26-D4 - GACC 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

*2LN1G00615980000049*

GACC1.0-P-EE-TX 1 76130

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 ACCIDENT 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 employer 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. Details of the benefits 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

NOTICE TO BUYER: THIS IS AN ACCIDENT ONLY POLICY AND IT DOES NOT

PAY BENEFITS FOR LOSS FROM SICKNESS. REVIEW YOUR POLICY CAREFULLY.

BENEFITS PROVIDED ARE NOT INTENDED TO COVER ALL MEDICAL

EXPENSES.

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 EMPLOYER DOES NOT

BECOME A SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM BY PURCHASING THIS POLICY, AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYER LOSES THOSE BENEFITS WHICH

WOULD OTHERWISE ACCRUE UNDER THE WORKERS' COMPENSATION LAWS. THE EMPLOYER 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

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

GACC1.0-P-EE-TX 2 76130

GACC1.0-P-EE-TX 3 76130

SECTION 3 - POLICY RATE SCHEDULE

Policyholder: City Of Burleson Policy Number: G0061598

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. 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.

Eligibility Period: 31 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 $ 17.53 $ 28.64

One-Parent Family Two-Parent Family $ 31.16 $ 42.27

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

GACC1.0-P-EE-TX 4 76130

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 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.

GACC1.0-P-EE-TX 5 76130

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.

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 a named insured is considered a representation and not a warranty. A statement made by the policyholder or a named 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 a named insured and the named insured has died or become incapacitated, the named insured’s beneficiary or personal representative.

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 when they are due.

The premium due dates are based on:

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

• the premium frequency.

GACC1.0-P-EE-TX 6 76130

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.

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 and the policyholder 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.

43975-7 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

GACC1.0-C-EE-TX 1 86699

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

1.800.325.4368 coloniallife.com A Stock Company

GROUP ACCIDENT INSURANCE CERTIFICATE

THIS CERTIFICATE EXPLAINS THE BENEFITS PROVIDED UNDER

THE GROUP ACCIDENT INSURANCE POLICY.

NOTICE TO BUYER: THIS IS AN ACCIDENT ONLY CERTIFICATE

AND IT DOES NOT PAY BENEFITS FOR LOSS FROM SICKNESS.

REVIEW YOUR CERTIFICATE CAREFULLY. BENEFITS PROVIDED

ARE NOT INTENDED TO COVER ALL MEDICAL EXPENSES.

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 employer 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.

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

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 EMPLOYER TO DETERMINE

WHETHER YOUR EMPLOYER IS A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM.

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 – PORTABILITY

SECTION 10 – GENERAL PROVISIONS

SECTION 11 – CLAIM PROVISIONS

GACC1.0-C-EE-TX 2 86699

GACC1.0-C-EE-TX Printed on 10/28/2021 3 86699

SECTION 3 - CERTIFICATE SCHEDULE

Policyholder: City Of Burleson Policy Number: G0061598

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

Accident Type: On & Off Job

All benefits are payable once per covered person per covered accident unless specified otherwise.

We will pay these benefits for any covered person who receives injuries as the result of a covered accident:

Accident Emergency Treatment $150 Maximum of 4 visit(s) per covered person per calendar year

Accident Follow Up Doctor Visit $50 Maximum of 4 visit(s) per covered person per covered accident Maximum of 16 visits(s) per covered person per calendar year

Accidental Death Named Insured $50,000 Spouse $50,000 Dependent Child(ren) $10,000

Accidental Death - Common Carrier Named Insured $200,000 Spouse $200,000 Dependent Child(ren) $40,000

Accidental Dismemberment (Loss of Finger, Toe, Hand, Foot or Sight of an Eye) Loss of one finger or one toe $1,050 Loss of two or more fingers; or two or more toes $2,100 Any combination of two or more fingers or toes $2,100 Loss of one hand or one foot; or sight of one eye $9,000 Loss of both hands or both feet; or sight of both eyes $18,000 Any combination of two or more hands, feet or sight of an eye $18,000

Air Ambulance $1,500

Ambulance $300

Appliance $100

Blood/Plasma/Platelets $400

GACC1.0-C-EE-TX Printed on 10/28/2021 4 86699

Burn

2nd degree burns Covering a total of at least 36% of the body surface $1,000

3rd degree burns Covering a total of: at least 9 square inches, but less than 18 square inches; or $2,000 At least 18 square inches, but less than 35 square inches; or $7,000 35 or more square inches of the body surface $15,000

