21-D5 - GCC G0061645 E5698931.pdf

Colonial Life & Accident Insurance Company P.O. Box 1365 Columbia, SC 29202-1365

City Of Burleson 141 W Renfro Street Burleson, TX 76028-0000

*2LN1G00616450000156*

Secretary President and Chief Executive Officer

GCC1.0-P-EE-TX 1 75751

*2LN1G00616450000156*

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY

1200 Colonial Life Boulevard, P. O. Box 1365, Columbia, South Carolina 29202

1.800.325.4368 coloniallife.com A Stock Company

CRITICAL ILLNESS AND CANCER GROUP SPECIFIED DISEASE INSURANCE

POLICY

Please Read This Policy Carefully This policy is a legal contract between the policyholder and us. To understand the coverage, this policy must be read as a whole.

Throughout this policy, the word policyholder refers to the organization shown on the Policy Rate Schedule. You or your refers to a named insured who is covered under this coverage. Named insured refers to the person who is a member of an eligible class as described on the Policy Rate Schedule, who holds a certificate of coverage and for whom the policyholder remits premium.

Covered person refers to any person covered under this policy as described on the Certificate Schedule. We, us, our or company refers to Colonial Life & Accident Insurance Company. The male pronoun includes the female whenever used.

This policy is delivered in and is governed by the laws of the governing jurisdiction shown on the Policy Rate Schedule and, to the extent applicable, by the Employee Retirement Income Security Act of 1974 (ERISA) and any amendments.

This policy is issued in consideration of the application of the policyholder, a copy of which is attached to and made a part of this policy, and the payment of premium when due. This policy takes effect at 12:01 a.m. Standard Time at the policyholder's address on the Policy Effective Date shown on the Policy Rate Schedule.

We agree to pay, in accordance with the terms of this policy, the benefit amounts of the policy to the named insureds. Details of the benefits are shown in the certificate.

Signed for Colonial Life & Accident Insurance Company:

THIS IS A LIMITED POLICY.

PLEASE READ IT CAREFULLY.

THE POLICY IS CANCELLABLE AT THE OPTION OF THE COMPANY.

PLEASE READ THE “TERMINATION OF THIS CONTRACT” PROVISION.

THIS IS NOT MEDICARE SUPPLEMENT COVERAGE.

THIS IS NOT A POLICY OF WORKERS' COMPENSATION INSURANCE. THE POLICYHOLDER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM BY PURCHASING THIS POLICY, AND IF THE POLICYHOLDER IS A NON-SUBSCRIBER, THE POLICYHOLDER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS' COMPENSATION LAWS. THE POLICYHOLDER MUST COMPLY WITH

THE WORKERS' COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED

NOTIFICATIONS THAT MUST BE FILED AND POSTED.

http://www.coloniallife.com

GCC1.0-P-EE-TX 2 75751

SECTION 2 - POLICY GUIDE

SECTION 1 - FACE PAGE

SECTION 2 - POLICY GUIDE

SECTION 3 - POLICY RATE SCHEDULE

SECTION 4 - POLICYHOLDER PROVISIONS

SECTION 5 - PREMIUM PAYMENTS

SECTION 6 - TERMINATION

1.Description of Eligible Classes All employees in active employment working a minimum of 30 hours per week. Temporary and seasonal workers are excluded from coverage.

Active Employment means the named insured is working for the policyholder at the worksite for earnings that are paid regularly, and he is performing the material and substantial duties of his regular occupation. The named insured will not be considered in active employment if employment status is being continued under a severance or termination agreement. The worksite must be:

• the policyholder's usual place of business;

• an alternative work site at the direction of the policyholder; or

• a location to which the named insured's job requires him to travel.

Material and substantial duties means duties that are normally required for the performance of the named insured's regular occupation, and cannot be reasonably omitted or modified.

Regular occupation means the occupation the named insured routinely performs on his job.

*2LN1G00616450000156*

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY

POLICY RATE SCHEDULE

Policyholder: City Of Burleson Policy Number: G0061645

Policyholder Address: 141 W Renfro Street Billing Control Number: E5698931 Burleson, TX 76028-0000 Governing Jurisdiction: Texas

Policy Effective Date: 01-01-2022 First Policy Anniversary: 01-01-2023

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Policyholder Plan Choice for Critical Illness Benefit:

A member of an eligible class chooses from the following options:

Face Amount for Named Insured in $1,000 increments from a minimum Face Amount of $5,000 up to a maximum Face Amount of $50,000.

Critical Illnesses Covered:

Heart Attack (Myocardial Infarction), Stroke, End Stage Renal (Kidney) Failure, Major Organ Failure, Permanent Paralysis Due to a Covered Accident, Coma, Blindness, Occupational HIV or Occupational Infectious Hepatitis B, C or D, Coronary Artery Disease.

Benefits Payable Upon Subsequent Diagnosis of a Critical Illness

Policyholder Plan Choice for Cancer Benefits:

Diagnosis of Cancer Benefit A member of an eligible class chooses from the following options:

Face Amount for Named Insured in $1,000 increments from a minimum Face Amount of $5,000 up to a maximum Face Amount of $50,000.

This policy may include enrollment, risk management and other support services related to the policyholder's benefit program.

