22-D6 - GMB G0061709 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

*2LN1G00617090000062*

GMB7000-P-EE-TX 1 81000

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

GROUP HOSPITAL INDEMNITY INSURANCE POLICY

THIS POLICY PROVIDES LIMITED BENEFITS. BENEFITS PROVIDED ARE A

SUPPLEMENT TO MAJOR MEDICAL COVERAGE AND ARE NOT A SUBSTITUTE

FOR MAJOR MEDICAL COVERAGE OR OTHER MINIMAL ESSENTIAL COVERAGE

AS IS REQUIRED BY FEDERAL LAW. LACK OF MINIMAL ESSENTIAL COVERAGE

MAY RESULT IN ADDITIONAL TAX PAYMENT BEING DUE.

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 refer 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. Benefit details are shown in the certificate.

Right to Return This Policy If, for any reason, you are not satisfied with this policy, you can return it to us at our home office within 30 days after you receive it.

At that time, you should ask us in writing to cancel it. We will consider this policy as if it never existed. Any premium paid will be refunded.

Signed for Colonial Life & Accident Insurance Company:

Secretary President and Chief Executive Officer

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.

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

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SECTION 3 - POLICY RATE SCHEDULE

Policyholder: City Of Burleson Policy Number: G0061709

Policyholder Address: 141 W Renfro Street Billing Control Number: E5698931

Burleson, TX 76028-0000

Policy Effective Date: 01/01/2022 Governing Jurisdiction: Texas

Description of Eligible Classes All employees in active employment working a minimum of 30 hours per week. An Employee is a person in active employment with the policyholder. 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.

New Hire Waiting Period: 30 days

New Hire Eligibility Period: 180 days

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

Initial Monthly Rates:

Named Insured Named Insured and Spouse $ 30.47 $ 66.94

Named Insured and Dependents Named Insured, Spouse and Dependents $ 42.30 $ 78.77

Rate Guarantee Period: A change in the initial monthly rates will not take effect before two years after the Policy Effective Date.

Divisions, subsidiaries or affiliated companies include:

City Of Burleson Burleson, TX

GMB7000-P-EE-TX 5 81000

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 form, 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 this 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 this policy;

• to whom benefits are payable;

• the limitations, exclusions and requirements that apply to coverage under this 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 will 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 the initial monthly rates 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 rates at any time. A change may take effect on an earlier date when both we and the policyholder agree in writing.

New Hires Members of an eligible class, as described on the Policy Rate Schedule, will become insured when they satisfy the requirements set forth in the certificate.

Late Entrants Members of an eligible class, as described on the Policy Rate Schedule, who do not enroll during their initial eligibility period and choose to enroll at a later date.

GMB7000-P-EE-TX 6 81000

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.

In the absence of fraud, a statement made by the policyholder or the insured is considered a representation and not a warranty. A statement made by the policyholder or the insured may not be used in any contest under the policy, unless a copy of the written instrument containing the statement is or has been provided to:

• the person making the statement; or

• if the statement was made by the insured and the insured has died or become incapacitated, the insured’s beneficiary or personal representative.

Clerical Error or Omission 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 monthly rates 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 on or before the due date.

The premium due dates are based on:

• the coverage effective dates shown on the Certificate Schedule; 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 this policy was in force as to any covered person.

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.

GMB7000-P-EE-TX 7 81000

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. The policyholder must pay all premiums due for the full period each certificate is in force.

Except for nonpayment of the required premium or the failure to meet continued underwriting standards, we may not cancel this 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 and the policyholder both agree. Coverage will end at 12:00 midnight Standard Time at the policyholder’s address on the cancellation date.

If this 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.

43975-7 43975-7

Have a complaint or need help?

If you have a problem with a claim or your premium, call your insurance company or HMO first. If you can’t work out the issue, the Texas Department of Insurance may be able to help.

Even if you file a complaint with the Texas Department of Insurance, you should also file a complaint or appeal through your insurance company or HMO. If you don’t, you may lose your right of appeal.

