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Benefit Booklet - 2024
Colonial Life provides benets that employees want for the unexpected moments in life. Whether planning for retirement, growing their families, or saving for college, they know an injury or illness won’t derail their dreams. 10-22 | NS-1017472Learn More ContactKitty Mellone<b>Kmellone@coloniallifenc.com704-907-3944Life is anything but expected. That’s why we’re here.ProductsHospital Confinement Indemnity Insurance (Medical Bridge)Provides benefits to help cover the cost of a hospital stay and other medical procedures for a covered accident or sickness, regardless of what health insurance pays.Accident InsuranceFrom a fall to a car accident, this coverage offers a range of benefits to help cover medical or non-medical related expenses due to a covered accident.Critical Illness InsuranceProvides lump sum benefits for a covered critical illness, such as a heart attack or stroke and cancer..
For more information, talk with your benefits counselor.GROUP MEDICAL BRIDGE – PLAN 5Group Hospital Confinement Indemnity InsurancePlan 5Group Medical BridgeSM insurance can help with medical costs that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children. Hospital confinement benefit ..............................................$1500 or $2500___ per dyaMaximum of one day per covered person per calendar yearDoctor oice visit benefit ...........................................................................$25 per dayMaximum of __3 /5______ days per calendar year for __Individual/ Family__________________ coverageEmergency room visit benefit .....................................................................$150 per dayMaximum of one day per covered person per calendar yearDiagnostic procedure benefit .......................................................$__500__________ per dayMaximum of one day per covered person per calendar yearOutpatient surgical procedure benefit Tier 1....................................................................................... $__750____________per day Tier 2....................................................................................... $__1500___________ per dayMaximum of $__2500______________ per covered person per calendar year for Tier 1 and 2 combined Maximum of one day per outpatient surgical procedureDiagnostic proceduresThe following is a list of common diagnostic procedures that may be covered. Breast– Biopsy (incisional, needle, stereotactic) Cardiac– Angiogram– Arteriogram– Thallium stress test– Transesophageal echocardiogram (TEE) Diagnostic radiology– Computerized tomography scan (CT scan)– Electroencephalogram (EEG)– Magnetic resonance imaging (MRI)– Myelogram– Nuclear medicine test– Positron emission tomography scan (PET scan) Digestive– Barium enema/lower GI series– Barium swallow/upper GI series– Esophagogastroduodenoscopy (EGD) Ear, nose, throat, mouth– Laryngoscopy Gynecological– Amniocentesis– Cervical biopsy– Cone biopsy– Endometrial biopsy– Hysteroscopy– Loop electrosurgical excisional procedure (LEEP) Liver– Biopsy Lymphatic– Biopsy Miscellaneous– Bone marrow aspiration/biopsy Renal– Biopsy Respiratory– Biopsy– Bronchoscopy– Pulmonary function test (PFT) Skin– Biopsy– Excision of lesion Thyroid– Biopsy Urinary– Cystoscopy
THIS POLICY PROVIDES LIMITED BENEFITS. EXCLUSIONS We will not pay benefits for losses which are caused by: alcoholism, drug addiction, dental procedures, elective procedures, cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide, intentional injuries, war or armed forces service. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months aer the eective date due to a pre-existing condition, which means those conditions, whether diagnosed or not, for which a covered person received medical advice, diagnosis, care or treatment was received or recommended within the one-year period immediately preceding the certificate eective date. If a covered person is 65 or older when this certificate is issued, pre-existing conditions will include only conditions specifically eliminated by rider.For cost and complete details, see your Colonial Life benefits counselor. Applicable to certificate number GMB1.0-C-NC-R. This is not an insurance contract and only the actual certificate provisions will control.ColonialLife.comUnderwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2018 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. 1-18 | 100028-2-NC Breast– Breast reduction Cardiac– Angioplasty– Cardiac catheterization Digestive– Exploratory laparoscopy– Laparoscopic appendectomy– Laparoscopic cholecystectomy Ear, nose, throat, mouth– Ethmoidectomy– Mastoidectomy– Septoplasty– Stapedectomy– Tympanoplasty– Tympanotomy Eye– Cataract surgery– Corneal surgery (penetrating keratoplasty)– Glaucoma surgery (trabeculectomy)– Vitrectomy Tier 2 outpatient surgical procedures Gynecological– Myomectomy Musculoskeletal system– Arthroscopic knee surgery with meniscectomy (knee cartilage repair)– Arthroscopic shoulder surgery– Clavicle resection– Dislocations (open reduction with internal fixation)– Fracture (open reduction with internal fixation)– Removal or implantation of cartilage– Tendon/ligament repair Thyroid– Excision of a massThe surgeries listed below are only a sampling of the surgeries that may be covered. Surgeries must be performed by a doctor in a hospital or ambulatory surgical center. For complete details and definitions, please refer to your certificate. Tier 1 outpatient surgical procedures Breast– Axillary node dissection– Breast capsulotomy– Breast reconstruction– Lumpectomy Cardiac– Pacemaker insertion Digestive– Colonoscopy– Fistulotomy– Hemorrhoidectomy (external)– Lysis of adhesions Skin– Laparoscopic hernia repair– Skin graing Ear, nose, throat, mouth– Adenoidectomy– Removal of oral lesions– Myringotomy– Tonsillectomy– Tracheostomy Gynecological– Dilation and curettage (D&C)– Endometrial ablation– Lysis of adhesions Liver– Paracentesis Musculoskeletal system– Carpal/cubital repair or release– Dislocation (closed reduction treatment) other than a finger or toe– Foot surgery (bunionectomy, exostectomy, arthroplasty, hammertoe repair)– Fracture (closed reduction treatment) other than a rib, finger or toe– Removal of orthopedic hardware– Removal of tendon lesion