Eligibility Period: days

Initial Monthly Rates/Unit for Critical Illness Benefit and Diagnosis of Cancer Benefit, Diagnosis of Carcinoma In Situ Benefit, Skin Cancer Benefit, and Cancer Vaccine Benefit:

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Tobacco Premium Class

Named Insured Named Insured and Spouse Issue Ages Rates/Unit Issue Ages Rates/Unit 16-29 $0.590 16-29 $0.880 30-39 $1.150 30-39 $1.710 40-49 $2.510 40-49 $3.760 50-59 $4.710 50-59 $7.230 60-74 $7.860 60-74 $12.040 One-Parent Family Two-Parent Family Issue Ages Rates/Unit Issue Ages Rates/Unit 16-29 $0.640 16-29 $0.930 30-39 $1.200 30-39 $1.760 40-49 $2.570 40-49 $3.820 50-59 $4.770 50-59 $7.290 60-74 $7.930 60-74 $12.110

Non-Tobacco Premium Class

Named Insured Named Insured and Spouse Issue Ages Rates/Unit Issue Ages Rates/Unit 16-29 $0.360 16-29 $0.540 30-39 $0.740 30-39 $1.100

40-49 $1.560 40-49 $2.340 50-59 $2.910 50-59 $4.450 60-74 $4.760 60-74 $7.270 One-Parent Family Two-Parent Family Issue Ages Rates/Unit Issue Ages Rates/Unit 16-29 $0.420 16-29 $0.600 30-39 $0.790 30-39 $1.150 40-49 $1.620 40-49 $2.400 50-59 $2.970 50-59 $4.510 60-74 $4.830 60-74 $7.330

Unit means $1,000 of Face Amount for named insured.

Rate Guarantee Period: A change in the premium rate table(s) will not take effect before two years after the policy effective date.

Divisions, subsidiaries or affiliated companies include:

City Of Burleson Burleson TX

GCC1.0-P-EE-TX 5 75751

SECTION 4 - POLICYHOLDER PROVISIONS

Ownership The policyholder is the owner of this policy and may agree with us to change it without the consent of or notice to the covered persons or their assignees.

Entire Contract The entire contract consists of:

• this policy;

• the application of the policyholder attached to this policy;

• each named insured's enrollment form and evidence of insurability, if applicable;

• certificates issued under this policy; and

• riders, endorsements or amendments to the policy or certificates.

Changes to the Contract Riders, endorsements and amendments add provisions to or change the terms of the policy.

Any changes to this policy, other than a change in the premium we charge, must be in writing and evidenced by endorsement on this policy, or by amendment to this policy signed by the policyholder and one of our executive officers at our home office.

No agent or anyone else can change this policy or waive any of its provisions.

Furnishing Certificates The company will provide a certificate for each named insured. The certificate will provide a description of the insurance provided by this policy and will state:

• the benefits provided under the policy;

• to whom benefits are payable;

• the limitations, exclusions and requirements that apply to coverage under the policy; and

• how to file a claim against the coverage.

If there is any discrepancy between the provisions of any certificate and the provisions of this policy, the provisions of this policy govern.

Contestability After two years from the Policy Effective Date, no misstatements made by the policyholder in the application will be used to void this policy or to deny a claim for loss incurred after the expiration of the two-year period.

Conformity with State Statutes Any provision of this policy that is in conflict with the applicable state laws of the state in which the named insured resides when he becomes insured is amended to conform to the minimum requirements of those laws.

Our Right to Change Premiums We have the right to change the premium we charge after notifying the policyholder in writing at least 60 days in advance. A change in premium rate table(s) will not take effect before the end of the rate guarantee period shown on the Policy Rate Schedule except for reasons which affect the risk assumed, including, but not limited to those reasons shown below:

• a change occurs in this policy;

• a division, subsidiary, or affiliated company is added or deleted;

• the number of insureds changes by 25% or more; or

• a new law or a change in any existing law is enacted which applies to this policy.

After the rate guarantee period, we can change premium rate table(s) at any time. A change may take effect on an earlier date when both we and the policyholder agree in writing.

New Entrants Any member of an eligible class, as described on the Policy Rate Schedule, and the eligible dependents of those members will become insured when they satisfy the requirements set forth in the certificate of insurance.

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Information to Be Furnished By the Policyholder The policyholder must keep a record of the named insureds and the particulars of the insurance on each and their covered spouse and dependent children, if applicable. As changes occur, the policyholder should provide us, on forms acceptable to us, information relative to any persons:

• who are eligible to enroll;

• who are insured by the coverage;

• whose status changes; and/or

• whose coverage terminates pursuant to the “Termination of Insurance” provision.

The policyholder should also provide us with any other information about the coverage that may be reasonably required, such as named insureds on leave of absence, including named insureds who are on leave under the Family and Medical Leave Act.

Policyholder records that have a bearing, in our opinion, on this policy will be available for review by us at any reasonable time.

We may inspect these records at any time while this policy is in force and within one year after the termination of this policy.

All statements made in any application are considered representations and not warranties (absolute guarantees). No representation by the policyholder in applying for insurance under this policy will make it void unless the representation is contained in the application of the policyholder.

Clerical error or omission by us will not:

• prevent a covered person from receiving coverage;

• affect the amount of a covered person's coverage; or

• cause a covered person's coverage to begin or continue when the coverage would not otherwise be effective.

Electronic Transactions Any transaction relating to this policy may be conducted by electronic means if performance of the transaction is consistent with applicable state and federal law. Any notice required by the provisions of this policy given by written, electronic, and telephonic, as applicable, means will have the same force and effect as notice given in writing.

SECTION 5 - PREMIUM PAYMENTS

Premium Payments The initial premium for each type of coverage under this policy is based on the initial premium rate table(s) shown on the Policy Rate Schedule.

Premium Amount To ensure accurate premium calculations, the policyholder is responsible for reporting to us the following information during the stated time periods:

• individuals who are eligible to enroll are to be reported during the month prior to or during the month the coverage becomes effective;

• covered persons whose coverage has terminated are to be reported within a month of the date coverage terminated; and

• changes in named insureds' class are to be reported within a month of the date that the change in insurance class took place.

When and Where to Pay Premiums The premiums for each certificate must be paid to us at our home office when they are due.

The premium due dates are based on:

• the coverage effective dates shown on the Certificate Schedules; and

• the premium frequency.

The premium frequency is how often the premiums are paid. The policyholder will be liable to us for all unpaid premiums for any period, including the grace period, during which coverage under the policy was in force as to any covered person.

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Premium increases or decreases which take effect during an insurance month are due on the next premium due date following the change. Changes will not be pro-rated daily.

If premiums are paid on other than a monthly basis, premiums for increases and decreases will result in a monthly pro-rated adjustment on the next premium due date.

Grace Period (If Premiums Are Not Paid When Due) After the first premium, if the premium is not paid when it is due, it can be paid during the next 31 days. These 31 days are called the grace period. During the grace period this coverage will stay in force. If the premium is not paid before the grace period ends, the coverage provided by this policy will terminate at the end of the grace period.

SECTION 6 - TERMINATION

Termination of This Contract This policy can be terminated:

• by the policyholder; or

• by us.

If the premium is not paid when it is due or during the grace period, this policy will terminate automatically at the end of the grace period.

Except for nonpayment of the required premium or the failure to meet continued underwriting standards, we may not cancel the policy prior to the first anniversary date of the policy effective date as specified on the Policy Rate Schedule. After the first anniversary date, we may cancel this policy for any reason.

If we cancel this policy for reasons other than the policyholder's failure to remit premium, a written notice will be delivered to the policyholder by certified mail at least 60 days prior to the cancellation date.

The policyholder may cancel this policy by written notice delivered to us at least 31 days prior to the cancellation date. This policy can be cancelled on an earlier date if we both agree. Coverage will end at 12:00 midnight Standard Time at the policyholder's address on the cancellation date.

If the policy is cancelled, the cancellation will not affect a claim for which we are liable under the terms of this policy.

Policyholder Responsibility to Named Insureds If this policy terminates for any reason, the policyholder must:

• notify each named insured of the effective date of the termination; and

• refund or otherwise account to each named insured all contributions received or withheld from them for premiums not actually paid to us.

Workers' Compensation This policy is not in lieu of, and does not affect, any requirement for coverage by workers' compensation insurance.

43975-1 43975-4

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY

P. O. Box 1365, Columbia, South Carolina 29202

1-800-325-4368

IMPORTANT NOTICE

To obtain information or make a complaint:

You may call Colonial Life & Accident Insurance Company’s toll-free telephone number for information or to make a complaint at:

1-800-3-Client (1-800-325-4368)

You may also write to:

Colonial Life & Accident Insurance Company

P.O. Box 1365 Columbia, South Carolina 29202

You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at:

1-800-252-3439

You may write the Texas Department of Insurance at:

P.O. Box 149104 Austin, Texas 78714-9104

Fax: (512) 475-1771 Web: http://www.tdi.state.tx.us

E-mail: ConsumerProtection@tdi.state.tx.us

PREMIUM OR CLAIM DISPUTES:

Should you have a dispute concerning your premium or about a claim you should contact the company first. If the dispute is not resolved, you may contact the Texas Department of Insurance.

ATTACH THIS NOTICE TO YOUR POLICY:

This notice is for information only and does not become a part or condition of the attached document.

AVISO IMPORTANTE

Para obtener informacion o para someter una queja:

Usted puede llamar al numero de telefono gratis de Colonial para informacion o para someter una queja al:

1-800-325-4368

Usted tambien puede escribir a Colonial Life & Accident Insurance Company:

P.O. Box 1365 Columbia, South Carolina 29202

Puede comunicarse con el Departamento de Seguros de Texas para obtener informacion acerca de companias, coberturas, derechos o quejas al:

1-800-252-3439

Puede escribir al Departamento de Seguros de Texas

P.O. Box 149104 Austin, Texas 78714-9104

Fax: (512) 475-1771 Web: http://www.tdi.state.tx.us

E-mail: ConsumerProtection@tdi.state.tx.us

DISPUTAS SOBRE PRIMAS O RECLAMOS:

Si tiene una disputa concerniente a su prima o a un reclamo, debe comunicarse con la compania primero. Si no se resuelve la disputa, puede entonces comunicarse con el departamento (TDI).

UNA ESTE AVISO A SU POLIZA:

Este aviso es solo para proposito de informacion y no se convierte en parte o condicion del documento adjunto.

*3SN1G00616450000165*

Secretary President and Chief Executive Officer

*2SN1G00616450000167*

GCC1.0-C-EE-TX 3 75752

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY

1200 Colonial Life Boulevard, P. O. Box 1365, Columbia, South Carolina 29202

1.800.325.4368 coloniallife.com A Stock Company

CRITICAL ILLNESS AND CANCER GROUP SPECIFIED DISEASE INSURANCE

CERTIFICATE

THIS CERTIFICATE EXPLAINS THE BENEFITS PROVIDED UNDER THE CRITICAL ILLNESS AND CANCER

GROUP SPECIFIED DISEASE INSURANCE POLICY.