Burn - Skin Graft

Skin graft for 2nd or 3rd degree burns 50% of applicable Burn benefit

Catastrophic Accident Named Insured $50,000 Spouse $50,000 Dependent Child(ren) $25,000

Subject to a 365-day elimination period Maximum of one benefit per lifetime per covered person

Coma $10,000

Concussion $375

Dislocation (Separated Joint) Joint Closed Reduction Open Reduction Hip $3,000 $6,000 Knee (except patella) $1,500 $3,000 Ankle - Bone or Bones of the Foot (other than toes) $1,200 $2,400 Collarbone (sternoclavicular) $800 $1,600 Lower Jaw $720 $1,440 Shoulder (glenohumeral) $1,200 $2,400 Elbow $450 $900 Wrist $600 $1,200 Bone or Bones of the Hand (other than fingers) $810 $1,620 Collarbone (acromioclavicular and separation) $200 $400 One Toe or Finger $200 $400

Incomplete Dislocation or dislocation reduction without anesthesia - 25% of the applicable amount for closed reduction of joint involved.

Emergency Dental Work Dental Crown, Denture or Implant $300 Dental Extraction $100

Eye Injury with surgical repair $300

GACC1.0-C-EE-TX Printed on 10/28/2021 5 86699

Fracture (Broken Bone) Bone Closed Reduction Open Reduction Skull, Depressed Skull fracture (except bones of face or nose) $3,750 $7,500 Skull, Simple Non-depressed Skull fracture (except bones of face or nose) $1,800 $3,600 Hip, Thigh (femur) $3,150 $6,300 Vertebrae, Body of (excluding vertebral processes) $2,700 $5,400 Pelvis (includes ilium, ischium, pubis, acetabulum except coccyx) $2,400 $4,800 Leg (tibia and/or fibula) $1,800 $3,600 Bones of Face or Nose (except mandible or maxilla) $910 $1,820 Upper Jaw, Maxilla (except alveolar process) $1,050 $2,100 Upper Arm between Elbow and Shoulder (humerus) $1,050 $2,100 Lower Jaw, Mandible (except alveolar process) $1,200 $2,400 Shoulder Blade (scapula), Collarbone (clavicle, sternum) $1,200 $2,400 Vertebral Processes $630 $1,260 Forearm (radius and/or ulna), Hand, Wrist (except fingers) $1,200 $2,400 Kneecap (patella) $1,200 $2,400 Foot (except toes) $1,200 $2,400 Ankle $1,200 $2,400 Rib $375 $750 Coccyx $320 $640 Finger, Toe $200 $400

Chip Fracture - 25% of the applicable amount for closed reduction of the bone listed above.

Maximum of one Chip Fracture benefit per covered person per covered accident.

Hospital Admission $1,000

Hospital Confinement $250 Maximum of 365 days per covered person per covered accident

Hospital Intensive Care Unit Admission $1,750

Hospital Intensive Care Unit Confinement $400 Maximum of 15 days per covered person per covered accident

Knee Cartilage - Torn $750

Laceration Repaired by stitches:

Total of all lacerations is less than two inches long (less than 5.08 centimeters) $150 Total of all lacerations is at least two but less than six inches long (5.08 to 15.23 centimeters) $300 Total of all lacerations is six inches or longer (15.24 centimeters or longer) $600

Laceration(s) with no repair: $50

Lodging $200 Maximum of 30 days per covered person per covered accident

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Medical Imaging Study $200 Maximum of one benefit per covered person per covered accident and one benefit per covered person per calendar year

Occupational or Physical Therapy $45 Maximum of 10 days per covered person per covered accident

Pain Management $150

Prosthetic Device/Artificial Limb One $1,250 More than one $2,500

Rehabilitation Unit Confinement $150 Maximum of 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 - Cranial, Open Abdominal and Thoracic/Hernia Cranial, Open Abdominal and Thoracic surgery $1,500 Hernia with surgical repair $300

Surgery - Exploratory and Arthroscopic $225

Tendon/Ligament/Rotator Cuff One with surgical repair $900 Two or more with surgical repair $1,800

Transportation $600 Maximum of 3 round trips per covered person per covered accident

X-Ray $60

GACC1.0-C-EE-TX 7 86699

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.

