25-D7 - Group Accident Plan Documents Combined.pdf

Group Accident Insurance Preferred Plan

ColonialLife.com

GAC4000 – PREFERRED PLAN

Nobody expects an accident to happen. But if it does, your main focus should be on recovery, not how you’re going to pay your bills. Colonial Life accident insurance provides benefits directly to you to use however you like – from medical costs to everyday expenses. Whether it's a fall or a car accident, your benefits offer support when you need it.

Benefits are per covered person per covered accident unless stated otherwise

Accident emergency treatment.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150 One visit per covered person per covered accident and Up to four visits per covered person per calendar year

Accident follow-up doctor visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$50 Up to four visits per covered person per covered accident and Up to 16 visits per covered person per calendar year

¾ Named insured.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50,000.. . . . . . . . . . . . . . . . . . $200,000 ¾ Spouse.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50,000.. . . . . . . . . . . . . . . . . . $200,000 ¾ Dependent child(ren).. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $10,000.. . . . . . . . . . . . . . . . . . . . $40,000

Examples of common carriers are mass transit trains, buses and planes

Accidental dismemberment Loss or loss of use ¾ One hand, arm, foot, leg or sight of an eye.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $9,000 ¾ Both hands, arms, feet, legs or the sight of both eyes; or any combination .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $18,000 ¾ One finger or one toe.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,050 ¾ Two or more fingers; two or more toes; or any combination.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $2,100

Air ambulance.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,500 Transportation to or from a hospital or medical facility

Ambulance (ground). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $300 Transportation to or from a hospital or medical facility

Appliance aid in personal locomotion or mobility.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100 Walking boot, neck brace, back brace, leg brace, cane, crutches, walker and wheelchair

Blood/plasma/platelets.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $400 Required during treatment of a covered accident

Burn ¾ 2nd-degree burns (covering at least 36% of the body’s surface). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,000 ¾ 3rd-degree burns (based on size).. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $2,000 – $15,000

Burn–skin graft.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50% of applicable burn benefit As a result of 2nd-degree or 3rd-degree burns

For more information contact

Debi Olson at 214-686-1940

Catastrophic accident Total and irrecoverable loss or loss of use

¾ Both hands, arms, feet, legs or the sight of both eyes; or any combination; or ¾ Loss of hearing in both ears or loss of ability to speak

Subject to a 365-day elimination period; payable once per lifetime per covered person ¾ Named insured...................................................................................................................................................$50,000 ¾ Spouse...................................................................................................................................................................$50,000 ¾ Dependent child(ren)........................................................................................................................................$25,000

Coma.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $10,000 Lasting for 14 or more consecutive days

Concussion.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $375

¾ �Incomplete dislocation or dislocation reduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25% of the applicable without anesthesia non-surgical amount

Emergency dental work ¾ Dental crown or denture.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $300 ¾ Dental extraction.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100

Eye injury.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $300 With surgical repair or removal of a foreign object

elbow and shoulder

¾ Chip fracture.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25% of the applicable non-surgical amount

Alex was cleaning out the gutters when he fell.

ALEX’S BENEFITS

Ambulance $300

Emergency room visit $150

X-ray $60

Hospital admission $1,000

Hospital confinement $750

Leg fracture (surgical) $3,600

Physical therapy $360

Appliance (crutches) $100

Doctor’s follow-up office visit $150

$6,470

EMERGENCY ROOM VISIT

Alex was taken by ambulance to the nearest emergency room and received immediate care.

The doctor ordered an X-ray and discovered Alex had fractured his leg.

DIAGNOSTIC PROCEDURE

Over the next several weeks, he had three follow-up appointments with his doctor.

DOCTORʼS OFFICE VISIT

Alex had eight sessions of physical therapy to help him regain the strength in his leg.

PHYSICAL THERAPY

Alex was admitted to the hospital for surgery on his leg. He was confined for three days.

HOSPITAL CONFINEMENT

For illustrative purposes only.

Benefit amounts may vary and may not cover all expenses. The certificate has exclusions and limitations.

ALEXʼS OUT-OF-POCKET EXPENSES

When Alex totaled up the bills, he had to pay his annual deductible, as well as co-payments for the ambulance, emergency room, hospital, surgery, physical therapy and follow-up visits.

Luckily, Alex had accident coverage to help with these expenses.

Alex used crutches.

APPLIANCE FOR MOBILITY

GAC4000 – PREFERRED PLAN

Hospital admission.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,000 Per covered person per covered accident

Hospital confinement.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250 per day Up to 365 days per covered person per covered accident

Hospital intensive care unit admission.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,750 Per covered person per covered accident

Hospital intensive care unit confinement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $400 per day Up to 15 days per covered person per covered accident

Knee cartilage (torn). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $750

Laceration (no repair, without stitches).. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$50

Laceration (repaired by stitches) ¾ Total of all lacerations is less than two inches long.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150 ¾ Total of all lacerations is at least two but less than six inches long. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $300 ¾ Total of all lacerations is six inches or longer.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $600

Lodging (companion). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200 per day Up to 30 days per covered person per covered accident

Medical imaging study (CT, CAT scan, EEG, MR or MRI).. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200 One benefit per covered person per covered accident per calendar year

Occupational or physical therapy.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $45 per day Up to 10 days per covered person per covered accident

Pain management for epidural anesthesia.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150

Prosthetic device/artificial limb One benefit per covered person per covered accident

¾ One.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,250 ¾ More than one.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $2,500

Rehabilitation unit confinement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150 per day Immediately after a period of hospital confinement due to a covered accident; up to 15 days per covered person per covered accident, not to exceed 30 days per covered person per calendar year

Ruptured disc with surgical repair.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $900

Surgery ¾ Cranial, open abdominal and thoracic.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,500 ¾ Hernia with surgical repair. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $300

Surgery (exploratory and arthroscopic).. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $225

Tendon/ligament/rotator cuff ¾ One with surgical repair. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $900 ¾ Two or more with surgical repair.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,800

Transportation for hospital confinement.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $600 per round trip Up to three round trips for more than 50 miles from home per covered person per covered accident

X-ray.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$60

For more information contact

Debi Olson at 214-686-1940

ColonialLife.com

3-21 | 101862-2

HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLE

This plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate.

It may also be offered to employees who do not have HSAs.

THIS INSURANCE PROVIDES LIMITED BENEFITS.

EXCLUSIONS

We will not pay benefits for losses that are caused by, contributed to by or occur as the result of a covered person s̓ felonies or illegal occupations, hazardous avocations, racing, semi-professional or professional sports, sickness, suicide or injuries which any covered person intentionally does to himself, war or armed conflict. In addition, we will not pay Catastrophic Accident benefits for injuries a child received during birth, or for injuries that are the result of being intoxicated or under the influence of any narcotics.

This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GACC1.0-P and certificate form GACC1.0-C (including state abbreviations where used, for example: GACC1.0-P-EE-TX and GACC1.0-C-EE-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2021 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 69827-1 Accident

This is not Medicare Supplement Insurance

This insurance provides limited benefits if you meet the conditions listed 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 when it pays:

the benefits stated in the policy and coverage for the same event is provided by

Medicare

Medicare generally pays for most or all of these expenses.

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.

Before You Buy This Insurance

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