1-800-327-9728 | HumanaVoluntaryBenefits.com

Indiana Floyd County Government

This is not a complete disclosure of plan qualifications and limitations. Please access our website to obtain a completedlist for the Workplace Voluntary Benefit products at Disclosure.Humana.com. Please review this information beforeapplying for coverage. The amount of benefits provided depends on the plan selected. Premiums will vary according tothe selection made.

Policy: 8011Underwritten by Kanawha Insurance Company, a Humana company.

VOL8074

Humana Critical Illness and Cancer

Consider coverage that helps protect you, your family, and your assets in the event of a critical illness. It offersspecialized benefits to supplement other health insurance when you and your family may be most vulnerable: duringthe working years. Benefit payments can assist in covering a variety of expenses associated with a critical illness:out-of-pocket medical care costs, home healthcare, travel to and from treatment facilities, rehabilitation, andother expenses.

Coverage type Voluntary Critical Illness insurance is a group policy form thatincludes coverage for heart/stroke, cancer, and other criticalillnesses.

Benefit amount Benefit amounts are available at various levels. You can choose:• $5,000 to $50,000 for employees

You can also add coverage for your dependents:• Spouse: $2,500 to $25,000. Spouse coverage benefit is equalto exactly half of the employee's coverage

• Child: $2,500 to $5,000 for each eligible child

Coverage for vascular conditions Percent of benefit amount paid at initial diagnosis:• Heart attack 100%• Transplant as a result of heart failure 100%• Stroke 100%• Coronary artery bypass surgery as a result

of coronary artery disease25%

Coverage for cancer conditions30 day waiting period

Percent of benefit amount paid at initial diagnosis:• First diagnosis of internal cancer or

malignant melanoma100%

• Carcinoma in situ 25%a

1-800-327-9728 | HumanaVoluntaryBenefits.com

Indiana Floyd County Government

This is not a complete disclosure of plan qualifications and limitations. Please access our website to obtain a completedlist for the Workplace Voluntary Benefit products at Disclosure.Humana.com. Please review this information beforeapplying for coverage. The amount of benefits provided depends on the plan selected. Premiums will vary according tothe selection made.

Policy: 8011Underwritten by Kanawha Insurance Company, a Humana company.

VOL8074

Humana Critical Illness and Cancer

Coverage for other critical illnesses Percent of benefit amount paid at initial diagnosis:• Transplant, other than heart 100%• End-stage renal failure 100%• Loss of sight, speech, or hearing 100%• Coma 100%• Severe burns 100%• Permanent paralysis due to an accident 100%• Occupational HIV 100%

Additional included benefits Waiver of premium for disability: This waives an employee'spremium if he or she becomes totally disabled for at least 180days after the effective date of coverage. For employees ages18-55.

Health screening: Benefit pays per calendar year for coveredhealth screenings. There are 18 covered tests includingmammograms, colonoscopies, and stress tests. There is a90-day waiting period.• Indemnity based and payable once per calendar yearper insured

• Employer selects this optional benefit and the benefitamount; Employee may decline the benefit if he/she chooses

• Coverage is same for all insureds on the certificate$150

Portability Portable after six months of continuous coverage if group masterpolicy remains in force and the insured is less than age 70.Participants may continue coverage by paying premiums on adirect billing method.• All ported certificates will be subject to any rate increases onthe Employer's Master Policy.

a

1-800-327-9728 | HumanaVoluntaryBenefits.com

VOL8074

Humana Critical Illness and Cancer rates

Floyd County GovernmentIndiana 6586014-01-002

Policy: 8011Underwritten by Kanawha Insurance Company, a Humana company.

Employee ratesDisplaying bi-weekly payroll deductions based on monthly premium calculation including $150 Health Screening Benefit.

Age Employee NTU Employee TU

BENEFIT: $5,000 $10,000 $20,000 $5,000 $10,000 $20,00018-29 $3.33 $4.30 $6.24 $3.78 $5.18 $8.0030-39 $4.17 $5.97 $9.57 $5.36 $8.36 $14.3640-49 $5.39 $8.41 $14.46 $7.67 $12.98 $23.6050-55 $7.32 $12.29 $22.21 $11.20 $20.04 $37.7256-59 $7.32 $12.29 $22.21 $11.20 $20.04 $37.7260-64 $8.88 $15.38 $28.40 $14.09 $25.81 $49.2565-69 $9.66 $16.95 $31.54 $15.01 $27.65 $52.95

a

Spouse ratesMonthly premiums with bi-weekly deductions including $150 Health Screening Benefit.

Age Spouse NTU Spouse TU

BENEFIT: $2,500 $5,000 $10,000 $2,500 $5,000 $10,00018-29 $1.92 $2.45 $3.51 $2.16 $2.93 $4.4830-39 $2.36 $3.35 $5.31 $3.03 $4.68 $7.9840-49 $3.05 $4.71 $8.03 $4.30 $7.22 $13.0650-55 $4.11 $6.83 $12.27 $6.24 $11.10 $20.8256-59 $4.11 $6.83 $12.27 $6.24 $11.10 $20.8260-64 $4.96 $8.54 $15.69 $7.83 $14.28 $27.1865-69 $5.40 $9.42 $17.45 $8.34 $15.30 $29.21

NTU: Non-tobacco user; TU; Tobacco user

Children ratesDisplaying bi-weekly payroll deductions based on monthly premium calculation including $150 Health Screening Benefit.

Age Children

BENEFIT: $2,500 $5,0000-24 $1.22 $1.75

a

GCA08PGHH 812

We’ve made it easy for you to see what specific tests are included in your health screening benefit. Below are the covered screens – typically used to detect critical or serious illnesses or conditions. Please note that this benefit is not a “well care check” and cannot be used for routine physicals. The benefit only applies to the 18 approved screenings listed..

Health screening benefitWe will pay the amount shown on the Schedule if, during a Calendar Year, a Covered Person has one or more of the following tests performed.

Because of the nature of the screenings listed it’s unlikely that your dependent child will utilize this benefit often, however they are covered should the need arise. Children are covered until age 24 or as determined by state laws.

Health screening benefit

Bone Marrow Testing CA 15-3 (blood test for breast cancer) CA-125 (blood test for ovarian cancer) CEA (blood test for colon cancer) Chest x-ray Colonoscopy Flexible Sigmoidoscopy Hemocult stool analysis Mammography (including breast ultrasound) Pap Smear (including ThinPrep Pap Test)

PSA (blood test for prostate cancer) Serum Protein Electrophoresis (test for myeloma) Biopsy for Skin Cancer Stress test (bike or treadmill) Electrocardiogram (EKG) (including stress EKG) Lipid Panel (total cholesterol count) Blood Test for Triglycerides Oral Cancer Screening using ViziLite, OraTest or other Current Dental Terminology© Code D0431

8011 IN 1

KANAWHA INSURANCE COMPANY 210 SOUTH WHITE STREET, POST OFFICE BOX 610,

LANCASTER, SC 29721-0610 TELEPHONE 1-855-448-6982

GROUP CRITICAL ILLNESS INSURANCE POLICY POLICY NUMBER: 850310-W26CILCN

ISSUED TO POLICYHOLDER: FLOYD COUNTY GOVERNMENT

INITIAL EFFECTIVE DATE: January 1, 2014 POLICY RENEWAL DATES: January 01

PREMIUMS PAYABLE: Bi-Weekly

SITUS STATE: Indiana

This Policy is a legal contract between Kanawha Insurance Company (“Company”) and the Policyholder. All the provisions on this page and the following are part of this Policy.

The insurance offered by the Company is shown on the Application for this Policy. Insurance selected by the Policyholder and issued by the Company is shown on the Schedule. Insurance on Covered Persons is shown in their Certificates.

This Policy may be renewed on each Policy Renewal Date by agreement between the Company and the Policyholder. Any change in the terms will be shown on an amendment or amended Schedule.

This Policy is non-participating. This means that it will not share in the Company’s profits or surplus earnings and the Company will pay no dividends on it.

This Policy is issued in and governed by the laws of the Situs State.

The Policy application may have been captured electronically or on paper. Please carefully review answers to questions on the Application to make sure they are answered correctly. If an error exists, please notify Us immediately.

Signed for the Company

Joan O. Lenahan Vice President and Corporate Secretary

Bruce Broussard President

THIS IS A GROUP CRITICAL ILLNESS POLICY. IT ONLY PROVIDES STATED BENEFITS FOR

SPECIFIED ILLNESSES OR OTHER BENEFITS THAT MAY BE ADDED. THIS POLICY DOES NOT PROVIDE BENEFITS FOR ANY OTHER ILLNESS OR CONDITION.

THIS IS A LIMITED POLICY. READ IT CAREFULLY. THIS POLICY DOES NOT PROVIDE BENEFITS DURING THE FIRST TWELVE MONTHS AFTER THE EFFECTIVE DATE FOR CONDITIONS THAT

WERE IN EXISTENCE PRIOR TO THE EFFECTIVE DATE.

BENEFITS REDUCE AT AGE 70

THIS POLICY IS NOT A MEDICARE SUPPLEMENT POLICY. IF YOU OR YOUR EMPLOYEES ARE ELIGIBLE FOR MEDICARE, REVIEW THE “GUIDE TO HEALTH INSURANCE FOR PEOPLE WITH

MEDICARE” AVAILABLE FROM THE COMPANY.

