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Employee Benefits Guide August 1, 2024–July 31, 2025The benefit descriptions shown below are partial summaries. Consult the certificate of coverage and official summary for further details.EligibilityAll full-time employees working at least 30 hours per week are eligible to enroll in the employee benefits outlined in this guide. If you are a newly hired employee, you become eligible for benefits on the first of the month following 30 days of hire. Employees may also enroll their spouse and any dependent children up to the age of 26 in the benefits they elect. If a dependent child turns 26 during the plan year, he or she will automatically be removed from the benefits at the end of their birth month as they are no longer eligible. For questions on dependent children eligibility, please visit https://www.healthcare.gov/young-adults/children-under-26/.Open EnrollmentOpen Enrollment is from August 5th - August 13th. Every eligible employee will be required to schedule a meeting with an Enrollment Counselor in order to learn about the benefit offerings and complete enrollment. You cannot make a change to your benefit elections mid-year unless you have a qualifying life event.Qualifying Life EventIf you have a qualifying life event during the plan year, you have 30 days from the date of the event to notify HR of any changes that need to be made to your benefit coverages. Examples of a qualifying life event include marriage, divorce, birth or adoption of a child, change in child’s dependent status, loss of other coverage, ordeath.BenefitsPage 2 – Preventive Care ServicesPage 6 - Minimum Essential Coverage (MEC) - Benefit Management Administrators Page 8 – Voluntary Dental & Vision CoveragePage 9 – Prescription Drug CoveragePage 11 – Colonial Voluntary ProductsWhat Do You Need to Do?1. Review the instructions provided to you so you can set up a time to visit with an Enrollment Counselor.2. Set up a time to meet with an Enrollment Counselor in person or by phone.3. Enrollment Counselors will review all lines of coverage and will assist you with plan selection and enrollment.
Administered By: Benefit Management Administrators, Inc Minimum Essential Coverage Enrollment Guide Minimum Essential Coverage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f you have questions about how to use your MEC benefits after you have enrolled, BMA has a toll free customer service telephone line dedicated to your service. Plan Designed for Employees of: This employer sponsored Self-Insured 0LQLPXP (VVHQWLDO &RYHUDJHplan FRYHUVRIWKHJRYHUQPHQW¶V OLVWHG 3UHYHQWLYH DQG :HOOQHVV%HQHILWVZKHQ\RXYLVLWDQHWZRUN SURYLGHU Gatesco /APTPW, LLC
Benefit Management Administrators, Inc. | 11550 IH10 W Suite 220, San Antonio, TX 78230 | (800) 934-6302 | bmatpa.com 2 Minimum Essential Coverage Minimum Essential Coverage What are the Covered Services in Minimum Essential Coverage?There are over 78 preventive services covered 100% (In-Network) under the MEC plan. SHUYLFes include annual well woman exams, men’s physicals, well child care, immunizations, blood pressure screenings, diabetes and cholesterol screenings, prenatal visits for pregnant women and more. Below is a full list of services: Covered Preventive Services for Adults 1. Abdominal Aortic Aneurysm one-time screening 2.Alcohol Misuse screening and counseling3.Aspirin use for men and women of certain ages4. Blood Pressure screening 5.Cholesterol screening 6.Colorectal Cancer screening 7.Depression screening 8. Type 2 Diabetes screening 9. Diet counseling 10. Hepatitis B screening for people at high risk11.Hepatitis C screening 12.HIV screening 13. Immunization vaccines for adults (Hepatitis A, Hepatitis B, Herpes Zoster, Human Papillomavirus, Influenza (Flu Shot), Measles, Mumps, Rubella, Meningococcal, Pneumococcal, Varicella, Tetanus, Diphtheria, Pertussis14. Obesity screening and counseling 15. Sexually Transmitted Infection (STI) prevention counseling16. Tobacco Use screening and cessation17. Syphilis screening for adults at high risk18. PrEP (pre-exposure prophylaxis_ HIV prevention medicationfor HIV-negative adults at high risk19. Lung cancer screening for adults at high risk20. Statin prevention medication for adults at high risk21. Tuberculosis screening for certain adults without symptomsat high risk22.Fall Prevention for adults 65 years and over in a community settingCovered Preventive Services for Women, Including Pregnant Women 1. Routine prenatal visits for pregnant women2. Bacteriuria urinary tract or other infection screening forpregnant women3.BRCA counseling about genetic testing for women at higher risk4.Breast Cancer Mammography screenings-Every two years for women 50 and over-As recommended by a provider for women 40-49 or women at high risk for breast cancer5. Breast Cancer Chemoprevention counseling for women at higher risk6. Breastfeeding comprehensive support and counselingfrom trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women7. Cervical Cancer screening (Pap Smear for women age 21-65)8. Chlamydia Infection screening9. Contraception: Food and Drug Administration-approvedcontraceptive methods and patient education and counseling, not including abortifacient drugs10.Domestic and interpersonal violence screening and counseling for all women11.Folic Acid supplements for women who may become pregnant13. Gestational diabetes screening14. Gonorrhea screening for all women at higher risk15. Hepatitis B screening for pregnant women16.Human Immunodeficiency Virus (HIV) screening and counseling17. Human Papillomavirus (HPV) DNA Test: high risk HPV DNAtesting every three years for women with normal cytology results who are 30 or older18. Bone density screening for all women over age 65 or womenage 64 and yonger that have gone through menopause19. Rh Incompatibility screening for all pregnant women and follow-up testing20.Tobacco Use screening and interventions for all women, andexpanded counseling for pregnant tobacco users21. Sexually Transmitted Infections (STI) counseling for sexuallyactive women22. Syphilis screening for all pregnant women or other women atincreased risk23.Well-woman visits to obtain recommended preventive service24.Maternal depression screening for mothers at well-baby visits25. Preeclampsia prevention and screening for pregnant women with high blood pressure26.Urinary incontinence screening for women yearly27. Diabetes screening for women with a history of gestational diabetes12.PrEP (pre-exposure prophylaxis) HIV prevention medication
Benefit Management Administrators, Inc. | 11550 IH10 W Suite 220, San Antonio, TX 78230 | (800) 934-6302 | bmatpa.com 3 Minimum Essential Coverage Minimum Essential Coverage Covered Preventive Services for Children 1. Alcohol and Drug Use assessments for adolescents2. Autism screening for children at 18 and 24 months3. Behavioral assessments for children limited to 5assessments up to age 174. Blood Pressure screening5. Depression screening for adolescents age 12 and older6. Developmental screening for children under age 3, andsurveillance throughout childhood7. Dyslipidemia screening for children8.Fluoride supplements for children without Fluoride in their water source9. Gonorrhea preventive medication for the eyes of allnewborns10. Hearing screening for all newborns11. Height, Weight and Body Mass Index measurementsfor children12. Hematocrit or Hemoglobin screening for children13. Hemoglobinopathies or sickle cell screening fornewborns14. HIV screening for adolescents15. Immunization vaccines for children from birth toage 18—doses, recommended ages, and recommended populations vary (Hepatitis A, Diphtheria, Tetanus, Pertussis, Hepatitis B, Haemophilus influenzae type b, Human Papillomavirus, Inactivated Poliovirus, Influenza (Flu Shot), Measles, Mumps, Rubella, Meningococcal, Pneumococcal, Rotavirus, Varicella16.Iron supplements for children ages 6 to 12 months at risk for anemia17.Lead screening for children at risk of exposure18.Obesity screening and counseling19.Oral Health risk assessment for children up to age 10 20.Phenylketonuria (PKU) screening for this genetic disorder in newborns21.Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk 22.Tuberculin testing for children23.Vision screening for all children 24. Bilirubin concentration screening for newborns25. Blood screening for newborns26. Hepatitis B screening for adolescents at a higher risk27. Hypothyroidism screening for newborns28.PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV 29. Well-baby and well-child visitsFor more information regarding preventive care recommendations and immunizations, visit the websites for the Centers for Disease Control and Preventions or the United States Department of Human Services: For Adults: xPreventive Services for Adults: http://www.guideline.gov/browse/by-topic.aspx xImmunization Schedule: http://www.cdc.gov/vaccinesFor Women’s Health: xhttp://www.cdc.gov/womenFor Men’s Health: xhttp://www.cdc.gov/menFor Children: xWell child check-ups: http://www.cdc.gov/ncbddd/xImmunization schedule: http://www.cdc.gov/vaccines
Minimum Essential Coverage Frequently Asked QuestionsHOW CAN I PARTICIPATE IN THIS PROGRAM? All employees that work a minimum of 30 hours per week are eligible to enroll. Eligible dependents include spouses and unmarried children or stepchildren, under age 26. Enroll in the plan by completing and returning the enrollment form. CAN I SIGN UP FOR COVERAGE AT ANY TIME? No, you must sign up for coverage within 30 days of completing your waiting period or during annual open enrollment. If you do not elect coverage during your initial offering, you will not be able to enroll until the next open enrollment period unless you experience a qualifying event. WHAT IS A ‘QUALIFYING EVENT’? At other times during the year besides open enrollment you may request a change in your enrollment when you have a “qualifying event”. A qualifying event is a family status change involving any of the following: 1. Marriage or divorce;2. Birth, Adoption, or change in legal custody of a child;3. A child attaining age 26;4. Death of spouse or child;5. Spouse obtaining new employment or insurance through their work; losing their employment or losing their insurance(non-voluntary)Changes, additions or voluntary cancellations cannot be made at any other times during the year, except during the open enrollment period. HOW ARE MY PREMIUMS PAID? Premiums will be taken pre-tax through payroll deductions as part of a Section 125 plan. You will not be able to change these elections until the next annual enrollment period, unless you have a qualifying event. HOW DO I USE MY MEC PLAN? xThe MEC comes with a Medical ID Card that needs to be presented to your medical provider at time of servicexTell your medical provider that you have a preventive-only service planxCommunicating with your medical provider about your MEC ahead of time will help ensure the services provided arecovered at 100%xIf the claim from the medical provider is coded with the correct preventive service indicator (one of the 63), it will be paidat 100% (In-Network) by the MEC planWHEN CAN I EXPECT TO RECEIVE MY ID CARD AND ENROLLMENT INFORMATION? The benefit kit will be mailed directly to you, at the address indicated on the Enrollment Form. Please allow approximately 2-weeks from the time of enrollment for the kit to arrive in your mailbox. WHO DO I CALL IF I HAVE QUESTIONS ABOUT MY MEC PLAN? LOCAL | ADMINISTRATIVE | EXCELLENCE P.O. Box 781709, San Antonio, TX 78278 | bmatpa.com Customer Service Contacts: BMA800934-63020RQGD\±)ULGD\)URP$0±30&67P.O. Box 781709, San Antonio, TX 78278 CustomerService@bmatpa.com www.bmatpa.com PPO Network: )LUVW+HDOWK1HWZRUN 226-5116 ǁǁǁ&ŝƌƐƚŚ,ĞĂůƚŚ>WĐŽŵPrescription Network:EHiM(800) 311-3446 www.ehimrx.com
Benefit Management Administrators, Inc. 11550 IH 10 West, Suite 220 San Antonio, Texas 78230 | (800) 934 – 6302 | www.bmatpa.com | customerservice@bmatpa.com APTPW, LLCAugust 2024 – July 2025MEC Plus Medical Benefit Plan Overview MEDICAL BENEFIT PLAN Annual & Lifetime Maximum Benefit For the most current information on participating providers, contact the provider network: First Health Network 1 (800) 226-5116 www.FirstHealthLBP.com Unlimited Benefit Network Non-Network Calendar Year Deductible $0 Not Covered Total Annual Out-of-Pocket Maximum Individual Family $6,450 $12,900 Benefit Network Non-Network Preventative Care $0 Co – Pay Not Covered There are 78 preventive services covered at 100% under the required government list of Preventive and Wellness Benefits when you visit a network provider. Examples of Covered Wellness Procedures Include, but are Not Limited to: • Blood Pressure Screenings, Diabetes and Cholesterol Screenings • Laboratory tests • Routine Physical Exam • Gynecological exam, Annual Well Woman Exam, Annual Pap Smear and Other Routine Lab • Prenatal Visits for Pregnant Women • Well Baby Care Exam/Well Child Care Exam • Routine Immunizations, Immunizations and inoculations • Flu Vaccine/Pneumonia Vaccine • Routine Lab, X-Ray, Diagnostic Testing and Other Medical Screenings • Routine Vision Screening (Under Age 19) • Routine Hearing Screening (Newborns) • Smoking/Tobacco Use Cessation (Limited to 2 Office Visits and a 3 Month Supply of Smoking Cessation Aids Covered Through the Rx Program) • FDA Approved Women’s Contraceptive Methods Benefit Network Non-Network Physician Services **All Services are limited to a combined 8 visits per plan year. Not Covered Office Visits Primary Care $15 Co-Pay Specialist $25 Co-Pay Injections, Labs and X-rays (Included with an Office Visit Charge) Included Injections, Labs and X-rays (without an Office Visit Charge) $25 Co-Pay Office visit surgery, surgical injection codes, infusion, hospital visits Not Covered Mental Health & Substance Abuse Services Outpatient Office Visit $25 Co-Pay Inpatient or Partial Day Treatments Not Covered Maternity Services Prenatal Office Visit $25 Co-Pay Ultrasound – office or outpatient setting (limited 3 per Pregnancy) $25 Co-Pay Convenience Care Clinic $15 Co-Pay Urgent Care Facility $25 Co-Pay Diagnostic Lab & X-Ray Office Visit (Services must be rendered in an office or outpatient setting) Plan pays 100% (if billed with an office visit) Independent Free-standing Facility $25 Co-Pay MRI, CT, PET scans – One Call Medical (800) 800-7616 Discount Only
Benefit Management Administrators, Inc. 11550 IH 10 West, Suite 220 San Antonio, Texas 78230 | (800) 934 – 6302 | www.bmatpa.com | customerservice@bmatpa.com Allergy Care* Office Visit and Serum (Testing Not Covered) Primary Care Provider Specialist Attention Deficit Disorder (ADD & ADHD)* Office Visits & Medication Management (Testing Not Covered) Primary Care Provider Specialist Autism Care* Office Visits & Medication Management (Testing Not Covered) Primary Care Provider Specialist $15 Co-Pay $25 Co-Pay $15 Co-Pay $25 Co-Pay $15 Co-Pay $25 Co-Pay .Prescription Drug Benefit Program / EHiM Pharmacy Help Desk 800.311.3446 – www.ehimrx.comRetail Pharmacy30 Day Supply OnlyGeneric Contraceptive Drugs All Other Generic Drugs Preferred Brand Non-Preferred Brand $0 $10 Not Covered Not Covered This Plan Overview is intended to be a brief summary of your Benefits and is not to be interpreted as the official benefit plan document. This benefit plan may not cover all of your health care expenses. More complete descriptions of Benefits and the terms under which they are provided are contained in the Plan Document. In case of discrepancy, the Employee Benefit Plan Document shall govern.