Colonial Life & Accident Insurance Company To file a complaint through your insurance company or HMO:

Call: Customer Relations Toll-Free: 800-321-3889; Option 2 Email: custrel@unum.com Mail: 2211 Congress Street

Portland, Maine 04122

The Texas Department of Insurance To get help with an insurance question or file a complaint with the state:

Call with a question: 1-800-252-3439 File a complaint: www.tdi.texas.gov Email: ConsumerProtection@tdi.texas.gov Mail: MC 111-1A

P.O. Box 149091 Austin, TX 78714-9091

¿Tiene una queja o necesita ayuda?

Si tiene un problema con una reclamacíon o con su prima de seguro, llame primero a su compañía de seguros o HMO. Si no puede resolver el problema, es posible que el Departamento de Seguros de Texas (Texas Department of Insurance, por su nombre en inglés) pueda ayudar.

Aun si usted presenta una queja ante el Departamento de Seguros de Texas, también debe presentar un queja a través del proceso de quejas o de apelaciones de su compañía de seguros o HMO. Si no lo hace, podria perder su derecho para apelar.

Colonial Life & Accident Insurance Company Para presenter una queja a través de su compañia de seguros o HMO:

Llamada: Relaciones con el cliente Teléfono gratuita: 800-321-3889; Opción 2 Correo electrónico: custrel@unum.com Dirección postal: 2211 Congress Street

Portland, Maine 04122

El Departamento de Seguros de Texas Para obtener ayuda con una pregunta relacionada con los seguros o para presenter una queja ante el estado:

Llame con sus preguntas al: 1-800-252-3439 Presente una queja en: www.tdi.texas.gov Correo electrónico: ConsumerProtection@tdi.texas.gov Dirección postal: MC 111-1A

P.O. Box 149091 Austin, TX 78714-9091

GMB7000-C-EE-TX 1 81002

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

1.800.325.4368 coloniallife.com A Stock Company

GROUP HOSPITAL INDEMNITY INSURANCE CERTIFICATE

THIS CERTIFICATE EXPLAINS THE BENEFITS PROVIDED UNDER THE GROUP HOSPITAL INDEMNITY INSURANCE

POLICY.

THIS CERTIFICATE PROVIDES LIMITED BENEFITS. BENEFITS PROVIDED ARE

A SUPPLEMENT TO MAJOR MEDICAL COVERAGE AND ARE NOT A

SUBSTITUTE FOR MAJOR MEDICAL COVERAGE OR OTHER MINIMAL

ESSENTIAL COVERAGE AS IS REQUIRED BY FEDERAL LAW. LACK OF

MINIMAL ESSENTIAL COVERAGE MAY RESULT IN ADDITIONAL TAX PAYMENT

BEING DUE.

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. Any provision of this Certificate of Coverage that is in conflict with the applicable state laws of the state in which you reside when you become insured is amended to conform to the minimum requirements of those laws.

Right to Return This Certificate If, for any reason, you are not satisfied with this certificate, you can return it to us at our home office within 30 days after you receive it. At that time, you should ask us in writing to cancel it. We will consider this certificate as if it never existed . Any premium paid will be refunded.

Signed for Colonial Life & Accident Insurance Company:

Secretary President and Chief Executive Officer

THE GROUP POLICY IS A LIMITED POLICY. 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.

http://www.coloniallife.com

SECTION 2 - CERTIFICATE GUIDE

SECTION 1 - FACE PAGE

SECTION 2 - CERTIFICATE GUIDE

SECTION 3 - CERTIFICATE SCHEDULE

SECTION 4 - GENERAL DEFINITIONS

SECTION 5 - ELIGIBILITY AND EFFECTIVE DATE

SECTION 6 - BENEFITS

SECTION 7 - GENERAL EXCLUSIONS AND LIMITATIONS

SECTION 8 - TERMINATION OF INSURANCE

SECTION 9 - GENERAL PROVISIONS

SECTION 10 - CLAIM PROVISIONS

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SECTION 3 - CERTIFICATE SCHEDULE

Policyholder: City Of Burleson Certificate Number: 9999999999

Named Insured: John A. Doe Billing Control Number: E5698931

Coverage Effective Date:

January 1, 2022

Coverage Type Two-Parent Family

BENEFITS

Hospital Confinement $2,000 per day Maximum of one day per covered person per calendar year

Waiver of Premium Available after 30 continuous days of a covered confinement of the named insured

Daily Hospital Confinement $100 per day Maximum of 365 days per covered person per confinement

Observation Room $100 per day Maximum of two days per covered person per calendar year

Rehabilitation Unit Confinement $100 per day Maximum of 15 days per confinement with a 30 day maximum per covered person per calendar year

PRE-EXISTING CONDITION LIMITATION PERIOD

Named Insured, Spouse and Dependent Children 12 months

GMB7000-C-EE-TX 5 81002

SECTION 4 - GENERAL DEFINITIONS

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

Accident means a bodily injury sustained by a covered person which is the direct cause of the loss, wholly independent of disease, bodily infirmity, or other cause and which occurs while the policy is in force.

