Critical_Illness_Policy_CITY_OF_ROSENBERG_EMPLOYEE_TRUST_GVCI_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 CRITICAL ILLNESS INSURANCE POLICY

NON-PARTICIPATING

American Heritage Life Insurance Company (referred to as we, us, our, or the company) will provide benefits under this policy. We make this promise subject to all of the provisions of this policy and any attached riders.

The policyholder should read this group 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, any amendments, riders, and/or attachments issued; and

2. the policyholders’ signed application.

This policy may be changed in whole or in part. The approval must be in writing, signed by one of 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.

This policy is a legal contract between the policyholder and the company.

Secretary President

THIS IS A GROUP CRITICAL ILLNESS POLICY WHICH ONLY PROVIDES

STATED BENEFITS FOR SPECIFIED CRITICAL ILLNESSES OR OTHER BENEFITS THAT MAY BE ADDED.

THIS POLICY DOES NOT PROVIDE BENEFITS FOR ANY OTHER SICKNESS OR CONDITION.

Read Your Policy Carefully.

GVCIP4TX Page 1

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 ...................................................................................................................... 4-5

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

EXCLUSIONS

BENEFIT INFORMATION ......................................................................................................................... 10 – 12

CONTINUATION OF INSURANCE COVERAGE

CLAIM INFORMATION............................................................................................................................. 14 – 15

GLOSSARY ............................................................................................................................................ 16 – 18

GVCIP4TX Page 2

POLICY SPECIFICATIONS

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.

ELIGIBLE CLASS(ES): All full-time active employees working at least 30 hours per week excluding those who are insured under any other critical illness policy issued by American Heritage Life Insurance Company

ELIGIBILITY WAITING PERIOD: None

EFFECTIVE DATES:

CERTIFICATE: The First Of The Month CHANGE IN COVERAGE: The First Of The Month TERMINATIONS: The End Of The Month

REINSTATEMENT IF REHIRED: Within 30 Days

INITIAL CRITICAL ILLNESS BENEFITS

PLAN I - BASIC BENEFIT AMOUNT: GUARANTEED ISSUE LIMIT:

Primary Insured Amount selected by the primary insured $10,000 Covered Spouse 50% of the primary insured’s Basic Benefit Amount $5,000 Covered Child(ren) 50% of the primary insured’s Basic Benefit Amount $5,000

ADDITIONAL BENEFITS:

Reoccurrence of Critical Illness Benefits Cancer Critical Illness Benefits Reoccurrence of Cancer Critical Illness Benefits

RIDERS:

Supplemental Critical Illness with HIV Rider Fixed Wellness Rider $50 per year Skin Cancer Rider $250 Specified Chronic Illness Rider

PLAN II - BASIC BENEFIT AMOUNT: GUARANTEED ISSUE LIMIT:

Primary Insured Amount selected by the primary insured $20,000 Covered Spouse 50% of the primary insured’s Basic Benefit Amount $10,000 Covered Child(ren) 50% of the primary insured’s Basic Benefit Amount $10,000

ADDITIONAL BENEFITS:

RIDERS:

Supplemental Critical Illness with HIV Rider Fixed Wellness Rider $50 per year Skin Cancer Rider $250 Specified Chronic Illness Rider

GVCIP4TX Page 3

POLICY SPECIFICATIONS (Continued)

MONTHLY RATES:

PLAN I - INITIAL RATE: MONTHLY RATE FOR EMPLOYEE:

PREMIUM

RATES

AGE

EMPLOYEE

ONLY

EMPLOYEE

& SPOUSE

EMPLOYEE

CHILD(REN)

FAMILY

UNI-TOBACCO 18-29 $4.53 $7.52 $4.53 $7.52

30-39 $9.46 $15.04 $9.46 $15.04 40-49 $19.23 $29.97 $19.23 $29.97 50-59 $33.94 $52.33 $33.94 $52.33 60-64 $46.35 $71.14 $46.35 $71.14 65+ $71.96 $109.93 $71.96 $109.93

