Accident_Policy_CITY_OF_ROSENBERG_EMPLOYEE_TRUST_GVA_CONTRACT.pdf

AMERICAN HERITAGE LIFE INSURANCE COMPANY

HOME OFFICE:

1776 AMERICAN HERITAGE LIFE DRIVE

JACKSONVILLE, FLORIDA 32224-6687

(904) 992-1776

A Stock Company

GROUP ACCIDENT INSURANCE POLICY

POLICYHOLDER: CITY OF ROSENBERG EMPLOYEE TRUST

POLICY NUMBER: 81606

POLICY EFFECTIVE DATE: October 1, 2017

POLICY ANNIVERSARY DATE:October 1, 2018 and the first day of October each calendar year thereafter.

GOVERNING JURISDICTION: the state of Texas and subject to the laws of that jurisdiction.

American Heritage Life Insurance Company will provide benefits under this policy. We make this promise subject to all of the provisions of this policy.

The policyholder should read this policy carefully and contact us promptly with any questions. This group policy is delivered in and is governed by the laws of the governing jurisdiction and, to the extent applicable, by the Employee Retirement Income Security Act of 1974 (ERISA), and consists of:

1. all policy provisions and any amendments and/or attachments issued; and

2. the policyholder’s signed application.

This policy may be changed in whole or in part. The approval must be in writing, signed by one our executive officers and endorsed on or attached to this policy. No other person, including an agent, may change this policy or waive any part of it.

Signed for American Heritage Life Insurance Company at its Home Office in Jacksonville, Florida on the policy effective date.

Secretary President

THIS IS A GROUP ACCIDENT ONLY POLICY WHICH PROVIDES BENEFITS FOR

ACCIDENTS AS DEFINED WITHIN THIS POLICY OR OTHER BENEFITS THAT MAY BE ADDED.

THIS POLICY DOES NOT PROVIDE BENEFITS FOR ANY OTHER CONDITIONS.

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.

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IMPORTANT NOTICE AVISO IMPORTANTE

TO OBTAIN INFORMATION OR MAKE A

COMPLAINT:

PARA OBTENER INFORMACION O

PARA SOMETER UNA QUEJA:

YOU MAY CALL AMERICAN HERITAGE

LIFE INSURANCE COMPANY'S TOLL-

FREE TELEPHONE NUMBER FOR

INFORMATION OR TO MAKE A

COMPLAINT AT

1-800-535-8086

USTED PUEDE LLAMAR AL NUMERO

DE TELEFONO GRATIS DE AMERICAN

HERITAGE LIFE INSURANCE

COMPANY'S PARA INFORMACION O

PARA SOMETER UNA QUEJA AL

1-800-535-8086

YOU MAY CONTACT THE TEXAS

DEPARTMENT OF INSURANCE TO

OBTAIN INFORMATION ON

COMPANIES, COVERAGES, RIGHTS

OR COMPLAINTS AT

1-800-252-3439

PUEDE COMUNICARSE CON EL

DEPARTAMENTO DE SEGUROS DE

TEXAS PARA OBTENER INFORMATION

ACERCA DE COMPANIAS,

COBERTURAS, DERECHOS O QUEJAS

AL

1-800-252-3439

YOU MAY WRITE THE TEXAS

DEPARTMENT OF INSURANCE

P. O. BOX 149104

AUSTIN, TX 78714-9104

FAX #(512) 475-1771

PUEDE ESCRIBAR AL

DEPARTAMENTO DE SEGUROS DE

TEXAS

P. O. BOX 149104

AUSTIN, TX 78714-9104

FAX #(512) 475-1771

PREMIUM OR CLAIM DISPUTES:

SHOULD YOU HAVE A DISPUTE

CONCERNING YOUR PREMIUM OR

ABOUT A CLAIM YOU SHOULD

CONTACT THE COMPANY FIRST. IF

THE DISPUTE IS NOT RESOLVED, YOU

MAY CONTACT THE TEXAS

DEPARTMENT OF INSURANCE.

DISPUTAS SOBRE PRIMAS O

RECLAMOS: SI TIENE UNA DISPUTA

CONCERNIENTE A SU PRIMA O A UN

RECLAMO, DEBE COMUNICARSE CON

EL COMPANIA PRIMERO. SI NO SE

RESUELVE LA DISPUTA, PUEDE

ENTONCES COMUNICARSE CON EL

DEPARTAMENTO (TDI).

ATTACH THIS NOTICE TO YOUR

POLICY: THIS NOTICE IS FOR

INFORMATION ONLY AND DOES NOT

BECOME A PART OR CONDITION OF

THE ATTACHED DOCUMENT.

UNA ESTE AVISO A SU POLIZA: ESTE

AVISO ES SOLO PARA PROPOSITO DE

INFORMACION Y NO SE CONVIERTE

EN PARTE O CONDICION DEL

DOCUMENTO ADJUNTO.

NENSPTX-GV

TABLE OF CONTENTS

POLICY SPECIFICATIONS

POLICYHOLDER PROVISIONS

GENERAL PROVISIONS .......................................................................................................................... 5–8

CONTINUATION OF INSURANCE COVERAGE

EXCLUSIONS AND LIMITATIONS

BENEFIT INFORMATION

CLAIM INFORMATION......................................................................................................................... 12–13

GLOSSARY ........................................................................................................................................ 14–16

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POLICY SPECIFICATIONS

ELIGIBLE CLASS(ES):

All full-time active employees working at least 30 hours per week excluding those who are insured under any other accident policy issued by American Heritage Life Insurance Company.

