we have set up your account information to withdraw from your designated bank account. Note: Your monthly deduction will show as Amwins on your bank statement. I authorize Amwins to withdraw my payment as communicated to me, by invoice or letter, from my checking or savings account. I agree to notify Amwins in writing or by phone, if my account information changes or to stop the direct debit authorization at least 10 days in advance of the scheduled transfer. I understand that the premium to be withdrawn may change, in which case I will be notified in writing at least 10 days before the new premium is withdrawn. To the extent I have enrolled in preauthorized checking, I understand that the addition or removal of a dependent will impact the amount withdrawn, and hereby consent to such change. I understand that Amwins will confirm the new preauthorized amount, but depending on when I submit this request, such confirmation may occur after the amounts are withdrawn from my account. If my account is erroneously charged, my financial institution will immediately credit the same amount to the account up to the 15 days following issuance of the statement or 45 days after posting, which occurs first. Signature: Date: Amwins Group Benefits, LLC: 50 Whitecap Drive, North Kingstown, RI 02852

WAIVER of COVERAGE If you DO NOT wish to enroll in the DePauw University Plan(s), please complete, sign and return this Waiver of Coverage form. Retiree Spouse (or Surviving Spouse) Name: Name: Address: Address: City: City: State: Zip Code: State: Zip Code: Please Sign & Date Below: NO, DO NOT ENROLL ME (us) in the DePauw University Plan(s). I (we) understand that by choosing this option, I am (we are) declining medical and prescription drug coverage, and may or may not be able to re-enroll at a later date. Retiree: Date: Spouse (or Surviving Spouse): Date: All applicable signatures are required for individuals declining coverage in the Plan. Reason for Declining Coverage: