NOTICE OF

PROTECTION PROVIDED BY

VIRGINIA LIFE, AND ACCIDENT AND SICKNESS

INSURANCE GUARANTY ASSOCIATION

This notice provides a brief summary of the Virginia Life, Accident and Sickness Insurance Guaranty Association ("the Association") and the protection it provides for policyholders. This safety net was created under Virginia law, which determines who and what is covered and the amounts of coverage.

The Association was established to provide protection in the unlikely event that a life, annuity or accident and sickness insurance company (including a health maintenance organization) licensed in the Commonwealth of Virginia becomes financially unable to meet its obligations and is taken over by its Insurance Department. If this should happen, the Association will typically arrange to continue coverage and pay claims, in accordance with Virginia law, with funding from assessments paid by other life and health insurance companies licensed in the Commonwealth of Virginia.

The basic protections provided by the Association are:

• Life Insurance o $300,000 in death benefits o $100,000 in cash surrender or withdrawal values

• Health Insurance o $500,000 for health benefit plans o $300,000 in disability income insurance benefits o $300,000 in long-term care insurance benefits o $100,000 in other types of accident and sickness insurance benefits

• Annuities o $250,000 in withdrawal and cash values

The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $350,000, except for hospital, medical and surgical insurance benefits, for which the limit is increased to $500,000.

Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to any portion(s) of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or a variable annuity contract. There are also various residency requirements and other limitations under Virginia law.

To learn more about the above protections, please visit the Association's website at www.valifega.org or contact:

VIRGINIA LIFE, ACCIDENT AND SICKNESS

INSURANCE GUARANTY ASSOCIATION

c/o APM Management Services, Inc.

1503 Santa Rosa Road, Suite 101 Henrico, VA 23229-5105 804-282-2240

STATE CORPORATION COMMISSION

Bureau of Insurance P.O. Box 1157 Richmond, VA 23218-1157 804-371-9741 Toll Free Virginia only: 1-800-552-7945 http://scc.virginia.gov/boi/index/aspx

Insurance companies and agents are not allowed by Virginia law to use the existence of the Association or its coverage to encourage you to purchase any form of insurance. When selecting an insurance company, you should not rely on Association coverage. If there is any inconsistency between this notice and Virginia law, then Virginia law will control.

COMMONWEALTH OF VIRGINIA

REQUIRED POLICY INFORMATION

In the event you need to contact someone regarding your insurance for any reason, please contact your agent.

If you have additional questions, you may contact the insurance company issuing this policy at the address and telephone number listed below.

If you have been unable to contact or obtain satisfaction from the company or the agent, you may contact the Virginia Bureau of Insurance at the address and telephone number listed below.

Written correspondence is preferable so that a record of your inquiry is maintained. When contacting your agent, company or the Bureau of Insurance, have your policy number available.

Name and address of the Insurance Company Standard Insurance Company

P.O. Box 711 Portland, OR 97207

Telephone Number (971) 321-7000

Insurance Department Address Virginia Bureau of Insurance

Life and Health Division P.O. Box 1157 Richmond, VA 23218

Telephone Number In state: 1-800-552-7945 Out-of-state: (804) 371-9741

GC0614-ACC 172963-C

The Group Policy has been issued to the Policyholder. We certify that you will be insured as provided by the terms of the Group Policy. If your insurance is changed by an amendment to the Group Policy, we will provide the Policyholder or Employer with a revised Certificate or other notice that will be available to you.

Possession of this Certificate does not necessarily mean you are insured. You are insured only if you meet the requirements set out in this Certificate.

"You" and "your" mean the Member. "We", "us" and "our" mean Standard Insurance Company. Other defined terms appear with the initial letters capitalized. Section and provision headings, and references to them, appear in boldface type.

Your Certificate describes the insurance under the Group Policy. Please read your Certificate carefully.

THIS CERTIFICATE IS ISSUED UNDER A LIMITED BENEFIT POLICY THAT PROVIDES ACCIDENT INSURANCE BENEFITS AND IT DOES NOT PAY BENEFITS FOR LOSS FROM SICKNESS. THE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED DOES NOT PROVIDE COMPREHENSIVE HEALTH INSURANCE COVERAGE. IT IS NOT INTENDED TO SATISFY THE INDIVIDUAL MANDATE OF THE AFFORDABLE CARE ACT (ACA) OR PROVIDE THE MINIMUM ESSENTIAL COVERAGE REQUIRED BY THE ACA (OFTEN REFERRED TO AS “ MAJOR MEDICAL COVERAGE” ). IT DOES NOT PROVIDE COVERAGE FOR HOSPITAL, SURGICAL, OR MAJOR MEDICAL EXPENSES.

THIS CERTIFICATE IS NOT A MEDICARE SUPPLEMENT POLICY. IF YOU ARE ELIGIBLE FOR MEDICARE, REVIEW

THE “ GUIDE TO HEALTH INSURANCE FOR PEOPLE WITH MEDICARE” AVAILABLE FROM US.

THIS IS AN EXCEPTED BENEFITS POLICY. IT PROVIDES COVERAGE ONLY FOR

THE LIMITED BENEFITS OR SERVICES SPECIFIED IN THE POLICY.