ELIGIBILITY WAITING PERIOD:

None

BENEFITS:

Initial Hospital Confinement $2,000 per calendar year Daily Hospital Confinement $400 per day Intensive Care $800 per day

RIDER(S):

Dislocation/Fracture Rider (3.00 unit(s)) – Scheduled Maximum Benefit $6,000 Accident Treatment and Urgent Care Rider (4.00 unit(s)) Ground Ambulance – $400 Air Ambulance – $1,200 Accident Physician’s Treatment – $200 X-Ray – $400 Urgent Care – $200 Emergency Room Services Rider (2.00 unit(s)) – $200 Outpatient Physician’s Treatment for Accident and Preventative Care Rider (2.00 unit(s)) – $50 Accidental Death, Dismemberment and Functional Loss Rider (4.00 unit(s)):

Accidental Death – $80,000 Common Carrier Accidental Death – $200,000 Dismemberment – Scheduled Maximum Benefit $80,000 Functional Loss – Scheduled Maximum Benefit $80,000 Benefit Enhancement Rider (3.00 unit(s)) – see page 3B for Benefit Amounts

INITIAL RATE:

The following are the initial rates for all available coverage types:

Monthly rate of $20.15 per insured employee for Individual Coverage; or $34.85 per insured employee for Individual and Spouse Coverage; or $42.92 per insured employee for Individual and Child(ren) Coverage; or $54.13 per insured employee for Family Coverage.

RATE GUARANTEE DATE:

10/01/2018

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POLICY SPECIFICATIONS (Continued)

PREMIUM DUE:

The initial date agreed to between American Heritage Life Insurance Company and the Policyholder and each specified date thereafter.

The policyholder must send all premiums on or before the premium due date to us. The premium must be paid in United States dollars.

COST OF COVERAGE:

The insured employee pays the cost of coverage.

DIVISIONS, SUBSIDIARIES OR AFFILIATED COMPANIES:

These are the policyholder’s divisions, subsidiaries, or affiliates listed below. The policyholder may act for and on behalf of any and all of these in all matters that pertain to this plan. Every act done by, agreement made with, or notice given to the policyholder will be binding on them.

Name Location (City and State) None

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ACCIDENT POLICY

BENEFIT ENHANCEMENT RIDER

SEE BENEFITS SECTION OF RIDER FOR DETAILS OF BENEFITS

BENEFITS AMOUNT

A. ACCIDENT FOLLOW-UP TREATMENT DAILY BENEFIT $150.00

B. LACERATIONS $150.00

C. BURNS

1. SECOND AND THIRD DEGREE BURNS COVERING LESS THAN 15% $300.00

OF THE TOTAL BODY SURFACE

2. SECOND AND THIRD DEGREE BURNS COVERING 15% OR MORE $1,500.00

OF THE TOTAL BODY SURFACE

D. SKIN GRAFT 50% OF BURN BENEFIT

E. BRAIN INJURY DIAGNOSIS $900.00

F. COMPUTED TOMOGRAPHY SCAN OR MAGNETIC RESONANCE IMAGING $150.00

G. PARALYSIS

1. PARAPLEGIA (PARALYSIS OF 2 OR 3 LIMBS) $22,500.00

2. QUADRIPLEGIA (PARALYSIS OF 4 LIMBS) $45,000.00

H. COMA WITH RESPIRATORY ASSISTANCE $30,000.00

I. OPEN ABDOMINAL OR THORACIC SURGERY $3,000.00

J. TENDON, LIGAMENT, ROTATOR CUFF OR KNEE CARTILAGE SURGERY

1. WITH REPAIR $1,500.00

2. WITHOUT REPAIR $450.00

K. RUPTURED DISC SURGERY $1,500.00

L. EYE SURGERY $300.00

M. GENERAL ANESTHESIA $300.00

N. BLOOD AND PLASMA $900.00

O. APPLIANCE $375.00

P. MEDICAL SUPPLIES $15.00

Q. MEDICINE $15.00

R. PROSTHESIS

1. 1 DEVICE $1,500.00

2. 2 OR MORE DEVICES $3,000.00

S. PHYSICAL, OCCUPATIONAL OR SPEECH THERAPY DAILY BENEFIT $90.00

T. REHABILITATION UNIT DAILY BENEFIT $300.00

U. NON-LOCAL TRANSPORTATION PER TRIP $750.00

V. FAMILY MEMBER LODGING DAILY BENEFIT $300.00

W. POST-ACCIDENT TRANSPORTATION $600.00

X. BROKEN TOOTH $300.00

Y. RESIDENCE/VEHICLE MODIFICATION $1,500.00

Z. PAIN MANAGEMENT (EPIDURAL INJECTION) $150.00

AA. MISCELLANEOUS OUTPATIENT SURGERY $300.00

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POLICYHOLDER PROVISIONS

RATE GUARANTEE

A change in premium rate will not take effect before the Rate Guarantee Date except for reasons which affect the risk assumed, including those reasons shown below:

1. a change occurs in this plan design; or

2. a division, subsidiary, or affiliated company is added or deleted; or

3. the number of insured employees changes by 25% or more; or

4. a new law or a change in any existing law is enacted which applies to this plan; or

5. less than 25% of those eligible for coverage are participating.

We will notify the policyholder in writing at least 60 days before a premium rate is changed. A change may take effect on an earlier date when both we and the policyholder agree in writing.

