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Deductions per year: 12 These rates were prepared on 1/8/2024 and are valid for 90 days.Group Disability for TX A Risk ClassApplicable to policy forms GDIS-P & GDIS-ClOff-Job Accident and Off-Job Sickness3 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $400* $1,000* $2,000* $3,000* $4,000**monthly benefit amount7 days Accident/7 days Sickness 17-49 $12.08 $30.20 $60.40 $90.60 N/A50-64 $14.08 $35.20 $70.40 $105.60 N/A65-74 $17.04 $42.60 $85.20 $127.80 N/A14 days Accident/14 days Sickness 17-49 $8.36 $20.90 $41.80 $62.70 $83.6050-64 $9.92 $24.80 $49.60 $74.40 $99.2065-74 $12.64 $31.60 $63.20 $94.80 $126.406 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $400* $1,000* $2,000* $3,000* $4,000**monthly benefit amount7 days Accident/7 days Sickness 17-49 $15.24 $38.10 $76.20 $114.30 N/A50-64 $20.20 $50.50 $101.00 $151.50 N/A65-74 $26.28 $65.70 $131.40 $197.10 N/A14 days Accident/14 days Sickness 17-49 $11.40 $28.50 $57.00 $85.50 $114.0050-64 $14.40 $36.00 $72.00 $108.00 $144.0065-74 $19.20 $48.00 $96.00 $144.00 $192.00Group Accident (GAC4100) for TXApplicable to policy forms GAC4100-P,GAC4100-ClAdditional Benefits:On/Off-Job Accident CoverageBENEFIT LEVEL AD&D BENEFIT LEVEL ISSUE AGE EMPLOYEE EMPLOYEE ANDSPOUSEEMPLOYEE ANDDEPENDENTCHILD(REN)EMPLOYEE, SPOUSEAND DEPENDENTCHILD(REN)Premier Not Included 17-99 $12.91 $19.77 $31.19 $38.20Premier Preferred 17-99 $15.10 $23.46 $34.20 $42.75Group Medical Bridge (GMB7000) for TXAge-BandedApplicable to Policy Forms GMB7000–P & GMB7000-ClWellbeing Assistance: Basic - $100HOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 3: $150017-49 $22.50 $33.85 $28.55 $39.9050-59 $26.70 $44.80 $32.75 $50.8560-64 $34.05 $61.90 $40.10 $67.9565-99 $44.40 $83.35 $50.45 $89.40HOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 5: $250017-49 $36.65 $59.25 $48.70 $71.3050-59 $44.90 $81.00 $56.95 $93.05Page 1 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 for Important Notice
Group Medical Bridge (GMB7000) for TXAge-BandedApplicable to Policy Forms GMB7000–P & GMB7000-ClWellbeing Assistance: Basic - $100HOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILY60-64 $59.65 $115.25 $71.70 $127.3065-99 $80.40 $158.25 $92.45 $170.30Group Medical Bridge (GMB7000) for TXAge-BandedApplicable to Policy Forms GMB7000–P & GMB7000-ClWellbeing Assistance: Basic - $100, Outpatient Surgical Procedure: Option 1 - ($500 / $1000 / $1500)HOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 3: $150017-49 $28.00 $44.40 $38.40 $54.8050-59 $35.15 $61.35 $45.55 $71.7560-64 $44.75 $83.35 $55.15 $93.7565-99 $57.05 $109.60 $67.45 $120.00HOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 5: $250017-49 $42.15 $69.80 $58.55 $86.2050-59 $53.35 $97.55 $69.75 $113.9560-64 $70.35 $136.70 $86.75 $153.1065-99 $93.05 $184.50 $109.45 $200.90Cancer Assist for TXApplicable to policy form CanAssistlwith $100 Health Screening BenefitCOVERAGE LEVEL ISSUE AGE NAMED INSURED EMPLOYEE AND SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILYLevel 2 17-75 $21.65 $33.85 $21.95 $34.15Level 3 17-75 $26.65 $44.40 $27.10 $44.85(Continued...)Page 2 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 for Important Notice