For more information, talk with your benefits counselor.ColonialLife.comGroup Hospital Indemnity InsuranceWellbeing Assistance Standard BenefitTHIS POLICY PROVIDES LIMITED BENEFITS. WAITING PERIODWaiting period means the first 30 days following any covered person’s coverage eective date, during which no benefits are payable. This information is not intended to be a complete description of the insurance coverage available. This coverage has exclusions and limitations that may aect benefits payable. For cost and complete details, see your Colonial Life benefits counselor. This brochure is applicable to policy forms GMB7000-P and GMB7000-P-TX. Coverage may vary by state and may not be available in all states. ©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.GMB7000 – WELLBEING ASSISTANCE STANDARD BENEFIT | 6-16 | 101730The Group Medical BridgeSM wellbeing assistance standard benefit can help pay for routine preventive tests you have each year.Wellbeing assistance standard.........................................$___50.00__________ per dayMaximum of one day per covered person per calendar year; subject to a 30-day waiting period Blood test for triglycerides Bone marrow testing Breast ultrasound CA 15-3 (blood test for breast cancer) CA 125 (blood test for ovarian cancer) Carotid Doppler CEA (blood test for colon cancer) Chest X-ray Colonoscopy Echocardiogram (ECHO) Electrocardiogram (EKG, ECG) Fasting blood glucose test Flexible sigmoidoscopy Hemoccult stool analysis Mammography Pap smear PSA (blood test for prostate cancer) Serum cholesterol test for HDL and LDL levels Serum protein electrophoresis (blood test for myeloma) Skin cancer biopsy Stress test on a bicycle or treadmill Thermography ThinPrep pap test Virtual colonoscopy
For more information, talk with your benefits counselor.Group Accident InsurancePremier PlanColonialLife.comGAC4000 – PREMIER PLANGroup accident insurance can help with medical or other costs associated with a covered accident or injury that your health insurance may not cover. With this coverage you may not need to use your savings or secure a loan to help pay those unexpected out-of-pocket expenses. Coverage options are available for you, your spouse and eligible dependent children. Benefits are per covered person per covered accident unless stated otherwiseAccident emergency treatment ................................................................................................ $200 One visit per covered person per covered accident and Up to four visits per covered person per calendar yearAccident follow-up doctor visit ..................................................................................................$50Up to six visits per covered person per covered accident andUp to 24 visits per covered person per calendar yearAccidental death Accidental deathPer covered person Accidental death common carrier¾ Named insured .....................................................................$50,000 .................. $200,000¾ Spouse ...............................................................................$50,000 .................. $200,000¾ Dependent child(ren) .............................................................. $10,000 ....................$40,000Examples of common carriers are mass transit trains, buses and planesAccidental dismembermentLoss or loss of use¾ One hand, arm, foot, leg or sight of an eye ........................................................................ $15,000¾ Both hands, arms, feet, legs or the sight of both eyes; or any combination ................................ $30,000¾ One finger or one toe ................................................................................................... $1,500¾ Two or more fingers; two or more toes; or any combination ................................................... $3,000Air ambulance .................................................................................................................. $2,000 Transportation to or from a hospital or medical facilityAmbulance (ground)..............................................................................................................$400 Transportation to or from a hospital or medical facilityAppliance aid in personal locomotion or mobility .........................................................................$200Walking boot, neck brace, back brace, leg brace, cane, crutches, walker and wheelchairBlood/plasma/platelets .........................................................................................................$500 Required during treatment of a covered accidentBurn¾ 2nd-degree burns (covering at least 36% of the body’s surface) ..................................................$1,500¾ 3rd-degree burns (based on size) ......................................................................... $3,000 – $21,000Burn–skin gra ...................................................................................50% of applicable burn benefitAs a result of 2nd-degree or 3rd-degree burns
Catastrophic accidentTotal and irrecoverable loss or loss of use¾ Both hands, arms, feet, legs or the sight of both eyes; or any combination; or¾ Loss of hearing in both ears or loss of ability to speak Subject to a 365-day elimination period; payable once per lifetime per covered person¾ Named insured ............................................................................................................................................... $100,000¾ Spouse ............................................................................................................................................................... $100,000 ¾ Dependent child(ren) ....................................................................................................................................... $50,000Coma ...............................................................................................................$20,000Lasting for 14 or more consecutive daysConcussion ............................................................................................................ $500Dislocation (separated joint) Non-surgical Surgical¾ Hip ........................................................................................$4,000 $8,000¾ Knee (except patella) ..................................................................$2,000 $4,000¾ Ankle, bone or bones of the foot (other than toes) ...............................$1,600 $3,200¾ Collarbone (sternoclavicular) ........................................................$1,100 $2,200¾ Collarbone (acromioclavicular and separation) ....................................$280 $560¾ Lower jaw ..................................................................................$990 $1,980¾ Shoulder (glenohumeral) ............................................................ $1,200 $2,400¾ Elbow .......................................................................................$600 $1,200¾ Wrist ........................................................................................$750 $1,500¾ Bone(s) of the hand, (other than fingers) ...........................................$1,050 $2,100¾ Finger, toe ..................................................................................$260 $520¾ Incomplete dislocation or dislocation reduction.................................. 25% of the applicable without anesthesia non-surgical amountEmergency dental work ¾ Dental crown or denture ....................................................................................$600¾ Dental extraction .............................................................................................$200Eye injury ..............................................................................................................$400 With surgical repair or removal of a foreign objectFracture (broken bone) Non-surgical Surgical¾ Skull, depressed fracture (except face/nose) ......................................$5,000 $10,000¾ Skull, simple non-depressed fracture (except face/nose) .......................$2,400 $4,800¾ Hip, thigh (femur) ......................................................................$4,200 $8,400¾ Body of vertebrae (excluding vertebral processes) ...............................$3,600 $7,200¾ Pelvis .....................................................................................$3,225 $6,450¾ Leg (tibia and/or fibula) ...............................................................$2,400 $4,800¾ Bones of the face or nose (except mandible or maxilla) ........................ $1,295 $2,590¾ Upper jaw, maxilla, upper arm between .......................................... $1,400 $2,800 elbow and shoulder¾ Lower jaw, mandible ................................................................. $1,200 $2,400¾ Kneecap, ankle, foot .................................................................. $1,200 $2,400¾ Shoulder blade, collarbone ......................................................... $1,200 $2,400¾ Vertebral processes ......................................................................$810 $1,620¾ Forearm, hand, wrist ................................................................. $1,200 $2,400¾ Rib ..........................................................................................$500 $1,000¾ Coccyx .....................................................................................$420 $840¾ Finger, toe .................................................................................$200 $400¾ Chip fracture .................................................25% of the applicable non-surgical amountAlex was cleaning out the gutters when he fell. ALEX’S BENEFITS Ambulance $400Emergency room visit $200X-ray $60Hospital admission $1,500Hospital confinement $1,050Leg fracture (surgical) $4,800Physical therapy $440Appliance (crutches) $200Doctor’s follow-up oice visit $150$8,800EMERGENCY ROOM VISITAlex was taken by ambulance to the nearest emergency room and received immediate care.The doctor ordered an X-ray and discovered Alex had fractured his leg.DIAGNOSTIC PROCEDUREOver the next several weeks, he had three follow-up appointments with his doctor.DOCTORʼS OFFICE VISITAlex had eight sessions of PT to help him regain the strength in his leg.PHYSICAL THERAPYAlex was admitted to the hospital for surgery on his leg. He was confined for three days.HOSPITAL CONFINEMENTFor illustrative purposes only.Benefit amounts may vary and may not cover all expenses. The certificate has exclusions and limitations.ALEXʼS OUT-OF-POCKET EXPENSESWhen Alex totaled up the bills, he had to pay his annual deductible, as well as co-payments for the ambulance, emergency room, hospital, surgery, physical therapy and follow-up visits. Luckily, Alex had accident coverage to help with these expenses.Alex used crutches.APPLIANCE FOR MOBILITY
