Laurens County Government 26-27 PY

SUPPLEMENTAL EMPLOYEE BENEFITS GUIDE 2026 PLAN YEAR:

MARCH 1, 2026 - FEBRUARY 28, 2027

LAURENS COUNTY GOVERNMENT

WWW.PIERCEGROUPBENEFITS.COM

EMPLOYEE SERVICES: 833-556-0006

TABLE OF CONTENTS

SUPPLEMENTAL EMPLOYEE BENEFITS GUIDE TABLE OF CONTENTS Welcome to Laurens County Government’s comprehensive supplemental benefits program. This guide highlights the supplemental benefits offered to all eligible employees for the plan year listed below. Benefits described in this guide are voluntary, employee-paid supplemental benefits unless

Important Contact Information............................... 3 Eligibility Requirements......................................... 4 Overview Of Supplemental Benefits........................ 5 Important Notices................................................. 6 Supplemental Qualifying Life Events....................... 7 Supplemental Enrollment Information.................... 9 Supplemental Self-Enrollment Instructions............. 10 Cancer Benefits..................................................... 12 Critical Illness Benefits.......................................... 19 Short-Term Disability Benefits................................ 30 Accident Benefits.................................................. 36 Medical Bridge Benefits......................................... 50 Whole Life Insurance............................................. 57 Colonial Life Policyholder Service Guide................. 66 Authorization For Colonial Life Insurance Form....... 67 Privacy Notices..................................................... 68 Continuation Of Coverage...................................... 69

otherwise noted.

ENROLLMENT DATES: January 12, 2026 - January 23, 2026 PLAN YEAR & EFFECTIVE DATES: March 1, 2026 - February 28, 2027

Click on the video below to help you prepare for enrollment and learn about the supplemental benefits available to you!

IMPORTANT NOTE & DISCLAIMER This is neither an insurance contract nor a Summary Plan Description and only the actual policy provisions will prevail.

LAURENS COUNTY GOVERNMENT 2026-2027 Supplemental Benefits Plan

March 1, 2026 - February 28, 2027

All information in this guide, including premiums quoted, is subject to change.

All policy descriptions are for informational purposes only. Your actual policies may be different than those in this guide.

Rev: 12/15/2025

IMPORTANT CONTACT INFORMATION Carrier

Phone/Fax

Email

Website

Gathr Online Enrollment

Gathr

P: 866-875-4772​

​

https://gathr.goco.io/companies/ laurens-county-government/invite/OTJh

To View Your Benefits Online

Pierce Group Benefits

P: 1-833-556-0006 F: 984-225-2605

service@ piercegroupbenefits.com

www.PierceGroupBenefits.com/ LaurensCountyGovernment

-

www.coloniallife.com

Customer Service & Wellness Screenings

Supplemental Benefits

Colonial Life

1-800-325-4368 F:1-800-880-9325 TDD For Hearing Impaired Customers

1-800-798-4040

Under certain qualifying events, employees and dependents may have the opportunity to continue their supplemental coverage. Please see the supplemental qualifying life events page of this guide for more info.

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ELIGIBILITY REQUIREMENTS CURRENT EMPLOYEE? ANNUAL ENROLLMENT DATES:

January 12, 2026 - January 23, 2026

PLAN YEAR & EFFECTIVE DATES: March 1, 2026 - February 28, 2027​​

ELIGIBILITY • Employees working 30 or more hours per week are eligible for benefits.

NEW HIRE? Congratulations on your new employment! Your employment means more than just a paycheck. Your employer also provides eligible employees with a valuable supplemental benefits package. Above you will find eligibility requirements and below you will find information about how to enroll in these supplemental benefits as a new employee.

Colonial Life Insurance Products - Please call PGB’s Employee Services within 30 days of your date of hire and a PGB Benefits Representative will help you enroll in benefits. The Employee Services number is located in the contact section of this guide.

Be sure to also review your group’s custom benefits website, that allows for easy, year-round access to benefit information, live chat support, benefit explainer videos, plan certificates and documents, and carrier contacts and forms.

www.PierceGroupBenefits.com/LaurensCountyGovernment

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OVERVIEW OF SUPPLEMENTAL BENEFITS PRE – TAX SUPPLEMENTAL BENEFITS

POST – TAX SUPPLEMENTAL BENEFITS

Cancer Benefits Colonial Life

Short-Term Disability Benefits Colonial Life

Accident Benefits Colonial Life

Critical Illness Benefits Colonial Life

Medical Bridge Benefits Colonial Life

Whole Life Insurance Colonial Life

PEBA INFORMATION PEBA administers the state’s employee insurance programs for South Carolina’s public workforce. Learn more about the benefits available to employees by visiting the link below or scanning the QR code. https://peba.sc.gov/peba-perks

Please note your insurance products will remain in effect unless you speak with a representative to change them.