GROUP ACCIDENT INSURANCE CERTIFICATE

Policyholder: Gloucester County Public Schools

Group Policy Number: 172963-C

Group Policy Effective Date: October 1, 2024

State of Issue: Virginia

STANDARD INSURANCE COMPANY

By

President and CEO

STANDARD INSURANCE COMPANY

A Stock Life Insurance Company 900 SW Fifth Avenue

Portland, Oregon 97204-1282

(503) 321-7000

Table of Contents

COVERAGE FEATURES

Employer(s)

Member

Class(es)

Work (Occupational) Accident Covered

Eligibility Waiting Period

Premium Contributions

Table Of Accident Insurance Benefit Amounts

Additional Features

ELIGIBILITY AND ENROLLMENT

Becoming Insured

When Your Insurance Becomes Effective

Changes in Your Insurance

Active Work Requirement

When Your Insurance Ends

CHILD INSURANCE

Eligibility for Child Insurance

When Child Insurance Becomes Effective

Changes in Child Insurance

When Child Insurance Ends

SPOUSE INSURANCE

Eligibility for Spouse Insurance

When Spouse Insurance Becomes Effective

Changes in Spouse Insurance

When Spouse Insurance Ends

ACCIDENT INSURANCE BENEFITS

Insuring Clause

Emergency Care Benefits

Air Ambulance Benefit

Blood, Plasma, and Platelet Benefit

Emergency Dental Benefit

Emergency Room Benefit

Ground Ambulance Benefit

Initial Care Visit Benefit

Major Diagnostic Exam Benefit

Outpatient X-Ray Benefit

Urgent Care Benefit

Specific Injury Benefits

Burn Benefit

Coma Benefit

Concussion Benefit

Dislocation Benefit

Eye Injury Benefit

Fracture Benefit

Laceration Benefit

Skin Graft Benefit

Surgical Benefits

Abdominal and Thoracic Surgery Benefit

Knee Cartilage Benefit

Ruptured Disc Benefit

Surgical Facility Benefit

Tendon, Ligament, and Rotator Cuff Surgery Benefit

Hospital Benefits

Critical Care Unit Admission Benefit

Daily Critical Care Unit Confinement Benefit

Daily Hospital Confinement Benefit

Daily Rehabilitation Facility Benefit

Hospital Admission Benefit

Follow Up Care Benefits

Appliance Benefit

Chiropractic Care Benefit

Follow Up Care Benefit

Hearing Device Benefit

Prosthesis Benefit

Therapy Services Benefit

Additional Benefits

Health Maintenance Screening Benefit

Lodging Benefit

Transportation Benefit

Youth Organized Sports Benefit

AD&D Benefits

Accidental Death Benefit

Accidental Dismemberment Benefit

Accidental Impairment Benefit

Value Added AD&D Benefits

Air Bag Benefit

Common Carrier Accidental Death Benefit

Helmet Benefit

Repatriation Benefit

Seat Belt Benefit

EXCLUSIONS

ADDITIONAL FEATURES

Reinstatement

Continuity of Coverage

Continuation of Insurance (Portability) for the Member

CLAIMS

Notice of Claim

Filing a Claim

Time Limits on Filing Proof Of Loss

Proof Of Loss

Investigation of Claim

Notice of Decision on Claim

Review Procedure

Time of Payment

Reimbursement

Unpaid Premium

BENEFIT PAYMENT AND BENEFICIARY PROVISIONS

Payment of Benefits

Naming a Beneficiary

Simultaneous Death Provision

No Surviving Beneficiary

GENERAL PROVISIONS

Assignment

Time Limits on Legal Actions

Incontestability of Insurance

Clerical Error

Agency

Misstatement of Age

DEFINITIONS

INDEX OF DEFINED TERMS

Accident or Accidental 27, 29 Active Work and Actively At Work 6 Admitted 27 Air Bag System 20 Ambulance (Ground or Air) 27 Ambulatory Surgical Center 27 Appliance 15 Automobile 27 Beneficiary 25 Calendar Year 27 Child 28 Child Safety Seat 21 Chip Fracture 12 Chiropractor 15 Coma 11 Common Carrier 20 Concussion 11 Confinement or Confined 28 Covered Accident 28 Critical Care Unit (CCU) 28 Dentist 9 Dependent(s) 28 Dislocation or Dislocated 11 Eligibility Waiting Period 28 Emergency Room 28 Employer 29 Follow Up Care 15 Fracture 12 Group Policy 29 Health Care Provider 29 Health Maintenance Screening Procedures 17 Health Service Facility or Facilities 29 Hearing Device 16 Helmet 20 Hemiplegia 19 Hospital 29 Initial Care 29 Injury or Injuries 29 Inpatient 29 Knee Cartilage 13 Laceration 12 Limb 29 Loss Of Hearing 19 Loss Of Sight 19 Major Diagnostic Exam 10 Mental Disorder 29 Moderate Loss Of Hearing 16 Novel infectious disease 17 Nurse Practitioner 30 Occupational Therapist 30 Organized Sport Event 18 Outpatient 30 Paraplegia 19

Physical Therapist 30 Physician 30 Physician Assistant 30 Pregnancy 30 Prior Plan 30 Proof Of Loss 23 Quadriplegia 19 Rehabilitation Facility 30 Seat Belt System 21 Speech Therapist 31 Spouse 31 Substance Abuse 31 Triplegia 19 Uniplegia 19 Urgent Care Facility 31

GC0614-ACC 1 172963-C

COVERAGE FEATURES

Employer(s)

Gloucester County Public Schools

Member

You are a Member if you are all of the following:

• A regular employee of the Employer working in the United States.

• Actively At Work at least 30 hours each week.

• A citizen or resident of the United States.

You are not a Member if you are:

• A temporary or seasonal employee.

• A full time member of the armed forces of any country.

• A leased employee.

• An independent contractor.

Class(es)

All Members

Work (Occupational) Accident Covered: Yes

Eligibility Waiting Period

If you are a Member on the Group Policy Effective Date, you are eligible on the first day of the calendar month following 30 consecutive days as a Member.

If you become a Member after the Group Policy Effective Date, you are eligible on the first day of the calendar month following 30 consecutive days as a Member.

Your Eligibility Waiting Period will be reduced by any continuous period as an employee of the Employer immediately prior to the date you become a Member.

Premium Contributions

For you and your Dependents: Contributory

Contributory means you pay all or part of the premium for insurance.

