Life, Dental and Vision Coverage

Effective Coverage Date: 8/1/2021

Insurance Provider: Principal

Enclosed:

Voluntary Dental Plan Pricing & Summary of Benefits

Voluntary Vision Plan Pricing & Summary of Benefits
Enrollment Form – must be completed by all employees.

Next Steps:

1. Review enclosed pricing and plans documents.

2. Complete Enrollment form and return into Christie. Even if declining
dental and vision coverage, form needs to be completed for company paid
Life Policy and turned in by Wednesday July 14th, 2021.

Contact Christie with any questions, comments, or concerns.

Christie Ford
Email: [email protected]
Ph: 239-260-1833 ext 201

COASTAL MAINTENANCE & RESTORATION, INC.

1925 Trade Center Way Suite #2- Naples, FL 34109 PH: 239-260-1833
CGC1530343 CCC1330558
 Principal

EMPLOYEE LIFE AND AD&D: (Non-Contributory)

Benefits $20,000 Per Employee
35% at age 65,
Benefit Reduction
additional 15% at age 70
Monthly Life Premium 100% Paid By Employor

DENTAL: (Voluntary) Principal Plan PPO

Calendar Year Deductible: www.principal.com
Preventive Care Waived
Basic & Major Services: Per Person $50
Family Maximum $150
Coinsurance:
Preventive Care 100%
Basic Services 80%
Major Services 50%
Calendar Year Maximum: Per Person $1,500
Maximum Rollover Included
Preventative Waiver Included
Endodontics/Periodontics Basic
Composite Resin Fillings All Teeth
Implants Major
Replacement Age 10 Years
UCR Percentile Reimbursement 85th

Dental Rates:
Employee 25.25
Employee & Spouse 52.49
Employee & Child(ren) 61.68
Employee & Family 93.28

This summary is not a full description of benefits or limitations. Rates shown are
ESTIMATES only, based on census provided by the client. Final rates will be provided
after the enrollment process has been completed and submitted to underwriting.
7/8/2021
Policyholder: Coastal Maintenance &
Restoration, Inc
Group voluntary dental insurance
Benefit summary for
all members
Effective date: 08/01/2021

What's available to me?

Dental insurance helps pay for all, or a portion, of the costs associated with dental care, from routine
cleanings to root canals.

Eligibility
Eligible employees All active, full-time employees
Calendar-year deductible Coinsurance your policy pays
In-network Out-of-network In-network Out-of-network
Preventive $0 $0 100% 100%
Basic $50 $50 80% 80%
Major $50 $50 50% 50%
Additional provisions
Family deductible 3 times the per person deductible amount
Combined deductible Your deductibles that are in-network for basic and major services are combined.
Your deductibles that are out-of-network for basic and major services are
combined.
Combined maximum Maximums for preventive, basic, and major procedures are combined. In-network
calendar year maximums are $1,500 per person. Non-network calendar year
maximums are $1,500 per person.
Maximum Included
accumulation
Plan type Unscheduled

Who can buy coverage?

• You may buy coverage if you're an active, full-time employee. Seasonal, temporary, or contract
employees can't purchase.
o If you’re on regularly scheduled day off, holiday, vacation day, jury duty, funeral leave, or personal time
off, you’re still considered actively at work, as long as you’re fulfilling your regular duties and were
working the day immediately prior to your time off.
o You must enroll within 31 days of being eligible. If you don’t, you’ll have to wait until the next open
enrollment period, or qualifying event.
Additional eligibility requirements may apply.

Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392
GP62509-4 06042110183 - 3 Page 1 of 4 01/2021
Which procedures are covered, and how often?
Preventive
Routine exams Once per six months
Routine cleanings Once per six months
Bitewing X-rays Once per calendar year
Full mouth X-rays Once every 60 months
Fluoride Once per calendar year (covered only for dependent children under age 14)
Sealants Covered only for dependent children under age 14; once per tooth each 36
months

Basic
Emergency exams Subject to routine exam frequency limit
Periodontal maintenance If three months have passed since active surgical periodontal treatment;
subject to routine cleaning frequency limit
Fillings Replacement fillings every 24 months
Composite (tooth colored) Covered on posterior teeth
Oral surgery Simple and complex
General anesthesia / IV Covered only for specific procedures
sedation
Simple endodontics Root canal therapy for anterior teeth
Complex endodontics Root canal therapy for molar teeth
Non-surgical periodontics, Once per quadrant per 24 months
including scaling and root
planning
Periodontal surgical Once per quadrant per 36 months
procedures

Major
Crowns Each 120 months per tooth
Core buildup Each 120 months per tooth
Implants Each 120 months per tooth
Bridges 120 months old (initial placement / replacement)
Dentures 60 months old (initial placement / replacement)

Additional benefits
Prevailing charge When you receive care from an out-of-network-provider, benefits will be based
on the 85th percentile of the usual and customary charges.

Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392
GP62509-4 06042110183 - 3 Page 2 of 4 01/2021
Maximum accumulation Some of your unused annual benefit maximum can be carried over to the next
year. To qualify, you must have had a dental service performed within the
calendar year and used less than the maximum threshold. The threshold is
equal to the lesser of 50% of the out-of-network maximum benefit or $1,000. If
the qualification is met, 50% of the threshold is carried over to next year's
maximum benefit. Individuals with fourth quarter effective dates will start
qualifying for rollover at the beginning of the next calendar year. You can
accumulate no more than four times the carry over amount. The entire
accumulation amount will be forfeited if no dental service is submitted within a
calendar year
Periodontal program If you’re pregnant or have diabetes or heart disease, you may receive scaling
and root planing covered at 100% (if dentally necessary), or one additional
cleaning (routine or periodontal) subject to deductible and coinsurance.
Second opinion program You may be eligible for second opinions from dental providers at 100%. This
program makes sure you get the best advice to make an informed decision
about your care.
Cancer treatment oral If you have cancer and are undergoing chemotherapy or head/neck radiation
health program therapy, you may receive up to three fluoride treatments every 12 months
covered at 100% plus one additional routine cleaning.

How do I find a network dentist?

When you receive services from a dentist in our network, your cost may be lower. Network dentists agree to
lower their fees for dental services and not charge you the difference. You’ll have access to the Principal Plan
Dental network, with more than 117,000 dentists nationwide. Visit principal.com/dentist to find a dentist or
call 800-247-4695.

What if my dentist isn't in the network?

You can refer your dentist to our network. Please submit the dentist’s name and information by calling
800-832-4450, or submitting a form at principal.com/refer-dental-provider.
What are the limitations and exclusions of my coverage?

• Missing tooth –The initial placement of bridges, partials, and dentures to replace teeth missing before this
coverage starts won’t be covered. If this policy replaces coverage with another carrier, continuous
coverage under the prior plan may be applied to the missing tooth provision requirement. This doesn’t
apply to pediatric essential benefits.
• Frequency limitations for services are calculated to the month and exact date from the last date of service
or placement date.

There are additional limitations to your coverage. Please review your booklet for more information.

U1P1 Yes

U1P2 No

U2P1 Yes

U2P2 No

U3P1 Yes

U3P2 No

Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392
GP62509-4 06042110183 - 3 Page 3 of 4 01/2021
 Principal VSP
VISION BENEFITS: (Voluntary) In-Network Non-Network
Once per 12 month period
Reimbursed
Eye Exam:
$10 Copay up to $45,
Less Copay
Non-Network
Materials Copay: $25 Copay Reimbursement,
Less Copay
Once per 12 month period

Materials Copay
Frames: then, $150 retail Reimbursed
allowance with 20% up to $70
off the balance

Lenses: Once per 12 month period

Reimbursed
Single Materials Copay
up to $30
Reimbursed
Bifocal Materials Copay
up to $50
Reimbursed
Trifocal Materials Copay
up to $65
Reimbursed
Lenticular Materials Copay
up to $100
Standard Progressives Discounted N/A

Premium Progressives, Scratch Resistant

Coating, Anti-Reflective Coating, Tints & Discounted N/A
Photochromics
Contact Lenses: Once per 12 month period
Elective
$60 Copay
Fitting & Evaluation Reimbursed
up to $105
Materials $150 allowance
Medically Necessary

Fitting & Evaluation Reimbursed

Materials Copay
up to $210
Materials

Rate Guarantee 1 Year

Rates: Principal VSP

Employee 5.83
Employee & Spouse 12.80
Employee & Child(ren) 13.81
Employee & Family 22.38
This summary is not a full description of benefits or limitations. Rates shown are ESTIMATES only, based on
census provided by the client. Final rates will be provided after the enrollment process has been completed and
submitted to underwriting.
7/8/2021
Policyholder: Coastal Maintenance &
Restoration, Inc
Group voluntary vision
Benefit summary for all members
Effective date: 08/01/2021

What's available to me?

Vision insurance is offered through Principal® and VSP® Vision Care. It provides choice, flexibility and savings
through a VSP doctor.

If you buy this coverage, an established network of VSP doctors will provide quality care for you and your
dependents.

VSP choice network

Exams Every 12 months, one exam is covered in full after $10 copay
Prescription glasses $25 copay
Lenses - 1 pair covered every
12 months • Single lenses
• Lined bifocal lenses
• Lined trifocal lenses
• Lenticular lenses
Frames - covered up to $150 • Polycarbonate lenses for dependent children under age 18
every 12 months; 20% off
amount over allowance1
Lens enhancements Standard progressive lenses covered once every 12 months with a $0 copay¹

Most other popular lens enhancements are covered after a copay, saving our
members an average of 30%¹
Elective contacts Covered up to $150 every 12 months. Contact lenses can be chosen instead
of glasses.
Contact fitting and Up to $60 copay
evaluation
Necessary contacts Covered in full after $25 copay every 12 months
1
This can vary based on state laws and provider location Savings may not apply at participating retail chains.

Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392
GP62454-3 06042110183 - 3 Page 1 of 4 06/2021
Who can buy coverage?
• You can buy coverage if you’re an active, full-time employee. Seasonal, temporary, or contract
employees can’t purchase.
o If you’re on regularly scheduled day off, holiday, vacation day, jury duty, funeral leave, or personal time
off, you’re still considered actively at work, as long as you’re fulfilling your regular duties and were
working the day immediately prior to your time off.
o You must enroll within 31 days of being eligible. If you don’t, you’ll have to wait until the next open
enrollment period.
• If you’re covered, you may buy coverage for your dependents.

Additional eligibility requirements may apply.

What's the difference between elective and necessary contacts?

• Elective - when vision can be corrected by glasses, but contacts are worn.
• Necessary - when vision can't be corrected with glasses due to extreme vision problems.

Why am I charged an additional copay for contact fitting and evaluation?

• Contact lens wearers require an additional evaluation of the eyes’ measurements, and possible follow-up
appointments, for fitting and training on proper use of contact lenses.
• For these additional services, you won’t pay more than $60 at in-network providers.

Are benefits the same for all VSP doctors?

• Yes, with the exception of Costco®, Walmart®, and Sam’s Club®. The frame allowance at these locations is
$80 which is equivalent to a $150 allowance at other VSP doctor locations. Not all providers at
participating retail chains are in-network for exam services.
• Benefits may also vary by location due to state law.

How do I find a VSP doctor?

• Visit vsp.com to locate VSP doctors close to you -- or to see if your current eye care professional is in the
VSP network.
o You’ll need to choose the “Choice” doctor network to view the VSP doctors for your coverage.
• Call 800-877-7195.

Will I get an ID card?

• Yes, your card will have a unique member ID that your doctor will use to verify benefits.

Will my doctor submit my claim?

• If you’re seeing a VSP doctor, they’ll submit the claim for you.
• If you’re seeing someone outside the VSP network, you’re responsible for submitting your own claim. You
can get that form from vsp.com after logging in as a member using your member ID. Or call 800-877-7195.

Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392
GP62454-3 06042110183 - 3 Page 2 of 4 06/2021
Are there any additional savings with VSP?
• Glasses and sunglasses - you can save an average of 20-25% off glasses or sunglasses from any VSP doctor
within 12 months of your last covered vision exam.
• Laser vision correction - you pay an average of 15% off the regular price and 5% off the promotional price.
You’ll only receive these discounts from contracted clinics.

These savings can vary based on state laws and provider location.

What benefits do I receive if my doctor is outside VSP's network?

Covered charges Benefit Frequency
Exams Up to $45 Once every 12 months
Single lenses Up to $30 One pair every 12 months
Lined bifocal lenses Up to $50 One pair every 12 months
Lined trifocal lenses Up to $65 One pair every 12 months
Lenticular lenses Up to $100 One pair every 12 months
Frames Up to $70 One set every 12 months
Elective contacts Up to $105 Contacts are instead of frames and lenses
Necessary contacts Up to $210 Contacts are instead of frames and lenses

What are the limitations of my benefits?

• Visual analysis or vision aids that aren't medically necessary aren't covered.
• No benefits will be paid for:
o Non-prescription glasses
o Medical or surgical treatment of the eyes
o Claims submitted by a doctor who is part of your family

Once enrolled, you'll receive a booklet with more details regarding your plan limitations and exclusions.

Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392
GP62454-3 06042110183 - 3 Page 3 of 4 06/2021
 110

Mailing Address Principal Life Employee Enrollment

Des Moines, IA 50392-0002 Insurance Company & Waiver-FL
PLEASE USE BLACK INK
PLEASE ENTER DATES AS MM/DD/YYYY
Company name Division level Account number/unit number
Coastal Maintenance & Restoration, Inc All Members

Employee Information
Name Social security number

Mailing address (street) Birth date male

female
(city) (state) (ZIP code)

Date employed full-time Hours worked per week Job occupation/class Location

Email address Phone number

Do you have an eligible spouse or domestic partner or child(ren)?

yes no
Payroll mode Employer ZIP code Employer county
monthly semi-monthly weekly bi-weekly 34109 COLLIER

or children)
Eligible Dependent Information (Complete if you are electing benefits for your spouse or domestic partner
Dependent name Birth date Gender Social security number Relationship
male Spouse
female domestic partner
male Child
female foster child*
disabled child**
male Child
female foster child*
disabled child**
male Child
female foster child*
disabled child**
male Child
female foster child*
disabled child**
*If you checked foster child, was the child placed with you by an authorized state placement agency or by order of a
court?
yes no

**When your child, who is developmentally or physically disabled, reaches/exceeds the maximum age, an Application
to Continue Disabled Child form must be completed and reviewed to determine eligibility.