Group Critical Illness (GCI6000) for TXApplicable to policy forms GCI6000-P, GCI6000-C,R-GCI6000-CB, R-GCI6000-BB, R-GCI6000-HB,R-GCI6000-INF, R-GCI6000-PDlPlan 1 - Critical Illness, Wellbeing Assistance Benefit - $50 BenefitNon-Tobacco RatesISSUE AGE NAMED INSURED NAMED INSURED ANDSPOUSENAMED INSURED ANDDEPENDENT CHILD(REN)NAMED INSURED, SPOUSEAND DEPENDENT CHILD(REN)$15,000 17-24 $6.20 $9.15 $6.20 $9.1525-29 $7.40 $10.95 $7.40 $10.9530-34 $8.60 $12.75 $8.60 $12.7535-39 $11.45 $17.25 $11.45 $17.2540-44 $14.45 $21.60 $14.45 $21.6045-49 $19.10 $29.25 $19.10 $29.2550-54 $24.50 $37.95 $24.50 $37.9555-59 $31.40 $48.60 $31.40 $48.6060-64 $41.90 $64.80 $41.90 $64.8065-69 $45.50 $70.20 $45.50 $70.2070-74 $51.95 $80.10 $51.95 $80.10$30,000 17-24 $9.50 $13.80 $9.50 $13.8025-29 $11.90 $17.40 $11.90 $17.4030-34 $14.30 $21.00 $14.30 $21.0035-39 $20.00 $30.00 $20.00 $30.0040-44 $26.00 $38.70 $26.00 $38.7045-49 $35.30 $54.00 $35.30 $54.0050-54 $46.10 $71.40 $46.10 $71.4055-59 $59.90 $92.70 $59.90 $92.7060-64 $80.90 $125.10 $80.90 $125.1065-69 $88.10 $135.90 $88.10 $135.9070-74 $101.00 $155.70 $101.00 $155.70Tobacco RatesISSUE AGE NAMED INSURED NAMED INSURED ANDSPOUSENAMED INSURED ANDDEPENDENT CHILD(REN)NAMED INSURED, SPOUSEAND DEPENDENT CHILD(REN)$15,000 17-24 $8.75 $12.90 $8.75 $12.9025-29 $11.00 $16.20 $11.00 $16.2030-34 $13.25 $19.50 $13.25 $19.5035-39 $18.35 $27.30 $18.35 $27.3040-44 $23.60 $35.25 $23.60 $35.2545-49 $32.15 $49.05 $32.15 $49.0550-54 $41.75 $64.65 $41.75 $64.6555-59 $54.35 $83.85 $54.35 $83.8560-64 $73.25 $112.95 $73.25 $112.9565-69 $79.55 $122.85 $79.55 $122.8570-74 $91.10 $140.70 $91.10 $140.70(Continued...)Page 3 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 for Important Notice
Group Critical Illness (GCI6000) for TXApplicable to policy forms GCI6000-P, GCI6000-C,R-GCI6000-CB, R-GCI6000-BB, R-GCI6000-HB,R-GCI6000-INF, R-GCI6000-PDlPlan 1 - Critical Illness, Wellbeing Assistance Benefit - $50 BenefitTobacco RatesISSUE AGE NAMED INSURED NAMED INSURED ANDSPOUSENAMED INSURED ANDDEPENDENT CHILD(REN)NAMED INSURED, SPOUSEAND DEPENDENT CHILD(REN)$30,000 17-24 $14.60 $21.30 $14.60 $21.3025-29 $19.10 $27.90 $19.10 $27.9030-34 $23.60 $34.50 $23.60 $34.5035-39 $33.80 $50.10 $33.80 $50.1040-44 $44.30 $66.00 $44.30 $66.0045-49 $61.40 $93.60 $61.40 $93.6050-54 $80.60 $124.80 $80.60 $124.8055-59 $105.80 $163.20 $105.80 $163.2060-64 $143.60 $221.40 $143.60 $221.4065-69 $156.20 $241.20 $156.20 $241.2070-74 $179.30 $276.90 $179.30 $276.90Important NoticeInsurance coverage has exclusions and limitations that may affect benefits payable. For a complete description of benefits, limitations and exclusions, please refer to anoutline of coverage, sample policy/certificate, proposal description or see your Colonial Life benefits counselor. Coverage type, benefits and rates vary by state. Coverage maynot be available in all states. Rates provided are illustrative and your actual premium may be different depending on your particular situation and plan choices.Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.© 2024 Colonial Life & Accident Insurance Company"Colonial Life," and the Colonial Life logo, separately and in combination, are service marks of Colonial Life & Accident Insurance Company. All rights reserved.(Continued...)Page 4 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 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.
