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Benefit Booklet 2023

Colonial Life provides benefits that employees want for the unexpected moments in life Whether planning for retirement growing their families or saving for college they know an injury or illness won t derail their dreams For more information Lisa Jones 980 622 3718 Lisa Jones ColonialLifeSales com Life is anything but expected That s why we re here Plan options Accident insurance Helps offset unexpected medical expenses such as emergency room fees deductibles and copayments that can result from a fracture dislocation or other covered accidental injury Hospital insurance Provides a lump sum benefit for a covered hospital confinement to help with co payments and deductibles that are not covered by most major medical plans Critical illness Cancer insurance Supplements your major medical coverage by providing a lump sum benefit you can use to pay the direct and indirect costs related to a covered critical illness Life insurance Enables you to tailor coverage for your individual needs and helps provide financial security for your family members Rates locked in at time of enrollment Rates never increase Change jobs retire Portable at same rate

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

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

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

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

For more information talk with your benefits counselor ColonialLife com Hospital Confinement Indemnity Insurance Plan 1 Our Individual Medical BridgeSM insurance can help with medical costs that your health insurance may not cover These benefits are available for you your spouse and eligible dependent children Hospital confinement ___2_0_0_0__ _4__0_0_0_____ Maximum of one benefit per covered person per calendar year Observation room 100 per visit Maximum of two visits per covered person per calendar year Rehabilitation unit confinement 100 per day Maximum of 15 days per confinement with a 30 day maximum per covered person per calendar year Waiver of premium Available a er 30 continuous days of a covered hospital confinement of the named insured Health savings account HSA compatible This plan is compatible with HSA guidelines This plan may also be o ered to employees who do not have HSAs Colonial Life Accident Insurance Company s Individual Medical Bridge o ers an HSA compatible plan in most states THIS POLICY PROVIDES LIMITED BENEFITS EXCLUSIONS We will not pay benefits for injuries received in accidents or for sicknesses which are caused by a alcoholism or drug addiction b dental procedures c elective procedures and cosmetic surgery d felonies or illegal occupations e pregnancy of a dependent child f psychiatric or psychological conditions g suicide or injuries which any covered person intentionally does to himself or herself or h war We will not pay benefits for hospital confinement i due to giving birth within the first nine months a er the e ective date of the policy or j for a newborn who is neither injured nor sick k The policy may have additional exclusions and limitations which may a ect any benefits payable PRE EXISTING CONDITION LIMITATION l We will not pay benefits for loss during the first 12 months a er the e ective date due to a pre existing condition m A preexisting condition is a sickness or physical condition for which a covered person was treated had medical testing received medical advice or had taken medication within the 12 months before the e ective date of the policy n This limitation applies to the following benefits if applicable Hospital Confinement Daily Hospital Confinement Enhanced Intensive Care Unit Confinement and Rehabilitation Unit Confinement This information is not intended to be a complete description of the insurance coverage available The insurance or its provisions may vary or be unavailable in some states The policy has exclusions and limitations which may a ect any benefits payable Applicable to policy form IMB7000 including state abbreviations where used for example IMB7000 TX For cost and complete details of coverage call or write your Colonial Life benefits counselor or the company This form is not complete without form 562973 Underwritten by Colonial Life Accident Insurance Company Columbia SC 2021 Colonial Life Accident Insurance Company All rights reserved Colonial Life is a registered trademark and marketing brand of Colonial Life Accident Insurance Company IMB7000 PLAN 1 1 21 562880

Specified Critical Illness Insurance If 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 ___1_0_k_ _2_0_k_ _3_0_k__ Critical illness benefit FOR THE DIAGNOSIS OF THIS COVERED CRITICAL ILLNESS CONDITION THIS PERCENTAGE OF THE FACE AMOUNT IS PAYABLE Cancer 100 Heart attack myocardial infarction 100 Stroke2 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 D 100 Coronary artery bypass graft surgery disease3 25 Carcinoma in situ 25 The maximum benefit amount for this policy is 3x the face amount for the named insured for all covered persons combined The policy will terminate when the maximum benefit amount for specified critical illness has been paid CRITICAL ILLNESS 1 0 WITH CANCER AND SUBSEQUENT DIAGNOSIS

