Return to flip book view

Gus Gianakopoulos Dentistry Benefit Booklet 2023

Gus Gianakopoulos DDS Colonial Life provides benefits that employees want for the unexpected moments in life Whether planning for retirement growing their families or saving for college they know an injury or illness won t derail their dreams RUPRUHLQIRUPDWLRQ 6KHOOH DUWVHOO 6KHOOH DUWVHOO RORQLDO LIH6DOHVFRP Life is anything but expected That s why we re here Plan options Accident insurance Helps o set unexpected medical expenses such as emergency room fees deductibles and copayments that can result from a fracture dislocation or other covered accidental injury Hospital insurance Provides a lump sum benefit for a covered hospital confinement or outpatient surgery to help with copayments and deductibles that are not covered by most major medical plans Disability insurance Helps replace a portion of your income to help make ends meet if you become disabled from a covered accident or covered sickness Cancer insurance Helps o set the out ofpocket medical and indirect non medical expenses related to cancer that most medical plans don t cover Critical illness insurance Supplements your major medical coverage by providing a lump sum benefit you can use to pay the direct and indirect costs related to a covered critical illness Life insurance Enables you to tailor coverage for your individual needs and helps provide financial security for your family members

Accident Insurance Accidents happen in places where you and your family spend the most time at work in the home and on the playground and they re unexpected How you care for them shouldn t be In your lifetime which of these accidental injuries have happened to you or someone you know l Sports related accidental injury l Broken bone l Burn l Concussion l Laceration l Back or knee injuries l Car accidents l Falls spills l Dislocation l Accidental injuries that send you to the Emergency Room Urgent Care or doctor s office Colonial Life s Accident Insurance is designed to help you fill some of the gaps caused by increasing deductibles co payments and out of pocket costs related to an accidental injury The benefit to you is that you may not need to use your savings or secure a loan to pay expenses Plus you ll feel better knowing you can have greater financial security What additional features are included l Worldwide coverage l Portable l Compliant with Healthcare Spending Account HSA guidelines Will my accident claim payment be reduced if I have other insurance You re paid regardless of any other insurance you may have with other insurance companies and the benefits are paid directly to you unless you specify otherwise What if I change employers If you change jobs or leave your employer you can take your coverage with you at no additional cost Your coverage is guaranteed renewable as long as you pay your premiums when they are due or within the grace period Can my premium change Colonial Life can change your premium only if we change it on all policies of this kind in the state where your policy was issued How do I file a claim Visit coloniallife com or call our Customer Service Department at 1 800 325 4368 for additional information Accident 1 0 Premier with Health Screening Benefit

Benefits listed are for each covered person per covered accident unless otherwise specified Initial Care l Accident Emergency Treatment 200 l X ray Benefit 60 l Ambulance 600 l Air Ambulance 2 000 Common Accidental Injuries Dislocations Separated Joint Hip Knee except patella Ankle Bone or Bones of the Foot other than Toes Collarbone Sternoclavicular Lower Jaw Shoulder Elbow Wrist Bone or Bones of the Hand Collarbone Acromioclavicular and Separation One Toe or Finger Non Surgical 9 600 4 800 3 840 2 400 1 440 1 440 480 480 Surgical 19 200 9 600 7 680 4 800 2 880 2 880 960 960 Fractures Depressed Skull Non Depressed Skull Hip Thigh Body of Vertebrae Pelvis Leg Bones of Face or Nose except mandible or maxilla Upper Jaw Maxilla Upper Arm between Elbow and Shoulder Lower Jaw Mandible Kneecap Ankle Foot Shoulder Blade Collarbone Vertebral Process Forearm Wrist Hand Rib Coccyx Finger Toe Non Surgical 9 000 3 600 5 400 2 700 1 260 1 260 1 260 1 080 1 080 1 080 900 720 360 Surgical 18 000 7 200 10 800 5 400 2 520 2 520 2 520 2 160 2 160 2 160 1 800 1 440 720 Your Colonial Life policy also provides benefits for the following injuries received as a result of a covered accident l Burn based on size and degree 1 000 to 12 000 l Coma 12 500 l Concussion 150 l Emergency Dental Work 100 Extraction 400 Crown Implant or Denture l Lacerations based on size 50 to 800 Requires Surgery l Eye Injury 300 l Tendon Ligament Rotator Cuff 750 one 1 500 two or more l Ruptured Disc 750 l Torn Knee Cartilage 750 Surgical Care l Surgery cranial open abdominal or thoracic 1 500 l Surgery hernia 150 l Surgery arthroscopic or exploratory 300 l Blood Plasma Platelets 300

Transportation Lodging Assistance If injured covered person must travel more than 50 miles from residence to receive special treatment and confinement in a hospital l Transportation 600 per round trip up to 3 round trips l Lodging family member or companion 150 per night up to 30 days for a hotel motel lodging costs Accident Hospital Care l Hospital Admission 2 000 per accident l Hospital ICU Admission 4 000 per accident We will pay either the Hospital Admission or Hospital Intensive Care Unit ICU Admission but not both l Hospital Confinement 300 per day up to 365 days per accident l Hospital ICU Confinement 600 per day up to 15 days per accident Accident Follow Up Care l Accident Follow Up Doctor Visit 50 up to 4 visits per accident l Medical Imaging Study 300 per accident limit 1 per covered accident and 1 per calendar year l Occupational or Physical Therapy 35 per treatment up to 10 days l Appliances 125 such as wheelchair crutches l Prosthetic Devices Artificial Limb 750 one 1 500 more than 1 l Rehabilitation Unit 150 per day up to 15 days per covered accident and 30 days per calendar year Maximum of 30 days per calendar year Accidental Dismemberment l Loss of Finger Toe 1 250 one 2 400 two or more l Loss or Loss of Use of Hand Foot Sight of Eye 12 000 one 24 000 two or more Catastrophic Accident For severe injuries that result in the total and irrecoverable l Loss of one hand and one foot l Loss of both hands or both feet l Loss or loss of use of one arm and one leg or l Loss or loss of use of both arms or both legs l Loss of the sight of both eyes l Loss of the hearing of both ears l Loss of the ability to speak Named Insured 25 000 Spouse 25 000 Child ren 12 500 365 day elimination period Amounts reduced for covered persons age 65 and over Payable once per lifetime for each covered person Accidental Death l Named Insured l Spouse l Child ren Accidental Death 50 000 50 000 10 000 Common Carrier 200 000 200 000 40 000