For more information, talk with your benefits counselor.GAC4000 – PREMIER PLANHospital admission .............................................................................................................$1,500Per covered person per covered accidentHospital confinement .................................................................................................. $350 per dayUp to 365 days per covered person per covered accidentHospital intensive care unit admission .................................................................................... $2,500 Per covered person per covered accidentHospital intensive care unit confinement ........................................................................ $600 per day Up to 15 days per covered person per covered accident Knee cartilage (torn) .......................................................................................................... $1,250 Laceration (no repair, without stitches) ..........................................................................................$75Laceration (repaired by stitches)¾ Total of all lacerations is less than two inches long ................................................................... $150¾ Total of all lacerations is at least two but less than six inches long .................................................$600¾ Total of all lacerations is six inches or longer ........................................................................ $1,200 Lodging (companion) ..................................................................................................$250 per day Up to 30 days per covered person per covered accident Medical imaging study (CT, CAT scan, EEG, MR or MRI) .....................................................................$400One benefit per covered person per covered accident per calendar yearOccupational or physical therapy ....................................................................................$55 per day Up to 10 days per covered person per covered accident Pain management for epidural anesthesia .................................................................................. $150 Prosthetic device/artificial limb One benefit per covered person per covered accident¾ One ........................................................................................................................$1,750 ¾ More than one ........................................................................................................... $3,500 Rehabilitation unit confinement ....................................................................................$200 per day Immediately aer a period of hospital confinement due to a covered accident; up to 15 days per covered person per covered accident, not to exceed 30 days per covered person per calendar yearRuptured disc with surgical repair ......................................................................................... $1,200 Surgery¾ Cranial, open abdominal and thoracic .............................................................................. $2,000 ¾ Hernia with surgical repair ............................................................................................... $400Surgery (exploratory and arthroscopic) ....................................................................................... $275Tendon/ligament/rotator cu¾ One with surgical repair ............................................................................................... $1,200¾ Two or more with surgical repair ..................................................................................... $2,400 Transportation for hospital confinement ...................................................................$700 per round tripUp to three round trips for more than 50 miles from home per covered person per covered accidentX-ray ...................................................................................................................................$60
ColonialLife.com4-18 | 101863HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLEThis plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be oered to employees who do not have HSAs.THIS CERTIFICATE PROVIDES LIMITED BENEFITS.EXCLUSIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of a covered personʼs felonies or illegal occupations, hazardous avocations, racing, semi-professional or professional sports, sickness, suicide or injuries which any covered person intentionally does to himself, war or armed conflict. In addition, we will not pay Catastrophic Accident benefits for injuries a child received during birth, or for injuries that are the result of being intoxicated or under the influence of any narcotics.This information is not intended to be a complete description of the insurance coverage available. This coverage has exclusions and limitations that may aect benefits payable. For cost and complete details, see your Colonial Life benefits counselor. This brochure is applicable to policy form GACC1.0-P and certificate form GACC1.0-C (plus state abbreviations where applicable, such as GACC1.0-P-EE-TX and certificate form GACC1.0-C-EE-TX). Coverage may vary by state and may not be available in all states. Premium at the eective date will vary according to the family coverage type.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2018 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.
Group Critical Illness InsuranceWellbeing Assistance BenefitThe wellbeing assistance benefit can help reduce the risk of serious illness through early detection of disease or risk factors.Wellbeing assistance benefit ..........................................................$ 50/ _YR___________ Maximum of one test per covered person per calendar year; subject to a 30-day waiting period before the benefit is payable. The test must be performed aer the waiting period. Blood test for triglycerides Bone marrow testing BRCA1 or BRCA2 testing (genetic test for breast cancer) Breast ultrasound CA 15-3 (blood test for ovarian cancer) CA 125 (blood test for breast cancer) Carotid Doppler CEA (blood test for colon cancer) Chest x-ray Colonoscopy Echocardiogram (ECHO) Electrocardiogram (EKG, ECG) Fasting blood glucose test Flexible sigmoidoscopy Hemoccult stool analysis Mammography Pap smear PSA (blood test for prostate cancer) Serum cholesterol test for HDL and LDL levels Serum protein electrophoresis (blood test for myeloma) Skin cancer biopsy Stress test on a bicycle or treadmill Thermography ThinPrep pap test Virtual colonoscopyFor more information, talk with your benefits counselor.ColonialLife.comGCI6000 – WELLBEING ASSISTANCE BENEFIT | 5-20 | 387307Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.THIS INSURANCE PROVIDES LIMITED BENEFITS.This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may aect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.