Table Of Accident Insurance Benefit Amounts

Emergency Care Benefits

Air Ambulance Benefit $1,500

Blood, Plasma, and Platelet Benefit $600

Emergency Dental Benefit

Crown

Extraction

$350

$150

Emergency Room Benefit $200

Ground Ambulance Benefit $600

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Initial Care Visit Benefit $60

Major Diagnostic Exam Benefit $300

Outpatient X-Ray Benefit $60

Urgent Care Benefit $60

Specific Injury Benefits

Burn Benefit

2nd degree burn less than or equal to 15% of body surface

$500

2nd degree burn greater than 15% of body surface

$1,500

3rd degree burn less than or equal to 15% of body surface

$7,500

3rd degree burn greater than 15% of body surface

$12,500

Coma Benefit $15,000

Concussion Benefit $200

Dislocation Benefit Non-surgical Surgical

Ankle $1,000 $2,000

Collarbone (sternocalvicular) $1,000 $2,000

Collarbone (acromio and separation)

$500 $1,000

Elbow $1,000 $2,000

Finger(s) $200 $400

Foot (not including toe(s)) $1,000 $2,000

Hand (not including finger(s)) $1,000 $2,000

Hip $3,500 $7,000

Knee (not including kneecap) $1,000 $2,000

Lower jaw $1,000 $2,000

Rib $200 $400

Shoulder $1,000 $2,000

Spine $500 $1,000

Toe(s) $200 $400

Wrist $1,000 $2,000

Partial Dislocation 25% of the non-surgical amount payable for the specific Dislocation amount shown above

Eye Injury Benefit $300

Fracture Benefit Non-surgical Surgical

Ankle $650 $1,300

GC0614-ACC 3 172963-C

Arm (elbow to wrist) $650 $1,300

Arm (shoulder to elbow) $650 $1,300

Bones of face (other than lower jaw or nose)

$750 $1,500

Coccyx $750 $1,500

Collarbone $650 $1,300

Elbow $650 $1,300

Finger(s) $200 $400

Foot (not including toe(s)) $650 $1,300

Hand (not including finger(s)) $650 $1,300

Hip $3,000 $6,000

Kneecap $650 $1,300

Leg (knee to ankle) $1,700 $3,400

Leg (hip to knee) $3,000 $6,000

Lower jaw $650 $1,300

Nose $750 $1,500

Pelvis $1,700 $3,400

Rib $500 $1,000

Shoulder blade $650 $1,300

Skull

Depressed

Non-depressed

$5,250

$2,000

$10,500

$4,000

Sternum $650 $1,300

Toe(s) $200 $400

Vertebrae $750 $1,500

Vertebral Column $1,700 $3,400

Wrist $650 $1,300

Chip Fracture 25% of the non-surgical amount payable for the specific Fracture shown above

Laceration Benefit

Less than 2 inches combined length for all lacerations

$100

2-6 inches combined length for all lacerations

$400

Over 6 inches combined length for all lacerations

$800

Skin Graft Benefit 50% of Burn Benefit

GC0614-ACC 4 172963-C

Surgical Benefits

Abdominal and Thoracic Surgery Benefit

Exploratory surgery (both laparoscopic and open)

$400

Laparoscopic surgical repair $1,000

Open surgical repair $2,000

Knee Cartilage Benefit

Exploratory surgery

One surgical repair

$250

$1,000

Ruptured Disc Benefit $1,000

Surgical Facility Benefit $500

Tendon, Ligament, and Rotator Cuff Surgery Benefit

Exploratory of any of the above

Repair of one of the above

Repair of more than one of the above

$250

$1,000

$1,500

Hospital Benefits

Critical Care Unit Admission Benefit $1,000

Daily Critical Care Unit Confinement Benefit

$200 per day

Daily Hospital Confinement Benefit $400 per day

Daily Rehabilitation Facility Benefit $150 per day

Hospital Admission Benefit $1,500

Follow Up Care Benefits

Appliance Benefit $200

Chiropractic Care Benefit $60 per day

Follow Up Care Benefit $70 per day

Hearing Device Benefit $600

Prosthesis Benefit

One Prosthetic

More than one Prosthetic

$1,000

$2,000

Therapy Services Benefit $50 per day

Additional Benefits

Health Maintenance Screening Benefit $50 per day

Lodging Benefit $200 per day

Transportation Benefit $200 per day

GC0614-ACC 5 172963-C

Youth Organized Sports Benefit 25% of total Covered Accident benefits payable for Child

Accidental Death and Dismemberment (AD&D) Benefits

Accidental Death Benefit (AD Benefit)

For you: $100,000

For your Spouse: $50,000

For your Child(ren): $25,000

Accidental Dismemberment Benefit

One hand or one foot 15% of AD Benefit

Both hands or feet 30% of AD Benefit

One hand and one foot 30% of AD Benefit

One finger or toe 2% of AD Benefit

More than one finger or toe 5% of AD Benefit

Accidental Impairment Benefit

Loss Of Hearing

One ear

Both ears

15% of AD Benefit

30% of AD Benefit

Loss Of Sight

One eye

Both eyes

15% of AD Benefit

30% of AD Benefit

Hemiplegia 30% of AD Benefit

Paraplegia 30% of AD Benefit

Quadriplegia 50% of AD Benefit

Triplegia 30% of AD Benefit

Uniplegia 15% of AD Benefit

Value Added AD&D Benefits

Air Bag Benefit 10% of AD Benefit

Common Carrier Accidental Death Benefit

100% of AD Benefit

Helmet Benefit 10% of AD Benefit

Repatriation Benefit 10% of AD Benefit

Seat Belt Benefit 10% of AD Benefit

Additional Features

Reinstatement

Continuity of Coverage

Continuation of Insurance (Portability) for the Member

GC0614-ACC 6 172963-C

ELIGIBILITY AND ENROLLMENT

Becoming Insured

To become insured you must:

• Be a Member.

• Complete your Eligibility Waiting Period.

• Meet the requirements shown in When Your Insurance Becomes Effective and Active Work Requirement.

When Your Insurance Becomes Effective

The Coverage Features states whether insurance is Contributory or Noncontributory. Subject to the Active Work Requirement, your insurance becomes effective as follows:

Contributory Insurance

You must apply in writing for Contributory insurance and agree to pay premiums. Contributory insurance becomes effective on:

• The date you become eligible if you apply on or before that date.

• The date you apply if you apply after you become eligible.

