F6 D9 De0 49956222

Welcome Linza Soasa,

Congratulations on your wise decision to enroll in this valuable insurance program– from National Union Fire Insurance Company of Pittsburgh, Pa.

Good news: we’ve made managing your Essential Protection Plan online safe and easy.At www.EssentialProtectionPlans.com you can access your account anytime for instantpolicy news, account updates, access claim forms, tips for healthy living, and informationabout other Essential Protection products. Everything you need is available when youneed it, 24 hours a day, with advanced security for your peace of mind.

We have enclosed your Insurance Documents. Please read them carefully so that youunderstand the many benefits available to you.

Your coverage starts at $400 a day to a maximum of 365 days for hospital stays due tocovered accidents or $200 a day for a covered illness, from the first day for each coveredillness that requires a hospital stay of three consecutive days or more.

Best of all, your coverage amounts automatically increase every3 months for 10 years with no increase in plan cost – regardless ofwhether or not you’ve used your coverage.

Receive benefits for a covered extended hospital stay.

To help ease the financial impact of an extended hospital confinement, the plan paysone of the following single lump-sum benefits in addition to your daily cash payouts:$5,000 after a 30 consecutive day stay or $10,000 after a 60 consecutive day stay.

continued

Welcome to thePlan that providesfor:

Hospital indemnitycoverage for coveredhospital stays

Cash benefits paiddirect to you orwhomever you choose

Cash paid in additionto any other insuranceyou have

No restrictions onhospitals or doctors

Linza Soasa100 Montgomery StJersey City, NJ 07302

Linza SoasaMember # 49956222

DTC101BNJ-408-110-2 1 DTC101BNJ

Insurance Claims:Insurance Customer Service:

Discount Services Customer Service:24-Hour Nurse Line:

1-866-960-07651-877-219-13651-888-822-89061-877-541-9189

Contact Us

Customer Care: 1-888-822-8906 Monday - Friday 9 a.m. - 7 p.m. EST.For all membership inquires or to locate participating providers. To locate participatingproviders online go to: www.mymemberinfo.com/EssentialHealth

24 Hour Nurse Care Hotline: 1-877-541-9189

Pharmacy Help Desk: 1-800-847-714724/7 Agelity Help Desk: For pharmacist use only

Bin: 009265PCN: AGGroup: UH07For ALL family members: Use person code 01

C-139-062609-EH THIS IS NOT HEALTH INSURANCE

Attention Participating Discount Medical Providers:Call 1-888-822-8906 if you have any questions. The member agrees to pay 100% of the allowableamount at the time of treatment. Please call to verify member eligibility and for repricing. Memberis directly responsible for payment to the Participating Provider.

For physicians and hospital use only: 1-866-643-2230 ext.3Call to determine members’s discounted fee. Provide theMember’s ID number, your Provider number and the CPTcodes. Collect full discounted payment at time of serviceunless other arrangements are made.

Through the use of this Membership, Member is acknowledging and accepting that he/she hasread and is bound by the TERMS AND CONDITIONS of membership.

THIS IS NOT HEALTH INSURANCE

Members also have access to the following networks

You’ll also receive coverage for doctor visits, emergency room treatment and ambulances:

• $50 for each covered doctor visit

• $300 for each covered Emergency Room treatment (this amount increases every 3 months you remain covered)

• $200 for each covered ambluance transportation (this amount also increases every 3 months)

PLUS, save on prescriptions, doctor and dentist visits, eye care and get 24-hour nursing assistance.*

Your plan includes full access to discounts which can save you 5-50% on routine doctor, hospital and lab visits whileproviding additional savings for prescription drugs, dentist and eye care at thousands of participating providersnationwide. You also have access to our 24-hour Nurse Hotline for answers to your family health questions. Please readthe enclosed brochure to learn how to use this valuable benefit.

Affordable monthly plan costs.

Your affordable monthly plan cost will not increase due to your growing older, and cannot change due to thenumber of claims you make or how often you use your plan benefits.

We want to be sure you make the most of your coverage.

Don’t forget: information and answers about your Essential Protection plan are always available atwww.EssentialProtectionPlans.com.

If you have any questions regarding your policy, call the Customer Service Department at one of the toll free numbersin the box below. A Customer Service Representative will be available between the hours of 9 am and 10 pm Mondaythrough Friday, Saturday 7 am to 3 pm Eastern Standard Time.

We appreciate the opportunity to provide you with this valuable coverage and look forward to serving you.

Sincerely,

Jonathan YeeSenior Vice PresidentAIU Holdings, Inc.

1-877-541-9189

1-866-960-0765

1-877-219-1365

1-888-822-8906

Insurance Claims:

Insurance Customer Service:

Discount Services Customer Service:

24-Hour Nurse Line:

1-888-822-8906

1-877-219-1365

1-866-960-0765

24-Hour Nurse Line: 1-877-541-9189

Coverage may not be available in all states.

This letter provides only a brief description of the insurance coverage available. The Policy contains reductions,limitations, exclusions and termination provisions. Full details of the insurance coverage are contained in each Policy.If there are any conflicts between this document and the Policy, the Policy (policy form numbers A30293NUFIC &C11695DBG) shall govern. Coverage may not be available in all states. Insurance is underwritten by National UnionFire Insurance Company of Pittsburgh, Pa., a Pennsylvania insurance company with its Administrative Offices at 80Pine Street, New York, NY 10270. It is currently authorized to transact business in all states and the District of Columbia.NAIC No.19445

National Union Fire Insurance Company of Pittsburgh, Pa., assumes no responsibility or liability for any of the listedservices, the providers of the services, the quality of the services, the delivery of the services, or the outcomes of theservices. Questions or concerns about the services should be addressed directly to the providers.Note: If you are 70 years of age or older on the date of a covered accident for which benefits are payable, the benefitslisted below will be reduced by fifty percent (50%), except for the Physician’s Office Visits Indemnity Benefit. Benefitamounts for dependents are lower than your benefit amounts.

*The Discount Medical Plans are provided by Patriot Health Florida, Inc., a discount medical plan organization. The features are not health insurance policies and are not available in all areas. The features provide discounts at certain health care providers for medical services and do not make payments directly to the providers of medical services. Themember is obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with Patriot Health Florida, Inc., located at 160 Eileen Way, Syosset, New York 11791. 800-292-3797 Not available in AK, FL, MT, ND, SD and VT. Coming soon to FL.

ENATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH,PA.

Administrative Offices: 80 Pine Street, New York, NY 10005(212) 770-7000

(a capital stock company, herein referred to as the Company)

Policyholder: Group Insurance Trust DelawarePolicy Number: 49956222

GROUP ACCIDENT INSURANCE CERTIFICATE

ABOUT THIS CERTIFICATE. This certificate describes accident insurance the Company provides to InsuredPersons under the Group Policy (herein called the Policy) issued to the Policyholder.

RIGHT TO EXAMINE THIS CERTIFICATE. This certificate of insurance is issued to You, the Insured, and can bereturned for any reason within the later of: (1) 30 days after it is received by You; or (2) 30 days after Your CoverageEffective Date. The certificate should be returned by mail or in person to the Company. Any premium paid will berefunded and the certificate will be treated as if it were never issued.

The President and Secretary of National Union Fire Insurance Company of Pittsburgh, Pa. witness this Certificate:

President Secretary

PLEASE READ THIS CERTIFICATE CAREFULLY.

THIS CERTIFICATE IS NOT A MEDICARE SUPPLEMENT CONTRACT. If you are eligible for Medicare, reviewthe Guide to Health Insurance for People with Medicare available from this Company.