THIS IS A LIMITED BENEFIT CERTIFICATE.

Please Read This Certificate Carefully This is your certificate of coverage as long as you are insured under the policy. You will want to read it carefully and keep it in a safe place.

Throughout this certificate, the word you or your refers to the named insured shown on the Certificate Schedule, who is a member of an eligible class as described on the Policy Rate Schedule, who holds a certificate of coverage and for whom premiums are remitted.

Covered person refers to any person covered under the policy as described on the Certificate Schedule. We, us, our or company refers to Colonial Life & Accident Insurance Company. Policyholder refers to the organization shown on the Policy Rate Schedule. It includes any division, subsidiary or affiliated company named in the Policy Rate Schedule. Policy means the group contract owned by the policyholder and available for review by you. The male pronoun includes the female whenever used. If the terms of your certificate of coverage and the policy differ, the policy will govern.

The policy and this certificate may be changed in whole or in part or cancelled as stated in the policy. Such an action may be taken without the consent of or notice to any covered person. Only an executive officer at our home office can approve a change. The approval must be in writing and evidenced by endorsement on the policy or certificate or an amendment signed by the policyholder and one of our executive officers at our home office. No other person, including an agent, may change the policy or certificate or waive any of its provisions. Premiums are subject to periodic changes. This Certificate replaces any and all Certificates previously issued for the eligible classes under the Policy.

The policy and this certificate are delivered in and are governed by the laws of the governing jurisdiction shown on the Policy Rate Schedule and to the extent applicable by the Employee Retirement Income Security Act of 1974 (ERISA) and any amendments.

Signed for Colonial Life & Accident Insurance Company:

Please read this certificate carefully.

THIS IS NOT MEDICARE SUPPLEMENT COVERAGE.

If you are eligible for Medicare, review the Guide To Health Insurance for People with Medicare available from the company.

THE INSURANCE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS' COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR POLICYHOLDER TO DETERMINE WHETHER YOUR

POLICYHOLDER IS A SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM.

GCC1.0-C-EE-TX 4 75752

SECTION 2 - CERTIFICATE GUIDE

SECTION 1 FACE PAGE

SECTION 2 CERTIFICATE GUIDE

SECTION 3 CERTIFICATE SCHEDULE

SECTION 4 GENERAL DEFINITIONS

SECTION 5 DEFINITIONS FOR CRITICAL ILLNESS BENEFIT

SECTION 6 DEFINITIONS FOR CANCER BENEFITS

SECTION 7 ELIGIBILITY AND EFFECTIVE DATE

SECTION 8 BENEFIT FOR CRITICAL ILLNESS

SECTION 9 BENEFITS FOR CANCER

SECTION 10 EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS

SECTION 11 EXCLUSIONS AND LIMITATIONS FOR CANCER

SECTION 12 TERMINATION OF INSURANCE

SECTION 13 PORTABILITY

SECTION 14 GENERAL PROVISIONS

SECTION 15 CLAIM PROVISIONS

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY

CERTIFICATE SCHEDULE

Policyholder: City Of Burleson Policy Number: G0061645

Named Insured: John A. Doe Certificate Number: 9999999999

Coverage Type: Two-Parent Family Governing Jurisdiction: Texas

Coverage Effective Date: January 1, 2022 Billing Control Number:

E5698931

Pre-existing Condition Limitation Period: 12 months

Premium Class: Tobacco Non-Tobacco

BENEFITS

Face Amount for Named Insured $50,000 Face Amount for Spouse $25,000 Face Amount for Dependent Children $25,000 The Face Amount(s) will reduce by 50% on the first Policy Anniversary Date after the named insured attains age 75.

GCC1.0-C-EE-TX Printed on 09/28/2021 5 75752

*2SN1G00616450000167*

Critical Illness Benefit Percentage of Face Amount Heart Attack (Myocardial Infarction) 100% Stroke 100% End Stage Renal (Kidney) Failure 100% Major Organ Failure 100% Permanent Paralysis due to a Covered Accident 100% Coma 100% Blindness 100% Occupational Infectious HIV or Occupational Infectious Hepatitis B, C or D 100% Coronary Artery Disease 25%

Cancer Benefits Percentage of Face Amount Diagnosis of Cancer Benefit 100% Diagnosis of Carcinoma in Situ Benefit 25%

Maximum Benefit Amount for a Diagnosis of Cancer Benefit: 100% of the Face Amount per covered person per lifetime.

Maximum Benefit Amount for a Diagnosis of Carcinoma in Situ Benefit: 25% of the Face Amount per covered person per lifetime.

Skin Cancer Benefit $500 per covered person, per lifetime Cancer Vaccine Benefit $50 per covered person, per lifetime

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GCC1.0-C-EE-TX Printed on 09/28/2021 6 75752

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SECTION 4 - GENERAL DEFINITIONS

Additional definitions may be contained in other certificate benefit provisions or any endorsement, amendment or rider.

Calendar Year means the period beginning on the coverage effective date shown on the Certificate Schedule and ending on December 31 of the same year. Thereafter, it is the period beginning on January 1 and ending on December 31 of each following year.

Coverage Effective Date means the date coverage begins as shown in the Certificate Schedule. The coverage effective date of this certificate is not the date you signed the application for coverage.

Dependent Children means your:

• natural children;

• step-children;

• grandchildren who are your dependents for federal income tax purposes;

• adopted children;

• children for whom you have filed a suit seeking adoption of the children;

• children whom you are required to insure under a medical support order issued under Section 14.061, Family Code, or enforceable by a court in this state; and

• children in your custody under a temporary court order that grants you conservatorship of the children.

