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Individual Dental InsuranceStandard Plan $1,000 | 100% | 80% | 50%This benet summary provides a quick reference for the dental plan benets. Policy detailsPolicy year maximum benefit• Per person (applies to Class A, B and C services)$1,000 Deductible• Per person (applies to Class B and C services only) • Maximum of three per family per policy year$50Standard Plan dental coverage at a glanceCo-insurance In-network1Out-of-network2 (MAC)Class A: Preventive services 100% 100%Class B: Basic services 80% 80%Class C: Major services 50% 50%Carryover benets3Carryover amount Per covered family memberThreshold limit Carryover account max$200 $500 $800 How carryover benefits work Receive a $200 benefit in your carryover account to use in the next benefit year when you meet these conditions:• One cleaning and one routine exam and• Total paid dental claims for Class A, B or C services below $500 (your threshold limit, the maximum amount of benets an insured can receive during a policy year and still be able to receive the carryover benet). Your carryover account can grow up to $800 to help pay for claims if you exceed your policy year maximum benefit.3INDIVIDUAL DENTAL - STANDARD PLAN
Covered services In-network coverage1Out-of-network coverage2 (MAC)Waiting periodClass A: Preventive services• Routine exams and cleanings ‐ Two per 12-month period ‐ One additional cleaning per 12 months if member is in second or third trimester of pregnancy4• X-rays (bitewing x-rays) ‐ Up to four lms, once every 12 months• Fluoride treatment ‐ Up to age 16, once every 12 months• Sealants ‐ Up to age 16, once every 36 months• Space maintainers ‐ Up to age 16, once every 24 months• Oral cancer screening ‐ For age 40+, once every 12 months100% 100% No waiting periodClass B: Basic services• Full mouth/panoramic x-rays ‐ Once every ve years• Fillings• Posterior composite restorations• Simple extractions• Emergency treatment80% 80% No waiting periodClass C: Major services• Oral surgery (surgical extractions and impacted teeth)• Anesthesia (covered with complex oral surgery)• Repair of crowns, dentures or bridges• Periodontics (gum treatments)• Endodontics (root canals)• Inlays and onlays• Crowns, bridges, dentures and endosteal implants• Crown lengthening 50% 50% 12-month waiting period5Contact your Colonial Life benets counselor to learn more.1 In-network benets are for covered dental services provided by a participating dentist. Participating dentists have agreed to accept negotiated fees as payment in full, subject to any deductibles, co-insurance and benet maximums, and will le claims for you.2 Out-of-network benets are for covered dental services provided by a non-participating dentist. Benets are provided at the lesser of the dentist’s actual fee or the Maximum Allowable Charge (MAC), a scheduled amount determined by Colonial Life. In Alaska only, benets are based on usual, customary, and reasonable charges (80th UCR) for the same covered procedure by providers of similar training or experience in the general geographic area, reviewed and updated periodically. Benets are subject to any deductibles, co-insurance and maximums. Dentists haven't agreed to accept reimbursement as payment in full. Additional out-of-pocket costs may apply. You may have to le a claim to receive benets.3 You must be covered for 12 consecutive months to receive the carryover benet; any break in coverage will eliminate the carryover account balance. The carryover benet may not be used for orthodontic treatment or services.4 Member may have one additional periodontal maintenance in place of an additional cleaning.5 Six-month waiting period in Vermont. Summary of Dental Benets and Coverage Disclosure Matrix (SDBC) is available at ColonialLifeDental.com/California.THIS POLICY PROVIDES LIMITED BENEFITS. A NETWORK ACCESS PLAN IS AVAILABLE.This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benets payable. Applicable to policy form IDN8100 (including state abbreviations where used, for example: IDN8100-TX).For cost and complete details of coverage, call or write your Colonial Life benets counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.© 2024 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. FOR EMPLOYEES 4-24 | 1763264ColonialLife.com
