GOWV 2023- Viking Well Service

Viking Well Service Plan Year: January 1, 2023—December 31, 2023 2023 Employee Benefits Guide

Table of Contents 2 2 • Overview—Available Benefits 2 • Overview—Eligibility 3 • Overview—Pre-Tax Section 125 4-6 • Overview—Qualifying Life Event 7 • Medical Benefits 8 • Health Savings Account (HSA) 9 • Flexible Spending Account (FSA) 10 • Dental Benefits 11 • Vision Benefits 12 • Company-Paid Disability Benefits 13 • Supplemental Disability Benefits 13 • Life and AD&D Benefits 14 • Supplemental Life and AD&D Benefits 15 • Employee Assistance Program (EAP) 16 • Notes Page 17 • Employee Resources 18 • Glossary of Terms • Annual Disclosures Notice This Benefit Guide contains highlights of the Gas and Oil Association of WV, Inc. Benefits Program. For more information, refer to the Summary Plan Descriptions for the Welfare Plan, which are available through the Human Resources Department. The official and controlling provisions of the Plans are contained in the Plan Documents, which include the master policies with insurance carriers. Should there be a conflict between this guide and the Plan Documents; the Plan Documents will be the final authority. The Plans are administered by Gas and Oil Association of WV, Inc. which has discretionary authority to interpret and apply the Plans’ provisions and make the rules necessary for their day-to-day operation. The content provided in this booklet has been prepared for informational and educational purposes only and is not intended to provide investment, legal, or tax advice. 1

Overview At Gas and Oil Association of WV, Inc., our employees are our most important asset. We understand how critical it is for employees to have a flexible and comprehensive benefits program - one that can fit different stages of life. You can choose the plans that best suit your individual needs, taking into consideration the benefits that are most important to you and your family. We encourage you to review each section and to discuss your benefit options with your family members. Available Benefit Programs:  Flexible Spending Account (FSA)  Medical & Prescription Coverage  Dental Coverage  Disability Coverage  Vision Coverage  Life and AD&D Coverage  Health Savings Account (HSA)  Employee Assistance Program Eligibility Employees Employees are eligible to participate in the Gas and Oil Association of WV, Inc. insurance plans if they are working a minimum of 30 hours per week. Coverage will become effective the first of the month following your date of hire. You must enroll in the insurance program within 30 days of becoming eligible for coverage. Dependents A dependent is defined as the legal spouse and/or dependent child(ren) of the employee or the spouse. The term “child” includes any of the following: • A natural child • A step child • A child for whom legal guardianship has been awarded to the employee or the employee’s spouse. Dependent children may be covered, under the Gas and Oil Association of WV, Inc. plan(s), until the end of the month in which they reach the age of 26 (regardless of student status). Pre-tax Benefits: Section 125 Gas and Oil Association of WV, Inc. allows employees to deduct medical, dental and vision premiums on a pre-tax basis. This means you do not pay federal, state, or Social Security and Medicare (FICA) taxes on your premiums, thereby reducing your taxable income. 2

Overview Qualifying Life Event Please keep in mind that benefit elections and their payroll deductions cannot be changed until the next Open Enrollment period unless you, your spouse, or your dependent child(ren) experience an IRS-defined Qualifying Life Event. Qualifying Life Events include: • Marriage • Eligibility for Medicare or Medicaid • Divorce • Special Enrollment Right (excluding domestic partners) • Birth or adoption of a child • Significant change in the cost of coverage for you or • Death of spouse, domestic partner, or child your spouse or domestic partner attributable to your • Change in employment of spouse spouse’s or domestic partner’s employment • Loss of coverage with a spouse • Loss of dependent status • Changing from full-time to part-time employment or from part-time to full-time employment • Court Order You must notify the Human Resources Department within 30 days of your Qualifying Life Event. Documentation supporting the change will be required. 3

Medical Utilize in-network benefits for the most cost effective approach. Medical Provider is the exclusive medical healthcare provider for Gas and Oil Association of WV, Inc. medical plans. You have the choice of 2 medical plans. Each option offers you the ability to choose the benefit plan that best meets your benefit and budgetary needs. Plan Year Deductible: The deductible is a specified dollar amount that you must pay for certain covered services per plan year. There are individual and family deductibles depending on your coverage tier selection, which must be met before your plan will pay for certain services. Once your deductible is met, some services may only require a copay. Plan Year Out-of-Pocket Maximum: The plan year out-of-pocket maximum is the amount of covered expenses - including deductible, coinsurance, and copayments—that must be paid by you, either individually or combined as a covered family. Once the out-of-pocket maximum for the relevant coverage tier (individual or family) is met, covered services that would require a copayment or coinsurance will be covered by Medical Provider in full. There are separate out-of- pocket maximums for In-Network services and Out-of-Network services. 4

