Return to flip book view

2025-2026 A GUIDE TO YOUR BENEFITS…. 1 Message

            

A work)    k if    

Deductions per year: 12 These rates were prepared on 3/22/2024 and are valid for 90 days.Group Accident (GAC4100) for TXApplicable to policy forms GAC4100-P,GAC4100-ClAdditional Benefits:On/Off-Job Accident CoverageBENEFIT LEVEL AD&D BENEFIT LEVEL ISSUE AGE EMPLOYEE EMPLOYEE ANDSPOUSEEMPLOYEE ANDDEPENDENTCHILD(REN)EMPLOYEE, SPOUSEAND DEPENDENTCHILD(REN)Premier Premier 17-99 $15.75 $24.56 $35.18 $44.20Group Medical Bridge (GMB7000) for TXAge-BandedApplicable to Policy Forms GMB7000–P & GMB7000-ClWithout Wellbeing AssistanceHOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 2: $100017-49 $9.50 $17.10 $13.55 $21.1550-59 $12.30 $24.40 $16.35 $28.4560-64 $17.20 $35.80 $21.25 $39.8565-99 $24.10 $50.10 $28.15 $54.15HOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 4: $200017-49 $18.90 $34.00 $26.95 $42.0550-59 $24.50 $48.60 $32.55 $56.6560-64 $34.30 $71.40 $42.35 $79.4565-99 $48.10 $100.00 $56.15 $108.05Group Critical Illness (GCI6000) for TXApplicable 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)$15,000 17-24 $8.90 $13.05 $8.90 $13.0525-29 $11.45 $16.95 $11.45 $16.9530-34 $14.15 $20.85 $14.15 $20.8535-39 $20.15 $30.00 $20.15 $30.0040-44 $26.15 $39.00 $26.15 $39.0045-49 $36.05 $54.30 $36.05 $54.3050-54 $45.80 $69.60 $45.80 $69.6055-59 $59.30 $90.15 $59.30 $90.1560-64 $79.85 $121.35 $79.85 $121.3565-69 $97.25 $148.05 $97.25 $148.0570-74 $97.25 $148.05 $97.25 $148.05Page 1 of 3Underwritten by Colonial Life & Accident Insurance CompanySee page 2 for Important Notice

Group Critical Illness (GCI6000) for TXApplicable 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)$30,000 17-24 $14.90 $21.60 $14.90 $21.6025-29 $20.00 $29.40 $20.00 $29.4030-34 $25.40 $37.20 $25.40 $37.2035-39 $37.40 $55.50 $37.40 $55.5040-44 $49.40 $73.50 $49.40 $73.5045-49 $69.20 $104.10 $69.20 $104.1050-54 $88.70 $134.70 $88.70 $134.7055-59 $115.70 $175.80 $115.70 $175.8060-64 $156.80 $238.20 $156.80 $238.2065-69 $191.60 $291.60 $191.60 $291.6070-74 $191.60 $291.60 $191.60 $291.60Tobacco RatesISSUE AGE NAMED INSURED NAMED INSURED ANDSPOUSENAMED INSURED ANDDEPENDENT CHILD(REN)NAMED INSURED, SPOUSEAND DEPENDENT CHILD(REN)$15,000 17-24 $12.50 $18.15 $12.50 $18.1525-29 $16.70 $24.45 $16.70 $24.4530-34 $20.90 $30.75 $20.90 $30.7535-39 $30.50 $45.15 $30.50 $45.1540-44 $40.10 $59.70 $40.10 $59.7045-49 $55.85 $84.15 $55.85 $84.1550-54 $71.45 $108.60 $71.45 $108.6055-59 $93.05 $141.60 $93.05 $141.6060-64 $125.90 $191.55 $125.90 $191.5565-69 $153.80 $234.00 $153.80 $234.0070-74 $153.80 $234.00 $153.95 $234.15$30,000 17-24 $22.10 $31.80 $22.10 $31.8025-29 $30.50 $44.40 $30.50 $44.4030-34 $38.90 $57.00 $38.90 $57.0035-39 $58.10 $85.80 $58.10 $85.8040-44 $77.30 $114.90 $77.30 $114.9045-49 $108.80 $163.80 $108.80 $163.8050-54 $140.00 $212.70 $140.00 $212.7055-59 $183.20 $278.70 $183.20 $278.7060-64 $248.90 $378.60 $248.90 $378.6065-69 $304.70 $463.50 $304.70 $463.5070-74 $304.70 $463.50 $305.00 $463.80Important NoticeInsurance coverage has exclusions and limitations that may affect benefits payable. For a complete description of benefits, limitations and exclusions, please refer to anoutline of coverage, sample policy/certificate, proposal description or see your Colonial Life benefits counselor. Coverage type, benefits and rates vary by state. Coverage maynot be available in all states. Rates provided are illustrative and your actual premium may be different depending on your particular situation and plan choices.Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.(Continued...)Page 2 of 3Underwritten by Colonial Life & Accident Insurance CompanySee page 2 for Important Notice

© 2024 Colonial Life & Accident Insurance Company"Colonial Life," and the Colonial Life logo, separately and in combination, are service marks of Colonial Life & Accident Insurance Company. All rights reserved.Mark | mark@colonialtx.com | (281) 714-8150(Continued...)Page 3 of 3Underwritten by Colonial Life & Accident Insurance CompanySee page 2 for Important NoticeGroup Disability for TX AAA Risk ClassApplicable to policy forms GDIS-P & GDIS-ClOff-Job Accident and Off-Job Sickness3 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $400* $1,000* $2,500* $4,000* $7,500**monthly benefit amount7 days Accident/7 days Sickness 17-49 $9.72 $24.30 $60.75 N/A N/A50-64 $11.20 $28.00 $70.00 N/A N/A65-74 $13.56 $33.90 $84.75 N/A N/A14 days Accident/14 days Sickness 17-49 $6.28 $15.70 $39.25 $62.80 $117.7550-64 $7.36 $18.40 $46.00 $73.60 $138.0065-74 $9.44 $23.60 $59.00 $94.40 $177.006 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $400* $1,000* $2,500* $4,000* $7,500**monthly benefit amount7 days Accident/7 days Sickness 17-49 $12.28 $30.70 $76.75 N/A N/A50-64 $16.20 $40.50 $101.25 N/A N/A65-74 $21.08 $52.70 $131.75 N/A N/A14 days Accident/14 days Sickness 17-49 $8.56 $21.40 $53.50 $85.60 $160.5050-64 $10.80 $27.00 $67.50 $108.00 $202.5065-74 $14.40 $36.00 $90.00 $144.00 $270.00