DTC101BNJA30298NUFIC - NJ 1

TABLE OF CONTENTS

Schedule............................................................................................................................3Classification of Eligible Persons.................................................................................3Insured.........................................................................................................................3Covered Activities ........................................................................................................3Insured’s Coverage Effective Date ..............................................................................3Premium Payments .....................................................................................................3Benefit Schedule..........................................................................................................3

Definitions ........................................................................................................................10

Insured's Effective and Termination Dates ......................................................................10Insured Dependent’s Effective and Termination Dates ...................................................10

Premium ..........................................................................................................................11

Benefits............................................................................................................................11Maximum Amount......................................................................................................11Emergency Transportation and Treatment Benefit ....................................................11In-Hospital Indemnity Daily Benefit ............................................................................12In-Hospital Indemnity Single Payment Benefit...........................................................12In-Hospital Indemnity Sickness Daily Benefit ............................................................13In-Hospital Indemnity Sickness Single Payment Benefit ...........................................14Physician’s Office Visits Benefit.................................................................................14

Limitations........................................................................................................................14Limitation on Multiple Covered Activities ...................................................................14Reduction Schedule...................................................................................................15

Exclusions........................................................................................................................15

Claims Provisions ............................................................................................................15

General Provisions ..........................................................................................................16

A30298NUFIC - NJ 2 DTC101BNJ

Benefit ScheduleBenefit Maximum Amount

PrimaryInsured

InsuredSpouse

InsuredDependentChild(ren)

Emergency Transportation BenefitMaximum Number of Transportation benefits Per Family Per Year: 4Policy Month in which Injury causing the Emergency Transportation occurs:1-3 $200.00 $100.00 $40.004-6 $205.00 $102.50 $41.007-9 $210.00 $105.00 $42.0010-12 $215.00 $107.50 $43.0013-15 $220.00 $110.00 $44.0016-18 $225.00 $112.50 $45.0019-21 $230.00 $115.00 $46.0022-24 $235.00 $117.50 $47.0025-27 $240.00 $120.00 $48.0028-30 $245.00 $122.50 $49.0031-33 $250.00 $125.00 $50.0034-36 $255.00 $127.50 $51.0037-39 $260.00 $130.00 $52.0040-42 $265.00 $132.50 $53.0043-45 $270.00 $135.00 $54.0046-48 $275.00 $137.50 $55.0049-51 $280.00 $140.00 $56.0052-54 $285.00 $142.50 $57.0055-57 $290.00 $145.00 $58.0058-60 $295.00 $147.50 $59.0061-63 $300.00 $150.00 $60.0064-66 $305.00 $152.50 $61.0067-69 $310.00 $155.00 $62.0070-72 $315.00 $157.50 $63.0073-75 $320.00 $160.00 $64.0076-78 $325.00 $162.50 $65.0079-81 $330.00 $165.00 $66.0082-84 $335.00 $167.50 $67.0085-87 $340.00 $170.00 $68.0088-90 $345.00 $172.50 $69.0091-93 $350.00 $175.00 $70.0094-96 $355.00 $177.50 $71.0097-99 $360.00 $180.00 $72.00100-102 $365.00 $182.50 $73.00103-105 $370.00 $185.00 $74.00106-108 $375.00 $187.50 $75.00109-111 $380.00 $190.00 $76.00112-114 $385.00 $192.50 $77.00115-117 $390.00 $195.00 $78.00118-120 $395.00 $197.50 $79.00120+ $400.00 $200.00 $80.00

SCHEDULE

CLASSIFICATION OF ELIGIBLE PERSONS:Class 1 All Members of Group Insurance Trust DelawareClass 2 Eligible Spouses of Class I InsuredsClass 3 Eligible Dependent Child(ren) of Class 1 Insureds

INSURED: Linza SoasaCOVERAGE EFFECTIVE DATE: 02/25/2010PREMIUM PAYMENTS:Monthly Premium: $45.95COVERED ACTIVITIES:24 Hour Coverage


Emergency Treatment BenefitMaximum Number of Visits Per Family Per Year: 6Policy Month in which Injury causing the Emergency Treatment occurs:1-3 $300.00 $150.00 $60.004-6 $307.50 $153.75 $61.507-9 $315.00 $157.50 $63.0010-12 $322.50 $161.25 $64.5013-15 $330.00 $165.00 $66.0016-18 $337.50 $168.75 $67.5019-21 $345.00 $172.50 $69.0022-24 $352.50 $176.25 $70.5025-27 $360.00 $180.00 $72.0028-30 $367.50 $183.75 $73.5031-33 $375.00 $187.50 $75.0034-36 $382.50 $191.25 $76.5037-39 $390.00 $195.00 $78.0040-42 $397.50 $198.75 $79.5043-45 $405.00 $202.50 $81.0046-48 $412.50 $206.25 $82.5049-51 $420.00 $210.00 $84.0052-54 $427.50 $213.75 $85.5055-57 $435.00 $217.50 $87.0058-60 $442.50 $221.25 $88.5061-63 $450.00 $225.00 $90.0064-66 $457.50 $228.75 $91.5067-69 $465.00 $232.50 $93.0070-72 $472.50 $236.25 $94.5073-75 $480.00 $240.00 $96.0076-78 $487.50 $243.75 $97.5079-81 $495.00 $247.50 $99.0082-84 $502.50 $251.25 $100.5085-87 $510.00 $255.00 $102.0088-90 $517.50 $258.75 $103.5091-93 $525.00 $262.50 $105.0094-96 $532.50 $266.25 $106.5097-99 $540.00 $270.00 $108.00100-102 $547.50 $273.75 $109.50103-105 $555.00 $277.50 $111.00106-108 $562.50 $281.25 $112.50109-111 $570.00 $285.00 $114.00112-114 $577.50 $288.75 $115.50115-117 $585.00 $292.50 $117.00118-120 $592.50 $296.25 $118.50120+ $600.00 $300.00 $120.00

In-Hospital Indemnity Daily Benefit (Maximum Number of Days: 365)Policy Month in which Injury causing Hospitalization occurs:1-3 $400.00 $200.00 $80.004-6 $410.00 $205.00 $82.007-9 $420.00 $210.00 $84.0010-12 $430.00 $215.00 $86.0013-15 $440.00 $220.00 $88.0016-18 $450.00 $225.00 $90.0019-21 $460.00 $230.00 $92.0022-24 $470.00 $235.00 $94.0025-27 $480.00 $240.00 $96.0028-30 $490.00 $245.00 $98.0031-33 $500.00 $250.00 $100.0034-36 $510.00 $255.00 $102.0037-39 $520.00 $260.00 $104.0040-42 $530.00 $265.00 $106.00


43-45 $540.00 $270.00 $108.0046-48 $550.00 $275.00 $110.0049-51 $560.00 $280.00 $112.0052-54 $570.00 $285.00 $114.0055-57 $580.00 $290.00 $116.0058-60 $590.00 $295.00 $118.0061-63 $600.00 $300.00 $120.0064-66 $610.00 $305.00 $122.0067-69 $620.00 $310.00 $124.0070-72 $630.00 $315.00 $126.0073-75 $640.00 $320.00 $128.0076-78 $650.00 $325.00 $130.0079-81 $660.00 $330.00 $132.0082-84 $670.00 $335.00 $134.0085-87 $680.00 $340.00 $136.0088-90 $690.00 $345.00 $138.0091-93 $700.00 $350.00 $140.0094-96 $710.00 $355.00 $142.0097-99 $720.00 $360.00 $144.00100-102 $730.00 $365.00 $146.00103-105 $740.00 $370.00 $148.00106-108 $750.00 $375.00 $150.00109-111 $760.00 $380.00 $152.00112-114 $770.00 $385.00 $154.00115-117 $780.00 $390.00 $156.00118-120 $790.00 $395.00 $158.00120+ $800.00 $400.00 $160.00