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.

Certificate means a document that provides a description of the insurance provided by the policy and states:

• 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.

Complications of Pregnancy means that part of your pregnancy during which abnormal conditions or concurrent disease significantly affect the pregnancy's usual medical management. A complication may exist during the pregnancy, during the delivery, or after the delivery.

Confined or Confinement means the assignment to a bed as a resident inpatient in a hospital on the advice of a physician or, for the purposes of the Hospital Confinement and Daily Hospital Confinement benefit(s) only, confinement in an observation unit within a hospital for a period of no less than 20 continuous hours on the advice of a physician.

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.

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.

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:

• unmarried and;

• younger than age 26.

Emergency Room means a specified area within a hospital which is designated for the emergency care of accidental injuries or sicknesses. This area must:

• be staffed and equipped to handle trauma;

• be supervised and provide treatment by physicians; and

• provide care seven days per week, 24 hours per day.

As used in this certificate, the term emergency room does not include urgent care facilities.

Enrollment Period means a period of time determined by us and the policyholder during which you are eligible to enroll for or change your coverage. This period of time may be limited.

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

GMB7000-C-EE-TX 6 81002

Hospital means a place that:

• is an institution licensed as a hospital and operating pursuant to law on a full-time basis;

• provides overnight care of injured and sick people;

• is supervised by a physician;

• has full-time nurses supervised by a registered nurse; and

• has at its locations or uses on a pre-arranged basis: X-ray equipment, a laboratory and an operating room where surgical operations take place.

Notwithstanding the above, a hospital is not:

• a nursing home;

• an extended care facility;

• a skilled nursing facility;

• a rest home or home for the aged;

• a standalone rehabilitation center;

• a hospice care facility;

• a facility for alcoholics or drug addicts; or

• an assisted living facility.

Observation Room means a specified area within a hospital, apart from the emergency room, where a patient can be monitored by a physician; and which:

• is under the direct supervision of a physician or registered nurse;

• is staffed by nurses assigned specifically to that unit; and

• provides care seven days per week, 24 hours per day.

Physician or Doctor 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, Physician or Doctor 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.

Pre-existing Condition means a sickness or physical condition, whether diagnosed or not, 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.

Rehabilitation Unit means an appropriately licensed facility that provides rehabilitation care services on an inpatient basis.

Rehabilitation care services consist of the combined use of medical, social, educational, and vocational services to enable patients disabled by sickness or accidental injury to achieve the highest possible functional ability. Services are provided by or under the supervision of an organized staff of physicians. The rehabilitation unit may be part of a hospital or a freestanding facility.

A rehabilitation unit is not:

• a nursing home;

• an extended care facility;

• a skilled nursing facility;

• a rest home or home for the aged;

• a hospice care facility;

• a facility for alcoholics or drug addicts; or

• an assisted living facility.

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

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 - 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.

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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.

A late entrant is an individual who fails to enroll during the eligibility period and 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 this 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.

A child is considered to be the dependent child of a named insured if the named insured is party to a suit in which the named insured seeks to adopt the child.

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 under other coverage.

Coverage on newborn children begins from the moment of live birth and extends 31 days. You must notify us of the birth of the newborn child and pay the additional premium required, if any, to maintain the coverage in force. 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 you must notify us of the birth of the newborn child or newly adopted child and pay the additional premium required, if any for one-parent family coverage or two-parent family coverage.

Coverage of a child who is the subject of a medical support order shall be automatically covered for the first 31 days after receipt of a medical support order.

SECTION 6 - BENEFITS

Hospital Confinement We will pay this benefit if any covered person incurs charges for and is confined to a hospital due to a covered accident or covered sickness. The confinement to a hospital must begin while the coverage is in force.

We will pay the amount shown on the Certificate Schedule.