For more information, talk with your benefits counselor.ColonialLife.comGroup Hospital Indemnity InsurancePlan 1 (HSA-Compliant)PA: “Hospital Confinement Admission” benefit replaces the “Hospital Confinement” benefitTHIS POLICY PROVIDES LIMITED BENEFITS.EXCLUSIONSWe will not pay any benefits for injuries received in accidents or for sicknesses which are caused by, contributed to by or occur as a result of the following exclusions and limitations. (a) alcoholism or drug addiction; (b) dental procedures; (c) elective procedures and cosmetic surgery; (d) felonies or illegal occupations; (e) mental or nervous disorders; (f) pregnancy of a dependent child; (g) suicide or injuries which any covered person intentionally does to himself or herself; (h) war, or (i) giving birth within the first nine months aer the eective date of the certificate. (j) We will not pay benefits for hospital confinement or daily hospital confinement, if included, of a newborn child following his birth unless he is injured or sick. (k)The policy may have additional exclusions and limitations which may aect any benefits payable.PRE-EXISTING CONDITION LIMITATIONS(l) We will not pay benefits for loss during the first 12 months aer the certificate eective date due to a pre-existing condition.(m) A pre-existing condition is a sickness or physical condition, whether diagnosed or not, for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the certificateeective date. (n) This limitation applies to the following benefits, if applicable: Hospital Confinement and Daily Hospital Confinement.This information is not intended to be a complete description of the insurance coverage available. This coverage has exclusions and limitations that may aect benefits payable. For cost and complete details, see your Colonial Life benefits counselor. This brochure is applicable to policy form GMB7000-P and certificate form GMB7000-C (including state abbreviations where applicable, such as policy forms GMB7000-P-AU-TX and GMB7000-P-EE-TX, and certificate forms GMB7000-C-AU-TX and GMB7000-C-EE-TX). Coverage may vary by state and may not be available in all states. This form is not complete without form #101733.GMB7000 – PLAN 1 | 11-18 | 101917Group Medical BridgeSM insurance can help with medical costs associated with a hospital stay that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children. Hospital confinement ............................................................... $_$1000 or $2000 per dayMaximum of one day per covered person per calendar yearWaiver of premiumAvailable aer 30 continuous days of a covered confinement of the named insured£ Daily hospital confinement .................................................................... $100 per dayMaximum of 365 days per covered person per confinement. Re-confinement for the same or related condition within 90 days of discharge is considered a continuation of a previous confinement.Health savings account (HSA) compatibleThis plan is compatible with HSA guidelines and any other HSA plan that a covered family member may participate in. It may also be oered to employees who do not have HSAs.Colonial Life & Accident Insurance Company’s Group Medical Bridge oers an HSA-compatible plan in most states.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 Hospital Indemnity InsuranceExclusions and LimitationsGMB7000 – EXCLUSIONS AND LIMITATIONSSTATE-SPECIFIC EXCLUSIONSAK: (a) Replaced by intoxicants and narcotics CA: (k) Additional exclusions include intoxicants and controlled substancesCT: (a) Replaced by intoxication or drug addiction; (d) Replaced by felonies; (f) Exclusion does not applyDE: (a) Exclusion does not apply IL: (a) Replaced by alcoholism, intoxication, or drug addiction; (f) Exclusion does not apply; (g) Exclusion does not applyKS: (a) Replaced by intoxicants and narcotics; (h) Replaced by war or armed conflict; (i) Exclusion does not applyKY: (a) Replaced by intoxicants, narcotics and hallucinogenics LA: (a) Replaced by intoxicants and narcotics MI: (g) Exclusion does not applyMO: (a) Replaced by drug addiction; (d) Replaced by illegal activitiesMS: (a) Replaced by intoxicants and narcoticsNC: (i) Exclusion does not applyND: (a) Exclusion does not apply; (e) Exclusion does not applyNV: (a) Exclusion does not apply OH: (f) Exclusion does not apply; (i) Replaced by 270 daysPA: (a) Replaced by intoxicants and narcotics; (c) Replaced by cosmetic surgery; (e) Replaced by mental, nervous or emotional disorders; (h) Replaced by war or armed conflictSD:(a) Exclusion does not apply TN: (f) Exclusion does not applyTX: (a) Replaced by intoxicants and narcotics VA: (i) Pregnancy resulting from the rape of any covered person, which was reported to the police within seven days following its occurrence, will be covered to the same extent as any other covered accident. The seven-day requirement will be extended to 180 days in the case of an act of rape or incest of a female under 13 years of age.STATE-SPECIFIC PRE-EXISTING CONDITION LIMITATIONSIN, SD, and WY: (m) applies within the six months before the certificate eective date.CA: (m) A pre-existing condition is a sickness or physical condition for which a covered person was diagnosed or treated within 12 months before the coverage eective date.FL: (m) A pre-existing condition is 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 eective date. Genetic information is not a pre-existing condition in the absence of a diagnosis of the condition related to such information. IL: (m) A pre-existing condition is a sickness or physical condition, whether diagnosed or not, for which a covered person was treated, had medical testing by a legally qualified physician or, received medical advice, produced symptoms or had taken medication within 12 months before the coverage eective date.KS: (n) Surgical Procedure replaces Outpatient Surgical Procedure ME: (m) A pre-existing condition is a sickness or physical condition, whether diagnosed or not, for which a covered person was treated, had medical testing, or received medical advice within 12 months before the coverage eective date.MI: (l) Applies during the first six months aer the certificate eective date (m) applies within the six months before the certificate eective date.MO: (m) A pre-existing condition means having a sickness or physical condition, whether diagnosed or not, for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage eective date of this certificate.NC: (m) A pre-existing condition is those conditions, whether diagnosed or not, for which a covered person received medical advice, diagnosis, care or treatment that was received or recommended within the one-year period immediately preceding the coverage eective date. If you are 65 or older when this certificate is issued, pre-existing conditions will include only conditions specifically eliminated by a rider.ND: (m) A pre-existing condition is 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 eective date.NV: (m) applies within the six months before the certificate eective date. Additionally, pre-existing condition does not include genetic information in the absence of a diagnosis of the condition related to such information.OR: (m) A pre-existing condition is a sickness or physical condition, whether diagnosed or not, for which a covered person was treated by a doctor, received advice from a physician or had taken medication prescribed by a doctor within the 12 months period immediately preceding the coverage eective date.PA: (m) A pre-existing condition is a disease or physical condition for which you received medical advice or treatment within 90 days before the coverage eective date. (n) Hospital Confinement Admission replaces Hospital Confinement. CA Lic # (if applicable): _________________11-18 | 101733-2This information is not intended to be a complete description of the insurance coverage available. This coverage has exclusions and limitations that may aect benefits payable. For cost and complete details, see your Colonial Life benefits counselor. This brochure is applicable to policy form GMB7000-P and certificate form GMB7000-C (including state abbreviations where applicable, such as policy forms GMB7000-P-AU-TX and GMB7000-P-EE-TX, and certificate forms GMB7000-C-AU-TX and GMB7000-C-EE-TX). Coverage may vary by state and may not be available in all states.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 Accident InsurancePremier PlanIf you are in an accident, your focus should be on recovery, not how you’re going to pay your bills. Colonial Life accident insurance can pay benets directly to you to use however you like — from medical costs to everyday expenses. Whether you’ve had a fall or a car accident, these benets can offer nancial support when you need it.Our coverage includes:• Benets payable directly to you• No medical questions to qualify for coverage• Coverage for simple and complex injuries• Benets payable regardless of other insurance• Worldwide coverage• Works alongside your Health Savings Account (HSA)BENEFITS STORY Milo was working in his yard when he tripped and injured his hand.With Colonial Life accident benets, Milo was able to pay the annual deductible and co-payments for his health insurance plan without using his savings or taking on debt.MILO’S ACCIDENT BENEFITSMilo went to an urgent care facility and received immediate care.Treatment in a physician’s office or urgent care facility$150The doctor ordered an X-ray and discovered Milo had fractured his hand.• X-ray• Fracture (hand)$60$1,200The doctor also found that Milo had a cut on his hand but did not require stitches. Laceration (no repair) $75Milo was discharged with a splint. Durable medical equipment $65Over the next several weeks, Milo had two follow-up appointments with his doctor. Physician follow-up visits (2 visits)$50 x 2 = $100Total $1,650For illustrative purposes only. Benet amounts may vary and may not cover all expenses. GROUP ACCIDENT (GAC4100) — PREMIER PLAN

Give your benets a boostWe know that more complicated or severe accidents result in more expensive medical bills and more disruption in your life. Group Accident includes a Benet Booster* to provide additional nancial support for serious accidents. If you have more than $5,000 in payable benets for a covered accident, we will give you a $500 boost to your benets to help you with whatever expenses you have. *Payable once per Insured per covered accidentBENEFITS STORY Olivia was driving to the store when she got into a car accident.Olivia’s benets helped her cover her medical expenses when she was injured in a car accident, helping her to focus on her recovery.OLIVIA’S ACCIDENT BENEFITSOlivia arrived by ambulance at the nearest emergency room and received immediate care.• Ambulance• Emergency department visit• Injury due to auto accident$400$250 $250The 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.• X-ray• Medical imaging• Fracture (thigh)$60$400 $4,200Olivia required surgery for her leg.• Surgical repair (thigh fracture)• General anesthesia$4,200 $300Olivia boarded her pet for two nights after her surgery. Pet boarding (2 days) $20 x 2 = $40Olivia had eight sessions of physical therapy to help regain the strength in her leg and two follow-up appointments with her doctor.• Therapy services (8 sessions)• Physician follow-up visits (2 visits)$55 x 8 = $440$50 x 2 = $100Olivia’s benefits for this accident totaled more than $5,000.Benefit Booster $500Total $11,140For illustrative purposes only. Benet amounts may vary and may not cover all expenses. Benets are per covered person per covered accident unless stated otherwiseInjury benets • Burns (based on size and degree) ............. $750–$21,000• Concussion ........................................ $500• Connective tissue damage ......................$100–$200• Eye injury .......................................... $400 • Hearing loss injuries ..................................$120(Maximum once per lifetime per ear per insured)• Injury due to auto accident ........................... $250 • Internal injuries ..................................... $200 • Knee cartilage (meniscus) injury ...................... $200 • Lacerations ...................................$75–$1,200• Loss of a digit — partial .........................$400–$800• Loss of a digit ..............................$1,000–$3,000• Ruptured or herniated disc ......................$200–$400

Fracture benets• Injury .......................................$200–$5,000 Examples: nger: $200 | wrist: $1,200 | hip: $4,200• Surgical repair of fracture ............................100%(Payable as an additional % of the applicable fractures benet)• Chip fracture ........................................25% (Payable as a % of the applicable fractures benet)Dislocation benets• Injury .......................................$260–$4,000 Examples: elbow: $600 | ankle: $1,600 | hip: $4,000• Surgical repair of dislocation ..........................100%(Payable as an additional % of the applicable dislocations benet)• Incomplete dislocation ................................25%(Payable as a % of the applicable dislocations benet)Treatment benets• Air ambulance .....................................$2,000 • Ambulance (ground or water) ......................... $400 • Durable medical equipment ......................$65–$250• Emergency dental repair ........................$200–$600• Emergency department .............................. $250(Maximum 4 per year) • Family care ................................... $50 per day (Maximum of one benet per day for all insureds combined, up to a maximum of three days per covered accident, regardless of the number of children)• Injections to prevent or limit infection ...................$50 • Lodging ..................................... $250 per day (Maximum 30 days)• Medical imaging ..................................... $400 • Pain management injections ..........................$150 • Pet boarding .................................. $20 per day (Maximum of one benet per day for all insureds combined, up to a maximum of three days per covered accident, regardless of the number of pets that are boarded)• Prosthetic device or articial limb ............$1,750–$3,500• Skin grafts (due to burns) .............................50%(Payable as a % of the applicable burn benet)• Skin grafts (not due to burns) ....................$375–$750• Transfusions ........................................ $500 • Transportation ............................... $200 per trip (Maximum 6 one-way trips)• Treatment in a physician’s oce or urgent care facility ...$150(Maximum 4 per year) • X-ray or ultrasound ....................................$60Surgery benets• Anesthesia ....................................$150–$300• Connective tissue surgery ..................... $150–$2,200• Eye surgery .........................................$400• General surgery –Abdominal, thoracic, or cranial ...................$2,000 –Exploratory surgery ...............................$275 • Hernia surgery ......................................$400 • Knee cartilage (meniscus) surgery ..............$150–$1,050• Outpatient surgical facility ............................$400 • Ruptured or herniated disc surgery ............ $150–$2,000Recovery care benets• At-home care ................................ $125 per day(Maximum 5 days) • Benet Booster .....................................$500• Physician follow-up visits ............................. $50 (Maximum 6 days per covered accident and 24 days per calendar year)• Rehabilitation or sub-acute rehabilitation unit connement .............................$200 per day (Maximum 15 days per covered accident and 30 days per calendar year)• Therapy services (speech, physical therapy, occupational therapy) ..........................$55 per day(Maximum 15 days)Options checked below have been chosen by your employer to enhance your Group Accident Coverage.  Recovery Plus package• Behavioral health therapy ...................$55 per day (Maximum 15 days)• Post-traumatic stress disorder (PTSD) ............ $200 • Prescription drug .................................$25 • Additional therapy services (chiropractic, acupuncture, alternative therapy) ......$55 (Existing therapy services benet maximum applies to additional therapy services, maximum 15 days)• Injury due to felonious act of violence or sexual assault ................................ $250(Maximum once per insured per calendar year, with an accompanying police report) Gunshot wound benetThis benet can help pay your medical expenses if you receive a non-fatal gunshot wound. It offers you a lump sum for a covered injury regardless of any other insurance you may have and includes on/off-job coverage.• Gunshot wound .............................$_________This benet covers a non-fatal gunshot wound from a conventional rearm that requires treatment by a doctor and overnight hospitalization within 24 hours of the injury. If you are shot more than once in a 24-hour period, we can pay benets only for the rst wound.