Group Accident InsurancePremier PlanIf you are in an accident, your focus should be on recovery, not how you’re going to pay your bills. Colonial Life accident insurance can pay benets directly to you to use however you like — from medical costs to everyday expenses. Whether you’ve had a fall or a car accident, these benets can offer nancial support when you need it.Our coverage includes:• Benets payable directly to you• No medical questions to qualify for coverage• Coverage for simple and complex injuries• Benets payable regardless of other insurance• Worldwide coverage• Works alongside your Health Savings Account (HSA)BENEFITS STORY Milo was working in his yard when he tripped and injured his hand.With Colonial Life accident benets, Milo was able to pay the annual deductible and co-payments for his health insurance plan without using his savings or taking on debt.MILO’S ACCIDENT BENEFITSMilo went to an urgent care facility and received immediate care.Treatment in a physician’s office or urgent care facility$150The doctor ordered an X-ray and discovered Milo had fractured his hand.• X-ray• Fracture (hand)$60$1,200The doctor also found that Milo had a cut on his hand but did not require stitches. Laceration (no repair) $75Milo was discharged with a splint. Durable medical equipment $65Over the next several weeks, Milo had two follow-up appointments with his doctor. Physician follow-up visits (2 visits)$50 x 2 = $100Total $1,650For illustrative purposes only. Benet amounts may vary and may not cover all expenses. GROUP ACCIDENT (GAC4100) — PREMIER PLAN
Give your benets a boostWe know that more complicated or severe accidents result in more expensive medical bills and more disruption in your life. Group Accident includes a Benet Booster* to provide additional nancial support for serious accidents. If you have more than $5,000 in payable benets for a covered accident, we will give you a $500 boost to your benets to help you with whatever expenses you have. *Payable once per Insured per covered accidentBENEFITS STORY Olivia was driving to the store when she got into a car accident.Olivia’s benets helped her cover her medical expenses when she was injured in a car accident, helping her to focus on her recovery.OLIVIA’S ACCIDENT BENEFITSOlivia arrived by ambulance at the nearest emergency room and received immediate care.• Ambulance• Emergency department visit• Injury due to auto accident$400$250 $250The doctor ordered an X-ray and discovered Olivia had fractured her thigh (femur). He also ordered a CT scan of her head to check for brain injury.• X-ray• Medical imaging• Fracture (thigh)$60$400 $4,200Olivia required surgery for her leg.• Surgical repair (thigh fracture)• General anesthesia$4,200 $300Olivia boarded her pet for two nights after her surgery. Pet boarding (2 days) $20 x 2 = $40Olivia had eight sessions of physical therapy to help regain the strength in her leg and two follow-up appointments with her doctor.• Therapy services (8 sessions)• Physician follow-up visits (2 visits)$55 x 8 = $440$50 x 2 = $100Olivia’s benefits for this accident totaled more than $5,000.Benefit Booster $500Total $11,140For illustrative purposes only. Benet amounts may vary and may not cover all expenses. Benets are per covered person per covered accident unless stated otherwiseInjury benets • Burns (based on size and degree) ............. $750–$21,000• Concussion ........................................ $500• Connective tissue damage ......................$100–$200• Eye injury .......................................... $400 • Hearing loss injuries ..................................$120(Maximum once per lifetime per ear per insured)• Injury due to auto accident ........................... $250 • Internal injuries ..................................... $200 • Knee cartilage (meniscus) injury ...................... $200 • Lacerations ...................................$75–$1,200• Loss of a digit — partial .........................$400–$800• Loss of a digit ..............................$1,000–$3,000• Ruptured or herniated disc ......................$200–$400