Health Screening Benefit l 50 per covered person per calendar year Provides a benefit if the covered person has one of the health screening tests performed This benefit is payable once per calendar year per person and is subject to a 30 day waiting period Tests include l Blood test for triglycerides l Bone marrow testing l Breast ultrasound l CA 15 3 blood test for breast cancer l CA125 blood test for ovarian cancer l Carotid doppler l CEA blood test for colon cancer l Chest x ray l Colonoscopy l Echocardiogram ECHO l Electrocardiogram EKG ECG l Fasting blood glucose test l Flexible sigmoidoscopy l Hemoccult stool analysis l Mammography l Pap smear l PSA blood test for prostate cancer l Serum cholesterol test to determine level of HDL and LDL l Serum protein electrophoresis blood test for myeloma l Stress test on a bicycle or treadmill l Skin cancer biopsy l Thermography l ThinPrep pap test l Virtual colonoscopy My Coverage Worksheet For use with your Colonial Life benefits counselor Who will be covered check one Employee Only Spouse Only One Child Only Employee Spouse One Parent Family with Employee One Parent Family with Spouse Two Parent Family When are covered accident benefits available check one On and Off Job Benefits Off Job Only Benefits EXCLUSIONS We will not pay benefits for losses that are caused by or are the result of hazardous avocations felonies or illegal occupations racing semi professional or professional sports sickness suicide or self inflicted injuries war or armed conflict in addition to the exclusions listed above we also will not pay the Catastrophic Accident benefit for injuries that are caused by or are the result of birth intoxication For cost and complete details see your Colonial Life benefits counselor Applicable to policy form Accident 1 0 HS NC This is not an insurance contract and only the actual policy provisions will control Accident 1 0 Premier with Health Screening Benefit Colonial Life 1200 Colonial Life Boulevard Columbia South Carolina 29210 coloniallife com 2014 Colonial Life Accident Insurance Company Colonial Life insurance products are underwritten by Colonial Life Accident Insurance Company for which Colonial Life is the marketing brand 6 14 71741 NC

For more information talk with your benefits counselor ColonialLife com Hospital Confinement Indemnity Insurance Plan 1 Our Individual Medical Bridge insurance can help with medical costs that your health insurance may not cover These benefits are available for you your spouse and eligible dependent children Hospital confinement __2_5_0__0____________ Maximum of one benefit per covered person per calendar year Observation room 100 per visit Maximum of two visits per covered person per calendar year Rehabilitation unit confinement 100 per day Maximum of 15 days per confinement with a 30 day maximum per covered person per calendar year Waiver of premium Available a er 30 continuous days of a covered hospital confinement of the named insured Health savings account HSA compatible This plan is compatible with HSA guidelines This plan may also be o ered to employees who do not have HSAs Colonial Life Individual Medical Bridge o ers an HSA compatible plan in most states THIS POLICY PROVIDES LIMITED BENEFITS This coverage is a supplement to health insurance It is not a substitute for essential health benefits or minimum essential coverage as defined in federal law Insureds in some states must be covered by comprehensive health insurance before applying for this coverage EXCLUSIONS We will not pay benefits for injuries received in accidents or for sicknesses which are caused by a alcoholism or drug addiction b dental procedures c elective procedures and cosmetic surgery d felonies or illegal occupations e pregnancy of a dependent child f psychiatric or psychological conditions g suicide or injuries which any covered person intentionally does to himself or herself or h war We will not pay benefits for hospital confinement i due to giving birth within the first nine months a er the e ective date of the policy or j for a newborn who is neither injured nor sick k The policy may have additional exclusions and limitations which may a ect any benefits payable PRE EXISTING CONDITION LIMITATION l We will not pay benefits for loss during the first 12 months a er the e ective date due to a pre existing condition m A preexisting 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 the 12 months before the e ective date of the policy n This limitation applies to the following benefits if applicable Hospital Confinement Daily Hospital Confinement Enhanced Intensive Care Unit Confinement and Rehabilitation Unit Confinement This information is not intended to be a complete description of the insurance coverage available The policy or its provisions may vary or be unavailable in some states The policy has exclusions and limitations which may a ect any benefits payable Applicable to policy form IMB7000 including state abbreviations where used for example IMB7000 TX For cost and complete details of coverage call or write your Colonial Life benefits counselor or the company This form is not complete without form 562973 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 IMB7000 PLAN 1 8 23 562880 1

For more information talk with your benefits counselor Hospital Confinement Indemnity Insurance Plan 2 Our Individual Medical Bridge Insurance can help with medical costs that your health insurance may not cover These benefits are available for you your spouse and eligible dependent children Hospital confinement __1_5__0_0_________ Maximum of one benefit per covered person per calendar year Observation room 100 per visit Maximum of two visits per covered person per calendar year Rehabilitation unit confinement 100 per day Maximum of 15 days per confinement with a 30 day maximum per covered person per calendar year Waiver of premium Available a er 30 continuous days of a covered hospital confinement of the named insured Outpatient surgical procedure Tier 1 ____5_0__0________ Tier 2 ____7_5__0________ Maximum of _1__5_0_0___________ per covered person per calendar year for all covered outpatient surgical procedures combined The surgeries listed below are only a sampling of the surgeries that may be covered Surgeries must be performed by a doctor in a hospital or ambulatory surgical center For complete details and definitions please refer to your policy Tier 1 outpatient surgical procedures Breast Axillary node dissection Breast capsulotomy Lumpectomy Cardiac Pacemaker insertion Digestive Colonoscopy Fistulotomy Hemorrhoidectomy Lysis of adhesions Ear nose throat mouth Adenoidectomy Removal of oral lesions Myringotomy Tonsillectomy Tracheostomy Tympanotomy Gynecological Dilation and curettage D C Endometrial ablation Lysis of adhesions Liver Paracentesis Musculoskeletal system Carpal cubital repair or release Foot surgery bunionectomy exostectomy arthroplasty hammertoe repair Removal of orthopedic hardware Removal of tendon lesion Skin Laparoscopic hernia repair Skin gra ing IMB7000 PLAN 2