Contact your Colonial Life benets counselor to learn more.CT: We will pay the air ambulance or ambulance benets directly to the licensed professional ambulance company. CT includes a benet for “outpatient emergency medical care for accidental ingestion of a controlled substance.” The at-home care benet maximum is 80 days. KS: Chiropractic therapy is not available. NH: NH includes a burn benet for 2nd degree burns under 5% of skin surface. The minimum benet for the loss or partial loss of a digit is $1,000.MD: The prescription drug benet is not available.PA: The pet boarding benet is not available. TN: The therapy services benet includes chiropractic. TX: The concussion benet is replaced by the “concussion and acquired brain injuries” benet. The therapy services benet includes the following services: cognitive communication therapy; cognitive rehabilitation therapy; community reintegration services; neurobehavioral; neurocognitive therapy and rehabilitation; neurofeedback therapy; neurophysiological; neuropsychological; post-acute transition services; psychophysiological testing or treatment; and remediation.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 offered to employees who do not have HSAs.THIS INSURANCE PROVIDES LIMITED BENEFITS.This coverage is a supplement to health insurance. It is not a substitute for essential health benets or minimum essential coverage as dened in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this insurance.EXCLUSIONSWe will not pay benets for claims that are caused by, contributed to by, or resulting from elective procedures, felonies or illegal occupations, hazardous avocations, impaired driving, incarceration, racing, semi-professional or professional sports, sickness, suicide or self-inicted injuries, war, or armed conict. ID: ”Semi-professional sports or professional sports” exclusion is replaced by “professional sports” exclusion. IL: We will not pay benets for claims that are caused by or resulting from Exclusions.MD: Includes an exclusion for “Prohibited referrals.” The “felonies or illegal occupations” and “impaired driving” exclusions apply only to Accidental Death and Dismemberment benets.MI: “Impaired driving” and “suicide or self-inicted injuries” exclusions do not apply. MN: “Suicide or self-inicted injuries” exclusion does not apply.NH: “Incarceration” and “racing” exclusions do not apply.UT: We will not pay benets for claims that are caused by or resulting from Exclusions.VT: “Impaired driving” exclusion does not apply. 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 benets payable. Applicable to policy form GAC4100-P and certicate form GAC4100-C (including state abbreviations where used, for example: GAC4100-P-TX and GAC4100-C-TX). For cost and complete details of coverage, call or write your Colonial Life benets counselor or the company.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 3-23 | 1212553ColonialLife.com

35,000

Term Life InsurancePeace of mind for you and your loved onesYou want what’s best for your family, and that includes making sure they’re prepared for the future. With term life insurance from Colonial Life & Accident Insurance Company, you can provide financial security to help them cover their ongoing living expenses.Advantages of term life insurance  Lower cost when compared to cash value life insurance  Same benefit payout throughout the duration of the policy  Several term period options for flexibility during high-need years  Benefit for the beneficiary that is typically tax-freeBenefits and features  Stand-alone spouse policy available whether or not you buy a policy for yourself  Guaranteed premiums that do not increase during the selected term  Ability to convert all or a portion of the benefit amount into cash value life insurance  Flexibility to keep the policy if you change jobs or retire  Built-in terminal illness accelerated death benefit that provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness  Premium savings for face amounts over $250,000 based on your healthTERM LIFE (ITL5000)LIMRA, 2017 Insurance Barometer Study.of Americans would have trouble paying living expenses immediately or within several months if the primary wage-earner died.54%married/partnered consumersLIMRA, 2018 Insurance Barometer Study.1-in-3wish their spouse or partner would purchase more life insurance.

How much coverage do you need?To learn more, talk with your Colonial Life benefits counselor.EXCLUSIONS AND LIMITATIONSIf the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage eective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid, without interest. Product may vary by state. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company. This brochure is applicable to policy forms ICC18-ITL5000/ITL5000 and rider forms ICC18-R-ITL5000-STR/R-ITL5000-STR, ICC18-R-ITL5000-CTR/R-ITL5000-CTR, ICC18-R-ITL5000-WP/R-ITL5000-WP, ICC18-R-ITL5000-ACCD/R-ITL5000-ACCD, ICC18-R-ITL5000-CI/R-ITL5000-CI, ICC18-R-ITL5000-CC/R-ITL5000-CC and applicable state variations. Spouse term life riderYour spouse may receive a maximum death benefit of $50,000; 10-year and 20-year spouse term riders are available. Children’s term life riderYou can purchase up to $20,000 in term life coverage for all of your eligible dependent children and pay one premium. The children’s term life rider may be added to either your policy or your spouse’s policy – not both.Accidental death benefit riderThe beneficiary may receive an additional benefit if the covered person dies as a result of an accident before age 70. The benefit doubles if the accidental bodily injury occurs while riding as a fare-paying passenger using public transportation, such as ride-sharing services. An additional 25% will be payable if the injury is sustained while driving or riding in a private passenger vehicle and wearing a seatbelt.Chronic care accelerated death benefit riderIf a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments. A chronic illness means you require substantial supervision due to a severe cognitive impairment or you may be unable to perform at least two of the six Activities of Daily Living. Premiums are waived during the benefit period. Critical illness accelerated death benefit riderIf you suer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable. A subsequent diagnosis benefit is included.Waiver of premium benefit riderPremiums are waived (for the policy and riders) if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period. 6-19 | 101895-1ColonialLife.com1 Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits.2 Activities of daily living are bathing, continence, dressing, eating, toileting and transferring.3 You must resume premium payments once you are no longer disabled.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.Optional ridersAt an additional cost, you can purchase the following riders for even more financial protection. YOU $ ___________________ Select the term period: 10-year 15-year 20-year 30-year SPOUSE $ ___________________ Select the term period: 10-year 15-year 20-year 30-yearSelect any optional riders: Spouse term life rider $ _____________ face amount for ________-year term period Children’s term life rider $ _____________ face amount Accidental death benefit rider Chronic care accelerated death benefit rider Critical illness accelerated death benefit rider Waiver of premium benefit rider

Your cost will vary based on the level of coverage you select. Whole Life InsuranceYou can’t predict your family’s future, but you can be prepared for it.You like to think that you’ll be there for your family in the years to come. But if something happened to you, would your family have the income they need?It’s not easy to think about such serious circumstances, but it’s important to make sure your family is financially protected. You can gain peace of mind with whole life insurance from Colonial Life.Advantages of whole life insurance  Permanent coverage that stays the same throughout the life of the policy  Guaranteed level premiums that do not increase because of changes in health or age  Access to the policy’s cash value through a policy loan for emergencies  Benefit for the beneficiary that is typically tax-freeBenefits and features  Two plan options to choose what age your premium payments will end – Paid-Up at Age 70 or Paid-Up at Age 100  Stand-alone spouse policy available whether or not you buy a policy for yourself  Flexibility to keep the policy if you change jobs or retire  Built-in terminal illness accelerated death benefit that provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness  Immediate $3,000 claim payment that can help your designated beneficiary pay for funeral costs or other expenses  Pays cash surrender value at age 100 (when the policy endows)WHOLE LIFE (IWL5000)HealthAairs.org, End-Of-Life Medical Spending In Last Twelve Months Of Life Is Lower Than Previously Reported, July 2017.Talk with your benefits counselor for information about what level of coverage would work best for you.In the U.S., medical spending in the last 12 months of life is nearly $80,000 per person.$

 YOU $ ___________________ Select the option: Paid-Up at Age 70 Paid-Up at Age 100 SPOUSE $ _______________ Select the option: Paid-Up at Age 70 Paid-Up at Age 100EXCLUSIONS AND LIMITATIONSIf the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage eective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you. Product may vary by state. For costs and complete details of the coverage, call or write your Colonial Life benefits counselor or the company.This brochure is applicable to policy forms ICC19-IWL5000-70/IWL5000-70, ICC19-IWL5000-100/IWL5000-100, ICC19-IWL5000J/IWL5000J and rider forms ICC19-R-IWL5000-STR/R-IWL5000-STR, ICC19-R-IWL5000-CTR/R-IWL5000-CTR, ICC19-R-IWL5000-WP/R-IWL5000-WP, ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD, ICC19-R-IWL5000-CI/R-IWL5000-CI, ICC19-R-IWL5000-CC/R-IWL5000-CC, ICC19-R-IWL5000-GPO/R-IWL5000-GPO and applicable state variations.Additional coverage optionsSpouse term life riderCover your spouse up to a maximum death benefit of $50,000; 10-year and 20-year spouse term riders are available.Juvenile whole life policyYou can purchase a policy while children are young and premiums are low – whether or not you buy a policy on yourself. You may also increase the coverage when the child is 18, 21 and 24 without providing proof of good health. The plan is paid-up at age 70.Children’s term life riderYou may purchase up to $20,000 in term life coverage for all of your eligible dependent children and pay one premium. The children’s term life rider may be added to either your policy or your spouse’s policy – not both.Accidental death benefit riderThe beneficiary may receive an additional benefit if the covered person dies as a result of an accident before age 70. The benefit doubles if the accidental bodily injury occurs while riding as a fare-paying passenger using public transportation, such as ride-sharing services. An additional 25% will be payable if the injury is sustained while driving or riding in a private passenger vehicle and wearing a seatbelt.Chronic care accelerated death benefit riderIf a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments. A chronic illness means you require substantial supervision due to a severe cognitive impairment or you may be unable to perform at least two of the six Activities of Daily Living (bathing, continence, dressing, eating, toileting and transferring). Premiums are waived during the benefit period.Critical illness accelerated death benefit riderIf you suer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable. A subsequent diagnosis benefit is included.Guaranteed purchase option riderIf you are age 50 or younger when you purchase the policy, you can add the rider, which allows you to purchase additional whole life coverage – without having to answer health questions – at three dierent points in the future. You may purchase up to your initial face amount, not to exceed a total combined maximum of $100,000 for all options.Waiver of premium benefit riderPremiums are waived (for the policy and riders) if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period. Once you are no longer disabled, premium payments will resume.Benefits worksheetFor use with your benefits counselorSelect any optional riders: Spouse term life rider $ _____________ face amount for ________-year term period Children’s term life rider $ _____________ face amount Accidental death benefit rider Chronic care accelerated death benefit rider Critical illness accelerated death benefit rider Guaranteed purchase option rider Waiver of premium benefit riderHOW MUCH COVERAGE DO YOU NEED?To learn more, talk with your benefits counselor.ColonialLife.com6-19 | 101935 DEPENDENT STUDENT $____________ Paid-Up at Age 70  Paid-Up at Age 100 1 Loan should be repaid to protect the policy’s value. 2 Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