Such children must be younger than age 26.

Doctor or Physician means a person who:

• is licensed by the state to practice a healing art; and

• performs services for a covered person which are allowed by his license.

For purposes of this definition, Doctor or Physician does not include any covered person or anyone related to any covered person by blood or marriage, a business or professional partner of any covered person, or any person who has a financial affiliation or a business interest with any covered person.

Evidence of Insurability means a statement of your medical history which we will use to determine if you are approved for coverage.

Policy Anniversary Date means the date that occurs annually on the same day and in the same month as the First Policy Anniversary shown on the Policy Rate Schedule.

Pre-existing Condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date.

Spouse means a person who is married to you on the day we issue your certificate.

Temporary Layoff or Leave of Absence means the named insured is temporarily absent from active employment for a period of time that has been agreed to in advance in writing by the employer. Normal vacation time or any period of disability is not considered a temporary layoff or leave of absence.

SECTION 5 - DEFINITIONS FOR CRITICAL ILLNESS BENEFIT

Additional definitions may be contained in other certificate benefit provisions or any endorsement, amendment or rider.

Accident means an unintended or unforeseen bodily injury sustained by a covered person, wholly independent of disease, bodily infirmity, illness, infection, or any other abnormal physical condition.

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Blindness means clinically proven irreversible reduction of sight in both eyes that has persisted for a period of at least 180 consecutive days. Sight must be reduced to a corrected visual acuity of less than 6/60 (Metric Acuity) or 20/200 (Snellen or E-Chart Acuity), or visual field restriction to 20º or less in both eyes.

The following are not to be construed as blindness for purposes of this certificate:

• if, in general medical opinion, any procedure, device, or implant could result in the partial or total restoration of sight;

• if the covered person has not attained age three or above on the date of diagnosis, and

• if the covered person's reduction of sight, as defined above, occurs prior to the coverage effective date of the covered person's coverage under this certificate.

Cardiologist means a doctor who is licensed to practice medicine and who is also licensed to practice by the American Board of Internal Medicine in the subspecialty of cardiovascular disease.

Coma means a continuous state of profound unconsciousness resulting from a covered accident or a covered sickness, characterized by the absence of:

• eye opening,

• motor response, and

• verbal response.

The condition must require intubation for respiratory assistance. The term "coma" does not include any medically induced coma.

Coronary Artery Disease means a narrowing or blockage of one or more coronary arteries for which a cardiologist recommends that coronary artery bypass graft surgery occur within 60 days following the date of the recommendation.

Covered Accident means an accident which:

• occurs on or after the coverage effective date shown on the Certificate Schedule;

• occurs while this certificate is in force; and

• is not excluded by name or specific description in this certificate.

Covered Sickness means a sickness which:

• occurs on or after the coverage effective date shown on the Certificate Schedule;

• occurs while this certificate is in force; and

• is not excluded by name or specific description in this certificate.

Critical Illness means one of the specified illnesses listed in the Critical Illness Benefit section of the Certificate Schedule.

Date of Diagnosis

• for Heart Attack (Myocardial Infarction), the date that the ischemic death of a portion of the heart muscle (myocardium) occurred based on the applicable criteria listed under the heart attack (myocardial infarction) definition;

• for Stroke, the date a stroke occurred based on neuroimaging or other neurodiagnostic study consistent with an acute or subacute infarction, hemorrhage, embolism, thrombosis and presence of neurological deficits persisting for a period of 30 days or greater;

• for End Stage Renal (Kidney) Failure, the date that regular hemodialysis or peritoneal dialysis begins;

• for Major Organ Failure, the date that the covered person is placed on the UNOS list for transplantation;

• for Permanent Paralysis due to a Covered Accident, the date the doctor confirms the permanent paralysis due to a covered accident continued for a period of 180 consecutive days;

• for Coma, the date a doctor confirms a coma resulting from a covered accident or a covered sickness has lasted 7 or more consecutive days;

• for Blindness, the date the doctor confirms the irreversible reduction of sight has continued for a period of 180 consecutive days;

• for Occupational Infectious HIV or Occupational Infectious Hepatitis B, C or D, the date of a positive antibody test for HIV or

Hepatitis B, C or D subsequent to a prior negative test for the same condition with a lapse of between 90 and 180 days between the two tests; and

• for Coronary Artery Disease, the date the cardiologist recommends the covered person undergo coronary artery bypass graft surgery within the 60 days following the date of the recommendation.

End Stage Renal (Kidney) Failure means chronic irreversible failure of the function of both kidneys such that the covered person must undergo at least weekly hemodialysis or peritoneal dialysis.

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Heart Attack (Myocardial Infarction) means the ischemic death of a portion of heart muscle (myocardium) as a result of obstruction of one or more of the coronary arteries. A positive diagnosis of myocardial infarction must occur and must be supported by three or more of the following:

• chest pain;

• electrocardiographic (EKG) changes indicative of myocardial infarction; in the case of myocardial infarction associated with percutaneous coronary intervention (balloon angioplasty, stent implantation, and related procedures to increase the flow of blood through the coronary arteries), evolving ST elevations or new Q wave changes must be documented and included as one of the criteria in establishing a diagnosis;

• elevation of biochemical markers of myocardial necrosis; and

• confirmatory imaging studies.

In the event of death, an autopsy, medical examiner's confirmation or death certificate identifying heart attack (myocardial infarction) as the cause of death will be accepted.