Tier 2 outpatient surgical procedures Breast Breast reconstruction Breast reduction Cardiac Angioplasty Cardiac catheterization Digestive Exploratory laparoscopy Laparoscopic appendectomy Laparoscopic cholecystectomy Ear nose throat mouth Ethmoidectomy Mastoidectomy Septoplasty Stapedectomy Tympanoplasty Eye Cataract surgery Corneal surgery penetrating keratoplasty Glaucoma surgery trabeculectomy Vitrectomy Gynecological Hysterectomy Myomectomy Musculoskeletal system Arthroscopic knee surgery with meniscectomy knee cartilage repair Arthroscopic shoulder surgery Clavicle resection Dislocations open reduction with internal fixation Fracture open reduction with internal fixation Removal or implantation of cartilage Tendon ligament repair Thyroid Excision of a mass Urologic Lithotripsy ColonialLife com THIS POLICY PROVIDES LIMITED BENEFITS This coverage is a supplement to health insurance It is not a substitute for essential health benefits or minimum essential coverage as defined in federal law Insureds in some states must be covered by comprehensive health insurance before applying for this coverage EXCLUSIONS We will not pay benefits for injuries received in accidents or for sicknesses which are caused by a alcoholism or drug addiction b dental procedures c elective procedures and cosmetic surgery d felonies or illegal occupations e pregnancy of a dependent child f psychiatric or psychological conditions g suicide or injuries which any covered person intentionally does to himself or herself or h war We will not pay benefits for hospital confinement i due to giving birth within the first nine months a er the e ective date of the policy or j for a newborn who is neither injured nor sick k The policy may have additional exclusions and limitations which may a ect any benefits payable PRE EXISTING CONDITION LIMITATION l We will not pay benefits for loss during the first 12 months a er the e ective date due to a pre existing condition m A preexisting 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 the 12 months before the e ective date of the policy n This limitation applies to the following benefits if applicable Hospital Confinement Daily Hospital Confinement Enhanced Intensive Care Unit Confinement and Rehabilitation Unit Confinement This information is not intended to be a complete description of the insurance coverage available The policy or its provisions may vary or be unavailable in some states The policy has exclusions and limitations which may a ect any benefits payable Applicable to policy form IMB7000 including state abbreviations where used for example IMB7000 TX For cost and complete details of coverage call or write your Colonial Life benefits counselor or the company This form is not complete without form 562973 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 8 23 562911 1

Disability Insurance How you can protect your income If you become disabled you could be out of work for a while Without your income how would you pay for your everyday living expenses Fortunately Colonial Life offers financial protection options that can help you What can cause a disability Many accidents or sicknesses can lead to short term disability claims including pregnancy and childbirth injuries from a major accident including dislocations sprains and fractures back problems side effects from medicines or medical procedures and some mental illnesses Regardless of your age or health a disabling sickness or accidental injuries could keep you out of work for weeks or even months How reliable is your safety net While many people with disabilities look to workers compensation or Social Security Disability Insurance SSDI for help these resources aren t always reliable In fact 68 of workers who apply for SSDI are denied 1 Even if these resources can help they might not be enough to meet your financial obligations How to help yourself You can be better prepared to preserve your way of life with short term disability insurance Disability insurance features Benefits payable directly to you in regular payments if you can t work because of a covered accident or sickness injury or illness Disability benefits may be available if you return to work part time In most cases you can keep your coverage even if you change jobs as long as you pay your premiums when due Your Colonial Life benefits counselor can help you determine the amount of coverage that s right for you Nearly 70 of Americans worry about having enough emergency savings to cover a month s worth of living expenses 2 25 of 20 year olds can expect to be out of work for at least a year for a disabling condition before they retire 3 DISABILITY INSURANCE

Disability Insurance Worksheet You can tailor disability coverage to fit your specific needs Talk with your benefits counselor about your expenses and other paid leave benefits such as state paid medical leave to help determine the coverage that s right for you 4 MONTHLY EXPENSES Rent 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 ROUND TO THE NEAREST HUNDRED Your state s paid medical leave approximate benefits if any Monthly benefit _____________ Benefit period up to _____________ Talk with your Colonial Life benefits counselor to learn more about disability insurance ColonialLife com 1 Social Security Administration SSI Annual Statistical Report 2021 2 Bankrate Bankrate s 2023 annual emergency savings report 2023 3 Social Security Administration Disability and Death Probability Tables for Insured Workers 2022 4 State paid medical leave PML benefits fall under state specific program names For example in New Jersey it may be referred to as Temporary Disability Insurance TDI Not available in all states For policies issued or delivered in the Commonwealth of Virginia THIS IS AN EXCEPTED BENEFITS POLICY IT PROVIDES COVERAGE ONLY FOR THE LIMITED BENEFITS OR SERVICES SPECIFIED IN THE POLICY This information is not intended to be a complete description of the insurance coverage available The insurance or its provisions may vary or be unavailable in some states The insurance has exclusions and limitations which may affect any benefits payable Applicable to policy forms ISTD3000 and rider form ISTD3000 ADIB including state abbreviations where used for example ISTD3000 TX and ISTD3000 ADIB TX policy form DIS1000 including state abbreviations where used for example DIS1000 TX policy form ED DIS 1 0 including state abbreviations where used for example ED DIS 1 0 TX policy form ICC21 DIP3000 and rider form ICC21 DIP3000 R DIS policy form GDIS P and certificate form GDIS C including state abbreviations where used for example GDIS P EE TX and GDIS C EE TX and policy form VSTDMP and certificate form VSTDC including state abbreviations where used for example VSTDMP TX and VSTDC TX Not applicable in Oregon for policy form ICC21 DIP3000 and rider form ICC21 DIP3000 R DIS For cost and complete details of coverage call or write your Colonial Life benefits counselor or the company An insurance producer may contact you Underwritten by Colonial Life Accident Insurance Company Columbia SC 2023 Colonial Life Accident Insurance Company All rights reserved Colonial Life is a registered trademark and marketing brand of Colonial Life Accident Insurance Company FOR EMPLOYEES 6 23 101165 10

