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SPOUSE SUPPLEMENTAL TERM LIFE INSURANCEMonthly Premium Amount (Cost per Pay Period – 12/Year)Premiums for the spouse are based on the spouse’s current age and increase as the spouse enters each new age category.Benefit 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000 50,000 55,000 60,000 65,000 70,000 75,000 80,000 85,000 90,000 95,000 100,000 105,000 110,000 115,000 120,000 125,000 130,000 135,000 140,000 145,000 150,000Under 7475 0.44 0.87 1.31 1.74 2.18 2.61 3.05 3.48 3.92 4.35 4.79 5.22 5.66 6.09 6.53 6.96 7.40 7.83 8.27 8.70 9.14 9.57 10.01 10.44 10.88 11.31 11.75 12.18 12.62 13.05 0.44 0.87 1.31 1.74 2.18 2.61 3.05 3.48 3.92 4.35 4.79 5.22 5.66 6.09 6.53 6.96 7.40 7.83 8.27 8.70 9.14 9.57 10.01 10.44 10.88 11.31 11.75 12.18 12.62 13.05 0.44 0.87 1.31 1.74 2.18 2.61 3.05 3.48 3.92 4.35 4.79 5.22 5.66 6.09 6.53 6.96 7.40 7.83 8.27 8.70 9.14 9.57 10.01 10.44 10.88 11.31 11.75 12.18 12.62 13.05 0.66 1.31 1.97 2.62 3.28 3.93 4.59 5.24 5.90 6.55 7.21 7.86 8.52 9.17 9.83 10.48 11.14 11.79 12.45 13.10 13.76 14.41 15.07 15.72 16.38 17.03 17.69 18.34 19.00 19.65 1.04 2.07 3.11 4.14 5.18 6.21 7.25 8.28 9.32 10.35 11.39 12.42 13.46 14.49 15.53 16.56 17.60 18.63 19.67 20.70 21.74 22.77 23.81 24.84 25.88 26.91 27.95 28.98 30.02 31.05 1.75 3.49 5.24 6.98 8.73 10.47 12.22 13.96 15.71 17.45 19.20 20.94 22.69 24.43 26.18 27.92 29.67 31.41 33.16 34.90 36.65 38.39 40.14 41.88 43.63 45.37 47.12 48.86 50.61 52.35 3.11 6.21 9.32 12.42 15.53 18.63 21.74 24.84 27.95 31.05 34.16 37.26 40.37 43.47 46.58 49.68 52.79 55.89 59.00 62.10 65.21 68.31 71.42 74.52 77.63 80.73 83.84 86.94 90.05 93.15 5.13 10.25 15.38 20.50 25.63 30.75 35.88 41.00 46.13 51.25 56.38 61.50 66.63 71.75 76.88 82.00 87.13 92.25 97.38 102.50 107.63 112.75 117.88 123.00 128.13 133.25 138.38 143.50 148.63 153.75 6.82 13.63 20.45 27.26 34.08 40.89 47.71 54.52 61.34 68.15 74.97 81.78 88.60 95.41 102.23 109.04 115.86 122.67 129.49 136.30 143.12 149.93 156.75 163.56 170.38 177.19 184.01 190.82 197.64 204.45 10.63 21.26 31.89 42.52 53.15 63.78 74.41 85.04 95.67 106.30 116.93 127.56 138.19 148.82 159.45 170.08 180.71 191.34 201.97 212.60 223.23 233.86 244.49 255.12 265.75 276.38 287.01 297.64 308.27 318.90 18.53 37.06 55.59 74.12 92.65 111.18 129.71 148.24 166.77 185.30 203.83 222.36 240.89 259.42 277.95 296.48 315.01 333.54 352.07 370.60 389.13 407.66 426.19 444.72 463.25 481.78 500.31 518.84 537.37 555.90 30.52 61.04 91.56 122.08 152.60 183.12 213.64 244.16 274.68 305.20 335.72 366.24 396.76 427.28 457.80 488.32 518.84 549.36 579.88 610.40 640.92 671.44 701.96 732.48 763.00 793.52 824.04 854.56 885.08 915.60CHILD(REN) SUPPLEMENTAL TERM LIFE INSURANCEMonthly Premium Amount (Cost per Pay Period – 12/Year)Benefit AmountCost For All Children 2,000 4,000 6,000 8,000 10,000 0.13 0.26 0.39 0.52 0.655962a NS 08/16 2016.The Hartford Financial Services Group, Inc. All rights reserved. Life Form Series includes GBD-1000, GBD-1100, or state equivalent.Prepare. Protect. Prevail. With The Hartford. The Hartford is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Home Office is Hartford,CT.This document explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this document and the policy, the terms of thepolicy apply. Benefits are subject to state availability. Policy terms and conditions vary by state. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy as issued tothe policyholder.PAGE 2 OF 2CREATION DATE: 08/26/2020JUSTICE ADMINISTRATIVE COMMISSION/677090

Benefits Enrollment Form for Justice Administrative CommissionHartford Life and Accident Insurance CompanyOne Hartford Plaza, Hartford, Connecticut 06155 (A stock insurance company)The Hartford is The Hartford Financial Services Group, Inc., and its subsidiaries.Instructions: 1) Please print clearly with blue or black ink and provide complete information. (Missing information causes delays.) 2) Please review theapplicable benefit highlight/summary information for each product prior to electing coverage. You (employee) and your dependent(s) (if applicable) areonly eligible for coverage as allowed by the applicable group policy. 3) For each coverage, please check the appropriate box(es) to elect or declinecoverage and enter amounts where necessary. 4) Please sign and date the form. 5) Submit the form as instructed by your benefits administrator by theenrollment deadline. (Do not submit or send the form directly to The Hartford.)EMPLOYEE INFORMATIONName (FIRST MI LAST)Employee IDDate of Hire (MM/DD/YYYY)Date of Birth (MM/DD/YYYY)Group Policy Number677090DEPENDENT INFORMATION (ADDITIONAL CHILDREN MAY BE LISTED ON SEPARATE PAPER AND ATTACHED TO/SUBMITTED WITHTHIS FORM)Spouse Name (FIRST MI LAST)Date of BirthGenderDate Married N/A M FChild Name (FIRST MI LAST)Date of BirthGenderChild Name (FIRST MI LAST)Date of BirthGender M F M F M F M FSUPPLEMENTAL TERM LIFE INSURANCEYou must enroll for this coverage in order for your dependents to be eligible for this coverage.Coverage for Employee &Monthly Premium AmountBenefit Amount – Select One OptionDependent(s)(Cost per Pay Period – 12/Year) 10,000 20,000 30,000 Employee 40,000 Decline Employee CoverageN/A 5,000 10,000 15,000 Spouse 