In-Hospital Indemnity Single Payment BenefitDays of Confinement: 30 DaysPolicy Month in which Injury causing Hospitalization occurs:1-3 $5,000.00 $2,500.00 $1,000.004-6 $5,125.00 $2,562.50 $1,025.007-9 $5,250.00 $2,625.00 $1,050.0010-12 $5,375.00 $2,687.50 $1,075.0013-15 $5,500.00 $2,750.00 $1,100.0016-18 $5,625.00 $2,812.50 $1,125.0019-21 $5,750.00 $2,875.00 $1,150.0022-24 $5,875.00 $2,937.50 $1,175.0025-27 $6,000.00 $3,000.00 $1,200.0028-30 $6,125.00 $3,062.50 $1,225.0031-33 $6,250.00 $3,125.00 $1,250.0034-36 $6,375.00 $3,187.50 $1,275.0037-39 $6,500.00 $3,250.00 $1,300.0040-42 $6,625.00 $3,312.50 $1,325.0043-45 $6,750.00 $3,375.00 $1,350.0046-48 $6,875.00 $3,437.50 $1,375.0049-51 $7,000.00 $3,500.00 $1,400.0052-54 $7,125.00 $3,562.50 $1,425.0055-57 $7,250.00 $3,625.00 $1,450.0058-60 $7,375.00 $3,687.50 $1,475.0061-63 $7,500.00 $3,750.00 $1,500.0064-66 $7,625.00 $3,812.50 $1,525.0067-69 $7,750.00 $3,875.00 $1,550.0070-72 $7,875.00 $3,937.50 $1,575.0073-75 $8,000.00 $4,000.00 $1,600.0076-78 $8,125.00 $4,062.50 $1,625.0079-81 $8,250.00 $4,125.00 $1,650.0082-84 $8,375.00 $4,187.50 $1,675.0085-87 $8,500.00 $4,250.00 $1,700.0088-90 $8,625.00 $4,312.50 $1,725.0091-93 $8,750.00 $4,375.00 $1,750.00


94-96 $8,875.00 $4,437.50 $1,775.0097-99 $9,000.00 $4,500.00 $1,800.00100-102 $9,125.00 $4,562.50 $1,825.00103-105 $9,250.00 $4,625.00 $1,850.00106-108 $9,375.00 $4,687.50 $1,875.00109-111 $9,500.00 $4,750.00 $1,900.00112-114 $9,625.00 $4,812.50 $1,925.00115-117 $9,750.00 $4,875.00 $1,950.00118-120 $9,875.00 $4,937.50 $1,975.00120+ $10,000.00 $5,000.00 $2,000.00

In-Hospital Indemnity Single Payment BenefitDays of Confinement: 60 DaysPolicy Month in which Injury causing Hospitalization occurs:1-3 $5,000.00 $2,500.00 $1,000.004-6 $5,125.00 $2,562.50 $1,025.007-9 $5,250.00 $2,625.00 $1,050.0010-12 $5,375.00 $2,687.50 $1,075.0013-15 $5,500.00 $2,750.00 $1,100.0016-18 $5,625.00 $2,812.50 $1,125.0019-21 $5,750.00 $2,875.00 $1,150.0022-24 $5,875.00 $2,937.50 $1,175.0025-27 $6,000.00 $3,000.00 $1,200.0028-30 $6,125.00 $3,062.50 $1,225.0031-33 $6,250.00 $3,125.00 $1,250.0034-36 $6,375.00 $3,187.50 $1,275.0037-39 $6,500.00 $3,250.00 $1,300.0040-42 $6,625.00 $3,312.50 $1,325.0043-45 $6,750.00 $3,375.00 $1,350.0046-48 $6,875.00 $3,437.50 $1,375.0049-51 $7,000.00 $3,500.00 $1,400.0052-54 $7,125.00 $3,562.50 $1,425.0055-57 $7,250.00 $3,625.00 $1,450.0058-60 $7,375.00 $3,687.50 $1,475.0061-63 $7,500.00 $3,750.00 $1,500.0064-66 $7,625.00 $3,812.50 $1,525.0067-69 $7,750.00 $3,875.00 $1,550.0070-72 $7,875.00 $3,937.50 $1,575.0073-75 $8,000.00 $4,000.00 $1,600.0076-78 $8,125.00 $4,062.50 $1,625.0079-81 $8,250.00 $4,125.00 $1,650.0082-84 $8,375.00 $4,187.50 $1,675.0085-87 $8,500.00 $4,250.00 $1,700.0088-90 $8,625.00 $4,312.50 $1,725.0091-93 $8,750.00 $4,375.00 $1,750.0094-96 $8,875.00 $4,437.50 $1,775.0097-99 $9,000.00 $4,500.00 $1,800.00100-102 $9,125.00 $4,562.50 $1,825.00103-105 $9,250.00 $4,625.00 $1,850.00106-108 $9,375.00 $4,687.50 $1,875.00109-111 $9,500.00 $4,750.00 $1,900.00112-114 $9,625.00 $4,812.50 $1,925.00115-117 $9,750.00 $4,875.00 $1,950.00118-120 $9,875.00 $4,937.50 $1,975.00120+ $10,000.00 $5,000.00 $2,000.00

In-Hospital Indemnity Sickness Daily Benefit (Maximum Number ofDays: 365)Policy Month in which Sickness causing Hospitalization occurs:1-3 $200.00 $100.00 $40.004-6 $205.00 $102.50 $41.007-9 $210.00 $105.00 $42.0010-12 $215.00 $107.50 $43.00


13-15 $220.00 $110.00 $44.0016-18 $225.00 $112.50 $45.0019-21 $230.00 $115.00 $46.0022-24 $235.00 $117.50 $47.0025-27 $240.00 $120.00 $48.0028-30 $245.00 $122.50 $49.0031-33 $250.00 $125.00 $50.0034-36 $255.00 $127.50 $51.0037-39 $260.00 $130.00 $52.0040-42 $265.00 $132.50 $53.0043-45 $270.00 $135.00 $54.0046-48 $275.00 $137.50 $55.0049-51 $280.00 $140.00 $56.0052-54 $285.00 $142.50 $57.0055-57 $290.00 $145.00 $58.0058-60 $295.00 $147.50 $59.0061-63 $300.00 $150.00 $60.0064-66 $305.00 $152.50 $61.0067-69 $310.00 $155.00 $62.0070-72 $315.00 $157.50 $63.0073-75 $320.00 $160.00 $64.0076-78 $325.00 $162.50 $65.0079-81 $330.00 $165.00 $66.0082-84 $335.00 $167.50 $67.0085-87 $340.00 $170.00 $68.0088-90 $345.00 $172.50 $69.0091-93 $350.00 $175.00 $70.0094-96 $355.00 $177.50 $71.0097-99 $360.00 $180.00 $72.00100-102 $365.00 $182.50 $73.00103-105 $370.00 $185.00 $74.00106-108 $375.00 $187.50 $75.00109-111 $380.00 $190.00 $76.00112-114 $385.00 $192.50 $77.00115-117 $390.00 $195.00 $78.00118-120 $395.00 $197.50 $79.00120+ $400.00 $200.00 $80.00

In-Hospital Indemnity Sickness Single Payment Benefit Payable only once during the lifetime of the Insured Person