Medical Plan Option Plan 1 In-network Benefits Plan 2 In-network Benefits $1,500 / $3,000 Out-of-Network Benefits Plan Feature $1,500 / $3,000 $6,000 / $12,000 Contract Year Deductible $6,900 / $13,800 (Individual/Family) $6,900 / $13,800 $9,000 / $18,000 Out-of-Pocket Maximum (Individual/Family) Deductible, then $25 copay Deductible, then $25 copay Deductible, then $70 copay Office Visits Primary Care Physician Specialist Deductible, then $50 copay Deductible, then $50 copay Deductible, then $70 copay Routine Wellness Visits $0 copay $0 copay Deductible, then $0 copay Deductible, then $25 copay Deductible, then $75 copay Outpatient, Non-Hospital Services Outpatient Lab Testing Deductible, then $25 copay X-rays Deductible, then $50 copay Deductible, then $50 copay Deductible, then $100 copay Complex Imaging Deductible, then $250 copay Deductible, then $250 copay Deductible, then $300 copay (MRI, PET, CT) Deductible, then $300 copay Deductible, then $300 copay Deductible, then $400 copay Office Surgery Hospitalization Deductible, then $500 copay Deductible, then $500 copay Deductible, then $600 copay Inpatient Care Emergency Services Deductible, then $250 copay Deductible, then $250 copay Paid as In-Network Emergency Room Visit Deductible, then $100 copay Deductible, then $100 copay Paid as In-Network Deductible, then $50 copay Deductible, then $50 copay Paid as In-Network Urgent Care Deductible, then $25 copay Deductible, then $25 copay Deductible, then $70 copay Ambulance Mental Health Deductible, then $50 copay Deductible, then $50 copay Deductible, then $70 copay Office Visits Outpatient Therapy Habilitative Services 5

Prescription Drugs Plan 1 Plan 2 Prescription Drug Retail Mail Order Retail Mail Order Deductible Combined with Medical Combined with Medical Generic Deductible, then Deductible, then Deductible, then Deductible, then $15 copay $30 copay $15 copay $30 copay Preferred Brand Deductible, then Deductible, then Deductible, then Deductible, then $45 copay $90 copay $45 copay $90 copay Non-preferred Deductible, then Deductible, then Deductible, then Deductible, then Brand $65 copay $130 copay $65 copay $130 copay Specialty Deductible, then 50% to Deductible, then 50% to Deductible, then 50% to Deductible, then 50% to a maximum of $150 a maximum of $300 a maximum of $150 a maximum of $300 Pre-Tax Per-Pay Deductions: Each plan has a different premium paid for through pre-tax paycheck deductions and employer contributions. These premiums are based on the number of covered individuals in your family - see the table below for deductions based on your choice of individual, dependent, and family totals. Note: These rates are based on a bi-weekly rate of pay. Coverage Tier Plan 1 Plan 2 $50.00 Employee Only $100.00 $65.00 Employee and Spouse $75.00 $130.00 Employee and Child(ren) $200.00 $110.00 Family $250.00 6

Health Savings Account An HSA is a personal bank account that you can use to pay out-of-pocket health care expenses with pre-tax dollars. Money deposited in the account is always yours, even if you change health plans or employers. The money in your HSA (including interest and investment earnings) grows tax-free. There are no vesting requirements or forfeiture provisions (FSA) and unused balances roll over from year-to-year. You are eligible for an HSA when you elect the Plan 1 HSA plan. Qualified Medical Expenses Use your HSA money to pay for eligible expenses now or in the future. Eligible expenses include deductibles, doctor’s office visits, dental expenses, eye exams, prescription expenses and LASIK eye surgery. Refer to IRS Publication 502 at www.irs.gov/pub/irs-pdf/p502.pdf for a complete list of eligible expenses Contribution Limits For 2021, the annual maximum contribution limit, based on a calendar year versus a medical plan policy year, is $3,550 for Individual Coverage or $7,100 per year for other coverage levels. Individuals, age 55 or older and not yet enrolled in Medicare, can make additional \"catch-up\" contributions of up to $1,000 per person. 7