Cancer Insurance Level 3 benefits Cancer insurance helps provide financial protection through a variety of benefits These benefits are not only for you but also for your covered family members BENEFIT DESCRIPTION BENEFIT AMOUNT Air ambulance 2 000 per trip Transportation to or from a hospital or medical facility max of two trips per confinement Ambulance 250 per trip Transportation to or from a hospital or medical facility max of two trips per confinement Anesthesia Administered during a surgical procedure for cancer treatment General anesthesia 25 of surgical procedures benefit Local anesthesia 40 per procedure Anti nausea medication 50 per day administered or per prescription filled Doctor prescribed medication for radiation or chemotherapy 200 monthly max Blood plasma platelets immunoglobulins 175 per day A transfusion required during cancer treatment 10 000 calendar year max Bone marrow donor screening 50 Testing in connection with being a potential donor once per lifetime Bone marrow or peripheral stem cell donation 750 Receiving another person s bone marrow or stem cells for a transplant once per lifetime Bone marrow or peripheral stem cell transplant 7 000 per transplant Transplant you receive in connection with cancer treatment max of two bone marrow transplant benefits per lifetime Cancer vaccine 50 An FDA approved vaccine for the prevention of cancer once per lifetime BENEFIT DESCRIPTION BENEFIT AMOUNT Companion transportation 0 50 per mile Companion travels by plane train or bus to accompany a covered cancer patient more than 50 miles one way for treatment up to 1 200 per round trip Egg s extraction or harvesting sperm collection and storage Extracted harvested or collected before chemotherapy or radiation once per lifetime Egg s extraction or harvesting sperm collection 1 000 Egg s or sperm storage cryopreservation 350 Experimental treatment 300 per day Hospital medical or surgical care for cancer 15 000 lifetime max Family care 50 per day Inpatient or outpatient treatment for a covered dependent child 2 500 calendar year max Hair external breast voice box prosthesis 350 per calendar year Prosthesis needed as a direct result of cancer Home health care services1 100 per day Examples include physical therapy occupational therapy speech therapy and audiology prosthesis and orthopedic appliances rental or purchase of durable medical equipment up to 30 days per calendar year or twice the number of days hospital confined whichever is greater Hospice initial or daily care 2 An initial one time benefit and a daily benefit for treatment 15 000 lifetime max for both Initial hospice care once per lifetime 1 000 Daily hospice care 50 per day CANCER ASSIST LEVEL 3

BENEFIT DESCRIPTION BENEFIT AMOUNT Hospital confinement Hospital stay including intensive care required for cancer treatment 30 days or less 250 per day 31 days or more 500 per day Lodging 75 per day Hotel motel expenses when being treated for cancer more than 50 miles from home 70 day calendar year max Medical imaging studies 175 per study Specific studies for cancer treatment 350 calendar year max Outpatient surgical center 300 per day Surgery at an outpatient center for cancer treatment 900 calendar year max Private full time nursing services 125 per day Services while hospital confined other than those regularly furnished by the hospital Prosthetic device artificial limb 2 000 per device or limb A surgical implant needed because of cancer surgery payable one per site 4 000 lifetime max Radiation chemotherapy Weekly benefit max once per week Injected chemotherapy by medical personnel 750 Radiation delivered by medical personnel 750 Monthly chemotherapy benefit max once per month Self injected 300 Pump 300 Topical 300 Oral hormonal 1 24 months 300 Oral hormonal 25 months 150 Oral non hormonal 300 BENEFIT DESCRIPTION BENEFIT AMOUNT Reconstructive surgery3 60 per surgical unit A surgery to reconstruct anatomic defects that result from cancer treatment up to 3 000 per procedure including 25 for general anesthesia Second medical opinion4 300 A second physician s opinion on cancer surgery or treatment once per lifetime Skilled nursing care facility 100 per day Confinement to a covered facility after hospital release up to the number of days paid for hospital confinement Skin cancer initial diagnosis 400 A skin cancer diagnosis while the policy is in force once per lifetime Supportive or protective care drugs and colony stimulating factors 150 per day Doctor prescribed drugs to enhance or modify radiation chemotherapy treatments 1 200 calendar year max Surgical procedures 60 per surgical unit Inpatient or outpatient surgery for cancer treatment 5 000 max per procedure Transportation 0 50 per mile Travel expenses when being treated for cancer more than 50 miles from home up to 1 200 per round trip Waiver of premium Is available No premiums due if the named insured is disabled longer than 90 consecutive days For more information talk with your Colonial Life benefits counselor ColonialLife com In MD Tobacco cessation benefit available 20 per prescription filled maximum of two 90 day prescriptions per covered person In MT Mammography benefit available 70 for one baseline mammogram for ages 35 39 one mammogram every two years for ages 40 49 one mammogram each year for ages 50 1 In CO Home health care services maximum is up to 60 days per calendar year or twice the number of days hospital confined whichever is greater In WI Home health care services maximum is up to 40 days per calendar year or twice the number of days hospital confined whichever is greater 2 In CO no hospice benefit available 3 In OK Reconstructive surgery is 30 per surgical unit 4 In MD Second medical opinion is 75 maximum of one per covered person per hospital confinement THIS POLICY PROVIDES LIMITED BENEFITS This information is not intended to be a complete description of the insurance coverage available The policy or its provisions may vary or be unavailable in some states The policy has exclusions and limitations which may affect any benefits payable Applicable to policy form CanAssist including state abbreviations where used for example CanAssist TX This chart is not complete without form number 1170702 Exclusions Limitations in states CO ID MD MN MO NC OK SC SD VT and WA For cost and complete details of coverage call or write your Colonial Life benefits counselor or the company Underwritten by Colonial Life Accident Insurance Company Columbia SC 2022 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 7 22 101484 4

Cancer Insurance Exclusions and limitations Waiting period All benefits and riders are subject to a 30 day waiting period Waiting period means the first 30 days following the policy s coverage effective date during which no benefits are payable See the following list for state specific variations ID MD MN MO OK SD VA and WA No waiting period Eligibility for cancer benefits We will pay benefits for the treatment of cancer including skin cancer where applicable if the date of diagnosis is after the waiting period the date of diagnosis is while this policy is in force a covered person receives treatment for cancer or skin cancer while this policy is in force and the cancer or treatment is not excluded by name or specific description in this policy If your cancer has a date of diagnosis before the end of the waiting period coverage for that cancer will apply only to losses commencing after this policy has been in force for two years unless it is excluded by name or specific descriptions in this policy If cancer is not pathologically or clinically diagnosed until after you die we will only pay benefits for cancer treatment performed during the 45day period before your death See the following list for state specific variations CO If your cancer has a date of diagnosis before the end of the waiting period coverage for that cancer will apply only to losses commencing after this policy has been in force for one year unless it is excluded by name or specific description in this policy NC If your cancer has a date of diagnosis before the end of the waiting period coverage for that cancer will apply only to losses commencing after the policy has been in force for 12 months unless it is excluded by name or specific description in the policy What is not covered by this policy We will not pay benefits for cancer or skin cancer if the diagnosis or treatment of cancer is received outside of the territorial limits of the United States and its possessions or for other conditions or diseases except losses due directly from cancer See the following list for state specific variations for cancer coverage ID Pre existing condition limitation We will not pay benefits if the diagnosis or treatment of cancer is a pre existing condition unless the covered person has satisfied the six month pre existing condition limitation period shown on the Policy Schedule on the date the covered person is initially diagnosed as having cancer or skin cancer Preexisting condition means having 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 policy coverage effective date of this policy MD Pre existing condition limitation We will not pay benefits if the diagnosis or treatment of cancer is a pre existing condition unless the covered person has satisfied the six month pre existing condition limitation period under your policy on the date the covered person is diagnosed as having cancer or skin cancer Pre existing condition means having 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 your policy effective date We will not pay benefits for cancer or skin cancer Unless the diagnosis and treatment is confirmed and received within the territorial limits of the United States and its possession or For any other conditions or diseases unless the losses due are directly from cancer MN Pre existing condition limitation We will not pay benefits if the diagnosis or treatment of cancer is a pre existing condition unless the covered person has satisfied the six month pre existing condition limitation period shown on the Policy Schedule on the date the covered person is initially diagnosed as having cancer or skin cancer Preexisting condition means having 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 policy coverage effective date of this policy MO Pre existing condition limitation We will not pay benefits if the diagnosis or treatment of cancer is a pre existing condition unless the covered person has satisfied the six month pre existing condition limitation period shown on the Policy Schedule on the date the covered person is initially diagnosed as having cancer or skin cancer Preexisting condition means having 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 policy coverage effective date of this policy OK Pre existing condition limitation We will not pay benefits if the diagnosis or treatment for cancer skin cancer or a specified disease is a pre existing condition unless the covered person has satisfied the six month pre existing condition limitation period under the policy on the date the covered person is initially diagnosed as having cancer skin cancer or a specified disease Pre existing condition means a condition for which the covered person received medical advice was given treatment or treatment was recommended by or received from a doctor within six months immediately preceding the effective date of the policy and which is not excluded by name or specific description in this policy SC We will not pay benefits for cancer or skin cancer If the diagnosis or treatment of cancer is received outside of the territorial limits of the United States and its possessions or For other conditions or diseases except losses due directly from cancer aggravated by cancer or resulting from cancer or treatment of cancer CANCER ASSIST EXCLUSIONS AND LIMITATIONS

