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Humane Society forSW WashingtonColonial Life Voluntary Booklet
Welcome to Your Employee Benefits At Humane Society for SW Washington, our greatest asset is people like you. We value your hard work and like to do what we can to reward your efforts. That’s why we are pleased to offer you these valuable employee benefits. Please review the information in this booklet to learn about the plans being offered and determine what coverage is right for you.The information contained in this booklet is only a summary of coverage and is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater detail. If there are differences between the information in the booklet and the contract, the contract will govern.
Voluntary BenefitsYou never know when an unexpected illness or injury could leave you and your family with financial difficulties. Health insurance can help, but you can still have deductibles, co-payments and other out-of-pocket expenses.That’s where voluntary benefits come in. Sometimes called supplemental insurance, voluntary benefits are designed to complement your health insurance and help provide extra financial protection. This year, your employer is helping you protect your way of life by giving you the opportunity to purchase the following voluntary benefits from Colonial Life: Accident insurance Critical illness insurance Disability insurance Hospital confinement indemnity insurance Term life insurance
Deductions per year: 24Term Life (ITL5000) for WAApplicable to policy form ITL500015-Year Term Base PlanNon-Tobacco RatesISSUE AGE $10,000 $25,000 $50,000 $75,000 $100,00025 $3.34 $5.35 $5.19 $6.78 $8.3835 $3.81 $6.51 $5.71 $7.56 $9.4245 $4.60 $8.50 $9.54 $13.31 $17.0955 $8.23 $17.57 $19.29 $27.94 $36.5865 $18.59 $25.79 $49.58 $73.37 $97.17Tobacco RatesISSUE AGE $10,000 $25,000 $50,000 $75,000 $100,00025 $5.22 $10.05 $8.96 $12.44 $15.9235 $5.78 $11.45 $9.94 $13.91 $17.8845 $7.51 $15.76 $20.54 $29.81 $39.0855 $16.12 $37.30 $48.75 $72.12 $95.5065 $33.54 $47.46 $92.92 $138.37 $183.83Individual Disability - ISTD3000 for WA A Risk ClassApplicable to policy form Individual DisabilityOff Job Accident & Off Job Sickness12 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $500* $1,000* $1,500* $2,000* $2,500**monthly benefit amount90 days Accident/90 days Sickness 17-49 $4.13 $8.25 $12.38 $16.50 $20.6350-64 $6.65 $13.30 $19.95 $26.60 $33.2565-74 $9.98 $19.95 $29.93 $39.90 $49.88Individual Medical Bridge for WAApplicable to policy form Individual Medical Bridge$1000 Hospital Confinement Benefit and Outpatient Surgical Procedure Benefit with a calendar year maximum of $1500,$50 Health Screening Benefit.ISSUE AGE EMPLOYEE EMPLOYEE AND SPOUSE EMPLOYEE AND DEPENDENTCHILDRENEMPLOYEE, SPOUSE ANDDEPENDENT CHILDREN17-49 $10.11 $18.98 $13.10 $21.9850-59 $13.88 $26.08 $16.88 $29.0860-64 $17.83 $33.58 $20.83 $36.5865-75 $22.53 $42.51 $25.53 $45.50Individual Accident (IAC4000) for WAApplicable to Policy Forms IAC4000Off-Job Accident CoverageBENEFIT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILYBasic 0-80 $5.01 $8.81 $12.68 $16.49Page 1 of 2Underwritten by Colonial Life & Accident Insurance CompanySee page 2 for Important Notice
Critical Illness 1.0 for WAApplicable to policy form CI-1.0HSA Compliant, with Subsequent Diagnosis Coverage, Health Screening Benefit, Cancer BenefitNon-Tobacco RatesISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$5,000 17-24 $1.90 $2.93 $2.25 $3.3025-29 $2.35 $3.60 $2.70 $3.9830-34 $2.80 $4.30 $3.15 $4.6835-39 $3.50 $5.38 $3.85 $5.7540-44 $4.08 $6.28 $4.45 $6.6545-49 $5.18 $7.98 $5.55 $8.3350-54 $6.95 $10.70 $7.30 $11.0555-59 $8.43 $12.98 $8.80 $13.3560-64 $11.00 $16.90 $11.38 $17.2865-70 $12.13 $18.65 $12.50 $19.00Tobacco RatesISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$5,000 17-24 $2.28 $3.50 $2.65 $3.8825-29 $3.00 $4.63 $3.38 $5.0030-34 $3.90 $6.03 $4.28 $6.4035-39 $5.00 $7.68 $5.38 $8.0540-44 $6.13 $9.43 $6.50 $9.8045-49 $7.70 $11.88 $8.08 $12.2350-54 $10.28 $15.83 $10.65 $16.2055-59 $12.93 $19.88 $13.28 $20.2360-64 $16.35 $25.13 $16.73 $25.5065-70 $18.20 $28.00 $18.58 $28.35Important 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.© 2020 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.Colonial Life | don.brink@colonial-nw.com | (503) 504-8347(Continued...)Page 2 of 2Underwritten by Colonial Life & Accident Insurance CompanySee page 2 for Important Notice