We will pay this benefit a maximum of one day per covered person per calendar year.

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We will not pay this benefit for emergency room treatment, outpatient treatment, or confinement of less than 20 hours in an observation room.

We will not pay the Hospital Confinement benefit and any of the following benefit(s) for the same dates of service:

• Observation Room

• Rehabilitation Unit Confinement

Waiver of Premium After you have been confined to a hospital or rehabilitation unit due to a covered accident or covered sickness for more than 30 continuous days while the policy and certificate are in force, and you received the Hospital Confinement benefit and any of the following benefits:

• Daily Hospital Confinement

• Rehabilitation Unit Confinement• , we will waive the premium for this certificate and any attached riders for as long as you are continuously confined, or up to 12 months, whichever occurs first.

This benefit does not apply to your spouse or your dependent children. We will waive premiums only if you, the named insured, are confined for more than 30 continuous days. However, if this is named insured and spouse coverage, one-parent family coverage, or two-parent family coverage, we will waive premiums on all family members insured by the certificate.

You must pay all premiums to keep this certificate and any attached rider(s) in force until you have been confined for more than 30 continuous days and the waiver of premium becomes effective.

Before we waive your premiums, you must send us a written notice prepared by your physician stating:

• the dates you were confined; and

• that you were confined due to a covered accident or covered sickness.

After we verify that you were confined, as defined in this certificate, for more than 30 continuous days, we will not require you to pay premiums for the length of time you continue to be confined due to a covered accident or covered sickness.

You must send us written notice as soon as you are no longer confined. We will assume you are no longer confined if:

• you do not send us satisfactory proof of loss when we request it; or

• you notify us that you are no longer confined.

You must pay all premiums to keep this certificate and any attached rider(s) in force beginning with the first premium due after you are no longer confined.

If we waive premiums during a confinement, and you become confined again within 90 days because of the same covered accident or covered sickness, we will treat these confinements as the same confinement. You will not be required to meet another 30-day waiting period to qualify for waiver of premium.

If more than 90 days have passed between the periods of confinement, we will treat the second confinement as a new confinement.

You must be confined for another 30 continuous days and receive a Hospital Confinement:

• or Daily Hospital Confinement

• or Rehabilitation Unit Confinement benefit before waiver of premium is applicable for a new confinement.

The Waiver of Premium benefit does not apply to any period that you are confined due to an accident, sickness or condition which is excluded by name or specific description.

Daily Hospital Confinement We will pay this benefit if any covered person incurs charges for and is confined to a hospital due to a covered accident or covered sickness. The confinement to a hospital must begin while this certificate is in force.

We will pay the Daily Hospital Confinement benefit in the amount shown on the Certificate Schedule for each day the covered person is confined to a hospital, up to the maximum benefit period shown on the Certificate Schedule. We will not pay this benefit for emergency room treatment, outpatient treatment, or confinement of less than 20 continuous hours in an observation unit within a hospital.

If a covered person is confined and is discharged and confined again for the same or related condition within 90 days of discharge, we will treat this later confinement as a continuation of the previous confinement. If more than 90 days have passed between the periods of hospital confinement, we will treat this later confinement as a new and separate confinement.

We will not pay the Daily Hospital Confinement benefit and any of the following benefit(s) for the same dates of service:

• Observation Room

• Rehabilitation Unit Confinement

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Observation Room We will pay this benefit if any covered person incurs charges for and receives treatment in an Observation Room in a hospital due to a covered accident or covered sickness, for a period of less than 20 hours while this certificate is in force. We will pay the amount shown up to the maximum number of days shown on the Certificate Schedule.

We will not pay the Observation Room benefit and any of the following benefit(s) for the same dates of service:

• Hospital Confinement

• Daily Hospital Confinement

This benefit is not payable for treatment received in an emergency room or confinement to an observation room following an outpatient surgical procedure.

Rehabilitation Unit Confinement We will pay this benefit if any covered person incurs charges for and is transferred to a rehabilitation unit immediately after a period of confinement due to a covered accident or covered sickness. We will pay the amount shown on the Certificate Schedule for each day of confinement in a rehabilitation unit, up to the maximum number of days shown on the Certificate Schedule.