                6 " + 7 * $ & +%'5&%3! " #$"%&  '()   ! $"%*+ ! , -      % ./ 0 . % . 1 .0 1% .0 / . %1 .% 0 . 0% . /1 . 0 . / . %1%% .1 / ./  ./0 % .11 ///% .  . 1 .0/ / . /      % . 1 .1  .%  . % . 0 . / .1  .0 %% .% 1 .% / .//  .1/ %% .  ./  .%0 / .1 1/% .0  . 0 . % . 0*+ 2 ! " ,  % . /% . 1% ./ %/34 ! " ,  *1 .% 

4 5 ( 6%4507  "# : ( (';  #< .      0 / /3. /.0 /1.10 /.3 /2 / /..0 /. /00. /00 /.3.      0 /30 /. /11 /30310 /. /1 /132 /220 /.. /10 /.33 /..'= & $ 5 :    0 /20 /1 /20310 /3 /2 /310 /11 /22 /1; ! * 5 ) # % *$&<%$>

Dental Benefits Summary for DL Glover EEM-0142-0921 MX2548680-E UnitedConcordia.com • 1-800-332-0366 Effective: July 1, 2025 Network: ElitePlus Benefit Category1 In-Network2 Non-Network2 Class I – Diagnostic/Preventive Services Exams 100% 100% Bitewing X-rays All Other X-rays Cleanings & Fluoride Treatments Sealants Space Maintainers Palliative Treatment Class II – Basic Services Basic Restorative (Fillings) 80% 80% Simple Extractions Repairs of Crowns, Inlays, Onlays, Bridges & Dentures Complex Oral Surgery General Anesthesia Class III – Major Services Endodontics 50% 50% Nonsurgical Periodontics Surgical Periodontics Inlays, Onlays, Crowns Prosthetics (Bridges, Dentures) Included Plan Features Preventive Incentive® Class I services do not count toward your annual program maximum Smile for Health®--Wellness3 Provides periodontal care for people with certain chronic medical conditions: diabetes, heart disease, lupus, oral cancer, organ transplant, rheumatoid arthritis and stroke Pregnancy is also a covered condition • Covers 1 additional periodontal maintenance per year and all are covered at 100% • Scaling and root planing are covered at 100% • 4 periodontal surgery procedures are covered at 100% Pregnancy Benefit3 Covers 1 additional cleaning during pregnancy in addition to the benefits listed for Smile for Health®--Wellness3 Maximums & Deductibles (applies to the combination of services received from network and non-network dentists) Calendar Year Deductible (per person/per family) $50/$150 Excludes Class I Calendar Year Maximum (per person) $2,000 Excludes Class I Reimbursement Elite Plus Advantage MAC Representative listing of covered services. For underwritten plans, your certificate of insurance/coverage provides complete details on covered services and exclusions and limitations which may affect benefits payable. For self-funded plans, see your employer’s Summary Plan Description for a detailed description of benefits. Dental plans are administered by United Concordia Companies, Inc. Fully insured plans are underwritten by United Concordia Insurance Company. For more information please visit the “Disclaimers” link at www.UnitedConcordia.com. Administrative and claims offices located at 1800 Center Street Suite 2B 220, Camp Hill, PA 17011. Call 1-800-332-0366. For additional plan details or questions, contact your account representative or visit www.ucci.com for more information. 1. Dependent children covered to age 26. 2. Reimbursement is based on our schedule of maximum allowable charges (MACs). Network dentists agree to accept our allowances as payment in full for covered services. Non-network dentists may bill the member for any difference between our allowance and their fee (also known as balance billing). We evaluate our MACs and OON percentile allowances annually based on proprietary claim experience and data purchased from independent sources such as FAIR Health. United Concordia Dental’s standard exclusions and limitations apply. 3. Members (subscribers or covered dependents) with certain medical conditions must sign up for this program through My Dental Benefits on UnitedConcordia.com.

EEM-0095-1120-3 MX2544706-C UnitedConcordia.com/ucvision • 1-888-789-8233 UCVision Benefits Summary – Plan III Included With Your Concordia Dental Plan In-Network Coverage Frequency (once every) Member Pays Eye Examination Eye Exam (with dilation when professionally indicated) 12 months $0 Frames Collection 12 months Fashion: $0 Designer: $0 Premier: $25 Non-Collection $0 ($150 allowance, 20% discount on remaining balance*) Spectacle Lenses Clear glass or plastic lenses in single vision, bifocal, trifocal or lenticular prescription 12 months $0 Spectacle Lens Options Oversize Lenses 12 months $0 Tinting of Plastic Lenses Scratch-Resistant Coating Premium Scratch-Resistant Coating $30 Polycarbonate Lenses $30 ($0 for dependent children, monocular patients and patients with prescriptions +/- 6.00 diopters or greater) Ultraviolet Coating $12 Anti-Reflective Coating (Standard / Premium / Ultra / Ultimate) $35 / $48 / $60 / $85 Progressive Lenses (Standard / Premium / Ultra / Ultimate) $50 / $90 / $140 / $175 Digital Single Vision Lenses $30 Blended Segment Lenses $20 High-Index Lenses (1.67 / 1.74) $55 / $120 Polarized Lenses $75 Photosensitive Lenses (Glass / Plastic) $20 / $65 Trivex Lenses $50 Blue Light Filtering $15 Scratch Protection Plan (Single Vision / Multifocal) $20 / $40 Contact Lenses (in lieu of eyeglasses) Contact Lens Evaluation, Fitting & Follow-up Care 12 months Collection: $0 Non-Collection: $0 ($60 allowance, 15% discount on remaining balance*) Contact Lenses Collection: $0 (Disposable - up to 8 boxes, Planned Replacement – up to 4 boxes) Non-Collection: $0 ($150 allowance, 15% discount on remaining balance*) Value-Added Features One-Year Eyeglass Breakage Warranty $0 Retinal Imaging $39 Laser Vision Correction Up to 40% discount Out-of-Network Coverage Frequency (once every) Member Reimbursement Eye Exam 12 months up to $45 Frames up to $50 Spectacle Lenses Single Vision up to $40 Bifocal up to $60 Trifocal up to $80 Lenticular up to $90 Non-Collection Contact Lenses (includes evaluation, fitting and follow-up care) up to $120 Representative listing of covered services – see plan documents. UCVision benefits administered by Davis Vision, Inc. Discounts and value-added features not underwritten by United Concordia Dental. *Discount does not apply to services or materials from a Walmart or Sam’s Club vision center.

Dental & Vision Rates

Group Short Term Disability InsuranceIf a covered accident or covered sickness prevents you from earning a paycheck, group short term disability insurance can provide a monthly benet to help you cover your ongoing expenses, often at a more reasonable rate than individual insurance.Disability insurance worksheet You can tailor disability coverage to t your specic needs. Talk with your benets counselor about your expenses and other paid leave benets, such as state paid medical leave, and use this worksheet to help determine the coverage that’s right for you.*MONTHLY 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: DISABILITY INSURANCE: WHAT’S RIGHT FOR ME?1. How much disability coverage do I need? Monthly benet amount for off-job accident and off-job sickness: $ Choose a monthly benet amount between $400 and $7,500. Subject to income requirements. If your plan includes on-job accident/sickness benets, the on-job benet is 50% of the off-job amount.2. How long do I want  benetscoverage? Benet period: months The partial disability benet period is three months. Partial disability benet is 50% of the total disability amount.3. When would I like my  totaldisabilitybenets  to start? After an accident: days After a sickness: daysGROUP DISABILITY INSURANCE - BASE

Frequently asked questions Whatisthedenitionoftotaldisability?“Totally disabled” or “total disability” means you are unable to perform the material and substantial duties of your regular occupation, not working at any occupation, and under the regular and appropriate care of a doctor.How does partial disability work? If you are able to return to work part time after at least 14 days of being paid for a total disability, you may be able to still receive 50% of your total disability benet.What is waiver of premium? We will waive your premium payments after 90 consecutive days of a covered disability.What are the age guidelines to qualify for this coverage? Coverage is available from ages 17 to 74.Can I keep my coverage if I change jobs or employers? Through a feature called “portability,” you may be able to keep your coverage even if you change jobs. Talk with your benets counselor for details.What happens if I am disabled while traveling outside of the country? If you are disabled while outside of the United States, Canada, Mexico, Puerto Rico, Bahama Islands, Virgin Islands, Bermuda or Jamaica, you may receive benets for up to 60 days before you have to return to the U.S. in order to continue receiving benets.To learn more, talk with your benetscounselor.* State paid medical leave (PML) benets fall under state-specic program names. Not available in all states.EXCLUSIONS AND LIMITATIONSWe will not pay benets for losses that are caused by, contributed to by or occur as the result of: alcoholism or drug addiction, felonies or illegal occupations, ying, hazardous avocations, intoxicants and narcotics, psychiatric or psychological conditions, racing, semi-professional or professional sports, suicide or injuries which you intentionally do to yourself, war or armed conict. We will not pay for losses due to you giving birth within the rst nine months after the coverage effective date of the certicate.Pre-existing condition means a sickness or physical condition, whether diagnosed or not, for which you were treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date.We will not pay for loss when the disability is a pre-existing condition as dened in this certicate, unless you have satised the pre-existing condition limitation period (typically 12 months) shown on the Certicate Schedule on the date you suffer a loss due to a covered accident or covered sickness.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 benets payable. Applicable to policy forms GDIS-P-EE-TX, GDIS-P-AU-TX and certicate forms GDIS-C-EE-TX, GDIS-C-AU-TX and rider form R-GDIS-RPO-TX. For cost and complete details of coverage, call or write your Colonial Life benets counselor or the company. 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 8-23 | 101296-5ColonialLife.com