20,000 Decline Spouse CoverageN/A 2,000 for each child 0.13 for all children 4,000 for each child 0.26 for all childrenChild(ren) 6,000foreachchild 0.39 for all children The premium amount(s) shown applyto all children, regardless of the 8,000 for each child 0.52 for all childrennumber of children you have 10,000 for each child 0.65 for all children Decline Child(ren) CoverageN/AAdditional Information: If you are electing coverage for the first time, or electing to increase your current coverage, you will be required to provide evidence of insurability that issatisfactory to The Hartford before coverage can become effective. For your spouse coverage, if you are electing coverage for the first time, or electing to increase your spouse's current cove rage, your spouse will needto provide evidence of insurability that is satisfactory to The Hartford before coverage can become effective. The premium amount(s) for you and your Spouse are based on your respective age; therefore, the premium amount(s) will change as you or yourSpouse grow older. The benefit amount available to you (employee) under this plan is subject to a reduction schedule beginning at age 70. The child benefit amount listed applies to any child age 6 months or older. A different amount may apply to any child under the age of 6 months.Form PA-9676 (FL)EMPLOYEE NAME:PAGE 1 OF 3CREATION DATE: 08/27/2020JUSTICE ADMINISTRATIVE COMMISSION/677090

BENEFICIARY DESIGNATION (PLEASE ENSURE YOUR BENEFICIARY DESIGNATION IS CLEAR SO THERE IS NO QUESTION OF YOUR INTENT)This designation is for all group insurance coverage issued by The Hartford for which benefits are payable to a beneficiary or survivor (as indicated byeach specific policy) in the event of your death, unless otherwise requested by you in writing. This designation may be changed upon written request. Allinformation requested is required, per beneficiary. If more than one beneficiary is named, the beneficiaries shall share benefits equally unless percentagesare stated below. The percentages must total 100% for all Primary Beneficiaries and 100% for all Contingent Beneficiaries. If you need to designatemore beneficiaries than space will allow, please include the additional information on a separate paper and attach it to/submit it with this form, clearlystating your name. Please consult your benefits administrator or legal advisor for assistance or additional information.Certain states are community property states. If you live in one of these states – AK, AR, CA, HI, ID, LA, NV, NM, TX, WA or WI – and designate someoneother than your spouse as your beneficiary, state law may require that your spouse consent to the designation. Puerto Rico an d certain tribal jurisdictionsmay also require spousal consent. Spousal consent may not apply to ERISA plans. Please consult your benefits administrator or legal advisor foradditional information.Primary Beneficiary(ies) (PRIMARY BENEFICIARIES ARE FIRST IN LINE TO RECEIVE BENEFITS IF LIVING AT THE TIME OF YOUR DEATH)1) Name (FIRST MI LAST)Date ofSSNRelationship to YouPercentBirth%Address (STREET, CITY, STATE & ZIP)2) Name (FIRST MI LAST)Phone NumberDate ofBirthSSNRelationship to YouPercent%Address (STREET, CITY, STATE & ZIP)Phone NumberContingent Beneficiary(ies) (CONTINGENT(S) WILL RECEIVE BENEFITS IF NO PRIMARY BENEFICIARY IS ALIVE AT THE TIME OF YOUR DEATH)1) Name (FIRST MI LAST)Date ofSSNRelationship to YouPercentBirth%Address (STREET, CITY, STATE & ZIP)2) Name (FIRST MI LAST)Phone NumberDate ofBirthSSNRelationship to YouPercent%Address (STREET, CITY, STATE & ZIP)Phone NumberCONFIRMATION & SIGNATUREBy signing below: I acknowledge that I have been given the opportunity to enroll in the insurance coverage offered by my employer. I understand and agree that: 1) If I decline coverage now, but later decide to enroll, I may be required to provide evidence of insurability that issatisfactory to The Hartford and be approved for such coverage before it becomes effective; 2) My request for coverage may be denied by The Hartford;3) Insurance will go into effect and remain in effect only in accordance with the provisions, terms and conditions of the insurance policy; 4) Only theinsurance policy(ies) issued to my employer can fully describe the provisions, terms, conditions, limitations and exclusions of my insurance coverage; 5)In the event of any difference between the enrollment form and the insurance policy, I agree to be bound by the insurance policy; 6) No insurance willbe valid or in force if I am not eligible in accordance with the terms of the group policy(ies) as issued to my employer; and 7) If group participationrequirements are required and are not met, the policy(ies) may not be implemented and the coverage I have elected may not be in force. I authorize payroll deductions from my wages to cover my cost of coverage where applicable. I understand that any premium amounts indicated on thisform are estimates, which are subject to change based on the final terms of the applicable policy, and may be subject to ongoing change based on myage and/or earnings. I also understand that rates and benefits may be changed by the insurer. I have read and understand the “Important Notice – Fraud Warning Statements” that applies to my state of residence.Employee SignatureDate of SignatureEND OF FORM – PLEASE REVIEW THE “IMPORTANT NOTICE – FRAUD WARNING STATEMENTS” ON THE FOLLOWING PAGEForm PA-9676 (FL)EMPLOYEE NAME:PAGE 2 OF 3CREATION DATE: 08/27/2020JUSTICE ADMINISTRATIVE COMMISSION/677090