PLAN II - INITIAL RATE: MONTHLY RATE FOR EMPLOYEE:

PREMIUM

RATES

AGE

EMPLOYEE

ONLY

EMPLOYEE

& SPOUSE

EMPLOYEE

CHILD(REN)

FAMILY

UNI-TOBACCO 18-29 $7.68 $12.20 $7.68 $12.20

30-39 $17.23 $26.69 $17.23 $26.69 40-49 $36.33 $55.55 $36.33 $55.55 50-59 $65.13 $99.08 $65.13 $99.08 60-64 $89.49 $135.84 $89.49 $135.84 65+ $139.94 $211.89 $139.94 $211.89

RATE GUARANTEE DATE:

October 1, 2018

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 primary insured 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 entities in all matters that pertain to this policy. Every act done by, agreement made with, or notice given to the policyholder will be binding on them.

Name Location (City and State) None

GVCIP4TX Page 3A

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;

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

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

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 at 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;

b. who are requesting a coverage change;

c. whose coverage ends;

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 can be canceled:

1. by us; or

2. by the policyholder.

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

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

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

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

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

5. fewer than 5 employees are insured; or

6. the policyholder fails to pay any premium due by the end of the grace period.

When both we and the policyholder agree, in writing, this policy may be modified on an earlier date.

If the premium is not paid during the grace period, this policy will terminate automatically on the due date of any unpaid premium. The policyholder is liable for the premium for coverage through the end of the grace period. The policyholder must pay us all premiums due for the full period this policy is in force.

The policyholder may cancel this policy by written 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.

GVCIP4TX Page 4

GENERAL PROVISIONS

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. a re-enrollment period, subject to evidence of insurability.

2. The primary insured may:

a. increase coverage at any time, subject to evidence of insurability;

b. decrease coverage at any time; or

c. discontinue coverage at any time.

WHEN EVIDENCE OF INSURABILITY IS REQUIRED

Evidence of insurability is required if:

1. the employee:

a. voluntarily canceled coverage and is reapplying;

b. is applying for an amount of coverage over the Guaranteed Issue Limit;

c. is applying for the coverage, or an increase in the amount of coverage, at any time after his or her initial enrollment period;

2. an eligible spouse or domestic partner was not enrolled within 31 days of eligibility.

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 him or her provided that he or she is actively employed on that date.

If the employee is not actively employed on that date due to a 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 his or her initial coverage is effective.

For any change in coverage that is subject to evidence of insurability, the change in coverage is effective on the date we approve such change and in accordance with the Policy Specifications page.

For any change in coverage that is not subject to evidence of insurability, the change in coverage is effective when we receive such request for change and as stated on the Policy Specifications page.

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

If an employee terminates employment and returns to work for the policyholder within the timeframe stated on the Policy Specifications page, this coverage may be reinstated without providing evidence of insurability.

CERTIFICATES OF INSURANCE

We will furnish to the policyholder a certificate of insurance for delivery to each primary insured that describes the terms of the coverage made available to the eligible employees of the policyholder and their eligible dependents. 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 or any attached riders, the provisions of this policy and any attached riders govern.

GVCIP4TX Page 5

GENERAL PROVISIONS (Continued)

ELIGIBILITY OF DEPENDENTS

Eligible dependents are the primary insured’s:

1. spouse or domestic partner; and

2. child(ren) and spouse’s or domestic partner’s children.

If the primary insured marries and desires coverage for his or her spouse, the policyholder must be notified of the marriage within 31 days of the marriage. Upon notice to us, we will change the coverage to include the spouse and provide notification of any additional premium due.

If the primary insured enters into a domestic partnership and desires coverage for his or her domestic partner, the policyholder must be notified 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 domestic partner and provide notification of the additional premium due.

A child born to the primary insured 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.

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 primary insured or his or her spouse or domestic partner has been entered within 31 days after the date of birth.

2. If adoption proceedings have been instituted by the primary insured or his or her spouse or domestic partner 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 primary insured or his or her spouse or domestic partner has custody of the child pursuant to decree of the court.