Benefit Management Administrators | (800) 934 – 6302 | CustomerService@bmatpa.com | www.bmatpa.com APTPW, LLCAugust 2024 – July 2025Dental & Vision Plan OverviewDENTAL BENEFIT PLAN Dental & Vision benefits are administered by Benefit Management Administrators, Inc. Questions? Contact BMA (800) 934-6302 or www.bmatpa.com Dental & Vision Benefits are Open Access, meaning you can choose to use any Dental Provider. Benefit Schedule Individual Family Calendar Year Deductible $50 – Individual $150 – Family Plan Year Maximum Benefit - Does Not Include Orthodontic Care $1,000 Per Covered Person Benefit Schedule - Preventative 100 % Covered – Deductible Waived Preventative Services Include Periodic oral exams limited to one every six months Prophy/ fluoride limited to one every six months Bitewings X-Rays, limited to one every six months Full mouth series or Panoramic limited to one every 36 months Sealants on non-restored posterior teeth only,limited to children under age 14Benefit Schedule - Basic 80 % Covered – After Deductible Basic Services Include Non periodic oral exams X-rays not listed in preventative services Periodontal procedures (charting required) Periodontal maintenance – Limited to one every 6 months Space maintainers (children under 14 only) Simple Extractions, Fillings other than goldBenefit Schedule - Major 50 % Covered – After Deductible Major Services Include * 6 month waiting period Endodontic Services Crowns (other than stainless steel crowns) Dentures, bridges, porcelain and resin crowns Inlays, onlays, and extractions Anesthesia and sedation based on Medical NecessityVISION BENEFIT PLAN Benefit ScheduleCalendar Year Deductible None Plan Year Maximum Benefit $200 Per Covered Person Eye Exam Comprehensive exam of visual functions and prescription of corrective eyewear. Covered at 100% up to a Max of $50 Per Person One Visit Per Calendar Year Materials / Eyewear Either Glass or Contacts Covered at 100% up to a Max of $150 Per Person Frames: once every 24 months – Lenses: once every 12 months Contact Lenses: once every 12 months *in lieu of glasses This information is intended to be a brief summary of our Benefit Program and is not to be interpreted as the official benefit plan document. More complete descriptions of Benefits and the terms under which they are provided are contained in the Plan Document. In case of discrepancy, the Employee Benefit Plan Document shall govern.
QUANTITY LIMITS FOR CERTAIN MEDICATIONSCertain medications under your program may be subject to quantity limits. Medications that are subject to quantity limits are to help ensure these medications are not utilized inappropriately or recommended maximum dosages are not exceeded. EHIM’sQuantity Limitations are based on FDA-approved dosing recommendations, pharmaceutical guidelines and have been reviewed and approved by our licensed, clinical staff. EHIM PHARMACY NETWORKEHIM has over 62,000 participating pharmacies across the country including all of the major chain pharmacies, regional pharmacies, and most independent pharmacies. You may visit our website at www.ehimrx.com for our National PharmacyDirectory and Pharmacy Locator tool.EHIM PHARMACY HELP DESKEHIM’s Pharmacy Help Desk is available for your convenience 24 hours a day, 7 days per week, 365 days per year. Our toll freenumber is (800) 311-3446 and will be printed on the back of your ID card and on all of our communication pieces. If you haveany questions regarding your benefits or just need help finding a participating pharmacy, please contact our Pharmacy Help Desk. You may also contact our help desk through our website at www.ehimrx.com.Copayment on any Covered Generic Medication that is part of the Generic Plus FormularyEHIM has a national pharmacy network, therefore, youcan receive your medications through any local retail pharmacyof your choosing. If you ever encounter a pharmacy not in our network, please call the EHIM Pharmacy Help Desk and we will enroll the pharmacy into the network. You will be receiving an EHIM ID Card to use at the pharmacy. The ID card will have the employee’s name on every card. All of the ID cards are interchangeable between family members.All members who are 18 or older will receive a card. If an additional ID card is required, please notify your HR Directoror call the EHIM Pharmacy Help Desk at 800-311-3446 to request additional cards.Customer Service 800-311-3446 • 24/7/365EHIM’s main mission is to provide our members with the best customer service possible. If you are experiencing a problem filling a retail or mail orderprescription please contact EHIM’s Pharmacy HelpDesk. For your convenience, our help desk has a representative available 24 hours a day, 7 days a week, 365 days a year. Our toll free number is 1-800-311-3446 and will be printed on the back ofyour ID card for easy reference.Welcome...to EHIM’s Prescription Benefit Program!We are excited to serve you and would like to introduceyou to our program before your benefits begin.Your BenefitsRXEHIM26711 Northwestern Highway, Suite 400 :: Southfield, MI 48033-2154 800-311-3446 :: 248-948-9900 :: www.ehimrx.com26711 Northwestern Highway, Suite 400 :: Southfield, MI 48033-2154 800-311-3446 :: 248-948-9900 :: www.ehimrx.com 00.01$APTPW, LLC Policy Period: August 1st - July 31st 8102/52/5
sales@bmatpa.com 1 (800) 934-6302 bmatpa.com© Benefi t Management Administrators 2021Health PortalOur health portal is your easy-to-use main hub for daily tasks for employers, members, and brokers.How to Create an Account1. Visit www.bmatpa.com2. Click the “Portal Login”button.3. Click the “Create a NewAccount” button.4. Follow the in-screenprompts.Member Portal Features• Find a doctor or hospital• Look up your health benefits• Access your health claims (EOBs)• Download benefit documents• Chat with Customer Service• Request new member ID card• Print a temporary ID card• Send and receive securemessages• Access to our HR Complianceknowledge base
Deductions per year: 24 These rates were prepared on 7/11/2023 and are valid for 90 days.Group Disability for TX AA 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**monthly benefit amount7 days Accident/7 days Sickness 17-49 $5.44 $13.60 $34.00 N/A50-64 $6.26 $15.65 $39.13 N/A65-74 $7.58 $18.95 $47.38 N/A14 days Accident/14 days Sickness 17-49 $3.52 $8.80 $22.00 $35.2050-64 $4.24 $10.60 $26.50 $42.4065-74 $5.40 $13.50 $33.75 $54.006 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $400* $1,000* $2,500* $4,000**monthly benefit amount7 days Accident/7 days Sickness 17-49 $6.84 $17.10 $42.75 N/A50-64 $9.10 $22.75 $56.88 N/A65-74 $11.82 $29.55 $73.88 N/A14 days Accident/14 days Sickness 17-49 $4.84 $12.10 $30.25 $48.4050-64 $6.12 $15.30 $38.25 $61.2065-74 $8.16 $20.40 $51.00 $81.60Group Accident for TXApplicable to policy forms GACC1.0-P & GACC1.0-ClOn/Off-Job Accident CoveragePreferredISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY17-99 $7.47 $12.32 $14.28 $19.14Group Medical Bridge (GMB7000) for TX Age-BandedApplicable to Policy Forms GMB7000–P & GMB7000-ClWellbeing Assistance: Basic - $50HOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 4: $200017-49 $11.53 $19.08 $15.55 $23.1050-59 $14.33 $26.38 $18.35 $30.4060-64 $19.23 $37.78 $23.25 $41.8065-99 $26.13 $52.08 $30.15 $56.10HOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 6: $300017-49 $19.08 $32.63 $26.30 $39.8550-59 $24.03 $45.68 $31.25 $52.9060-64 $32.88 $66.23 $40.10 $73.4565-99 $45.33 $92.03 $52.55 $99.25Page 1 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 for Important Notice