GROUP CRITICAL ILLNESS INSURANCE POLICY NON PARTICIPATING

8011 IN 2

TABLE OF CONTENTS

SCHEDULE ................................................................................................................................... 3 ELIGIBILITY .................................................................................................................................. 4 BENEFITS ..................................................................................................................................... 5 CLAIM PROVISIONS .................................................................................................................. 9 CONTINUATION OF INSURANCE ......................................................................................... 10 TERMINATION OF INSURANCE – COVERED PERSONS ............................................... 10 POLICY RENEWAL, AMENDMENT AND TERMINATION ................................................. 11 PREMIUM PROVISIONS.......................................................................................................... 11 GENERAL PROVISIONS ......................................................................................................... 12 DEFINITIONS ............................................................................................................................. 14

8011 IN 3

SCHEDULE

CRITICAL ILLNESS BENEFITS

Insureds: All Associates

Maximum Issue Amount: $50,000

Benefit Groups

Vascular:

Heart Attack 100% of Face Amount

Heart Transplant 100% of Face Amount

Stroke 100% of Face Amount

Coronary Artery Bypass Surgery 25% of Face Amount

Cancer:

Invasive Cancer or Malignant Melanoma 100% of Face Amount

Carcinoma in Situ 25% of Face Amount

Other Critical Illnesses:

Major Organ Transplant 100% of Face Amount

End Stage Renal Failure 100% of Face Amount

Loss of Vision, Speech or Hearing 100% of Face Amount

Coma 100% of Face Amount

Severe Burns 100% of Face Amount

Permanent Paralysis due to Accident 100% of Face Amount

Occupational HIV Benefit 100% of Face Amount

Payment of Benefits within a Benefit Group will not exceed 100% of the Face Amount. Payment of Benefits within the Vascular and Cancer Benefit Groups will not exceed 100% of the Face Amount and Other Critical Illnesses Benefit Group will not exceed 100% of the Face Amount.

Vascular, Cancer and Other Critical Illness Benefits reduce by 50% at Age 70 Waiver of Premium Benefit Waives Certificate Premiums when Covered

Employee is Totally Disabled for more than 180 days.

8011 IN 4

Health Screening Benefit All Associates

If one or more covered Health Screening Tests are performed, $150.00 per calendar year

Face Amount Payable reduces by 50% at

Age 70

Policy Benefits are limited to the Maximum Issue Amount, or the Face Amount selected by the Covered Employee, if less.

Family Option:

Spouse Benefit Limited to 50% of the Employee's Benefit not to exceed

$25,000 $ 25,000.00

Child(ren) Benefit Limited to 50% of the Employee's Benefit not to exceed

$5,000 $ 150.00

ELIGIBILITY

Classes of Eligible Employees: Classes of Eligible Dependents: All Associates Spouses of Insured Eligible Employees Children of Insured Eligible Employees Eligibility Requirements for Eligible Employees In order to Enroll, an Eligible Employee must be Actively at Work (Active Employment):

For All Associates Actively At Work means 30 hours per week

Waiting Periods for Eligible Employees are as follows:

All Associates are Eligible to Enroll on Date of Employment

However, if an Eligible Employee is not Actively At Work at the end of the Waiting Period, the Wait ing Period will be extended until the Eligible Employee resumes work in a pattern that will establish Active Employment.

Eligible Employees must be Age 18 but not more than Age 69.

Additional Eligibility Requirements for Dependents

Waiting Periods for Eligible Employees apply to their Eligible Dependents.

Spouses of Insureds must be Age18 but not more than Age 69. A Spouse who is an Eligible Employee may be covered as an Insured or a Spouse, but not both.

Children of Insureds must be Age 1 day but not more than Age 24. A child who is an Eligible Employee may be covered as an Insured or a Child, but not both.

8011 IN 5

EFFECTIVE DATES FOR CHANGES IN AMOUNTS OF INSURANCE

Increases in the amount of insurance based on Policy provisions will occur on the first day of the Calendar Month following the change.

If Evidence of Insurability is not required, increases requested by the Insured will occur on the first day of the Calendar Month following the change request.

If Evidence of Insurability is required, increases requested by the Insured will occur on the first day of the Calendar Month after We approve the Evidence of Insurability.

Decreases requested by the Insured will occur on the first day of the Calendar Month following receipt of the written request by the Policyholder.

Decreases on account of Age will occur on the first day of the Calendar Month following the Age change.

ELIGIBILITY TO ENROLL

A person is Eligible to Enroll when He or She:

is a member of a Class of Eligible Employees listed on the Schedule; and meets the Eligibility Requirements shown on the Schedule.

EFFECTIVE DATE OF INSURANCE

Subject to payment of Premium, insurance starts when a person:

joins a Class of Eligible Employees; meets the Eligibility Requirements shown on the Schedule; and completes an Enrollment Form, if required.

However, if the Eligible Employee does not Enroll, insurance will not become effective until the first day of the Calendar Month following a later Enrollment.

We may require Evidence of Insurability if Enrollment takes place more than 30 days after an Employee first becomes Eligible.

The Face Amount available without Evidence of Insurability is shown on the Schedule.

EFFECTIVE DATE FOR CHANGES IN THE AMOUNT OF INSURANCE

Changes will occur on the dates specified on the Schedule.

BENEFITS

Benefits and Face Amounts selected by the Policyholder and approved by the Company are shown on the Schedule of this Policy.

Benefits shown on the Certificate are available:

to persons Eligible; who have Enrolled for the Benefits; are covered under the terms and conditions of this Policy; and for whom Premiums are paid.

Changes to the amount of insurance based on Age, Class or other factors agreed to by the Company and the Policyholder are shown on the Schedule.

8011 IN 6

All Benefits of this Policy are subject to the Benefit Conditions, Limitations and Exclusions provision.

VASCULAR BENEFITS

Heart Attack Benefit

We will pay this Benefit when We receive Proof of Loss showing that a Covered Person has suffered a covered Heart Attack.

Heart Transplant Benefit

We will pay this Benefit when We receive Proof of Loss showing that a Covered Person:

demonstrates Heart Failure; and is registered with and on the waiting list of the United Network for Organ Sharing or its successor for

a human to human replacement of the whole heart.

Heart Transplant under this Policy includes a heart lung transplant.

Stroke Benefit

We will pay this Benefit when We receive Proof of Loss showing that a Covered Person has suffered a covered Stroke.

Coronary Artery Bypass Surgery Benefit

We will pay this Benefit when We receive Proof of Loss showing that a Covered Person has undergone a covered Coronary Artery Bypass Surgery.

CANCER BENEFITS

Invasive Cancer or Malignant Melanoma Benefit

We will pay this Benefit when We receive Proof of Loss showing that a Covered Person suffers from a covered Invasive Cancer.

Carcinoma in Situ Benefit

We will pay this Benefit when We receive Proof of Loss showing that a Covered Person suffers from a covered Carcinoma in Situ.

OTHER CRITICAL ILLNESSES BENEFITS

Major Organ Transplant Benefit

We will pay this Benefit when We receive Proof of Loss showing that a Covered Person:

demonstrates Major Organ Failure; and is registered with and on the waiting list of the United Network for Organ Sharing or its successor for

a human to human replacement of the failing Major Organ.

Major Organ Transplant does not include:

Heart Transplant; or Heart Lung Transplant.

End Stage Renal Failure Benefit

We will pay this Benefit when We receive Proof of Loss showing that a Covered Person suffers from a covered End Stage Renal Failure.

8011 IN 7

Loss of Vision, Speech or Hearing Benefit

We will pay this Benefit when We receive Proof of Loss showing that a Covered Person suffers from a Covered:

Loss of Vision; Loss of Speech; or Loss of Hearing.

Coma Benefit

We will pay this Benefit when We receive Proof of Loss showing that a Covered Person suffers from a covered Coma.

Severe Burns Benefit

We will pay this Benefit when We receive Proof of Loss showing that a Covered Person has suffered covered Severe Burns caused by an Accident.

Permanent Paralysis Benefit

We will pay this Benefit when We receive Proof of Loss showing that a Covered Person suffers from a covered Permanent Paralysis caused by an Accident.

Occupational HIV Benefit

We will pay this Benefit when We receive Proof of Loss showing that a Covered Person suffers from an Occupational HIV.WAIVER OF PREMIUM BENEFIT

We will waive Premiums from the first day of Total Disability when the Insured’s Total Disability:

starts while this Policy and His Certificate are in force or in the Grace Period; starts before the Certificate Anniversary following His 60th birthday; and continues without interruption for at least 180 days.

Waiver will start on the first day of Total Disability. We will waive Premiums:

as they fall due while the Insured remains Totally Disabled; and using the mode of Premium payment that was in effect when Total Disability began.

We will not end a claim if the Insured attempts to return to work for 14 days or less.

HEALTH SCREENING BENEFIT

We will pay the amount shown on the Schedule if, during a Calendar Year, a Covered Person has one or more of the following tests performed more than 90 days after the Date of Certificate.

Bone Marrow Testing CA 15-3 (blood test for breast cancer) CA-125 (blood test for ovarian cancer) CEA (blood test for colon cancer) Chest x-ray Colonoscopy Flexible Sigmoidoscopy Hemocult stool analysis Mammography (including breast ultrasound) Pap Smear (including ThinPrep Pap Test) PSA (blood test for prostate cancer) Serum Protein Electrophoresis (test for myeloma) Biopsy for Skin Cancer Stress test (bike or treadmill) Electrocardiogram (EKG) (including stress EKG) Lipid Panel (total cholesterol count) Blood Test for Triglycerides Oral Cancer Screening using ViziLite, OraTest or

other Current Dental Terminology © Code D0431

The 90-day period will be reduced by one day for each day that a Replaced Policy was in force.

8011 IN 8

PAYMENT OF BENEFITS

We will pay Benefits when We receive Proof of Loss acceptable to Us. Benefits are subject to the Benefit Conditions, Limitations and Exclusions provision.

BENEFIT CONDITIONS, LIMITATIONS AND EXCLUSIONS

A Critical Illness must be diagnosed during the lifetime of the Covered Person.

Any loss due to a Pre-existing Condition will not be covered if the loss begins within 12 months after the Covered Person’s Effective Date of Insurance.

When a named Critical Illness is contributed to or caused by another named Critical Illness, We will pay only one Benefit. The Benefit paid will be the larger. If the Benefits are equal, the Insured may choose the Benefit to be paid.

A Tentative, Clinical or Pathological Diagnosis of Invasive Cancer during the 30-day period after a Covered Person’s Effective Date of Insurance is not Covered.

Benefits for Invasive Cancer or Carcinoma in Situ will not be payable based on a Tentative Diagnosis.

All Vascular Benefits end when We have paid 100% of a Covered Person’s Face Amount for any of the following:

Heart Attack; Heart Transplant; or Stroke.

When We pay a Benefit for Coronary Artery Bypass Surgery, the Face Amount for other Vascular Benefits is reduced by 25%.

All Cancer Benefits end when We have paid 100% of a Covered Person’s Face Amount for Invasive Cancer.