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IMPORTANT NOTICES When do my supplemental benefits start? The plan year for Colonial Life Insurance runs from March 1, 2026, through February 28, 2027.

When do my supplemental deductions start? Deductions for Colonial Life Insurance start March 2026 for all enrolled employees.

Why have my Cancer, Accident, or Medical Bridge benefits not started yet? The Colonial Cancer plan and the Health Screening Rider on the Colonial Accident and Colonial Medical Bridge plan has a 30-day waiting period for new enrollees. Coverage, therefore, will not begin until March 31, 2026.

I want to sign my family up for supplemental benefits as well, what information will I need? If signing up for any coverage on your spouse and/or children, please have their dates of birth and social security numbers available when speaking with the Benefits Representative.

What does Pre-Tax vs. Post-Tax Change? Pre-Tax benefits take funds directly from your paycheck to cover benefits before going through State and Federal taxing process. Post-Tax collects funds for benefits after taxes have been taken out. Please be aware there are certain coverages that may be subject to federal and state tax when premium is paid by pretax deduction or employee contribution.

Can I change my supplemental benefit elections outside of the enrollment period? Elections made during this enrollment period CANNOT BE CHANGED AFTER THE ENROLLMENT PERIOD unless there is a family status change, otherwise known as a qualifying life event (QLE), as defined by the Internal Revenue Code. Examples of a QLE can be found in the chart on the next page. Once a QLE has occurred, an employee has 30 days to notify PGB’s SC Employee Services at 1-833-556-0006 to request a change in elections.

I have a pre-existing condition. Will I still be covered? Some policies may include a pre-existing condition clause.

Please read your policy carefully for full details.

SC Employee Services: 833-556-0006

www.PierceGroupBenefits.com/ LaurensCountyGovernment 6

Effective Dates:

March 1, 2026 - February 28, 2027

SUPPLEMENTAL QUALIFYING LIFE EVENTS The benefit elections you make during Annual Enrollment or as a New Hire will remain in effect for the entire plan year. You will not be able to change or revoke your elections once they have been made unless a Supplemental Qualifying Life Event (status change) occurs. The summary of events that allow an employee to make benefit changes and instructions for processing those life event changes can be reviewed in the chart below.

Qualifying Life Event

Action Required

Result If Action Is Not Taken

New Hire

Make elections within 30 days of hire date.

Documentation is required.

You and your dependents are not eligible until the next Annual Enrollment period.

Marriage

Add your new spouse to your elections within 30 days of the marriage date. A copy of the marriage certificate must be presented.

Your spouse is not eligible until the next Annual Enrollment period.

Divorce

Remove the former spouse within 30 days of the divorce. Proof of the divorce will be required. A copy of the divorce decree must be presented.

Benefits are not available for the divorced spouse and will be recouped if paid erroneously.

Enroll the new dependent in your elections within 30 days of the birth or adoption date, even if you already have family coverage. A copy of the birth certificate, mother’s copy of birth certificate, or hospital discharge papers must be presented. Once you receive the child’s Social Security Number, don’t forget to update your child’s insurance information record.

The new dependent will not be covered until the next Annual Enrollment period.

Remove or update dependent elections within 30 days of the dependent aging out. For more information and assistance, please call PGB Employee Services at 833-556-0006.

Coverage for the dependent will end at the time of the dependent aging out and the policyholder must remove/update the dependent elections in order for the change to be reflected in the employee’s deductions.

Death of a Spouse or Dependent

Remove the dependent from your elections within 30 days from the date of death. Death certificate must be presented.

You could pay a higher premium than required and you may be overpaying for coverage required.

Change in Spouse’s Employment or Coverage

Add or drop benefits from your elections within 30 days of the event date. A letter from the employer or insurance company must be presented.

You will not be able to make changes until the next Annual Enrollment period.

Birth or Adoption of a Child

Dependent Aging Out

The examples included in this chart are not all-inclusive. Please speak to a Benefits Representative to learn more.

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SUPPLEMENTAL QUALIFYING LIFE EVENTS Qualifying Life Event

Action Required

Result If Action Is Not Taken

Part-Time to Full-Time or Vice Versa

Change your elections within 30 days from the employment status change to receive COBRA information or to enroll in benefits as a full-time employee. Documentation from the employer must be provided.