We will not pay the Rehabilitation Unit Confinement benefit and any of the following benefit(s) for the same dates of service:

• Hospital Confinement

• Daily Hospital Confinement

SECTION 7 - GENERAL EXCLUSIONS AND LIMITATIONS

We will not pay any benefits for injuries received in accidents or for sicknesses which are caused by, contributed to by or occurs as a result of the covered person's:

Dental Procedures - Treatment for dental care or dental procedures, unless treatment is the result of a covered accident.

Elective Procedures and Cosmetic Surgery - Undergoing elective procedures or cosmetic surgery. This includes procedures or hospital confinement for complications arising from elective or cosmetic surgery. This does not include congenital birth defects or anomalies of a child; or reconstructive surgery related to a covered sickness or injuries received in a covered accident.

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

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

Mental or Nervous Disorders - Having a disorder including but not limited to affective disorders, neurosis, anxiety, stress and adjustment reactions. Alzheimer's Disease and other organic senile dementias are not considered mental or nervous disorders.

Pregnancy of a Dependent Child - Dependent child’s pregnancy, including services rendered to her child after birth.

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 - 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.

Birth Limitation - We will not pay benefits for Hospital Confinement or Daily Hospital Confinement due to any covered person giving birth within the first nine (9) months after the coverage effective date of this certificate as a result of a normal pregnancy, including Cesarean. Complications of pregnancy will be covered to the same extent as any other covered sickness.

Pre-existing Condition Limitation - We will not pay benefits for Hospital Confinement or any of the following benefit(s) for any covered person when such loss results from 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:

• Rehabilitation Unit Confinement

• Daily Hospital Confinement

Well Baby Care Limitation - We will not pay benefits for Hospital Confinement or Daily Hospital Confinement of a newborn child following his birth unless he is injured or sick.

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SECTION 8 - TERMINATION OF INSURANCE

Termination of the Named Insured’s Coverage The coverage on a named insured under the policy will terminate on the earliest of the following dates:

• the date the policy terminates; or

• the end of the grace period following the premium due date we fail to receive the required premium for the named insured; or

• the date the named insured is no longer in an eligible class; or

• the date the named insured’s class is no longer included for insurance; or

• the date the next premium is due after the named insured asks us to end his coverage.

Extension of Benefits Termination of coverage will not affect any claim that began while the coverage was in force, subject to our right to withhold premium from claim payments as described in the Unpaid Premium provision.

When Coverage Ends on Your Spouse and Dependent Children If this is a named insured and spouse coverage or two-parent family coverage, coverage on your spouse will end on the earliest of the following dates:

• the date your coverage under the policy terminates; or

• the end of the grace period following the premium due date we fail to receive the required premium for your spouse; or

• the date the next premium is due after you ask us to end your spouse’s coverage; or

• the date you die; or

• the date the next premium is due after you divorce your spouse or your marriage is annulled. If this is a named insured and spouse coverage, one-parent family coverage or two-parent family coverage and you divorce your spouse or your marriage is annulled and you do not notify us, the extent of our liability will be to refund premium paid for the time period for which he did not qualify.

If this is a one-parent family or two-parent family coverage, coverage on your dependent children will end on the earliest of the following dates:

• the date your coverage under the policy terminates; or

• the end of the grace period following the premium due date we fail to receive the required premium for your dependent children;

or

• the date the next premium is due after you ask us to end your dependent children’s coverage; or

• the date you die; or

• the date they no longer meet the definition of dependent children shown in the General Definitions section of this certificate.

We will provide coverage for a claim for which we are liable under the terms of this certificate if the loss occurs while your spouse and/or dependent child is covered.

A dependent child who reaches age 26 may remain covered if that child is and continues to be intellectually or physically disabled and is dependent on you for support and maintenance. You must submit satisfactory proof of incapacity and dependency to us within 31 days of the termination date and subsequently as we may require, but not more frequently than annually after the two-year period following the termination date. We will continue to charge any appropriate premium for that child as long as he meets the definition of a dependent child. It is your responsibility to notify us if any dependent child no longer qualifies as an eligible dependent. If this is one-parent family or two-parent family coverage and all of your dependent children no longer qualify as eligible dependents and you do not notify us, the extent of our liability will be to refund premium paid for the time period for which they did not qualify.