When We pay a Benefit for Carcinoma in Situ, the Face Amount for Invasive Cancer is reduced by 25%.All Other Critical Illness Benefits end when We have paid 100% of a Covered Person’s Face Amount for any of the following:

Major Organ Transplant; End Stage Renal Disease; Loss of Vision, Speech or Hearing; Coma; Severe Burns; Permanent Paralysis; or Occupational HIV.

No Benefits of this Policy will be paid for loss that is contributed to, caused by, or occurs during;

any intentionally self-inflicted injury; suicide, or attempted suicide, while sane or insane; active duty military service; participation in the commission or attempted commission of a felony; being intoxicated or under the influence of alcohol, drugs or any narcotic (including overdose) unless

administered on, and taken in accordance with, the instructions of a Physician; psychosis; or alcoholism or drug addiction.

8011 IN 9

CLAIM PROVISIONS

NOTICE OF CLAIM

Written notice of Claim must be given to Us within 30 days after the date of a loss. If that is not possible, We must be notified as soon as it is reasonably possible to do so.

When We receive written notice of Claim, We will send claim forms. If the Claim forms are not received within 15 days after the notice is sent, written proof of Claim can be sent to Us without waiting for the forms.

PROOF OF LOSS

Proof of Loss must be given to Us within 90 days after a loss occurs or starts .

If it is not possible to give proof within this time limit, it must be given as soon as reasonably possible. Proof of Loss may not be given later than one year after the time such proof is otherwise required, except if the individual is legally unable to provide it.

Proof of Loss includes a Claim Form or other documents satisfactory to Us.

Proof of Loss may also include statements completed by the Insured and/or the claimant, the Policyholder and the attending Physician documenting:

the nature of the loss; the date, or inclusive dates, of loss; and the cause of loss.

For the Waiver of Premium Benefit, We may require Proof of Loss on a monthly basis. We will not require such Proof of Loss on a monthly basis when it is no longer reasonably necessary to do so.

On request, We will tell the Insured or other claimant what forms or documents are required.

We may require authorizations to obtain medical and psychiatric information as well as non-medical information, including personal financial information.

We will give the Insured or the claimant a Claim Form upon request. He or She is responsible for any costs to complete the Claim Form.

We may ask for other Proof of Loss from hospitals and Physicians. We will pay the reasonable cost of obtaining these records.

PAYMENT OF CLAIMS

Benefits will be paid to the Insured. If the Insured does not live to receive payment, any Benefit will be paid to His or Her:

Beneficiary, if one is named; or estate.

If Benefits are payable to the Insured’s estate or to a Beneficiary who cannot give Us a valid release, We can pay up to $1,000 to someone related to the Insured, by blood or marriage, whom We find is justly entitled to payment. Such a payment made in good faith will discharge Us to the extent of the amount paid.

The Employee may assign proceeds of a Claim. Assignment of a Certificate as collateral security is not allowed.

8011 IN 10

TIME PAYMENT OF CLAIMS

Payment will be issued upon receipt of Proof of Loss acceptable to Us but not later than 30 days after receipt of Proof of Loss.

EXAMINATION AND AUTOPSY

We, at Our own expense, will have the right and opportunity to have a claimant examined by a Physician of Our choice. This right may be exercised as often as reasonably required.

We, at Our own expense, will have the right to have an autopsy performed in the case of death, where autopsy is not forbidden by law.

CONTINUATION OF INSURANCE

Insurance may be continued under certain conditions when the Insured is no longer an Eligible Employee. The Policyholder must treat all Employees in the same way when continuing coverage.

As Required by Law or Regulation

The Policyholder will continue insurance on Covered Persons if required to do so by state or federal law or regulation.

The Company does not have nor does it assume, either expressly or impliedly, any responsibility for any such Policyholder obligation.

TERMINATION OF INSURANCE – COVERED PERSONS

Subject to the Continuation of Insurance and Portability provision(s), all insurance ends on the earliest of the following dates:

the Employee‘s retirement; the Maximum Renewal Age shown on the Schedule, except that an Employee who remains Actively

At Work may continue the coverage; the end of the Grace Period, if Premium for this coverage is not paid; the end of the billing period when the Covered Person is no longer Eligible; this Policy’s termination date; the end of the billing period when We receive a request to end this insurance; the date that a Spouse reaches Age 70; the date that a Child reaches Age 26; or the Covered Person‘s death.

When the Insured’s coverage ends, insurance on other persons covered by the certificate will also end.

Termination of insurance on a Covered Person or of the Policy is without prejudice to claims that occur or start prior to the date of termination.

VOLUNTARY TERMINATION

We must receive notification of voluntary terminations. The date that coverage ends will be the last day of the billing period in which the termination took place. If the Policyholder fails to report voluntary

8011 IN 11

termination of Covered Persons, Our liability shall be limited to a return of Premium back to the date on which insurance should have ended, less any Claims paid during this period.

POLICY RENEWAL, AMENDMENT AND TERMINATION

POLICYHOLDER RENEWAL

With Our consent, the Policyholder may renew coverage on each Policy Renewal Date. This is subject to the payment of Premiums.

Insurance will end at 11:59 p.m. local time at the Policyholder’s mailing address as shown in Our records on the day before the anniversary date if it is not renewed, unless it ends as provided in the Termination of Policy provision.

POLICY AMENDMENT

With Our consent, the Policyholder may amend Policy provisions to add, modify or delete Benefits or other provisions.

On any Policy Renewal Date, We may amend this Policy to add, modify or delete Benefits or other provisions. We will give the Policyholder at least 45-days advance written notice of any such change.

Deletion or reduction of a Benefit is without prejudice to any Claim that took place or started prior to the date of the change.

A change in or deletion of Benefits may change the Premiums charged.

POLICY TERMINATION

The Policyholder has the right to cancel this Policy on any Premium due date. Written notice must be given to Us at least 30 days before the date this Policy is to end.

We have the right to cancel this Policy on:

any Policy Renewal Date; or any Premium due date.

However, if We have given a Rate Guarantee, We will not cancel this Policy except at the end of such Rate Guarantee period. We will give the Policyholder at least 45 days’ notice before this Policy is to end.

This Policy and its insurance shall end if the Policyholder fails to pay the Premium before the end of the Grace Period.

Termination is without prejudice to any Claim that takes place or starts prior to the date of termination.

PREMIUM PROVISIONS

PREMIUMS

Premiums are payable to the Company.

The first Premium is due on the Initial Effective Date. Later Premiums are due according to the mode of Premium payment shown on the face page of this Policy.

8011 IN 12

We actuarially determine the Premiums. We reserve the right to change the Premiums as stated in the Change in Premium provision.

CHANGE IN PREMIUM

We may change the Premium rates:

when the number of Insureds covered changes by 20% or more after the Initial Effective Date, or the last renewal date, if later;

whenever Policy terms or conditions are modified; there is a material change in the risk insured; the Policyholder is sold or merges with another entity; the Policyholder purchases, acquires or establishes a new affiliate or subsidiary; or on any Policy Renewal Date.

However, if the Company has given a Rate Guarantee, We will not change Premiums except at the end of such Rate Guarantee period.

We will provide the Policyholder with at least 45 days advance notice of any Premium rate change.

PREMIUM REFUNDS

If We receive Premiums for periods after Eligibility ends, We will refund Premiums paid after the end of Eligibility. In all other cases, We will refund Premiums paid since the last Policy Renewal Date.

GENERAL PROVISIONS

AGREEMENTS AND POLICY CHANGES

No change in this Policy shall be valid unless made by endorsement or amendment. Such a change is valid only if signed by Our Chairman, Chief Executive Officer, President, a Vice President or the Secretary.

No other person can waive any Policy terms or make any agreements about this policy that are binding on Us.

ASSIGNMENT

The Insured may assign proceeds of a Claim.

Assignment of this Policy or of a Certificate is not allowed.

We are not responsible:

for the validity of any Assignment; or to honor any Assignment unless it is given to Us with any claim subject to the Assignment.

Our payment in good faith as outlined above will fully discharge Us with respect to the amount(s) paid.

BENEFICIARY, CHANGE OF BENEFICIARY

Benefits will be paid as stated in the Payment of Claims provision.

The Insured may add or change the Beneficiary by filing a form with the Policyholder.

8011 IN 13

We are not:

responsible for the validity of any Beneficiary designation; or required to honor any Beneficiary designation unless it is given to Us with any affected claim.

CERTIFICATES

We will give a Certificate to the Policyholder for delivery to each Insured stating:

the insurance protection provided, including; any insurance for Spouse and/or Children; and to whom the insurance Benefits are payable; and the Portability rights provided by this Policy.

CLERICAL ERROR

No Clerical Error by the Policyholder will:

delay the Effective Date of a Covered Person’s insurance; end insurance otherwise validly in force; or continue insurance otherwise validly terminated.

CONFORMITY WITH STATE

Any Policy wording that, on the Initial Effective Date, is in conflict with the statutes of the Situs State is hereby amended to meet the minimum requirements of such statutes.

DATA REQUIRED

The Policyholder will give Us all data and proof that We may reasonably need to administer this Policy.

DATE OF BIRTH AND GENDER

If a Covered Person’s date of birth or gender is misstated, We will adjust the Benefits payable. The Benefits will be those which We would have issued based on the correct information.

ENTIRE CONTRACT

This Policy, the Application, Enrollment forms and Evidence of Insurability as well as any endorsements and amendments shall make up the entire contract.

Statements made by the Policyholder or Insured individuals shall be deemed representations and not warranties.

EVIDENCE OF INSURABILITY

We may require evidence that a person meets our underwriting standards for this insurance.

GRACE PERIOD

This Policy has a Grace Period of thirty-one (31) days for the payment of any Premium due except the first.

During the Grace Period, this Policy is in force, unless the Policyholder gives Us written notice to cancel it before the end of the Grace Period. The Policyholder shall be liable to Us for the payment of a pro-rata premium for the time this Policy was in force during the Grace Period.

INCONTESTABILITY

The validity of this Policy will not be contested except for nonpayment of Premiums after it has been in force for two years from its Initial Effective Date.

8011 IN 14

No statement made by any person insured shall be used in any contest unless a copy of the statement is or has been furnished to:

the person insured; or in the event of death or incapacity of the person insured, to His or Her beneficiary or personal

representative.