Term Life InsurancePeace of mind for you and your loved onesYou want what’s best for your family, and that includes making sure they’re prepared for the future. With term life insurance from Colonial Life & Accident Insurance Company, you can provide financial security to help them cover their ongoing living expenses.Advantages of term life insurance Lower cost when compared to cash value life insurance Same benefit payout throughout the duration of the policy Several term period options for flexibility during high-need years Benefit for the beneficiary that is typically tax-freeBenefits and features Stand-alone spouse policy available whether or not you buy apolicy for yourself Guaranteed premiums that do not increase during the selected term Ability to convert all or a portion of the benefit amount into cashvalue life insurance Flexibility to keep the policy if you change jobs or retire Built-in terminal illness accelerated death benefit that provides up to75% of the policy’s death benefit (up to $150,000) if you’re diagnosedwith a terminal illness Premium savings for face amounts over $250,000 based on your healthTERM LIFE (ITL5000)LIMRA, 2017 Insurance Barometer Study.of Americans would have trouble paying living expenses immediately or within several months if the primary wage-earner died.54%married/partnered consumersLIMRA, 2018 Insurance Barometer Study.1-in-3wish their spouse or partner would purchase more life insurance.
How much coverage do you need?To learn more, talk with your Colonial Life benefits counselor.EXCLUSIONS AND LIMITATIONSIf the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage eective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid, without interest. Product may vary by state. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company. This brochure is applicable to policy forms ICC18-ITL5000/ITL5000 and rider forms ICC18-R-ITL5000-STR/R-ITL5000-STR, ICC18-R-ITL5000-CTR/R-ITL5000-CTR, ICC18-R-ITL5000-WP/R-ITL5000-WP, ICC18-R-ITL5000-ACCD/R-ITL5000-ACCD, ICC18-R-ITL5000-CI/R-ITL5000-CI, ICC18-R-ITL5000-CC/R-ITL5000-CC and applicable state variations. Spouse term life riderYour spouse may receive a maximum death benefit of $50,000; 10-year and 20-year spouse term riders are available. Children’s term life riderYou can purchase up to $20,000 in term life coverage for all of your eligible dependent children and pay one premium. The children’s term life rider may be added to either your policy or your spouse’s policy – not both.Accidental death benefit riderThe beneficiary may receive an additional benefit if the covered person dies as a result of an accident before age 70. The benefit doubles if the accidental bodily injury occurs while riding as a fare-paying passenger using public transportation, such as ride-sharing services. An additional 25% will be payable if the injury is sustained while driving or riding in a private passenger vehicle and wearing a seatbelt.Chronic care accelerated death benefit riderIf a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments. A chronic illness means you require substantial supervision due to a severe cognitive impairment or you may be unable to perform at least two of the six Activities of Daily Living. Premiums are waived during the benefit period. Critical illness accelerated death benefit riderIf you suer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable. A subsequent diagnosis benefit is included.Waiver of premium benefit riderPremiums are waived (for the policy and riders) if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period. 6-19 | 101895-1ColonialLife.com1 Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits.2 Activities of daily living are bathing, continence, dressing, eating, toileting and transferring.3 You must resume premium payments once you are no longer disabled.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.Optional ridersAt an additional cost, you can purchase the following riders for even more financial protection.£ YOU $ ___________________ Select the term period:£ 10-year£ 15-year£ 20-year£ 30-year£ SPOUSE $ ___________________ Select the term period:£ 10-year£ 15-year£ 20-year£ 30-yearSelect any optional riders:£ Spouse term life rider $ _____________ face amount for ________-year term period£ Children’s term life rider $ _____________ face amount£ Accidental death benefit rider£ Chronic care accelerated death benefit rider£ Critical illness accelerated death benefit rider£ Waiver of premium benefit rider