Group Critical Illness InsurancePlan 2GCI6000 – PLAN 2 – CRITICAL ILLNESS AND CANCERWhen life takes an unexpected turn, your focus should be on recovery — not finances. Colonial Life’s group critical illness insurance helps relieve financial worries by providing a lump-sum benefit payable directly to you to use as needed.Coverage amount: ____________________________COVERED CRITICAL ILLNESS CONDITIONPERCENTAGE OF APPLICABLE COVERAGE AMOUNTBenign brain tumor100%Coma100%End stage renal (kidney) failure100%Heart attack (myocardial infarction)100%Loss of hearing100%Loss of sight100%Loss of speech100%Major organ failure requiring transplant100%Occupational infectious HIV or occupational infectious hepatitis B, C, or D100%Permanent paralysis due to a covered accident100%Stroke100%Sudden cardiac arrest100%Coronary artery disease25%COVERED CANCER CONDITIONPERCENTAGE OF APPLICABLE COVERAGE AMOUNTInvasive cancer (including all breast cancer)100%Non-invasive cancer25%Skin cancer initial diagnosis ............................................................ $400 per lifetimeCritical illness and cancer benefitsSpecial needs daycareA hospital stay and treatment for corrective heart surgeryPhysical therapy to build muscle strengthFor illustrative purposes only.Preparing for a lifelong journeyRebecca was born with Down syndrome. Her parents’ critical illness coverage provided a benefit that can help cover expenses related to Rebecca’s care and her changing needs. HOW THEIR COVERAGE HELPEDThe lump-sum amount from the family coverage benefit helped pay for:
ColonialLife.com5-20 | 3871001. Refer to the certificate for complete definitions of covered conditions. 2. Dates of diagnoses of a covered critical illness must be separated by more than 180 days. 3. Critical illnesses that do not qualify include: coronary artery disease, loss of hearing, loss of sight, loss of speech, and occupational infectious HIV or occupational infectious hepatitis B,C,or D.THIS INSURANCE PROVIDES LIMITED BENEFITSInsureds in MA must be covered by comprehensive health insurance before applying for this coverage.EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS We will not pay the Critical Illness Benefit, Benefits Payable Upon Subsequent Diagnosis of a Critical Illness or Additional Critical Illness Benefit for Dependent Children that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a critical illness.EXCLUSIONS AND LIMITATIONS FOR CANCER We will not pay the Invasive Cancer (including all Breast Cancer) Benefit, Non-Invasive Cancer Benefit, Benefit Payable Upon Reoccurrence of Invasive Cancer (including all Breast Cancer) or Skin Cancer Initial Diagnosis Benefit for a covered person’s invasive cancer or non-invasive cancer that: is diagnosed or treated outside the territorial limits of the United States, its possessions, or the countries of Canada and Mexico; is a pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is initially diagnosed as having invasive or non-invasive cancer. No pre-existing condition limitation will be applied for dependent children who are born or adopted while the named insured is covered under the certificate, and who are continuously covered from the date of birth or adoption.PRE-EXISTING CONDITION LIMITATION We will not pay a benefit for a pre-existing condition that occurs during the 12-month period aer the coverage eective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage eective date.This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may aect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.COVERED CONDITIONPERCENTAGE OF APPLICABLE COVERAGE AMOUNTCerebral palsy 100%Cle lip or palate 100%Cystic fibrosis 100%Down syndrome 100%Spina bifida 100%KEY BENEFITSAdditional covered conditions for dependent childrenSubsequent diagnosis of a dierent critical illnessIf you receive a benefit for a critical illness, and are later diagnosed with a dierent critical illness, 100% of the coverage amount may be payable for that particular critical illness.Subsequent diagnosis of the same critical illnessIf you receive a benefit for a critical illness, and are later diagnosed with the same critical illness,3 25% of the coverage amount is payable for that critical illness.Reoccurrence of invasive cancer (including all breast cancer)If you receive a benefit for invasive cancer and are later diagnosed with a reoccurrence of invasive cancer, 25% of the coverage amount is payable if treatment-free for at least 12 months and in complete remission prior to the date of reoccurrence; excludes non-invasive or skin cancer.For more information, talk with your benefits counselor.Preparing for the unexpected is simpler than you think. With Colonial Life, youʼll have the support you need to face lifeʼs toughest challenges. Available coverage for spouse and eligible dependent children at 50% of your coverage amount Cover your eligible dependent children at no additional cost Receive coverage regardless of medical history, within specified limits Works alongside your health savings account (HSA) Benefits payable regardless of other insurance