Subsequent diagnosis of a different critical illness4 If you receive a benefit for a specified critical illness and later you are diagnosed with a different specified critical illness the original percentage of the face amount is payable for that particular specified critical illness For more information talk with your Colonial Life benefits counselor Subsequent diagnosis of the same critical illness4 If you receive a benefit for a specified critical illness and later you are diagnosed with the same specified critical illness 25 of the original face amount is payable Critical illness conditions that do not qualify are cancer coronary artery bypass graft surgery disease carcinoma in situ and occupational infectious HIV or occupational infectious hepatitis B C or D Cancer vaccine benefit 50 This benefit is payable if you or your covered family members incur a charge for any FDA approved cancer vaccine while your policy is inforce ColonialLife com Specified Critical Illness Insurance and Critical Illness 1 0 are marketing names of the insurance policy filed as Limited Benefit Health Coverage for Specified Critical Illness In ME and NH the policy is called Limited Benefit Health Coverage for Specified Disease In SC the policy is an Individual Specified Disease policy In VT the policy is an Individual Limited Benefit Insurance policy 1 Please refer to the policy for complete definitions of covered conditions 2 In NH Stroke is referred to as Severe Stroke 3 Benefit for coronary artery disease applicable in lieu of benefit for coronary artery bypass graft surgery when health savings account HSA compliant plan is selected 4 Dates of diagnoses of a covered specified critical illness must be separated by at least 180 days THIS POLICY PROVIDES LIMITED BENEFITS This coverage is a supplement to health insurance It is not a substitute for essential health benefits or minimum essential coverage as defined in federal law Insureds in some states must be covered by comprehensive health insurance before applying for this insurance EXCLUSIONS AND LIMITATIONS FOR SPECIFIED CRITICAL ILLNESS We will not pay benefits for a specified critical illness that occurs as a result of a covered person s alcoholism or drug addiction felonies or illegal occupations intoxicants and narcotics pre existing condition psychiatric or psychological condition suicide or self inflicted injuries or war or armed conflict This information is not intended to be a complete description of the insurance coverage available The policy or its provisions may vary or be unavailable in some states The policy has exclusions and limitations which may affect any benefits payable Applicable to policy form CI 1 0 CI 1 0 PL7 CI 1 0 PL8 or CI 1 0 PL10 including state abbreviations where used for example CI 1 0 TX For cost and complete details of coverage call or write your Colonial Life benefits counselor or the company Underwritten by Colonial Life Accident Insurance Company Columbia SC 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 5 23 101825 4

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

Life insurance Term or Whole Life insurance for all phases of your employees lives If you re wondering which life insurance to offer your employees term or whole life The answer is They need both options Term and Whole Life work hand in hand Term and Whole Life insurance work together to provide financial protection for your employees and their loved ones at all phases of life whether they re just starting out raising a family or planning for retirement Term Life offers financial protection and peace of mind for employees and their families during their working years Whole Life provides coverage employees can keep into retirement at competitive rates when they buy it early Young professional Mid career Childhood Retirement Whole life Term life When employees purchase both types of life insurance they have valuable financial protection that can last a lifetime By offering these benefits at work with premiums paid by payroll deduction you provide valuable coverage options for employees without added costs to your bottom line Coverage for spouse and children also provides critical protection for your employees family LIFE INSURANCE

Term Life WHAT IS TERM LIFE Offers financial protection for loved ones during an employee s working years Offers highest amount of life insurance coverage for the lowest premiums KEY BENEFITS Income replacement if the insured passes away Can help pay ongoing expenses for the family such as Mortgage or rent Education Saving for retirement HOW IT WORKS Group Term Life Employer owned Limited portability options Flexible coverage that normally ends at retirement Benefit typically decreases after age 70 Guaranteed issue coverage with no health questions or exams Individual Term Life Employee can continue their coverage if they change jobs or retire The insured chooses a term period of 10 15 20 or 30 years Guaranteed level premiums that do not increase during the selected term period After the term period the insured can end or renew coverage or convert to a whole life policy Whole Life WHAT IS WHOLE LIFE Provides financial protection for loved ones through their retirement KEY BENEFITS Can help with final expenses Can provide a living benefit to help pay for expenses associated with a terminal illness chronic illness or critical illness1 Accumulates cash value at a guaranteed interest rate employees can borrow against this value during times of need2 HOW IT WORKS Guaranteed issue coverage with no health questions or exams Permanent coverage for life with level premiums that can be paid up at age 70 or 100 Death benefit stays the same as long as the employee makes payments How they work together Term Life and Whole Life provide comprehensive life insurance with financial protection during working years and benefits that carry into retirement Together Term Life and Whole Life can help your employees and their loved ones give each other stronger financial security and perhaps some peace of mind after they re gone To learn more talk with your Colonial Life benefits representative ColonialLife com 1 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 Accessing the accumulated cash value reduces the death benefit by the amount accessed Cash value will be reduced by any outstanding loans against the policy This information is not intended to be a complete description of the insurance coverage available The policies or their provisions may vary or be unavailable in some states The policies have exclusions and limitations which may affect any benefits payable Applicable to policy forms GTL1 0 P and certificate number GTL1 0 C ICC18 ITL5000 ITL5000 ICC19IWL5000 70 IWL5000 70 ICC19 IWL5000 100 IWL5000 100 and ICC19 IWL5000J IWL5000J and applicable state variations For cost and complete details of the coverage call or write your Colonial Life benefits counselor or the company Underwritten by Colonial Life Accident Insurance Company Columbia SC 2021 Colonial Life Accident Insurance Company All rights reserved Colonial Life is a registered trademark and marketing brand of Colonial Life Accident Insurance Company FOR BROKERS AND EMPLOYERS 7 21 691150