Group Critical Care for TXApplicable to policy forms GCC1.0-P & GCC1.0-ClFull CI Benefit, with Subsequent Diagnosis, Diagnosis of Cancer Benefit, $50 Health Screening BenefitNon-Tobacco RatesISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$15,000 16-29 $4.15 $6.30 $4.53 $6.6830-39 $6.78 $10.20 $7.15 $10.5840-49 $12.48 $18.75 $12.93 $19.2050-59 $21.63 $33.00 $22.08 $33.4560-74 $33.93 $51.75 $34.38 $52.20$30,000 16-29 $6.85 $10.35 $7.60 $11.1030-39 $12.10 $18.15 $12.85 $18.9040-49 $23.50 $35.25 $24.40 $36.1550-59 $41.80 $63.75 $42.70 $64.6560-74 $66.40 $101.25 $67.30 $102.15Tobacco RatesISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$15,000 16-29 $5.80 $8.78 $6.25 $9.1530-39 $9.78 $14.63 $10.15 $15.0040-49 $18.85 $28.35 $19.30 $28.8050-59 $33.40 $51.23 $33.85 $51.6860-74 $53.95 $82.50 $54.40 $83.03$30,000 16-29 $10.15 $15.30 $11.05 $16.0530-39 $18.10 $27.00 $18.85 $27.7540-49 $36.25 $54.45 $37.15 $55.3550-59 $65.35 $100.20 $66.25 $101.1060-74 $106.45 $162.75 $107.35 $163.80Term Life (ITL5000) for TXApplicable to policy form ITL5000l20-Year Term Base PlanNon-Tobacco RatesISSUE AGE $10,000 $25,000 $50,000 $75,000 $100,00025 $3.36 $5.39 $5.27 $6.91 $8.5435 $3.85 $6.62 $5.79 $7.69 $9.5945 $4.84 $9.11 $10.90 $15.35 $19.7955 $9.03 $19.57 $23.17 $33.75 $44.3365 $20.50 $30.77 $59.54 $88.31 $117.08Tobacco RatesISSUE AGE $10,000 $25,000 $50,000 $75,000 $100,00025 $5.24 $10.11 $9.11 $12.66 $16.2135 $5.86 $11.65 $10.31 $14.47 $18.6345 $7.95 $16.87 $22.73 $33.10 $43.4655 $16.97 $39.42 $53.02 $78.53 $104.0465 $35.07 $51.84 $101.69 $151.53 $201.37(Continued...)Page 2 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 for Important Notice
Term Life (ITL5000) for TXApplicable to policy form ITL5000l20-Year Term Base Plan20-Year Spouse Term Life BenefitISSUE AGE $10,000 $20,000 $30,000 $40,000 $50,00025 $1.18 $2.36 $3.54 $4.72 $5.9035 $1.41 $2.81 $4.21 $5.62 $7.0245 $3.28 $6.56 $9.84 $13.12 $16.40Children's Term Life BenefitISSUE AGE $10,000 $20,0000-18 $2.50 $5.00Whole Life Plus (IWL5000) for TXApplicable to policy forms ICC19-IWL5000-70/IWL5000-70,ICC19-IWL5000-100/IWL5000-100,ICC19-IWL5000J/IWL5000J and rider formsICC19-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-GPOlAdult Base Plan Paid-Up at Age 100Non-Tobacco RatesISSUE AGE $10,000 $25,000 $50,000 $75,000 $100,00025 $4.60 $11.50 $23.00 $34.50 $46.0035 $6.26 $15.65 $31.29 $46.94 $62.5845 $9.94 $24.86 $49.71 $74.56 $99.4255 $16.23 $40.56 $81.12 $121.69 $162.2565 $28.88 $72.19 $144.37 $216.56 $288.74Tobacco RatesISSUE AGE $10,000 $25,000 $50,000 $75,000 $100,00025 $8.04 $20.09 $40.17 $60.25 $80.3335 $9.78 $24.44 $48.88 $73.31 $97.7545 $14.56 $36.39 $72.77 $109.15 $145.5455 $24.53 $61.33 $122.66 $184.00 $245.3365 $41.96 $104.89 $209.79 $314.68 $419.5720-Year Spouse Term Life BenefitISSUE AGE $10,000 $20,000 $30,000 $40,000 $50,00025 $1.66 $3.32 $4.98 $6.64 $8.2935 $2.11 $4.21 $6.31 $8.42 $10.5245 $3.79 $7.57 $11.35 $15.14 $18.92Children's Term Life BenefitISSUE AGE $10,000 $20,0000-18 $2.50 $5.00(Continued...)Page 3 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 3 for Important Notice
Group Disability InsuranceGROUP DISABILITY BASEYou never know when a disability could impact your way of life. Fortunately, there’s a way to help protect your income. If a covered accident or sickness prevents you from earning a paycheck, disability insurance can provide a monthly benefit to help you cover your ongoing expenses.Can you aord to not protect your income? You don’t have the same lifestyle expenses as the next person. That’s why you need disability coverage that can be customized to fit your specific needs.Aer calculating your monthly expenses, your benefits counselor can help you complete the benefits worksheet.ColonialLife.comMONTHLY EXPENSESRound to the nearest hundred.1 Rent or mortgage $2 Transportation $3 Utilities (phone, internet, electricity/gas, water, etc.) $4 Food and necessities $5 Other expenses $ Total monthly expenses (add lines 1-5 together) $Benefits worksheetHow much coverage do I need?Monthly benefit amount for o-job accident and o-job sickness: ______________Choose a monthly benefit amount between $400 and $7,500.*If your plan includes on-job accident/sickness benefits, the benefit is 50% of the o-job amount.What is the benefit period?Benefit period: _______ monthsThe partial disability benefit period is three months.When may my total disability benefits start?Aer an accident: _______ days Aer a sickness: _______ days*Subject to income requirements
EXCLUSIONS AND LIMITATIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of: alcoholism or drug addiction, felonies or illegal occupations, flying, 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 conflict. We will not pay for losses due to you giving birth within the first nine months aer the coverage eective date of the certificate. We will not pay for loss when the disability is a pre-existing condition as described in the certificate.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 eective date.We will not pay for loss when the disability is a pre-existing condition as defined in this certificate, unless you have satisfied the pre-existing condition limitation period (typically 12 months) shown on the Certificate Schedule on the date you suer a loss due to a covered accident or covered sickness.For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form GDIS-P-EE-TX and certificate form GDIS-C-EE-TX. This is not an insurance contract and only the actual policy and certificate provisions will control.Product information and features Total disabilityTotally 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.Partial disabilityIf you are able to return to work part time aer at least 14 days of being paid for a total disability, you may be able to still receive 50% of your total disability benefit.Waiver of premiumWe will waive your premium payments aer 90 consecutive days of a covered disability.Geographical limitationsIf you are disabled while outside of the United States, Mexico or Canada, you may receive benefits for up to 60 days before you have to return to the U.S. Issue ageCoverage is available from ages 17 to 74.PortabilityYou may be able to keep your coverage even if you change jobs.For more information, talk with your benefits counselor.10-19 | 101296-3Underwritten 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.