PREMIUM INCREASES OR DECREASES

Premium increases or decreases may take effect any time subject to the RATE GUARANTEE provision. If they take effect during a policy month, they are adjusted and 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.

INFORMATION REQUIRED FROM THE POLICYHOLDER

The policyholder must provide us with the following on a regular basis:

1. information about employees:

a. who are eligible to become insured; and

b. who are insured; and

c. whose coverage changes; and

d. whose coverage ends; and

2. any information that may be required to manage a claim; and

3. any other information that may be reasonably required.

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

CANCELING POLICY

This policy and any riders can be canceled:

1. by us; or

2. by the policyholder.

We may cancel or offer to modify this policy, with at least 31 days notice to the policyholder, if:

1. less than 25% of those eligible for coverage are participating; or

2. this policy has been in effect more than 12 months; or

3. the policyholder does not promptly provide us with information that is reasonably required; or

4. the policyholder fails to perform any of its obligations that relate to this policy; or

5. fewer than 5 employees are insured; or

6. premiums are not received within the 31 day grace period.

If the premiums are not received during the grace period, this policy will terminate automatically at the end of the grace period. This policy provides no coverage during the grace period unless premiums are paid in full prior to the end of the grace period. All premiums due must be paid to us for the full period this policy is in force.

The policyholder may cancel this policy by notice delivered to us at least 31 days prior to the cancellation date. When both the policyholder and we agree, this policy can be canceled on an earlier date. If canceled, coverage will end at 12:00 midnight on the last day of coverage.

If this policy is canceled, the cancellation will not affect a payable claim incurred prior to cancellation.

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GENERAL PROVISIONS

EFFECTIVE DATE OF COVERAGE

Coverage for each eligible employee will be effective at 12:01 a.m. on the effective date shown on page 3 of the certificate of insurance issued to that employee provided he or she is actively employed on that date.

If the employee is not actively employed on that date due to temporary layoff, leave of absence or Family and Medical Leave of Absence, coverage begins on the date he or she returns to active employment. This applies to initial coverage, as well as any increase in coverage that occurs after the employee’s initial coverage is effective.

For any change in coverage, the change is effective on the date we receive such request for change.

Any decrease in coverage will take effect on the first day of the calendar month that next follows the date the employee applies for the decrease, but will not affect a payable claim that occurs prior to the effective date of the decrease.

CERTIFICATES OF INSURANCE

We will furnish to the policyholder a certificate of insurance for delivery to each insured employee. The certificate will provide a description of the insurance provided by this policy and will state:

1. the essential features of the insurance coverage; and

2. to whom benefits are payable.

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

WHEN AN ELIGIBLE EMPLOYEE CAN ENROLL, CHANGE OR DISCONTINUE COVERAGE

1. The employee may apply for coverage during:

a. the initial enrollment period; or

b. at any time.

2. The insured employee may increase coverage at any time.

3. The insured employee may decrease coverage at any time.

4. The insured employee may discontinue coverage at any time.

(This space intentionally left blank)

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GENERAL PROVISIONS (Continued)

ELIGIBILITY OF DEPENDENTS

Eligible dependents are the insured employee’s:

1. legal spouse or domestic partner; and

2. children and domestic partner’s children.

A child is a person under age 26 who is:

1. the insured employee’s or his or her domestic partner’s natural or adopted son or daughter, stepson or stepdaughter;

or

2. a foster child who is placed with the insured employee or his or her domestic partner by an authorized placement agency or by judgment, decree or other order of any court of competent jurisdiction; or

3. the insured employee’s or his or her domestic partner’s dependent grandchildren.

A child born to the insured employee or his or her spouse or domestic partner will be eligible for coverage. This coverage begins at the moment of birth of such child and benefits will be the same as provided for any other child insured under this policy. No additional premium will be required for newborns added if the insured employee already has children or family coverage in force at the time the newborn is added.

If the insured employee does not already have children or family coverage in force, newborn children are automatically covered from the moment of birth for a period of 31 days. If the insured employee desires uninterrupted coverage for a newborn child, he or she must notify the policyholder within 31 days of that child’s birth. Upon notice to us, we will change the coverage to include the additional child and provide notification of the additional premium due. If the insured employee does not notify the policyholder within 31 days of the birth of the child, the temporary automatic coverage ends.

If the insured employee marries and desires coverage for his or her spouse, he or she must notify the policyholder of the marriage within 31 days of the marriage. Upon notice to us, we will change the coverage to include the insured employee’s spouse and provide notification of the additional premium due.

If the insured employee enters into a domestic partnership and desires coverage for his or her domestic partner, he or she must notify the policyholder of the domestic partnership within 31 days of the date the domestic partnership was formed.

Upon notice to us, we will change the coverage to include the insured employee’s domestic partner and provide notification of the additional premium due.

An adopted child or child pending adoption will be covered as follows:

1. Coverage is retroactive from the moment of birth for a child with respect to whom a decree of adoption by the insured employee has been entered within 31 days after the date of birth.

2. If adoption proceedings have been instituted by the insured employee within 31 days after the date of birth and he or she has temporary custody, coverage is provided from the moment of birth.

3. Coverage shall begin from the moment of placement.

Coverage will be provided as long as the insured employee has custody of the child pursuant to decree of the court and required premiums are paid.