TRICON GARAGE Last Name First 2023 M I DOB Street Address Apartment Unit City Phone Job Title Sex Spouse s Name State E mail Address Date of Hire Social Security No Sex ZIP Tobacco Y or N Spouse s DOB Height Weight Dependent 1 Sex Dependent DOB Dependent 2 Sex Dependent DOB Beneficiary Name Address DOB phone relationship BI WEEKLY RATES ACCIDENT From everyday mishaps to broken bones burns cuts to more extensive accidents Colonial pays 200 for seeking treatment The more severe the accident the more money paid 50K Life insurance 50 Wellness for each family member on the plan Individual 12 24 Ind Spouse 16 76 Ind Child 18 32 Family 22 85 HOSPITAL Plan 1 2000 payout for 24hr stay Plan 2 4000 payout for 24hr stay Ind 17 49 12 05 50 59 16 75 60 64 22 89 65 75 33 60 Ind Sp 17 49 22 85 50 59 31 87 60 64 43 48 65 75 63 72 Ind Ch 17 49 16 89 50 59 21 60 60 64 27 74 65 75 38 93 Family 17 49 27 69 50 59 36 72 60 64 48 32 65 75 69 05 Ind 17 49 23 68 50 59 32 72 60 64 44 77 65 75 65 72 Ind Sp 17 49 44 91 50 59 62 24 60 64 85 02 65 75 124 64 Ind Ch 17 49 33 14 50 59 42 18 60 64 54 23 65 75 76 13 Family 17 49 54 37 50 59 71 70 60 64 94 48 65 75 135 05 CRITICAL CARE CANCER Lump Sum payout 10K 75K 50 Wellness I would like a rate ____ Example 10K payout 25 29 yr old nontobacco 3 81 30 34 yr old 4 77 35 39 yr old 6 21 40 44 yr old 7 45 45 49 yr old 9 71

Term Whole Life If you have a family who depends on you life insurance is especially important Without you would they be able to pay for housing utilities and other everyday expenses I would like a rate ___________ 10K AD D Life insurance No charge Waive all employee funded benefit options Rates never increase Rates are locked in even if you change jobs Plans are portable If you leave Tricon Garage for any reason you can take your participating plans with you at no additional charge Plans are guaranteed renewable Once you qualify for a plan you can always renew it without question Signature ___________________________________ Date ________________________