A heart attack (myocardial infarction) is not congestive heart failure, atherosclerotic heart disease, angina, coronary artery disease, cardiac arrest (including arrhythmias), or any other disease, injury or dysfunction of the cardiovascular system.

Major Organ Failure means diagnosis of major organ failure of the heart, kidney, liver, lung, or pancreas resulting in the covered person being placed on the UNOS (United Network for Organ Sharing) list for a transplant.

Occupational Infectious HIV or Occupational Infectious Hepatitis B, C or D means diagnosis of Human Immunodeficiency Virus (HIV) infection or Hepatitis B, C or D resulting from exposure to HIV-contaminated or Hepatitis B, C or D contaminated body fluids as the result of a covered accident during the normal course of performing an occupation for which remuneration is earned.

We will pay this benefit if:

• within five days of the covered accident, it is reported and recorded by the appropriate person according to the legislation, regulations, standards or guidelines that apply to the covered person’s occupation or profession;

• the covered accident is investigated and a written investigation report is provided to us by the covered person's employer;

• a confirmatory antibody HIV or Hepatitis B, C or D test is taken within five days of the covered accident and HIV or

Hepatitis B, C or D is not present;

• all HIV or Hepatitis B, C or D tests are performed by a state certified and licensed laboratory; and

• a follow-up confirmatory antibody HIV or Hepatitis B, C or D test is taken between 90 days and 180 days after the covered accident, and the result is positive.

Occupational Infectious HIV or Occupational Infectious Hepatitis B, C or D excludes:

• HIV or Hepatitis B, C or D infection as the result of IV drug use;

• HIV or Hepatitis B, C or D infection as the result of sexual transmission; and

• HIV or Hepatitis B, C or D infection determined not to have been the result of a covered accident.

Permanent Paralysis Due to a Covered Accident means the complete and permanent loss of the use of two or more limbs through paralysis as the result of a covered accident as defined in this certificate for a continuous period of 180 days, as confirmed by a doctor. Loss of use of two or more limbs through paralysis as the result of a stroke will not be construed as permanent paralysis due to a covered accident for purposes of this certificate.

Sickness means an illness, infection, disease or any other abnormal physical condition not caused by an accident. Sickness includes complications of pregnancy.

Stroke means an acute or sub-acute cerebrovascular incident, including infarction of brain tissue, cerebral and subarachnoid hemorrhage, cerebral embolism and cerebral thrombosis. The diagnosis must be supported by:

• evidence of persistent neurological deficits confirmed by a neurologist at least 30 days after the event; and

• confirmatory neuroimaging studies consistent with the diagnosis of a new stroke.

The following are not to be construed as a stroke for purposes of this certificate:

• transient ischemic attack;

• brain injury related to trauma or infection;

• brain injury associated with hypoxia/anoxia or hypotension;

• vascular disease affecting the eye or optic nerve; and

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• ischemic disorders of the vestibular system.

In the event of death, an autopsy confirmation identifying stroke as the cause of death will be accepted.

SECTION 6 - DEFINITIONS FOR CANCER BENEFITS

Additional definitions may be contained in other certificate benefit provisions or any endorsement, amendment or rider.

Cancer (internal or invasive) means a disease that is identified by the presence of malignant cells or a malignant tumor characterized by the uncontrolled and abnormal growth and spread of invasive malignant cells.

The following are not to be construed as cancer (internal or invasive) for purposes of this certificate:

• pre-malignant conditions or conditions with malignant potential;

• carcinoma in situ;

• basal cell carcinoma and squamous cell carcinoma of the skin; and

• melanoma that is diagnosed as Clark's Level I or II or Breslow less than .75mm.

Carcinoma in Situ means cancer that is in the natural or normal place, confined to the site of origin without having invaded neighboring tissue. Skin cancer will not be considered carcinoma in situ for purposes of this certificate.

Date of Diagnosis for Cancer (internal or invasive) or Carcinoma in Situ means the date the tissue specimen, blood samples or titer(s) are taken upon which the diagnosis of cancer (internal or invasive) or carcinoma in situ is based.

Pathologist means a doctor who is licensed to practice medicine and who is also licensed to practice pathologic anatomy by the American Board of Pathology. A pathologist also means an Osteopathic Pathologist who is certified by the Osteopathic Board of Pathology.

Skin Cancer means melanoma of Clark's Level I or II (Breslow less than .75mm); basal cell carcinoma; or squamous cell carcinoma of the skin.

SECTION 7 - ELIGIBILITY AND EFFECTIVE DATE

Coverage Effective Date Your coverage under the policy will start at 12:01 a.m. Standard Time in the time zone where you live on the coverage effective date shown on your Certificate Schedule.

Enrollment An individual who is a member of an eligible class may enroll in coverage during the eligibility period, as shown on the Policy Rate Schedule, that follows the later of:

• the policy effective date as shown on the Policy Rate Schedule;

• the date the individual first becomes a member of an eligible class;

• the date the individual completes the policyholder probationary period shown on the application of the policyholder, if applicable;

• the date the individual meets evidence of insurability requirements, if any.

An individual who fails to enroll during the eligibility period may enroll only during an open enrollment period. Evidence of insurability may be required. The policyholder and the company will determine when an open enrollment period begins and ends.

After the coverage effective date, the named insured cannot make any changes to the coverage type under the certificate until an open enrollment period, unless the named insured has a qualifying event. A qualifying event, for the purposes of this provision, means:

• birth or adoption of a child;

• issuance of a court order requiring coverage of a child;

• marriage;

• divorce; or

• death of a covered person.