Flexible Spending Account Gas and Oil Association of WV, Inc. offers a Flexible Spending Account (FSA) that can provide you with a tax- advantaged way to pay for eligible out-of-pocket health care expenses. You set aside money on a pre-tax basis to the FSA, and the money remains tax-free when you reimburse yourself for qualified expenses. An FSA is easy to use. Simply estimate your out-of-pocket health care expenses for the upcoming calendar year; then indicate the annual flat dollar amount you want to contribute to the FSA. Your pre-tax FSA payroll contributions will be pro-rated based on your pay period cycle. You can set aside up to $2,500 in pre-tax dollars to cover eligible healthcare expenses for yourself and your eligible dependents. Mobile Solutions Mobile App We offer a secure, interactive mobile application for Android, iOS and Windows devices.  View account balance, account alerts, and transaction history  View all claims, claims requiring action, and claims details  Submit a new claim  Make payments with Online Bill Pay and Click-to-Pay (if Using Your Payment Card Employees who join mid-plan year will have their contributions pro-rated based We provide a convenient payment card to access account on the number of pay periods remaining in funds. You will receive this card in the mail. the plan year. 1. Pay for Qualified Expenses with Your Card Pay for qualified As with your other benefits paid with products and services directly at approved merchants. pre-tax dollars, you cannot change your The money comes right out of your health care account. Health Care and Dependent Care FSA contributions during the year unless you 2. Get Your Balance By frequently checking your account experience a qualified family status balance online, you will have a good idea of the amount change. of funds available in your account. 3. Know What’s Eligible Familiarize yourself with what expenses are eligible using the list of Eligible Expenses 8

Dental Gas and Oil Association of WV, Inc. offers a PPO dental plan. You and your covered family members receive the greatest benefit when you use “In-Network” Dentists. While the plan permits you to use any provider, out-of-network providers can bill for the difference between the dentist’s actual charges and Dental Provider’s reimbursement amount. Dental Plan Preferred Provider Network In-Network Out-of-Network Deductible (Individual/Family) Annual Maximum $25 / $75 $50 / $150 Class 1 Preventive & Diagnostic $2,000 Class 2 Basic Restorative Plan pays 100% Plan pays 100% Class 3 Major Restorative Including: Exams, X-rays, Cleanings, Fluoride Treatments, Sealants, and Palliative Treatment, Prophylaxis Plan pays 80% after deductible Plan pays 80% after deductible Including: Fillings, Simple Extractions, Endodontics, Periodontics, Oral Surgery, and General Anesthesia Plan pays 50% after deductible Plan pays 50% after deductible Including: Inlays, Onlays, Crowns, Prosthetics, Implants, and Dentures Orthodontia Not Covered How to Search for Providers 1. Visit www.Website.com. 2. Hover over “FIND A PROVIDER” in the top menu and choose “DENTAL” 3. You can choose to allow Provider to see your location to help you find nearby providers. If not, you can choose to enter your zip code, city, or an address. 4. Choose a specialty, then a Plan Type (Choice PPO), and click Find. You can find provider addresses, distance from your location and get directions, additional languages they may speak, hours, contact information, and handicap accessibility. 9

Vision The voluntary vision plan offers employees and covered family member’s services for routine eye care, including eye exams, eyeglasses (lenses and frames), or contact lenses. At the time of service, routine vision examinations and basic optical needs will be covered as shown on the plan’s schedule of benefits. Cosmetic services, as well as any upgrades, will be additional if chosen at the time of the appointment. Most benefits are covered once per 12 months – see your benefit summary for details. Vision Plan Coverage Type In-network Out-of-network $0 copay Routine Eye Examination Plan pays $45, Frames Plan pays up to $100, you pay balance Retail you pay balance Lenses Plan pays up to $100, Basic Single Vision $0 copay you pay balance Basic Bifocal $0 copay Basic Trifocal $0 copay Plan pays up to $52, Lenticular (post-cataract) $0 copay you pay balance Contact Lenses Medically Necessary $0 copay with prior approval Plan pays up to $82, Plan pays up to $97, you pay balance Elective—Formulary you pay balance Plan pays up to $101, you pay balance Plan pays up to $181, you pay balance Plan pays up to $285, you pay balance Plan pays up to $97, you pay balance Coverage Tier Bi-Weekly Pay Deductions Employee Only $2.00 Employee and Spouse $3.00 Employee and Child(ren) $4.00 Family $6.00 10