Individual Dental InsuranceEnhanced Plan $3,000 | 100% | 80% | 50%This benet summary provides a quick reference for the dental plan benets. Policy detailsPolicy year maximum benefit• Per person (applies to Class A, B and C services)$3,000 Deductible• Per person (applies to Class B and C services only) • Maximum of three per family per policy year$50Enhanced Plan dental coverage at a glanceCo-insurance In-network1Out-of-network2 (MAC)Class A: Preventive services 100% 100%Class B: Basic services 80% 80%Class C: Major services 50% 50%Carryover benets3Carryover amount Per covered family memberThreshold limit Carryover account max$400 $800 $1,600 How carryover benefits work Receive a $400 benefit in your carryover account to use in the next benefit year when you meet these conditions:• One cleaning and one routine exam and• Total paid dental claims for Class A, B or C services below $800 (your threshold limit, the maximum amount of benets an insured can receive during a policy year and still be able to receive the carryover benet). Your carryover account can grow up to $1,600 to help pay for claims if you exceed your policy year maximum benefit.3INDIVIDUAL DENTAL - ENHANCED PLAN
Covered services In-network coverage1Out-of-network coverage2 (MAC)Waiting periodClass A: Preventive services• Routine exams and cleanings ‐ Two per 12-month period ‐ One additional cleaning per 12 months if member is in second or third trimester of pregnancy4• X-rays (bitewing x-rays) ‐ Up to four lms, once every 12 months• Full mouth/panoramic x-rays ‐ Once every ve years• Fluoride treatment ‐ Up to age 16, once every 12 months• Sealants ‐ Up to age 16, once every 36 months• Space maintainers ‐ Up to age 16, once every 24 months• Oral cancer screening ‐ For age 40+, once every 12 months100% 100% No waiting periodClass B: Basic services• Fillings• Posterior composite restorations• Simple extractions• Repair of crowns, dentures or bridges• Periodontics (gum treatments)• Endodontics (root canals)• Emergency treatment80% 80% No waiting periodClass C: Major services• Oral surgery (surgical extractions and impacted teeth)• Anesthesia (covered with complex oral surgery)• Inlays and onlays• Crowns, bridges, dentures and endosteal implants• Crown lengthening 50% 50% 12-month waiting period5Contact your Colonial Life benets counselor to learn more.1 In-network benets are for covered dental services provided by a participating dentist. Participating dentists have agreed to accept negotiated fees as payment in full, subject to any deductibles, co-insurance and benet maximums, and will le claims for you.2 Out-of-network benets are for covered dental services provided by a non-participating dentist. Benets are provided at the lesser of the dentist’s actual fee or the Maximum Allowable Charge (MAC), a scheduled amount determined by Colonial Life. In Alaska only, benets are based on usual, customary, and reasonable charges (80th UCR) for the same covered procedure by providers of similar training or experience in the general geographic area, reviewed and updated periodically. Benets are subject to any deductibles, co-insurance and maximums. Dentists haven’t agreed to accept reimbursement as payment in full. Additional out-of-pocket costs may apply. You may have to le a claim to receive benets.3 You must be covered for 12 consecutive months to receive the carryover benet. The carryover benet may not be used for orthodontic treatment or services. A break in dental coverage will eliminate the carryover account balance.4 Member may have one additional periodontal maintenance in place of an additional cleaning.5 Six-month waiting period in Vermont. Summary of Dental Benets and Coverage Disclosure Matrix (SDBC) is available at ColonialLifeDental.com/California.THIS POLICY PROVIDES LIMITED BENEFITS. A NETWORK ACCESS PLAN IS AVAILABLE.This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benets payable. Applicable to policy form IDN8100 (including state abbreviations where used, for example: IDN8100-TX).For cost and complete details of coverage, call or write your Colonial Life benets counselor or the company.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.© 2024 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. FOR EMPLOYEES 4-24 | 1764147ColonialLife.com
