23-D8 - Group Critical Care Plan Documents Combined.pdf

Group Critical Illness Insurance Plan 2 Full

For the diagnosis of this covered critical illness condition:1 This percentage of the face amount is payable:

Heart attack (myocardial infarction) 100%

Stroke 100%

End-stage renal (kidney) failure 100%

Major organ failure 100%

Coma 100%

Permanent paralysis due to a covered accident 100%

Blindness 100%

Occupational infectious HIV or occupational infectious hepatitis B, C or D 100%

Coronary artery bypass graft surgery/disease2 25%

GROUP CRITICAL CARE PLAN 2 FULL

Subsequent diagnosis of a different critical illness3

If you receive a benefit for a critical illness, and later you are diagnosed with a different critical illness, the original percentage of the face amount is payable for that particular critical illness.

Subsequent diagnosis of the same critical illness3

If you receive a benefit for a critical illness, and later you are diagnosed with the same critical illness, 25% of the original face amount is payable. Critical illness conditions that do not qualify are: coronary artery bypass graft surgery/coronary artery disease2 and occupational infectious HIV or occupational infectious hepatitis B, C or D.

ColonialLife.com

If you’re diagnosed with a covered critical illness or cancer, group critical illness insurance* from Colonial Life can help with your expenses, so you can concentrate on what’s most important – your treatment, care and recovery.

*The policy name is Critical Illness and Cancer Group Specified Disease Insurance.

Face amount: $10,000 or $20,000 or $30,000

Critical illness benefit

For more information, contact Debi Olson at 214-686-1940

ColonialLife.com

Covered cancer benefits

For this condition:1 The amount payable is:

Diagnosis of cancer (internal or invasive) 100% of the face amount

Diagnosis of carcinoma in situ 25% of the face amount

Skin cancer $500

Diagnosis of cancer benefit

Cancer vaccine benefit: .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50

This benefit is payable if you or your covered family members incur a charge for any FDA-approved cancer vaccine while your certificate is inforce.

1 Please refer to the certificate for complete definitions of covered conditions.

2 �Benefit for coronary artery disease applicable in lieu of benefit for coronary artery bypass graft surgery when health savings account (HSA) compliant plan is selected.

3 Dates of diagnoses of a covered critical illness must be separated by at least 180 days.

THIS POLICY PROVIDES LIMITED BENEFITS.

Insureds in MA must be covered by comprehensive health insurance before applying for this coverage.

EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS

We will not pay the Critical Illness Benefit or Benefit Payable Upon Subsequent Diagnosis of a Critical Illness that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics;

psychiatric or psychological conditions; suicide or injuries which any covered person intentionally does to himself; war or armed conflict; or pre-existing condition, 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.

EXCLUSIONS AND LIMITATIONS FOR CANCER

We will not pay the Diagnosis of Cancer Benefit, Diagnosis of Carcinoma in Situ Benefit, the Cancer Treatment and Care Benefit or the Skin Cancer Benefit for a covered person’s cancer (internal or invasive), carcinoma in situ or skin cancer that: is diagnosed or treated outside the territorial limits of the United States, its possessions, or the countries of Canada and Mexico;

is a pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is initially diagnosed as having cancer (internal or invasive), carcinoma in situ or skin cancer. No pre-existing condition limitation will be applied for dependent children who are born or adopted while you are covered under the policy, and who are continuously covered from the date of birth or adoption.

This is not an insurance contract and only the actual certificate provisions will control. Applicable to certificate form GCC1.0-C (including state abbreviations where used, for example: GCC1.0-C-TX). The certificate or its provisions may vary or be unavailable in some states. Please see your Colonial Life benefits counselor for details.

10-19 | 100361-2

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

Account Name:

Date:

Situs State:

By electing coverage, you confirm to have received and read the enrollment materials found in the links, including statements regarding eligibility for coverage, possible delayed effective dates, benefit provisions, costs, exclusions, limitations, terminations and benefit reductions, offsets and any required outlines of coverage and I acknowledge and agree to them and the statements below.

You consent to the electronic delivery of insurance documents, including legally required disclosure and policy documents. You have an email address and an electronic device such as a computer or a smart phone to access the internet and view and retain PDF documents. You can withdraw your consent; update your email address and request, free of charge, a paper copy of any document at any time by contacting Co lonial Life &

Accident Insurance Company.

You are actively at work at the time of enrollment and working at least 20 hours per week.

If you or any covered family members are Medicare eligible, you attest to having access to the Important Notice to Persons on Medicare document. You may also reference the official US government Medicare handbook at https://www.medicare.gov/Pubs/pdf/10050-Medicare-and-You.pdf.

Group Critical Care:

o You attest that you have not used any tobacco products (cigarettes, cigars, snuff, dip, chew, pipe) and/or any nicotine delivery system with in the last 12 months if applying for a non-tobacco policy.

o You attest that if covering a spouse and/or eligible dependents, coverage is no more than 50% of the employee’s face amount.

o The Face Amount will reduce by 50% on the certificate anniversary date after the named insured’s

75th birthday.

You attest to receipt of the following Colonial Life documents within the enrollment site:

o Colonial Life Disclosures, Limitations & Exclusions o Colonial Life Group Accident Brochure o Colonial Life Group Critical Care Brochures o Colonial Life Group Medical Bridge Brochures o Important Notice to Persons on Medicare

City of Burleson

5/18/2022

Texas

Colonial Life Disclosures, Limitations and Exclusions https://www.medicare.gov/Pubs/pdf/10050-Medicare-and-You.pdf

NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND SICKNESS INSURANCE

According to your application and the information you have furnished, you intend to lapse or otherwise terminate existing accident and sickness insurance and replace it with a policy to be issued by the Company. For your own information and protection, you should be aware of and seriously consider certain factors which may affect the insurance protection available to you under the new policy.

1. Health conditions which you may presently have, may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits under the new policy, whereas a similar claim might have been payable under your present policy.

2. Any benefits you have accrued under your present policy may not be payable or transferrable under the new policy.

3. If you are transferring from individual coverage to group coverage, the circumstances under which you may continue your coverage may be limited or no longer available.

4. You may wish to secure the advice of your present insurer or its agent regarding the proposed replacement of your present policy. This is not only your right, but it is also in your best interests to make sure you understand all the relevant factors involved in replacing your present coverage.

5. If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical/health history. Failure to include all material medical information on an application may provide a basis for the Company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, reread it carefully to be certain that all information has been properly recorded.

Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketi ng brand. Similar policies, if approved, are underwritten in New York by The Paul Revere Life Insurance Company. Colonial Life &

Accident Insurance Company is a subsidiary of Unum Corporation.

Medicare Notice 48434-4 Cancer/Critical Illness

This is not Medicare Supplement Insurance

This insurance pays a fixed amount, regardless of your expenses, if you meet the policy conditions, for one of the specific diseases or health conditions named in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement Insurance.

This insurance duplicates Medicare benefits because Medicare generally pays for most of the expenses for diagnosis and treatment of the specific conditions or diagnoses named in the policy.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

hospitalization physician services hospice outpatient prescription drugs if you are enrolled in Medicare Part D other approved items and services

Check the coverage in all health insurance policies you already have.

For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program.

Important Notice to Persons on Medicare This Insurance Duplicates Some Insurance Benefits

Before You Buy This Insurance