For more information, talk with your benefits counselor.Group Accident InsurancePreferred PlanColonialLife.comGAC4000 – PREFERRED PLANNobody expects an accident to happen. But if it does, your main focus should be on recovery, not how you’re going to pay your bills. Colonial Life accident insurance provides benefits directly to you to use however you like – from medical costs to everyday expenses. Whether it's a fall or a car accident, your benefits oer support when you need it.Benefits are per covered person per covered accident unless stated otherwiseAccident emergency treatment ................................................................................................$150 One visit per covered person per covered accident and Up to four visits per covered person per calendar yearAccident follow-up doctor visit ..................................................................................................$50Up to four visits per covered person per covered accident andUp to 16 visits per covered person per calendar yearAccidental death Accidental deathPer covered person Accidental death common carrier¾ Named insured .....................................................................$50,000 .................. $200,000¾ Spouse ...............................................................................$50,000 .................. $200,000¾ Dependent child(ren) .............................................................. $10,000 ....................$40,000Examples of common carriers are mass transit trains, buses and planesAccidental dismembermentLoss or loss of use¾ One hand, arm, foot, leg or sight of an eye ......................................................................... $9,000¾ Both hands, arms, feet, legs or the sight of both eyes; or any combination ................................ $18,000¾ One finger or one toe ................................................................................................... $1,050¾ Two or more fingers; two or more toes; or any combination ................................................... $2,100Air ambulance .................................................................................................................. $1,500 Transportation to or from a hospital or medical facilityAmbulance (ground)..............................................................................................................$300 Transportation to or from a hospital or medical facilityAppliance aid in personal locomotion or mobility .........................................................................$100Walking boot, neck brace, back brace, leg brace, cane, crutches, walker and wheelchairBlood/plasma/platelets .........................................................................................................$400 Required during treatment of a covered accidentBurn¾ 2nd-degree burns (covering at least 36% of the body’s surface) ..................................................$1,000¾ 3rd-degree burns (based on size) ......................................................................... $2,000 – $15,000Burn–skin gra ...................................................................................50% of applicable burn benefitAs a result of 2nd-degree or 3rd-degree burns
Catastrophic accidentTotal and irrecoverable loss or loss of use¾ Both hands, arms, feet, legs or the sight of both eyes; or any combination; or¾ Loss of hearing in both ears or loss of ability to speak Subject to a 365-day elimination period; payable once per lifetime per covered person¾ Named insured ..................................................................................................................................................$50,000¾ Spouse ..................................................................................................................................................................$50,000 ¾ Dependent child(ren) .......................................................................................................................................$25,000Coma ...............................................................................................................$10,000Lasting for 14 or more consecutive daysConcussion ............................................................................................................ $375Dislocation (separated joint) Non-surgical Surgical¾ Hip ........................................................................................$3,000 $6,000¾ Knee (except patella) ..................................................................$1,500 $3,000¾ Ankle, bone or bones of the foot (other than toes) ...............................$1,200 $2,400¾ Collarbone (sternoclavicular) ..........................................................$800 $1,600¾ Collarbone (acromioclavicular and separation) ....................................$200 $400¾ Lower jaw ..................................................................................$720 $1,440¾ Shoulder (glenohumeral) ............................................................ $1,200 $2,400¾ Elbow ....................................................................................... $ 450 $900¾ Wrist ........................................................................................$600 $1,200¾ Bone(s) of the hand, (other than fingers) ............................................. $810 $1,620¾ Finger, toe ..................................................................................$200 $400¾ Incomplete dislocation or dislocation reduction.................................. 25% of the applicable without anesthesia non-surgical amountEmergency dental work ¾ Dental crown or denture ....................................................................................$300 ¾ Dental extraction .............................................................................................$100 Eye injury ..............................................................................................................$300 With surgical repair or removal of a foreign objectFracture (broken bone) Non-surgical Surgical¾ Skull, depressed fracture (except face/nose) ......................................$3,750 $7,500¾ Skull, simple non-depressed fracture (except face/nose) .......................$1,800 $3,600¾ Hip, thigh (femur) ......................................................................$3,150 $6,300¾ Body of vertebrae (excluding vertebral processes) ...............................$2,700 $5,400¾ Pelvis .....................................................................................$2,400 $4,800¾ Leg (tibia and/or fibula) ...............................................................$1,800 $3,600¾ Bones of the face or nose (except mandible or maxilla) ...........................$910 $1,820¾ Upper jaw, maxilla, upper arm between .......................................... $1,050 $2,100 elbow and shoulder¾ Lower jaw, mandible ................................................................. $1,200 $2,400¾ Kneecap, ankle, foot .................................................................. $1,200 $2,400¾ Shoulder blade, collarbone ......................................................... $1,200 $2,400¾ Vertebral processes ...................................................................... $630 $1,260¾ Forearm, hand, wrist ................................................................. $1,200 $2,400¾ Rib ..........................................................................................$375 $750¾ Coccyx .....................................................................................$320 $640¾ Finger, toe .................................................................................$200 $400¾ Chip fracture .................................................25% of the applicable non-surgical amountAlex was cleaning out the gutters when he fell. ALEX’S BENEFITS Ambulance $300Emergency room visit $150X-ray $60Hospital admission $1,000Hospital confinement $750Leg fracture (surgical) $3,600Physical therapy $360Appliance (crutches) $100Doctor’s follow-up oice visit $150$6,470EMERGENCY ROOM VISITAlex was taken by ambulance to the nearest emergency room and received immediate care.The doctor ordered an X-ray and discovered Alex had fractured his leg.DIAGNOSTIC PROCEDUREOver the next several weeks, he had three follow-up appointments with his doctor.DOCTORʼS OFFICE VISITAlex had eight sessions of physical therapy to help him regain the strength in his leg.PHYSICAL THERAPYAlex was admitted to the hospital for surgery on his leg. He was confined for three days.HOSPITAL CONFINEMENTFor illustrative purposes only.Benefit amounts may vary and may not cover all expenses. The certificate has exclusions and limitations.ALEXʼS OUT-OF-POCKET EXPENSESWhen Alex totaled up the bills, he had to pay his annual deductible, as well as co-payments for the ambulance, emergency room, hospital, surgery, physical therapy and follow-up visits. Luckily, Alex had accident coverage to help with these expenses.Alex used crutches.APPLIANCE FOR MOBILITY