IF YOU ARE APPLYING FOR HOSPITAL CRITICAL CARE CANCER LIFE PLEASE ANSWER THE FOLLOWING 1 Within the last five years has anyone to be covered been diagnosed with or treated by a member of the medical profession at a health facility for any of the following Heart Attack Stroke or transient ischemic attack TIA Kidney disease or disorder excluding stones Yes No 2 Within the last five years has anyone to be covered had or been advised by a member of the medical profession of the need to have any of the following Major organ transplant Coronary artery bypass surgery Angioplasty or stent placement Yes No 3 Is anyone to be covered the mother or father of a child currently conceived but as yet unborn or within the last 12 months has anyone to be covered been diagnosed with or treated by a member of the medical profession for infertility Yes No 4 Has anyone to be covered ever been diagnosed with or received medical treatment for any of the following by a member of the medical profession Cerebral vascular insufficiency Congenital heart disease excluding surgically corrected atrial septal defect Acquired immune deficiency syndrome AIDS Angina Congestive heart failure Cystic fibrosis Systemic lupus Yes No 5 Has anyone to be covered ever been diagnosed with or received medical treatment by a member of the medical profession for diabetes requiring the use of insulin within the last five years with complications to include retinopathy neuropathy or nephropathy with continued tobacco use or diagnosed prior to age 30 excluding gestational Yes No 6 Is anyone to be covered currently confined in a hospital or nursing home or within the last 12 months has hospitalization been recommended by a Physician Yes No 7 Has anyone to be covered ever been diagnosed with or medically treated by a member of the medical profession for sickle cell anemia or emphysema or has anyone to be covered required the use of oxygen for a chronic respiratory disease disorder excluding the use of a CPAP machine for the treatment of sleep apnea Yes No 8 In the last 12 months has anyone to be covered received treatment for more than 24 hours in a Hospital Intensive Care Unit not including treatment as a result of an accident Yes No 9 Has anyone to be covered had or been advised to have or consulted with or been evaluated by a member of the medical profession of the need to have any of the following Defibrillator placement Pacemaker placement Heart valve surgery Yes No 10 Within the last 12 months has anyone to be covered been prescribed medication for irregular heartbeat heart palpitation or tachycardia not including preventive treatment with antibiotics prior to dental appointment received medical treatment in an emergency room or hospital for hypertension high blood pressure not related to pregnancy or had a medication change to improve blood pressure readings by a member of the medical profession Yes No 11 Has anyone to be covered ever been diagnosed with or received medical treatment for any of the following by a member of the medical profession Heart Attack two or more Coronary artery disease Bypass surgery Atrial fibrillation Cardiomyopathy Arterial blockage Peripheral vascular disease Stroke or TIA two or more Yes No If any one of Questions 1 through 11 is answered yes Any person s indicated yes to the above will not be covered under the policy If the named person is the Proposed Insured a policy will not be issued therefore do not submit this application If a child are any other children to be covered Yes No Please list any medications Dosage frequency reason Signature __________________________________ Date _____________________

Deductions per year 26 These rates were prepared on 9 27 2023 and are valid for 90 days Critical Illness 1 0 for NC l with Subsequent Diagnosis Coverage Health Screening Benefit Cancer Benefit Non Tobacco Rates ISSUE AGE NAMED INSURED EMPLOYEE SPOUSE ONE PARENT FAMILY 10 000 17 24 25 29 30 34 35 39 40 44 45 49 50 54 55 59 60 64 65 70 2 88 3 81 4 77 6 21 7 45 9 71 13 45 16 54 21 90 26 01 4 38 5 81 7 29 9 50 11 40 14 95 20 67 25 43 33 64 39 97 3 62 4 54 5 51 6 94 8 19 10 50 14 19 17 33 22 68 26 84 20 000 17 24 25 29 30 34 35 39 40 44 45 49 50 54 55 59 60 64 65 70 4 77 6 62 8 56 11 42 13 91 18 44 25 91 32 10 42 81 51 02 7 24 10 10 13 06 17 49 21 27 28 38 39 83 49 34 65 77 78 41 6 25 8 10 10 04 12 90 15 39 20 01 27 39 33 67 44 37 52 68 30 000 17 24 25 29 30 34 35 39 40 44 45 49 50 54 55 59 60 64 65 70 6 67 9 44 12 34 16 64 20 37 27 16 38 37 47 65 63 71 76 04 10 10 14 40 18 83 25 47 31 15 41 81 58 98 73 24 97 89 116 86 8 88 11 65 14 56 18 85 22 59 29 51 40 59 50 01 66 07 78 53 Applicable to policy form CI 1 0 TWO PARENT FAMILY 5 17 6 60 8 07 10 29 12 18 15 69 21 41 26 21 34 43 40 80 8 81 11 67 14 63 19 06 22 84 29 86 41 30 50 90 67 34 80 07 12 46 16 75 21 18 27 83 33 50 44 03 61 20 75 60 100 24 119 35 Page 1 of 6 Underwritten by Colonial Life Accident Insurance Company See page 6 for Important Notice