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

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;

• is of the Accident Type listed on the Certificate Schedule; 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 at the time the application for coverage of the grandchild is made;

• newborn child;

• 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.

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.

GACC1.0-C-EE-TX 8 86699

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.

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.

Hospital means a place that:

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

• provides overnight care of injured and sick people;

• is supervised by a doctor;

• 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 rehabilitation center;

• a place for alcoholics or drug addicts; or

• an assisted living facility.

Hospital Intensive Care Unit means a place which:

• is a specifically designated area of the hospital that is reserved for patients who are critically ill or injured and who require intensive comprehensive observation and care;

• is separate and apart from the surgical recovery room and from rooms, beds and wards customarily used for patient confinement;

• is permanently equipped with special lifesaving equipment for the care of the critically ill or injured;

• is under constant and continuous observation by a specially trained nursing staff assigned exclusively to the intensive care unit on a 24 hour basis; and

• has a doctor assigned to the intensive care unit on a full-time basis.

A hospital intensive care unit that meets the definition may include, but not limited to, hospital units with the following names:

• Intensive Care Unit;

• Coronary Care Unit;

• Pediatric Intensive Care Unit;

• Pulmonary Care Unit;

• Burn Unit; or

• Transplant Unit.

A hospital intensive care unit is not any of the following step down units:

• a progressive care unit;

• an intermediate care unit;

• a private monitored room;

• sub-acute intensive care unit;

• an observation unit; or

• any facility not meeting the definition of a hospital intensive care unit as defined in this certificate.

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Hospital Sub-Acute Intensive Care Unit means a place which:

• is a specifically designated area of the hospital that provides a level of medical care below intensive care, but above a regular private or semi-private room or ward;

• is separate and apart from the surgical recovery room and from rooms, beds and wards customarily used for patient confinement;

• is permanently equipped with special lifesaving equipment for the care of the critically ill or injured; and

• is under constant and continuous observation by a specially trained nursing staff.

A hospital sub-acute intensive care unit may be referred to by other names such as progressive care, intermediate care, or a step-down unit, but it is not a regular private or semi-private room, or a ward with or without monitoring equipment.

Injury means a wound to a covered person's body that is caused solely by or is the result of a covered accident.

Observation Unit means a specified area within a hospital, apart from the emergency room, where a patient can be monitored following outpatient surgery or treatment in the emergency room by a doctor and which:

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

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

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

Occupational Therapist is a person who:

• possesses the designation “Occupational Therapist Registered (OTR)”;

• is licensed by the state to practice occupational therapy;

• performs services which are allowed by his license; and

• performs services for which benefits are provided by this certificate.

For purposes of this definition, occupational therapist does not include any covered person or anyone related to any covered person by blood or marriage.

Off-Job Accident means an accident that occurs while a covered person is not working at any job for pay or benefits.

On-Job Accident means an accident that occurs while a covered person is working at any job for pay or benefits.

Physical Therapist is a person who:

• is licensed by the state to practice physical therapy;

• performs services which are allowed by his license;

• performs services for which benefits are provided by this certificate; and

• practices according to the Code of Ethics of the American Physical Therapy Association.

For purposes of this definition, physical therapist does not include any covered person or anyone related to any covered person by blood or marriage.

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 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 place for alcoholics or drug addicts; or

• an assisted living facility.

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

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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.

Urgent Care Facility means a place other than a doctor's office, hospital or emergency room that provides emergency care and treatment for injured people.

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.

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.

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.

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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 and extends for 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

SECTION 6 - BENEFITS

Accident Emergency Treatment We will pay the amount and up to the maximum number of visits shown on the Certificate Schedule for Accident Emergency Treatment if any covered person is injured as the result of a covered accident and incurs a charge for and requires examination and treatment by a doctor in a hospital emergency room, urgent care facility or doctor's office (other than acupuncture or occupational or physical therapy) within 72 hours after the covered accident.

We will pay this amount once per covered person per covered accident. We will not pay the Accident Emergency Treatment and the Accident Follow-Up Doctor Visit benefits for visits on the same day.

Accident Follow-Up Doctor Visit We will pay the amount and up to the maximum number of visits shown on the Certificate Schedule for Accident Follow-Up Doctor Visit if any covered person incurs a charge for and receives follow-up treatment (other than occupational or physical therapy). We will also pay this benefit if any covered person incurs a charge for and receives initial treatment more than 72 hours after the covered accident.