Individual Short-Term Disability InsuranceIs your paycheck protected?It’s important to be financially prepared for the future. That’s why youhave insurance for your house, your car and your health. But if you’relike many Americans, you don’t have insurance for the one thingyou use to pay for these expenses — your paycheck.If an accident or illness prevented you from earning an income, howwould you pay for your everyday expenses? Colonial Life’s disability insurance can help pay for your expenses and keep you focused on what really matters — recovery.To learn more, contact:ColonialLife.comINDIVIDUAL SHORT TERM DISABILITY 3000 NS-16167 ASHLEYWhile jogging aer work one evening, Ashley injured her leg. Her doctor advised her to stay o of her leg for three weeks. Aer using paid time o for a week, Ashley stopped receiving a paycheck.How her disability policy helped: Ashley used her disability benefits to help with her rent and monthly student loan payment.Recent college graduate with first full-time jobOver 1 in 4 of today’s 20-year-olds will become disabled before reaching age 67.Social Security Administration, Social Security Basic Facts, https://www.ssa.gov/news/press/factsheets/basicfact-alt.pdf (accessed July 5, 2017)Your bills continue, even if your paycheck doesn’tThink about your ongoing monthly expenses — everything from your mortgage or rent to your groceries and utilities. If a disability le you without a paycheck, you might rely on savings as a backup plan, but would you have enough?
Basic benefitsMonthly disability benefit for off-job coverageChoose a monthly benefit up to 60% of your income, between $400 and $4,000*.*Subject to income requirements.Benefit and elimination periodsThe benefit period is the maximum length of time for which you can receive benefits. The elimination period is the length of time between when your disability begins and when you are eligible to receive the monthly disability benefits.Benefit period: 12 monthsElimination period(s):AccidentSickness90 days 90 days Product informationTotal disability definition – Total Disability means you are: unable to perform the material and substantial duties of your occupation; not, in fact, working at any occupation for which you are qualified by reason of education, training or experience; and under the regular and appropriate care of a physician.How partial disability works – If you are able to return to work part-time after at least 14 days of being paid for a total disability, you may be able to still receive 50% of your total disability benefit.Waiver of premium – We will waive your premium payments after 90 consecutive days of a covered disability.Geographical limitations – If you are disabled while outside of the United States, Canada or Mexico, you may receive benefits for up to 60 days before you have to return to the U.S. in order to continue receiving benefits.Issue age – Coverage is available from ages 17 to 74.Keep your coverage – You can keep your coverage to age 75 at no additional cost, even if you change jobs, as long as you pay your premiums when they are due.Exclusions and limitationsWe will not pay benefits for losses that are caused by, contributed to by or occur as the result of:• alcoholism or drug addiction,• aviation,• cosmetic surgery,• felonies, riots, or insurrections,• mental or nervous disorders,• psychiatric or psychological conditions,• substance abuse,• 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 after the coverage effective date of the policy. We will not pay for loss when the disability is a pre-existing condition as described in the policy.Pre-existing conditionPre-existing Condition means: the existence of symptoms which would cause an ordinarily prudent person to seek diagnosis, care or treatment within 12 months preceding the Policy Coverage Effective Date or a condition for which medical advice or treatment was recommended by a physician or received from a physician within 12 months preceding the Policy Coverage Effective Date.For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form ISTD3000. This is not an insurance contract and only the actual policy and rider provisions will control.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC© 2018 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. Individual Short Term Disability Insurance7-18 | NS-16167More than 65% of workers who apply for Social Security Disability Insurance are denied.Social Security Administration, Selected Data from Social Security Program, 2018NS-16167 Coverage advantages Benefits are payable directly to you (unless you specify otherwise), and you can use them however you’d like. At enrollment, you can choose the disability benefit amount to best meet your needs (subject to income). Benefits are payable regardless of any insurance you may have with other companies. Disability benefits may also be available if you return to work part-time.