Cancer Insurance Wellness Benefits1 Part one Cancer wellness health screening Provided when one of the tests listed below is performed after the waiting period and while the policy is in force Payable once per calendar year per covered person CANCER WELLNESS TESTS2 Bone marrow testing Breast ultrasound CA 15 3 blood test for breast cancer CA 125 blood test for ovarian cancer CEA blood test for colon cancer Chest X ray Colonoscopy Flexible sigmoidoscopy Hemoccult stool analysis Mammography3 Pap smear PSA blood test for prostate cancer Serum protein electrophoresis blood test for myeloma Skin biopsy Thermography ThinPrep Pap test4 Virtual colonoscopy HEALTH SCREENING TESTS Blood test for triglycerides Carotid Doppler Echocardiogram ECHO Electrocardiogram EKG ECG Fasting blood glucose test Serum cholesterol test for HDL and LDL levels Stress test on a bicycle or treadmill Part two Cancer wellness additional invasive diagnostic test or surgical procedure Provided when a doctor performs a diagnostic test or surgical procedure after the waiting period as the result of an abnormal result from one of the covered cancer wellness tests in part one We will pay the benefit regardless of the test results Payable once per calendar year per covered person To encourage early detection our cancer insurance offers benefits for wellness and health screening tests For more information talk with your Colonial Life benefits counselor CANCER ASSIST WELLNESS

Specified Critical Illness Insurance If you re diagnosed with a covered critical illness specified critical illness insurance from Colonial Life can help with your expenses so you can concentrate on what s most important your treatment care and recovery Face amount __1_0_K___o_r__2_0_K___ Critical illness benefit FOR THE DIAGNOSIS OF THIS COVERED CRITICAL ILLNESS CONDITION Heart attack myocardial infarction Stroke2 End stage renal kidney failure Major organ failure Permanent paralysis due to a covered accident Coma Blindness Occupational infectious HIV or occupational infectious hepatitis B C or D Coronary artery bypass graft surgery disease3 THIS PERCENTAGE OF THE FACE AMOUNT IS PAYABLE 100 100 100 100 100 100 100 100 25 The maximum benefit amount for this policy is 3x the face amount for the named insured for all covered persons combined The policy will terminate when the maximum benefit amount for specified critical illness has been paid Subsequent diagnosis of a different critical illness If you receive a benefit for a specified critical illness and later you are diagnosed with a different specified critical illness the original percentage of the face amount is payable for that particular specified critical illness Subsequent diagnosis of the same critical illness4 If you receive a benefit for a specified critical illness and later you are diagnosed with the same specified critical illness 25 of the original face amount is payable Critical illness conditions that do not qualify are coronary artery bypass graft surgery disease3 and occupational infectious HIV or occupational infectious hepatitis B C or D CRITICAL ILLNESS 1 0 WITH SUBSEQUENT DIAGNOSIS

