ELIGIBILITY PROVISIONS: INSURANCE FOR YOU PEBB ELIGIBLE RETIREE Class 1 Retiree Term Life Plan: WA State Health Care Authority PEBB and WA State Health Care Authority SEBB employees enrolled in Basic Life Insurance who meet qualifications for enrollment in PEBB retiree insurance coverage on or after January 1, 2017; and Retirees who elected to move from the Policyholder’s $3,000 benefit plan to this Class 1 Retiree Term Life Plan during the 2016 open enrollment period. Class 2 Legacy Retiree Term Life Plan: Retirees enrolled in the Policyholder’s $3,000 benefit plan prior to January 1, 2017 who did not move to the Policyholder’s new Class 1 Retiree Term Life Plan during the 2016 open enrollment period. You are eligible for insurance if You were covered for insurance on the day immediately preceding the date Your PEBB retiree insurance coverage begins. DATE YOU ARE ELIGIBLE FOR INSURANCE You may only become eligible for the insurance available for Your eligible class as shown in the SCHEDULE OF BENEFITS. If You are a PEBB Eligible Retiree on January 1, 2024, You will be eligible for the insurance described in this certificate on that date. If You become a PEBB Eligible Retiree after January 1, 2024, You will be eligible for the insurance described in this certificate on the date You become a PEBB Eligible Retiree. ENROLLMENT PROCESS If You are eligible as described in the section of this certificate titled PEBB ELIGIBLE RETIREE, You may enroll by completing the required forms and submitting them to the Policyholder. The required forms must be received by the Policyholder within the required time frame. You must elect Retiree Term Life Insurance no later than 60 days after the date Your Basic Life Insurance ends or for an official leaving public office, no later than 60 days after leaving public office. If the Policyholder does not receive the required enrollment forms electing Retiree Term Life Insurance within the required 60 day time frame, You cannot elect Retiree Term Life Insurance at a later date unless Your Supplemental Life Insurance premiums are being waived under the terms of the WA State Health Care Authority PEBB or WA State Health Care Authority SEBB certificates for Supplemental Life Insurance. If Your Supplemental Life Insurance premiums are being waived under the terms of the Policyholder’s certificate for Supplemental Life Insurance, You must elect Retiree Term Life Insurance no later than 60 days after the date Your waiver of premium benefit ends. We will notify You of the cost of the insurance You elect. You must pay the premium for such insurance. DATE YOUR INSURANCE TAKES EFFECT Rules for Retiree-Paid Insurance Class 1 Retiree Term Life Plan: If You are eligible and elect Retiree Term Life Insurance, such insurance will take effect on the first day of the month following the date Your Basic Life Insurance ends or the first day of the month following the date Your waiver of premium benefit ends. If You return to work and regain eligibility for enrollment under the WA State Health Care Authority PEBB or WA State Health Care Authority SEBB Basic Life Insurance Group Policy, You may choose to maintain Your Retiree Term Life Plan; however, You must continue to pay the cost of such insurance. If you choose not to maintain Your Retiree Term Life Plan enrollment, You may elect to re-enroll in such insurance provided We receive Your enrollment forms no later than 60 days after the date Your Basic Life Insurance ends. GCERT2024-WSHCA-WA-LIFE-RETIREE1 23