If the insured employee does not already have children or family coverage in force, adopted children or children pending adoption are automatically covered as described above for a period of 31 days. If the insured employee desires uninterrupted coverage for an adopted child or child pending adoption, he or she must notify the policyholder within 31 days of the moment of placement. Upon notice to us, we will change the coverage to include the additional adopted child or child pending adoption and provide notification of the additional premium due.

If the insured employee already has children or family coverage in force, no additional premium will be required for an adopted child or foster child at the time the adopted child or foster child is added.

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TERMINATION OF COVERAGE

The insured employee’s coverage under this policy ends on the earliest of:

1. the date this policy is canceled; or

2. the last day of the period for which any required premium payments were made; or

3. the last day the insured employee is actively employed with the employer that is the policyholder, except as provided under the TEMPORARY LAYOFF, LEAVE OF ABSENCE OR FAMILY AND MEDICAL LEAVE OF ABSENCE provision;

or

4. the date the insured employee is no longer in an eligible class; or

5. the date the insured employee’s class is no longer eligible; or

6. our discovery of fraud or material misrepresentation in the presentation of a claim under this policy.

We will provide coverage for a payable claim that occurs while a covered person is covered under this policy.

If the insured employee’s spouse is a covered person, the spouse’s coverage ends upon valid decree of divorce or the insured employee’s death.

If the insured employee’s domestic partner is a covered person, the domestic partner’s coverage ends upon termination of the domestic partnership or the insured employee’s death.

Coverage for a child will end upon the insured employee’s death, or on the issue day of the month that follows when the child: (a) reaches age 26; or (b) otherwise does not meet the requirements of an eligible dependent.

Coverage does not end for an incapacitated dependent child who:

1. is incapable of self-sustaining employment by reason of mental or physical incapacity; and

2. became so incapacitated prior to the attainment of the limiting age of eligibility under this policy; and

3. is chiefly dependent upon the insured employee or member for support and maintenance.

Coverage for an incapacitated dependent child continues as long as this policy remains in force and the child remains in such condition. Proof of the incapacity and dependency of the child must be furnished, in writing, to us when the child reaches the limiting age of eligibility. Thereafter, such proof must be furnished as often as may be required, but no more often than annually after the child’s attainment of the limiting age for eligibility.

If we accept a premium for coverage extending beyond the date, age or event specified for termination as to a covered person, such premium will be refunded, coverage will terminate and claims will not be paid. There may be no refund due if the insured employee has children or family coverage in force and there are other eligible dependents still insured under this policy.

Coverage may be eligible for continuation as outlined in the CONTINUATION OF INSURANCE COVERAGE provision.

TEMPORARY LAYOFF, LEAVE OF ABSENCE OR FAMILY AND MEDICAL LEAVE OF ABSENCE

If the insured employee ceases active employment because of a temporary layoff or leave of absence while coverage is in force, we will continue the coverage in accordance with the personnel practices of the policyholder, if premium payments continue and the policyholder approved the leave in writing. Coverage will be continued for 3 months following the date the insured employee ceased active employment.

If the insured employee’s coverage ends while on a Family and Medical Leave of Absence, the coverage will be reinstated when he or she returns to active status.

DISCRETIONARY AUTHORITY, IF GOVERNED BY ERISA

The following applies only when the administration of the policy is governed by the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq.:

We may construe disputed or seemingly inconsistent provisions of the policy and make decisions regarding eligibility and/or entitlement to coverage or benefits.

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LEGAL ACTION

No legal action may be brought to obtain benefits under this policy:

1. for at least 60 days after proof of loss has been furnished; or

2. after the expiration of 3 years from the time proof of loss is required to have been furnished.

INCONTESTABILITY

After 2 years from the effective date of this policy, no misstatement of the policyholder, made in writing, can be used to void this policy. After 2 years, the validity of the policy may not be contested except for nonpayment of premiums.

CLERICAL ERROR

Clerical error on the part of the policyholder or us will not invalidate insurance otherwise in force nor continue insurance otherwise terminated. Upon discovery of any error, an adjustment will be made in the premiums and/or benefits available.

Complete proof must be supplied by the policyholder documenting any clerical errors.

AGENCY

For purposes of this policy, the policyholder acts on its own behalf or as the insured employee’s agent. Under no circumstances will the policyholder be deemed the agent of American Heritage Life Insurance Company.

ENTIRE CONTRACT

The contract consists of the following items:

1. the group policy; and

2. any amendments and endorsements; and

3. the applications and other written statements of the policyholder; and

4. any individual applications, enrollments, or other statements made by a covered person.

Any statements made by the policyholder or by a covered person, in the absence of fraud, are representations and not warranties. Only written statements signed by the policyholder or a covered person will be used in defense of a claim. A copy of any written statement, if applicable, will be furnished to the policyholder or the covered person or his or her personal representative, if any, if such written statement will be used in defense of a claim.

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CONTINUATION OF INSURANCE COVERAGE

This section provides for automatic Continuation of Insurance Coverage, hereafter referred to as Continuation Coverage.

It applies if a covered person suffers the loss of this group accident coverage due to one of the following events:

1. Termination of the insured employee’s employment; or of an insured employee’s eligibility due to reduction in his or her hours; or the date such insured employee is no longer in an eligible class; or the date such insured employee’s class is no longer eligible. Insurance may be continued for any covered person.

2. The death of an insured employee. Insurance may be continued for any covered person.

3. Divorce or legal separation. Insurance may be continued for any covered person whose insurance would otherwise end.

4. The insured employee or member becoming eligible for Medicare. Insurance may be continued for any covered person who is not entitled to Medicare.