Specified Critical Illness Insurance Exclusions limitations and additional disclosures State specific variations on exclusions AK Alcoholism or Drug Addiction Exclusion does not apply CT Alcoholism or Drug Addiction Exclusion replaced with Intoxication or Drug Addiction Felonies or Illegal Occupations replaced with Felonies DE Alcoholism or Drug Addiction Exclusion does not apply FL Alcoholism or Drug Addiction Exclusion does not apply Psychiatric or Psychological Condition Exclusion does not apply ID Alcoholism or Drug Addiction Exclusion does not apply Psychiatric or Psychological Condition Exclusion replaced with Mental or Emotional Disorders IN Accidents or Sicknesses Occurring While the Policy is not In Force Exclusion added KY Alcoholism or Drug Addiction Exclusion does not apply Hallucinogenics added to Intoxicants and Narcotics Exclusion MD Alcoholism or Drug Addiction Exclusion does not apply Felonies or Illegal Occupations Exclusion does not apply Intoxicants and Narcotics Exclusion does not apply Suicide or Self Inflicted Injuries Exclusion replaced with Self Destruction or Self Inflicted Injuries MO Alcoholism or Drug Addiction Exclusion replaced with Drug Addiction Felonies or Illegal Occupations Exclusion replaced with Illegal Activities NH Intoxicants and Narcotics exclusion does not apply NJ Alcoholism or Drug Addiction replaced with Drug Addiction Felonies or Illegal Occupations Exclusion replaced with Felonies or Illegal Jobs Psychiatric or Psychological Condition Exclusion replaced with Mental or Emotional Disease or Disorder OR Alcoholism or Drug Addiction Exclusion does not apply Intoxicants and Narcotics Exclusion does not apply Suicide or Self Inflicted Injuries Exclusion does not apply Felonies or Illegal Occupations Exclusion replaced with Felonies SC Alcoholism or Drug Addiction Exclusion does not apply Psychiatric or Psychological Condition Exclusion replaced with Mental or Emotional Disorders SD Alcoholism or Drug Addiction Exclusion does not apply Intoxicants and Narcotics Exclusion does not apply TX Alcoholism or Drug Addiction Exclusion does not apply UT Alcoholism or Drug Addiction Exclusion replaced with Alcoholism VT Alcoholism or Drug Addiction Exclusion does not apply Intoxicants and Narcotics Exclusion does not apply Psychiatric or Psychological Condition Exclusion does not apply War or Armed Conflict Exclusion replaced with War State specific pre existing condition limitations FL 12 12 Pre existing Condition means having a sickness or physical condition that during the 12 months immediately preceding the Policy Coverage Effective Date of this policy had manifested itself in such a manner as would cause an ordinarily prudent person to seek medical advice diagnosis care or treatment or for which medical advice diagnosis care or treatment was recommended or received IA 12 12 Pre existing Condition means having a condition for which medical advice or treatment or medication was recommended by a physician or received from a physician within 12 months preceding the Policy Coverage Effective Date of the covered person s policy MD 12 12 Pre existing Condition means having a sickness or physical condition for which any covered person was treated had medical testing received medical advice or had taken medication within 12 months before the Policy Coverage Effective Date of this policy A condition admitted or disclosed on the application will be covered unless the disease or condition is excluded by name or specific description effective on the date of loss NC 12 12 Pre existing Condition means having a sickness or physical condition for which any covered person was treated had medical testing received medical advice or had taken medication within 12 months before the Policy Coverage Effective Date of this policy If a covered person is 65 or older when this policy is issued pre existing conditions for that covered person will include only conditions specifically eliminated by rider NH 6 6 Pre existing condition means having a sickness or physical condition for which any covered person was diagnosed treated had medical testing or received medical advice within 6 months before the Policy Coverage Effective Date of this policy NJ 6 6 Pre existing Condition means having a sickness or physical condition for which any covered person was treated had medical testing received medical advice or had taken medication within six months before the Policy Coverage Effective Date of this policy NV 6 12 Pre existing Condition means having a sickness or physical condition for which any covered person was treated had medical testing received medical advice or had taken medication within six months before the Policy Coverage Effective Date of this policy

Critical Illness Insurance Health Screening Benefit The optional health screening benefit can help you reduce the risk of serious illness through early detection Health screening benefit __50 00_____________ Maximum of one screening test per covered person per calendar year Blood test for triglycerides Pap smear Bone marrow testing PSA blood test for prostate cancer Breast ultrasound Serum cholesterol test for HDL and LDL levels CA 15 3 blood test for breast cancer CA 125 blood test for ovarian cancer Carotid Doppler CEA blood test for colon cancer Chest X ray Colonoscopy Echocardiogram ECHO Electrocardiogram EKG ECG For more information talk with your benefits counselor Fasting blood glucose test Serum protein electrophoresis blood test for myeloma Skin cancer biopsy Stress test on a bicycle or treadmill Thermography ThinPrep pap test Virtual colonoscopy Flexible sigmoidoscopy Hemoccult stool analysis Mammography ColonialLife com THIS POLICY INSURANCE PROVIDES LIMITED BENEFITS Insureds in GA MA MN and VT must be covered by comprehensive health insurance before applying for critical illness or cancer insurance This information is not intended to be a complete description of the insurance coverage available The policy insurance or its provisions may vary or be unavailable in some states The policy insurance has exclusions and limitations which may affect any benefits payable Applicable to policy form CI 1 0 P and GCC1 0 P and certificate form GCC1 0 C including state abbreviations where used for example CI 1 0 P TX GCC1 0 P TX and GCC1 0 C TX For cost and complete details of coverage call or write your Colonial Life benefits counselor or the company Underwritten by Colonial Life Accident Insurance Company Columbia SC 2021 Colonial Life Accident Insurance Company All rights reserved Colonial Life is a registered trademark and marketing brand of Colonial Life Accident Insurance Company GROUP CRITICAL CARE CRITICAL ILLNESS 1 0 HEALTH SCREENING BENEFIT 5 21 100355 4

In the U S medical spending in the last 12 months of life is nearly 80 000 per person HealthAffairs org End Of Life Medical Spending In Last Twelve Months Of Life Is Lower Than Previously Reported July 2017 Your cost will vary based on the level of coverage you select Talk with your benefits counselor for information about what level of coverage would work best for you Whole Life Insurance You 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 emergencies1 Benefit for the beneficiary that is typically tax free Benefits 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 illness2 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

Term Life Insurance Peace of mind for you and your loved ones You 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 44 of Americans say their household would face financial hardship within six months should a wage earner die unexpectedly LIMRA 2022 Life Insurance Barometer Study Benefit for the beneficiary that is typically tax free Benefits and features Stand alone spouse policy available whether or not you buy a policy for yourself GA P 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 illness1 Premium savings for face amounts over 250 000 based on your health 54 of Americans have life insurance coverage with an average coverage gap of 200 000 LIMRA 2021 Industry Associations Unite to Help Address the Life Insurance Coverage Gap in the United States TERM LIFE ITL5000

DR GUS Deductions per year 52 These rates were prepared on 10 10 2023 and are valid for 90 days Cancer Assist for NC l with Progressive Payment Benefit 100 Health Screening Benefit 4 000 Initial Diagnosis Benefit COVERAGE LEVEL ISSUE AGE NAMED INSURED EMPLOYEE AND SPOUSE Level 3 17 75 Level 4 17 75 6 000 Initial Diagnosis Benefit 9 33 11 40 16 49 19 95 COVERAGE LEVEL ISSUE AGE NAMED INSURED EMPLOYEE AND SPOUSE Level 3 17 75 Level 4 17 75 8 000 Initial Diagnosis Benefit 10 03 12 10 17 64 21 10 COVERAGE LEVEL ISSUE AGE NAMED INSURED EMPLOYEE AND SPOUSE Level 3 17 75 Level 4 17 75 10 000 Initial Diagnosis Benefit 10 72 12 79 18 80 22 26 COVERAGE LEVEL ISSUE AGE NAMED INSURED EMPLOYEE AND SPOUSE Level 3 Level 4 17 75 17 75 11 41 13 48 19 95 23 41 Applicable to policy form CanAssist ONE PARENT FAMILY 9 53 11 63 TWO PARENT FAMILY 16 68 20 18 ONE PARENT FAMILY 10 27 12 37 TWO PARENT FAMILY 17 88 21 38 ONE PARENT FAMILY 11 00 13 10 TWO PARENT FAMILY 19 08 22 58 ONE PARENT FAMILY 11 74 13 84 TWO PARENT FAMILY 20 28 23 78 Critical Illness 1 0 for NC l with Subsequent Diagnosis Coverage Health Screening Benefit Cancer Benefit Non Tobacco Rates ISSUE AGE NAMED INSURED EMPLOYEE SPOUSE ONE PARENT FAMILY 10 000 17 24 25 29 30 34 35 39 40 44 45 49 50 54 55 59 60 64 65 70 1 45 1 91 2 39 3 11 3 73 4 86 6 73 8 28 10 95 13 01 2 19 2 91 3 64 4 75 5 70 7 48 10 34 12 71 16 82 19 98 1 82 2 28 2 76 3 48 4 10 5 25 7 10 8 67 11 35 13 42 Applicable to policy form CI 1 0 TWO PARENT FAMILY 2 58 3 30 4 04 5 14 6 09 7 84 10 71 13 11 17 21 20 40 Page 1 of 7 Underwritten by Colonial Life Accident Insurance Company See page 7 for Important Notice