Fracture benets• Injury .......................................$200–$5,000 Examples: nger: $200 | wrist: $1,200 | hip: $4,200• Surgical repair of fracture ............................100%(Payable as an additional % of the applicable fractures benet)• Chip fracture ........................................25% (Payable as a % of the applicable fractures benet)Dislocation benets• Injury .......................................$260–$4,000 Examples: elbow: $600 | ankle: $1,600 | hip: $4,000• Surgical repair of dislocation ..........................100%(Payable as an additional % of the applicable dislocations benet)• Incomplete dislocation ................................25%(Payable as a % of the applicable dislocations benet)Treatment benets• Air ambulance .....................................$2,000 • Ambulance (ground or water) ......................... $400 • Durable medical equipment ......................$65–$250• Emergency dental repair ........................$200–$600• Emergency department .............................. $250(Maximum 4 per year) • Family care ................................... $50 per day (Maximum of one benet per day for all insureds combined, up to a maximum of three days per covered accident, regardless of the number of children)• Injections to prevent or limit infection ...................$50 • Lodging ..................................... $250 per day (Maximum 30 days)• Medical imaging ..................................... $400 • Pain management injections ..........................$150 • Pet boarding .................................. $20 per day (Maximum of one benet per day for all insureds combined, up to a maximum of three days per covered accident, regardless of the number of pets that are boarded)• Prosthetic device or articial limb ............$1,750–$3,500• Skin grafts (due to burns) .............................50%(Payable as a % of the applicable burn benet)• Skin grafts (not due to burns) ....................$375–$750• Transfusions ........................................ $500 • Transportation ............................... $200 per trip (Maximum 6 one-way trips)• Treatment in a physician’s oce or urgent care facility ...$150(Maximum 4 per year) • X-ray or ultrasound ....................................$60Surgery benets• Anesthesia ....................................$150–$300• Connective tissue surgery .....................$150–$2,200• Eye surgery ......................................... $400• General surgery –Abdominal, thoracic, or cranial ...................$2,000 –Exploratory surgery ...............................$275 • Hernia surgery ...................................... $400 • Knee cartilage (meniscus) surgery ..............$150–$1,050• Outpatient surgical facility ............................$400 • Ruptured or herniated disc surgery ............ $150–$2,000Recovery care benets• At-home care ................................ $125 per day(Maximum 5 days) • Benet Booster .....................................$500• Physician follow-up visits ............................. $50 (Maximum 6 days per covered accident and 24 days per calendar year)• Rehabilitation or sub-acute rehabilitation unit connement .............................$200 per day (Maximum 15 days per covered accident and 30 days per calendar year)• Therapy services (speech, physical therapy, occupational therapy) ..........................$55 per day(Maximum 15 days)Options checked below have been chosen by your employer to enhance your Group Accident Coverage. Recovery Plus package• Behavioral health therapy ...................$55 per day (Maximum 15 days)• Post-traumatic stress disorder (PTSD) ............ $200 • Prescription drug .................................$25 • Additional therapy services (chiropractic, acupuncture, alternative therapy) ......$55 (Existing therapy services benet maximum applies to additional therapy services, maximum 15 days)• Injury due to felonious act of violence or sexual assault ................................ $250(Maximum once per insured per calendar year, with an accompanying police report) Gunshot wound benetThis benet can help pay your medical expenses if you receive a non-fatal gunshot wound. It offers you a lump sum for a covered injury regardless of any other insurance you may have and includes on/off-job coverage.• Gunshot wound .............................$_________This benet covers a non-fatal gunshot wound from a conventional rearm that requires treatment by a doctor and overnight hospitalization within 24 hours of the injury. If you are shot more than once in a 24-hour period, we can pay benets only for the rst wound.