Group Critical Illness InsuranceExclusions and LimitationsSTATE-SPECIFIC EXCLUSIONSAK: Alcoholism or Drug Addiction Exclusion does not applyCO: Suicide exclusion: whether sane or not replaced with while sane CT: Alcoholism or Drug Addiction Exclusion replaced with Intoxication or Drug Addiction; Felonies or Illegal Occupations Exclusion replaced with Felonies; Intoxicants and Narcotics Exclusion does not applyDE: Alcoholism or Drug Addiction Exclusion does not applyIA: Exclusions and Limitations headers renamed to Exclusions and Limitations for Critical Illness Covered Conditions and Critical Illness Cancer Covered ConditionsID: War or Armed Conflict Exclusion replaced with War; Felonies and Illegal Occupations Exclusion replaced with Felonies; Intoxicants and Narcotics Exclusion does not apply; Domestic Partner added to SpouseIL: Alcoholism or Drug Addiction Exclusion replaced with Alcoholism or Substance Abuse DisorderKS: Alcoholism or Drug Addiction Exclusion does not applyKY: Alcoholism or Drug Addiction Exclusion does not apply; Intoxicants and Narcotics Exclusion replaced with Intoxicants, Narcotics and Hallucinogenics.LA: Alcoholism or Drug Addiction Exclusion does not apply; Domestic Partner added to SpouseMA: Exclusions and Limitations headers renamed to Limitations and Exclusions for critical illness and cancerMI: Intoxicants and Narcotics Exclusion does not apply; Suicide Exclusion does not applyMN: Alcoholism or Drug Addiction Exclusion does not apply; Suicide Exclusion does not apply; Felonies and Illegal Occupations Exclusion replaced with Felonies or Illegal Jobs; Intoxicants and Narcotics Exclusion replaced with Narcotic AddictionMS: Alcoholism or Drug Addiction Exclusion does not applyND: Alcoholism or Drug Addiction Exclusion does not applyNV: Intoxicants and Narcotics Exclusion does not apply; Domestic Partner added to SpousePA: Alcoholism or Drug Addiction Exclusion does not apply; Suicide Exclusion: whether sane or not removedSD: Alcoholism or Drug Addiction Exclusion does not apply; Intoxicants and Narcotics Exclusion does not applyTX: Alcoholism or Drug Addiction Exclusion does not apply; Doctor or Physician Relationship added as an additional exclusionUT: Alcoholism or Drug Addiction Exclusion replaced with AlcoholismVT: Alcoholism or Drug Addiction Exclusion does not apply; Intoxicants and Narcotics Exclusion does not apply; Suicide Exclusion: whether sane or not removedSTATE-SPECIFIC PRE-EXISTING CONDITION LIMITATIONSFL: Pre-existing is 6/12; Pre-existing Condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within six months before the coverage eective date shown on the Certificate Schedule. Genetic information is not a pre-existing condition in the absence of a diagnosis of the condition related to such information.GA: Pre-existing Condition means the existence of symptoms which would cause an ordinarily prudent person to seek diagnosis, care, or treatment, or a condition for which medical advice or treatment was recommended by or received within 12 months preceding the coverage eective date.ID: Pre-existing is 6 months/12 months; Pre-existing Condition means a sickness or physical condition which caused a covered person to seek medical advice, diagnosis, care or treatment during the six months immediately preceding the coverage eective date shown on the Certificate Schedule.IL: Pre-existing Condition means a sickness or physical condition for which a covered person was diagnosed, treated, had medical testing by a legally qualified physician, received medical advice, produced symptoms or had taken medication within 12 months before the coverage eective date shown on the Schedule of Benefits.IN: Pre-existing is 6 months/12 monthsMA: Pre-existing is 6 months/12 months; Pre-existing Condition means a sickness or physical condition for which a covered person was treated, had medical testing, or received medical advice within six months before the coverage eective date shown on the Certificate Schedule.ME: Pre-existing is 6 months/6 months; Pre-existing Condition means a sickness or physical condition for which a covered person was treated, had medical testing, or received medical advice within six months before the coverage eective date shown on the Certificate Schedule.MI: Pre-existing is 6 months/6 monthsNC: Pre-existing Condition means those conditions for which medical advice, diagnosis, care, or treatment was received or recommended within the one-year