5. A child ceasing to be an eligible dependent as defined in the group policy. Insurance may continue for that child.

6. The policyholder filing a Chapter 11 Bankruptcy petition. Insurance may be continued for any insured retiree and his or her covered dependents. But this only applies if the insurance ends or is substantially reduced within 1 year before or after the filing of the bankruptcy.

7. Termination of the group policy. (Benefits will be determined as if the group policy had remained in full force and effect.)

8. Strike, layoff, leave of absence for personal reasons (not Family or Medical Leave Act (FMLA)). Insurance may be continued for any covered person.

9. Military Service. The insured employee’s leave of absence due to military service. Insurance may be continued for any covered person, except for the person who is in active military service.

Continuation Coverage is not available for any person if coverage under the group policy terminated due to his or her failure to make required premium payments.

Continuation Coverage is not available to any person who is on FMLA. Continuation Coverage is also not available if a person fails to pay premium while on FMLA.

To be eligible for Continuation Coverage, a person must be insured under the group policy on the day before the event that caused loss of coverage. In the case of bankruptcy, the person must also be: (a) an employee who retired on or before the date insurance ends or is substantially reduced; or (b) a dependent of the retiree on the day before the bankruptcy.

COVERAGE CONTINUED

A person will not be denied Continuation Coverage solely because he or she is covered under another group accident plan like this one, or eligible for Medicare on the date of the event that caused loss of coverage.

The Continuation Coverage may include any eligible dependents who were covered under the group policy. The coverage being continued is subject to all terms and provisions of the group policy that do not conflict with this section. The coverage will be the same as that provided under the group policy for other persons in the same insurance class in which such person would have been if the loss of coverage had not occurred. The coverage will be subject to any changes to the group policy affecting the benefits of such class. The coverage will be effective on the day after the insurance under the group policy terminates.

NOTIFICATION AND PAYMENT REQUIREMENTS

The insured employee or other qualifying dependents have the responsibility to inform the insurer of: (a) divorce; (b) legal separation; or (c) a child losing eligibility under the policy. This notice must be made within 60 days of these events. Failure to provide this notification within 60 days will result in the loss of the right to continue the insurance.

The policyholder has the responsibility of notifying the insurer of: (a) an insured’s death, termination of employment, or reduction in hours; or (b) the policyholder’s bankruptcy. This notice must be made within 30 days of the event.

The insurer will notify the qualifying person of the right to continue within 14 days of the notice described above.

The qualifying person will be required to pay a premium for the Continuation Coverage to the insurer.

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CONTINUATION OF INSURANCE COVERAGE (Continued)

PREMIUMS

Premiums are due and payable in advance to us at our home office. Premium due dates are the first day of each calendar month. The premium rate for the first 36 months of Continuation Coverage will not exceed 102% of the rate in effect under the group policy covering a similarly situated class of employees who have not elected Continuation Coverage. After the first 36 months, the premium rate may change for the class of persons covered under Continuation Coverage. Notice will be given at least 60 days before any change is to take effect.

GRACE PERIOD

The grace period, as defined, will apply to each certificate holder of Continuation Coverage as if such insured is the policyholder.

TERMINATION OF INSURANCE

Insurance under Continuation Coverage will automatically end on the earliest of the following dates:

1. The date the person again becomes eligible for insurance under the group policy.

2. The last day for which premiums have been paid, if the insured fails to pay premiums when due, subject to the grace period.

3. With respect to insurance for dependents:

a. the date the insured employee’s insurance terminates; or

b. the date the dependent ceases to be an eligible dependent under the group policy.

A dependent child whose Continuation Coverage terminates when he or she reaches the age limit may apply for Continuation Coverage in his or her own name, if he or she is otherwise eligible.

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EXCLUSIONS AND LIMITATIONS

We will not pay any benefits for any loss that is caused by, contributed to by or results from:

1. injury incurred prior to the covered person’s effective date of coverage subject to the INCONTESTABILITY provision;

or

2. any act of war whether or not declared, participation in a riot, insurrection or rebellion; or

3. suicide, or any attempt at suicide, whether sane or insane; or

4. intentionally self-inflicted injury or action; or

5. any bacterial infection (except pyogenic food poisoning and infections which shall occur with and through an accidental cut or wound); or

6. participation in any form of aeronautics except as a fare-paying passenger in a licensed aircraft provided by a common carrier and operating between definitely established airports; or

7. engaging in an illegal occupation or committing or attempting to commit a felony; or

8. driving in any organized or scheduled race or speed test or while testing an automobile or any vehicle on any racetrack or speedway; or

9. hernia, including complications due to hernia; or

10. any injury sustained or contracted in consequence of the covered person’s being intoxicated or under the influence of any narcotic, unless administered and taken as prescribed by a physician.

Any injury incurred while a covered person is an active member of the Military, Naval, or Air Forces of any country or combination of countries is not covered. Upon notice and proof of service in such forces, we will return the pro-rata portion of the premium paid for any period of such service.

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BENEFIT INFORMATION

We pay the following benefits for a loss if, while this policy is in force, a covered person sustains an injury as a result of an accident. The injury must be diagnosed by a physician and the services described below must be provided or received within 180 days of the covered accident, or unless otherwise stated. Any loss not stated in the BENEFIT INFORMATION provision is not covered under this policy. The services must be received in the United States or its territories, except in the case of an emergency.