Contact your Colonial Life benets counselor to learn more.CT: We will pay the air ambulance or ambulance benets directly to the licensed professional ambulance company. CT includes a benet for “outpatient emergency medical care for accidental ingestion of a controlled substance.” The at-home care benet maximum is 80 days. KS: Chiropractic therapy is not available. NH: NH includes a burn benet for 2nd degree burns under 5% of skin surface. The minimum benet for the loss or partial loss of a digit is $1,000.MD: The prescription drug benet is not available.PA: The pet boarding benet is not available. TN: The therapy services benet includes chiropractic. TX: The concussion benet is replaced by the “concussion and acquired brain injuries” benet. The therapy services benet includes the following services: cognitive communication therapy; cognitive rehabilitation therapy; community reintegration services; neurobehavioral; neurocognitive therapy and rehabilitation; neurofeedback therapy; neurophysiological; neuropsychological; post-acute transition services; psychophysiological testing or treatment; and remediation.HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLEThis plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate.It may also be offered to employees who do not have HSAs.THIS INSURANCE PROVIDES LIMITED BENEFITS.This coverage is a supplement to health insurance. It is not a substitute for essential health benets or minimum essential coverage as dened in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this insurance.EXCLUSIONSWe will not pay benets for claims that are caused by, contributed to by, or resulting from elective procedures, felonies or illegal occupations, hazardous avocations, impaired driving, incarceration, racing, semi-professional or professional sports, sickness, suicide or self-inicted injuries, war, or armed conict. ID: ”Semi-professional sports or professional sports” exclusion is replaced by “professional sports” exclusion. IL: We will not pay benets for claims that are caused by or resulting from Exclusions.MD: Includes an exclusion for “Prohibited referrals.” The “felonies or illegal occupations” and “impaired driving” exclusions apply only to Accidental Death and Dismemberment benets.MI: “Impaired driving” and “suicide or self-inicted injuries” exclusions do not apply. MN: “Suicide or self-inicted injuries” exclusion does not apply.NH: “Incarceration” and “racing” exclusions do not apply.UT: We will not pay benets for claims that are caused by or resulting from Exclusions.VT: “Impaired driving” exclusion does not apply. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benets payable. Applicable to policy form GAC4100-P and certicate form GAC4100-C (including state abbreviations where used, for example: GAC4100-P-TX and GAC4100-C-TX). For cost and complete details of coverage, call or write your Colonial Life benets counselor or the company.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.© 2023 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. FOR EMPLOYEES 3-23 | 1212553ColonialLife.com
For more information, talk with your benefits counselor.ColonialLife.comGroup Hospital Indemnity InsurancePlan 1 (HSA-Compliant)PA: “Hospital Confinement Admission” benefit replaces the “Hospital Confinement” benefitTHIS INSURANCE PROVIDES LIMITED BENEFITS.Insureds in California must be covered by comprehensive health insurance before applying for Hospital Confinement Indemnity Insurance.EXCLUSIONSWe will not pay any benefits for injuries received in accidents or for sicknesses which are caused by, contributed to by or occur as a result of the following exclusions and limitations. (a) alcoholism or drug addiction; (b) dental procedures; (c) elective procedures and cosmetic surgery; (d) felonies or illegal occupations; (e) mental or nervous disorders; (f) pregnancy of a dependent child; (g) suicide or injuries which any covered person intentionally does to himself or herself; or (h) war. We will not pay benefits for hospital confinement (i) due to giving birth within the first nine months aer the eective 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 aect any benefits payable.PRE-EXISTING CONDITION LIMITATIONS(l) We will not pay benefits for loss during the first 12 months aer the certificate eective date due to a pre-existing condition. (m) A pre-existing condition is a sickness or physical condition, whether diagnosed or not, for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the certificate eective date. (n) This limitation applies to the following benefits, if applicable: Hospital Confinement, Daily Hospital Confinement, Inpatient Mental and Nervous, Rehabilitation Unit Confinement and Specified Critical Illness.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 formGMB7000-P and certificate form GMB7000-C (including state abbreviations where applicable, such as policy forms GMB7000-P-AU-TX and GMB7000-P-EE-TX, and certificate forms GMB7000-C-AU-TX and GMB7000-C-EE-TX). 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 #101733.GMB7000 – PLAN 1 | 6-21 | 101917-2Group Medical BridgeTM 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.Health savings account (HSA) compatibleThis plan is compatible with HSA guidelines and any other HSA plan that a covered family member may participate in. It may also be oered to employees who do not have HSAs.Colonial Life & Accident Insurance Company’s Group Medical Bridge oers an HSA-compatible plan in most states.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 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.