period immediately preceding the eective date of a covered person. If a covered person is 65 or older when this certificate is issued, pre-existing conditions for that covered person will include only conditions specifically eliminated. NV: Pre-existing is 6 months/12 months; Pre-existing Condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within six months before the coverage eective date. Pre-existing Condition does not include genetic information in the absence of a diagnosis of the condition related to such information.PA: Pre-existing is 90 days/12 months; Pre-existing Condition means a disease or physical condition for which you received medical advice or treatment within 90 days before the coverage eective date shown on the Certificate Schedule.SD: Pre-existing is 6 months/12 monthsTX: Pre-existing condition means a sickness or physical condition for which a covered person received medical advice or treatment within 12 months before the coverage eective date shown on the Certificate Schedule.UT: Pre-existing is 6 months/6 monthsThis information is not intended to be a complete description of the insurance coverage available. The insurance, its name or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may aect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. This form is not complete without base form 385403, 387100, 387169, 402383, 402558 or 387238, and rider form 387307, 387381, 387452, 387523, 387594, 387665, 402605 or 402671.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. GCI6000 – EXCLUSIONS AND LIMITATIONS | 8-20 | 388113-1
Deductions per year: 52Buckeye Fire Equipment Rates 52 Pay PeriodsIndividual Accident (GAC4000) for NCApplicable to Policy Forms IAC4000lOn/Off-Job Accident Coverage, Wellbeing Assistance Standard - $50BENEFIT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILYPremier 0-80 $6.07 $9.88$10.47$14.28Group Critical Illness (GCI6000) for NCApplicable to policy forms GCI6000-P, GCI6000-C,R-GCI6000-CB, R-GCI6000-BB, R-GCI6000-HB,R-GCI6000-INF, R-GCI6000-PDlPlan 2 - Critical Illness & Cancer, Wellbeing Assistance Benefit - $50 BenefitNon-Tobacco RatesISSUE AGE NAMED INSURED NAMED INSURED ANDSPOUSENAMED INSURED ANDDEPENDENT CHILD(REN)NAMED INSURED, SPOUSEAND DEPENDENT CHILD(REN)$10,000 17-24 $1.59 $2.36 $1.59 $2.3625-29 $1.99 $2.96 $1.99 $2.9630-34 $2.40 $3.56 $2.40 $3.5635-39 $3.32 $4.96 $3.32 $4.9640-44 $4.25 $6.35 $4.25 $6.3545-49 $5.77 $8.70 $5.77 $8.7050-54 $7.27 $11.06 $7.27 $11.0655-59 $9.35 $14.22 $9.35 $14.2260-64 $12.51 $19.02 $12.51 $19.0265-69 $15.19 $23.12 $15.19 $23.1270-74 $15.19 $23.12 $15.19 $23.12Page 1 of 1Group Medical Bridge for NCCompositeApplicable to Policy Forms GMB1.0-P & GMB1.0-ClHospital Confinement: $2500, Health Screening: $50, Outpatient Surgery: Tier 1=$750, Tier 2=$1500, CY Max=$2500,Diagnostic Procedure Benefit: $500, Emergency Room: $150, Doctor Office Visit: $25ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY17-99 $13.25 $26.25 $19.66 $32.27Group Medical Bridge for NCCompositeApplicable to Policy Forms GMB1.0-P & GMB1.0-ClHospital Confinement: $1500, Health Screening: $50, Outpatient Surgery: Tier 1=$750, Tier 2=$1500, CY Max=$2500,Diagnostic Procedure Benefit: $500, Emergency Room: $150, Doctor Office Visit: $25ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY17-99 $10.55 $20.86 $15.99 $25.90ISSUE AGE NAMED INSURED NAMED INSURED ANDSPOUSENAMED INSURED ANDDEPENDENT CHILD(REN)NAMED INSURED, SPOUSEAND DEPENDENT CHILD(REN)$10,000 17-24 $2.15 $3.14 $2.15 $3.1425-29 $2.79 $4.11 $2.79 $4.1130-34 $3.44 $5.08 $3.44 $5.0835-39 $4.92 $7.29 $4.92 $7.2940-44 $6.39 $9.53 $6.39 $9.5345-49 $8.82 $13.29 $8.82 $13.2950-54 $11.22 $17.06 $11.22 $17.0655-59 $14.54 $22.13 $14.54 $22.1360-64 $19.59 $29.82 $19.59 $29.8265-69 $23.89 $36.35 $23.89 $36.3570-74 $23.89 $36.35 $23.91 $36.37Tobacco Rates
Buckeye Fire Equipment, Inc. Colonial Interest Form Name_________________________________Job Title_______________ Pay Period 52_____26_____ Social Security #_________________ Address________________________________ City ___________________ST. __________Zip_______ Work Phone___________________ Cell Phone________________ Email Address____________________________________________________ Date of Birth (DOB) ________________ Tobacco______ Non Tobacco_____ Date of Hire____________________ Beneficiary__________________________________DOB___________Relationship____________ Dependent Information: Spouse________________________________DOB_______________ Relationship____________ Child_________________________________DOB________________Relationship____________ Child_________________________________DOB________________Relationship____________ Child_________________________________DOB________________Relationship____________ ____ Waive Colonial Coverage. I understand that I can only enroll during Annual Enrollment unless I have a qualified event during the year. Signature__________________________________________Date____________ Questions or Assistance Contact: Kitty Mellone 704-907-3944 (D) Email: Kmellone@coloniallifenc.comFax Completed Form with Rate Sheet & elected coverage’s circled fax to: 704-895-9779(FAX)