DR GUS Continued Critical Illness 1 0 for NC l with Subsequent Diagnosis Coverage Health Screening Benefit Cancer Benefit Tobacco Rates ISSUE AGE NAMED INSURED EMPLOYEE SPOUSE ONE PARENT FAMILY 20 000 17 24 25 29 30 34 35 39 40 44 45 49 50 54 55 59 60 64 65 70 3 18 4 70 6 59 8 85 11 21 14 53 19 93 25 47 32 62 39 22 4 87 7 22 10 13 13 59 17 24 22 36 30 62 39 11 50 10 60 25 3 96 5 48 7 38 9 64 11 99 15 32 20 72 26 21 33 41 40 05 30 000 17 24 25 29 30 34 35 39 40 44 45 49 50 54 55 59 60 64 65 70 4 52 6 80 9 64 13 03 16 56 21 55 29 65 37 95 48 68 58 58 6 92 10 45 14 81 20 01 25 48 33 16 45 55 58 29 74 77 90 00 5 69 7 98 10 82 14 21 17 74 22 72 30 82 39 06 49 86 59 83 Applicable to policy form CI 1 0 TWO PARENT FAMILY 5 65 7 96 10 91 14 38 18 02 23 10 31 41 39 85 50 88 61 08 8 10 11 56 15 99 21 18 26 65 34 27 46 73 59 40 75 94 91 24 Applicable to policy forms ICC19 IWL5000 70 IWL5000 70 Whole Life Plus IWL5000 for NC 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 ICC23 IWL5000 LTC IWL5000 LTC l Adult Base Plan Paid Up at Age 100 Accelerated Death Benefit for Long Term Care Services Non Tobacco Rates ISSUE AGE 10 000 20 000 30 000 18 4 24 8 48 12 72 19 4 26 20 4 26 8 50 8 50 12 76 12 78 21 4 28 22 4 28 23 4 28 24 4 30 25 4 32 8 54 8 56 8 58 8 62 8 68 12 82 12 84 12 86 12 92 13 00 26 4 40 27 4 50 8 80 9 00 13 18 13 50 Page 3 of 7 Underwritten by Colonial Life Accident Insurance Company See page 7 for Important Notice

DR GUS Continued Critical Illness 1 0 for NC l with Subsequent Diagnosis Coverage Health Screening Benefit Cancer Benefit Non Tobacco Rates ISSUE AGE NAMED INSURED EMPLOYEE SPOUSE ONE PARENT FAMILY 20 000 17 24 25 29 30 34 35 39 40 44 45 49 50 54 55 59 60 64 65 70 2 39 3 32 4 28 5 72 6 96 9 22 12 96 16 05 21 41 25 52 3 62 5 05 6 53 8 74 10 64 14 19 19 91 24 67 32 88 39 21 3 13 4 05 5 02 6 45 7 70 10 01 13 70 16 84 22 19 26 35 30 000 17 24 25 29 30 34 35 39 40 44 45 49 50 54 55 59 60 64 65 70 3 34 4 72 6 18 8 32 10 19 13 58 19 19 23 83 31 86 38 02 5 05 7 20 9 41 12 74 15 58 20 91 29 49 36 62 48 94 58 43 4 45 5 83 7 28 9 43 11 30 14 76 20 30 25 01 33 04 39 27 Tobacco Rates ISSUE AGE 10 000 17 24 25 29 30 34 35 39 40 44 45 49 50 54 55 59 60 64 65 70 NAMED INSURED 1 84 2 60 3 55 4 68 5 85 7 52 10 22 12 98 16 56 19 86 EMPLOYEE SPOUSE 2 81 3 99 5 44 7 18 9 00 11 56 15 69 19 94 25 43 30 51 ONE PARENT FAMILY 2 23 2 99 3 94 5 07 6 25 7 91 10 61 13 35 16 95 20 28 Applicable to policy form CI 1 0 TWO PARENT FAMILY 4 41 5 84 7 31 9 53 11 42 14 93 20 65 25 45 33 67 40 04 6 23 8 38 10 59 13 91 16 75 22 01 30 60 37 80 50 12 59 68 TWO PARENT FAMILY 3 21 4 36 5 84 7 57 9 39 11 93 16 08 20 31 25 82 30 92 Page 2 of 7 Underwritten by Colonial Life Accident Insurance Company See page 7 for Important Notice

DR GUS Continued Applicable to policy forms ICC19 IWL5000 70 IWL5000 70 Whole Life Plus IWL5000 for NC 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 ICC23 IWL5000 LTC IWL5000 LTC l Adult Base Plan Paid Up at Age 100 Accelerated Death Benefit for Long Term Care Services Non Tobacco Rates ISSUE AGE 10 000 20 000 30 000 28 4 62 9 26 13 88 29 4 80 30 4 94 9 56 9 90 14 34 14 84 31 5 12 10 24 15 36 32 5 28 10 60 15 90 33 5 50 11 00 16 50 34 5 70 11 40 17 10 35 5 92 11 86 17 78 36 6 16 12 34 18 50 37 6 42 12 86 19 28 38 6 72 13 40 20 12 39 7 02 14 02 21 04 40 7 34 14 70 22 04 41 7 70 15 42 23 14 42 8 12 16 20 24 32 43 8 52 17 04 25 56 44 8 98 17 92 26 90 45 9 42 46 9 90 47 10 40 48 10 90 49 11 40 18 84 19 80 20 80 21 78 22 84 28 26 29 70 31 16 32 68 34 24 50 11 96 51 12 56 23 90 25 12 35 88 37 68 52 13 20 53 13 92 54 14 70 55 15 54 56 16 46 26 42 27 84 29 40 31 08 32 94 39 62 41 78 44 10 46 62 49 40 57 17 46 58 18 50 34 90 36 98 52 36 55 48 59 19 60 60 20 78 61 22 08 62 23 46 39 22 41 60 44 18 46 90 58 82 62 38 66 26 70 38 Page 4 of 7 Underwritten by Colonial Life Accident Insurance Company See page 7 for Important Notice