Cancer InsuranceLevel 2 benetsCancer insurance helps provide nancial protection through a variety of benets. These benets are not only for you but also for your covered family members.BENEFIT DESCRIPTION BENEFIT AMOUNTAir ambulance ............................. $2,000 per tripTransportation to or from a hospital or medical facility [max. of two trips per connement]Ambulance ..................................$250 per tripTransportation to or from a hospital or medical facility [max. of two trips per connement]AnesthesiaAdministered during a surgical procedure for cancer treatment • General anesthesia .... 25% of surgical procedures benet• Local anesthesia ..................... $30 per procedureAnti-nausea medication .......... $40 per day administered or per prescription lledDoctor-prescribed medication for radiation or chemotherapy [$160 monthly max.]Blood/plasma/platelets/immunoglobulins .......$150 per dayA transfusion required during cancer treatment [$10,000 calendar year max.]Bone marrow donor screening ..........................$50Testing in connection with being a potential donor [once per lifetime]Bone marrow or peripheral stem cell donation ......... $500Receiving another person’s bone marrow or stem cells for a transplant [once per lifetime]Bone marrow or peripheral stem cell transplant .......................$4,000 per transplantTransplant you receive in connection with cancer treatment [max. of two bone marrow transplant benets per lifetime]Cancer vaccine .......................................$50An FDA-approved vaccine for the prevention of cancer [once per lifetime]BENEFIT DESCRIPTION BENEFIT AMOUNTCompanion transportation ...................$0.50 per mileCompanion travels by plane, train or bus to accompany a covered cancer patient more than 50 miles one way for treatment [up to $1,000 per round trip]Egg(s) extraction or harvesting/sperm collection and storageExtracted/harvested or collected before chemotherapy or radiation [once per lifetime]• Egg(s) extraction or harvesting/sperm collection ......$700• Egg(s) or sperm storage (cryopreservation) ...........$200Experimental treatment ......................$250 per dayHospital, medical or surgical care for cancer [$12,500 lifetime max.]Family care ...................................$40 per dayInpatient or outpatient treatment for a covered dependent child [$2,000 calendar year max.]Hair/external breast/ voice box prosthesis ................$200 per calendar yearProsthesis needed as a direct result of cancerHome health care services1 ..................... $75 per dayExamples 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 conned, whichever is greater]Hospice (initial or daily care)2 An initial, one-time benet and a daily benet for treatment [$15,000 lifetime max. for both]• Initial hospice care [once per lifetime] ............. $1,000• Daily hospice care ...........................$50 per dayCANCER ASSIST — LEVEL 2
BENEFIT DESCRIPTION BENEFIT AMOUNTHospital connementHospital stay (including intensive care) required for cancer treatment• 30 days or less .............................$150 per day• 31 days or more .............................$300 per dayLodging ...................................... $50 per dayHotel/motel expenses when being treated for cancer more than 50 miles from home [70-day calendar year max.]Medical imaging studies .....................$125 per studySpecic studies for cancer treatment [$250 calendar year max.]Outpatient surgical center ....................$200 per daySurgery at an outpatient center for cancer treatment [$600 calendar year max.]Private full-time nursing services ............... $75 per dayServices while hospital conned other than those regularly furnished by the hospitalProsthetic device/articial limb ....$1,500 per device or limbA surgical implant needed because of cancer surgery [payable one per site, $3,000 lifetime max.]Radiation/chemotherapyWeekly benet [max. once per week]• Injected chemotherapy by medical personnel .........$500• Radiation delivered by medical personnel ............$500Monthly chemotherapy benet [max. once per month]• Self-injected ......................................$200• Pump ............................................$200• Topical ...........................................$200• Oral hormonal [1–24 months] ........................$200• Oral hormonal [25+ months] ........................$100• Oral non-hormonal .................................$200BENEFIT DESCRIPTION BENEFIT AMOUNTReconstructive surgery3 ...............$40 per surgical unitA surgery to reconstruct anatomic defects that result from cancer treatment [up to $2,500 per procedure, including 25% for general anesthesia]Second medical opinion4 ............................. $200A second physician’s opinion on cancer surgery or treatment [once per lifetime]Skilled nursing care facility. . . . . . . . . . . . . . . . . . . . $100 per dayConnement to a covered facility after hospital release [up to the number of days paid for hospital connement]Skin cancer initial diagnosis .......................... $300A skin cancer diagnosis while the policy is in force [once per lifetime]Supportive or protective care drugs and colony stimulating factors ................ $100 per dayDoctor-prescribed drugs to enhance or modify radiation/chemotherapy treatments [$800 calendar year max.] Surgical procedures ...................$50 per surgical unitInpatient or outpatient surgery for cancer treatment [$3,000 max. per procedure]Transportation ..............................$0.50 per mileTravel expenses when being treated for cancer more than 50 miles from home [up to $1,000 per round trip]Waiver of premium .............................Is availableNo premiums due if the named insured is disabled longer than 90 consecutive daysFor more information, talk with your Colonial Life benets counselor.In MD, Tobacco cessation benet available. $20 per prescription lled, maximum of two 90-day prescriptions per covered person.In MT, Mammography benet 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 conned, 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 conned, whichever is greater.2. In CO, no hospice benet available.3. In OK, Reconstructive surgery is $20 per surgical unit.4. In MD, Second medical opinion is $50 maximum of one per covered person per hospital connement. 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 benets 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 benets 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 | 101483-4ColonialLife.com
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.