Days of Confinement: 30 DaysPolicy Month in which Sickness causing Hospitalization occurs:1-3 $5,000.00 $2,500.00 $1,000.004-6 $5,125.00 $2,562.50 $1,025.007-9 $5,250.00 $2,625.00 $1,050.0010-12 $5,375.00 $2,687.50 $1,075.0013-15 $5,500.00 $2,750.00 $1,100.0016-18 $5,625.00 $2,812.50 $1,125.0019-21 $5,750.00 $2,875.00 $1,150.0022-24 $5,875.00 $2,937.50 $1,175.0025-27 $6,000.00 $3,000.00 $1,200.0028-30 $6,125.00 $3,062.50 $1,225.0031-33 $6,250.00 $3,125.00 $1,250.0034-36 $6,375.00 $3,187.50 $1,275.0037-39 $6,500.00 $3,250.00 $1,300.0040-42 $6,625.00 $3,312.50 $1,325.0043-45 $6,750.00 $3,375.00 $1,350.0046-48 $6,875.00 $3,437.50 $1,375.0049-51 $7,000.00 $3,500.00 $1,400.0052-54 $7,125.00 $3,562.50 $1,425.0055-57 $7,250.00 $3,625.00 $1,450.0058-60 $7,375.00 $3,687.50 $1,475.0061-63 $7,500.00 $3,750.00 $1,500.00


64-66 $7,625.00 $3,812.50 $1,525.0067-69 $7,750.00 $3,875.00 $1,550.0070-72 $7,875.00 $3,937.50 $1,575.0073-75 $8,000.00 $4,000.00 $1,600.0076-78 $8,125.00 $4,062.50 $1,625.0079-81 $8,250.00 $4,125.00 $1,650.0082-84 $8,375.00 $4,187.50 $1,675.0085-87 $8,500.00 $4,250.00 $1,700.0088-90 $8,625.00 $4,312.50 $1,725.0091-93 $8,750.00 $4,375.00 $1,750.0094-96 $8,875.00 $4,437.50 $1,775.0097-99 $9,000.00 $4,500.00 $1,800.00100-102 $9,125.00 $4,562.50 $1,825.00103-105 $9,250.00 $4,625.00 $1,850.00106-108 $9,375.00 $4,687.50 $1,875.00109-111 $9,500.00 $4,750.00 $1,900.00112-114 $9,625.00 $4,812.50 $1,925.00115-117 $9,750.00 $4,875.00 $1,950.00118-120 $9,875.00 $4,937.50 $1,975.00120+ $10,000.00 $5,000.00 $2,000.00

In-Hospital Indemnity Sickness Single Payment Benefit Payable only once during the lifetime of the Insured Person

Days of Confinement: 60 DaysPolicy Month in which Sickness causing Hospitalization occurs:1-3 $5,000.00 $2,500.00 $1,000.004-6 $5,125.00 $2,562.50 $1,025.007-9 $5,250.00 $2,625.00 $1,050.0010-12 $5,375.00 $2,687.50 $1,075.0013-15 $5,500.00 $2,750.00 $1,100.0016-18 $5,625.00 $2,812.50 $1,125.0019-21 $5,750.00 $2,875.00 $1,150.0022-24 $5,875.00 $2,937.50 $1,175.0025-27 $6,000.00 $3,000.00 $1,200.0028-30 $6,125.00 $3,062.50 $1,225.0031-33 $6,250.00 $3,125.00 $1,250.0034-36 $6,375.00 $3,187.50 $1,275.0037-39 $6,500.00 $3,250.00 $1,300.0040-42 $6,625.00 $3,312.50 $1,325.0043-45 $6,750.00 $3,375.00 $1,350.0046-48 $6,875.00 $3,437.50 $1,375.0049-51 $7,000.00 $3,500.00 $1,400.0052-54 $7,125.00 $3,562.50 $1,425.0055-57 $7,250.00 $3,625.00 $1,450.0058-60 $7,375.00 $3,687.50 $1,475.0061-63 $7,500.00 $3,750.00 $1,500.0064-66 $7,625.00 $3,812.50 $1,525.0067-69 $7,750.00 $3,875.00 $1,550.0070-72 $7,875.00 $3,937.50 $1,575.0073-75 $8,000.00 $4,000.00 $1,600.0076-78 $8,125.00 $4,062.50 $1,625.0079-81 $8,250.00 $4,125.00 $1,650.0082-84 $8,375.00 $4,187.50 $1,675.0085-87 $8,500.00 $4,250.00 $1,700.0088-90 $8,625.00 $4,312.50 $1,725.0091-93 $8,750.00 $4,375.00 $1,750.0094-96 $8,875.00 $4,437.50 $1,775.0097-99 $9,000.00 $4,500.00 $1,800.00100-102 $9,125.00 $4,562.50 $1,825.00103-105 $9,250.00 $4,625.00 $1,850.00106-108 $9,375.00 $4,687.50 $1,875.00109-111 $9,500.00 $4,750.00 $1,900.00112-114 $9,625.00 $4,812.50 $1,925.00


115-117 $9,750.00 $4,875.00 $1,950.00118-120 $9,875.00 $4,937.50 $1,975.00120+ $10,000.00 $5,000.00 $2,000.00Physician’s Office Visits BenefitMaximum Number of Visits Per Family: Months 1 to 36: 5 VisitsMaximum Number of Visits Per Family: Months 37+: 8 Visits

Maximum Number of Visits Per Calendar Quarter Per Family: 2Policy Month in which Physician’s Office Visits occurs:1-3 $50.00 $50.00 $50.004-6 $50.00 $50.00 $50.007-9 $50.00 $50.00 $50.0010-12 $50.00 $50.00 $50.0013-15 $50.00 $50.00 $50.0016-18 $50.00 $50.00 $50.0019-21 $50.00 $50.00 $50.0022-24 $50.00 $50.00 $50.0025-27 $50.00 $50.00 $50.0028-30 $50.00 $50.00 $50.0031-33 $50.00 $50.00 $50.0034-36 $50.00 $50.00 $50.0037-39 $50.00 $50.00 $50.0040-42 $50.00 $50.00 $50.0043-45 $50.00 $50.00 $50.0046-48 $50.00 $50.00 $50.0049-51 $50.00 $50.00 $50.0052-54 $50.00 $50.00 $50.0055-57 $50.00 $50.00 $50.0058-60 $50.00 $50.00 $50.0061-63 $50.00 $50.00 $50.0064-66 $50.00 $50.00 $50.0067-69 $50.00 $50.00 $50.0070-72 $50.00 $50.00 $50.0073-75 $50.00 $50.00 $50.0076-78 $50.00 $50.00 $50.0079-81 $50.00 $50.00 $50.0082-84 $50.00 $50.00 $50.0085-87 $50.00 $50.00 $50.0088-90 $50.00 $50.00 $50.0091-93 $50.00 $50.00 $50.0094-96 $50.00 $50.00 $50.0097-99 $50.00 $50.00 $50.00100-102 $50.00 $50.00 $50.00103-105 $50.00 $50.00 $50.00106-108 $50.00 $50.00 $50.00109-111 $50.00 $50.00 $50.00112-114 $50.00 $50.00 $50.00115-117 $50.00 $50.00 $50.00118-120 $50.00 $50.00 $50.00120+ $50.00 $50.00 $50.00

The Maximum Amounts are used to determine amounts payable under each Benefit. Actual amounts payable will not exceedthe maximums, and may be less than the maximums under circumstances specified in this Certificate.

The Maximum Amounts specified above for an Insured Person who is age 70 or older on the date of an accident for whichbenefits are payable, except the Physician’s Office Visits Indemnity Benefit, will be reduced by 50%.