Hospital Indemnity InsuranceHow will you pay for what your health insurance won’t cover?No matter how well you plan, you can’t predict when sudden medical expenses could impact your way of life. If you’re admitted to the hospital for a covered accident or covered sickness, Individual Medical Bridge,SM Colonial Life’s hospital indemnity insurance, could help pay for out-of-pocket costs.To learn more, contact:Bankrate.com, Survey: How Americans Contend with Unexpected Expenses (Jan. 6, 2016)ColonialLife.comNathan was doing yard work with his wife when his chest pains began. After an emergency room visit, the couple was relieved to learn it was a false alarm. A few weeks later, Nathan had a follow-up appointment with his family doctor. Nathan’s Individual Medical Bridge benefits helped pay for the out-of-pocket expenses associated with his medical care.One family’s journeyThis is an example and does not represent your actual plan benefits. Cost of treatment benefits and benefit amounts may vary. Benefits may not cover all expenses. The policy has exclusions and limitations.NATHAN’S OUT-OF-POCKET EXPENSESEmergency room co-pay $100Deductible $1,500 Doctor’s visit co-pay $25Coinsurance $1,800$3,425NATHAN’S BENEFITS Emergency room visit $100Diagnostic procedure $250Hospital confinement $1,500Doctor’s office visit $25$1,875Only 37% of Americans would have enough savings to pay an unexpected expense of around $1,000.INDIVIDUAL MEDICAL BRIDGE, IMB7000 NS-15599 Plan 2
Basic benefitsHospital confinement $1,000Maximum of one benefit per covered person per calendar yearObservation room $100 per visitMaximum of two visits per covered person per calendar yearRehabilitation unit confinement$100 per dayMaximum of 15 days per confinement with a 30-day maximum per covered person per calendar yearWaiver of premiumAvailable after 30 continuous days of a covered confinementof the named insuredOutpatient surgical procedureTier 1 $500Tier 2 $1,000Maximum of $1,500 per covered person per calendar year for all covered outpatient surgical procedures combined. Maximum of one day per outpatient surgical procedure.Health screening benefitThis benefit can help pay for routine preventive tests you have each year.Health screening $50Maximum of one health screening benefit per covered person per calendar year;subject to a 30-day waiting periodBelow is a sample of the tests that may be covered - Blood test for breast cancer - Blood test for triglycerides - Breast ultrasound - Carotid Doppler - Colonoscopy- Echocardiogram (ECHO)- Electrocardiogram (EKG, ECG)- Fasting blood glucose test- Immunizations - not including influenza (flu) vaccinations and allergy shots- Mammography- Pap smear- Physicals- PSA (prostate cancer blood test)- Serum cholesterol test for HDL and LDL levels- Skin cancer biopsy- Stress test — bicycle or treadmillAdditional benefitsEmployee-optional benefitsAt an additional cost, you can enhance your coverage with these benefit options. Daily hospital confinement$100 per dayPer covered person per day of hospital confinement. Maximum of 365 days per covered person per confinement.Enhanced intensive care unit confinement$500 per dayPer covered person per day of intensive care unit confinement. Maximum of 30 days per covered person per confinement. Outpatient proceduresThe following procedures are a sampling of the procedures that may be covered. Surgical procedures must be performed by a doctor in a hospital or ambulatory surgical center.Tier 1 outpatient surgical proceduresBreast - Axillary node dissection - LumpectomyCardiac - Pacemaker insertionDigestive - Colonoscopy - HemorrhoidectomyEar, nose, throat, mouth - Adenoidectomy - TonsillectomyGynecological - Dilation and curettage (D&C)- Endometrial ablationLiver- ParacentesisMusculoskeletal- Carpal/cubital repair or release- Foot surgerySkin- Skin graftingHospital Indemnity InsuranceNS-15599 Plan 21-18 | NS-15599These benefits are available for you, your spouse and eligible dependent children. This brochure provides an overview of the plan. For complete details, refer to your certificate.There are approximately 36 million hospital stays in the U.S. each year.Agency for Healthcare Research and Quality, “Overview of Hospital Stays in the United States,” 2012, HCUP Statistical Brief #180, 2014