DR GUS Continued Applicable to policy forms ICC19 IWL5000 70 IWL5000 70 Whole Life Plus IWL5000 for NC 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 ICC23 IWL5000 LTC IWL5000 LTC l Adult Base Plan Paid Up at Age 100 Accelerated Death Benefit for Long Term Care Services Non Tobacco Rates ISSUE AGE 10 000 20 000 30 000 63 24 92 49 84 74 74 64 26 48 65 28 16 52 98 56 30 79 44 84 46 66 30 02 67 32 00 68 34 12 69 36 44 70 38 90 60 02 64 02 68 28 72 84 77 82 90 06 96 02 102 40 109 28 116 70 71 39 04 72 41 90 78 08 83 82 117 12 125 72 73 45 16 90 32 135 48 74 48 86 97 72 146 58 75 53 06 106 12 159 16 76 57 80 115 58 173 38 77 63 12 126 24 189 36 78 69 06 138 12 207 18 79 75 66 151 34 227 00 Tobacco Rates ISSUE AGE 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 10 000 6 40 6 60 6 76 6 94 7 10 7 24 7 38 7 50 7 62 7 72 7 82 7 96 8 08 8 24 8 44 20 000 12 80 13 16 13 52 13 88 14 20 14 48 14 78 15 00 15 24 15 44 15 68 15 90 16 16 16 50 16 86 30 000 19 20 19 76 20 28 20 82 21 28 21 72 22 14 22 50 22 84 23 16 23 50 23 84 24 24 24 74 25 30 Page 5 of 7 Underwritten by Colonial Life Accident Insurance Company See page 7 for Important Notice

DR GUS Continued Applicable to policy forms ICC19 IWL5000 70 IWL5000 70 Whole Life Plus IWL5000 for NC 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 ICC23 IWL5000 LTC IWL5000 LTC l Adult Base Plan Paid Up at Age 100 Accelerated Death Benefit for Long Term Care Services Tobacco Rates ISSUE AGE 10 000 20 000 30 000 33 8 66 17 32 25 96 34 8 90 17 82 26 72 35 9 18 18 34 27 52 36 9 46 37 9 80 38 10 12 39 10 48 40 10 90 18 94 19 58 20 26 20 96 21 76 28 40 29 34 30 38 31 46 32 66 41 11 32 42 11 84 22 66 23 66 33 98 35 50 43 12 40 44 13 02 45 13 68 46 14 38 47 15 08 48 15 80 49 16 56 24 78 26 04 27 36 28 74 30 16 31 62 33 10 37 18 39 06 41 04 43 12 45 26 47 42 49 66 50 17 34 51 18 24 52 19 28 53 20 48 54 21 80 34 68 36 48 38 54 40 94 43 62 52 02 54 72 57 82 61 42 65 42 55 23 22 56 24 72 46 46 49 44 69 70 74 16 57 26 20 58 27 68 59 29 18 60 30 70 61 32 34 52 40 55 40 58 36 61 40 64 68 78 62 83 08 87 54 92 10 97 04 62 34 12 63 36 08 68 26 72 14 102 38 108 22 64 38 12 65 40 30 66 42 64 67 45 00 76 28 80 62 85 24 90 00 114 40 120 92 127 88 135 00 Page 6 of 7 Underwritten by Colonial Life Accident Insurance Company See page 7 for Important Notice

DR GUS Continued Applicable to policy forms ICC19 IWL5000 70 IWL5000 70 Whole Life Plus IWL5000 for NC 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 ICC23 IWL5000 LTC IWL5000 LTC l Adult Base Plan Paid Up at Age 100 Accelerated Death Benefit for Long Term Care Services Tobacco Rates ISSUE AGE 10 000 20 000 30 000 68 47 46 94 90 142 34 69 49 98 99 98 149 96 70 52 72 105 42 158 14 71 53 10 106 18 159 28 72 56 50 113 00 169 50 73 60 38 120 76 181 14 74 64 66 129 30 193 96 75 69 28 138 54 207 82 76 74 22 148 44 222 66 77 79 46 158 92 238 38 78 84 96 169 92 254 88 79 90 68 181 38 272 06 Important Notice Insurance coverage has exclusions and limitations that may affect benefits payable For a complete description of benefits limitations and exclusions please refer to an outline of coverage sample policy certificate proposal description or see your Colonial Life benefits counselor Coverage type benefits and rates vary by state Coverage may not 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 2023 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 Page 7 of 7 Underwritten by Colonial Life Accident Insurance Company See page 7 for Important Notice

How to File a Claim for Colonial Life Benefits FOR FASTEST RESULTS FILE ONLINE 1 Go to ColonialLife com access to login or register 2 Fill out the required information and click Submit 3 Enjoy streamlined claims management and faster service online DIGITALLY FILE ALL TYPES OF CLAIMS Disability Insurance Accident Hospital Insurance Life Insurance Critical Illness Cancer Insurance Wellness benefits for screening tests Not sure which type of claim to file No problem Just answer a few questions on the portal and we ll help you figure everything out BEFORE YOU FILE Review the appropriate claims checklist at ColonialLife com and have this information handy to make the process go smoothly Proper documentation must be submitted when filing your claim AFTER YOU FILE Check your claim status and manage your claim by logging into your account at ColonialLife com access Live chat is also available 9 a m 5 p m EST OTHER WAYS TO FILE A CLAIM Fax 1 800 880 9325 Mail P O Box 100195 Columbia SC 29202 Colonial Life is committed to providing you our valued customer a market leading claims experience We look forward to serving you on ColonialLife com On the policyholder portal you can View benefit details Here you ll find a copy of your policy to see what s covered and benefit amounts Track your claim Log in anytime to view status or opt in to receive status alerts by email or text so you know instantly if we require additional information Sign up for direct deposit to get approved payments up to a week faster than paper check Colonial Life insurance products are underwritten by Colonial Life Accident Insurance Company Columbia SC 2022 Colonial Life Accident Insurance Company All rights reserved Colonial Life is a registered trademark and marketing brand of Colonial Life Accident Insurance Company ADR 1312251

Thank you Colonial Life Voluntary Benefits Please contact Shelley Hartsell Benefits Specialist 704 883 4838 Shelley Hartsell ColonialLifeSales com