Para obtener más información, habla con tu consejero de benecios.ColonialLife.comSeguro Colectivo de Indemnización HospitalariaPlan 1 (Cumple con la HSA): Se reemplaza el benecio de “Admisión por Hospitalización” por el benecio de “Hospitalización”ESTE SEGURO BRINDA BENEFICIOS LIMITADOS.Este seguro es un complemento de un seguro de salud. No sustituye a los benecios de salud esenciales ni a la cobertura mínima esencial denida en la ley federal. Los asegurados en algunos estados deben tener cobertura de un seguro médico integral antes de solicitar esta cobertura.No pagaremos ningún benecio por lesiones recibidas en accidentes o enfermedades que sean causadas, se deriven u ocurran como resultado de las siguientes exclusiones y restricciones: (a) alcoholismo o drogadicción; (b) procedimientos odontológicos; (c) procedimientos electivos y cirugía estética; (d) delitos graves u ocupaciones ilegales; (e) trastornos mentales o nerviosos; (f) embarazo de una hija dependiente; (g) suicidio o lesiones autoinigidas; o (h) guerra. No pagaremos benecios por hospitalización (i) por dar a luz dentro de los primeros nueve meses de la fecha de entrada en vigencia de la póliza o (j) por un recién nacido que no esté lesionado ni enfermo. (k) La póliza puede contener exclusiones y restricciones adicionales que pueden afectar los benecios a pagar.(l) No pagaremos benecios por pérdida durante los primeros 12 meses después de la fecha de entrada en vigencia por una afección preexistente. (m) Una afección preexistente es una enfermedad o una afección física, diagnosticada o no, por la cual una persona cubierta recibió tratamiento, se hizo estudios médicos, tuvo asesoramiento médico o tomó medicamentos dentro de los 12 meses anteriores a la fecha de entrada en vigencia del certicado. (n) Esta restricción se aplica a los siguientes benecios, si corresponde: Hospitalización, Hospitalización Diaria, Hospitalización Mental y Nerviosa,Hospitalización en la Unidad de Rehabilitación y Enfermedades Especícas Graves.Esta información no pretende ser una descripción completa de la cobertura del seguro disponible. El seguro o sus disposiciones pueden variar o no estar disponibles en ciertos estados. El seguro contiene exclusiones y restricciones que pueden afectar los benecios a pagar. Aplicable al formulario de póliza GMB7000-P y al formulario de certicado GMB7000-C (incluidas las abreviaturas de los estados cuando corresponda, como los formularios de póliza GMB7000-P-AU-TX y GMB7000-P-EE-TX, y los formularios de certicado GMB7000-C-AU-TX y GMB7000-C-EE-TX). Para conocer el costo y los detalles completos de la cobertura, llame o escriba a su consejero de benecios de Colonial Life o a la empresa. Este formulario no está completo sin el formulario #101733-SP.7-24 | 101917-2-SPEl Seguro Colectivo de Medical Bridge puede ayudar con los gastos médicos asociados con una internación hospitalaria que tu seguro de salud no puede cubrir. Los benecios están disponibles para ti, tu cónyuge y tus hijos dependientes elegibles.  ........................................................................ Máximo de un día por persona cubierta por año calendarioDisponible después de 30 días continuos de una hospitalización cubierta del asegurado principal£ ...........................................................................Máximo de 365 días por persona cubierta por hospitalización. El reingreso por la misma afección, o una afección relacionada, dentro de los 90 días del alta se considerará como una continuación de la hospitalización anterior.Este plan es compatible con las pautas de las HSA y cualquier otro plan de HSA en el que pueda participar un miembro de la familia cubierto. También se puede ofrecer a los empleados que no tienen HSA.El Seguro Colectivo de Medical Bridge de Colonial Life & Accident Insurance Company ofrece un plan compatible con las HSA en la mayoría de los estados.Suscrito por Colonial Life & Accident Insurance Company, Columbia, SC.©2024 Colonial Life & Accident Insurance Company. Todos los derechos reservados. Colonial Life es una marca registrada y de comercialización de Colonial Life & Accident Insurance Company.

Seguro Colectivo de Indemnización por HospitalizaciónExclusiones y restriccionesESTE SEGURO BRINDA BENEFICIOS LIMITADOS. Para las pólizas emitidas o entregadas en el Estado de Virginia: ESTA ES UNA PÓLIZA DE BENEFICIOS CON EXCEPCIÓN. BRINDA COBERTURA SOLO PARA LOS BENEFICIOS LIMITADOS O SERVICIOS ESPECIFICADOS EN LA PÓLIZA.Esta cobertura es un complemento de un seguro de salud. No sustituye a los beneficios de salud esenciales ni a la cobertura mínima esencial definida en la ley federal. Los asegurados en algunos estados deben tener cobertura de un seguro médico integral antes de solicitar esta cobertura.Esta información no pretende ser una descripción completa de la cobertura del seguro disponible. El seguro o sus disposiciones pueden variar o no estar disponibles en ciertos estados. El seguro contiene exclusiones y restricciones que pueden afectar los beneficios a pagar. Aplicable al formulario de póliza GMB7000-P y al formulario del certificado GMB7000-C (incluidas las abreviaturas de los estados, cuando se utilicen, por ejemplo: GMB7000-C-TX). Para conocer el costo y los detalles completos de la cobertura, llame o escriba a su consejero de beneficios de Colonial Life o a la empresa. Este formulario no está completo sin el formulario base 101917 o 101918.Suscrito por Colonial Life & Accident Insurance Company, Columbia, SC ©2024 Colonial Life & Accident Insurance Company. Todos los derechos reservados.Colonial Life es una marca registrada y de comercialización de Colonial Life & Accident Insurance Company.GMB7000 – EXCLUSIONS AND LIMITATIONS | 5-24 | 101733-5-SPDIVULGACIONES ESPECÍFICAS POR ESTADO KY: La prima variará según la cobertura seleccionada y la edad del asegurado principal.Elegibilidad para beneficiosLas disposiciones de esta póliza aseguran a una persona cubierta contra pérdidas debidas a lesiones recibidas en un accidente cubierto o pérdidas debidas a una enfermedad cubierta. Accidente Cubierto es una lesión corporal no intencionada o imprevista sufrida por una persona cubierta, totalmente independiente de padecimiento, dolencia corporal, enfermedad, infección o cualquier otra afección física anormal y que: ocurre en o después de la fecha de entrada en vigencia de la cobertura; ocurre mientras la póliza está vigente; y no está excluido por nombre o descripción específica en esta póliza. Enfermedad Cubierta es una enfermedad, infección, padecimiento o cualquier otra afección física anormal, no causada por un accidente, que: ocurre en o después de la fecha de entrada en vigencia de la cobertura de la póliza; ocurre mientras esta política esté vigente; y no está excluido por nombre o descripción específica en esta póliza.Fin de la cobertura del asegurado principalEsta póliza tiene garantía de renovación de por vida siempre que pagues las primas cuando vencen o dentro del período de gracia. EXCLUSIONES ESPECÍFICAS POR ESTADOAK: (a) Reemplazado por intoxicantes y narcóticosCA: (k) Las exclusiones adicionales incluyen intoxicantes y sustancias controladasCT: (a) Reemplazado por intoxicación o drogadicción; (d) Reemplazado por delitos graves; (f) No se aplican exclusionesDE: (a) No se aplican exclusionesIL: (a) Reemplazado por alcoholismo, intoxicación o drogadicción; (f) No se aplican exclusiones; (g) No se aplican exclusionesKS: (a) Reemplazado por intoxicantes y narcóticos; h) Reemplazado por guerra o conflicto armado; (i) No se aplican exclusionesKY: (a) Reemplazado por intoxicantes, narcóticos y alucinógenosLA: (a) Reemplazado por intoxicantes y narcóticosMI: (g) No se aplican exclusionesMO: (a) Reemplazado por drogadicción; (d) Reemplazado por actividades ilegalesMS: (a) Reemplazado por intoxicantes y narcóticosNC: (i) No se aplican exclusionesND: (a) No se aplican exclusiones; (e) No se aplican exclusionesNV: (a) No se aplican exclusionesOH: (f) No se aplican exclusiones; (i) Reemplazado por 270 díasPA: (a) Reemplazado por intoxicantes y narcóticos; (c) Reemplazado por cirugía estética; e) Reemplazado por trastornos mentales, nerviosos o emocionales; (h) Reemplazado por guerra o conflicto armadoSD: (a) No se aplican exclusionesTN: (f) No se aplican exclusionesTX: (a) Reemplazado por intoxicantes y narcóticosVA: (i) Embarazo que resulta de la violación de cualquier persona cubierta, que haya sido denunciado a la policía dentro de los siete días siguientes a su ocurrencia, estará cubierto en la misma medida que cualquier otro accidente cubierto. El requisito de siete días se ampliará a 180 días en el caso de un acto de violación o incesto de una mujer menor de 13 años.RESTRICCIONES DE AFECCIONES PREEXISTENTES ESPECÍFICAS POR ESTADOIN, SD y WY: (m) Se aplica dentro de los seis meses anteriores a la fecha de entrada en vigencia del certificado.CA: (m) Una afección preexistente es una enfermedad o afección física por la cual una persona cubierta recibió un diagnóstico o el tratamiento dentro de los 12 meses anteriores a la fecha de entrada en vigencia de la cobertura.FL: (m) Una afección preexistente es una enfermedad o afección física por la cual una persona cubierta recibió tratamiento, se hizo estudios médicos, tuvo asesoramiento médico o tomó medicamentos dentro de los seis meses anteriores a la fecha de entrada en vigencia de la cobertura. La información genética no es una afección preexistente si carece de un diagnóstico de la afección relacionada con dicha información.IL: (m) Una afección preexistente es una enfermedad o una afección física, diagnosticada o no, por la cual una persona cubierta recibió tratamiento, se hizo estudios médicos por un médico legalmente calificado, tuvo asesoramiento médico, presentó síntomas o tomó medicamentos dentro de los 12 meses anteriores a la fecha de entrada en vigencia de la cobertura.KS: (n) Procedimiento Quirúrgico reemplaza Procedimiento Quirúrgico Ambulatorio ME: (m) Una afección preexistente es una enfermedad o una afección física, diagnosticada o no, por la cual una persona cubierta recibió tratamiento, se hizo estudios médicos o tuvo asesoramiento médico dentro de los 12 meses anteriores a la fecha de entrada en vigencia de la cobertura.MI: (l) Aplica durante los primeros seis meses después de la fecha de entrada en vigencia del certificado; (m) se aplica dentro de los seis meses anteriores a la fecha de entrada en vigencia del certificado.MO: (m) Una afección preexistente es una enfermedad o una afección física, diagnosticada o no, por la cual una persona cubierta recibió tratamiento, se hizo estudios médicos o tuvo asesoramiento médico o tomó medicamentos dentro de los 12 meses anteriores a la fecha de entrada en vigencia de la cobertura de este certificado.NC: (m) Una afección preexistente es aquella afección, diagnosticada o no, por la cual una persona cubierta tuvo asesoramiento médico, diagnóstico, atención o tratamiento o para las cuales se hayan recomendado dentro de un período de un año inmediatamente anterior a la fecha de entrada en vigencia de la cobertura. Si tiene 65 años o más al momento de la emisión de este certificado, las afecciones preexistentes incluirán solo las afecciones específicamente eliminadas por una cláusula adicional.ND: (m) Una afección preexistente es una enfermedad o afección física por la cual una persona cubierta recibió tratamiento, se hizo estudios médicos, tuvo asesoramiento médico o tomó medicamentos dentro de los 12 meses anteriores a la fecha de entrada en vigencia de la cobertura.NV: (m) Se aplica dentro de los seis meses anteriores a la fecha de entrada en vigencia del certificado. Además, la afección preexistente no incluye información genética en ausencia de un diagnóstico de la afección relacionada con dicha información.OR: (m) Una afección preexistente es una enfermedad o una afección física, diagnosticada o no, por la cual una persona cubierta recibió tratamiento de un médico, tuvo asesoramiento médico o tomó medicamentos prescritos por un médico dentro de los 12 meses inmediatamente anteriores a la fecha de entrada en vigencia de la cobertura.PA: (m) Una afección preexistente es una enfermedad o afección física por la cual tuvo asesoramiento médico o recibió tratamiento dentro de los 90 días anteriores a la fecha de entrada en vigencia de la cobertura. (n) Ingreso por Hospitalización reemplaza Hospitalización.