Initial Hospital Confinement: We pay the amount stated on page 3 the first time a covered person is confined in a hospital after that person’s effective date of coverage. This benefit is payable only once per covered person, per calendar year.

Daily Hospital Confinement: We pay the amount stated on page 3 for each day a covered person is confined in a hospital, up to a maximum of 365 days for any 1 accident, starting with the first full day of confinement. This maximum number of days may be used over a 2-year period following the date of the accident.

Intensive Care: We pay the amount stated on page 3 for each day a covered person is confined in a hospital intensive care unit, up to 180 days for each period of continuous confinement, starting with the first full day of confinement.

GVAEP6TX Page 11

CLAIM INFORMATION

NOTICE OF CLAIM

We encourage the insured employee to notify us of a claim as soon as possible so that a claim decision can be made in a timely manner. Notice of claim must be given to us within 20 days after the loss or commencement of any benefit covered by this policy, or as soon as reasonably possible. Notice given to us by, or on behalf of, the insured employee or the beneficiary at 1776 American Heritage Life Drive, Jacksonville, Florida 32224-6687, or to any authorized agent of ours, with the insured employee’s name and certificate number, is notice to us.

The claim form can be requested from us. If the form is not received within 15 days of the request, proof of the claim may be sent to us without waiting for the form.

FILING A CLAIM

The covered person must complete all applicable sections of the claim form and then give it to the attending physician. The physician should complete his or her section of the form and send it directly to us.

PROOF OF CLAIM

Proof must be given to us within 90 days after each loss. If it is not possible to give us proof in the time required, we will not reduce or deny any claim for this reason, as long as the proof is filed as soon as reasonably possible. In any event, the proof required must be given to us no later than 1 year from the time specified unless the insured employee is legally incapacitated.

PHYSICAL EXAMINATION AND AUTOPSY

We have the right, at our own expense, to have any covered person examined by a physician of our choosing, as often as may be reasonably required while a claim is pending. We may have an autopsy performed during the period of incontestability, where it is not forbidden by law.

PAYMENT OF CLAIMS

After receiving proof of loss, we pay all benefits then due under this policy. We will make payments to the insured employee unless such payments are assigned. Any amounts unpaid at the insured employee’s death may, at our option, be paid either to the named beneficiary or to the insured employee’s estate.

If benefits are payable to the insured employee’s estate or a beneficiary who cannot execute a valid release, we can pay benefits up to $1,000 to someone related to the insured employee or beneficiary by blood or marriage whom we consider to be entitled to the benefits. We will be discharged to the extent of any such payment made in good faith. There may be cases where a law requires that any benefits to be paid, be paid to an agency of government. We will abide by any such law that may apply. We will not be liable to the insured employee or anyone else for such benefits to the extent we are required by the law to pay them to such agency.

ASSIGNMENT

An assignment of the coverage under this policy is not binding on us, unless:

1 it is a request; and 2 it is received and recorded by us at our home office.

We are not responsible for the validity of any assignment. An assignment is subject to any payment we make or other action we take before we record the assignment. An assignee may not change the owner or beneficiary.

OVERPAID CLAIM

We have the right to recover any overpayments due to:

1. fraud; or

2. any error we make in processing a claim.

The insured employee must reimburse us in full. We will work with such insured employee to develop a reasonable method of repayment if he or she is financially unable to repay us in a lump sum.

We will not recover more money than the amount we overpaid.

GVAEP6TX Page 12

CLAIM INFORMATION (Continued)

CLAIM REVIEW

If a claim is denied, we will give written notice of:

1. the reason for denial; and

2. the policy provision that relates to the denial; and

3. the right to ask for a review of the claim; and

4. any additional information that might allow us to change our decision.

The insured employee may, upon request, read any reports that are not confidential. For a small fee, we will make copies of those reports for his or her use.

APPEALS PROCEDURE

Prior to filing any lawsuit and within 60 days after denial of a claim, the insured employee or his or her beneficiary must appeal any denial of benefits under the policy by making a request for review of the denial.

GVAEP6TX Page 13

GLOSSARY

(Glossary may contain terms that are not included in the coverage selected) Accident means a sudden, unforeseen and unexpected event which occurs without the covered person’s intent which results in an injury to the covered person independent of disease, infirmity or any other cause.

Active employment or actively employed means the employee is working for the employer for earnings that are paid regularly and that he or she is performing the material and substantial duties of his or her regular occupation. For the purposes of this policy:

1. the employee must be working at least the minimum number of hours as described under Eligible Class(es); and

2. the employee will be deemed to be in active employment on a day which is not the employer’s scheduled work days only if he or she was actively employed on the preceding scheduled work day.

The employee’s work site must be:

1. the employer’s usual place of business; or

2. an alternative work site at the direction of the employer; or

3. a location to which the job requires such employee to travel.

Normal vacation is considered active employment. However, if vacation days are used to cover disability, sickness or injury, those days are not considered active employment. Temporary and seasonal workers are excluded from coverage.

Calendar year means a consecutive 12 month period beginning on January 1st of each year and ending on December 31st of the same year.

Common carrier means only the following: commercial airlines; or passenger trains; or intercity buslines. It does not include: taxis; or intracity buslines; or private charter planes.

Confined or confinement means admitted to and confined as an inpatient in an institution for which a room and board charge is made by the institution. It does not include confinement for an observation room.

Continuous confinement means 1 continuous confinement or 2 or more confinements not separated by more than 30 days. If there are more than 30 days between confinements, they are considered separate confinements.