Continued Critical Illness 1 0 for NC l with Subsequent Diagnosis Coverage Health Screening Benefit Cancer Benefit Tobacco Rates ISSUE AGE 10 000 20 000 30 000 17 24 25 29 30 34 35 39 40 44 45 49 50 54 55 59 60 64 65 70 17 24 25 29 30 34 35 39 40 44 45 49 50 54 55 59 60 64 65 70 17 24 25 29 30 34 35 39 40 44 45 49 50 54 55 59 60 64 65 70 NAMED INSURED 3 67 5 19 7 08 9 34 11 70 15 02 20 42 25 96 33 11 39 71 6 34 9 39 13 17 17 70 22 41 29 05 39 85 50 93 65 24 78 44 9 02 13 59 19 27 26 05 33 11 43 08 59 28 75 90 97 36 117 16 EMPLOYEE SPOUSE 5 63 7 98 10 89 14 35 18 00 23 12 31 38 39 87 50 86 61 01 9 74 14 44 20 26 27 18 34 47 44 72 61 24 78 23 100 20 120 50 13 84 20 90 29 63 40 01 50 95 66 32 91 10 116 58 149 54 180 00 ONE PARENT FAMILY 4 45 5 97 7 87 10 13 12 48 15 81 21 21 26 70 33 90 40 54 7 91 10 96 14 74 19 27 23 97 30 62 41 42 52 41 66 81 80 10 11 37 15 94 21 62 28 41 35 47 45 44 61 64 78 11 99 71 119 65 Term Life ITL5000 for NC l 20 Year Term Base Plan Non Tobacco Rates ISSUE AGE 10 000 25 3 10 35 3 55 45 4 47 55 8 34 65 18 93 25 000 4 97 6 11 8 41 18 07 28 41 Applicable to policy form CI 1 0 TWO PARENT FAMILY 6 41 8 72 11 67 15 14 18 78 23 86 32 17 40 61 51 64 61 84 11 30 15 92 21 83 28 75 36 04 46 20 62 81 79 70 101 77 122 17 16 20 23 12 31 98 42 37 53 30 68 54 93 46 118 80 151 89 182 49 Applicable to policy form ITL5000 Page 2 of 6 Underwritten by Colonial Life Accident Insurance Company See page 6 for Important Notice

Continued Term Life ITL5000 for NC l 20 Year Term Base Plan Tobacco Rates ISSUE AGE 10 000 25 4 84 35 5 41 45 7 34 55 15 66 65 32 38 25 000 9 33 10 75 15 57 36 39 47 86 Whole Life Plus IWL5000 for NC l Adult Base Plan Paid Up at Age 100 Non Tobacco Rates ISSUE AGE 100 000 18 41 69 19 41 77 20 41 84 21 41 92 22 42 00 23 42 07 24 42 19 25 42 46 26 43 04 27 44 00 28 45 23 29 46 69 30 48 27 31 49 92 32 51 69 33 53 58 34 55 62 35 57 77 36 60 07 37 62 58 38 65 30 39 68 30 40 71 58 41 75 11 42 78 92 43 83 00 200 000 83 38 83 53 83 69 83 84 84 00 84 15 84 38 84 92 86 07 88 00 90 46 93 38 96 54 99 84 103 38 107 15 111 23 115 53 120 15 125 15 130 61 136 61 143 15 150 23 157 84 165 99 Applicable to policy form ITL5000 250 000 104 22 104 42 104 61 104 80 105 00 105 19 105 48 106 15 107 59 109 99 113 07 116 73 120 67 124 80 129 23 133 94 139 03 144 42 150 18 156 43 163 26 170 76 178 93 187 78 197 30 207 49 Applicable to policy forms ICC19 IWL5000 70 IWL5000 70 ICC19 IWL5000 100 IWL5000 100 ICC19 IWL5000J IWL5000J and rider forms ICC19 R IWL5000 STR R IWL5000 STR ICC19 R IWL5000 CTR R IWL5000 CTR ICC19 R IWL5000 WP R IWL5000 WP ICC19 R IWL5000 ACCD R IWL5000 ACCD ICC19 R IWL5000 CI R IWL5000 CI ICC19 R IWL5000 CC R IWL5000 CC ICC19 R IWL5000 GPO R IWL5000 GPO ICC23 IWL5000 LTC IWL5000 LTC Page 3 of 6 Underwritten by Colonial Life Accident Insurance Company See page 6 for Important Notice