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DEFINITIONS

Any capitalized terms in this Certificate and any riders, endorsements, or other attached papers are to be given the meanings as ascribed in this section or as later defined. Age - means the age of the Insured Person on the Insured Person's most recent birthday, regardless of the actual time of birth. Covered Activity (ies) - means those activities set out in the Covered Activities section of the Schedule with respect to which Insured Persons are provided accident insurance under the Policy.

Eligible Spouse – means Your legal spouse. Eligible Dependent – means an Eligible Spouse or Eligible Dependent Child. Eligible Dependent Child – means Your unmarried child(ren), including natural, step, foster or adopted children from the moment of placement in Your home, under age 19 ( 23 if attending an accredited institution of higher learning on a full time basis) and primarily dependent on You for support and maintenance. If the Insured has a court order to provide coverage under the Policy to a child, the amount of support contributed by the Insured for such child will not be used to determine whether or not such child is an “eligible dependent child.” Immediate Family Member - means a person who is related to the Insured Person in any of the following ways: spouse, brother-in-law, sister-in-law, son-in-law, daughter-in-law, mother-in-law, father-in-law, parent (includes stepparent), grandparent, brother or sister (includes stepbrother or stepsister), or child (includes legally adopted or stepchild). Injury - means bodily injury: (1) which is sustained as a direct result of an unintended, unanticipated accident that is external to the body and that occurs while the injured person's coverage under the Policy is in force; (2) which directly (independent of sickness, disease, mental incapacity, bodily infirmity or any other cause) causes a covered loss; and (3) which occurs while such person is participating in a Covered Activity.

Insured - means a person: (1) who is a member of an eligible class of persons as described in the Classification of Eligible Persons section of the Schedule; (2) for whom premium has been paid when due; (3) while covered under the Policy; and (4) who has enrolled for coverage under the Policy, if required. However, an Insured does not include any person

covered under the Policy solely as an Insured Dependent.

Insured Dependent – means Your Insured Spouse or Insured Dependent Child. Insured Dependent Child - means Your Eligible Dependent Child: (1) whom You have elected to cover under the Policy; (2) for whom premium has been paid when due; and (3) while covered under the Policy. Insured Person – means the Insured or an Insured Dependent.

Insured Spouse – means Your Eligible Spouse; (1) whom You have elected to cover under the Policy; (2) for whom premium has been paid when due; and (3) while covered under the Policy.

Physician - means a licensed practitioner of the healing arts acting within the scope of his or her license who is not: 1) the Insured Person; 2) an Immediate Family Member; or 3) retained by the Policyholder. You, Your – means the Insured. INSURED'S EFFECTIVE AND TERMINATION DATES

Effective Date. Your coverage under the Policy begins on the latest of: (1) the Policy Effective Date; (2) the date for which the first premium for Your coverage is paid when due; (3) the date You become a member of an eligible class of persons, as described in the Classification of Eligible Persons section of the Schedule; (4) if individual enrollment is required, the date enrollment is received. Termination Date. Your coverage under the Policy ends on the earliest of: (1) the date the Policy is terminated (unless the Company and the Policyholder agree, in writing, to permit coverage to continue to the end of the period for which premiums have been paid in lieu of a return of unearned premiums); (2) the premium due date if premiums are not paid when due; (3) the date You cease to be a member of any eligible class(es) of persons, as described in the Classification of Eligible Persons section of the Schedule; (4) the date You request that Your coverage be terminated; or (5) the date You attain Age 85. Termination of coverage will not affect a claim for a covered loss that occurred while Your coverage was in force under the Policy.

INSURED DEPENDENT’S EFFECTIVE AND TERMINATION DATES

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Effective Date. Your Eligible Dependent’s coverage under the Policy begins on the latest of: (1) the date Your coverage under the Policy begins, (2) the date the first premium for the Eligible Dependent’s coverage is paid when due; (3) the date the person becomes an Eligible Dependent; or 4) if individual enrollment is required, the date Your enrollment is received. Termination Date. An Insured Dependent’s coverage under the Policy ends on the earliest of: (1) the date Your coverage under the Policy ends; (2) the premium due date if premiums for the Insured Dependent are not paid when due; (3) the date You request that coverage for the Insured Dependent be terminated; or (4) the date the Insured Dependent ceases to meet the definition of an Eligible Dependent. Termination of coverage will not affect a claim for a covered loss that occurred while the Insured Dependent’s coverage was in force under the Policy.

PREMIUM

Premiums. The Company provides insurance in return for premium payments. The premium shown in the Schedule is payable to the Company in the manner described in the Schedule. The Company may change the required premiums due by giving the Policyholder at least 31 days advance written notice. The Company may also change the required premiums at any time when any coverage change affecting premiums is made in the Policy. Grace Period. A Grace Period of 31 days will be provided for the payment of any premium due after the first. An Insured Person’s coverage will not be terminated for nonpayment of premium during the Grace Period if all premiums due are paid by the last day of the Grace Period. An Insured Person’s coverage will terminate on the last day of the period for which all premiums have been paid if all premiums due are not paid by the last day of the Grace Period. If the Company expressly agrees to accept late payment of a premium without terminating coverage under the Policy, the Company does so in accordance with the Noncompliance with Policy Requirements provision of the General Provisions section. No Grace Period will be provided if the Company receives notice to terminate the Insured Person’s coverage under the Policy prior to a premium due date.

BENEFITS

Maximum Amount. As applicable to each Benefit provided by the Policy for each Insured Person, Maximum Amount means the amount shown as the maximum amount for that Benefit for the Insured

Person’s class in the Benefit Schedule, subject to the Reduction Schedule shown in the Limitations section.

Emergency Transportation and Treatment Benefit

Emergency Transportation Benefit. If an Insured Person suffers an Injury that requires Emergency Treatment within 24 hours of the date of the accident that caused the Injury and it is determined that it is Medically Necessary that such Insured Person be transported to a Hospital or a Satellite Emergency Center by Ambulance, the Company will pay 100% of the Emergency Transportation Maximum Amount shown in the Benefit Schedule. Only one Emergency Transportation Benefit is payable for any one accident per Insured Person. The maximum number of Emergency Transportation Benefits payable per calendar year per Insured Person regardless of the number of accidents incurred, is shown in the Benefit Schedule. Emergency Treatment Benefit. If an Insured Person suffers an Injury that, within 24 hours of the date of the accident that caused the Injury, requires him or her to receive Medically Necessary Emergency Treatment in a Hospital emergency room or a Satellite Emergency Center, the Company will pay 100% Emergency Treatment Benefit Maximum Amount shown in the Benefit Schedule. Only one Emergency Treatment Benefit is payable for any one accident per Insured Person. The maximum number of Emergency Treatment Benefits payable per calendar year per Insured Person regardless of the number of accidents incurred, is shown in the Benefit Schedule. Definitions Ambulance – means any publicly or privately owned surface, water or air vehicle, including a helicopter, that is specifically designed and constructed or modified and equipped to be used, maintained or operated primarily for the transportation of individuals who are sick, injured or wounded. Ambulance does not include a surface, water or air vehicle that is owned and operated to accommodate an incapacitated or disabled person who does not require medical monitoring, care or treatment during transport. Emergency Treatment – means treatment for a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson with average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in: 1. Placing the health of the person (or with respect to a

pregnant woman, the health of her unborn child) in serious jeopardy;

2. Serious impairment to bodily functions; or

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3. Serious dysfunction of any bodily organ or part. Hospital - means a facility which: (1) is operated according to law for the care and treatment of injured and sick people; (2) has organized facilities for diagnosis and surgery on its premises or in facilities available to it on a prearranged basis; (3) has 24 hour nursing service by registered nurses (R.N.’s); and (4) is supervised by one or more Physicians. A Hospital does not include: (1) a nursing, convalescent or geriatric unit of a hospital when a patient is confined mainly to receive nursing care; or (2) a facility that is, other than incidentally, a rest home, nursing home, convalescent home or home for the aged; nor does it include any ward room, wing, or other section of the hospital that is used for such purposes. Medically Necessary – means an Emergency Treatment or Transportation is: (1) essential for the diagnosis, treatment and care of the Injury; (2) meets generally accepted standards of medical practice; (3) is ordered by a Physician and performed under the Physician’s care, supervision or order; or (4) with regard to Emergency Transportation, is subsequently authorized by a Physician as appropriate due to the nature of the Injury. Satellite Emergency Center - means a licensed facility providing outpatient care under the direction of a Physician on a 24 hour basis. Available services must include: (1) diagnostic care, including laboratory services and diagnostic x-rays; and (2) treatment or medical care, including availability of the means for stabilization of emergency medical conditions. A Satellite Emergency Center does not include a Hospital or an office maintained by a Physician for the practice of medicine or dentistry.