For more information, talk with your benefits counselor.GAC4000 – PREFERRED PLANHospital admission .............................................................................................................$1,000Per covered person per covered accidentHospital confinement .................................................................................................. $250 per dayUp to 365 days per covered person per covered accidentHospital intensive care unit admission .................................................................................... $1,750 Per covered person per covered accidentHospital intensive care unit confinement ........................................................................ $400 per day Up to 15 days per covered person per covered accident Knee cartilage (torn) ............................................................................................................. $750 Laceration (no repair, without stitches) ..........................................................................................$50 Laceration (repaired by stitches)¾ Total of all lacerations is less than two inches long ...................................................................$150¾ Total of all lacerations is at least two but less than six inches long .................................................$300 ¾ Total of all lacerations is six inches or longer ...........................................................................$600 Lodging (companion) ..................................................................................................$200 per day Up to 30 days per covered person per covered accident Medical imaging study (CT, CAT scan, EEG, MR or MRI) .....................................................................$200 One benefit per covered person per covered accident per calendar yearOccupational or physical therapy .................................................................................... $45 per day Up to 10 days per covered person per covered accident Pain management for epidural anesthesia .................................................................................. $150 Prosthetic device/artificial limb One benefit per covered person per covered accident¾ One ....................................................................................................................... $1,250 ¾ More than one ........................................................................................................... $2,500 Rehabilitation unit confinement ....................................................................................$150 per day Immediately aer a period of hospital confinement due to a covered accident; up to 15 days per covered person per covered accident, not to exceed 30 days per covered person per calendar yearRuptured disc with surgical repair ............................................................................................$900 Surgery¾ Cranial, open abdominal and thoracic .............................................................................. $1,500 ¾ Hernia with surgical repair ............................................................................................... $300Surgery (exploratory and arthroscopic) ....................................................................................... $225Tendon/ligament/rotator cu¾ One with surgical repair ..................................................................................................$900 ¾ Two or more with surgical repair ..................................................................................... $1,800 Transportation for hospital confinement ...................................................................$600 per round tripUp to three round trips for more than 50 miles from home per covered person per covered accidentX-ray ...................................................................................................................................$60
For more information, talk with your benefits counselor.Group Hospital Indemnity InsurancePlan 2ColonialLife.comGroup 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 ............................................................... $_______________ per dayMaximum of one day per covered person per calendar yearWaiver of premiumAvailable aer 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.£ Diagnostic procedure .................................................................. $_______________ per dayMaximum of one day per covered person per calendar year£ Outpatient surgical procedure¾ Tier 1 .................................................................................... $_______________ per day¾ Tier 2 .................................................................................... $_______________ per dayMaximum of $________________ per covered person per calendar year for Tier 1 and 2 combined Maximum of one day per outpatient surgical procedureGMB7000 – PLAN 2Diagnostic proceduresThe following is a list of common diagnostic procedures that may be covered if the diagnostic procedure benefit is selected. Breast– Biopsy (incisional, needle, stereotactic) Cardiac– Angiogram– Arteriogram– Thallium stress test– Transesophageal echocardiogram (TEE) Diagnostic radiology– Computerized tomography scan (CT scan)– Electroencephalogram (EEG)– Magnetic resonance imaging (MRI)– Myelogram– Nuclear medicine test– Positron emission tomography scan (PET scan) Digestive– Barium enema/lower GI series– Barium swallow/upper GI series– Esophagogastroduodenoscopy (EGD) Ear, nose, throat, mouth– Laryngoscopy Gynecological– Amniocentesis– Cervical biopsy– Cone biopsy– Endometrial biopsy Liver– Biopsy Lymphatic– Biopsy Miscellaneous– Bone marrow aspiration/biopsy Renal– Biopsy Respiratory– Biopsy– Bronchoscopy– Pulmonary function test (PFT) Skin– Biopsy– Excision of lesion Thyroid– Biopsy Urologic– Cystoscopy– Hysteroscopy– Loop electrosurgical excisional procedure (LEEP)
ColonialLife.com©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. 6-16 | 101732* Colonoscopy must result in polyp removal or be recommended by a physician for the purposes of treating or diagnosing a sickness.If a covered family member has a qualified high deductible health plan (HDHP) and actively contributes to a health savings account (HSA), their HSA can be disqualified with this coverage. THIS POLICY PROVIDES LIMITED BENEFITS.PRE-EXISTING CONDITION LIMITATION We will not pay benefits for loss during the first 12 months aer the certificate eective date due to a pre-existing condition. 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 certificate eective date.This information is not intended to be a complete description of the insurance coverage available. This coverage has exclusions and limitations that may aect benefits payable. For cost and complete details, see your Colonial Life benefits counselor. This brochure is applicable to policy forms GMB7000-P and GMB7000-P-TX. Coverage may vary by state and may not be available in all states. 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 Tier 2 outpatient surgical procedures 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– LithotripsyThe procedures listed below are only a sampling of the procedures that may be covered if the outpatient surgical procedure benefit is selected. Procedures must be performed by a doctor in a hospital or ambulatory surgical center. For complete details and definitions, refer to your certificate.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 graing
ColonialLife.comGroup Hospital Indemnity InsuranceExclusions and LimitationsGMB7000 – EXCLUSIONS AND LIMITATIONSGeneral exclusions We 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 covered person’s: Addiction to alcohol or drugs, except for drugs taken as prescribed by his physician. Treatment for dental care or dental procedures, unless treatment is the result of a covered accident. Undergoing elective procedures or cosmetic surgery. This includes procedures or hospital confinement for complications arising from elective or cosmetic surgery. This does not include congenital birth defects or anomalies of a child, or reconstructive surgery related to a covered sickness or injuries received in a covered accident. Committing or attempting to commit a felony, or engaging in an illegal occupation. Having a disorder including but not limited to aective disorders, neurosis, anxiety, stress and adjustment reactions. Alzheimer’s disease and other organic senile dementias are not considered mental or nervous disorders. This exclusion does not apply to inpatient mental and nervous benefit, if included. Dependent child’s pregnancy, including services rendered to her child aer birth. Committing or trying to commit suicide or his injuring himself intentionally, whether he is sane or not. Being exposed to war or any act of war, declared or undeclared, or serving in the armed forces of any country or authority. Losses as a result of acts of terrorism or nuclear release committed by individuals or groups will not be excluded from coverage unless the covered person who suered the loss committed the act of terrorism or nuclear release.Hospital confinement limitationsWe will not pay benefits for hospital confinement or daily hospital confinement, if included, due to any covered person giving birth within the first nine (9) months aer the coverage eective date of the certificate as a result of a normal pregnancy, including cesarean. Complications of pregnancy will be covered to the same extent as any other covered sickness.KS – no birth limitation. TN – adds that complications of pregnancy are those conditions, requiring treatment, whose diagnoses are distinct from pregnancy but are adversely aected by pregnancy or caused by pregnancy. These include, but are not limited to, acute nephritis, nephrosis, cardiac decompensation, missed abortion and similar medical and surgical conditions of comparable severity. This does not include false labor, morning sickness, hyperemesis gravaidarum, and similar conditions associated with the management of a diicult pregnancy.VA – adds that pregnancy resulting from the act of 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. 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.AR – no well baby care limitation.CA – well baby care limitation has special wording that diers from language above. MD – no well baby care limitation.