Except for claims incurred within two years after a Covered Person’s Effective Date of Insurance, no statement made by any person insured when applying for insurance will be used to contest the validity of that insurance after:

the insurance has been continuously in force for two years during the lifetime of the person insured; and

unless it is contained in a written form signed by the Insured.

This provision shall not preclude the assertion at any time of defenses based upon Policy provisions that relate to eligibility for coverage.

LEGAL ACTIONS

Legal action cannot be taken against Kanawha Insurance Company:

Sooner than 60 days after due Proof of Loss has been filed; or 3 years after the time written Proof of Loss is required to be filed according to the terms of the Policy.

NON-PARTICIPATING

This Policy is a non-participating policy. We will not pay dividends on this Policy.

DEFINITIONS

For the purposes of this Policy when these words are used in this Policy, they have the meanings stated.

Accident means a sudden, unexpected, violent and external event that causes bodily Injury to a Covered Person.

Actively At Work (Active Employment) means the person must be working:

on a full-time basis and paid regular earnings; at least the minimum number of hours shown in the Schedule; at the Employer’s usual place of business; or at a location to which the Employer’s business requires the person to travel.

A person must be considered Actively At Work if the Employee was actually at work on the day immediately preceding:

a weekend; holidays; paid vacations; any non-scheduled work day; excused leave of absence (except medical leave and lay-off); or emergency leave of absence (except emergency medical leave required by His Illness or Injury).

Persons classified as part-time or temporary workers by the Employer or Policyholder are not Actively At Work except as agreed between the Policyholder and the Company.

Persons on strike are not Actively At Work except as agreed by the Policyholder and the Company.

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The Active Employment must be for an Employer that has a workforce of Employees who are Eligible for Policy Coverage.

Application means the forms the Policyholder completed when applying for this Policy that are attached to this Policy.

Age means the Age of a Covered Person on His or Her last birthday as of the Initial Effective Date.

If coverage is effective after the Initial Effective Date, Age means age as of the last birthday preceding the request for insurance coverage.

Benefit Group means a set of Critical Illnesses that is shown on the Schedule for which the Policy pays Benefits.

Calendar Month means any of the named months, January through December.

Calendar Year means a 12 month period, January 1 through December 31.

Carcinoma In Situ means a diagnosis of cancer wherein the tumor cells still lie within the tissue of origin without having invaded neighboring tissue.

Carcinoma in Situ does not include:

Prostate cancer histologically classified as Gleason score of less than 7, or TNM classification less than T2NOMO;

Malignant melanoma of less than 1.0 mm. maximum thickness as determined by histological examination using the Breslow method;

other skin malignancies; pre-malignant lesions (such as intraepithelial neoplasia); or benign tumors or polyps.

Carcinoma in Situ must be identified pursuant to a Pathological or Clinical Diagnosis. Pathological or Clinical Diagnosis must occur after the Effective Date of Insurance.

Certificate of Insurance (Certificate) means the document We issue for delivery to each Insured stating the protection to which He or She is entitled, to whom We will pay Benefits and a statement of any family member’s or dependent’s coverage.

Child (Children) means a person who is financially dependent upon the Insured.

A financially dependent child includes a natural or adopted child of the Insured or Spouse regardless of support level or a stepchild of the Insured, a grandchild of the Insured, a child subject to the Insured’s legal guardianship or other blood relative who depends on the Insured for more than 50% of the child’s support.

A child is considered an adopted child on the earlier of: (a) the date the child is legally placed with the Insured for adoption; or (b) the date the child’s custody for purposes of adoption has been granted to the Insured. A child is no longer considered an adopted child if placement with the Insured is disrupted prior to legal adoption and the child is removed from placement with the Insured.

Child does not include a:

person not meeting the above Child definition; Child living outside of the United States (unless living with an Insured); or Child on active military duty for a period in excess of 30 days.

Class means a group of persons that We and the Policyholder have agreed to insure.

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Clinical Diagnosis means a clinical identification of Invasive Cancer or Carcinoma in Situ based on history, laboratory study and symptoms. We will pay benefits for a Clinical Diagnosis only if:

a pathological diagnosis cannot be made because it is medically inappropriate or life threatening; there is medical evidence to support the diagnosis; and a Physician is treating the Covered Person for Cancer.

Coma means a state of complete and continuous unconsciousness not less than 96 hours in duration which exhibits an inability to be aroused or to respond to external stimuli aside from primitive avoidance reflexes.

The diagnosis of Coma must be made by a board-certified Neurologist.

Benefits are not payable for medically-induced comas.

Payment of benefit is based upon Date of Diagnosis made after the Effective Date of Insurance.

Coronary Artery Bypass Surgery means major surgery requiring median sternotomy (division of breast bone) to correct narrowing or blockage of one or more coronary arteries with bypass graft s on the advice of a cardiologist.

Diagnosis of coronary heart disease must be made by accepted angiography testing.

The following procedures are not considered coronary artery by-pass surgery: balloon angioplasty, laser embolectomy, atherectomy, stent placement, or other non-surgical procedures.

Payment of benefits is based upon Date of Diagnosis made after the Effective Date of Insurance.

Covered Employee means the Eligible Employee, when covered by this Policy.

Covered Employee also means a person who has ported coverage as allowed by the Portability provision.

Covered Person means an eligible Employee or Eligible Dependent who is covered under this Policy. Persons eligible for coverage are shown on the Schedule.

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Critical Illness means:

Heart Attack; Heart Transplant; Stroke; or Coronary Artery Bypass Surgery; Invasive Cancer or Malignant Melanoma; Carcinoma in Situ; Major Organ Transplant; End Stage Renal Failure; Loss of Vision, Speech or Hearing; Coma; Severe Burns; Permanent Paralysis; or Occupational HIV.

Date of Diagnosis means the earliest of the date of:

Tentative Diagnosis; Clinical Diagnosis; or the day the tissue specimen, culture and/or titer(s) are taken, upon which the Tentative or

Pathological Diagnosis of Invasive Cancer or Carcinoma in Situ is made.

Eligible Dependents means a Spouse, His or Her Child(ren) and the Child(ren) of an Eligible Employee.

We must approve eligibility of the Spouse and Child(ren) of an Employee.

Each such person must meet the Eligibility requirements shown in the Schedule.

If a Child is covered by this Policy, the Child’s Eligibility will not end if the Child is and remains:

incapable of self-sustaining employment due to mental incapacity or physical handicap; and chiefly dependent on the Employee or Spouse for support.

However, in no event will Eligibility or coverage of any Child continue beyond the date that the Employee’s coverage ends.

The Employee must furnish Us with proof of physical or mental incapacity within 31 days after the Chi ld’s Eligibility would otherwise end. Thereafter, We may require proof, but not more frequently than annually.

Eligible Employee means a person who:

is in Active Employment of the Policyholder; and meets the Enrollment Eligibility, Qualification Period and Maximum Renewal Age provisions shown

in the Schedule.

Employer means an entity that employs a workforce of persons in Active Employment. Employer includes any division, subsidiary or affiliated company named in the Application.

End-Stage Renal Failure means End Stage Renal disease which:

results in chronic irreversible failure of both kidneys to function; and which requires a Covered Person to undergo regular renal dialysis at least weekly.

The diagnosis of End Stage Renal Failure must be made by a Physician, after the Effective Date of Insurance.

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Enroll means application by an Eligible Employee for Policy coverage. By agreement between the Company and the Policyholder, Enrollment may:

require completion of an Enrollment Form by the Eligible Employee; be automatic, in which case it is not necessary for the Eligible Employee to complete an Enrollment

Form; and require Evidence of Insurability.

Evidence of Insurability means a form acceptable to Us showing that a person meets Our requirements for coverage under this Policy.

Heart Attack (Myocardial Infarction) means the death of a portion of the heart muscle resulting from blockage of one or more coronary arteries. A covered Heart Attack is one that:

displays new EKG changes consistent with and supporting the diagnosis of Heart Attack; exhibits elevation of cardiac enzymes above generally accepted laboratory levels of normal (in case

of CPK, a CPK-MB measurement must be used); is confirmed by imaging studies such as thallium scans, MUGA scans or stress ec hocardiograms;

and occurs after the Effective Date of Insurance.

The Date of Diagnosis is the date of ischemic death of an area of the heart muscle, as confirmed by the above criteria. Diagnosis is to be made based on generally accepted principles of medic ine at the time the diagnosis is made.

The following are not considered as a Heart Attack:

an EKG change consistent with transient ischemic change; angina; chance finding of EKG changes suggestive of a previous Heart Attack; or the death of the heart muscle coincidental with death from other causes.

Heart attack that occurs during or within 24 hours after a cardiac or coronary artery procedure is excluded.

Payment of benefit is based upon Date of Diagnosis made after the Effective Date of Insurance.

Heart Failure means clinical evidence showing disease of or injury to the heart that is, by generally accepted medical standards, sufficient to require a human to human replacement of the whole heart.

The diagnosis of Heart Failure must be made after the Effective Date of Insurance.

Heart Transplant means that a Covered Person:

demonstrates Heart Failure; and is registered with and on the waiting list of the United Network for Organ Sharing or its recognized

successor for a human to human replacement of the whole heart. Illness means sickness or disease of a Covered Person.

Initial Effective Date means the date that coverage begins under this Policy.

Injury means the bodily harm resulting directly from an Accident and independently of all other causes.

Insured means an Eligible Employee who is covered by this Policy.

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Invasive Cancer means a malignant tumor characterized by:

the uncontrolled growth and spread of malignant cells; and the invasion of local or distant tissue.

This includes Leukemia and Lymphoma.

Payment of Benefit is based upon Date of Diagnosis. The diagnosis must be a Pathological Diagnosis, and must be made more than 30 days after the Effective Date of Insurance. We will accept a Clinical Diagnosis in place of a Pathological Diagnosis only if:

a Pathological Diagnosis cannot be made because it is medically inappropriate or life-threatening; there is medical evidence to support the diagnosis; and a physician is treating the Insured for cancer.

We will not pay Benefits based on a Tentative Diagnosis.

The following are not considered Invasive Cancer for purposes of this Benefit:

Carcinoma in Situ; All skin cancers, unless there is evidence of metastasis; Malignant melanoma of less than 1.0 mm. maximum thickness as determined by histological

examination using the Breslow method; or Prostate cancer histologically classified as Gleason score of less than 7, or TNM classification less

than T2NOMO.