Disability Employer Paid Short-Term Disability Gas and Oil Association of WV, Inc. provides Short-Term Disability (STD) benefits to eligible salaried employees. The STD benefit pays the employee a percentage of gross weekly pre-disability earnings if an employee becomes disabled due to an illness or non-work related injury. Eligibility Full time employees working at least 30 hours or more per week Benefits Start After X consecutive days of disability for illness/injury Benefit Amount X% of pre-disability earnings up to a maximum of $X weekly Benefit Duration X weeks Employer Paid Long-Term Disability At no cost to the employee, Gas and Oil Association of WV, Inc. provides Long-Term Disability (LTD) insurance to all eligible salaried employees. The LTD benefit pays the employee a percentage of gross monthly pre-disability earnings if an employee becomes disabled due to an illness or non-work related injury. Eligibility Full time employees working at least 30 hours or more per week Benefits Start After Benefit Amount X consecutive days of disability for illness/injury Benefits Duration X% of pre-disability earnings up to a maximum of $X monthly Waiting Period for Pre-existing Conditions Until normal retirement age If you have sought medical treatment, consultation, care, diagnostic services or prescribed medications, for any disability during the three (3) months prior to your effective date, benefits are not covered unless your disability begins twelve (12) months after your coverage effective date. Disability Benefit Offsets All STD and LTD benefits will be offset by the amounts received from a state disability program. California, New York, New Jersey, Rhode Island, Hawaii and Puerto Rico have state disability programs. If you receive a disability benefit, from a state, your disability benefits from Gas and Oil Association of WV, Inc. will be adjusted appropriately. 11

Disability Voluntary Short-Term Disability Eligible employees have the option to purchase voluntary Short-Term Disability (STD) Insurance. This is an important benefit and each employee should consider electing coverage. The STD benefit pays the employee a percentage of gross weekly pre-disability earnings if an employee becomes disabled due to an illness or non-work related injury. You must apply for and pursue other income sources for which you are or may become eligible, including but not limited to Social Security disability and/or dependent benefits, and do what is needed to obtain them. Disability Provider will take into account the total of all your income from other sources of income in determining the amount of your weekly benefit. Eligibility Full time employees working at least 30 hours or more per week Cost $X per $X of weekly benefit to a maximum of $X Benefits Start After X consecutive days of disability for illness/injury Benefit Duration X weeks Voluntary Long-Term Disability Eligible employees have the option to purchase voluntary Long-Term Disability (LTD) Insurance. This is an important benefit and each employee should consider electing coverage. The LTD benefit pays the employee a percentage of gross monthly pre-disability earnings if an employee becomes disabled due to an illness or non-work related injury. Eligibility Full time employees working at least 30 hours or more per week Cost Elimination Period $X per $10 of weekly benefit/salary to a maximum of $X Benefit Amount Benefit Duration X days Waiting Period for X% of pre-disability earnings to a maximum of $X monthly Pre-existing Conditions Until normal retirement age If you have sought medical treatment, consultation, care, diagnostic services or prescribed medications for any disability during the three (3) months prior to your effective date, benefits are not covered unless your disability begins twelve (12) months after your coverage effective date. 12

Life and AD&D Company-Paid Basic Life and AD&D Benefits At no cost to the employee, Gas and Oil Association of WV, Inc. provides Basic Term Life insurance for all eligible employees. The group Basic Term Life insurance benefit for active employees is X times their annual salary to a maximum of $X. Eligible employees are automatically enrolled in the coverage. Employees can designate and update life insurance beneficiary information at any time during the year. Base Benefit Amount Xx Annual Salary up to $X Benefit Reduction X% reduction of base amount at age X X% reduction of base amount at age X Voluntary Life and AD&D Benefits Eligible employees may elect to purchase additional life insurance on a voluntary basis. This coverage may be purchased in addition to the Basic Term Life coverage. Supplemental Life Insurance offers coverage for the employee, spouse, and/or child(ren) at different benefit levels. Newly eligible employees may purchase Voluntary Employee Life Insurance without having to go through medical underwriting, also known as Evidence of Insurability (EOI), up to the Guaranteed Issue amount of 5x their salary up to $100,000 for yourself, 100% of Employee’s Benefit up to $30,000 for your spouse, and 100% of Employee’s Benefit up to $10,000 for each child. If an employee does not enroll when first eligible for Supplemental Life Insurance, then Evidence of Insurability must be provided; coverage is subject to Provider’s approval. Employee and spouse’s rates are based on the employee’s age. Employee 15-24 25-29 30-34 35-39 Employee Age Monthly Premium 60-64 65-69 70-74 75-79 Coverage per 30-34 35-39 40-44 45-49 50-54 55-59 70-74 75-79 $1,000 Minimum Employee Benefit Election: $ Maximum Employee Benefit Election: $ Spouse Age Monthly Premium Spouse Coverage per 40-44 45-49 50-54 55-59 60-64 65-69 15-24 25-29 Maximum Spouse Benefit Election: $ $1,000 Child Monthly Premium Minimum Spouse Benefit Election: $ Child Coverage per $1,000 Maximum Child Benefit Election: $ Minimum Child Benefit Election: $ AD&D Monthly Premium AD&D Coverage Employee, Spouse, and Child rates per $1,000 of coverage 13