The average expense for a hospital stay ranges from $9,100 for a medical stay to $22,700 for a surgical stay.Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project, Trends in Hospital Inpatient Stays in the United States, 2005–2014 (2017).Tier 2 outpatient surgical proceduresBreast - Breast reconstruction - Breast reductionCardiac - Angioplasty - Cardiac catheterizationDigestive - Exploratory laparoscopy - Laparoscopic appendectomyEar, nose, throat, mouth - Ethmoidectomy - MastoidectomyEye - Cataract surgery - Glaucoma surgeryGynecological - Hysterectomy - MyomectomyMusculoskeletal - Arthropscopic knee surgery with knee cartilage repair- FractureThyroid- Excision of a massUrologic- LithotripsyEXCLUSIONS AND LIMITATIONSTHIS POLICY PROVIDES LIMITED BENEFITS.PRE-EXISTING CONDITION LIMITATION The following benefits, if contained in your policy, will not be paid for any covered person when such loss results from a pre-existing condition as defined in the policy, unless the covered person has satisfied the pre-existing condition limitation period shown on the Policy Schedule: Hospital Confinement Rehabilitation Unit Confinement Outpatient Surgical Procedure Diagnostic Procedures Daily Hospital Confinement Rider Enhanced Intensive Care Unit Confinement RiderGENERAL EXCLUSIONS We will not pay benefits for sicknesses which are caused by: - Any covered person’s addiction to alcohol or drugs, except for drugs taken as prescribed by his physician. - Any covered person’s treatment for dental care or dental procedures, unless treatment is the result of a covered accident. - Any covered person’s 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. - Any covered person’s participating or attempting to participate in a felony, riot, or insurrection. - Any pregnancy of a dependent child, including services rendered to her child after birth. - Any covered person’s having a psychiatric or psychological condition including but not limited to neuroses, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder of any kind. However, Alzheimer’s Disease and other organic senile dementias are covered under the policy. - Any covered person’s committing or trying to commit suicide or his injuring himself intentionally, whether he is sane or not. - Any covered person’s 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 suffered the loss committed or contributed to the act of terrorism or nuclear release.BIRTH LIMITATIONWe will not pay benefits for hospital confinement due to any covered person’s giving birth within the first nine (9) months aer the eective date of the policy as a result of a normal pregnancy, including Cesarean. Complications of pregnancy will be covered to the same extent as any other covered sickness.WELL BABY CARE LIMITATIONWe will not pay benefits for hospital confinement of a newborn child following his birth unless he is injured or sick.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 form IMB7000-P.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC© 2017 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.1-18 | NS-15599
Accident InsuranceBasic PlanIAC4000 – BASIC PLANYou never expect an accident to happen. But if it does, your focus should be on recovery — not medical bills. Colonial Life accident insurance can help cover medical costs. Whether the accident is as simple as a cut hand from a fall or as complex as a car accident, you can count on us to support you. DOCTORʼS OFFICE VISITOver the next several weeks, he had three follow-up appointments with his doctor.URGENT CARE CENTER VISITMilo went to an urgent care center and received immediate care.DIAGNOSTIC PROCEDUREThe doctor ordered an X-ray and discovered Milo had fractured his hand.LACERATIONThe doctor also found that Milo had a cut on his hand.MEDICAL EQUIPMENTMilo was discharged with a splint.MILOʼS BENEFITSWith Colonial Life accident benefits, Milo’s parents were able to pay the annual deductible and co-payments.Accident emergency treatment $100X-ray $40Laceration (no stitches) $30Fracture (hand) $400Medical equipment (splint) $40Accident follow-up treatment (3 visits)$135Total: $745For illustrative purposes only.Benefit amounts may vary and may not cover all expenses. The policy has exclusions and limitations.Milo was running on the playground when he tripped and injured his hand. Benefits payabledirectly to you No medical questionsto qualify for coverage Coverage for simpleand complex injuries Benefits payable, regardless of otherinsurance Worldwide coverage Keep coverage nomatter where you go Works alongside yourhealth savings account(HSA)OUR COVERAGE INCLUDES:All of this can help you get back on your feet.