Individual Dental InsuranceOrthodontic BenetYour dental coverage includes orthodontia benets that help pay for braces and other orthodontic care. Orthodontic treatment can help correct overcrowded teeth or a severe overbite, and can help boost self-condence with a healthier smile. PLAN DETAILS• Available for employee and spouse• Available for dependent children up to age 26• $1,500 maximum lifetime benet per person• Up to $375 of lifetime benet may be payable for initial banding1 • Remaining benet may be used toward follow-up visits, with 50% coinsurance• 12-month waiting period2 ORTHODONTIC EXAMPLE This example illustrates how your orthodontic benet works.Total orthodontic treatment cost: $5,000$37525% of the lifetime maximum ($375 out of $1,500) paid toward initial orthodontic banding1$1,125 ÷Remaining $1,125 of the lifetime maximum available to be used towards monthly visitsFor illustrative purposes.1 At the time of initial placement of braces or appliances, the plan pays 25% of the allowable charge or 25% of the lifetime maximum benet, whichever is less. The benet amount will be payable as of the date appliances or bands are inserted.2 Waiting periods may be waived if takeover applies. Six-month waiting period in Vermont.THIS POLICY PROVIDES LIMITED BENEFITS. A NETWORK ACCESS PLAN IS AVAILABLE.Summary of Dental Benets and Coverage Disclosure Matrix (SDBC) is available at ColonialLifeDental.com/California.This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benets payable. Applicable to policy form IDN8100 (including state abbreviations where used, for example: IDN8100-TX). For cost and complete details of coverage, call or write your Colonial Life benets counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.© 2024 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.ColonialLif e. com FOR EMPLOYEES 4-24 | 1820700
Individual Dental InsuranceVision Rider Our vision coverage helps you and your family maintain your vision wellness, with coverage for eye exams and optical materials, such as eyeglasses or contact lenses. This benet summary provides a quick reference to the rider’s benets.Co-pays (per insured)1Benefits (once per 12 months) In-network2Out-of-network3Vision exam $10 N/AContact lenses fitting $25 N/AMaterials $25 N/ABenets and allowances1Benets, after co-pay In-network2Out-of-network3Vision exam Covered in full $35 allowanceContact lenses fitting, after co-payStandard4Up to $60 allowance Up to $45 allowanceSpecialty5Up to $100 allowance Up to $75 allowanceMaterials: Eyeglass lenses and frames, after co-pay6Single vision Covered in full Up to $25 allowanceBifocals Covered in full Up to $40 allowanceTrifocals Covered in full Up to $50 allowanceLenticular Up to $120 allowance Up to $50 allowanceProgressives Up to $70 allowance Up to $40 allowancePolycarbonate lenses (for children to age 19 only)Covered in full Up to $30 allowanceFrames Up to $170 allowance Up to $50 allowanceMaterials: Contact lenses, after co-pay7Elective Up to $170 allowance Up to $100 allowanceNon-elective Up to $210 allowance Up to $210 allowanceMAXIMIZE YOUR BENEFITS Maximize your vision benets with any provider in our large, nationwide network, including independent eye doctors, and retail stores such as: • Walmart and Sam’s Club Optical• Target Optical• Pearle Vision• VisionworksYou can choose different providers for eye exams, eyeglasses and contact lenses.ID CARDS• Vision ID cards are mailed to your home address within 10 business days of enrolling, separate from dental ID cards.• Digital ID cards are available on the policyholders portal when your coverage starts.• Only the primary insured’s name will be listed.INDIVIDUAL DENTAL - VISION RIDER
Disability InsuranceHow you can protect your incomeIf you become disabled, you could be out of work for a while. Without your income, how protection options that can help you. What can cause a disability? Many accidents or sicknesses can lead to short term disability claims, including pregnancy and childbirth; injuries from a major accident including dislocations, sprains and fractures; back problems; side effects from medicines or medical procedures; and some mental illnesses. Regardless of your age or health, a disabling sickness or accidental injuries could keep you out of work for weeks or even months.How reliable is your safety net? While many people with disabilities look to workers’ compensation or Social Security Disability Insurance (SSDI) for help, these resources aren’t always reliable. In fact, 68% of workers who apply for SSDI are denied.1 Even if these How to help yourself You can be better prepared to preserve your way of life with short term disability insurance. Disability insurance features:• of a covered accident or sickness (injury or illness).• • In most cases, you can keep your coverage even if you change jobs, as long as you pay your premiums when due.coverage that’s right for you.70%of Americans worry about having enough emergency savings to cover a month’s worth of living expenses.2Nearly25%of 20 year olds can expect to be out of work for at least a year for a disabling condition before they retire.3DISABILITY INSURANCE