Changes in Your Insurance

Subject to the Active Work Requirement, you may apply in writing for any increase in your insurance, for which you are eligible.

Increases become effective on the latest of:

• The first day of the calendar month coinciding with or next following the date you apply for the increase.

Decreases become effective on the later of:

• The first day of the calendar month coinciding with or next following the date of change in your Class.

• The first day of the calendar month coinciding with or next following the date the Policyholder or Employer receives your written request for the decrease.

Active Work Requirement

If you are incapable of Active Work because of Sickness, Injury or Pregnancy on the day before the scheduled effective date of your insurance or an increase in your insurance under the Group Policy, your insurance or increase in your insurance will not become effective until the day after you complete 1 full day(s) of Active Work as an eligible Member.

Active Work and Actively At Work mean performing the material duties of your own occupation at your Employer's usual place of business.

You will also meet the Active Work Requirement if you meet all of the requirements shown below:

• You were absent from Active Work because of a regularly scheduled day off, holiday, or vacation day.

• You were Actively At Work on your last scheduled work day before the date of your absence.

• You were capable of Active Work on the day before the scheduled effective date of your insurance or increase in your insurance.

GC0614-ACC 7 172963-C

When Your Insurance Ends

Insurance ends automatically on the earliest of the following:

• For Contributory insurance, the date you notify your Employer or Policyholder in writing that coverage is to be terminated.

• The date the last period ends for which the premium was paid for your insurance.

• The date the Group Policy or your Employer's coverage under the Group Policy terminates, unless you continue your insurance under the Continuation of Insurance (Portability) for the Member provision.

• The date your employment terminates, unless you continue your insurance under the Continuation of Insurance (Portability) for the Member provision.

• The date you cease to be a Member. However, if you cease to be a Member because you are not working the required minimum number of hours, your insurance will be continued with payment of premium:

• During the first 60 day(s) of a temporary or indefinite administrative leave of absence or sick leave.

• During any other scheduled leave of absence approved by your Employer in advance and in writing and lasting not more than 60 day(s).

• During a leave of absence which is required by the federal or a state-mandated family or medical leave act or law.

CHILD INSURANCE

Eligibility for Child Insurance

You become eligible to insure your Child(ren) on the later of:

• The date your insurance becomes effective if you have a Child on that date.

• The date you first acquire a Child, if you are insured on that date.

A Member may not be insured as both a Member and a Child. A Child may not be insured by more than one Member.

For Contributory Child insurance, if you do not have Child insurance at the time you acquire a newborn or adopted Child, that Child is automatically insured for 31 days from the moment of birth or placement. However, you must apply in writing and pay premium back to the date of birth or placement within 31 days for Child insurance to continue. If your application is received after that 31 days, your automatic Child insurance under this provision ends on the first day after the 31 day period. This provision does not apply to you if you have an existing Child and you previously declined to enroll in Child insurance.

When Child Insurance Becomes Effective

The Coverage Features states whether your Child insurance is Contributory or Noncontributory. You must apply in writing for Contributory Child insurance and agree to pay premiums.

Contributory Child insurance becomes effective on the latest of:

• The date your insurance becomes effective if you have a Child on that date and you have applied for Child insurance.

• The first day of the calendar month coinciding with or next following the date you apply to insure your Child.

Changes in Child Insurance

Increases or decreases resulting from changes in your insurance will become effective for the Child on the effective date of your change in insurance.

GC0614-ACC 8 172963-C

When Child Insurance Ends

Your insurance for a Child ends automatically on the earliest of:

• The date your insurance ends, unless the Child insurance is continued under the Continuation of Insurance (Portability) for the Member provision.

• The date the Child insurance terminates under the Group Policy, unless the Child insurance is continued under the Continuation of Insurance (Portability) for the Member provision.

• The date a Child ceases to meet the definition of Child.

• The date the last period ends for which the premium was paid for your Child insurance.

• The date the Group Policy terminates or the date your Employer’s coverage under the Group Policy terminates, unless Child insurance is continued under the Continuation of Insurance (Portability) for the Member provision.

SPOUSE INSURANCE

Eligibility for Spouse Insurance

You become eligible to insure your Spouse on the later of:

• The date you become eligible for insurance if you have a Spouse on that date.

• The date you acquire a Spouse if you are insured on that date.

A Member may not be insured as both a Member and a Spouse.

When Spouse Insurance Becomes Effective

The Coverage Features states whether your Spouse insurance is Contributory or Noncontributory. You must apply in writing for Contributory Spouse insurance and agree to pay premiums.

Contributory Spouse insurance becomes effective on the latest of:

• The date your insurance becomes effective if you apply on or before that date to insure your Spouse.

• The first day of the calendar month coinciding with or next following the date you apply to insure your Spouse.

Changes in Spouse Insurance

Increases or decreases resulting from changes in your insurance will become effective for your Spouse on the effective date of your change in insurance.

When Spouse Insurance Ends

Your insurance for a Spouse ends automatically on the earliest of:

• The date your insurance ends, unless Spouse insurance is continued under the Continuation of Insurance (Portability) for the Member provision.

• The date Spouse insurance terminates under the Group Policy.

• The date a Spouse ceases to meet the definition of Spouse.

• The date the last period ends for which the premium was paid for your Spouse insurance.

• The date the Group Policy terminates, unless Spouse insurance is continued under the Continuation of Insurance (Portability) for the Member provision.

GC0614-ACC 9 172963-C

ACCIDENT INSURANCE BENEFITS

Insuring Clause

If you or your Dependent meet the requirements for Accident Insurance Benefits while insured under the Group Policy, we will pay benefits according to the terms of the Group Policy after we receive Proof Of Loss satisfactory to us.

Emergency Care Benefits

Air Ambulance Benefit

We will pay an Air Ambulance Benefit if you or your Dependent meet all of the following requirements:

• Transportation via air Ambulance is for the same Covered Accident for which a Daily Hospital Confinement Benefit, Hospital Admission Benefit, or Emergency Room Benefit is payable.

• Transportation is to a Hospital or Health Service Facility within 72 hours of the Covered Accident.