Olivia was driving to the store when she got into a car accident.AMBULANCE AND EMERGENCY ROOM VISITOlivia was admitted to the hospital for surgery on her leg. She was confined for three days.Over the next several weeks, she had six follow-up appointments with her doctor.Olivia had eight sessions of physical therapy to help regain the strength in her leg.The doctor ordered an X-ray and discovered Olivia had fractured her thigh (femur). He also ordered a CT scan of her head to check for brain injury.OLIVIA'S BENEFITSOlivia’s accident benefits helped cover her annual deductible and co-payments.Ambulance $200Accidental injury due to an automobile accident$250Accident emergency treatment $100X-ray $40Medical imaging study (CT) $200Hospital admission $1,250Hospital confinement (3 days) $750Thigh fracture – femur (surgical) $3,600Surgery (exploratory/arthroscopic) $250Medical equipment (crutches) $100Accident follow-up treatment (6 visits)$270Physical therapy (8 days) $240Total: $7,250Olivia arrived by ambulance to the nearest emergency room and received immediate care.DIAGNOSTIC PROCEDURESHOSPITAL ADMISSION, CONFINEMENT AND SURGERYDOCTORʼS OFFICE VISITSPHYSICAL THERAPYFor illustrative purposes only.Benefit amounts may vary and may not cover all expenses. The policy has exclusions and limitations.INITIAL CAREAccident emergency treatment ........................................................................ $100 Hospital emergency room, urgent care facility or physician’s oiceAccidental injury due to an automobile accident .................................................. $250 Air ambulance ........................................................................................... $1,600 Ambulance – ground or water .................................................................$150/$4,200 Observation room (up to two days per calendar year) .................................. $175 per day X-ray ........................................................................................................... $40 COMMON ACCIDENTAL INJURIESBurn (based on size and degree)......................................................... $1,000 – $12,000Burn – skin gra ......................................................... 50% of applicable burn benefitComa (lasting for seven or more consecutive days).............................................$12,500Concussion ................................................................................................. $100 Dislocation – separated joint¾ Non-surgical – repair .................................................................... $100 – $2,250Incomplete dislocation – or dislocation without anesthesia .................... 25% of benefit Examples: elbow: $500 | ankle: $1,000 | knee: $1,250 | hip: $2,250 ¾ Surgical – repair .......................................................................... $200 – $4,500 Examples: elbow: $1,000 | ankle: $2,000 | knee: $2,500 | hip: $4,500Emergency dental work .......................................................................... $50 – $200Dental extraction or dental crown, denture or implantEye injury – with surgical repair or removal of a foreign object ................................... $250 Fracture – complete¾ Non-surgical – repair .................................................................... $275 – $3,000Chip fracture ............................................................................. 25% of benefit Examples: hand: $400 | foot: $400 | collarbone: $625 | leg: $875¾ Surgical – repair .......................................................................... $550 – $6,000 Examples: hand: $800 | foot: $800 | collarbone: $1,250 | leg: $1,750Hearing-loss injuries1 .................................................................................... $140 Knee cartilage – torn (with surgical repair) ........................................................... $600 Laceration (based on repair and length) ....................................................... $30 – $625 Ruptured disc (with surgical repair) ................................................................... $600 Tendon/ligament/rotator cu (with surgical repair) ¾ One ......................................... $600 ¾ Two or more ........................ $1,200 HOSPITAL CAREHospital admission ..................................................................................... $1,250 Hospital confinement (up to 365 days) ..................................................... $250 per dayHospital sub-acute intensive care unit confinement (up to 30 days) ................. $350 per dayIntensive care unit admission ........................................................................ $1,750 Intensive care unit confinement (up to 15 days) .......................................... $450 per daySURGICAL CAREBlood/plasma/platelets – transfusion ................................................................ $400 Surgery (based on type of repair and surgery) ............................................ $225 – $1,200Benefits are per covered person per covered accident unless stated otherwise.