Loss of Hearing means clinically-proven irreversible loss of hearing in both ears, with an auditory threshold of more than 90 decibels, as a result of Illness or Injury that has continued without interruption for a period of at least six (6) consecutive months after diagnosis.

No benefit will be paid if, in general medical opinion, surgery, a hearing aid, device, or implant could result in the partial or total restoration of hearing.

The diagnosis must be made by physical examination by an audiologist after the Effective Date of Insurance.

For Optional Child Benefit, the Covered Person must be age three (3) years or older at the time of diagnosis.

Loss of Speech means the clinically-proven total, permanent and irreversible loss of the ability to speak as a result of Illness or Injury that has continued without interruption for a period of at least six (6) consecutive months.

No benefit will be payable if, in general medical opinion, surgery, a device or implant could result in the partial or total restoration of speech.

The diagnosis must be made by physical examination by a speech pathologist after the Effective Date of Insurance.

For Optional Child Benefit, the Covered Person must be age three (3) years or older at the time of diagnosis.

8011 IN 20

Loss of Vision means clinically-proven, irreversible reduction of sight in both eyes as a result of Illness or Injury. The corrected visual acuity must be:

less than 20/200;or a visual field restriction to 20 degrees or less in both eyes.

There must be clear proof that blindness was due to Illness or Injury, and that the condition has continued without interruption for a period of at least six (6) consecutive months after diagnosis.

No benefit will be paid if, in general medical opinion, surgery, a device, or implant could result in the partial or total restoration of sight.

The diagnosis must be made:

by physical examination by an ophthalmologist; and after the Effective Date of Insurance.

For Optional Child Benefit, the Covered Person must be age three (3) years or older at the time of diagnosis.

Major Organ Failure means clinical evidence showing disease of or injury to one of the following Major Organs that is, by generally accepted medical standards, sufficient to require a human to human replacement of the whole organ:

liver; kidney; pancreas or pancreas-kidney; or lung or lungs.

The diagnosis of Major Organ Failure must be made after the Effective Date of Insurance.

Major Organ Transplant means that a Covered Person:

demonstrates Major Organ Failure; and is registered with and on the waiting list of the United Network for Organ Sharing or its successor for

a human to human replacement of the failing organ.

Occupational HIV means that the Covered Person initially contracted and was diagnosed with Human Immunodeficiency Virus (HIV) after the Date of Certificate. Benefits will only be paid if all of the following conditions are met:

the cause of the HIV must be from an accidental needle stick/sharp injury or by mucous membrane exposure to blood or bloodstained bodily fluid which occurred during the twelve (12) months preceding diagnosis, after the Effective Date of Insurance and while His insurance is in force;

the accident must have occurred while the Covered Person was following the normal occupational duties and reported in accordance with the established occupational procedures for such accidents;

the Covered Person must have undergone a blood test within five (5) days of the accident which indicated the absence of HIV or antibodies to such a virus; and

within twelve (12) months of the accident, the Covered Person must undergo a follow up blood test indicating the presence of HIV or antibodies to such a virus.

Pathological Diagnosis means identification of cancer based on a microscopic study of fixed tissue or preparations from the hemi (blood) system.

8011 IN 21

The diagnosis must be:

made by a certified pathologist; and in keeping with the standards set by the American Board of Pathology.

Permanent Paralysis means only:

Hemiplegia; Paraplegia; or Quadriplegia.

The loss must:

be expected to be permanent; have been present continuously for at least 180 days be caused by Injury sustained in an Accident occurring after the Effective Date of Insurance; have been first diagnosed after the Effective Date of Insurance; be evidenced by the total and irreversible loss of use of two or more limbs; and be marked by loss of muscle function in two arms, two legs, or one arm and one leg.

Paralysis does not include paralysis that results from a Stroke.

Physician means a medical doctor or other person recognized by law or regulation in the state where services are rendered as a Physician. The person must be licensed and practicing in the United States.

Physician does not include:

You; a person related to You by blood or marriage; or a medical doctor or other person practicing outside of the United States.

Policy means the group Policy issued to the Policyholder.

Policy Month means a period of time:

beginning on the day of the month corresponding to the Initial Effective Date; and continuing through the end of the preceding day in the next Calendar Month.

Policy Year Means a period of time:

beginning on the Initial Effective Date or its anniversary; and continuing through the end of the day preceding the next anniversary.

Policyholder means the entity so named on the Policy face page.

8011 IN 22

Pre-existing Condition means any of the following which a Physician has treated or for which a Physician has advised treatment of the Covered Person within 12 months before the Covered Person’s Effective Date of Insurance:

Heart Attack; or Stroke; Invasive Cancer; or Carcinoma in Situ; Coma; End-Stage Renal Failure; Loss of Vision, Speech or Hearing; Severe Burns; Permanent Paralysis; or Occupational HIV.

Pre-existing Condition also means any of the following which a Physician has treated or for which a Physician has advised treatment (by transplant, bypass surgery, medication or otherwise) of the Covered Person within 12 months before the Covered Person’s Effective Date of Insurance:

failure of the liver, kidney(ies), pancreas, or lung(s); failure of the heart; or coronary artery disease.

Pre-existing Condition also means that a Physician has given a Tentative Diagnosis of Invasive Cancer or Carcinoma in Situ of the covered Person within 12 months before the Covered Person’s Effective Date of Insurance.

Pre-existing Condition also means a condition causing Total Disability which a Physician has treated or for which a Physician has advised treatment of the Employee within 12 months before the Employee’s Effective Date of Insurance.

Proof means evidence satisfactory to Us for insurability or for other matters which require Proof.

Rate Guarantee means a written agreement by the Company that rates charged for the insurance provided by the Policy will not change for a specified period.

Renal Failure means End Stage Renal Failure.

Schedule means page(s) so labeled in this Policy and the Certificate.

Severe Burns means that the Covered Person has sustained third degree burns covering at least 20% of the surface area of His body. Third degree means the destruction of the skin through the entire thickness or depth of the dermis and the layer of tissue below the skin (subcutaneous tissue). The diagnosis of Severe Burns must be made by a physician board-certified in Plastic Surgery and after the Effective Date of Insurance.

Spouse means:

1. the person recognized as the covered Insured’s husband or wife under the laws of the state in which the Insured lives.

2. persons who, by written agreement between the Company and the Policyholder, may be covered by this Policy on a spousal equivalent basis.

This Policy will at no time cover more than one person as an Insured’s Spouse.

8011 IN 23

Stroke means death of brain tissue due to a cerebrovascular event resulting in neurological damage including infarction, hemorrhage or embolization of brain tissue from an extra cranial source for at least 60 days.

Stroke does not mean a transient ischemic attack, transient global amnesia, chronic cerebrovascular insufficiency, attacks of vertebrobasilar ischemia or a cerebrovascular event resulting from Accidental Injury.

Diagnosis of a Stroke must be based on all of the following criteria:

documented neurological impairment or deficits; evidence of brain tissue damage shown by neuroimaging (CT, MRI, or PET Tomography or similar

test); permanent neurological deficit measured three months or more after the event that results in a score

of 2 or higher on the Modified Rankin Scale for stroke outcome; and which was made after the Effective Date of Insurance.

Tentative Diagnosis means a diagnosis of Invasive Cancer or Carcinoma in Situ based upon dated medical records.

Totally Disabled (Total Disability) means, for the first 24 months of a disability, that the Covered Employee is:

unable to perform the substantial and material duties of His regular occupation; not working in any other occupation; and under the care of a Physician for the disability.

After 24 months of Total Disability, Totally Disabled means that the Insured is:

unable to perform the duties of any gainful occupation for which He is reasonably fitted by training, education or experience; and

under the care of a Physician for the disability.

We will not require care of a Physician when it is no longer needed for the sound medical care of the condition causing Total Disability.

We, Us, Our and Company all mean Kanawha Insurance Company.

You and Your mean the Covered Person.

Any reference to “He,” “Him” or “His” will also refer to “She” or “Her,” “they,” “them” or “their. ”

210 South White Street Lancaster, South Carolina 29720 1-855-448-6982 Toll-free

1745

KANAWHA INSURANCE COMPANY

Portability Rider The Certificate issued by the Company to the Policyholder is hereby amended, effective upon receipt of this Rider, as follows:

The terms and conditions of that certain Certificate are hereby confirmed in their entirety with the exception that to the extent the terms and conditions of this Rider are in conflict with the terms and conditions of the Certificate, the terms of this Rider shall govern.

PORTABILITY PRIVILEGE

You are eligible for portability coverage if:

You are less than Age 70; You are not Totally Disabled; and You are no longer Actively At Work as an Employee.

The Policy must be in force on the date that You port coverage.

Such coverage will not be available for a Covered Person, unless:

1) Coverage under the policy terminates; and 2) We receive written request and payment for the first premium for the portability coverage not later

than 63 days after such termination; and 3) A request is made for that purpose.

No portability coverage will be provided for any person if coverage under the Policy terminated due to non-payment of premium.

You are not eligible for Portability while absent from work due to:

temporary layoff; suspension of business operations; or Policyholder-approved leave of absence for non-medical reasons.

Portability Coverage

The benefits, terms and conditions of the portability coverage will be the same as those provided under the Policy when the coverage terminated. Portability coverage may include any eligible dependents who were covered under the Policy. Any change made to the Policy after a person is covered under this Portability Privilege will not apply to that person unless it is required by law.

Portability coverage will be effective on the day after coverage under the Policy is terminated, when the first premium for portability coverage is paid.

1745

Portability Premiums

Premiums are due and payable in advance of the premium due date. Premium due dates are the first day of each calendar month. The portability premium rate is the rate in effect under the Policy. The premium rate for portability coverage may change for the class of covered persons on portability on any premium due date. Written notice will be given at least 45 days before the change is to take effect.

Grace Period

The grace period, as defined in the Policy, will apply to each certificate holder of portability coverage as if such covered person is the policyholder.