Employee Assistance Program 14

Notes 15

Employee Resources Benefit Group Contact Phone Website/Email Number Number Medical Provider www.Provider.com 5462315869 (XXX) XXX-XXXX Dental FD564 Provider (XXX) XXX-XXXX www.Provider.com Vision HN561 Provider (XXX) XXX-XXXX www.Provider.com Health 5496GFD Provider (XXX) XXX-XXXX www.Provider.com Savings Account Flexible Spending 526V Provider (XXX) XXX-XXXX www.Provider.com Account Disability 4N5FG Provider (XXX) XXX-XXXX www.Provider.com Life and AD&D FD87E89 Provider (XXX) XXX-XXXX www.Provider.com Employee 84956 Provider (XXX) XXX-XXXX www.Provider.com Assistance - - Account Manager (XXX) XXX-XXXX AM@ Program BlueRidgeRiskPartners.com Blue Ridge Risk Contact (XXX) XXX-XXXX www.Client.com Partners Gas and Oil Association of WV, Inc. 16

Glossary of Terms Beneficiary The person you, as the policyholder, designate to receive the proceeds paid out by Carrier the insurance company for your Life and AD&D coverage. The insurance company COBRA / State Continuation COBRA (or State Continuation) is a governmental act that allows employees to continue paying for and receiving their insurance coverage for a specific length of Coinsurance The percentage of costs of a covered health care service you pay after you have paid your deductible. Copay The dollar amount you can expect to pay for certain covered services, such as a doctor’s office visit. This amount may OR may not go towards satisfying your Deductible The initial amount of expenses an individual must pay before receiving benefits Dependent under a policy. Eligible Employee HIPAA Employee’s legal spouse, domestic partner, natural children, or court-ordered children Employees who have met their waiting period requirements for insurance and are working the specified number of hours. The Health Insurance Portability and Accountability Act provides federal legislation for protection of privacy, portability, and continuity of health insurance coverage. HRA Health Reimbursement Arrangement—Employer-funded accounts to reimburse employees for IRS eligible incurred expenses; generally available for medical and HSA Health Savings Account—Employee-funded account in conjunction with an IRS qualified high deductible medical plan. Money is contributed on a pre-tax basis to cover eligible medical, prescription, dental, and vision claims. Funds are employee- Short/Long-Term Disability Policy that protects an employee from loss of income in the event of being unable to Maximum Out-of-Pocket work due to illness, injury, or accident for a specified period of time. Network Primary Care Physician The financial ‘safety net’ which includes the deductible and co-insurance up to a Qualified Life Event specified amount before the plan pays 100% of claims. Waiting Period The listing of providers which have contracted to provide services to insureds at negotiated prices. A provider which delivers basic or general care with the intention to be the patient’s first level of contact for medical care. A Life change which results in an employee becoming eligible to enroll or change benefits for themselves or eligible dependents. The period of time an employee is required to work prior to becoming eligible for benefits. 17