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

If the primary insured 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 he or she ceased active employment.

If his or her coverage ends while on a Family and Medical Leave of Absence, the coverage may be reinstated when he or she returns to active status.

We will not require evidence of insurability.

GVCIP4TX Page 6

TERMINATION OF COVERAGE

The coverage under this policy ends on the earliest of:

1. the date this policy is canceled;

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

3. the last day the primary insured 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;

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

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

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

Coverage for a covered person terminates when he or she has exhausted all available benefits under this policy and any attached riders.

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

The primary insured or other qualifying dependents have the responsibility to inform us of: (a) divorce; (b) legal separation;

or (c) a child losing eligibility under this policy.

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

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

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

Coverage for a dependent grandchild will not terminate solely because they are no longer dependent on the primary insured for federal income tax purposes.

Coverage does not end at age 26 for an incapacitated dependent child who:

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

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

3. is chiefly dependent upon the primary insured 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 receive premium for coverage extending beyond the date or event specified for termination as to a covered person, such premium will be refunded, coverage will terminate and claims will not be paid.

Coverage may be eligible for continuation as outlined in the Continuation of Insurance Coverage provision.

DISCRETIONARY AUTHORITY, IF GOVERNED BY ERISA

The following applies only when the administration of this 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 this policy and any attached riders and to make all decisions regarding eligibility and/or entitlement to coverage or benefits. Whenever we make reasonable determinations which are not arbitrary or capricious in the administration of this policy, such determinations shall be final and conclusive.

GVCIP4TX Page 7

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 or covered person, made in any application, can be used to void this policy. After 2 years, the validity of the policy may not be contested except for nonpayment of premiums.

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.

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 primary insured’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;

2. any amendments and endorsements;

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

4. any individual applications, enrollments, evidence of insurability or other statements of the primary insured or a covered person.

CHANGE OF BENEFICIARY

Any change of beneficiary must be filed at our home office. It will not take effect unless so filed, but if so filed, will take effect on the date signed by the primary insured. This will be true whether or not the primary insured is living on the date it is filed.

There will be no prejudice to us on account of any payment we make prior to its receipt by us at our home office.

The right to change a beneficiary is reserved to the primary insured. The consent of the beneficiary or beneficiaries will not be required to assign benefits or to change a beneficiary or beneficiaries, or to make any other changes, unless the designation of the beneficiary is irrevocable.

ASSIGNMENT

An assignment of benefit is not binding on us unless:

1. it is a written request; and

2. it is received by us at our home office.

An assignment will take effect when recorded at our home office. We are not responsible for the validity of any assignment.

GVCIP4TX Page 8

EXCLUSIONS

We will not pay benefits for a critical illness that is, or is caused by, or contributed to by, or results from:

1. intentionally self-inflicted injury or action;

2. illegal activities or committing or attempting to commit a felony;

3. suicide while sane, or self-destruction while insane, or any attempt at either;

4. substance abuse, to include abuse of alcohol, alcoholism, abuse of legally obtained prescription medication, or illegal use of a non-prescribed drug or narcotic; or

5. the covered person being under the influence of alcohol, a drug, or a narcotic, unless administered and taken as prescribed by a physician.

(This space intentionally left blank.)

GVCIP4TX Page 9

CRITICAL ILLNESS BENEFITS

GENERAL

Subject to the conditions, limitations and exclusions of this policy and any attached riders, we will pay a benefit when a covered person is diagnosed with a critical illness described in this policy or any attached rider if:

1. the date of diagnosis for the critical illness or the date of loss is while the covered person is insured under this policy and any attached riders; and

2. the critical illness is not excluded by name or specific description.

A covered person can receive benefits for different critical illnesses or specified diseases described in this policy and any attached riders if the dates of diagnosis for each critical illness are separated by at least 30 days.

Each critical illness must be diagnosed by a physician qualified to make such diagnosis. Claims for benefits not satisfying all the criteria for diagnosis may be subject to review by an independent physician consultant.

We do not pay any benefit for any condition or loss not described in this policy or any attached rider.