Termination of Insurance

Insurance under this Portability Privilege will automatically end of the earliest of the following dates:

1. The date the person again becomes eligible for insurance under the Policy; or 2. The last day for which premiums have been paid if the covered person fails to pay premiums

when due, subject to the grace period; or 3. when You request termination; or 4. when You reach the Maximum Renewal age; or 5. upon Your death; or 6. for a Spouse, Age 70; or 7. for a Child, Age 26; or 8. With respect to insurance for dependents:

a) The date the primary insured’s coverage terminates; or b) The date the dependent ceases to be an eligible dependent, as defined.

A dependent child whose portability coverage terminates when he or she reaches the age limit may apply for portability coverage in his or her own name, if she or he is otherwise eligible.

Termination of the Policy

If the Policy terminates, covered persons will be eligible to exercise the Portability Privilege on the termination date of the Policy. Portability coverage may continue beyond the termination date of the Policy, subject to timely payment of premiums. Benefits for portability coverage will be determined as if the Policy had remained in full force and effect.

It is agreed and acknowledged that this Rider shall be effective upon receipt by Certificateholder.

As used in this Rider, the term “Certificateholder” means the Covered Employee covered under the Policy.

Accepted by Kanawha Insurance Company

Bruce Broussard President

1759

210 South White Street Lancaster, South Carolina 29720

1-855-448-6982 Toll-free

KANAWHA INSURANCE COMPANY

NOTICE OF NON-INSURED BENEFITS

Discount/access disclosure From time to time, we may offer or provide you with additional goods and/or services that are not related to the benefits provided under the Policy. In addition, we may arrange for third-party service providers to provide you with discounts on goods and services. Some of these third-party service providers may make payments to us when these discount programs are used. These payments offset the cost to us of making these programs available and may help reduce the costs of your plan administration. Who has responsibility for these discounts? Although we have arranged for third parties to offer discounts on these goods and services, these discount programs are not insured benefits under the Policy. The third-party providers are solely responsible for providing the goods and/ or services. We are not responsible for any goods and/ or services nor are we liable if vendors refuse to honor such discounts. Further, we are not liable for the negligent provision of such goods and/ or services by third-party service providers. Discount programs may not be available to people who "opt out" of marketing communications, or where otherwise restricted by law.

Notices The following pages contain important information about Humana's claims procedures and certain federal laws. There may be differences between the Certificate of Insurance and this Notice packet. There may also be differences between this notice packet and state law. The Plan participant is eligible for the rights more beneficial to the participant. This section includes notices about: Claims and Appeal Procedures Federal Legislation

Medical Child Support Orders Continuation of Coverage for Full-time Students During Medical Leave of Absence

General Notice of COBRA Continuation of Coverage Rights

Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)

Family and Medical Leave Act (FMLA)

Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) ~Your Rights under ERISA

Privacy and Confidentiality Statement

CLAIMS AND APPEALS PROCEDURES The Employee Retirement Income Security Act of 1974 (ERISA) established minimum requirements for claims procedures. Humana complies with these standards. Covered persons in insured plans subject to ERISA should also consult their insurance benefit plan documents (e.g., the Certificate of Insurance or Evidence of Coverage). Humana complies with the requirements set forth in any such benefit plan document issued by it with respect to the plan unless doing so would prevent compliance with the requirements of the federal ERISA statute and the regulations issued thereunder. The following claims procedures are intended to comply with the ERISA claims regulation, and should be interpreted consistent with the minimum requirements of that regulation. Covered persons in plans not subject to ERISA should consult their benefit plan documents for the applicable claims and appeals procedures. DISCRETIONARY AUTHORITY With respect to paying claims for benefits or determining eligibility for coverage under a policy issued by Humana, Humana as administrator for claims determinations and as ERISA claims review fiduciary, shall have full and exclusive discretionary authority to: 1. Interpret plan provisions; 2. Make decisions regarding eligibility for coverage and benefits; and 3. Resolve factual questions relating to coverage and benefits. CLAIMS PROCEDURES Definitions Adverse determination: means a decision to deny benefits for a pre-service claim or a post-service claim under a group health plan. Claimant: A covered person (or authorized representative) who files a claim. Concurrent-care Decision: A decision by the plan to reduce or terminate benefits otherwise payable for a course of treatment that has been approved by the plan (other than by plan amendment or termination) or a decision with respect to a request by a Claimant to extend a course of treatment beyond the period of time or number of treatments that has been approved by the plan. Group health plan: an employee welfare benefit plan to the extent the plan provides health care to employees or their dependents directly (self insured) or through insurance (including HMO plans), reimbursement or otherwise. Health insurance issuer: the offering company listed on the face page of your Certificate of Insurance or Certificate of Coverage and referred to in this document as "Humana." Post-service Claim: Any claim for a benefit under a group health plan that is not a Pre-service Claim. Pre-service Claim: A request for authorization of a benefit for which the plan conditions receipt of the benefit, in whole or in part, on advance approval. Urgent-care Claim (expedited review): A claim for covered services to which the application of the time periods for making non-urgent care determinations: could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain

maximum function; or in the opinion of a physician with knowledge of the covered person's medical condition, would subject the covered person to severe pain that cannot be adequately managed without the service that is the subject of the claim. Humana will make a determination of whether a claim is an Urgent-care Claim. However, any claim a physician, with knowledge of a covered person's medical condition, determines is a "Urgent-care Claim" will be treated as a "claim involving urgent care." Submitting a Claim This section describes how a Claimant files a claim for plan benefits. A claim must be filed in writing and delivered by mail, postage prepaid, by FAX or e-mail. A request for pre-authorization may be filed by telephone. The claim or request for pre-authorization must be submitted to Humana or to Humana's designee at the address indicated in the covered person's benefit plan document or identification card. Claims will be not be deemed submitted for purposes of these procedures unless and until received at the correct address. Claims submissions must be in a format acceptable to Humana and compliant with any legal requirements. Claims not submitted in accordance with the requirements of applicable federal law respecting privacy of protected health information and/or electronic claims standards will not be accepted by Humana. Claims submissions must be timely. Claims must be filed as soon as reasonably possible after they are incurred, and in no event later than the period of time described in the benefit plan document. Claims submissions must be complete and delivered to the designated address. At a minimum they must include: Name of the covered person who incurred the covered expense;

Name and address of the provider;

Diagnosis;

Procedure or nature of the treatment;

Place of service;

Date of service;

Billed amount.

A general request for an interpretation of plan provisions will not be considered a claim. Requests of this type, such as a request for an interpretation of the eligibility provisions of the plan, should be directed to the plan administrator. Procedural Defects If a Pre-service Claim submission is not made in accordance with the plan's requirements, Humana will notify the Claimant of the problem and how it may be remedied within five (5) days (or within 24 hours, in the case of an Urgent-care Claim). If a Post-service Claim is not made in accordance with the plan's requirement, it will be returned to the submitter.

Authorized Representatives A covered person may designate an authorized representative to act on his or her behalf in pursuing a benefit claim or appeal. The authorization must be in writing and authorize disclosure of health information. If a document is not sufficient to constitute designation of an authorized representative, as determined by Humana, the plan will not consider a designation to have been made. An assignment of benefits does not constitute designation of an authorized representative. Any document designating an authorized representative must be submitted to Humana in advance or at the time

an authorized representative commences a course of action on behalf of the covered person. Humana may verify the designation with the covered person prior to recognizing authorized representative status.

In any event, a health care provider with knowledge of a covered person's medical condition acting in

connection with an Urgent-care Claim will be recognized by the plan as the covered person's authorized representative.

Covered persons should carefully consider whether to designate an authorized representative. Circumstances may arise under which an authorized representative may make decisions independent of the covered person, such as whether and how to appeal a claim denial. Claims Decisions After a determination on a claim is made, Humana will notify the Claimant within a reasonable time, as follows: Pre-service Claims Humana will provide notice of a favorable or adverse determination within a reasonable time appropriate to the medical circumstances but no later than 15 days after the plan receives the claim. This period may be extended by an additional 15 days, if Humana determines the extension is necessary due to matters beyond the control of the plan. Before the end of the initial 15-day period, Humana will notify the Claimant of the circumstances requiring the extension and the date by which Humana expects to make a decision. If the reason for the extension is because Humana does not have enough information to decide the claim, the notice of extension will describe the required information, and the Claimant will have at least 45 days from the date the notice is received to provide the necessary information. Urgent-care Claims (expedited review) Humana will determine whether a particular claim is an Urgent-care Claim. This determination will be based on information furnished by or on behalf of a covered person. Humana will exercise its judgment when making the determination with deference to the judgment of a physician with knowledge of the covered person's condition. Humana may require a Claimant to clarify the medical urgency and circumstances supporting the Urgent -care Claim for expedited decision-making. Notice of a favorable or adverse determination will be made by Humana as soon as possible, taking into account the medical urgency particular to the covered person's situation, but not later than 72 hours after receiving the Urgent-care Claim. If a claim does not provide sufficient information to determine whether, or to what extent, services are covered under the plan, Humana will notify the Claimant as soon as possible, but not more than 24 hours after receiving the Urgent-care Claim. The notice will describe the specific information necessary to complete the claim. The

Claimant will have a reasonable amount of time, taking into account the covered person's circumstances, to provide the necessary information - but not less than 48 hours. Humana will provide notice of the plan's Urgent-care Claim determination as soon as possible but no more than 48 hours after the earlier of: The plan receives the specified information; or

The end of the period afforded the Claimant to provide the specified additional information.