Treatment must:

• be provided by a doctor for injuries received as the result of a covered accident;

• begin within 60 days and be completed within 365 days of the accident;

• be due to injuries received as the result of a covered accident;

• occur in a doctor's office, urgent care facility or emergency room; and

• not be for routine examinations or preventive testing.

We will pay this amount and up to the maximum number of visits per covered person per covered accident. We will not pay the Accident Emergency Treatment and the Accident Follow-Up Doctor Visit benefits for visits on the same day.

Accidental Death We will pay the amount shown on the Certificate Schedule for Accidental Death if any covered person is injured as the result of a covered accident, and the injury causes the covered person to die within 90 days after the covered accident.

Benefits will be paid to the named insured or his beneficiary. If a beneficiary is not named, we will pay the death benefit subject to the Payment of Claim provision.

If we pay this benefit, we will not pay the Accidental Death – Common Carrier benefit.

Accidental Death – Common Carrier We will pay the amount shown on the Certificate Schedule for Accidental Death – Common Carrier if any covered person is injured as the result of a covered accident while a fare paying passenger on a common carrier and the injury causes the covered person to die within 90 days after the covered accident. Common carrier means commercial airplanes, trains, buses, trolleys, subways, ferries and boats that operate on a regularly scheduled basis between predetermined points or cities. Taxis and privately chartered vehicles are not common carriers.

Benefits will be paid to the named insured or his beneficiary. If a beneficiary is not named, we will pay the death benefit

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subject to the Payment of Claim provision.

If we pay this benefit, we will not pay the Accidental Death benefit.

Accidental Dismemberment (Loss of Finger, Toe, Hand, Foot or Sight of an Eye) We will pay the amount shown on the Certificate Schedule for Accidental Dismemberment (Loss of Finger, Toe, Hand, Foot or Sight of an Eye) if a charge is incurred for loss of a finger, toe, hand, foot or sight of an eye received as the result of a covered accident and which occurs within 90 days after the covered accident.

For purposes of this benefit, the following definitions apply. Loss of a hand means that the hand is cut off through or above the wrist joint or the use of the hand is permanently lost. Loss of a foot means that the foot is cut off through or above the ankle joint or the use of the foot is permanently lost. Loss of a finger means that the finger is cut off at the joint proximate to the first interphalangeal joint where it is attached to the hand. Loss of a toe means that the toe is cut off at the joint proximate to the first interphalangeal joint where it is attached to the foot. Loss of sight of an eye means that at least 80 percent of vision is permanently lost.

If the covered person loses a finger or toe and later loses a hand or foot within 90 days on the same side of the body as the result of the same covered accident, we will subtract the amount we paid for that loss of a finger or toe from the benefit we paid for the loss of a hand or foot.

Air Ambulance We will pay the amount shown on the Certificate Schedule for Air Ambulance if a charge is incurred and a licensed professional air ambulance company transports by air any covered person to or from a hospital or between medical facilities where treatment for injuries is received as the result of a covered accident. The air ambulance transportation must be within 48 hours after the covered accident. We will pay this amount once per covered person per covered accident.

Ambulance We will pay the amount shown on the Certificate Schedule for Ambulance if a charge is incurred and a licensed professional ambulance company transports any covered person by ground transportation to or from a hospital or between medical facilities, where treatment for injuries is received as the result of a covered accident. The ambulance transportation must be within 90 days after the covered accident. We will pay this amount once per covered person per covered accident.

Appliance We will pay the amount shown on the Certificate Schedule for Appliance if any covered person is injured as the result of a covered accident, a doctor prescribes the use of a medical appliance as an aid in personal locomotion or mobility and a charge is incurred for the appliance. For purposes of this benefit, appliance means a walking boot that extends above the ankle, brace for the neck, back or leg, cane, crutches, walker and wheelchair. The use of an appliance must begin within 90 days after the covered accident.

We will pay this amount once per covered person per covered accident.

Blood/Plasma/Platelets We will pay the amount shown on the Certificate Schedule for Blood/Plasma/Platelets if any covered person is injured as the result of a covered accident and incurs a charge for and requires the transfusion of blood/plasma/platelets as the result of the injury. The blood/plasma/platelets must be administered within 90 days after the covered accident. We will pay this amount once per covered person per covered accident.