INITIAL CRITICAL ILLNESS BENEFITS

A covered person can receive a benefit for each critical illness only once, unless the Reoccurrence of Critical Illness Benefits provision is included in the coverage.

A. BENEFIT AMOUNTS. The benefit amount for each Initial Critical Illness is the percentage shown below for that Initial

Critical Illness multiplied by the Basic Benefit Amount for the Initial Critical Illness Benefit shown on the Policy Specifications page applicable to the covered person.

Initial Critical Illness Percentage of Basic Benefit Amount

Heart Attack 100% Stroke 100%

End Stage Renal Failure 100% Major Organ Transplant 100%

Coronary Artery By-Pass Surgery 25%

B. BENEFIT DESCRIPTIONS. The Initial Critical Illnesses are:

1. Heart Attack. The death of a portion of heart muscle as a result of inadequate blood supply to the relevant area.

The diagnosis must be based on both:

a. new electrocardiographic changes; and

b. elevation of cardiac enzymes or biochemical markers showing a pattern and to a level consistent with a diagnosis of heart attack.

Heart Attack does not include an established (old) myocardial infarction or cardiac arrest.

The date of diagnosis for Heart Attack is the date of death (infarction) of a portion of the heart muscle.

2. Stroke. The death of a portion of the brain producing neurological sequelae including infarction of brain tissue, hemorrhage and embolization from an extra-cranial source. There must be evidence of permanent neurological deficit.

Stroke does not include: transient ischemic attacks (TIA’s), head injury, chronic cerebrovascular insufficiency or reversible ischemic neurological deficits.

The date of diagnosis for Stroke is the date the stroke occurred based on documented neurological deficits and neuroimaging studies.

GVCIP4TX Page 10

CRITICAL ILLNESS BENEFITS (Continued)

B. BENEFIT DESCRIPTIONS. (Continued)

3. End Stage Renal Failure. The irreversible failure of both kidneys to perform their essential functions, with the covered person undergoing peritoneal dialysis or hemodialysis.

End stage renal failure does not include renal failure caused by a traumatic event, including surgical traumas.

The date of diagnosis for End Stage Renal Failure is the date renal dialysis first begins due to the irreversible failure of both kidneys to perform their essential functions.

4. Major Organ Transplant. Being placed on the National Transplant List or the performance of a surgical transplantation of a major organ.

a. Candidate Benefit. A covered person is placed on the National Transplant List as an active or an inactive candidate for a major organ transplant.

The Candidate Benefit is not payable if we have previously paid:

i. the Candidate Benefit on the covered person, for any reason; or

ii. the Surgery Benefit on the covered person for the same major organ.

b. Surgery Benefit. A covered person undergoes a major organ transplant, performed by a physician.

The Surgery Benefit is not payable if we have previously paid the Candidate Benefit on the covered person for the same major organ. If we paid the Candidate Benefit for a covered person listed as a candidate for multiple major organ transplants, only the first one of those major organs transplanted will be considered the same major organ.

No benefit is payable for major organ transplants using mechanical or non-human organs.

Major Organ means the heart, lungs, liver, pancreas, or kidneys. Lungs and kidneys are each one major organ regardless of whether one or both lungs, or one or both kidneys, are transplanted.

Major organ transplant means the surgical transplant, by a physician, of a major organ. Each major organ transplanted is a major organ transplant eligible for the Surgery Benefit, even if multiple major organ transplants are performed in one surgical procedure.

National Transplant List means the database containing information on all people in the United States and Puerto Rico who are waiting for one or more major organ transplants, as mandated by the National Organ Transplant Act.

The date of loss for Major Organ Transplant is the date a covered person:

a. is placed on the National Transplant List, as an active or an inactive candidate, for a major organ transplant; or

b. undergoes the actual surgery for a major organ transplant.

5. Coronary Artery By-Pass Surgery. The surgical operation to correct narrowing or blockage of one or more coronary arteries with by-pass grafts on the advice of a cardiologist registered in the United States. Angiographic evidence to support the necessity for this surgery will be required.