12-16 | 101733-1©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.This information is not intended to be a complete description of the insurance coverage available. This coverage has exclusions and limitations that may aect benefits payable. For cost and complete details, see your Colonial Life benefits counselor. This brochure is applicable to policy forms GMB7000-P (including state abbreviations, where used, for example: GMB7000-P-TX). Coverage may vary by state and may not be available in all states.Additional state-specific exclusions and limitationsIn the following states, we will not pay any benefits for injuries or sicknesses which are caused by, contributed to by or occur as a result of the covered person’s:AK, LA, MS and TX – being intoxicated or under the influence of any narcotic unless administered on the advice of his doctor/physician. This replaces the alcoholism or drug addiction exclusion above.AR – having a disorder including neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder of any kind. Alzheimer’s disease and other organic senile dementias are not considered mental or nervous disorders. This exclusion does not apply to inpatient mental and nervous benefit, if included. CA – We will not pay any benefits for injuries or sicknesses which are caused by, contributed to by or occurs as a result of the covered person’s: having a treatment for dental care or dental procedures, unless treatment is the result of a covered injury. Intoxicants and Controlled Substances exclusion has been added and means any covered person being intoxicated or under the influence of any controlled substance unless administered on the advice of a physician. Suicide exclusion has special language. DE – no alcoholism or drug addiction exclusion. KS – being intoxicated or under the influence of any narcotic unless administered on the advice of his physician. This replaces the alcoholism or drug addiction exclusion above. The war or armed conflict exclusion is defined as: being exposed to war or any act of war, declared or undeclared, or serving in the armed forces of any country or authority. KY – being intoxicated or under the influence of any narcotic or any hallucinogenic unless administered on the advice of his physician. This replaces the alcoholism or drug addiction exclusion above.MD – no alcoholism or drug addiction exclusion; no felonies or illegal occupations exclusions; no birth limitation. MD’s elective procedures and cosmetic surgery adds the treating provider, acting inde-pendently from us, shall determine whether a procedure is elective or cosmetic. Pregnancy or a depen-dent child adds: However, complications of pregnancy of a dependent child will be covered to the same extent as any other covered sickness. Prohibited Practitioner Referral means the policy will not provide payment of any claim, bill, or other demand or request for payment for health care service provided as a result of a referral prohibited by the Health Occupation Article. MD’s suicide exclusion is defined as com-mitting or trying to commit suicide or his injuring himself intentionally, while sane or insane. The war or armed conflict exclusion is defined as: being exposed to war or any act of war, declared or undeclared, or serving in the armed forces of any country or authority.MO – addiction to drugs, except for drugs taken as prescribed by his physician; and participating or attempting to participate in illegal activities. This replaces the alcoholism and drug addiction, and felonies or illegal occupations exclusions above. MO’s pregnancy of a dependent child exclusion adds that complications of pregnancy will be covered to the same extent as any other covered sickness. MO’s suicide exclusion is defined as committing or trying to commit suicide or his injuring himself intentionally, while sane.NE – commission of or attempting to commit a felony or to which a contributing cause was the covered person engaging in an illegal occupation. This replaces the felonies or illegal occupations exclusion aboveOH – no pregnancy of a dependent child exclusion. The birth limitation is the first 270 days aer the chronic energy deficiency (CED), rather than the first nine months.OK – being exposed to war or any act of war, declared or undeclared, while serving in the military or an auxiliary unit attached to the military or working in an area of war whether voluntarily or as required by an employer. This replaces the war exclusion above. OK’s pregnancy of a dependent child exclusion adds complications of pregnancy, including cesarean births, will be covered to the same extent as any other sickness. SD – committing a felony, or engaging in an illegal occupation. In SD, there’s no alcoholism or drug addiction exclusion. This replaces the felonies or illegal occupations exclusion above.TN – treatment for dental care or dental procedures, unless treatment is the result of a covered accident, except for covered expenses for procedures performed on a minor, eight years or younger, that cannot be safely performed in a dental oice setting. There’s no pregnancy of a dependent child exclusion. UT – being addicted to alcohol or drugs that contribute to, cause the loss, or are over the legal limit, unless you are addicted to a narcotic taken on the advice of a physician; voluntarily participating in, committing or attempting to commit a felony, or engaging in an illegal occupation; having a neurosis, psychoneurosis, psychopathy, psychosis, or any other mental or emotional disease or disorder which does not have a demonstrable organic cause. This exclusion does not apply to inpatient mental and nervous benefit, if included.
For more information, talk with your benefits counselor.Group Critical Illness InsurancePlan 2 FullIf you’re diagnosed with a covered critical illness or cancer, group 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.*The policy name is Critical Illness and Cancer Group Specified Disease Insurance.For the diagnosis of this covered critical illness condition:1This percentage of the face amount is payable:Heart attack (myocardial infarction) 100%Stroke 100%End-stage renal (kidney) failure 100%Major organ failure 100%Coma 100%Permanent paralysis due to a covered accident 100%Blindness 100%Occupational infectious HIV or occupational infectious hepatitis B, C or D 100%Coronary artery bypass gra surgery/disease225%GROUP CRITICAL CARE PLAN 2 FULLFace amount: $_______________ Critical illness benefitSubsequent diagnosis of a dierent critical illness3If you receive a benefit for a critical illness, and later you are diagnosed with a dierent critical illness, the original percentage of the face amount is payable for that particular critical illness.Subsequent diagnosis of the same critical illness3If you receive a benefit for a critical illness, and later you are diagnosed with the same critical illness, 25% of the original face amount is payable. Critical illness conditions that do not qualify are: coronary artery bypass gra surgery/coronary artery disease2 and occupational infectious HIV or occupational infectious hepatitis B, C or D.ColonialLife.com5,000 - 50,000
ColonialLife.comCovered cancer benefitsFor this condition:1The amount payable is:Diagnosis of cancer (internal or invasive) 100% of the face amountDiagnosis of carcinoma in situ 25% of the face amountSkin cancer $500Diagnosis of cancer benefitCancer vaccine benefit: ................................................................................$50This benefit is payable if you or your covered family members incur a charge for any FDA-approved cancer vaccine while your certificate is inforce.1 Please refer to the certificate for complete definitions of covered conditions. 2 Benefit for coronary artery disease applicable in lieu of benefit for coronary artery bypass gra surgery when health savings account (HSA) compliant plan is selected.3 Dates of diagnoses of a covered critical illness must be separated by at least 180 days.THIS POLICY PROVIDES LIMITED BENEFITS.Insureds in MA must be covered by comprehensive health insurance before applying for this coverage. EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESSWe will not pay the Critical Illness Benefit or Benefit Payable Upon Subsequent Diagnosis of a Critical Illness that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; psychiatric or psychological conditions; suicide or injuries which any covered person intentionally does to himself; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a critical illness.EXCLUSIONS AND LIMITATIONS FOR CANCER We will not pay the Diagnosis of Cancer Benefit, Diagnosis of Carcinoma in Situ Benefit, the Cancer Treatment and Care Benefit or the Skin Cancer Benefit for a covered person’s cancer (internal or invasive), carcinoma in situ or skin cancer that: is diagnosed or treated outside the territorial limits of the United States, its possessions, or the countries of Canada and Mexico; is a pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is initially diagnosed as having cancer (internal or invasive), carcinoma in situ or skin cancer. No pre-existing condition limitation will be applied for dependent children who are born or adopted while you are covered under the policy, and who are continuously covered from the date of birth or adoption. This is not an insurance contract and only the actual certificate provisions will control. Applicable to certificate form GCC1.0-C (including state abbreviations where used, for example: GCC1.0-C-TX). The certificate or its provisions may vary or be unavailable in some states. Please see your Colonial Life benefits counselor for details.10-19 | 100361-2Underwritten 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.