Concurrent-care Decisions Humana will notify a Claimant of a Concurrent-care Decision involving a reduction or termination of pre-authorized benefits sufficiently in advance of the reduction or termination to allow the Claimant to appeal and obtain a determination. Humana will decide Urgent-care Claims involving an extension of a course of treatment as soon as possible taking into account medical circumstances. Humana will notify a Claimant of the benefit determination, whether adverse or not, within 24 hours after the plan receives the claim, provided the claim is submitted to the plan 24 hours prior to the expiration of the prescribed period of time or number of treatments. Post-service Claims Humana will provide notice of a favorable or adverse determination within a reasonable time appropriate to the medical circumstances but no later than 30 days after the plan receives the claim. This period may be extended an additional 15 days, if Humana determines the extension is necessary due to matters beyond the plan's control. Before the end of the initial 30-day period, Humana will notify the affected Claimant of the extension, the circumstances requiring the extension and the date by which the plan expects to make a decision. If the reason for the extension is because Humana does not have enough information to d ecide the claim, the notice of extension will describe the required information, and the Claimant will have at least 45 days from the date the notice is received to provide the specified information. Humana will make a decision on the earlier of the date o n which the Claimant responds or the expiration of the time allowed for submission of the requested information. Initial Denial Notices Notice of a claim denial (including a partial denial) will be provided to Claimants by mail, postage prepaid, by FAX or by e-mail, as appropriate, within the time frames noted above. With respect to adverse decisions involving Urgent-care Claims, notice may be provided to Claimants orally within the time frames noted above. If oral notice is given, written notification must be provided no later than 3 days after oral notification. A claims denial notice will convey the specific reason for the adverse determination and the specific plan provisions upon which the determination is based. The notice will also include a des cription of any additional information necessary to perfect the claim and an explanation of why such information is necessary. The notice will disclose if any internal plan rule, protocol or similar criterion was relied upon to deny the claim. A copy of th e rule, protocol or similar criterion will be provided to Claimants, free of charge, upon request. The notice will describe the plan's review procedures and the time limits applicable to such procedures, including a statement of the Claimant's right to bring a civil action under ERISA Section 502(a) following an adverse benefit determination on review.

If an adverse determination is based on medical necessity, experimental treatment or similar exclusion or limitation, the notice will state that an explanation of the scientific or clinical basis for the determination will be provided, free of charge, upon request. The explanation will apply the terms of the plan to the covered person's medical circumstances. In the case of an adverse decision of an Urgent-care Claim, the notice will provide a description of the plan's expedited review procedures. APPEALS OF ADVERSE DETERMINATIONS A Claimant must appeal an adverse determination within 180 days after receiving written notice of the denial (or partial denial). An appeal may be made by a Claimant by means of written application to Humana, in person, or by mail, postage prepaid. A Claimant, on appeal, may request an expedited appeal of an adverse Urgent -care Claim decision orally or in writing. In such case, all necessary information, including the plan's benefit determination on review, will be transmitted between the plan and the Claimant by telephone, facsimile, or other available similarly expeditious method, to the extent permitted by applicable law. Determination of appeals of denied claims will be conducted promptly, will not defer to the initial determination and will not be made by the person who made the initial adverse claim determination or a subordinate of that person. The determination will take into account all comments, documents, records, and other information submitted by the Claimant relating to the claim. On appeal, a Claimant may review relevant documents and may submit issues and comments in writing. A Claimant on appeal may, upon request, discover the identity of medical or vocational experts whose advice was obtained on behalf of the plan in connection with the adverse determination being appealed, as permitted under applicable law. If the claims denial is based in whole, or in part, upon a medical judgment, including determinations as to whether a particular treatment, or other service is experimental, investigational, or not medically necessary or appropriate, the person deciding the appeal will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. The consulting health care professional will not be the same person who decided the initial appeal or a subordinate of that person. Time Periods for Decisions on Appeal Appeals of claims denials will be decided and notice of the decision provided as follows:

Urgent-care Claims As soon as possible but no later than 72 hours after Humana receives the appeal request.

Pre-service Claims Within a reasonable period but no later than 30 days after Humana receives the appeal request.

Post-service Claims Within a reasonable period but no later than 60 days after Humana receives the appeal request.

Concurrent-care Decisions

Within the time periods specified above depending on the type of claim involved.

Appeals Denial Notices Notice of a claim denial (including a partial denial) will be provided to Claimants by mail, postage prepaid, by FAX or by e-mail, as appropriate, within the time periods noted above.

A notice that a claim appeal has been denied will include: The specific reason or reasons for the adverse determination.

Reference to the specific plan provision upon which the determination is based.

If any internal plan rule, protocol or similar criterion was relied upon to deny the claim. A copy of the rule,

protocol or similar criterion will be provided to the Claimant, free of charge, upon request. A statement describing any voluntary appeal procedures offered by the plan and the claimant's right to obtain

the information about such procedures, and a statement about the Claimant's right to bring an action under section 502(a) of ERISA.

If an adverse determination is based on medical necessity, experimental treatment or similar exclusion or

limitation, the notice will state that an explanation of the scientific or clinical basis for the determination will be provided, free of charge, upon request. The explanation will apply the terms of the plan to the covered person's medical circumstances.

In the event an appealed claim is denied, the Claimant, will be entitled to receive without charge reasonable access to, and copies of, any documents, records or other information that: Was relied upon in making the determination.

Was submitted, considered or generated in the course of making the benefit determination, without regard to

whether such document, record or other information was relied upon in making the benefit determination. Demonstrates compliance with the administrative processes and safeguards required in making the

determination. Constitutes a statement of policy or guidance with respect to the plan concerning the denied treatment option or

benefit for the claimant's diagnosis, without regard to whether the statement was relied on in making the benefit determination.

EXHAUSTION OF REMEDIES Upon completion of the appeals process under this section, a Claimant will have exhausted his or her administrative remedies under the plan. If Humana fails to complete a claim determination or appeal within the time limits set forth above, the claim shall be deemed to have been denied and the Claimant may proceed to the next level in the review process. After exhaustion of remedies, a Claimant may pursue any other legal remedies available, which may include bringing civil action under ERISA section 502(a) for judicial review of the plan's determination. Additional information may be available from the local U.S. Department of Labor Office. LEGAL ACTIONS AND LIMITATIONS No lawsuit may be brought with respect to plan benefits until all remedies under the plan have been exhausted. No lawsuit with respect to plan benefits may be brought after the expiration of the applicable limitations period stated in the benefit plan document. If no limitation is stated in the benefit plan document, then no such suit may be brought after the expiration of the applicable limitations under applicable law.

MEDICAL CHILD SUPPORT ORDERS An individual who is a child of a covered employee shall be enrolled for coverage under the group health plan in accordance with the direction of a Qualified Medical Child Support Order (QMCSO) or a National Medical Support Notice (NMSO). A QMCSO is a state-court order or judgment, including approval of a settlement agreement that: (a) provides for support of a covered employee's child; (b) provides for health care coverage for that child; (c) is made under state domestic relations law (including a community property law); (d) relates to benefits under the group health plan; and (e) is "qualified," i.e., it meets the technical requirements of ERISA or applicable state law. QMCSO also means a state court order or judgment enforcing state Medicaid law regarding medical child support required by the Social Security Act section 1908 (as added by Omnibus Budget Reconciliation Act of 1993). An NMSO is a notice issued by an appropriate agency of a state or local government that is similar to a QMCSO requiring coverage under the group health plan for a dependent child of a non-custodial parent who is (or will become) a covered person by a domestic relations order providing for health care coverage. Procedures for determining the qualified status of medical child support orders are available at no cost upon request from the plan administrator. CONTINUATION OF COVERAGE FOR FULL-TIME STUDENTS DURING MEDICAL LEAVE OF ABSENCE A dependent child who is in regular full-time attendance at an accredited secondary school, college or university, or licensed technical school continues to be eligible for coverage for until the earlier of the following if the dependent child takes a medically necessary leave of absence:

- Up to one year after the first day of the medically neces sary leave of absence; or - The date coverage would otherwise terminate under the plan.

We may require written certification from the dependent child’s health care practitioner that the dependent child has a serious bodily injury or sickness requiring a medically necessary leave of absence. GENERAL NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS Introduction You are receiving this notice because you have recently become covered under a group health plan (the Plan). This notice contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to p rotect the right to receive it. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you when you would otherwise lose your group health coverage. It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage. For additional information about your rights and obligations under the Plan and under federal law, you should review the Plan’s benefit plan document or contact the Plan Administrator. What is COBRA Continuation Coverage? COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end becau se of a life event known as a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying

event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, the qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because either one of the following qualifying events happens: Your hours of employment are reduced; or

Your employment ends for any reason other than gross misconduct.

If you are the spouse of an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because any of the following events happen: Your spouse dies;

Your spouse’s hours of employment are reduced;

Your spouse’s employment ends for any reason other than his or her gross misconduct;

Your spouse becomes entitled to Medicare benefits (under Part A, Part B or both); or

You become divorce or legally separation from your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of any of the following qualifying events happen: The parent-employee dies;

The parent-employee’s hours of employment are reduced;

The parent-employee’s employment ends for any reason other than his or her gross misconduct;

The parent-employee becomes entitled to Medicare benefits (Part A, Part B or both);

The parents become divorced or legally separated; or

The child stops being eligible for coverage under the plan as a "dependent child."

When is COBRA Coverage Available The plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. When the qualifying event is the end of employment or reduction of hours of employment, death of the employee, or commencement of a proceeding in bankruptcy with respect to the employer, the employer must notify the Plan Administrator of the qualifying event. You Must Give Notice of Some Qualifying Events For the other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child) you must notify the Plan Administrator within 60 days after the qualifying event occurs.

How is COBRA Coverage Provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. Once the Plan Administrator offers COBRA continuation coverage, the qualified beneficiaries must elect such coverage within 60 days. COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the death of the employee, your divorce or legal separation, or a dependent child’s losing eligibility as a dependent child, COBRA continuation coverage last for up to a total of 36 months. When the qualifying event is the end of employment, or reduction in the employee’s hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the employee last until 36 months after the date of Medicare entitlement. For example, if a covered employee becomes entitled to Medicare 8 months before the date on which the employment terminates, COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months). Otherwise, when the qualifying event is the end of employment or reduction of the employee’s hours of employment, COBRA continuation coverage generally last for only up to a total of 18 months. There are two ways in which this 18-month period of COBRA continuation coverage can be extended. Disability Extension of 18-Month Period of Continuation Coverage If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator within 60 days of such determination, you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage. Second Qualifying Event Extension of 18-Month Period of Continuation Coverage If your family experiences another qualifying event while receiving 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is given to the Plan within 60 days of the event. This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies, gets divorced or legally separated, or if the dependent child stops being eligible under the plan as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. If You Have Questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the Plan Administrator. For more information about your rights under ERISA, including COBRA, or other laws affecting your group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gob/ebsa. (address and phone numbers of Regional and District EBSA Office are available through EBSA’s website.)