Coronary Artery By-Pass Surgery does not include: abdominal aortic bypass; balloon angioplasty; laser embolectomy; atherectomy; stent placement; or other non-surgical procedures.

The date of loss for Coronary Artery By-Pass Surgery is the date the actual coronary artery by-pass surgery occurs.

GVCIP4TX Page 11

ADDITIONAL BENEFITS

REOCCURRENCE OF CRITICAL ILLNESS BENEFITS

We will pay a benefit for a reoccurrence of a critical illness if a covered person is diagnosed for a second time with an initial critical illness for which a benefit was previously paid under the Initial Critical Illness Benefits provision if:

1. the second date of diagnosis is more than 12 months after the first date of diagnosis for the initial critical illness; and

2. the second date of diagnosis is while the covered person is insured under this policy.

The benefit amount is equal to the benefit amount previously paid for that initial critical illness. A covered person can receive a benefit for a reoccurrence of a critical illness only once for each initial critical illness.

Initial Critical Illness Heart Attack

Stroke End Stage Renal Failure Major Organ Transplant

Coronary Artery By-Pass Surgery

CANCER CRITICAL ILLNESS BENEFITS

A. BENEFIT AMOUNTS. The benefit amount for each Cancer Critical Illness is the percentage shown below for that

Cancer Critical Illness multiplied by the Basic Benefit Amount for the Initial Critical Illness Benefit shown on the Policy Specifications page applicable to the covered person.

Cancer Critical Illness Percentage of Basic Benefit Amount

Carcinoma In Situ 25% Invasive Cancer 100%

B. BENEFIT DESCRIPTIONS. The Cancer Critical Illnesses are:

1. Carcinoma In Situ. A cancer wherein the tumor cells still lie within the tissue of origin without having invaded neighboring tissue. Carcinoma In Situ includes:

a. early prostate cancer diagnosed as stages A, I or II or equivalent staging; and

b. melanoma not invading the dermis.

Carcinoma In Situ does not include:

a. other skin malignancies;

b. pre-malignant lesions (such as intraepithelial neoplasia); or

c. benign tumors or polyps.

2. Invasive Cancer. A malignant tumor characterized by the uncontrolled growth and spread of malignant cells and the invasion of tissue. Invasive Cancer includes Leukemia and Lymphoma.

Invasive Cancer does not include:

a. Carcinoma In Situ;

b. skin cancer other than invasive malignant melanoma in the dermis or deeper or skin malignancies that have become metastatic; or

c. early prostate (stages A, I or II) cancer.

C. DIAGNOSIS REQUIREMENTS. A Cancer Critical Illness must be diagnosed in one of two ways:

1. Pathological diagnosis means identification of cancer based on a microscopic study of fixed tissue or preparations from the hemic (blood) system. This type of diagnosis must be done by a certified pathologist whose diagnosis is in keeping with the standards set by the American Board of Pathology.

2. Clinical diagnosis means a clinical identification of cancer based on history, laboratory study, and symptoms. We will pay benefits for a clinical diagnosis only if:

a. a pathological diagnosis cannot be made because it is medically inappropriate or life-threatening; and

b. there is medical evidence to support the diagnosis.

The date of diagnosis for Cancer Critical Illness is the day the tissue specimen, culture and/or titer(s) are taken on which the first diagnosis of cancer is based.

The “first diagnosis of cancer” includes a diagnosis of a reoccurrence of a cancer that was previously diagnosed before the effective date of coverage if, after the previous diagnosis and before the date of diagnosis of the reoccurrence, the covered person is free of any symptoms and treatment of the cancer for the 12 consecutive months immediately preceding the effective date of coverage or any 12 consecutive months thereafter.

For purposes of this benefit, “treatment” does not include maintenance drug therapy or routine follow-up office visits to verify if the Cancer Critical Illness has returned.

“Maintenance drug therapy” means ongoing hormonal therapy, immunotherapy or chemo-prevention therapy that may be given following the full remission of a cancer due to primary treatment. It is meant to decrease the risk of cancer reoccurrence rather than the palliation or suppression of a cancer that is still present.