Covered person means any of the following:

1. any eligible family member (including the employee) as named in the enrollment form and acceptable for coverage by us; or

2. any eligible family member added by endorsement after the effective date; or

3. a newborn child.

Day means a 24 hour period.

Domestic partner means the insured employee’s same-sex or opposite-sex partner who is eligible for coverage provided that:

1. both the insured employee and his or her same-sex or opposite-sex partner must be considered as domestic partners according to the law of the insured employee’s state of residence; or

2. if the insured employee’s state of residence has no domestic partnership law, the insured employee must satisfy the definition of domestic partner as defined by the policyholder.

Eligibility Waiting Period means the continuous period of time that the employee must be in active employment in an eligible class before he or she is eligible for coverage.

Employee means a person who is a citizen or resident of the United States or one of its territories in active employment with his or her employer.

Employer means the individual, company or corporation where the employee is in active employment, and includes any division, subsidiary, or affiliated company named in this policy.

Family coverage means coverage that includes the insured employee, as defined, his or her eligible spouse or domestic partner and children.

GVAEP6TX Page 14

GLOSSARY (Continued)

Grace period means a period of 31 days following the premium due date during which premium payment may be made.

Hospital means a legally operated institution with established facilities (either on its premises or available to the hospital on a contractual, pre-arranged basis and under the supervision of a staff of one or more duly licensed physicians), for the care and treatment of sick and injured persons for diagnosis, surgery, and 24-hour nursing service. Hospital does not include:

1. any institution which is mainly a rest home, nursing home, convalescent home, or home for the aged; or

2. any institution which is mainly for the care and treatment of alcoholics or drug addicts, or mental or nervous disorders.

Hospital intensive care unit means a hospital area of special care, including cardiac and coronary care units, surgical intensive care units or cardiovascular intensive care units, which at the time of admission are separate and apart from the surgical recovery room, or other rooms, beds or wards normally used for patient confinement. In addition, such a unit must provide the following:

1. 24-hour continuous nursing care and attendance by nurses assigned to the unit on a full-time basis; and

2. direction and/or supervision by a full-time physician director or a standing “intensive care” committee of the medical staff; and

3. special medical apparatus used to treat the critically ill.

The following do not qualify as “hospital intensive care units”:

1. progressive care units;

2. sub-acute intensive care units;

3. intermediate care units;

4. private rooms with monitoring;

5. step-down units; or

6. any other lesser care treatment units.

Individual coverage means coverage that includes only the insured employee, as defined.

Individual and child(ren) coverage means coverage that includes only the insured employee, as defined, and eligible children.

Individual and spouse coverage means coverage that includes only the insured employee, as defined, and his or her eligible spouse or domestic partner.

Initial enrollment period means one of the following periods during which the employee may first apply in writing for coverage under this policy:

1. if the employee is eligible for coverage on the policy effective date, a period before the policy effective date as set by us and the policyholder; or

2. if the employee becomes eligible for coverage after the policy effective date, the period ending 31 days after the date he or she is first eligible to apply for coverage.

Injury means accidental bodily injury to a covered person as the result of an accident while coverage under this policy is in force and the injury is the direct cause of the loss independent of disease, bodily infirmity, or any other cause which results in medical treatment received within 180 days after the injury is sustained. All injuries sustained in any 1 accident and all complications and recurrences of complications are considered to be a single “injury”.

Inpatient means a covered person who is a resident patient using the room and board facilities of an institution.

Insured employee means the employee accepted for coverage by us who has completed and signed the enrollment form and whose name appears on the certificate specifications page.

Issue day means the same day of the month as the effective date of coverage.

Material and substantial duties means duties that:

1. are normally required for the performance of the employee’s regular occupation; and

2. cannot be reasonably omitted or modified, except that if the employee is required to work on average in excess of 40 hours per week, we will consider him or her able to perform that requirement if he or she is working or has the capacity to work 40 hours per week.

GVAEP6TX Page 15

GLOSSARY (Continued)

Nurse means any one of the following who is not a member of the covered person’s immediate family or employed by the hospital where the covered person is confined:

1. licensed practical nurse (L.P.N.); or

2. licensed vocational nurse (L.V.N.); or

3. graduate registered nurse (R.N.).

Payable claim means a claim for which we are liable under the terms of the policy.

Physician means:

1. a person performing tasks that are within the limits of his or her medical license; and

2. a person who is licensed to practice medicine and prescribe and administer drugs or to perform surgery; or

3. a person who is a legally qualified medical practitioner according to the laws and regulations of the state he or she practices in.

We will not recognize an employee, his or her spouse or domestic partner, children, parents, or siblings as a physician for a claim.

Plan means a line of coverage under the policy.

Policyholder means the legal entity to whom the policy is issued.

Temporary layoff or leave of absence or family and medical leave of absence means the insured employee is absent from active employment for a period of time that has been agreed to in advance in writing by the current employer.

Normal vacation time or any period of disability is not considered a temporary layoff or leave of absence.

Under the influence means a condition as determined by the laws of the state in which the loss occurred.

We, us and our means American Heritage Life Insurance Company.

GVAEP6TX Page 16

THIS IS A GROUP ACCIDENT ONLY POLICY WHICH PROVIDES BENEFITS FOR

ACCIDENTS AS DEFINED WITHIN THIS POLICY OR OTHER BENEFITS THAT MAY BE ADDED.