Policyholder Service Guide At Colonial Life our goal is to give you an excellent customer experience that is simple modern and personal Getting started Consider your options The easiest way to manage your business with us is through the My Colonial Life policyholder section of ColonialLife com Whether online or by phone we ll provide the service you need To sign up for the website 1 Visit ColonialLife com 2 Click Register at the top right 3 On the sign up page click Join the Policyholder Website Need ColonialLife com Submit your claim using our eClaims system 3 File health screening wellness and doctor s office visit claims up to 18 months 3 3 Check the status of your claim 3 3 Review print or download a copy of your policy certificate 3 Access claim and service forms 3 3 Access your claim correspondence 3 3 3 Complete a notification for a life claim 3 3 Update your contact information After providing some basic information you ll be ready to go 800 325 4368 Filing claims eClaims With the eClaims feature on ColonialLife com you can file claims online by simply answering a few questions and uploading your supporting documentation You re able to spend less time on paperwork and we re able to process your claim faster With eClaims you can file most claims online including Accident Hospital confinement indemnity Disability Critical illness Cancer Vision You can access eClaims through your computer or mobile device and upload any required supporting documentation Once you re logged in to ColonialLife com visit the Claims Center and select File an Online Claim to get started
Contact us Online ColonialLife com Log in and click on Contact Us to email us Telephone 1 800 325 4368 Contact Center representatives are available Monday through Friday 8 a m to 8 p m ET Information is available 24 7 through our automated phone system Please have your Social Security or policy number ready when you call Hearing impaired customers Customers with a Telecommunications Device for the Deaf TDD should call 803 798 4040 If you do not have a TDD call Voiance Telephone Interpretation Services at 844 495 6105 to reach us Health screening wellness claims The quickest way to receive the applicable benefits for your health screening wellness services is to file online For health screening wellness claims within 18 months of the date you are filing the claim click on File a Wellness Claim Online on the Claims Center page If you do not want to file online you can use the automated customer service center at 1 800 325 4368 For health screening wellness claims over 18 months you ll be directed to print out a paper claim form under the claims and service forms section on the Claims Center page Paper claims If you don t want to file online download the form you need by visiting the Claims Center page on ColonialLife com and clicking on claims and service forms For instructions on how to correctly complete your claim form view the claims videos on the Claims Center page Be sure that you complete all sections of the claim form Also include a diagnosis from your doctor along with copies of any appropriate bills if required Keep a copy of your claim information for your records When we receive information regarding your claim you ll be notified by telephone or email If you select the electronic messaging option you ll receive a call when the claim is processed Claim tips and information When submitting your claim make sure to include all required supporting documentation as this will allow us to process your claim quicker To view correspondence pertaining to your claim visit ColonialLife com Once you log in to your secure account select My Correspondence from the home page Whether you submit your claims online or by paper form you can select optional services that authorize us to Communicate claims information via electronic messaging to your phone number Send claim benefits overnight by deducting a fee from your claim payment Release information to your benefits representative plan administrator or family member You can always check the status of your claim on the My Colonial Life site at ColonialLife com ColonialLife com Applicable to vision rider on the individual dental plan 2016 Colonial Life Accident Insurance Company Columbia SC Colonial Life insurance products are underwritten by Colonial Life Accident Insurance Company for which Colonial Life is the marketing brand 4 16 43233 37