For more information, talk with your benefits counselor.IAC4000 – BASIC PLANTRANSPORTATION & LODGINGTransportation for hospital confinement ..................................................... $500 per round trip(up to three round trips, 50+ miles from home)Lodging – companion (up to 30 days) .................................................................. $125 per dayFOLLOW-UP CAREAccident follow-up treatment – including transportation/telemedicine ...................................$45 (up to six benefits per covered person per covered accident and up to 12 benefits per covered person per calendar year)Medical equipment¾ Tier 1 ............................................................................................................... $40 Arm sling, cane, medical ring cushion, neck brace or wrist/ankle splint ¾ Tier 2 ............................................................................................................. $100 Bedside commode, cold therapy system (cryotherapy), crutches, leg brace, shower chair, walker or walking boot ¾ Tier 3 ............................................................................................................. $200 Back brace, body jacket, continuous passive movement (CPM), halo, electric scooter, hospital bed (including rental), knee scooter, stair li chair, wheelchairMedical imaging study – CT, CAT scan, EEG, EMG, MR or MRI................................................. $200 (one per calendar year)Pain management for epidural anesthesia – non-surgical ................................................... $125 Post-traumatic stress disorder (PTSD) .......................................................................... $250 Prosthetic device/artificial limb¾ One ............................................ $600 ¾ More than one ..............................$1,200¾ Repair/replacement2 ................................................................................... $300/$600Rehabilitation unit confinement ....................................................................... $125 per day(up to 15 days, not to exceed 30 days per calendar year)Therapy – occupational, physical or speech (up to ten days)........................................$30 per dayACCIDENTAL DISMEMBERMENTAccidental dismemberment ........................................................................... $300 – $20,000¾ Loss, loss of use or paralysis – hand, arm, foot, leg, sight of eye¾ Loss, loss of use – finger, toe, partial dismemberment of finger or toeAccidental dismemberment due to a catastrophic accidentNamed insured, spouse or child ...........................................................................$12,5003¾ Total and irrecoverable loss, loss of use or paralysis – 180-day elimination period¾ Both hands, arms, feet, legs or the sight of both eyes; or any combination; or¾ Loss of hearing in both ears, or loss of ability to speakACCIDENTAL DEATHAccidental death¾ Named insured, spouse .................................................................................. $25,000¾ Child ........................................................................................................... $5,000Accidental death common carrierExamples of common carriers are mass transit trains, buses and planes¾ Named insured, spouse ................................................................................. $100,000¾ Child ......................................................................................................... $15,000
ColonialLife.com8-19 | 1019531 One benefit for each injured ear per covered person per lifetime. 2 One repair or replacement per prosthetic device/artificial limb per covered person per lifetime.3 Payable once per lifetime per covered person. Also, PA does not have a 180-day elimination period. TN has a 90-day elimination period.HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLEThis plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be oered to employees who do not have HSAs.THIS POLICY PROVIDES LIMITED BENEFITS.EXCLUSIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of a covered personʼs felonies or illegal occupations, hazardous avocations, racing, semi-professional or professional sports, sickness, suicide or injuries which any covered person intentionally does to himself, war or armed conflict. In addition, we will not pay Accidental Dismemberment Due to Catastrophic Accident benefits for injuries a child sustains during birth, or for injuries that are the result of intoxication or use of narcotics.State Variations for Exclusions and LimitationsKS: Not applicable to "for injuries a child sustains during birth, or."MI: Not applicable to "suicide or injuries which any covered person intentionally does to himself," nor "or for injuries that are the result of intoxication or use of narcotics." OR: Not applicable to "hazardous avocations, racing, semi-professional or professional sports." Not applicable to "for injuries a child sustains during birth, or for injuries that are the result of intoxication or use of narcotics" and add "for injuries that are the result of alcoholism, drug addiction or narcotics."SC: Not applicable to "hazardous avocations, racing, semi-professional or professional sports."WA: Not applicable to "or illegal occupations" and add "riots or insurrections." Not applicable to "hazardous avocations, racing, semi-professional or professional sports." Not applicable to "intoxication or use of narcotics" and add "alcoholism or drug addiction."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 IAC4000 (plus state abbreviations where applicable, such as IAC4000-TX). Coverage may vary by state and may not be available in all states. Premium will vary according to the family coverage type.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.