Cancer InsuranceLevel 3 benetsCancer insurance helps provide nancial protection through a variety of benets. These benets are not only for you but also for your covered family members.BENEFIT DESCRIPTION BENEFIT AMOUNTAir ambulance ............................. $2,000 per tripTransportation to or from a hospital or medical facility [max. of two trips per connement]Ambulance ..................................$250 per tripTransportation to or from a hospital or medical facility [max. of two trips per connement]AnesthesiaAdministered during a surgical procedure for cancer treatment • General anesthesia .... 25% of surgical procedures benet• Local anesthesia ..................... $40 per procedureAnti-nausea medication ...........$50 per day administered or per prescription lledDoctor-prescribed medication for radiation or chemotherapy [$200 monthly max.]Blood/plasma/platelets/immunoglobulins .......$175 per dayA transfusion required during cancer treatment [$10,000 calendar year max.]Bone marrow donor screening ..........................$50Testing in connection with being a potential donor [once per lifetime]Bone marrow or peripheral stem cell donation ......... $750Receiving another person’s bone marrow or stem cells for a transplant [once per lifetime]Bone marrow or peripheral stem cell transplant ....................... $7,000 per transplantTransplant you receive in connection with cancer treatment [max. of two bone marrow transplant benets per lifetime]Cancer vaccine .......................................$50An FDA-approved vaccine for the prevention of cancer [once per lifetime]BENEFIT DESCRIPTION BENEFIT AMOUNTCompanion transportation ...................$0.50 per mileCompanion 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 storageExtracted/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) ...........$350Experimental treatment ......................$300 per dayHospital, medical or surgical care for cancer [$15,000 lifetime max.]Family care ...................................$50 per dayInpatient or outpatient treatment for a covered dependent child [$2,500 calendar year max.]Hair/external breast/ voice box prosthesis ................$350 per calendar yearProsthesis needed as a direct result of cancerHome health care services1 .................... $100 per dayExamples 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 conned, whichever is greater]Hospice (initial or daily care)2 An initial, one-time benet and a daily benet for treatment [$15,000 lifetime max. for both]• Initial hospice care [once per lifetime] ............. $1,000• Daily hospice care ...........................$50 per dayCANCER ASSIST — LEVEL 3
BENEFIT DESCRIPTION BENEFIT AMOUNTHospital connementHospital stay (including intensive care) required for cancer treatment• 30 days or less .............................$250 per day• 31 days or more .............................$500 per dayLodging ...................................... $75 per dayHotel/motel expenses when being treated for cancer more than 50 miles from home [70-day calendar year max.]Medical imaging studies .....................$175 per studySpecic studies for cancer treatment [$350 calendar year max.]Outpatient surgical center ....................$300 per daySurgery at an outpatient center for cancer treatment [$900 calendar year max.]Private full-time nursing services ...............$125 per dayServices while hospital conned other than those regularly furnished by the hospitalProsthetic device/articial limb ....$2,000 per device or limbA surgical implant needed because of cancer surgery [payable one per site, $4,000 lifetime max.]Radiation/chemotherapyWeekly benet [max. once per week]• Injected chemotherapy by medical personnel .........$750• Radiation delivered by medical personnel ............$750Monthly chemotherapy benet [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 .................................$300BENEFIT DESCRIPTION BENEFIT AMOUNTReconstructive surgery3 ............... $60 per surgical unitA surgery to reconstruct anatomic defects that result from cancer treatment [up to $3,000 per procedure, including 25% for general anesthesia]Second medical opinion4 ............................. $300A second physician’s opinion on cancer surgery or treatment [once per lifetime]Skilled nursing care facility. . . . . . . . . . . . . . . . . . . . $100 per dayConnement to a covered facility after hospital release [up to the number of days paid for hospital connement]Skin cancer initial diagnosis .......................... $400A skin cancer diagnosis while the policy is in force [once per lifetime]Supportive or protective care drugs and colony stimulating factors .................$150 per dayDoctor-prescribed drugs to enhance or modify radiation/chemotherapy treatments [$1,200 calendar year max.] Surgical procedures ...................$60 per surgical unitInpatient or outpatient surgery for cancer treatment [$5,000 max. per procedure]Transportation ..............................