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The named insured will have 31 days from the date of occurrence of a qualifying event in which to:

• notify us he wishes to make a change;

• complete any required enrollment form; and

• pay any additional premium, if applicable.

Delayed Coverage Effective Date The effective date of your coverage will be delayed if you are not a member of an eligible class on the coverage effective date shown on the Certificate Schedule. The coverage will be effective on the date that you return to status as a member of an eligible class. If this is named insured and spouse coverage, one-parent family or two-parent family coverage, coverage on the spouse and/or dependent children will be effective on the date that you return to status as a member of an eligible class.

Who is Covered By This Certificate If this is named insured coverage as shown on the Certificate Schedule, we insure you, the named insured.

If this is named insured and spouse coverage as shown on the Certificate Schedule, we insure you and your spouse.

If this is one-parent family coverage as shown on the Certificate Schedule, we insure you and your dependent children.

If this is two-parent family coverage as shown on the Certificate Schedule, we insure you, your spouse and your dependent children.

You may not apply for coverage for your spouse if your spouse is covered as a named insured.

Coverage on newborn children begins from the moment of live birth. Coverage for adopted children begins with the date of placement into your custody for adoption or the date you filed a suit seeking adoption of the children. If the coverage is named insured coverage or named insured and spouse coverage, the coverage on the newborn or newly adopted child will end 31 days later if you do not request a change in coverage type as provided in the Enrollment provision above.

SECTION 8 - BENEFIT FOR CRITICAL ILLNESS

Critical Illness Benefit We will pay this benefit if a covered person is diagnosed with a critical illness, as defined in this Certificate, and:

• the date of diagnosis is while this certificate is in force; and

• the critical illness is not excluded by name or specific description in this certificate.

We will pay the percentage of the covered person's face amount shown on the Certificate Schedule for the critical illness diagnosed.

We will pay the benefit for Coronary Artery Disease only once per lifetime per covered person.

If, on the same day, a covered person is placed on the UNOS list for a transplant of two or more major organs listed above in the definition of major organ failure (example: heart and lungs), a single benefit will be paid.

We will pay the benefit for Occupational Infectious HIV or Occupational Infectious Hepatitis B, C or D only once per lifetime per covered person.

If the date of diagnosis of two or more critical illnesses is the same day, we will pay only one critical illness benefit. We will pay the larger of the critical illness benefit.

The Critical Illness Benefit is not payable for conditions other than the critical illnesses defined in this certificate.

Benefit Payable Upon Subsequent Diagnosis of a Critical Illness If a covered person has been diagnosed with and received a benefit for a critical illness and is subsequently diagnosed with a different critical illness, we will pay the percentage of the covered person's face amount as shown on the Certificate Schedule for the critical illness diagnosed, if:

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• the date of diagnosis of the subsequent critical illness is more than 180 days after any previous date of diagnosis for a critical illness;

• the subsequent date of diagnosis is while coverage under this certificate is in force; and

• the critical illness is not excluded by name or specific description in this certificate.

If a covered person has been diagnosed with and received a benefit for a critical illness and is subsequently diagnosed with the same critical illness (other than Coronary Artery Disease and Occupational Infectious HIV or Occupational Infectious Hepatitis B, C or D), we will pay an amount equal to 25 percent of the Face Amount for the covered person as shown on the Certificate Schedule, if:

• the date of diagnosis of the subsequent critical illness is more than 180 days after any previous date of diagnosis for the same critical illness;

• the covered person has not received treatment during the 180 days between the dates of diagnosis for the same critical illness.

For purposes of the preceding sentence, treatment does not include medications and follow-up visits to the covered person's doctor;

• the subsequent date of diagnosis is while coverage under this certificate is in force; and

• the critical illness is not excluded by name or specific description in this certificate.

Benefit Reduction The Face Amount(s) will reduce by 50 percent on the first policy anniversary date after the named insured attains age 75. All critical illness benefits payable after that date will be based on the reduced Face Amount.

SECTION 9 - BENEFITS FOR CANCER

Diagnosis of Cancer Benefit We will pay this benefit when you are diagnosed as having cancer (internal or invasive) if:

• the date of diagnosis is while this certificate is in force;

• for a cancer (internal or invasive) diagnosed during the 12 months following the coverage effective date, the cancer (internal or invasive) is not a pre-existing condition; and

• the cancer (internal or invasive) is not excluded by name or specific description in the certificate.

We will pay the percentage of the covered person's face amount shown on the Certificate Schedule. We will pay no more than the Maximum Benefit Amount for the Diagnosis of Cancer shown on the Certificate Schedule per covered person per lifetime.

We will not pay the Diagnosis of Cancer Benefit for any cancer (internal or invasive) diagnosed during the 12 months following the coverage effective date if the cancer (internal or invasive) is a pre-existing condition.

Cancer (internal or invasive) must be diagnosed in one of two ways:

1. Pathological Diagnosis A pathological diagnosis of cancer (internal or invasive) is based on a microscopic study of fixed tissue or preparations from the hemic (blood) system. This type of diagnosis must be done by a pathologist whose diagnosis of malignancy is in keeping with the standards established by the American Board of Pathology. A pathological diagnosis of cancer (internal or invasive) can be made before or after death.