Disability Insurance Worksheet state paid medical leave, to help determine the coverage that’s right for you.4MONTHLY EXPENSES ROUND TO THE NEAREST HUNDREDRent or mortgage (insurance, minor home repairs) $Transportation (car note, bus fare, insurance, gas, maintenance)$Utilities (cell phone, Wi-Fi, electricity/gas, water) $Food and household necessities (toiletries, cleaning supplies)$Childcare (daycare, after-school care) $Health (medical needs and prescription drugs) $Other (gym/fitness, streaming/cable, extracurricular) $Total monthly expenses (add lines 1-7 together) $Your state’s paid medical leave approximate benefits (if any):Monthly benefit: _____________ Benefit period up to: _____________Talk with your counselor to learn more about disability insurance.ColonialLife.com1. Social Security Administration, SSI Annual Statistical Report, 2021.2. Bankrate, Bankrate’s 2023 annual emergency savings report, 2023. 3. Social Security Administration, Disability and Death Probability Tables for Insured Workers, 2022.4. referred to as Temporary Disability Insurance (TDI). Not available in all states.For policies issued or delivered in the Commonwealth of Virginia, THIS IS AN EXCEPTED BENEFITS POLICY. IT PROVIDES COVERAGE ONLY FOR THE LIMITED BENEFITS OR SERVICES SPECIFIED IN THE POLICY.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 affect any used, for example: ISTD3000-TX and ISTD3000-ADIB-TX ), policy form DIS1000 (including state abbreviations where used, for example DIS1000-TX), policy form ED-DIS 1.0 (including state abbreviations where used, for example ED-DIS 1.0-TX), policy VSTDC (including state abbreviations where used, for example VSTDMP-TX and VSTDC-TX). Not applicable in Oregon for policy form ICC21-DIP3000 and rider form ICC21-DIP3000-R-DIS. For cost and complete details of coverage, call or write your Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.© 2023 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. FOR EMPLOYEES 6-23 | 101165-10
Filing online means never waiting for mail or dealing with fax machines and complex paper forms . Our guided question wizard walks you through the process and checks for missing information that could cause delays. Opting for direct deposit can also get approved payments to you up to a week faster than paper check. NEED TO FILE A CLAIM?Here’s what you can do on Colonial Life for Policyholders:Update yourpersonal info& preferencesFile claimswith a simple,guided form Opt for instant alerts by email or textView claim statusor policy details anytimeCheck your claim status by logging into your account at ColonialLife.com/access. You can also sign up for text or email alerts so you know instantly if status changes or more information is needed. For your convenience, you can login anytime with a mobile device to photograph and upload documents with your camera.AFTER YOU FILE:Find out how simple your claims and benefits experience can be by learning more about the Colonial Life for Policyholders portal. Just visit ColonialLife.com to see what this online account administration platform can do for you.LEARN MOREBECOME A MEMBER TODAY:Go to ColonialLife.com/access to register.Click “create an account”, fill out the required information and click Submit.Enjoy faster service and improved benefits awareness.123THE PORTALOFFERS YOU:Faster service than calling/emailingConfirmation when a claim has been submittedSimplified bill payment and managementAnswers to frequently asked questions and live chat assistance if you don’t see what you are looking for.Colonial Life for Policyholders PortalA faster, simpler way to manage your benefitsColonial Life for Policyholders is an online portal created with you in mind. It’s the most convenient and ecient way to file a claim and manage your benefits. Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2022 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.43233-41Set up directdeposit forapproved payments