Seguro Colectivo por AccidentesPlan SuperiorSi sufres un accidente, tu atención debe estar puesta en la recuperación y no en cómo pagarás tus facturas. El seguro por accidentes de Colonial Life te provee benecios para que los aproveches de la manera que desees: desde costos médicos hasta gastos diarios. Ya sea que hayas sufrido una caída o un accidente automovilístico, estos benecios te pueden ofrecer apoyo nanciero cuando lo necesites.Nuestra cobertura incluye:• Los benecios que se te pagan directamente• Sin preguntas médicas para calicar para la cobertura• Cobertura de lesiones simples y complejas• Se pagan los benecios independientemente de cualquier otro seguro• Cobertura mundial• Es un complemento de tu Cuenta de Ahorros de Salud (HSA)HISTORIAL DE BENEFICIOS Milo estaba trabajando en su patio cuando tropezó y se lesionó la mano.Con los benecios por accidente de Colonial Life, Milo pudo pagar el deducible anual y los copagos de su plan de seguro de salud sin usar sus ahorros ni endeudarse.BENEFICIOS POR ACCIDENTE DE MILOMilo fue a un centro de atención de urgencias y fue atendido de inmediato.Tratamiento en el consultorio de un médico o centro de atención de urgencias$150El médico ordenó una radiografía y observó que Milo se había fracturado la mano.• Radiografía• Fractura (mano)$60$1,200El médico también observó que Milo tenía un corte en la mano, pero no requería suturas. Laceración (sin sutura) $75Milo fue dado de alta con una férula. Equipo médico duradero $65Durante las semanas siguientes, Milo tuvo dos visitas de seguimiento con su médico. Visita de seguimiento con el médico (2 visitas)$50 X 2 = $100Total $1,650Solo con nes ilustrativos. Es posible que el monto de los benecios varíen y no cubran todos los gastos. GROUP ACCIDENT (GAC4100) — PREMIER PLANESPAÑOL

Dales un refuerzo a tus beneciosSabemos que los accidentes más complicados o graves resultan en facturas médicas más caras y más interrupciones en tu vida. El Seguro Colectivo por Accidentes incluye un Refuerzo de Benecios* para proporcionar apoyo nanciero adicional en accidentes graves. Si tienes más de $5,000 en benecios pagaderos por un accidente cubierto, te daremos un aumento de $500 a tus benecios para ayudarte con los gastos que tengas. *Se paga una vez por asegurado y por accidente cubiertoHISTORIAL DE BENEFICIOS Olivia sufrió un accidente automovilístico mientras conducía a la tienda.Los benecios de Olivia la ayudaron a cubrir sus gastos médicos cuando resultó lesionada en un accidente automovilístico, ayudándola a ocuparse de su recuperación.BENEFICIOS POR ACCIDENTE DE OLIVIASe trasladó a Olivia en ambulancia hasta la sala de emergencias más cercana y allí recibió atención inmediata.• Ambulancia• Visita al servicio de emergencias• Lesiones debido a accidente automovilístico$400$250 $250El médico ordenó una radiografía y observó que Olivia presentaba una fractura en el muslo (fémur). También ordenó un tomografía computada de su cabeza para ver si había una lesión cerebral.• Radiografía• Diagnóstico por imágenes• Fractura (muslo)$60$400 $4,200Olivia requirió cirugía para su pierna.• Reparación quirúrgica (fractura en muslo)• Anestesia general$4,200 $300Olivia alojó a su mascota durante dos noches después de su cirugía. Alojamiento de mascotas (2 días) $20 X 2 = $40Olivia recibió ocho sesiones de fisioterapia para ayudar a recuperar la fuerza en su pierna y dos citas de seguimiento con su médico.• Servicios de terapia (8 sesiones)• Visita de seguimiento del médico (2 visitas)$55 X 8 = $440$50 X 2 = $100Los beneficios de Olivia por este accidente totalizaron más de $5,000.Refuerzo de Beneficios $500Total $11,140Solo con nes ilustrativos. Es posible que el monto de los benecios varíen y no cubran todos los gastos. Los benecios se otorgan por persona cubierta y por accidente cubierto, a menos que se indique lo contrarioBenecios por lesión • Quemaduras (según el tamaño y grado) ........ $750–$21,000• Conmoción cerebral ................................. $500• Daño del tejido conectivo .......................$100–$200• Lesión ocular ....................................... $400 • Lesiones de pérdida auditiva ..........................$120(Máximo una vez de por vida por oído por asegurado)• Lesiones por accidente automovilístico ............... $250 • Lesiones internas ................................... $200 • Lesión del cartílago de rodilla (menisco) ............... $200 • Laceraciones ..................................$75–$1,200• Pérdida de un dedo — parcial ....................$400–$800• Pérdida de un dedo ..........................$1,000–$3,000• Ruptura o hernia de disco .......................$200–$400