2. Clinical Diagnosis A clinical diagnosis of cancer (internal or invasive) is based on the study of symptoms. We will pay benefits for a clinical diagnosis only if:

• a pathological diagnosis cannot be made because it is medically inappropriate or life-threatening;

• there is medical evidence to support the diagnosis; and

• a doctor is treating the covered person for cancer (internal or invasive).

In addition to the pathological or clinical diagnosis required, we may require additional information from the attending doctor and hospital.

If a covered person has been diagnosed with and received a benefit for carcinoma in situ and is subsequently diagnosed with cancer (internal or invasive), we will pay the Diagnosis of Cancer Benefit for the covered person as shown on the Certificate

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Schedule, up to the Maximum Benefit Amount for a Diagnosis of Cancer Benefit and subject to the provisions of this certificate, if the date of diagnosis of the cancer (internal or invasive) is more than 180 days after the date of diagnosis for the carcinoma in situ.

Diagnosis of Carcinoma In Situ Benefit We will pay this benefit when you are diagnosed as having carcinoma in situ, if:

• the date of diagnosis is while this certificate is in force;

• for a carcinoma in situ diagnosed during the 12 months following the coverage effective date, the carcinoma in situ is not a pre-existing condition; and

• the carcinoma in situ is not excluded by name or specific description in the certificate.

We will pay the percentage of the covered person's face amount shown on the Certificate Schedule. We will pay no more than the Maximum Benefit Amount for the Diagnosis of Carcinoma In Situ shown on the Certificate Schedule per covered person per lifetime.

We will not pay the Diagnosis of Carcinoma In Situ Benefit for any carcinoma in situ diagnosed during the 12 months following the coverage effective date if the carcinoma in situ is a pre-existing condition.

Carcinoma in situ must be diagnosed in one of two ways:

1. Pathological Diagnosis A pathological diagnosis of carcinoma in situ is based on a microscopic study of fixed tissue or preparations from the hemic (blood) system. This type of diagnosis must be done by a pathologist whose diagnosis of malignancy is in keeping with the standards established by the American Board of Pathology. A pathological diagnosis of carcinoma in situ can be made before or after death.

2. Clinical Diagnosis A clinical diagnosis of carcinoma in situ is based on the study of symptoms. We will pay benefits for a clinical diagnosis only if:

• a pathological diagnosis cannot be made because it is medically inappropriate or life-threatening;

• there is medical evidence to support the diagnosis; and

• a doctor is treating the covered person for carcinoma in situ.

In addition to the pathological or clinical diagnosis required, we may require additional information from the attending doctor and hospital.

If a covered person has been diagnosed with and received a benefit for cancer (internal or invasive) and is subsequently diagnosed with carcinoma in situ, we will pay the Diagnosis of Carcinoma In Situ Benefit for the covered person as shown on the Certificate Schedule, up to the Maximum Benefit Amount for a Diagnosis of Carcinoma In Situ Benefit and subject to the provisions of this certificate, if the date of diagnosis of the carcinoma in situ is more than 180 days after the date of diagnosis for the cancer (internal or invasive).

Skin Cancer Benefit We will pay this benefit if a covered person is diagnosed with skin cancer if:

• the date of diagnosis is while this certificate is in force;

• for a skin cancer diagnosed during the 12 months following the coverage effective date, the skin cancer is not a pre-existing condition; and

• the skin cancer is not excluded by name or specific description in this certificate.

We will pay the amount shown on the Certificate Schedule.

We will pay this benefit only once per covered person per lifetime.

Cancer Vaccine Benefit We will pay this benefit if a covered person incurs a charge for and receives any cancer vaccine that is FDA approved for the prevention of cancer. The vaccine must be administered by licensed medical personnel while coverage under this certificate is in force. We will pay the amount shown on the Certificate Schedule. This benefit is limited to one payment per covered person, per lifetime.

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Benefit Reduction The Face Amount(s) and the Maximum Benefit Amount for a Diagnosis of Cancer Benefit and the Maximum Benefit Amount for a Diagnosis of Carcinoma In Situ will reduce by 50% on the policy anniversary date after the named insured attains age 75. All Diagnosis of Cancer Benefits and Diagnosis of Carcinoma In Situ Benefits payable after that date will be based on the reduced Face Amount and the reduced Maximum Benefit Amount.

SECTION 10 - EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS

We will not pay benefits for a critical illness that occurs as a result of a covered person's:

Felonies or Illegal Occupations Committing or attempting to commit a felony or engaging in an illegal occupation.

Intoxicants and Narcotics Being intoxicated or under the influence of any narcotic unless administered on the advice of his doctor.

Psychiatric or Psychological Conditions Having a psychiatric or psychological condition, including but not limited to affective disorders, neuroses, anxiety, stress and adjustment reactions. However, Alzheimer's Disease and other organic senile dementias are covered under this certificate.

Suicide or Injuries Which Any Covered Person Intentionally Does to Himself Committing or trying to commit suicide or his injuring himself intentionally, whether he is sane or not.

War or Armed Conflict Being exposed to war or any act of war, declared or undeclared, or serving in the armed forces of any country or authority. Losses as a result of acts of terrorism or nuclear release committed by individuals or groups will not be excluded from coverage unless the covered person who suffered the loss committed the act of terrorism or nuclear release.

Pre-Existing Condition Limitation We will not pay the Critical Illness Benefit or Benefits Payable Upon Subsequent Diagnosis of a Critical Illness for any covered person when the critical illness is a pre-existing condition as defined in this certificate, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a critical illness.

SECTION 11 - EXCLUSIONS AND LIMITATIONS FOR CANCER

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