We will pay an Air Ambulance Benefit once per Covered Accident per insured person. A Ground Ambulance Benefit and Air Ambulance Benefit may be payable for the same Covered Accident.

Blood, Plasma, and Platelet Benefit

We will pay a Blood, Plasma, and Platelet Benefit if you or your Dependent meet all of the following requirements:

• Require a transfusion of blood, plasma, or platelets (including, the administration, cross matching, typing, and processing of blood, plasma, or platelets) for a Covered Accident.

• The transfusion is administered within 90 days of the Covered Accident.

We will pay a Blood, Plasma, and Platelet Benefit once per Covered Accident per insured person.

Emergency Dental Benefit

We will pay an Emergency Dental Benefit if you or your Dependent meet all of the following requirements:

• Suffer one or more broken teeth as a result of a Covered Accident which is repaired by a Dentist with dental crown(s) and/or dental extraction(s).

• Repair must begin within 90 days of the Covered Accident.

We will pay an Emergency Dental Benefit for 1 dental crown(s) and 1 dental extraction(s) per Covered Accident per insured person, regardless of how many dental crowns and dental extractions occur. We will not pay for routine dental examinations or procedures.

Dentist means a licensed doctor of dentistry, acting within the scope of the license. Dentist does not include you or your Spouse, or the brother, sister, parent or child of either you or your Spouse.

Emergency Room Benefit

We will pay an Emergency Room Benefit if you or your Dependent meet all of the following requirements:

• Visit an Emergency Room for a Covered Accident.

• The visit is within 72 hours of the Covered Accident.

We will pay an Emergency Room Benefit once per Covered Accident per insured person.

Ground Ambulance Benefit

We will pay a Ground Ambulance Benefit if you or your Dependent meet all of the following requirements:

• Transportation via ground Ambulance is for the same Covered Accident for which a Daily Hospital Confinement Benefit, Hospital Admission Benefit, or Emergency Room Benefit is payable.

GC0614-ACC 10 172963-C

• Transportation is to a Hospital or Health Service Facility within 90 days of the Covered Accident.

We will pay a Ground Ambulance Benefit once per Covered Accident per insured person. A Ground Ambulance Benefit and Air Ambulance Benefit may be payable for the same Covered Accident.

Initial Care Visit Benefit

We will pay an Initial Care Visit Benefit if you or your Dependent meet all of the following requirements:

• Visit a Health Care Provider for Initial Care due to a Covered Accident.

• The visit is within 72 hours of the Covered Accident.

We will pay an Initial Care Visit Benefit once per Covered Accident per insured person.

An Initial Care Visit Benefit is not payable if:

• Initial Care is rendered in an Urgent Care Facility or Emergency Room and an Urgent Care Benefit or Emergency Room Benefit is payable for the same Covered Accident.

• Initial Care occurs in a Health Care Provider’s office or clinic and a subsequent visit is made for the same Covered Accident to an Urgent Care Facility or Emergency Room within 24 hours of the Initial Care and an Urgent Care Benefit or Emergency Room Benefit is payable for the same Covered Accident.

Major Diagnostic Exam Benefit

We will pay a Major Diagnostic Exam Benefit if you or your Dependent meet all of the following requirements:

• Undergo a Major Diagnostic Exam due to a Covered Accident.

• The Major Diagnostic Exam is performed within 90 days of the Covered Accident.

Major Diagnostic Exam means:

• Computerized Tomography (CT) scan.

• Magnetic Resonance Imaging (MRI).

• Electroencephalogram (EEG).

• Magnetic Resonance Angiogram scan (MRA).

• Positron Emission Tomography (PET).

• Spectroscopy (SPECT).

We will pay a Major Diagnostic Exam Benefit once per Covered Accident per insured person, regardless of the number of Major Diagnostic Exams.

Outpatient X-Ray Benefit

We will pay an Outpatient X-Ray Benefit if you or your Dependent meet all of the following requirements:

• Undergo an X-ray due to a Covered Accident.

• An X-ray was performed on an Outpatient basis at a Hospital or Health Service Facility within 90 days of the Covered Accident.

We will pay an Outpatient X-Ray Benefit once per Covered Accident per insured person.

Urgent Care Benefit

We will pay an Urgent Care Benefit if you or your Dependent meet all of the following requirements:

• Visit an Urgent Care Facility due to a Covered Accident.

• The visit is within 72 hours of the Covered Accident.

GC0614-ACC 11 172963-C

We will pay an Urgent Care Benefit once per Covered Accident per insured person. An Urgent Care Benefit is not payable if an Emergency Room Benefit is payable for the same Covered Accident.

Specific Injury Benefits

Burn Benefit

We will pay a Burn Benefit if you or your Dependent meet all of the following requirements:

• Sustain a second or third degree burn as a result of a Covered Accident.

• Treated by a Physician within 72 hours of the Covered Accident.

We will pay a Burn Benefit once per Covered Accident per insured person. If you or your Dependent sustain a second degree and third degree burn for the same Covered Accident, we will pay both benefit amounts.

Coma Benefit

We will pay a Coma Benefit if you or your Dependent sustain a Coma due to a Covered Accident. We will pay a Coma Benefit once per Covered Accident per insured person.

Coma means a diagnosis for which there is a profound state of mental unconsciousness from which one cannot be aroused and there is no evidence of appropriate response to external stimulation, other than primitive avoidance reflexes. The diagnosis must:

• Be made by a Physician.

• Must last for at least 96 consecutive hours resulting in neurological deficit with persisting clinical symptoms.

Coma which is medically induced or coma as a result of Substance Abuse is not included.

Concussion Benefit

We will pay a Concussion Benefit if you or your Dependent meet all of the following requirements:

• Suffer a Concussion as a result of a Covered Accident.

• The diagnosis is made by a Physician within 72 hours of the Covered Accident.

We will pay a Concussion Benefit once per Covered Accident per insured person.

Concussion means a disruption of brain function resulting from a traumatic blow to the head, neck, or upper body.