Benecios por fractura• Lesión . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200–$5,000 Ejemplos: dedo: $200 | muñeca: $1,200 | cadera: $4,200• Tratamiento quirúrgico de fractura � � � � � � � � � � � � � � � � � � � � 100%(Pagadero como un % adicional del benecio por fractura aplicable)• Fractura conminuta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25% (Pagadero como un % del benecio por fractura aplicable)Benecios por dislocación• Lesión . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $260–$4,000 Ejemplos: codo: $600 | tobillo: $1,600 | cadera: $4,000• Tratamiento quirúrgico de dislocación � � � � � � � � � � � � � � � � � 100%(Pagadero como un % adicional del benecio aplicable por dislocación)• Dislocación incompleta � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 25%(Pagadero como % del benecio aplicable por dislocación)Benecios del tratamiento• Ambulancia aérea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $2,000 • Ambulancia (terrestre o por agua) . . . . . . . . . . . . . . . . . . . . . .$400 • Equipo médico duradero . . . . . . . . . . . . . . . . . . . . . . . . . .$65–$250• Reparación odontológica de emergencia . . . . . . . . . $200–$600• Servicio de urgencias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250(Máximo de 4 por año) • Atención familiar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50 por día (Máximo de un benecio por día para todos los asegurados combinados, hasta un máximo de tres días por accidente cubierto, independientemente del número de hos)• Inyecciones para prevenir o limitar la infección . . . . . . . . . . . $50 • Alojamiento . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250 por día (Máximo 30 días)• Diagnóstico por imágenes . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$400 • Inyecciones para el manejo del dolor . . . . . . . . . . . . . . . . . . . $150 • Alojamiento de mascotas . . . . . . . . . . . . . . . . . . . . . . . $20 por día (Máximo de un benecio por día para todos los asegurados combinados, hasta un máximo de tres días por accidente cubierto, independientemente del número de mascotas que se alojen)• Prótesis/miembro articial . . . . . . . . . . . . . . . . . . $1,750–$3,500• Injertos de piel (debido a quemaduras) . . . . . . . . . . . . . . . . . 50%(Pagadero como un % del benecio por quemaduras aplicable)• Injertos de piel (no debido a quemaduras) . . . . . . . . . .$375–$750• Transfusiones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $500 • Transporte . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$200 por viaje (Máximo 6 viajes en una sola dirección)• Tratamiento en el consultorio de un médico o centro de atención de urgencia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150(Máximo de 4 por año) • Radiografía o ultrasonido . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $60Benecios quirúrgicos• Anestesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$150–$300• Cirugía del tejido conectivo . . . . . . . . . . . . . . . . . . . . . $150–$2,200• Cirugía de ojo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$400• Cirugía general –Abdominal, torácica o craneal . . . . . . . . . . . . . . . . . . . . . $2,000 –Cirugía exploratoria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $275 • Cirugía de hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$400 • Cirugía de cartílago de rodilla (menisco) . . . . . . . . . $150–$1,050• Centro quirúrgico para pacientes ambulatorios � � � � � � � � � $400 • Cirugía de disco roto o herniado . . . . . . . . . . . . . . . . $150–$2,000Benecios de cuidado para la recuperación• Atención en el hogar . . . . . . . . . . . . . . . . . . . . . . . . . . . .$125 por día(Máximo 5 días) • Refuerzo de benecios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $500• Visitas de seguimiento del médico . . . . . . . . . . . . . . . . . . . . . . $50 (Máximo 6 días por accidente cubierto y 24 por año calendario)• Internación en la unidad de rehabilitación o de rehabilitación subaguda . . . . . . . . . . . . . . . . . . . . . $200 por día (Máximo de 15 días por accidente cubierto y 30 por año calendario)• Servicios de terapia (habla, sioterapia, terapia ocupacional) . . . . . . . . . . . . . . . . . . . . . . . . . . . . $55 por día(Máximo 15 días)Las opciones seleccionadas a continuación han sido elegidas por tu empleador para mejorar tu Cobertura Colectiva por Accidente.  Paquete Recovery Plus• Terapia de salud del comportamiento . . . . . . . . . . $55 por día (Máximo 15 días)• Trastorno por estrés postraumático (TEPT) . . . . . . . . . . $200 • Medicamentos de venta con receta . . . . . . . . . . . . . . . . . . .$25 • Servicios de terapia adicionales (quiropráctica, acupuntura, terapia alternativa) . . . . . . . . . . . . . . . . . . . . . .$55 (El máximo de benecios de los servicios de terapia existentes se aplica a los servicios de terapia adicionales, máximo 15 días)• Lesión por delito de violencia o agresión sexual . . . . . . $250(Máximo una vez por asegurado por año calendario, con un informe policial adjunto) Benecio por herida con arma de fuegoEste benecio puede ayudarte a pagar tus gastos médicos si recibes una herida de bala no mortal. Te ofrece una suma global para una herida cubierta, independientemente de cualquier otro seguro que puedas tener e incluye cobertura dentro y fuera del trabajo.• Herida de bala ������������������������������$_________Esta póliza cubre una herida no mortal de un arma de fuego convencional que requiera tratamiento médico y una noche de hospitalización dentro de las 24 horas de recibir la herida. Si fuiste baleado más de una vez en un período de 24 horas, solamente podremos pagar los benecios correspondientes a la primer herida.

Habla con tu consejero de benecios de Colonial Life para obtener más información�CT: Se pagarán los benecios de ambulancia aérea o ambulancia directamente a la compañía de ambulancias profesional con licencia. CT incluye un benecio para “atención médica de emergencia ambulatoria por ingesta accidental de una sustancia controlada”. El máximo del benecios de atención en el hogar es de 80 días. KS: La terapia quiropráctica no está disponible. NH: NH incluye un benecio por quemaduras para quemaduras de 2nd grados por debajo del 5% de la supercie de la piel. El benecio mínimo por la pérdida o pérdida parcial de un dedo es de $1,000.MD: El benecio de medicamentos con receta no está disponible.PA: El benecio de alojamiento de mascotas no está disponible. TN: El benecio de los servicios terapéuticos incluye quiropráctico. TX: El benecio por conmoción cerebral es reemplazado por el benecio por “conmoción cerebral y lesiones cerebrales adquiridas”. El benecio de los servicios terapéuticos incluye los siguientes servicios: terapia de comunicación cognitiva; terapia de rehabilitación cognitiva; servicios de reintegración comunitaria; neuroconductual; terapia y rehabilitación neurocognitiva; terapia de neuroretroalimentación; neurosiológica; neuropsicológica; servicios de transición posaguda; pruebas psicosiológicas o tratamiento; y remediación.COMPATIBLE CON LA CUENTA DE AHORROS DE SALUD (HSA)Este plan es compatible con las pautas de las HSA y cualquier otro plan de HSA en el que pueda participar un familiar cubierto.También se puede ofrecer a los empleados que no tienen HSA.ESTE SEGURO BRINDA BENEFICIOS LIMITADOS�Esta cobertura es un complemento de un seguro de salud. No sustituye a los benecios de salud esenciales ni a la cobertura mínima esencial denida en la ley federal. Los asegurados en algunos estados deben tener una cobertura de un seguro médico integral antes de solicitar este seguro.EXCLUSIONESNo pagaremos benecios a una persona cubierta por reclamos que sean causados, deriven u ocurran como resultado de delitos graves u ocupaciones ilícitas, pasatiempos peligrosos, carreras, deportes semiprofesionales o profesionales o enfermedad; suicidio o lesiones autoiningidas intencionalmente, guerra o conicto armado. ID: La exclusión “Deportes semiprofesionales o deportes profesionales” se sustituye por la exclusión “Deportes profesionales”. IL: No pagaremos benecios por reclamos que sean causados o deriven de las Exclusiones.MD: Incluye una exclusión para “Derivaciones prohibidas”. Las exclusiones de “delitos graves u ocupaciones ilegales” y “conducir intoxicado” se aplican solo a los benecios por Muerte Accidental y Desmembramiento.MI: Las exclusiones de "conducir intoxicado" y "suicidio o lesiones autoiningidas" no se aplican. MN: La exclusión de "suicidio o lesiones autoiningidas" no se aplica.NH: Las exclusiones de "encarcelamiento" y "carreras" no se aplican.UT: No pagaremos benecios por reclamos que sean causados o deriven de las Exclusiones.VT: La exclusión de "conducir intoxicado" no se aplica. Esta información no pretende ser una descripción completa de la cobertura del seguro disponible. El seguro o sus disposiciones pueden variar o no estar disponibles en ciertos estados. El seguro contiene exclusiones y restricciones que pueden afectar los benecios a pagar. Aplicable al formulario de póliza GAC4100-P y al formulario de certicado GAC4100-C (que incluye abreviaturas de los estados, cuando se usen, por ejemplo: GAC4100-P-TX y GAC4100-C-TX). Para conocer el costo y los detalles completos de la cobertura, llame o escriba a su consejero de benecios de Colonial Life o a la empresa.Suscrito por Colonial Life & Accident Insurance Company, Columbia, SC.© 2023 Colonial Life & Accident Insurance Company. Todos los derechos reservados. Colonial Life es una marca registrada y de comercialización de Colonial Life & Accident Insurance Company. FOR EMPLOYEES 5-23 | 1212553-SPColonialLife�comESPAÑOL

Para más información, habla con tu consejero de beneficios.Seguro Colectivo contra Enfermedades GravesPlan 2 CompletoColonialLife.comSi se te diagnóstica una enfermedad grave o un cáncer cubiertos, el seguro colectivo contra enfermedades graves* de Colonial Life te puede ayudar con tus gastos para que puedas enfocarte en lo que realmente importa — los tratamientos y la atención que recibas, y tu recuperación. *El nombre de la póliza es el Seguro Colectivo contra Enfermedades Específicas con Cobertura contra Enfermedades Graves y Cáncer.Valor nominal: $_______________ Por el diagnóstico de esta condición de enfermedad grave cubierta1:Se paga este porcentaje del valor nominal:Ataque al corazón (infarto de miocardio) 100%Derrame cerebral 100%Insuficiencia renal (de riñón) terminal 100%Insuficiencia de órganos principales 100%Coma 100%Parálisis permanente debido a un accidente cubierto 100%Ceguera 100%VIH laboral infeccioso o hepatitis laboral infecciosa B, C o D 100%Cirugía de injertos de revascularización coronaria/Arteriopatía coronaria225%Beneficio de enfermedades gravesGROUP CRITICAL CARE PLAN 2 FULLDiagnóstico subsiguiente de una enfermedad grave diferente3Si recibes un beneficio por una enfermedad grave, y más tarde se te diagnóstica una enfermedad grave diferente, será pagadero el porcentaje original del valor nominal por esa enfermedad grave particular.Diagnóstico subsiguiente de la misma enfermedad grave3Si recibes un beneficio por una enfermedad grave, y más tarde se te diagnóstica la misma enfermedad grave, será pagadero el 25% de la cantidad nominal. Las condiciones de enfermedades graves que no reúnen los requisitos son las siguientes: cirugía de injertos de revascularización coronaria/Arteriopatía coronaria2, y VIH laboral infeccioso o hepatitis laboral infecciosa B, C o D.