Benefits may not be available to you or your dependents if you wait to enroll in COBRA. Full-time employees will have to wait until the next Annual Enrollment period.

Transferring Employers

If you are transferring from one PGB client to another, some benefits may be eligible for transfer.

Please call PGB Employee Services at 833-556-0006 for more information and assistance.

You may lose the opportunity to transfer benefits.

Loss of Government or Education Sponsored Health Coverage

If you, your spouse, or a dependent loses coverage under any group health coverage sponsored by a governmental or educational institution, you may be eligible to add additional coverage for eligible benefits.

You and your dependents are not eligible until the next Annual Enrollment period.

Entitlement to Medicare or Medicaid

If you, your spouse, or dependent becomes entitled to or loses coverage under Medicare or Medicaid, you may be able to change coverage under the accident or health plan.

You and your dependents are not eligible until the next Annual Enrollment period.

Non-FMLA Leave

An employee taking a leave of absence, other than under the Family & Medical Leave Act, may not be eligible to re-enter the Flexible Benefits program until next plan year. Please contact your Benefit Administrator for more information.

You and your dependents are not eligible until the next Annual Enrollment period.

Retiring

Your individual supplemental/voluntary policies through Colonial Life are portable! To move them from payroll deduction to direct billing, please complete and submit the Payment Method Change Form to Colonial Life within 30 days of retiring. You are also eligible for post-employment Dental, Vision, and Telemedicine benefits through PGB. Please visit: www.piercegroupbenefits.com/ individualcoverage or call our Employee Services at 833-556-0006 for more information and assistance.

If you do not transfer your policies from payroll deduction to direct billing, Colonial Life will terminate your policies resulting in a loss of coverage.

The examples included in this chart are not all-inclusive. Please speak to a Benefits Representative to learn more.

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SUPPLEMENTAL ENROLLMENT INFORMATION IN-PERSON During your annual enrollment period, a PGB Benefits Representative will be available by appointment to meet with you one-on-one to help you evaluate your benefits based on your individual and family needs, answer any questions you may have, and assist you in the enrollment process.

ANNUAL ENROLLMENT PERIOD:

JANUARY 12, 2026 - JANUARY 23, 2026 SUPPLEMENTAL BENEFIT ELECTION OPTIONS YOU CAN MAKE THE FOLLOWING SUPPLEMENTAL BENEFIT ELECTIONS DURING THE ANNUAL ENROLLMENT PERIOD: •

Enroll in Colonial coverage.

ACCESS YOUR BENEFIT OPTIONS WHENEVER, WHEREVER You can view details about what benefits your employer offers, view educational videos about all of your benefits, download forms, chat with one of our knowledgeable Benefits Representatives, and more on your personalized benefits website. To view your custom benefits website, visit: www.PierceGroupBenefits.com/LaurensCountyGovernment 9

SUPPLEMENTAL SELF-ENROLLMENT INSTRUCTIONS

Below is a series of instructions outlining the enrollment process. Please have the following information available before you begin: •

Username and password. If you have forgotten your password, please visit the enrollment website and select “Forgot login or password?”.

• Social security numbers of the spouse or any dependents you wish to enroll • Dates of birth for the spouse and any dependents you wish to enroll • Beneficiary names and social security numbers

HELPFUL TIPS : • If you are a new employee, please refer to the New Hire information on the Eligibility Requirements page of this guide or contact PGB Employee Services at 833-556-0006 between 8:30am and 5:00pm for assistance.

• If you are an existing employee and unable to log into the online system, please contact the Gathr Help Desk at 866-875-4772, or speak with the Benefits Representative assigned to your location.

1. LOGGING IN First-time users: Enter your Social Security Number and Date of Birth and click ‘Continue.’ Follow the system prompts to setup your account and two-factor authentication.

Returning users: Enter your Social Security Number and Date of Birth and click ‘Continue.’ Log in with the username and password you setup upon initial onboarding. If necessary, click ‘Forgot login or password?’ above the Password field to locate the email address used or reset your password.

To login, visit: https://gathr.goco.io/companies/laurens-county-government/invite/OTJh

2.

2. ONBOARDING (FIRST-TIME USERS ONLY) Complete the onboarding steps by verifying your Personal Info and Contact Info.

1.

3. NEXT STEPS (FIRST-TIME USERS ONLY) Click ‘Continue’ to navigate to the homepage.

4. START ENROLLMENT Click ‘Start Enrolling.’

Then click ‘Finish.’