Annual Notice Disclosure COBRA Notice of Privacy Practices Act (HIPAA) Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) of For purposes of the health benefits offered under the Plan, the Plan uses and 1985, COBRA qualified beneficiaries (QBs) generally are eligible for group discloses health information about you and any covered dependents only as coverage during a maximum of 18 months for qualifying events due to needed to administer the Plan. To protect the privacy of health information, employment termination or reduction of hours of work. Certain qualifying access to your health information is limited to such purposes. The health plan events, or a second qualifying event during the initial period of coverage, options offered under the Plan will comply with the applicable health information may permit a beneficiary to receive a maximum of 36 months of coverage. privacy requirements of federal Regulations issued by the Department of Health and Human Services. The Plan’s privacy policies are described in more detail in COBRA coverage is not extended for those terminated for gross the Plan’s Notice of Health Information Privacy Practices or Privacy Notice. Plan misconduct. Upon termination, or other COBRA qualifying event, the former participants in company-sponsored health and welfare benefit plan are reminded employee and any other QBs will receive COBRA enrollment information. that the employer’s Notice of Privacy Practices may be obtained by submitting a written request to the Human Resources Department. For any insured health Qualifying events for employees include voluntary/involuntary termination of coverage, the insurance issuer is responsible for providing its own Privacy employment, and the reduction in the number of hours of employment. Notice, so you should contact the insurer if you need a copy of the insurer’s Qualifying events for spouses/domestic partners or dependent children Privacy Notice. include those events above, as well as the covered employee becoming entitled to Medicare; divorce or legal separation of the covered employee; Newborns’ and Mothers’ Health Protection Act death of the covered employee; and the loss of dependent status under the plan rules. If a QB chooses to continue group benefits under COBRA, they must Group health plans and health issuers generally may not, under federal law, complete an enrollment form and return it to the Plan Administrator with the restrict benefits for any hospital length of stay in connection with childbirth for the appropriate premium due. Upon receipt of premium payment and mother or newborn child to less than 48 hours following a vaginal delivery, or less enrollment form, the coverage will be reinstated. Thereafter, premiums are than 96 hours following a cesarean section. However, federal law generally does due on the 1st of the month. If premium payments are not received in a not prohibit the mother’s or newborn’s attending provider, after consulting with timely manner, Federal law stipulates that your coverage will be cancelled the mother, from discharging the mother or her newborn earlier than 48 hours (or after a 30-day grace period. If you have any questions about COBRA or the 96 hours as applicable). In any case, plans and issuers may not, under federal Plan, please contact the Plan Administrator. law, require that a provider obtain authorization from the plan or issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours if applicable). Women’s Health and Cancer Rights Act (WHCRA) The Women’s Health and Cancer Rights Act (WHCRA) provides protections Premium Assistance Under Medicaid & the Children’s for individuals who elect breast reconstruction after a mastectomy. Under Health Insurance Program (CHIP) WHCRA, group health plans offering mastectomy coverage must also provide coverage for certain services relating to the mastectomy, in a If you or your children are eligible for Medicaid or CHIP and you’re eligible for manner determined in consultation with the attending physician and the health coverage from your employer, your state may have a premium assistance patient. Required coverage includes all stages of reconstruction of the program that can help pay for coverage, using funds from their Medicaid or CHIP breast on which the mastectomy was performed, surgery and reconstruction programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t of the other breast to produce a symmetrical appearance, prostheses, and be eligible for these premium assistance programs, but you may be able to buy treatment of physical complications of the mastectomy, including individual insurance coverage through the Health Insurance Marketplace. For lymphedema. Written notice about the availability of these mastectomy- more information, visit www.healthcare.gov. related benefits must be delivered to participants in a group health plan upon enrollment and then each year afterwards. If you or your dependents are already enrolled in Medicaid or CHIP, contact your State Medicaid or CHIP office to find out if premium assistance is available. Notice Regarding Special Enrollment 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 If you are waiving enrollment in the Medical plan for yourself or your programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW dependents (including your spouse/domestic partner) because of other or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your health insurance coverage, you may, in the future, be able to enroll yourself state if it has a program that might help you pay the premiums for an employer- or your dependents in the Medical plan, provided that you request sponsored plan. enrollment within 30 days after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement If you or your dependents are eligible for premium assistance under Medicaid or for adoption, you may be able to enroll yourself and your dependents CHIP, as well as eligible under your employer plan, your employer must allow provided that you request enrollment within 30 days after the marriage, birth, you to enroll in your employer plan if you aren’t already enrolled. This is called a adoption, or placement for adoption. “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, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). For a complete copy of the Children’s Health Insurance Program (CHIP) Notice, including contact information for resources in your state, visit: https://www.dol.gov/sites/default/ files/ebsa/laws-and-regulations/laws/chipra/model-notice.doc 18

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