THIS POLICY DOES NOT PROVIDE BENEFITS FOR ANY OTHER CONDITIONS.

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.

GVAEP6TX

HOME OFFICE:

1776 AMERICAN HERITAGE LIFE DRIVE

JACKSONVILLE, FLORIDA 32224-6687

(904) 992-1776

A Stock Company

1776 American Heritage Life Drive, Jacksonville, Florida 32224-6687

ACCIDENTAL DEATH, DISMEMBERMENT AND FUNCTIONAL LOSS RIDER

This rider is issued in consideration of the rider premium and the written request for the rider. Benefits are paid in addition to the benefits of the policy to which it is attached. Benefits are subject to all of the terms, conditions and provisions of the policy. All terms defined and used in the policy apply to this rider unless otherwise provided in this rider.

DEFINITIONS

Common carrier means only the following: commercial airlines; or passenger trains; or intercity buslines. It does not include taxis; or intracity buslines; or private charter planes.

Injury means accidental bodily injury to a covered person as the result of an accident while coverage under this rider is in force and the injury is the direct cause of the loss independent of disease, bodily infirmity, or any other cause which results in a loss of life, dismemberment or functional loss within 180 days after the date the injury is sustained. All injuries sustained in any 1 accident and all complications and recurrences of complications are considered to be a single “injury”.

Policy means the policy to which this rider is attached.

Rider date means the effective date of coverage under this rider. The rider date is the policy effective date, unless this rider is applied for at a later date. If this rider is applied for at a later date, the rider date is the effective date assigned by our home office in accordance with our coverage dating rules in effect at the time this rider is issued.

BENEFIT

We pay the following benefits for a loss if, while this rider is in force, a covered person sustains an injury as a result of an accident. The injury must be diagnosed by a physician and the losses described below must occur within 180 days of the covered accident. Any loss not stated in the BENEFIT provision is not covered under this rider. The loss must occur in the United States or its territories, except in the case of an emergency.

Accidental Death: We pay the amount shown on page 3 of the policy if death results from an injury.

Common Carrier Accidental Death: We pay the amount shown on page 3 of the policy if death results from an injury while riding as a fare-paying passenger on a scheduled common carrier.

Dismemberment: We pay the amount shown on page 3 of the policy, multiplied by the applicable factor in the Schedule of Dismemberment and Functional Loss Factors if a covered person suffers a dismemberment that results from an injury.

If more than 1 dismemberment is sustained in any 1 injury, the total amount we will pay for the multiple dismemberments will not exceed the scheduled maximum benefit amount shown on page 3 of the policy.

Loss of hand or hands, or foot or feet, means total and permanent severance at or above the wrist or ankle joint. Loss of arm or arms or leg or legs, means severance at or above the elbow joint or knee joint. The loss of eye or eyes means the entire and irrecoverable loss of sight. The loss of finger means the severance through or above the proximal interphalangeal joint.

Functional Loss: We pay the amount shown on page 3 of the policy, multiplied by the applicable factor in the Schedule of Dismemberment and Functional Loss Factors if a covered person suffers a functional loss that results from an injury. If more than 1 functional loss is sustained in any 1 injury, the total amount we will pay for the multiple functional losses will not exceed the scheduled maximum benefit amount shown on page 3 of the policy.

Loss of hearing means the total and irreversible loss of hearing in both ears. Loss of hearing does not include loss of hearing that can be corrected by the use of any hearing aid or device. Loss of hearing must last for a continuous period of not less than 90 days as confirmed by a physician. Loss of speech means total and permanent loss of audible communication, if such loss cannot be corrected to any functional degree by any procedure, aid or device. Loss of speech must last for a continuous period of not less than 90 days as confirmed by a physician.

GEP6ADDTX Page 1

SCHEDULE OF DISMEMBERMENT AND FUNCTIONAL LOSS FACTORS

For the Loss of: Factor

Both Eyes 1.00

One Eye 0.50

Both Hands or Both Arms 1.00

Both Feet or Both Legs 1.00

One Hand or Arm and One Foot or Leg 1.00

One Hand or One Arm 0.50

One Foot or One Leg 0.50

One or more entire Toes 0.10

One or more entire Fingers 0.10

Hearing 1.00

Speech 1.00

The EXCLUSIONS AND LIMITATIONS provision of the policy applies to this rider.

TERMINATION

The insured employee’s coverage under this rider terminates at the earliest of:

1. the date the group policy is canceled; or

2. the last day of the period for which any required premium payments were made; or

3. the last day the insured employee is actively employed with the employer that is the policyholder, except as provided under the TEMPORARY LAYOFF, LEAVE OF ABSENCE OR FAMILY AND MEDICAL LEAVE OF ABSENCE provision;

or

4. the date the insured employee is no longer in an eligible class; or

5. the date the insured employee’s class is no longer eligible; or

6. the date of our discovery of fraud or material misrepresentation in the presentation of a claim under this rider.

Signed for AMERICAN HERITAGE LIFE INSURANCE COMPANY at its Home Office.

GEP6ADDTX Page 2

ACCIDENT TREATMENT AND URGENT CARE RIDER

This rider is issued in consideration of the rider premium and the written request for the rider. Benefits are paid in addition to the benefits of the policy to which it is attached. Benefits are subject to all of the terms, conditions and provisions of the policy. All terms defined and used in the policy apply to this rider unless otherwise provided in this rider.

DEFINITIONS

Policy means the policy to which this rider is attached.

Ride…