Term Life InsurancePeace 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 nancial security to help them cover their ongoing living expenses.Advantages of term life insurance Lower cost when compared to cash value life insurance Same benet payout throughout the duration of the policy Several term period options for exibility during high-need years Benet for the beneciary that is typically tax freeBenets 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 benet amount into cash value life insurance• Flexibility to keep the policy if you change jobs or retire• Built-in terminal illness accelerated death benet that provides up to 75% of the policy’s death benet (up to $150,000) if you’re diagnosed with a terminal illness1• Premium savings for face amounts over $250,000 based on your health44% of Americans say their household would face nancial hardship within six months should a wage earner die unexpectedly.LIMRA, 2022 Life Insurance Barometer Study.GAP54% 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)
Optional ridersAt an additional cost, you can purchase the following riders for even more nancial protection.Spouse term life riderYour spouse can have up to $50,000 of coverage for a 10-year or 20-year term period.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 benet riderThe beneciary may receive an additional benet if the covered person dies as a result of an accident before age 70. The benet 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 benet riderIf a licensed health care practitioner certies that you have a chronic illness, you may receive an advance on all or a portion of the death benet, available in a one-time lump sum or monthly payments.1 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.² Premiums are waived during the benet period. Critical illness accelerated death benet riderIf you suffer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benet is payable.1 A subsequent diagnosis benet is included.Waiver of premium benet 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.3How much coverage do you need? 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 benet rider Chronic care accelerated death benet rider Critical illness accelerated death benet rider Waiver of premium benet riderTo learn more, talk with your Colonial Life benets counselor.1. Any payout would reduce the death benet. Benets may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benets. 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.EXCLUSIONS AND LIMITATIONSIf the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benet. We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you.This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benets payable. Applicable to policy 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 (plus state abbreviations where applicable, for example ITL5000-TX). For cost and complete details of the coverage, call or write your Colonial Life benets counselor or the company.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. FOR EMPLOYEES 6-22 | 101895-3ColonialLife.com
Group Critical Illness InsuranceWellbeing Assistance BenefitThe wellbeing assistance benefit can help reduce the risk of serious illness through early detection of disease or risk factors.Wellbeing assistance benefit ............................................................. $_____________ Maximum of one test per covered person per calendar year; subject to a 30-day waiting period before the benefit is payable. The test must be performed aer the waiting period. Blood test for triglycerides Bone marrow testing BRCA1 or BRCA2 testing (genetic test for breast cancer) Breast ultrasound CA 15-3 (blood test for ovarian cancer) CA 125 (blood test for breast cancer) Carotid Doppler CEA (blood test for colon cancer) Chest x-ray Colonoscopy Echocardiogram (ECHO) Electrocardiogram (EKG, ECG) Fasting blood glucose test Flexible sigmoidoscopy Hemoccult stool analysis Mammography Pap smear PSA (blood test for prostate cancer) Serum cholesterol test for HDL and LDL levels Serum protein electrophoresis (blood test for myeloma) Skin cancer biopsy Stress test on a bicycle or treadmill Thermography ThinPrep pap test Virtual colonoscopyFor more information, talk with your benefits counselor.ColonialLife.comGCI6000 – WELLBEING ASSISTANCE BENEFIT | 5-20 | 387307Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.THIS INSURANCE PROVIDES LIMITED BENEFITS.This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may aect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.50
Life insurance: Term or Whole?LIFE INSURANCEIf you’re wondering which life insurance to offer your employees — term or whole life? The answer is: They need both options. Term and Whole Life work hand in hand Term and Whole Life insurance work together to provide nancial protection for your employees and their loved ones at all phases of life — whether they’re just starting out, raising a family or planning for retirement. Term Life offers nancial protection and peace of mind for employees and their families during their working years.Whole Life provides coverage employees can keep into retirement — at competitive rates when they buy it early. Life insurance for all phases of your employees’ livesWhole life Term life Childhood Young professional Mid-career RetirementBy offering these benets at work with premiums paid by payroll deduction, you provide valuable coverage options for employees without added costs to your bottom line. Coverage for spouse and children also provides critical protection for your employees’ family.When employees purchase both types of life insurance, they have valuable nancial protection that can last a lifetime.
This information is not intended to be a complete description of the insurance coverage available. The policies or their provisions may vary or be unavailable in some states. The policies have exclusions and limitations which may affect any benets payable. Applicable to policy forms GTL1.0-P and certicate number GTL1.0-C, ICC18-ITL5000/ITL5000, ICC19- IWL5000-70/IWL5000-70, ICC19-IWL5000-100/IWL5000-100, and ICC19-IWL5000J/IWL5000J and applicable state variations. For cost and complete details of the coverage, call or write your Colonial Life benets 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. FOR BROKERS AND EMPLOYERS 7-21 | 6911501. Any payout would reduce the death benet. Benets may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benets.2. Accessing the accumulated cash value reduces the death benet by the amount accessed. Cash value will be reduced by any outstanding loans against the policy.Term LifeWHAT IS TERM LIFE?• Offers nancial protection for loved ones during an employee’s working years • Offers highest amount of life insurance coverage for the lowest premiums KEY BENEFITS• Income replacement if the insured passes away• Can help pay ongoing expenses for the family, such as: ‐ Mortgage or rent ‐ Education ‐ Saving for retirementHOW IT WORKS Group Term Life • Employer-owned • Limited portability options• Flexible coverage that normally ends at retirement• Benet typically decreases after age 70• Guaranteed issue — coverage with no health questions or examsIndividual Term Life • Employee can continue their coverage if they change jobs or retire• The insured chooses a term period of 10, 15, 20, or 30 years• Guaranteed level premiums that do not increase during the selected term period • After the term period, the insured can end or renew coverage, or convert to a whole life policyWhole Life WHAT IS WHOLE LIFE? • Provides nancial protection for loved ones through their retirementKEY BENEFITS • Can help with nal expenses• Can provide a living benet to help pay for expenses associated with a terminal illness, chronic illness or critical illness1• Accumulates cash value at a guaranteed interest rate; employees can borrow against this value during times of need2HOW IT WORKS • Guaranteed issue — coverage with no health questions or exams• Permanent coverage for life with level premiums that can be paid-up at age 70 or 100• Death benet stays the same, as long as the employee makes payments How they work togetherTerm Life and Whole Life provide comprehensive life insurance with nancial protection during working years and benets that carry into retirement. Together, Term Life and Whole Life can help your employees and their loved ones give each other stronger nancial security and, perhaps, some peace of mind after they’re gone. ColonialLife.comTo learn more, talk with your Colonial Life benets representative.