Burn We will pay the amount shown on the Certificate Schedule for Burn if any covered person receives burns as described on the Certificate Schedule as the result of a covered accident which are treated by a doctor within 72 hours after the covered accident. A charge must be incurred for treatment. We will pay this amount once per covered person per covered accident. If any covered person receives both second and third degree burns in a covered accident, we will pay the highest applicable burn benefit based on the measurement and type of burn, but not both the Second Degree Burn and Third Degree Burn benefits.

Burn – Skin Graft We will pay the amount shown on the Certificate Schedule for Burn Skin Graft if any covered person incurs a charge for and receives a skin graft for a burn for which a benefit was received under the Burn benefit of this certificate. This benefit will be

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payable only once per covered person per covered accident. This benefit will not be paid for elective procedures and/or cosmetic surgery that are not the result of a covered accident.

Catastrophic Accident We will pay the amount shown on the Certificate Schedule for Catastrophic Accident at the end of the elimination period if any covered person:

• sustains a catastrophic loss as the result of a covered accident;

• is under the appropriate care of a doctor during the elimination period; and

• remains alive at the end of the elimination period.

For purposes of this benefit, elimination period means the period of 365 days after the date of a covered accident.

For purposes of this benefit, catastrophic loss means an injury that within 365 days of the covered accident results in total and irrecoverable:

• loss of both hands or both feet; or

• loss or loss of use of both arms or both legs; or

• loss of one hand and one foot; or

• loss or loss of use of one arm and one leg; or

• loss of the sight of both eyes; or

• loss of the hearing of both ears; or

• loss of the ability to speak.

For purposes of this benefit, the following definitions apply. Loss of a hand means that the hand is cut off through or above the wrist joint. Loss of a foot means that the foot is cut off through or above the ankle joint. Loss of an arm means the arm is cut off above the elbow. Loss of a leg means the leg is cut off above the knee. Loss of use of an arm means the loss of function of the entire arm from the shoulder to the hand. Loss of use of a leg means the loss of function of the entire leg from the hip to the foot. Loss of sight of both eyes means at least 80 percent of vision is permanently lost in both eyes, such that it cannot be corrected to any functional degree by any procedure, aid or device. Loss of hearing of both ears means deafness in both ears, such that it cannot be corrected to any functional degree by any procedure, aid or device. Loss of the ability to speak means loss of audible communication, such that it cannot be corrected to any functional degree by any procedure, aid or device.

The Catastrophic Accident benefit will be payable once per lifetime for each covered person in this certificate.

Coma We will pay the amount shown on the Certificate Schedule for Coma if any covered person incurs a charge for and is diagnosed with or treated for a coma lasting for a period of 14 or more consecutive days resulting from a severe traumatic brain injury due to a covered accident. The condition must require intubation for respiratory assistance and be diagnosed or treated by a doctor within 90 days after the covered accident.

For purposes of this benefit, coma means a continuous state of profound unconsciousness characterized by the absence of:

• eye opening,

• motor response, and

• verbal response.

The term "coma" does not include any medically induced coma.

This benefit will be payable once per covered person per covered accident.

Concussion We will pay the amount shown on the Certificate Schedule for Concussion if any covered person sustains a concussion as the result of a covered accident and incurs a charge for and is diagnosed by a doctor within 72 hours from the date of the covered accident. This benefit will be payable once per covered person per covered accident.

Dislocation (Separated Joint) We will pay the amount shown on the Certificate Schedule for Dislocation (Separated Joint) if any covered person receives a dislocation as the result of a covered accident. A dislocation is a completely separated joint. It must be diagnosed as a

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dislocation by a doctor within 90 days after the covered accident. The dislocation must require correction with anesthesia by a doctor, and a charge must be incurred for the correction. It can be corrected by open (surgical) or closed (non-surgical) reduction.

After all of these things occur, we will pay the applicable amount shown on the Certificate Schedule for Dislocation (Separated Joint) for the joint involved.

If any covered person receives more than one dislocation in a covered accident, and he requires open or closed reduction, we will pay for all dislocations. However, we will pay no more than two times the amount for the joint involved which has the highest benefit amount.

If the dislocation requires reduction without anesthesia by a doctor, we will pay 25 percent of the applicable amount shown on the Certificate…