Dislocation Benefit

We will pay a Dislocation Benefit if you or your Dependent meet all of the following requirements:

• Suffer a Dislocation or Partial Dislocation as a result of a Covered Accident and it is diagnosed within 90 days of the Covered Accident.

• The Dislocation or Partial Dislocation must require a surgical or nonsurgical procedure by a Physician.

• If a surgical procedure is required, the procedure must begin within 90 days of the Covered Accident.

We will pay a Dislocation Benefit for each Dislocation and Partial Dislocation per Covered Accident per insured person.

Dislocation or Dislocated means a separation of two bones where they meet at a joint.

Partial Dislocation means the partial, abnormal separation of the articular surfaces of a joint. Also, referred to as an incomplete dislocation or subluxation.

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Eye Injury Benefit

We will pay an Eye Injury Benefit if you or your Dependent meet one of the following requirements:

• Surgical repair of an eye is performed by a Physician due to a Covered Accident within 90 days of a Covered Accident.

• A Physician removes an embedded foreign body from the eye (with or without anesthesia) due to a Covered Accident within 90 days of a Covered Accident.

We will pay an Eye Injury Benefit once per eye per Covered Accident per insured person. The Eye Injury Benefit is not payable solely for an Injury to the eyelid or for an examination of the eye.

Fracture Benefit

We will pay a Fracture Benefit if you or your Dependent meet all of the following requirements:

• Suffer a Fracture or Chip Fracture as a result of a Covered Accident and it is diagnosed within 90 days of the Covered Accident.

• The Fracture or Chip Fracture must be corrected by a surgical or nonsurgical procedure by a Physician.

• If a surgical procedure is required, the procedure must begin within 90 days of the Covered Accident.

We will pay a Fracture Benefit for each Fracture and Chip Fracture suffered per Covered Accident per insured person.

Chip Fracture means any small fragmental Fracture, usually one involving a bony process near a joint.

Fracture means a break in a bone which is confirmed by X-ray or other diagnostic examination.

Laceration Benefit

We will pay a Laceration Benefit if you or your Dependent meet all of the following requirements:

• Suffer a Laceration as a result of a Covered Accident and it is treated within 72 hours of the Covered Accident.

• A wound closure is performed by a Health Care Provider to repair the Laceration. Wound closure includes, but is not limited to: staples, sutures, stitches, glue, or steristrips.

We will pay a Laceration Benefit once per Covered Accident per insured person. The amount payable is the total length of all lacerations received in any one Covered Accident per insured person.

Laceration means a cut.

Skin Graft Benefit

We will pay a Skin Graft Benefit if you or your Dependent meet all of the following requirements:

• A Burn Benefit is payable for the same Covered Accident.

• Skin grafting is performed by a Physician to repair the Injury.

We will pay a Skin Graft Benefit once per Covered Accident per insured person.

Surgical Benefits

Abdominal and Thoracic Surgery Benefit

We will pay an Abdominal and Thoracic Surgery Benefit if you or your Dependent meet all of the following requirements:

• An abdominal or thoracic surgery is performed by a Physician due to Injuries sustained in a Covered Accident.

• The surgery is performed within 72 hours of a Covered Accident.

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We will pay an Abdominal and Thoracic Surgery Benefit once per Covered Accident per insured person. If more than one abdominal or thoracic surgery is performed as a result of the same Covered Accident, we will pay the benefit for the surgery with the highest payable benefit amount.

Knee Cartilage Benefit

We will pay a Knee Cartilage Benefit if you or your Dependent meet one of the following requirements:

• Undergo exploratory surgery by a Physician for a suspected tear, rupture, or severance of the knee cartilage of one or both knees due to a Covered Accident within 90 days after the Covered Accident.

• Suffer a tear, rupture or severance of the knee cartilage of one or both knees due to a Covered Accident with diagnosis within 90 days after the Covered Accident with surgical repair by a Physician completed within 180 days of the Covered Accident.

We will pay a Knee Cartilage Benefit once per Covered Accident per insured person, regardless of whether one or both knees require surgical repair. If exploratory and surgical repair are performed for the same Covered Accident, we will pay the surgical repair benefit amount.

Knee Cartilage means the fibrous cartilage contained in the knee, known as the meniscus.

Ruptured Disc Benefit

We will pay a Ruptured Disc Benefit if you or your Dependent meet all of the following requirements:

• Suffer at least one ruptured disc in the spinal column as a result of a Covered Accident for which surgery is required.

• The ruptured disc must be treated by a Physician within 90 days of a Covered Accident, with completion of the surgery within 180 days of a Covered Accident.

We will pay a Ruptured Disc Benefit once per Covered Accident per insured person, regardless of the number of discs ruptured.

Surgical Facility Benefit

We will pay a Surgical Facility Benefit if you or your Dependent meet all of the following requirements:

• Surgery is performed by a Physician for a Covered Accident.

• Surgery for a Covered Accident is performed on an Outpatient basis at a Hospital or an Ambulatory Surgical Center.

• Surgery is within 90 days of the Covered Accident.

We will pay a Surgical Facility Benefit once per Covered Accident per insured person.

Tendon, Ligament, and Rotator Cuff Surgery Benefit

We will pay a Tendon, Ligament, and Rotator Cuff Surgery Benefit if you or your Dependent meet one of following requirements:

• Undergo exploratory surgery by a Physician for an Injury of the tendon, ligament, or rotator cuff due to a Covered Accident within 90 days of the Covered Accident.

• Suffer an Injury of the tendon, ligament, or rotator cuff due to a Covered Accident with diagnosis within 90 days after the Covered Accident with surgical repair by a Physician completed within 180 days of the Covered Accident.

We will pay a Tendon, Ligament, and Rotator Cuff Surgery Benefit once per Covered Accident per insured person. If we pay for one surgical repair and a second surgical repair is required for the same Covered Accident and the requirements above are met, we will pay the difference between the amount already paid for the first surgical repair and the amount due for the second surgical repair. If an exploratory and surgical repair are performed for the same Covered Accident, we will pay the surgical repair amount.