In-Hospital Indemnity Daily Benefit If an Insured Person suffers an Injury that, within 90 days of the date of the accident that caused the Injury, requires him or her to be confined in a Hospital as an Inpatient, the Company will pay a benefit after 1 Day of Medically Necessary Confinement due to that Injury, retroactive to the first Day of Confinement. No benefit is provided for any Day(s) of Confinement that are not Medically Necessary. The amount of the benefit is equal to 100% of the Daily Maximum Amount shown for the In-Hospital Indemnity Daily Benefit in the Benefit Schedule per day of Medically Necessary Inpatient confinement due to that Injury. It is payable monthly up to the Maximum Number of Days shown for the In-Hospital Indemnity Daily Benefit in the Benefit Schedule during any one Period of Confinement. Only one benefit is provided for any one Day of Confinement, regardless of the number of Injuries for which the confinement is required.

Day(s) of Confinement - means a day of Hospital confinement as an Inpatient. Hospital - means a facility which: (1) is operated according to law for the care and treatment of injured and sick people; (2) has organized facilities for diagnosis and surgery on its premises or in facilities available to it on a prearranged basis; (3) has 24 hour nursing service by registered nurses (R.N.’s); and (4) is supervised by one or more Physicians. A Hospital does not include: (1) a nursing, convalescent or geriatric unit of a hospital when a patient is confined mainly to receive nursing care; or (2) a facility which is, other than incidentally, a rest home, nursing home, convalescent home or home for the aged; nor does it include any ward room, wing, or other section of the hospital that is used for such purposes. Inpatient - means a person: (1) who is confined in a Hospital as a registered bed patient; and (2) for whom at least one day's room and board is charged by the Hospital unless the Insured Person is confined as an Inpatient in any military, veterans or other government supported or sponsored Hospital for which a charge for room and board is not made. Medically Necessary – means that confinement as an In-patient in a Hospital is (1) essential for the diagnosis, treatment and care of the Injury; (2) in accordance with generally accepted standards of medical practice; and (3) ordered by a Physician. Period of Confinement - means a period of consecutive Days of Confinement as an Inpatient for all Injuries caused by the same accident. However, successive confinements as an Inpatient for all Injuries caused by the same accident are considered to be part of the same Period of Confinement, unless the discharge date for the prior confinement is separated from the admission date for the next confinement by at least 60 days.

In-Hospital Indemnity Single Payment Benefit If an Insured Person suffers an Injury that, within 90 days of the date of the accident that caused the Injury, requires him or her to be confined in a Hospital as an Inpatient, the Company will pay a benefit after 30 consecutive Day(s) of Medically Necessary Confinement due to that Injury. No benefit is provided if the Insured Person is confined for less than 30 consecutive Medically Necessary Days of Confinement. The amount of the benefit is equal to 100% of the Maximum Amount shown for the In-Hospital Indemnity Single Payment Benefit in the Benefit Schedule. Only one benefit is provided for any one accident per Insured Person regardless of the number of Injuries for which the confinement is required or the number of times the Insured Person must be confined due to Injuries resulting from the same accident.

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If an Insured Person suffers an Injury that, within 90 days of the date of the accident that caused the Injury, requires him or her to be confined in a Hospital as an Inpatient, the Company will pay a benefit after 60 consecutive Day(s) of Medically Necessary Confinement due to that Injury. No benefit is provided if the Insured Person is confined for less than 60 consecutive Medically Necessary Days of Confinement. The amount of the benefit is equal to 100% of the Maximum Amount shown for the In-Hospital Indemnity Single Payment Benefit in the Benefit Schedule. Only one benefit is provided for any one accident per Insured Person regardless of the number of Injuries for which the confinement is required or the number of times the Insured Person must be confined due to Injuries resulting from the same accident. Day(s) of Confinement - means a day of Hospital confinement as an Inpatient. Hospital - means a facility which: (1) is operated according to law for the care and treatment of injured and sick people; (2) has organized facilities for diagnosis and surgery on its premises or in facilities available to it on a prearranged basis; (3) has 24 hour nursing service by registered nurses (R.N.’s); and (4) is supervised by one or more Physicians. A Hospital does not include: (1) a nursing, convalescent or geriatric unit of a hospital when a patient is confined mainly to receive nursing care; or (2) a facility which is, other than incidentally, a rest home, nursing home, convalescent home or home for the aged; nor does it include any ward room, wing, or other section of the hospital that is used for such purposes. Inpatient - means a person: (1) who is confined in a Hospital as a registered bed patient; and (2) for whom at least one day's room and board is charged by the Hospital unless the Insured Person is confined as an Inpatient in any military, veterans or other government supported or sponsored Hospital for which a charge for room and board is not made. Medically Necessary – means that confinement as an In-patient in a Hospital is (1) essential for the diagnosis, treatment and care of the Injury; (2) in accordance with generally accepted standards of medical practice; and (3) ordered by a Physician.

In-Hospital Indemnity Sickness Daily Benefit

Not applicable to Insured Persons Age 75 or older

If, after an Insured Person has been covered under the Policy for at least 0 consecutive months and that Insured Person suffers a Sickness that requires him or her to be confined in a Hospital as an Inpatient, the Company will pay a benefit after 3 consecutive Day(s) of Medically Necessary Confinement due to that Sickness, retroactive to the first Day of Confinement. No benefit is

provided for any Day(s) of Confinement that are not Medically Necessary. The amount of the benefit is equal to 100% of the In-Hospital Indemnity Sickness Daily Benefit shown in the Benefit Schedule per day of Medically Necessary Inpatient confinement due to that Sickness. The benefit is payable monthly up to the Maximum Number of Days shown for the In-Hospital Indemnity Sickness Daily Benefit in the Benefit Schedule during any one Period of Confinement. Only one benefit is provided for any one Day of Confinement, regardless of the number of Sicknesses for which the confinement is required. Day(s) of Confinement - means a day of Hospital confinement as an Inpatient. Hospital - means a facility which: (1) is operated according to law for the care and treatment of injured and sick people; (2) has organized facilities for diagnosis and surgery on its premises or in facilities available to it on a prearranged basis; (3) has 24 hour nursing service by registered nurses (R.N.’s); and (4) is supervised by one or more Physicians. A Hospital does not include: (1) a nursing, convalescent or geriatric unit of a hospital when a patient is confined mainly to receive nursing care; or (2) a facility which is, other than incidentally, a rest home, nursing home, convalescent home or home for the aged; nor does it include any ward room, wing, or other section of the hospital that is used for such purposes. Inpatient - means a person: (1) who is confined in a Hospital as a registered bed patient; and (2) for whom at least one day's room and board is charged by the Hospital unless the Insured Person is confined as an Inpatient in any military, veterans or other government supported or sponsored Hospital for which a charge for room and board is not made. Medically Necessary – means that confinement as an In-patient in a Hospital is (1) essential for the diagnosis, treatment and care of the Sickness; (2) in accordance with generally accepted standards of medical practice; and (3) ordered by a Physician. Period of Confinement - means a period of consecutive Days of Confinement as an Inpatient for the same Sickness. However, successive confinements as an Inpatient for the same Sickness are considered to be part of the same Period of Confinement, unless the discharge date for the prior confinement is separated from the admission date for the next confinement by at least 60 days. If the same Insured Person is again confined due to the same Sickness or a new Sickness and such successive confinement is separated from the admission date for the first confinement by at least 60 days and the Insured Person has not been paid the Maximum Number of Days shown in the In-Hospital Indemnity Sickness Daily