Accident InsurancePreferred PlanIAC4000 – PREFERRED PLANOUR COVERAGE INCLUDES:All of this can help you get back on your feet. Nobody expects an accident to happen. But if it does, your main focus should be on recovery, not how you’re going to pay your bills. Colonial Life accident insurance provides benefits directly to you to use however you like – from medical costs to everyday expenses. Whether it's a fall or a car accident, your benefits oer support when you need it.DOCTORʼS OFFICE VISITOver the next several weeks, he had three follow-up appointments with his doctor.URGENT CARE CENTER VISITMilo went to an urgent care center and received immediate care.DIAGNOSTIC PROCEDUREThe doctor ordered an X-ray and discovered Milo had fractured his hand.LACERATIONThe doctor also found that Milo had a cut on his hand.MEDICAL EQUIPMENTMilo was discharged with a splint.MILOʼS BENEFITSWith Colonial Life accident benefits, Milo’s parents were able to pay the annual deductible and co-payments.Accident emergency treatment $125X-ray $30Laceration (no stitches) $30Fracture (hand) $375Medical equipment (splint) $30Accident follow-up treatment (3 visits)$165Total: $755For illustrative purposes only.Benefit amounts may vary and may not cover all expenses. The policy has exclusions and limitations.Milo was running on the playground when he tripped and injured his hand. Benefits payable directly to you No medical questions to qualify for coverage Coverage for simple and complex injuries Benefits payable, regardless of other insurance Worldwide coverage Keep coverage no matter where you go Works alongside your health savings account (HSA)
INITIAL CAREAccident emergency treatment ........................................................................ $125Hospital emergency room, urgent care facility or physician’s oiceAccidental injury due to an automobile accident .................................................. $250 Air ambulance1 .......................................................................................... $2,000 Ambulance – ground or water1 ......................................................................... $200 Observation room (up to two days per calendar year) .................................. $150 per day X-ray ........................................................................................................... $30 COMMON ACCIDENTAL INJURIESBurn (based on size and degree)......................................................... $1,000 – $12,000Burn – skin gra ......................................................... 50% of applicable burn benefitComa (lasting for seven or more consecutive days).............................................$12,500Concussion ................................................................................................. $150 Dislocation – separated joint¾ Non-surgical – repair .................................................................... $100 – $2,250Incomplete dislocation – or dislocation without anesthesia .................... 25% of benefit Examples: elbow: $500 | ankle: $1,000 | knee: $1,125 | hip: $2,250 ¾ Surgical – repair .......................................................................... $200 – $4,500 Examples: elbow: $1,000 | ankle: $2,000 | knee: $2,250 | hip: $4,500Emergency dental work .........................................................................$100 – $300Dental extraction or dental crown, denture or implantEye injury – with surgical repair or removal of a foreign object ................................... $300 Fracture – complete¾ Non-surgical – repair .................................................................... $250 – $3,000Chip fracture ............................................................................. 25% of benefit Examples: hand: $375 | foot: $375 | collarbone: $625 | leg: $1,000¾ Surgical – repair .......................................................................... $500 – $6,000 Examples: hand: $750 | foot: $750 | collarbone: $1,250 | leg: $2,000Hearing-loss injuries2 .................................................................................... $120 Knee cartilage – torn (with surgical repair) ........................................................... $650 Laceration (based on repair and length) ....................................................... $30 – $600 Ruptured disc (with surgical repair) ................................................................... $750 Tend on /l igam en t/ rota tor cu (with surgical repair) ¾ One ......................................... $650 ¾ Two or more ........................ $1,300 HOSPITAL CAREHospital admission ..................................................................................... $1,000 Hospital confinement (up to 365 days) ..................................................... $250 per dayHospital sub-acute intensive care unit confinement (up to 30 days) ................. $325 per dayIntensive care unit admission ........................................................................ $2,000 Intensive care unit confinement (up to 15 days) .......................................... $450 per daySURGICAL CAREBlood/plasma/platelets – transfusion ................................................................ $300 Surgery (based on type of repair and surgery) ............................................ $200 – $1,500Benefits are per covered person per covered accident unless stated otherwise.Olivia was driving to the store when she got into a car accident.AMBULANCE AND EMERGENCY ROOM VISITOlivia was admitted to the hospital for surgery on her leg. She was confined for three days.Over the next several weeks, she had six follow-up appointments with her doctor.Olivia had eight sessions of physical therapy to help regain the strength in her leg.The doctor ordered an X-ray and discovered Olivia had fractured her thigh (femur). He also ordered a CT scan of her head to check for brain injury.OLIVIA'S BENEFITSOlivia’s accident benefits helped cover her annual deductible and co-payments.Ambulance $200Accidental injury due to an automobile accident$250Accident emergency treatment $125X-ray $30Medical imaging study (CT) $200Hospital admission $1,000Hospital confinement (3 days) $750Thigh fracture – femur (surgical) $4,400Surgery (exploratory/arthroscopic) $300Medical equipment (crutches) $100Accident follow-up treatment (6 visits)$330Physical therapy (8 days) $280Total: $7,965Olivia arrived by ambulance to the nearest emergency room and received immediate care.DIAGNOSTIC PROCEDURESHOSPITAL ADMISSION, CONFINEMENT AND SURGERYDOCTORʼS OFFICE VISITSPHYSICAL THERAPYFor illustrative purposes only.Benefit amounts may vary and may not cover all expenses. The policy has exclusions and limitations.
For more information, talk with your benefits counselor.IAC4000 – PREFERRED PLANTRANSPORTATION & LODGINGTransportation for hospital confinement .....................................................$600 per round trip(up to three round trips, 50+ miles from home)Lodging – companion (up to 30 days) .................................................................. $125 per dayFOLLOW-UP CAREAccident follow-up treatment – including transportation/telemedicine ................................... $55 (up to six benefits per covered person per covered accident and up to 12 benefits per covered person per calendar year)Medical equipment¾ Tier 1 ............................................................................................................... $30 Arm sling, cane, medical ring cushion, neck brace or wrist/ankle splint ¾ Tier 2 ............................................................................................................. $100 Bedside commode, cold therapy system (cryotherapy), crutches, leg brace, shower chair, walker or walking boot ¾ Tier 3 ............................................................................................................. $200 Back brace, body jacket, continuous passive movement (CPM), halo, electric scooter, hospital bed (including rental), knee scooter, stair li chair, wheelchairMedical imaging study – CT, CAT scan, EEG, EMG, MR or MRI................................................. $200 (one per calendar year)Pain management for epidural anesthesia – non-surgical ................................................... $100 Post-traumatic stress disorder (PTSD) .......................................................................... $200 Prosthetic device/artificial limb¾ One ............................................ $750 ¾ More than one ..............................$1,500¾ Repair/replacement3 ................................................................................... $375/$750Rehabilitation unit confinement ....................................................................... $150 per day(up to 15 days, not to exceed 30 days per calendar year)Therapy – occupational, physical or speech (up to 10 days) .........................................$35 per dayACCIDENTAL DISMEMBERMENTAccidental dismemberment ...........................................................................$450 – $20,000¾ Loss, loss of use or paralysis – hand, arm, foot, leg, sight of eye¾ Loss, loss of use – finger, toe, partial dismemberment of finger or toe4Accidental dismemberment due to a catastrophic accidentNamed insured, spouse or child ...........................................................................$25,0005¾ Total and irrecoverable loss, los s of use or paralysi s – 180-d ay e limina tion peri od¾ 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 speakACCIDENTAL DEATHAccidental death¾ Named insured, spouse .................................................................................. $40,000¾ Child ......................................................................................................... $10,000Accidental death common carrierExamples of common carriers are mass transit trains, buses and planes¾ Named insured, spouse ................................................................................. $160,000¾ Child ......................................................................................................... $30,000