Is your spouse or domestic partner employed by this company?

yes no

GP60106-02 06042110183 - 3
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07/2017
 110
Coverage Employee Spouse or Domestic Partner* Child(ren)
NOTE: Employee coverage must be elected to elect any dependent coverage.
Dental Elect Decline Elect Decline Elect Decline
Vision Elect Decline Elect Decline Elect Decline
Group Term Life X Elect

*NOTE: Domestic Partners can only be added if your employer allows this coverage. If enrolling a Domestic Partner,
please attach a separate Declaration of Domestic Partnership/Enrollment Form Addendum (GP60447).
Group Term Life Beneficiary Designation (Complete if covered for group term life coverage.)
All primary and contingent beneficiaries, whether adults or minors, should be included in the beneficiary
designation below. Additional beneficiaries can be added as an attachment.
Primary Beneficiaries:
Name SSN Date of birth Relationship Check here if a Percentage
minor
Name SSN Date of birth Relationship Check here if a Percentage
minor

Contingent Beneficiaries:
Name SSN Date of birth Relationship Check here if a Percentage
minor
Name SSN Date of birth Relationship Check here if a Percentage
minor

The right to make future changes is reserved by the employee. If two or more beneficiaries are named, the proceeds
shall be paid to the named beneficiaries, or to the survivor or survivors, in equal shares, unless specified otherwise.
If any beneficiary is designated as trustee, it is understood and agreed that Principal Life Insurance Company shall not be
a party to nor bound by the conditions of any trust and payment of the net proceeds of said policy on the death of the
insured to the then designated beneficiary shall be a complete discharge as to Principal Life.
If you have designated a minor child(ren) as your beneficiary, you must complete the Uniform Transfers to Minors Act
form (GP55229).

Declining Coverage
Important! If declining any coverage for yourself or any dependent, give reason. Covered under:
spouse's or domestic partner's group coverage individual insurance
other coverage offered by my employer other _________________________________________

Employee Agreement (Read and sign)

I understand and agree with the following statements:

• My dependents are not eligible for coverages I don't have. My dependents, including step and foster children and
any over the maximum age, are eligible based on plan provisions but those over the maximum age will be verified
when a claim is filed.
• If I refuse dental or vision coverage, I and my dependents may enroll later but this will affect the level of benefits.
• If I refuse coverage, I cannot enroll after retirement.
• If I refuse life, disability, or critical illness coverage, I may apply later but I must show proof of good health and
coverage will be subject to approval by Principal Life Insurance Company.
• If the group policy does not require my contribution, I cannot decline coverage unless the policy indicates otherwise.
• If the group policy requires my contribution, I authorize my employer to deduct from my pay.
• I represent all information on this form and attachments is complete and true to the best of my knowledge. They are
part of this request for coverage. I agree Principal Life is not liable for a claim before the effective date of coverage

GP60106-02 06042110183 - 3
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07/2017
 110
and all policy provisions apply. I have read, or had read to me, the information and my answers on this form. During
the first two years coverage is in force, misrepresentations contained in writing in this document can cause changes
in my coverage, including cancellation back to the effective date.
• Explanation of Benefits reflecting claims payments for myself and my dependents will be sent to my home address. I
also understand collection of social security numbers for myself and/or my dependents will be used by Principal Life
only as allowed by law.
• I authorize Principal Life to release data as required by law. If signed in connection with an application,
reinstatement or a change in benefits, this form will be valid two years from the date below. I may revoke
authorization for information not yet obtained. I understand data obtained will be used by Principal Life for claims
administration and determining eligibility for life, disability, and critical illness. Information will not be used for any
purposes prohibited by law.
• I understand that as the employee, the insurance I and my dependents have applied for will begin on the effective
date of coverage provided I am at work on that date. If I am not actively at work on such date, subject to the terms
of the group policy, coverage may not go into effect until after my return to work. Furthermore, I understand that no
insurance may become effective for any member of my family while he/she is in a period of limited activity.

A copy of this form will be as valid as the original.

I declare that the information I have completed on this enrollment form is complete and true to the best of my knowledge
and belief. I understand an agent or broker cannot guarantee coverage, revise rates, benefits or provisions without
written approval from Principal Life Insurance Company.

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application
containing any false, incomplete or misleading information is guilty of a felony of the third degree.

Your signature X_______________________________________ Date Signed ________________

Instructions
After this form is completed and signed, make two copies and send the original to Principal Life Insurance Company:
• One for the employee
• One for the employer

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