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Benefit for previous Medically Necessary Days of Confinement, benefits will continue to be payable under this benefit for the same Sickness or a new Sickness in accordance with the requirements specified above until the Maximum Number of Days shown in the In-Hospital Indemnity Sickness Daily Benefit in the Benefit Scheduled have been paid for that Insured Person. Once the maximum has been reached, no benefits are payable for any additional confinements due to Sickness for the lifetime of the Insured Person. Sickness – means an illness or disease which is diagnosed or treated by a Physician after the effective date of coverage under this Policy. Any exclusion within the Exclusions section regarding sickness or disease; stroke or cerebrovascular accident or event; cardiovascular accident or event; myocardial infarction or heart attack; coronary thrombosis or aneurysm is hereby waived for this benefit.

In-Hospital Indemnity Sickness Single Payment Benefit

Not applicable to Insured Persons Age 75 or older

If, after an Insured Person has been covered under the Policy for at least 0 consecutive months and that Insured Person suffers a Sickness that requires him or her to be confined in a Hospital as an Inpatient, the Company will pay a benefit after 30 consecutive Day(s) of Medically Necessary Confinement due to that Sickness. No benefit is provided if the Insured Person is confined for less than 30 consecutive Medically Necessary Days of Confinement. The amount of the benefit is equal to 100% of the Maximum Amount shown for the In-Hospital Indemnity Sickness Single Payment Benefit in the Benefit Schedule. The maximum number of In-Hospital Indemnity Sickness Single Payment Benefits payable is shown in the Benefit schedule. If, after an Insured Person has been covered under the Policy for at least 0 consecutive months and that Insured Person suffers a Sickness that requires him or her to be confined in a Hospital as an Inpatient, the Company will pay a benefit after 60 consecutive Day(s) of Medically Necessary Confinement due to that Sickness. No benefit is provided if the Insured Person is confined for less than 60 consecutive Medically Necessary Days of Confinement. The amount of the benefit is equal to 100% of the Maximum Amount shown for the In-Hospital Indemnity Sickness Single Payment Benefit in the Benefit Schedule. The maximum number of In-Hospital Indemnity Sickness Single Payment Benefits payable is shown in the Benefit schedule. Day(s) of Confinement - means a day of Hospital confinement as an Inpatient. Hospital - means a facility which: (1) is operated according to law for the care and treatment of injured

and sick people; (2) has organized facilities for diagnosis and surgery on its premises or in facilities available to it on a prearranged basis; (3) has 24 hour nursing service by registered nurses (R.N.’s); and (4) is supervised by one or more Physicians. A Hospital does not include: (1) a nursing, convalescent or geriatric unit of a hospital when a patient is confined mainly to receive nursing care; or (2) a facility which is, other than incidentally, a rest home, nursing home, convalescent home or home for the aged; nor does it include any ward room, wing, or other section of the hospital that is used for such purposes. Inpatient - means a person: (1) who is confined in a Hospital as a registered bed patient; and (2) for whom at least one day's room and board is charged by the Hospital unless the Insured Person is confined as an Inpatient in any military, veterans or other government supported or sponsored Hospital for which a charge for room and board is not made. Medically Necessary – means that confinement as an In-patient in a Hospital is (1) essential for the diagnosis, treatment and care of the Sickness; (2) in accordance with generally accepted standards of medical practice; and (3) ordered by a Physician. Sickness – means an illness or disease which is diagnosed or treated by a Physician after the effective date of coverage under this Policy. Any exclusion within the Exclusions section regarding sickness or disease; stroke or cerebrovascular accident or event; cardiovascular accident or event; myocardial infarction or heart attack; coronary thrombosis or aneurysm is hereby waived for this benefit.

Physician’s Office Visits Indemnity Benefit

If the Insured visits a Physician’s office for treatment of Routine Well Care, an Injury or Sickness while the Insured’s coverage under this Benefit is in force, the Company will pay a benefit equal to the Per Visit Benefit shown in the Benefit Schedule, subject to Maximum Number of Visits and the Maximum Benefit Amount shown in the Benefit Schedule. Definitions Routine Well Care - means a physical examination or appropriate immunization. Service must be under the supervision of or recommended by a Physician. Sickness – means an illness or disease which is diagnosed or treated by a Physician after the effective date of coverage under the Policy. The Sickness exclusions in the Exclusions section of the Certificate or as amended shall not apply with respect to

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benefits payable under the Physician’s Office Visits Indemnity Benefit.

LIMITATIONS Reduction Schedule. The Maximum Amount used to determine the amount payable for a loss will be reduced if an Insured Person is age 70 or older on the date of the accident causing the loss with respect to any of the following Benefits provided by the Policy: Emergency Transportation and Treatment Benefit, In-Hospital Indemnity Daily Benefit, In-Hospital Indemnity Single Payment Benefit, In-Hospital Indemnity Sickness Daily Benefit, In-Hospital Indemnity Sickness Single Payment Benefit. The Maximum Amount is reduced to a percentage of the Maximum Amount that would be used if the Insured Person were under age 70 on the date of the accident, according to the following schedule: AGE ON DATE PERCENTAGE OF UNDER- OF ACCIDENT AGE-70 MAXIMUM AMOUNT 70 or older 50% Premium for an Insured Person age 70 or older is based on 100% of the coverage that would be in effect if the Insured Person were under age 70.

EXCLUSIONS No coverage shall be provided under the Policy and no payment shall be made for any loss resulting in whole or in part from, or contributed to by, or as a natural and probable consequence of any of the following excluded risks even if the proximate or precipitating cause of the loss is an accidental bodily Injury. 1. suicide or any attempt at suicide or intentionally self-

inflicted Injury or any attempt at intentionally self-inflicted Injury or autoeroticism.

2. sickness, disease, mental incapacity or bodily infirmity whether the loss results directly or indirectly from any of these

3. the Insured Person's commission of or attempt to commit a felony.

4. infections of any kind regardless of how contracted, except bacterial infections that are directly caused by botulism, ptomaine poisoning or an accidental cut or wound independent and in the absence of any underlying sickness, disease or condition including but not limited to diabetes.

5. declared or undeclared war, or any act of declared or undeclared war, except if specifically provided by the Policy.

6. participation in any team sport or any other athletic activity, except participation in a Covered Activity.

7. full-time active duty in the armed forces, National Guard or organized reserve corps of any country or international authority. (Unearned premium for any period for which the Insured Person is not covered due to his or her active duty status will be refunded)

(Loss caused while on short-tem National Guard or reserve duty for regularly scheduled training purposes is not excluded).