$0.50 per mileTravel expenses when being treated for cancer more than 50 miles from home [up to $1,200 per round trip]Waiver of premium .............................Is availableNo premiums due if the named insured is disabled longer than 90 consecutive daysFor more information, talk with your Colonial Life benets counselor.In MD, Tobacco cessation benet available. $20 per prescription lled, maximum of two 90-day prescriptions per covered person.In MT, Mammography benet 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 conned, 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 conned, whichever is greater.2. In CO, no hospice benet 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 connement. 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 benets 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 benets 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 | 101484-4ColonialLife.com
Group Critical Illness InsurancePlan 1GCI6000 – PLAN 1 – CRITICAL ILLNESSWhen life takes an unexpected turn due to a critical illness diagnosis, your focus should be on recovery — not finances. Colonial Life’s group critical illness insurance helps provide financial support by providing a lump-sum benefit payable directly to you for your greatest needs. Coverage amount: ____________________________Household expenses while he was unable to workCo-payments and hospital bills not covered by his medical insurancePhysical therapy to get back to doing what he lovesFor illustrative purposes only.An unexpected moment changes life foreverChris was mowing the lawn when he suered a stroke. His recovery will be challenging, and he's worried, since his family relies on his income. HOW CHRIS’S COVERAGE HELPEDThe lump-sum payment from his critical illness insurance helped pay for:COVERED CONDITION¹PERCENTAGE OF APPLICABLE COVERAGE AMOUNTBenign brain tumor 100%Coma 100%End stage renal (kidney) failure 100%Heart attack (myocardial infarction) 100%Loss of hearing 100%Loss of sight 100%Loss of speech 100%Major organ failure requiring transplant 100%Occupational infectious HIV or occupational infectious hepatitis B, C or D100%Stroke 100%Sudden cardiac arrest 100%Coronary artery disease 25%Critical illness benefit
ColonialLife.com6-20 | 385403-TXUnderwritten by Colonial Life & Accident Insurance Company, Columbia, SC.©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.For more information, talk with your benefits counselor. Available coverage for spouse and eligible dependent children at 50% of your coverage amount Cover your eligible dependent children at no additional cost Receive coverage regardless of medical history, within specified limits Works alongside your health savings account (HSA) Benefits payable regardless of other insuranceKEY BENEFITSCOVERED CONDITION¹PERCENTAGE OF APPLICABLE COVERAGE AMOUNTCerebral palsy 100%Cle lip or palate 100%Cystic fibrosis 100%Down syndrome 100%Spina bifida 100%Additional covered conditions for dependent childrenSubsequent diagnosis of a different critical illness2If you receive a benefit for a critical illness and are later diagnosed with a dierent critical illness, 100% of the coverage amount may be payable for that particular critical illness.Subsequent diagnosis of the same critical illness2If you receive a benefit for a critical illness and are later diagnosed with the same critical illness,3 25% of the coverage amount may be payable for that critical illness.1. Refer to the certificate for complete definitions of covered conditions. 2. Dates of diagnoses of a covered critical illness must be separated by more than 180 days. 3. Critical illnesses that do not qualify include: coronary artery disease, loss of hearing, loss of sight, loss of speech, and occupational infectious HIV or occupational infectious hepatitis B,C or D.THIS INSURANCE PROVIDES LIMITED BENEFITS.EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS We will not pay the Critical Illness Benefit, Benefits Payable Upon Subsequent Diagnosis of a Critical Illness or Additional Critical Illness Benefit for Dependent Children that occurs as a result of a covered person’s: doctor or physician relationship; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a critical illness.PRE-EXISTING CONDITION LIMITATION We will not pay a benefit for a pre-existing condition that occurs during the 12-month period aer the coverage eective date. Pre-existing condition means a sickness or physical condition for which a covered person received medical advice or treatment within 12 months before the coverage eective date.This information is not intended to be a complete description of the insurance coverage available. The insurance has exclusions and limitations which may aect any benefits payable. Applicable to policy forms GCI6000-P-EE-TX and GCI6000-P-AU-TX and certificate forms GCI6000-C-EE-TX and GCI6000-C-AU-TX. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.Preparing for the unexpected is simpler than you think. With Colonial Life, youʼll have the support you need to face lifeʼs toughest challenges.