ColonialLife.comBeneficios por cáncer cubiertos Por esta condición1: El monto pagadero es del:Diagnóstico del cáncer (interno o invasor) 100% del valor nominalDiagnóstico del carcinoma in situ 25% del valor nominalCáncer de piel $500Beneficio por el diagnóstico del cáncer Beneficio de vacuna contra el cáncer: ...............................................................$50Este beneficio es pagadero si tú o tus familiares cubiertos incurren en gastos por cualquier vacuna contra el cáncer aprobada por la Administración de Medicamentos y Alimentos (FDA, por sus siglas en inglés) mientras tu certificado esté vigente.1 Consulte el certificado para obtener las definiciones completas de las condiciones cubiertas.2 Se aplica el beneficio por arteriopatía coronaria en lugar del beneficio de cirugía de injertos de revascularización coronaria cuando se elige un plan que cumpla con el requisito de tener una cuenta de ahorros para gastos médicos (HSA, por sus siglas en inglés).3 Las fechas de diagnóstico de una enfermedad grave cubierta deben estar separadas por un mínimo de 180 días.ESTA PÓLIZA PROPORCIONA BENEFICIOS LIMITADOS.Los asegurados en Massachusetts deben estar cubiertos por un seguro de salud integral para poder solicitar esta cobertura.EXCLUSIONES Y LIMITACIONES DE ENFERMEDADES GRAVESNo pagaremos el Beneficio de enfermedades graves o el Beneficio pagadero luego de un diagnóstico de una enfermedad grave que ocurra como resultado de: alcoholismo o drogadicción de la persona cubierta; delitos graves u ocupaciones ilegales; estupefacientes y narcóticos; condiciones psiquiátricas o psicológicas; suicidio o autolesiones que cualquier persona cubierta se haga a sí misma; guerra o conflicto armado; o condiciones preexistentes, a menos que la persona cubierta haya cumplido con el periodo de limitación por condiciones preexistentes que se muestra en el Plan del Certificado en la fecha que a la persona cubierta se le diagnostique una enfermedad grave.EXCLUSIONES Y LIMITACIONES DE CÁNCER No pagaremos el Beneficio por el diagnóstico del cáncer; Beneficio por el diagnóstico del carcinoma in situ; Beneficio de tratamiento y cuidados por el cáncer; o el Beneficio por el cáncer de piel debido al cáncer (interno o invasor), carcinoma in situ o cáncer de piel de una persona cubierta que: se diagnostique o trate fuera de los límites territoriales de los Estados Unidos, sus posesiones, o los países de Canadá y México; sea una condición preexistente, a menos que la persona cubierta haya cumplido con el periodo de limitación de condiciones preexistentes que se muestra en el Plan del Certificado en la fecha que la persona cubierta reciba un diagnóstico del cáncer (interno o invasor), carcinoma in situ o cáncer de piel. No se aplicará ningún límite de condiciones preexistentes para hijos dependientes que nazcan o sean adoptados mientras usted tiene cobertura conforme a la póliza, y los cuales tendrán cobertura continua a partir de la fecha de nacimiento o adopción.Esto no es un contrato de seguros y solo regirán las provisiones reales del certificado. Se aplica al formulario de certificado GCC1.0-C (incluyendo cualquier abreviación del estado donde ésta sea utilizada, por ejemplo: GCC1.0-C-TX). Es posible que el certificado o sus provisiones varíen o no estén disponibles en algunos estados. Por favor, consulte a su consejero de beneficios para conocer los detalles.4-23 | 100497-2Suscrito por Colonial Life & Accident Insurance Company, Columbia, SC©2023 Colonial Life & Accident Insurance Company. Todos los derechos reservados. Colonial Life es una marca registrada y marca de comercialización de Colonial Life & Accident Insurance Company.

Dental Benefits Summary for DL Glover EEM-0142-0921 MX2548680-E UnitedConcordia.com • 1-800-332-0366 Effective: July 1, 2025 Network: ElitePlus Benefit Category1 In-Network2 Non-Network2 Class I – Diagnostic/Preventive Services Exams 100% 100% Bitewing X-rays All Other X-rays Cleanings & Fluoride Treatments Sealants Space Maintainers Palliative Treatment Class II – Basic Services Basic Restorative (Fillings) 80% 80% Simple Extractions Repairs of Crowns, Inlays, Onlays, Bridges & Dentures Complex Oral Surgery General Anesthesia Class III – Major Services Endodontics 50% 50% Nonsurgical Periodontics Surgical Periodontics Inlays, Onlays, Crowns Prosthetics (Bridges, Dentures) Included Plan Features Preventive Incentive® Class I services do not count toward your annual program maximum Smile for Health®--Wellness3 Provides periodontal care for people with certain chronic medical conditions: diabetes, heart disease, lupus, oral cancer, organ transplant, rheumatoid arthritis and stroke Pregnancy is also a covered condition • Covers 1 additional periodontal maintenance per year and all are covered at 100% • Scaling and root planing are covered at 100% • 4 periodontal surgery procedures are covered at 100% Pregnancy Benefit3 Covers 1 additional cleaning during pregnancy in addition to the benefits listed for Smile for Health®--Wellness3 Maximums & Deductibles (applies to the combination of services received from network and non-network dentists) Calendar Year Deductible (per person/per family) $50/$150 Excludes Class I Calendar Year Maximum (per person) $2,000 Excludes Class I Reimbursement Elite Plus Advantage MAC Representative listing of covered services. For underwritten plans, your certificate of insurance/coverage provides complete details on covered services and exclusions and limitations which may affect benefits payable. For self-funded plans, see your employer’s Summary Plan Description for a detailed description of benefits. Dental plans are administered by United Concordia Companies, Inc. Fully insured plans are underwritten by United Concordia Insurance Company. For more information please visit the “Disclaimers” link at www.UnitedConcordia.com. Administrative and claims offices located at 1800 Center Street Suite 2B 220, Camp Hill, PA 17011. Call 1-800-332-0366. For additional plan details or questions, contact your account representative or visit www.ucci.com for more information. 1. Dependent children covered to age 26. 2. Reimbursement is based on our schedule of maximum allowable charges (MACs). Network dentists agree to accept our allowances as payment in full for covered services. Non-network dentists may bill the member for any difference between our allowance and their fee (also known as balance billing). We evaluate our MACs and OON percentile allowances annually based on proprietary claim experience and data purchased from independent sources such as FAIR Health. United Concordia Dental’s standard exclusions and limitations apply. 3. Members (subscribers or covered dependents) with certain medical conditions must sign up for this program through My Dental Benefits on UnitedConcordia.com.

EEM-0095-1120-3 MX2544706-C UnitedConcordia.com/ucvision • 1-888-789-8233 UCVision Benefits Summary – Plan III Included With Your Concordia Dental Plan In-Network Coverage Frequency (once every) Member Pays Eye Examination Eye Exam (with dilation when professionally indicated) 12 months $0 Frames Collection 12 months Fashion: $0 Designer: $0 Premier: $25 Non-Collection $0 ($150 allowance, 20% discount on remaining balance*) Spectacle Lenses Clear glass or plastic lenses in single vision, bifocal, trifocal or lenticular prescription 12 months $0 Spectacle Lens Options Oversize Lenses 12 months $0 Tinting of Plastic Lenses Scratch-Resistant Coating Premium Scratch-Resistant Coating $30 Polycarbonate Lenses $30 ($0 for dependent children, monocular patients and patients with prescriptions +/- 6.00 diopters or greater) Ultraviolet Coating $12 Anti-Reflective Coating (Standard / Premium / Ultra / Ultimate) $35 / $48 / $60 / $85 Progressive Lenses (Standard / Premium / Ultra / Ultimate) $50 / $90 / $140 / $175 Digital Single Vision Lenses $30 Blended Segment Lenses $20 High-Index Lenses (1.67 / 1.74) $55 / $120 Polarized Lenses $75 Photosensitive Lenses (Glass / Plastic) $20 / $65 Trivex Lenses $50 Blue Light Filtering $15 Scratch Protection Plan (Single Vision / Multifocal) $20 / $40 Contact Lenses (in lieu of eyeglasses) Contact Lens Evaluation, Fitting & Follow-up Care 12 months Collection: $0 Non-Collection: $0 ($60 allowance, 15% discount on remaining balance*) Contact Lenses Collection: $0 (Disposable - up to 8 boxes, Planned Replacement – up to 4 boxes) Non-Collection: $0 ($150 allowance, 15% discount on remaining balance*) Value-Added Features One-Year Eyeglass Breakage Warranty $0 Retinal Imaging $39 Laser Vision Correction Up to 40% discount Out-of-Network Coverage Frequency (once every) Member Reimbursement Eye Exam 12 months up to $45 Frames up to $50 Spectacle Lenses Single Vision up to $40 Bifocal up to $60 Trifocal up to $80 Lenticular up to $90 Non-Collection Contact Lenses (includes evaluation, fitting and follow-up care) up to $120 Representative listing of covered services – see plan documents. UCVision benefits administered by Davis Vision, Inc. Discounts and value-added features not underwritten by United Concordia Dental. *Discount does not apply to services or materials from a Walmart or Sam’s Club vision center.

Dental & Vision Rates

OTRAS FORMAS DE PRESENTAR UNA RECLAMACIÓN:Fax: 1.800.880.9325Correo: P.O. Box 100195, Columbia, SC 29202Colonial Life se compromete en proporcionarle a usted, nuestro valioso cliente, una experiencia de reclamación líder en el mercado. Esperamos poder servirle en ColonialLife.com.Aquí encontrará una copia de su póliza para conocer lo que está cubierto y los importes de los beneficiosInicie sesión en cualquier momento para ver el estado, u opte por recibir alertas de estado por correo electrónico o mensaje de texto para saber instantáneamente si necesitamos información adicional.En el portal del asegurado usted puede:Ver los detalles de los beneficiosTrack your claim ¡Ela el depósito directo para obtener los pagos aprobados hasta una semana más rápido que el cheque en papel!Los productos de seguros de Colonial Life son suscritos por Colonial Life & Accident Insurance Company, Columbia, SC.©2022 Colonial Life & Accident Insurance Company. Todos los derechos reservados. Colonial Life es una marca registrada y de comercialización de Colonial Life & Accident Insurance Company.Cómo presentar una reclamación de beneficios de Colonial LifeDIGITALLY FILE ALL TYPES OF CLAIMSSeguro por discapacidadSeguro de enfermedades críticas y cáncer Seguro por accidente y hospitalización Seguro de vida Beneficios de bienestar para pruebas de detección¿No está seguro sobre qué reclamación presentar? No hay problema.Sólo responda algunas preguntas en el portal y lo ayudaremos a resolver todo.ANTES DE PRESENTAR LA RECLAMACIÓN:evise la lista de verificación de reclamaciones correspondientes en ColonialLife.com y tenga esta información a mano para que el proceso se desarrolle sin problemas. Se debe enviar la documentación adecuada cuando presenta una reclamación.LUEGO DE PRESENTAR LA RECLAMACIÓN:Compruebe el estado de su reclamación y gestione su reclamación al iniciar sesión en su cuenta en ColonialLife.com/access. También hay disponible un chat en vivo de 9 a. m. - 5 p. m. EST.PARA RESULTADOS MÁS RÁPIDOS, PRESENTAR LA RECLAMACIÓN EN LÍNEA:Diríjase a ColonialLife.com/access para iniciar sesión o registrarseComplete la información requerida y haga clic en Enviar.Disfrute de una gestión de reclamaciones agilizada y de un servicio en línea más rápido.123ADR-1312251