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Hospital Benefits

Critical Care Unit Admission Benefit

We will pay a Critical Care Unit Admission Benefit if you or your Dependent meet all of the following requirements:

• Admitted by a Physician to a Critical Care Unit due to a Covered Accident.

• Admission occurs within 90 days of a Covered Accident for diagnosis or treatment of Injuries sustained in a Covered Accident.

We will pay a Critical Care Unit Admission Benefit once per Covered Accident per insured person, regardless of the number of days Confined in the Critical Care Unit. The Critical Care Unit Admission Benefit may be paid in addition to the Hospital Admission Benefit.

Daily Critical Care Unit Confinement Benefit

We will pay a Daily Critical Care Unit Confinement Benefit for the days you or your Dependent meet all of the following requirements:

• Confined to a Critical Care Unit of a Hospital due to a Covered Accident.

• Confinement occurs within 15 days of a Covered Accident.

We will pay a Daily Critical Care Unit Confinement Benefit for up to 15 days per Covered Accident per insured person. A Daily Critical Care Unit Confinement Benefit may be paid in addition to a Daily Hospital Confinement Benefit.

Only one Daily Critical Care Unit Confinement Benefit is payable at a time, even if Confinement is caused by more than one Covered Accident.

Daily Hospital Confinement Benefit

We will pay a Daily Hospital Confinement Benefit for the days you or your Dependent meet all of the following requirements:

• Confined to a Hospital due to a Covered Accident.

• Confinement occurs within 15 days of the Covered Accident.

We will pay a Daily Hospital Confinement Benefit for up to 365 days per Covered Accident per insured person.

Only one Daily Hospital Confinement Benefit is payable at a time, even if Confinement is caused by more than one Covered Accident.

Daily Rehabilitation Facility Benefit

We will pay a Daily Rehabilitation Facility Benefit for the days you or your Dependent meet all of the following requirements:

• A Physician prescribes Confinement in a Rehabilitation Facility providing rehabilitation care services due to a Covered Accident.

• Confinement in the Rehabilitation Facility immediately follows a Confinement in a Hospital due to a Covered Accident.

We will pay a Daily Rehabilitation Facility Benefit for up to 90 days per Covered Accident per insured person.

A Daily Rehabilitation Facility Benefit is not payable if a Daily Hospital Confinement Benefit or Daily Critical Care Unit Benefit is payable for the same days of the same Covered Accident.

Only one Daily Rehabilitation Facility Benefit is payable at a time, even if Confinement is caused by more than one Covered Accident.

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Hospital Admission Benefit

We will pay a Hospital Admission Benefit if you or your Dependent meet all of the following requirements:

• Admitted by a Physician to a Hospital due to a Covered Accident.

• Admission occurs within 90 days of the Covered Accident.

We will pay a Hospital Admission Benefit once per Covered Accident per insured person, regardless of the number of days Confined in a Hospital. The Hospital Admission Benefit may be paid in addition to the Critical Care Unit Admission Benefit.

Follow Up Care Benefits

Appliance Benefit

We will pay an Appliance Benefit if you or your Dependent meet all of the following requirements:

• Use an Appliance as prescribed by a Physician, Physical Therapist, or Occupational Therapist as necessary due to an Injury sustained in a Covered Accident.

• Use of the Appliance is within 90 days of the Covered Accident.

We will pay an Appliance Benefit for 1 Appliance(s) per Covered Accident per insured person.

Appliance means a wheelchair, leg or back brace, crutches, walker, cane, a walking boot that extends above the ankle, or a brace for the neck.

Chiropractic Care Benefit

We will pay a Chiropractic Care Benefit if you or your Dependent meet all of the following requirements:

• Suffer a structural imbalance as a result of a Covered Accident and receive chiropractic care services from a Chiropractor in a chiropractic office.

• Visit the Chiropractor within 90 days of the Covered Accident and receive initial treatment within 90 days of a Covered Accident, with completion of the follow up treatment within 365 days of the Covered Accident.

We will pay a Chiropractic Care Benefit for up to 2 day(s) per Covered Accident per insured person.

Chiropractor means an individual who has obtained a professional degree in chiropractic care, is licensed by the state and performs chiropractic services acting within the scope of the license. Chiropractor does not include you or your Spouse or the brother, sister, parent or child of either you or your Spouse.

Follow Up Care Benefit

We will pay a Follow Up Care Benefit if you or your Dependent meet all of the following requirements:

• Visit a Health Care Provider for Follow Up Care of a Covered Accident.

• The Follow Up Care occurs within 90 days after Initial Care for the same Covered Accident, with completion of the Follow Up Care within 365 days of the Initial Care.

We will pay a Follow Up Care Benefit for up to 3 day(s) per Covered Accident per insured person.

A Follow Up Care Benefit is not payable if Follow Up Care is rendered in an Urgent Care Facility or Emergency Room and an Urgent Care Benefit or Emergency Room Benefit is payable for the same Covered Accident.

Follow Up Care means a visit to a Health Care Provider for ongoing medical services due to a Covered Accident.

Follow Up Care does not include occupational therapy, speech therapy, physical therapy, or chiropractic treatment.

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Hearing Device Benefit

We will pay a Hearing Device Benefit if you or your Dependent meet all of the following requirements:

• Suffer a Moderate Loss Of Hearing due to a Covered Accident and not due to the natural aging process.

• A licensed hearing aid specialist, audiologist, or a Diplomate of the American Board of Otolaryngology recommends a Hearing Device for a Covered Accident within 90 days of a Covered Accident.

• A Hearing Device is procured within 365 days of the recommendation.

We will pay a Hearing Device Benefit once per Covered Accident per insured person.

Hearing Device means an electronic device worn in or on the ear to help a person who has hearing loss to improve one’s ability to hear.

Moderate Loss Of Hearing means a loss of between 56-70 dB as certified by a licensed hearing aid specialist, audiologist, or a Diplomate of the American Board of Otolaryngology.