Leave of Absence Under the Family and Medical Leave Act A named insured may continue his coverage during absences for family or medical leave. If a named insured is on a family or medical leave of absence, coverage will continue under this certificate as if the named insured were in active employment, if the following conditions are met:

• the premiums are paid in accordance with the policy’s provisions; and

• the policyholder has approved the named insured’s leave in writing.

Coverage will be continued for up to the greater of:

• the leave period required by the federal Family and Medical Leave Act of 1993, and any amendments; or

• the leave period required by applicable state law.

If coverage is not continued during a family or medical leave of absence, upon the named insured’s return to active employment:

• no new waiting periods will be applied;

• no new pre-existing condition limitation will be applied; and

• no new evidence of insurability will be required to reinstate the coverage which was in effect before the leave began.

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In order for these conditions to apply, the policyholder must notify us and commence paying premiums for the named insured’s coverage within 31 days following a named insured’s return to active employment following a leave of absence for family or medical leave.

The time period in the pre-existing condition limitation period will continue to run through a named insured’s family or medical leave of absence.

Leave of Absence - Other If the named insured is on a temporary layoff or leave of absence other than for family or medical leave and premium is paid in accordance with the policy’s provisions, he will be covered through the premium due date immediately following the date the temporary layoff or leave of absence begins.

If premium is remitted beyond the premium due date referenced above, our only liability will be to return the premium.

SECTION 9 - GENERAL PROVISIONS

Coverage Provided by the Policy We insure a covered person for loss according to the provisions of the policy.

Misstatement of Age If the age of the named insured has been misstated, we will make any equitable adjustment of premiums. We will refund any excess premium payment over the amount due based on your correct age. We will request payment for any overdue premium based on your correct age. If the misstatement is discovered after a payment is due and payable, we will reduce or increase the benefit amount payable by the amount of excess or overdue premium due to the misstatement. If a named insured is not eligible because of age we will refund all premiums paid.

Contestability No statement made by any named insured relating to his insurability or the insurability of his dependents shall be used to contest the validity of the insurance after the insurance has been in force prior to the contest for a period of two years during the lifetime of the person about whom the statement was made and unless the statement is contained in a written instrument signed by the named insured making the statement, unless the statement was fraudulent.

Contest means that we question the validity of coverage under the policy through a letter to the policyholder or the named insured.

This contest is effective on the date we mail the letter and refund premiums.

All statements made by the policyholder or any named insured shall be deemed representations and not warranties. No written statement made by the policyholder or any named insured shall be used in any contest unless a copy of the statement is furnished to:

• the person making the statement; or

• if the statement was made by a named insured and the named insured has died or become incapacitated, the named insured’s beneficiary or personal representative

Policyholder as Agent For purposes of the policy and this certificate, the policyholder acts on its own behalf or as your agent. Under no circumstances will the policyholder be deemed our agent.

SECTION 10 - CLAIM PROVISIONS

Notice of Claim If a covered person has an injury or sickness that may result in a claim for benefits under the policy, written notice must be given to us at our home office. This must be done within 90 days after a covered loss begins. If notice cannot be given within that time, it must be given as soon as is reasonably possible. The notice must contain enough information to identify the covered person.

Claim Forms When we receive written or verbal notice of a claim, claim forms will be sent with which to file Proof of Loss. If these forms are not given to you within 15 days, you will be excused from filing the forms as long as you send us Proof of Loss as described below.

Proof of Loss We must receive a written proof of loss before the 91st day after the covered loss begins. If you are not able to give us written proof of loss before the 91st day, it will not have a bearing on this claim if proof is given to us as soon as it is reasonably possible. In any event, proof must be given no later than one year from the time stated unless you are legally unable to do so.

Written proof of loss must include one or more of the following: a physician’s bill, a hospital bill or other proof of charges.

Time of Payment of Claim After we receive written proof of loss and process your claim, we will pay any benefits due within 60 days.

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If any person covered under this policy is receiving financial and medical benefits through the Texas Department of Human Services, benefits payable for such person under this policy will be paid to the Texas Department of Human Services whenever:

• The Texas Department of Human Services is paying benefits pursuant to Chapters 31 and 32 of the Human Resources Code, i.e., financial and medical assistance service programs administered pursuant to the Human Resources Code; and

• We are notified at the time of claim that the covered person is receiving financial and medical assistance.

Payment of Claim Benefits will…