REOCCURRENCE OF CANCER CRITICAL ILLNESS BENEFITS

We will pay a benefit for a reoccurrence of cancer critical illness if a covered person is diagnosed for a second time with a cancer critical illness for which a benefit was previously paid under the Cancer Critical Illness Benefits provision if:

1. the second date of diagnosis is more than 12 months after the first date of diagnosis for the cancer critical illness;

2. the covered person did not receive treatment during that 12 month period; and

3. the second date of diagnosis is while the covered person is insured under this policy.

The benefit amount is equal to the benefit amount previously paid for that cancer critical illness. A covered person can receive a benefit for a reoccurrence of a cancer critical illness only once for each cancer critical Illness.

Cancer Critical Illness Carcinoma In Situ Invasive Cancer

For purposes of this benefit, “treatment” does not include maintenance drug therapy or routine follow-up office visits to verify if the cancer critical illness has returned.

WAIVER OF PREMIUM BENEFIT

We will waive premiums for this coverage if, while covered under this policy and any attached riders, the primary insured:

1. becomes disabled due to a covered critical illness for which a benefit is paid; and

2. remains disabled for at least 90 consecutive days.

After the 90th day, we will waive the premiums due for the first 90 days and each consecutive day thereafter the primary insured is disabled, until the earliest of:

1. the date the primary insured is no longer disabled;

2. 2 years from the first day of disability; or

3. the date coverage ends according to the Termination of Coverage provision.

“Disabled” means the primary insured is:

1. unable to work;

2. not working at any job for pay or benefits; and

3. under the care of a physician for the treatment of a covered critical illness.

“Unable to work” means:

1. During the first 365 days of disability, the primary insured is unable to perform the material and substantial duties of the occupation he or she was performing when his or her disability began.

2. During the second 365 days of disability, the primary insured is unable to perform the material and substantial duties of any gainful occupation for which he or she is suited by education, training or experience.

This benefit is payable only for the disability of the primary insured. It does not apply to any other covered person. The primary insured must provide sufficient proof of disability at least once every 6 months.

GVCIP4TX Page 12

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 critical illness coverage due to one of the following events:

1. Termination of the primary insured’s employment; or of a primary insured’s eligibility due to reduction in his or her hours;

or the date such primary insured is no longer in an eligible class; or the date such primary insured’s class is no longer eligible. Insurance may be continued for any covered person.

2. The death of a primary insured. 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 primary insured 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 this policy. Insurance may continue for that child.

6. The policyholder filing a Chapter 11 Bankruptcy petition. Insurance may be continued for any retired primary insured 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 policy. (Benefits will be determined as if the policy had remained in full force and effect.)

8. Strike, layoff, leave of absence for personal reasons. Insurance may be continued for any covered person.

9. Military Service. The primary insured’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 policy terminated due to his or her failure to make required premium payments.

To be eligible for continuation coverage, a person must be insured under the 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 critical illness plan, 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 policy. The coverage being continued is subject to all terms and provisions of the policy that do not conflict with this section. The coverage will be the same as that provided under the 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 policy affecting the benefits of such class. The continuation coverage will be effective on the day after the coverage under the policy terminates.

NOTIFICATION AND PAYMENT REQUIREMENTS

The primary insured or other qualifying dependents have the responsibility to inform the insurer of: (a) divorce; (b) legal separation; or (c) a child losing eligibility under this 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) a covered person’s death; (b) termination of the primary insured’s employment or reduction in hours; or (c) 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.

GVCIP4TX Page 13

COIC

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 policy covering a similarly situated class of primary insureds 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 covered person is the policyholder.

TERMINATION OF INSURANCE

Insurance under continuation coverage will automatically end on the earliest of the following dates:

1. the date the covered person again becomes eligible for insurance under the policy;

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

3. with respect to insurance for dependents:

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

b. the date the dependent ceases to be an eligible dependent under the 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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GVCIP4TX Page 13A

COIC

CLAIM INFORMATION

NOTICE OF CLAIM

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

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

FILING A CLAIM

The primary insured must complete all applicable sections of the claim form and then give it to the covered person’s attending physician. The physician should complete the attending physician’s statement and send it directly to us.