Prosthesis Benefit

We will pay a Prosthesis Benefit if you or your Dependent meet all of the following requirements:

• Sustain Injuries due to a Covered Accident for which you or your Dependent receive one or more prosthetic devices or artificial limbs as prescribed by a Physician for functional use.

• Receive an Accidental Dismemberment Benefit for the same Covered Accident for which the prosthetic device or artificial limb replaces.

• The prosthetic devices or artificial limbs must be prescribed by a Physician and received within 365 days of the Covered Accident.

The following are not prosthetic devices or artificial limbs:

• Hearing Devices.

• Dental aids (including false teeth).

• Eyeglasses.

• Artificial joints (including but not limited to hip and knee replacements).

• Cosmetic prosthesis such as hair wigs.

We will pay a Prosthesis Benefit once per Covered Accident per insured person.

Therapy Services Benefit

We will pay a Therapy Services Benefit if you or your Dependent meet all of the following requirements:

• A Health Care Provider prescribes occupational, speech or physical therapy by a licensed Occupational, Speech, or Physical Therapist due to a Covered Accident.

• Treatment must begin within 90 days of the Covered Accident and must be completed within 365 days.

We will pay a Therapy Services Benefit for up to 4 day(s) per Covered Accident per insured person.

Additional Benefits

Health Maintenance Screening Benefit

We will pay a Health Maintenance Screening Benefit if you or your Dependent meet all of the following requirements:

• A Health Maintenance Screening Procedure is performed.

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Health Maintenance Screening Procedures are limited to the following:

• Abdominal aortic aneurysm ultrasound.

• Ankle Brachial Index (ABI) screening for peripheral vascular disease.

• Biopsies for cancer.

• Bone density screening.

• Breast ultrasound.

• Cancer antigen 125 blood test for ovarian cancer (CA 125).

• Cancer antigen 15-3 blood test for breast cancer (CA 15-3).

• Carcinoembryonic antigen blood test for colon cancer (CEA).

• Colonoscopy.

• Complete Blood Count (CBC).

• Comprehensive Metabolic Panel (CMP).

• Electrocardiogram (EKG).

• Hemocult stool analysis.

• Hemoglobin AIC.

• Human Papillomavirus (HPV) vaccination.

• Lipid panel.

• Mammography.

• Mental health assessments, including but not limited to, PHQ-9, Beck’s Depression Inventory, Hamilton’s Depression Rating Scale.

• Novel infectious disease testing, including testing for antibodies related to novel infectious diseases.

• Pap smears or thin prep pap test.

• Prostate specific antigen (PSA) test.

• Stress test on a bicycle or treadmill.

We will pay a Health Maintenance Screening Benefit for 1 day(s) per insured person per Calendar Year.

Lodging Benefit

We will pay a Lodging Benefit for the days you or your Dependent meet all of the following requirements:

• Travel at least 50 miles from your or your Dependent’s residence to a place for treatment due to a Covered Accident and for which another Accident Insurance Benefit is payable.

• A lodging expense is incurred by you or your Dependent or another person.

We will pay you a Lodging Benefit for up to 30 days per Covered Accident per insured person. We will pay a total of 90 days during any 365 day period.

Transportation Benefit

We will pay a Transportation Benefit for the days you or your Dependent meet all of the following requirements:

• Travel at least 50 miles from your or your Dependent’s residence to a place for treatment due to a

• Another Accident Insurance Benefit is payable for the same Covered Accident.

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We will pay a Transportation Benefit for up to 30 days per Covered Accident per insured person. We will pay a total of 90 days during any 365 day period. The Transportation Benefit is not payable for travel in an Ambulance.

Youth Organized Sports Benefit

We will pay a Youth Organized Sports Benefit if all of the following requirements are met:

• While your Child is participating in an Organized Sport Event or scheduled practice, the Child suffers a Covered Accident and for which another Accident Insurance Benefit is payable for the same Covered Accident.

• Your Child is age 18 or younger.

• You provide proof of your Child’s registration in the Organized Sport Event.

We will pay a Youth Organized Sports Benefit once per Covered Accident per Child.

Organized Sport Event means a physical activity which is governed by an organization and requires formal registration to participate. This may include school, church, or other recreational leagues.

AD&D Benefits

Accidental Death Benefit

We will pay an Accidental Death Benefit if you or your Dependent meet all of the following requirements:

• Death is caused solely and directly by a Covered Accident.

• The death occurs independently of all other causes.

• The death occurs within 365 days after the Covered Accident.

Death will be presumed if you or your Dependent disappear and the disappearance:

• Is caused solely and directly by a Covered Accident that reasonably could have caused death.

• Occurs independently of all other causes.

• Continues for a period of 365 days after the date of the Covered Accident, despite reasonable search efforts.

Accidental Dismemberment Benefit

We will pay an Accidental Dismemberment Benefit if you or your Dependent meet all of the following requirements:

• As a result of a Covered Accident suffer one of the following dismemberments:

• One hand and one foot.

• Both hands or feet.

• One hand or one foot.

• One finger or toe.

• More than one finger or toe.

With respect to a hand or foot, dismemberment means actual and permanent severance from the body at or above the wrist or ankle joints, whether or not surgically reattached; or permanent, complete and irreversible loss of function.

With respect to finger(s), dismemberment means actual and permanent severance from the body at or above the metacarpophalangeal joints, whether or not surgically reattached; or permanent, complete and irreversible loss of function.

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With respect to toe(s), dismemberment means actual and permanent severance from the body at or above the metatarsophalangeal joints, whether or not surgically reattached; or permanent, complete and irreversible loss of function.

An Accidental Dismemberment Benefit is not payable for the dismemberment of fingers of the same hand if an Accidental Dismemberment Benefit is payable for the dismemberment of the entire hand.

An Accidental Dismemberment Benefit is not payable for the dismemberment of toes of the same foot if an Accidental Dismemberment Benefit is payable for the dismemberment of the entire foot.

• The dismemberment occurs within 365 days of the Covered Accident.

In the event you or your Dependent suffer more than one dismemberment as a result of the same Covered Accident, we will pay the applicable percentage for each dismemberment as shown in…