Keep Your Plan Informed of Address Changes In order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send the Plan Administrator. IMPORTANT NOTICE FOR INDIVIDUALS ENTITLED TO MEDICARE TAX EQUITY AND FISCAL RESPONSIBILITY ACT OF 1982 (TEFRA) OPTIONS Where an employer employs more than 20 people, the Tax Equity And Fiscal Responsibility Act of 1982 (TEFRA) allows covered employees in active service who are age 65 or older and their covered spouses who are eligible for Medicare to choose one of the following options. OPTION 1 - The benefits of their group health plan will be payable first and the benefits of Medicare will be payable second. OPTION 2 - Medicare benefits only. The employee and his or her dependents, if any, will not be insured by the group health plan. The employer must provide each covered employee and each covered spouse with the choice to elect one of these options at least one month before the covered employee or the insured spouse becomes age 65. All new covered employees and newly covered spouses age 65 or older must be offered these options. If Option 1 is chosen, its issue is subject to the same requirements as for an employee or dependent that is under age 65. Under TEFRA regulations, there are two categories of persons eligible for Medicare. The calculation and payment of benefits by the group health plan differs for each category. Category 1 Medicare eligibles are: Covered employees in active service who are age 65 or older who choose Option 1;

Age 65 or older covered spouses; and

Age 65 or older covered spouses of employees in active service who are either under age 65 or age 70 or older.

Category 2 Medicare eligibles are any other covered persons entitled to Medicare, whether or not they enrolled. This category includes, but is not limited to: Retired employees and their spouses; or

Covered dependents of a covered employee, other than his or her spouse.

Calculation and Payment of Benefits For covered persons in Category 1, benefits are payable by the policy without regard to any benefits payable by Medicare. Medicare will then determine its benefits. For covered persons in Category 2, Medicare benefits are payable before any benefits are payable by the policy. The benefits of the policy will then be reduced by the full amount of all Medicare benefits the covered person is entitled to receive, whether or not the eligible individual is actually enrolled for Medicare Benefits.

FAMILY AND MEDICAL LEAVE ACT (FMLA) If an employee is granted a leave of absence (Leave) by the employer as required by the Federal Family and Medical Leave Act, s/he may continue to be covered under the plan for the duration of the Leave under the same conditions as other employees who are currently employed and covered by the plan. If the employee chooses to terminate coverage during the Leave, or if coverage terminates as a result of nonpayment of any required cont ribution, coverage may be reinstated on the date the employee returns to work immediately following the end of the Leave. Charges incurred after the date of reinstatement will be paid as if the employee had been continuously covered. UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT OF 1994 (USERRA) Continuation of Benefits Effective October 13, 1994, federal law requires health plans offer to continue coverage for employees that are absent due to service in the uniformed services and/or dependents. Eligibility An employee is eligible for continuation under USERRA if he or she is absent from employment because of voluntary or involuntary performance of duty in the Armed Forces, Army National Guard, Air National Guard, or commissioned corps of the Public Health Service. Duty includes absence for active duty, active duty for training, initial active duty for training, inactive duty training and for the purpose of an examination to determine fitness for duty. An employee's dependents that have coverage under the plan immediately prior to the date of the employee's covered absence are eligible to elect continuation under USERRA. If continuation of Plan coverage is elected under USERRA, the employee or dependent is responsible for payment of the applicable cost of coverage. If the employee is absent for not longer than 31 days, the cost will be the amount the employee would otherwise pay for coverage. For absences exceeding 30 days, the cost may be up to 102% of the cost of coverage under the plan. This includes the employee's share and any portion previously paid by the employer. Duration of Coverage Of elected, continuation coverage under USERRA will continue until the earlier of: 1. Twenty-four months beginning the first day of absence from employment due to service in the uniformed services; or 2. The day after the employee fails to apply for a return to employment as required by USERRA, after the completion of a period of service. Under federal law, the period coverage available under USERRA shall run concurrently with the COBRA period available to an employee and/or eligible dependent. Other Information Employees should contact their employer with any questions regarding coverage normally available during a military leave of absence or continuation coverage and notify the employer of any changes in marital status, or change of address.

YOUR RIGHTS UNDER ERISA Under the Employee Retirement Income Security Act of 1974 (ERISA), all plan participants covered by ERISA are entitled to certain rights and protections, as described below. Notwithstanding anything in the group health plan or group insurance policy, following are a covered person’s minimum rights under ERISA. ERISA requirements do not apply to plans maintained by governmental agencies or churches. Information About the Plan and Benefits Plan participants may: 1. Examine, free of charge, all documents governing the plan. These documents are available in the plan administrator's office. 2. Obtain, at a reasonable charge, copies of documents governing the plan, including a copy of any updated summary plan description and a copy of the latest annual report for the plan (Form 5500), if any, by writing to the plan administrator. 3. Obtain, at a reasonable charge, a copy of the latest annual report (Form 5500) for the plan, if any, by writing to the plan administrator. As a plan participant, you will receive a summary of any material changes made in the plan within 210 days after the end of the plan year in which the changes are made unless the change is a material reduction in covered services or benefits, in which case you will receive a summary of the material reduction within 60 days after the date of its adoption. If the plan is required to file a summary annual financial report, you will receive a copy from the plan administrator. Responsibilities of Plan Fiduciaries In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for the operation of the plan. These people, called 'fiduciaries" of the plan, have a duty to act prudently and in the interest of plan participants and beneficiaries. No one, including an employer, may discharge or otherwise discriminate against a plan participant in any way to prevent the participant from obtaining a benefit to which the participant is otherwise entitled under the plan or from exercising ERISA rights. Continue Group Health Plan Coverage Participants may be eligible to continue health care coverage for themselves, their spouse or dependents if there is a loss of coverage under the group health plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review the COBRA notice in this document regarding the rules governing COBRA continuation coverage rights. Claims Determinations If a claim for a plan benefit is denied or disregarded, in whole or in part, participants have the right to know why this was done, to obtain copies of documents relating to the decision without charge and to appeal any denia l within certain time schedules. Enforce Your Rights Under ERISA, there are steps participants may take to enforce the above rights. For instance, if a participant requests a copy of plan documents does not receive them within 30 days, the participant may file suit in a Federal court. In such a case, the court may require the plan administrator to provide the materials and pay you up to $ 110 a

day until the participant receives the materials, unless the materials were not sent because of reasons beyond t he control of the plan administrator. If a claim for benefits is denied or disregarded, in whole or in part, the participant may file suit in a state or Federal court. In addition, if the participant disagrees with the plan's decision, or lack thereof, concerning the qualified status of a domestic relations order or a medical child support order, the participant may file suit in Federal court. If plan fiduciaries misuse the plan's money, or if participants are discriminated against for asserting their rights, they may seek assistance from the U.S. Department of Labor, or may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If the participant is successful, the court may order the person sued to pay costs and fees. If the participant loses, the court may order the participant to pay the costs and fees. Assistance with Questions Contact the group health plan human resources department or the plan administrator with questions about the plan. Contact the nearest area office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210 with questions about ERISA rights. Call the publications hotline of the Employee Benefits Security Administration to obtain publications about ERISA rights. PRIVACY AND CONFIDENTIALITY STATEMENT We understand the importance of keeping your personal and health information private (PHI). PHI includes both medical information and individually identifiable information, such as your name, address, telephone number or social security number. We are required by applicable federal and state law to maintain the privacy of your PHI. Under both law and our policies, we have a responsibility to protect the privacy of your PHI. We: Protect your privacy by limiting who may see your PHI; Limit how we may use or disclose your PHI; Inform you of our legal duties with respect to your PHI; Explain our privacy policies; and Strictly adhere to the policies currently in effect.

We reserve the right to change our privacy practices at any time, as allowed by applicable law, rules and regulations. We reserve the right to make changes in our privacy practices for all PHI that we maintain, including information we created or received before we made the changes. When we make a significant change in our privacy practices, we will send notice to our health plan subscribers. For more information about our privacy practices, please contact us. As a covered person, we may use and disclose you PHI, without your consent/authorization, in the following ways: Treatment: we may disclose your PHI to a health care practitioner, a hospital or other entity which asks for it in order for you to receive medical treatment. Payment: we may use and disclose your PHI to pay claims for covered services provided to you by health care practitioners, hospitals or other entities. We may use and disclose your PHI to conduct other health care operations activities.

It has always been our goal to ensure the protection and integrity of your personal and health information. Therefore, we will notify you of any potential situations where your identification would be used for reasons other than treatment, payment and health plan operations .

Form 1217-78-99 7/05

KANAWHA INSURANCE COMPANY 210 SOUTH WHITE STREET, POST OFFICE BOX 610

LANCASTER, SOUTH CAROLINA 29721-0610 TELEPHONE NUMBER: 1-855-448-6982

NOTICE TO POLICYHOLDERS Questions regarding your policy or coverage should be directed to:

Kanawha Insurance Company 210 South White Street PO Box 610 Lancaster, SC 29721-0610 1-855-448-6982

If you (a) need the assistance of the governmental agency that regulates insurance; or (b) have a complaint you have been unable to resolve with your insurer you may contact the Department of Insurance by mail, telephone or email:

State of Indiana Department of Insurance Consumer Services Division 311 West Washington Street, Suite 300 Indianapolis, Indiana 46204 Consumer Hotline: (800)-622-4461; (317) 232-2395 Complaints can be filed electronically at www.in.gov/idoi.

1643

Summary Document

The Indiana Life and Health Insurance Guaranty Association provides coverage of claims under some types of policies if the insurer becomes impaired or insolvent. COVERAGE MAY NOT BE AVAILABLE FOR YOUR POLICY. Even if coverage is provided, there are significant limits and exclusions. Coverage is always conditioned on residence in this state. Other conditions may also preclude coverage. The Indiana Life and Health Insurance Guaranty Association will respond to any questions you may have which are not answered by this document. Your insurer and agent are prohibited by law from using the existence of the association or its coverage to sell you an insurance policy. You should not rely on availability of coverage under the Indiana Life and Health Insurance Guaranty Association when selecting an insurer. You may contact the Indiana Life and Health Insurance Guaranty Association as follows:

Indiana Life and Health Insurance Guaranty Association 251 E. Ohio Street, Suite 1070

Indianapolis, IN 46204 (317) 636-8204 www.inlifega.org

You may contact the Indiana Department of Insurance as follows:

Indiana Department of Insurance 311 W. Washington Street

Indianapolis, IN 46204 (317) 232-2385 www.in.gov/idoi

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