PROOF OF CLAIM

Written proof of claim must be furnished to us within 90 days of each critical illness or payable loss. If it is not possible to give us written proof in the time required, we will not reduce or deny any claim as long as it can be shown that it was not reasonably possible to provide the proof at an earlier date, and the proof is provided as soon as was reasonably possible.

In any event, the proof required must be given to us no later than one (1) year from the time specified, unless the primary insured is legally incapacitated.

Written proof of the eligibility of dependent child(ren) may be required at the time of claim.

PHYSICAL EXAMINATION AND AUTOPSY

We have the right, at our own expense, to have the 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 all required written proof of claim, we will pay all benefits then due under this policy and any attached riders.

We will make payment to the primary insured, unless such payments are assigned. Any amounts unpaid at the primary insured’s death will be paid to the named beneficiary.

If there is no named beneficiary, or the named beneficiary does not survive the primary insured, we will pay any benefits due in the following order:

1. to the primary insured’s living spouse or domestic partner; otherwise

2. to the covered person’s living children, in equal shares; otherwise

3. to the covered person’s living parents, in equal shares; otherwise

4. to the covered person’s living siblings, in equal shares; otherwise

5. to the covered person’s estate.

If benefits are payable to an individual who cannot execute a valid release, or to the primary insured’s estate, we may pay benefits up to $1,000, to someone related to the primary insured or his or her beneficiary by blood, law, or marriage whom we consider to be entitled to the benefits. We will be discharged from liability 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 primary insured or anyone else for such benefits to the extent we are required by the law to pay them to such agency.

GVCIP4TX Page 14

CLAIM INFORMATION (Continued)

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 primary insured must reimburse us in full. We will work with the primary insured 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.

UNPAID PREMIUM

Upon the payment of a claim under this policy and any attached riders, any unpaid premium may be deducted.

CLAIM REVIEW

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

1. the reason for denial;

2. the policy or rider provision that relates to the denial;

3. the primary insured’s right to ask for a review of the denial; and

4. the primary insured’s right to submit any additional information that might allow us to change our decision.

He or she may, upon written request, have copies of any claim documents that are not confidential, for a fee.

APPEALS PROCEDURE

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

GVCIP4TX Page 15

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.

Active employment or actively employed means the employee is working for his or her 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 the employee:

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

2. 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;

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

3. a location to which the job requires the 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.

Child means a person under age 26 who is the primary insured’s or his or her spouse’s or domestic partner natural or adopted son or daughter, stepson or stepdaughter, grandchild, child pending adoption procedures, or a foster child who is placed with the primary insured or his or her spouse or domestic partner by an authorized placement agency or by judgment, decree or other order of any court of competent jurisdiction.

Covered person means any of the following:

1. any eligible family member (including the primary insured) named on the enrollment or evidence of insurability form and accepted for coverage by us;

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

3. a newborn or adopted child.

Critical illness means one of the critical illnesses described in the Critical Illness Benefits provision, any Additional Benefits, or any attached riders, for which a benefit may be paid.

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

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

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

GVCIP4TX Page 16

GLOSSARY (Continued)

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 to enroll or apply for coverage.

Employee means a person who is: (a) a citizen or resident of the United States or one of its territories; and (b) in active employment with the employer named as the policyholder.

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.

Evidence of insurability means a statement of the employee’s or a dependent’s medical history which we will use to determine if he or she is approved for coverage.

Family Coverage means coverage that includes the primary insured, his or her eligible spouse or domestic partner, and his or her eligible child(ren).

Grace period means a period of 31 days for the payment of each premium falling due after the first premium.

Individual and Child(ren) Coverage means coverage that includes the primary insured and eligible children.

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 harm or damage to a covered person, independent of disease, bodily infirmity, or any other cause.

Insured employee means the employee accepted for coverage by us who has completed and signed the enrollment form or evidence of insurability and whose name…