Continued Whole Life Plus IWL5000 for NC l Adult Base Plan Paid Up at Age 100 Non Tobacco Rates ISSUE AGE 100 000 44 87 30 45 91 77 46 96 30 47 100 96 48 105 72 49 110 65 50 115 84 51 121 46 52 127 61 53 134 38 54 141 80 55 149 76 56 158 26 57 167 30 58 176 92 59 187 22 60 198 26 61 210 07 62 222 72 63 236 30 64 250 87 65 266 53 66 283 33 67 301 41 68 320 87 69 341 91 70 364 87 71 390 37 72 419 06 73 451 60 74 488 59 75 530 56 76 577 94 77 631 17 78 690 63 79 756 66 200 000 174 61 183 53 192 61 201 91 211 45 221 30 231 68 242 91 255 22 268 76 283 61 299 52 316 53 334 60 353 83 374 45 396 52 420 14 445 44 472 60 501 75 533 05 566 67 602 82 641 74 683 82 729 74 780 74 838 12 903 19 977 19 1 061 11 1 155 88 1 262 34 1 381 25 1 513 32 250 000 218 26 229 41 240 76 252 39 264 32 276 62 289 60 303 64 319 02 335 95 354 50 374 41 395 66 418 25 442 29 468 06 495 66 525 17 556 80 590 75 627 18 666 32 708 34 753 53 802 18 854 77 912 18 975 92 1 047 65 1 128 99 1 221 49 1 326 39 1 444 85 1 577 92 1 726 56 1 891 66 Applicable to policy forms ICC19 IWL5000 70 IWL5000 70 ICC19 IWL5000 100 IWL5000 100 ICC19 IWL5000J IWL5000J and rider forms ICC19 R IWL5000 STR R IWL5000 STR ICC19 R IWL5000 CTR R IWL5000 CTR ICC19 R IWL5000 WP R IWL5000 WP ICC19 R IWL5000 ACCD R IWL5000 ACCD ICC19 R IWL5000 CI R IWL5000 CI ICC19 R IWL5000 CC R IWL5000 CC ICC19 R IWL5000 GPO R IWL5000 GPO ICC23 IWL5000 LTC IWL5000 LTC Page 4 of 6 Underwritten by Colonial Life Accident Insurance Company See page 6 for Important Notice

Continued Whole Life Plus IWL5000 for NC l Adult Base Plan Paid Up at Age 100 Tobacco Rates ISSUE AGE 100 000 18 63 27 19 65 11 20 66 88 21 68 58 22 70 15 23 71 61 24 72 96 25 74 15 26 75 19 27 76 23 28 77 27 29 78 34 30 79 61 31 81 15 32 83 00 33 85 15 34 87 57 35 90 23 36 93 07 37 96 15 38 99 46 39 103 03 40 106 92 41 111 26 42 116 19 43 121 73 44 127 84 45 134 34 46 141 03 47 147 84 48 154 80 49 162 00 50 169 61 51 178 19 52 188 15 53 199 72 200 000 126 54 130 23 133 76 137 15 140 30 143 22 145 92 148 30 150 38 152 46 154 53 156 69 159 23 162 30 165 99 170 30 175 14 180 45 186 15 192 30 198 91 206 07 213 84 222 53 232 38 243 45 255 68 268 68 282 06 295 68 309 60 323 99 339 22 356 37 376 29 399 45 250 000 158 16 162 78 167 21 171 43 175 38 179 03 182 40 185 38 187 98 190 57 193 16 195 86 199 03 202 88 207 49 212 88 218 94 225 57 232 68 240 37 248 64 257 58 267 30 278 16 290 47 304 32 319 60 335 85 352 58 369 60 387 00 404 98 424 02 445 46 470 37 499 31 Applicable to policy forms ICC19 IWL5000 70 IWL5000 70 ICC19 IWL5000 100 IWL5000 100 ICC19 IWL5000J IWL5000J and rider forms ICC19 R IWL5000 STR R IWL5000 STR ICC19 R IWL5000 CTR R IWL5000 CTR ICC19 R IWL5000 WP R IWL5000 WP ICC19 R IWL5000 ACCD R IWL5000 ACCD ICC19 R IWL5000 CI R IWL5000 CI ICC19 R IWL5000 CC R IWL5000 CC ICC19 R IWL5000 GPO R IWL5000 GPO ICC23 IWL5000 LTC IWL5000 LTC Page 5 of 6 Underwritten by Colonial Life Accident Insurance Company See page 6 for Important Notice

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

Thank you Colonial Life Voluntary Benefits Please contact Lisa Jones Benefits Specialist 980 622 3718 Lisa Jones ColonialLifeSales com