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THANKS FOR SELECTING US!Berkshire HathawayGUARDInsuranceCompanieswww.guard.comDB 99 01 00 07 11Kids Care Pediatric Associates PC2266 Dutch BroadwayElmont, NY 11003In cooperation withPAYCHEX INSURANCEAGENCYA WARM WELCOME FROM GUARD ANDPAYCHEX INSURANCE AGENCY!Thank you for accepting AmGUARD Insurance Company as your insurance carrier for New York State disabilitybenefits. Our DBL coverage is provided in accordance with the provisions of New York State Workers’ CompensationLaw, Article 9. As required, we will file the Workers’ Compensation Board (WCB) Form DB-820/829 (commonlyreferred to as Certificate of Insurance) with the WCB to show proof of your disability coverage.CONTACT INFORMATIONShould you have any questions about your disability benefits insurance policy, please do not hesitate to contact us at1-800-673-2465, via email at csr@guard.com, or via your agent.FILING CLAIMSIf one of your covered employees becomes ill or injured away from the job, please complete the employer’s section onNY DBL - DB 99 10 08 07 11 Notice and Proof of Claim (DB-450) – accompanied by the Statement of Rights (FormDB-271S) – and have the employee (claimant) and health care practitioner complete their respective sections. Returnthe Notice and Proof of Claim to us within 30 days of the start of the disability. The forms are available on ourInternet Policyholder Service Center accessible from the POLICYHOLDERS link at www.guard.com. (Use yourpolicy number, inception date, and FEIN to create an account.)TAXABLE INCOMEPublic Law 96-601 (Tax Administrative Provisions Revision Act of 1979) requires that employers compute the taxableportion of the New York State mandated disability benefits paid to employees. The amount must be stated on eachW-2 statement provided to the employee by January 31st of each year.In general, sick pay received by an employee under a noncontributory plan is included in the employee’s grossincome. However, if the employee contributes to the cost of the sick pay plan, any benefits received that are allocableto the employee’s contribution are excludable from the employee’s gross income. Under current Internal RevenueService (IRS) regulations, the excludable portion of sick pay is determined by calculating the ratio between theemployee’s contribution and the net premiums during the calendar year in which the sick pay is received. If theemployee’s contribution for a package of benefits is not allocated by type of coverage, the excludable portion of sickpay is determined by calculating the ratio between the employee’s total contributions under the plan and the netpremium for the entire plan determined in the same manner.The above explanation provides general information only and should not be relied upon to prepare any IRS or statetax forms. Discuss with your tax advisor the application of Public Law 96-601 to your business and/oremployees.DB 99 01 00 07 11AmGUARD Insurance CompanyP.O. Box A-H Wilkes-Barre, PA 18703-0020 www.guard.comPage 1 of 1

Berkshire HathawayGUARDInsuranceCompaniesDISABILITY BENEFITSDB 99 00 02 07 11NEW YORK STATE DISABILITY BENEFITS LAW (DBL) INSURANCE POLICYSUMMARY OF POLICY NO.: DB01626254The following is a summary of your New York State Disability Benefits Law Policy. Please review this information andthe pages that follow. If you require assistance or changes to your coverage, contact your agent.[1]Named Policyholder and Mailing AddressKids Care Pediatric Associates PC2266 Dutch BroadwayElmont, NY 11003[2]AgencyPAYCHEX INSURANCE AGENCY150 Sawgrass DriveRochester, NY 14620[3]Policy PeriodThis policy is effective from 02/01/2016, At 12:01 AM Standard Time at your mailing address shown above andcontinues in force until canceled. The Anniversary Date is 02/01/2017.[4]Benefit LevelStatutory .[5]Current Employee CountNumber of Male Employees:2 Number of Female Employees: 23[6]Billing CyclePaychex Agency Bill[7]Rate for CoverageThe premium shown below may be subject to adjustment. In return for your payment of premium, and subjectto all terms of this policy, we agree with you to provide insurance as stated in this policy.Premium: 1,452.00Monthly Rates:Male: 2.36 Female: 5.06[8]CoverageThe following riders/endorsements have been included:DB 99 00 00 07 11 – Policy Coverage formDB 99 00 02 07 11 – Policy SummaryDB 99 00 02 07 11AmGUARD Insurance CompanyP.O. Box A-H Wilkes-Barre, PA 18703-0020 www.guard.comPage 1 of 1

Berkshire HathawayGUARDDISABILITY BENEFITSDB 99 00 03 07 11InsuranceCompaniesNEW YORK STATE DISABILITY BENEFITS LAW (DBL) INSURANCE POLICYPRIVACY POLICYThis notice describes how health information about you may be used and disclosed and how you can getaccess to this information.AmGUARD Insurance Company (the Company) maintains confidential policyholder and individual insured files. Incompliance with state and federal law, protected health information may be collected and/or released to assist theCompany in underwriting or claims processing activities or pursuant to an order from a court of competentjurisdiction.Insureds may access personal information (except when access is prohibited by law) by contacting:Customer ServiceAmGUARD Insurance CompanyP.O. Box A-HWilkes-Barre, PA 18703-0020Telephone: 1-800-673-2465Fax: 570-823-2059E-mail: csr@guard.comIf there is a change in your personal information, you should notify the Company. The Company may amend itsprivacy policy and/or our notice as necessary. You may obtain a copy of the Company’s current privacy policy bycontacting Customer Service.AMGUARD INSURANCE COMPANY’S POLICIES AND PRACTICESPROTECT YOUR PERSONAL INFORMATIONIn general, the Company does not release any protected health information or other confidential information unlessyou provide a signed release authorization valid for two years. Protected health information (PHI) is individuallyidentifiable health information related to your physical or mental health or condition, health care services provided toyou, or payments made for your care. PHI may be released to a plan sponsor or policyholder for policy administrationpurposes without a signed authorization. PHI may be released to a treating physician or to permit the Company toprocess a claim. PHI may be exchanged with third parties responsible for payment of related charges.PERSONAL HEALTH INFORMATION:The Company collects and uses personal information in connection withunderwriting functions, policy application review, policy administration, and claims processing. Where permitted bylaw, the Company collects information from licensed insurance brokers and agents in connection with the sale of itsproducts. Information may be exchanged with your medical provider to permit the Company to process your claim.Information may be provided to your plan administrator to assist it in seeking policy amendments, modifications, orimprovements or to permit it to process claim requests.INFORMATION SECURITY: The Company does not release any information about any insured or claimant without acurrent authorization signed by the insured, except as authorized by law. The Company maintains all policyholder andinsured records in confidential, secure locations.DB 99 00 03 07 11AmGUARD Insurance CompanyP.O. Box A-H Wilkes-Barre, PA 18703-0020 www.guard.comPage 1 of 1

02/01/2016DB01626254

AmGUARD Insurance CompanyP.O. Box A-H, Wilkes-Barre, PA 18703-0020 1-800-673-2465

AmGUARD Insurance CompanyP.O. Box A-H, Wilkes-Barre, PA 18703-0020 1-800-673-2465

AmGUARD Insurance Company Fax: 570-823-2059 P.O. Box A-H E-mail: csr@guard.com Wilkes-Barre, PA 18703-0020 If there is a change in your personal information, you should notify the Company. The Company may amend its privacy policy and/or our notice as necessary. You may obtain a copy of