For more information, talk with your benefits counselor.ColonialLife.comSubsequent diagnosis of a dierent critical illnessIf you receive a benefit for a specified critical illness, and later you are diagnosed with a dierent specified critical illness, 25% of the original face amount is payable for that particular specified critical illness.Subsequent diagnosis of the same critical illnessIf you receive a benefit for a specified critical illness, and later you are diagnosed with the same specified critical illness, 25% of the original face amount is payable. Critical illness conditions that do not qualify are: cancer, carcinoma in situ, and occupational infectious HIV or occupational infectious hepatitis B, C or D.Specified Critical Illness InsuranceIf you’re diagnosed with a covered critical illness or cancer, specified critical illness insurance from Colonial Life can help with your expenses, so you can concentrate on what’s most important – your treatment, care and recovery.Face amount: $_______________ For the diagnosis of this covered critical illness condition:1This percentage of the face amount is payable:Cancer 100%Heart attack (myocardial infarction) 100%Stroke 100%End-stage renal (kidney) failure 100%Major organ failure 100%Permanent paralysis due to a covered accident 100%Coma 100%Blindness 100%Occupational infectious HIV or occupational infectious hepatitis B, C or D100%Carcinoma in situ 25%Critical illness benefitCRITICAL ILLNESS 1.0 WITH CANCER AND SUBSEQUENT DIAGNOSIS The maximum benefit amount for this policy is 3x the face amount for the named insured for all covered persons combined. The policy will terminate when the maximum benefit amount for specified critical illness has been paid.ELECT UP TO $20,000 FACE AMOUNT
ColonialLife.com1 Please refer to the policy for complete definitions of covered conditions. THIS POLICY PROVIDES LIMITED BENEFITS.EXCLUSIONS AND LIMITATIONS FOR SPECIFIED CRITICAL ILLNESSWe will not pay benefits for a specified critical illness that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies; intoxicants and narcotics; pre-existing condition; psychiatric or psychological condition; suicide or self-inflicted injuries; or war or armed conflict. This is not an insurance contract and only the actual policy provisions will control. Applicable to policy form CI-1.0-PL7-WA or CI-1.0-PL8-WA. Please see your Colonial Life benefits counselor for details.6-17 | 101825-WAUnderwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2017 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.
Filing online means never waiting for mail or dealing with fax machines and complex paper forms . Our guided question wizard walks you through the process and checks for missing information that could cause delays. Opting for direct deposit can also get approved payments to you up to a week faster than paper check. NEED TO FILE A CLAIM?Here’s what you can do on Colonial Life for Policyholders:Update yourpersonal info& preferencesFile claimswith a simple,guided form Opt for instant alerts by email or textView claim statusor policy details anytimeCheck your claim status by logging into your account at ColonialLife.com/access. You can also sign up for text or email alerts so you know instantly if status changes or more information is needed. For your convenience, you can login anytime with a mobile device to photograph and upload documents with your camera.AFTER YOU FILE:Find out how simple your claims and benefits experience can be by learning more about the Colonial Life for Policyholders portal. Just visit ColonialLife.com to see what this online account administration platform can do for you.LEARN MOREBECOME A MEMBER TODAY:Go to ColonialLife.com/access to register.Click “create an account”, fill out the required information and click Submit.Enjoy faster service and improved benefits awareness.123THE PORTALOFFERS YOU:Faster service than calling/emailingConfirmation when a claim has been submittedSimplified bill payment and managementAnswers to frequently asked questions and live chat assistance if you don’t see what you are looking for.Colonial Life for Policyholders PortalA faster, simpler way to manage your benefitsColonial Life for Policyholders is an online portal created with you in mind. It’s the most convenient and ecient way to file a claim and manage your benefits. Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2022 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.43233-41Set up directdeposit forapproved payments