8. travel or flight in or on (including getting in or out of, or on or off of) any vehicle used for aerial navigation, if the Insured Person is:

a. riding as a passenger in any aircraft not intended or licensed for the transportation of passengers; or

b. performing, learning to perform or instructing others to perform as a pilot or crew member of any aircraft; or

c. riding as a passenger in an aircraft owned, leased or operated by the Policyholder or the Insured’s employer;

9. the Insured Person being under the influence of intoxicants.

10. the Insured Person being under the influence of drugs unless taken under the advice of and as specified by a Physician.

11. the medical or surgical treatment of sickness, disease, mental incapacity or bodily infirmity whether the loss results directly or indirectly from the treatment.

12. stroke or cerebrovascular accident or event; cardiovascular accident or event; myocardial infarction or heart attack; coronary thrombosis; aneurysm.

13. any condition for which the Insured Person is entitled to benefits under any Worker’s Compensation Act or similar law.

14. the Insured Person riding in or driving any type of motor vehicle as part of a speed contest or scheduled race, including testing such vehicle on a track, speedway or proving ground.

15. any loss incurred while outside the United States, its Territories or Canada.

CLAIMS PROVISIONS

Notice of Claim. Written notice of claim must be given to the Company within 20 days after an Insured Person's loss, or as soon thereafter as reasonably possible. Notice given by or on behalf of the Insured Person to the Company at LOTSolutions, Claims Department, P. O. Box 2066, Jacksonville, FL 32203-2066, with information sufficient to identify the Insured Person, is deemed notice to the Company. Claim Forms. The Company will send claim forms to the claimant upon receipt of a written notice of claim. If such forms are not sent within 15 days after the giving of notice, the claimant will be deemed to have met the proof of loss requirements upon submitting, within the time fixed in the Policy for filing proofs of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made. The notice should include Your name, the Insured Person’s name, if

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different, the Policyholder's name and the Policy number. Proof of Loss. Written proof of loss must be furnished to the Company within 90 days after the date of the loss. If the loss is one for which the Policy requires continuing eligibility for periodic benefit payments, subsequent written proofs of eligibility must be furnished at such intervals as the Company may reasonably require. Failure to furnish proof within the time required neither invalidates nor reduces any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity of the claimant, later than one year from the time proof is otherwise required. Payment of Claims. Upon receipt of due written proof of death, payment for loss of life of an Insured Person will be made to the Insured Person’s beneficiary as described in the applicable Beneficiary Designation and Change provision. Upon receipt of due written proof of loss, payments for all losses, except loss of life, will be made to (or on behalf of, if applicable) the Insured Person suffering the loss. If an Insured Person dies before all payments due have been made, the amount still payable will be paid to his or her beneficiary as described in the applicable Beneficiary Designation and Change provision. If any payee is a minor or is not competent to give a valid release for the payment, the payment will be made to the legal guardian of the payee’s property. If the payee has no legal guardian for his or her property, a payment not exceeding $1,000 may be made, at the Company’s option, to any relative by blood or connection by marriage of the payee, who, in the Company’s opinion, has assumed the custody and support of the minor or responsibility for the incompetent person’s affairs. Any payment the Company makes in good faith fully discharges the Company's liability to the extent of the payment made. Time of Payment of Claims. Benefits payable under the Policy for any loss other than loss for which the Policy provides any periodic payment will be paid immediately upon the Company’s receipt of due written proof of the loss. Subject to the Company’s receipt of due written proof of loss, all accrued benefits for loss for which the Policy provides periodic payment will be paid at the expiration of each month during the continuance of the period for which the Company is liable and any balance remaining unpaid upon termination of liability will be paid immediately upon receipt of such proof.

GENERAL PROVISIONS

Assignment. You may not assign any of your rights, privileges or benefits under the Policy. Clerical Error. Clerical error, whether by the Policyholder or the Company, will not void the insurance of any Insured Person if that insurance would otherwise have been in effect nor extend the insurance of any Insured Person if that insurance would otherwise have ended or been reduced as provided in the Policy. Conformity With State Statutes. Any provision of the Policy which, on its effective date, is in conflict with the statutes of the state in which the Policy is delivered is hereby amended to conform to the minimum requirements of those statutes. Entire Contract; Changes. The Policy, the Application(s), this Certificate, any individual Enrollment Forms, riders, endorsements and any other attached papers make up the entire contract between the Policyholder and the Company. In the absence of fraud, all statements made by the Policyholder or any Insured Person will be considered representations and not warranties. No written statement made by an Insured Person will be used in any contest unless a copy of the statement is furnished to the Insured Person or his or her beneficiary or personal representative. No change in the Policy will be valid until approved by an officer of the Company. The approval must be noted on or attached to the Policy. No agent may change the Policy or waive any of its provisions. Incontestability. After an Insured Person has been insured under the Policy for two year(s) during his lifetime, no statement made by You or an Insured Dependent, if applicable, except a fraudulent one, will be used to contest a claim under the Policy. The Company may only contest coverage if the misstatement is made by You. Insured Beneficiary Designation and Change. Your designated beneficiary(ies) is (are) the person(s) so named by You as shown on the Company’s records kept on the Policy. If You are an Insured over the age of majority and legally competent, You may change Your beneficiary designation at any time, unless an irrevocable designation has been made, without the consent of the designated beneficiary(ies), by providing the Company, with a written request for change. When the request is received by the Company, whether You are then living or not, the change of beneficiary will relate back to and take effect as of the date of execution of the request, but without prejudice to the Company on account of any payment made by it prior to receipt of the request. If there is no designated beneficiary or no designated beneficiary is living after Your death, the benefits will be

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paid, in equal shares, to the survivors in the first surviving class of those that follow: Your (1) spouse; (2) children; (3) parents; or (4) brothers and sisters. If no class has a survivor, the beneficiary is Your estate. Insured Dependent’s Beneficiary Designation and Change. The Insured Dependent’s beneficiary is You unless You have named (a) different beneficiary(ies) for Your Insured Dependent’s coverage as shown on the Company’s records kept on the Policy. If You are over the age of majority and legally competent, You may change the beneficiary designation for Your Insured Dependent’s coverage at any time, unless an irrevocable beneficiary designation has been made, without the consent of the Insured Dependent or the designated beneficiary(ies), by providing the Company with a written request for change. When the request is received by the Company, whether You or Your Insured Dependent is then living or not, the change of beneficiary will relate back to and take effect as of the date of execution of the written request, but without prejudice to the Company on account of any payment made by it prior to receipt of the request. If no beneficiary is living on the date of an Insured Dependent’s death, the beneficiary is Your estate. Legal Actions. No action at law or in equity may be brought to recover on the Policy prior to the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of the Policy. No such action may be brought after the expiration of 3 years after the time written proof of loss is required to be furnished. Misstatement of Age. If premiums for the Insured Person are based on age and the Insured Person has misstated his or her age, there will be a fair adjustment of premiums based on his or her true age. If the benefits for which the Insured Person is insured are based on age and the Insured Person has misstated his or her age, there will be an adjustment of said benefit based on his or her true age. The Company may require satisfactory proof of age before paying any claim. Noncompliance with Policy Requirements. Any express waiver by the Company of any requirements of the Policy will not constitute a continuing waiver of such requirements. Any failure by the Company to insist upon compliance with any Policy provision will not operate as a waiver or amendment of that provision. Physical Examination and Autopsy. The Company at its own expense has the right and opportunity to examine the person of any individual whose loss is the basis of claim under the Policy when and as often as it may reasonably require during the pendency of the claim and to make an autopsy in case of death where it is not forbidden by law.

Workers' Compensation. The Policy is not in lieu of and does not affect any requirements for coverage by any Workers' Compensation Act or similar law.

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