Benefits Enrollment FormImportant Notice – Fraud Warning StatementsHartford Life and Accident Insurance CompanyOne Hartford Plaza, Hartford, Connecticut 06155 (A stock insurance company)The Hartford is The Hartford Financial Services Group, Inc., and its subsidiaries.Please read the statement that applies to your state of residence prior to signing the enrollment form.For residents of all states EXCEPT Arizona, California, Colorado, Florida, Kentucky, Maine, Maryland, New Jersey, New Mexico, New York,North Carolina, Ohio, Oregon, Pennsylvania, Puerto Rico, Tennessee, Virginia and Washington: Any person who knowingly presents a false orfraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may besubject to fines and confinement in prison.For Residents of Arizona: For your protection Arizona law requires the following statement to appear on this form. Any personwho knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.For Residents of California: The falsity of any statement in the application for any policy covered by this chapter shall not bar the right to recovery underthe policy unless such false statement was made with actual intent to deceive or unless it materially affected either the acceptance of the risk or thehazard assumed by the insurer.For residents of Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for thepurpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Anyinsurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder orclaimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement award payable from insuranceproceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.For residents of Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an applicat ioncontaining any false, incomplete, or misleading information is guilty of a felony of the third degree.For residents of Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim or anapplication for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact materialthereto commits a fraudulent insurance act, which is a crime.For residents of Maine, Tennessee and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurancecompany for the purpose of defrauding the company. Penalties may include imprisonment, fines and denial of insurance benefits.For residents of Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly orwillfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and con finement in prison.For residents of New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminaland civil penalties. Any person who includes any false or misleading information on an application for insurance is subject to criminal and civil penalties.For residents of New Mexico and North Carolina: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit orknowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.For residents of New York (not applicable to Life Insurance): Any person who knowingly and with intent to defraud any insurance company or otherperson files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading,information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be sub ject to a civil penalty not toexceed five thousand dollars and the stated value of the claim for each such violation.For residents of Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files aclaim containing a false or deceptive statement is guilty of insurance fraud.For residents of Oregon: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insuranceor statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material issubject to a denial and/or reduction in insurance benefits and may be subject to any civil penalties available.For residents of Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application forinsurance or statement of claim containing any materially false information or conceals for the purpose of misleading, inform ation concerning any factmaterial hereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.For residents of Puerto Rico: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, orpresents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for thesame damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars( 5,000) and not more than ten thousand dollars ( 10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravatingcircumstances be present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it maybe reduced to a minimum of two (2) years.For residents of Virginia: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an applicat ion orfiles a claim containing a false or deceptive statement may have violated the state law.Form PA-9676 (FL)EMPLOYEE NAME:PAGE 3 OF 3CREATION DATE: 08/27/2020JUSTICE ADMINISTRATIVE COMMISSION/677090

The Hartford is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Home Office is . exclusions are in the Certificate of Insurance issued to each insured individual and the Master Policy as issued to the policyholder .