ColonialLife.com8-20 | 101776-31 In Nevada , air ambulance or ambulance: We will pay this benefit directly to the provider unless the air ambulance or ambulance bill shows that all charges have been paid in full.2 One benefit for each injured ear per covered person per lifetime. 3 One repair or replacement per prosthetic device/artificial limb per covered person per lifetime.4 In Maine, the minimum benefit for full dismemberment of finger or toe is $1,000.5 Payable once per lifetime per covered person.HEALTH 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 POLICY 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 Accidental Dismemberment Due to Catastrophic Accident benefits for injuries a child sustains during birth, or for injuries that are the result of intoxication or use of narcotics.State Variations for Exclusions and LimitationsIL: Also includes “aviation.” Not applicable to “hazardous avocations, racing, semi-professional or professional sports.”MT: Not applicable to “suicide or injuries which you intentionally do to yourself" and "injuries a child sustains during birth.”NV: Not applicable to "intoxicants and narcotics."OK: Not applicable to “hazardous avocations, racing and semi-professional or professional sports.” For Accidental Dismemberment Due to Catastrophic Accidents, replace “injuries a child sustains during birth, or for injuries that are the result of intoxication” with “alcoholism or drug addiction, or narcotics.”UT: Also includes “aviation.” Not applicable to “hazardous avocations, racing, semi-professional or professional sports.”This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may aect any benefits payable. Applicable to policy forms IAC4000 (including state abbreviations where used, for example: IAC4000-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.
For more information, talk with your benefits counselor.ColonialLife.comCancer vaccine benefit: ................................................................. $50 This benefit is payable if you or your covered family members incur a charge for any FDA-approved cancer vaccine while your policy is inforce.Specified Critical Illness InsuranceIf you’re diagnosed with a covered critical illness or cancer, specified critical illness insurance from Colonial Life can help with your expenses, so you can concentrate on what’s most important – your treatment, care and recovery.Face amount: $_______________ CRITICAL ILLNESS 1.0 WITH CANCER The maximum benefit amount for this policy is 100% of the face amount for each covered person. We will not pay more than 100% of the face amount for all covered specified critical illnesses combined. The policy will terminate when the maximum benefit amount for specified critical illness has been paid. For the diagnosis of this covered critical illness condition:1This percentage of the face amount is payable:Cancer 100%Heart attack (myocardial infarction) 100%Stroke 100%End-stage renal (kidney) failure 100%Major organ failure 100%Permanent paralysis due to a covered accident 100%Coma 100%Blindness 100%Occupational infectious HIV or occupational infectious hepatitis B, C or D100%Coronary artery bypass gra surgery/disease225%Carcinoma in situ 25%Critical illness benefit5,000-$20,000
ColonialLife.com1 Please refer to the policy for complete definitions of covered conditions. 2 Benefit for coronary artery disease applicable in lieu of benefit for coronary artery bypass gra surgery when health savings account (HSA) compliant plan is selected.THIS POLICY PROVIDES LIMITED BENEFITS.EXCLUSIONS AND LIMITATIONS FOR SPECIFIED CRITICAL ILLNESSWe will not pay benefits for a specified critical illness that occurs as a result of a covered person’s: felonies or illegal occupations; intoxicants and narcotics; pre-existing condition; psychiatric or psychological condition; suicide or self-inflicted injuries; or war or armed conflict. This is not an insurance contract and only the actual policy provisions will control. Applicable to policy form CI-1.0-AK, CI-1.0-DE or CI-1.0-TX. Please see your Colonial Life benefits counselor for details.6-17 | 101823-AK-DE-TXUnderwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2017 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.