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Enrollment instructions continued on next page >>>

SUPPLEMENTAL SELF-ENROLLMENT INSTRUCTIONS

5. DEPENDENT INFORMATION You will need to add any dependents you wish to enroll before moving forward.

Then click ‘Continue.’

TIP: Have dependent details handy. To enroll a dependent in coverage you will need their Social Security Number and Date of Birth.

6. ENROLL IN BENEFITS Click ‘Start’ next to each benefit to enroll in that benefit or waive coverage.

Once you’ve finished enrolling, click ‘Continue.’

TIP: If you miss a benefit it will be marked Incomplete. Click ‘Start’ next to any Incomplete benefits to enroll in or waive coverage.

8. FINISH ENROLLMENT If you are finished making elections, click ‘Yes, I’m Finished’ to complete your enrollment. NOTE: If you click ‘Yes, I’m Finished,’ you will no longer be able to make changes to your elections.

If you would like to save your elections and make changes later, click ‘Finish Later.’ NOTE: If you click ‘Finish Later,’ your enrollment is not complete and you will need to finish the enrollment before the enrollment period ends.

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7. REVIEW & CONFIRM BENEFIT ELECTIONS Click ‘Start’ next to Enrollment Summary. Next, fill in your legal name and click ‘Click here to sign’ to sign your enrollment summary. Then, check the box next to ‘I have read and reviewed my benefit enrollments.’ Finally, click ‘Sign.’

Click on the video below to learn more about Cancer Benefits!

CANCER BENEFITS

Cancer Insurance Cancer Assist helps protect employees and their loved ones through diagnosis, treatment and recovery.

This individual voluntary policy provides benefits that can be used for both medical and out-of-pocket, non-medical expenses traditional health insurance may not cover. Cancer Assist can enhance any competitive benefits package without adding costs to a company’s bottom line.

Competitive advantages

Composite rates are available.

There are four distinct plan levels, each featuring the same benefits with premiums and benefit amounts designed to meet a variety of budgets and coverage needs (benefits overview on reverse).

Indemnity-based benefits provide exactly what’s listed for the selected plan level.

The plan’s family care benefit provides a daily benefit when a covered dependent child receives inpatient or outpatient cancer treatment.

Employer-optional cancer wellness/health screening benefits are available: – Part One covers 24 tests. If selected, the employer chooses one of four benefit amounts for employees: $25, $50, $75 or $100. This benefit is payable once per covered person per calendar year.

– Part Two covers an invasive diagnostic test or surgical procedure if an abnormal result from a Part One test requires additional testing. This benefit is payable once per calendar year per covered person and matches the Part One benefit.

Flexible family coverage

Individual, individual/spouse, one-parent and two-parent family policies Family coverage that includes eligible dependent children (to age 26) for the same rate, regardless of the number of children covered

Attractive features

Optional riders

(available at an additional cost/payable once per covered person)

Available for businesses with 3+ eligible employees Broad range of policy issue ages, 17-75 Full schedule of 30+ benefits and three optional riders (benefit amounts may vary based on plan level selected) with each plan level Benefits that don’t coordinate with any other coverage from any other insurer HSA-compliant Guaranteed renewable Portable Waiver of premium if named insured is disabled due to cancer for longer than 90 consecutive days and the date of diagnosis is after the waiting period and while the policy is in force Form 1099s may not be issued in most states because all benefits require that a charge is incurred.

Discuss details with your benefits representative, or consult your tax adviser if you have questions.

Initial diagnosis of cancer rider provides a one-time benefit for the initial diagnosis of cancer.

A benefit amount in $1,000 increments from $1,000-$10,000 may be chosen. The benefit for covered dependent children is two and a half times ($2,500-25,000) the chosen benefit amount.

Initial diagnosis of cancer progressive payment rider provides a $50 lump-sum payment for each month the rider has been in force, after the waiting period, once cancer is first diagnosed.

The issue ages for this rider are 17-64.

Specified disease hospital confinement rider provides $300 per day for confinement to a hospital for treatment of one of 34 specified diseases covered under the rider.

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CANCER ASSIST

Cancer Assist benefits overview This overview shows benefits available for all four plan levels and the range of benefit amounts payable for most common cancer treatments.

Each benefit is payable for each covered person under the policy.

Actual benefits vary based on the plan level selected.

Talk with your benefits representative to learn more.

THIS POLICY PROVIDES LIMITED BENEFITS. Each benefit requires that charges are incurred for treatment. All benefits and riders are subject to a 30-day waiting period. Waiting period means the first 30 days following the policy’s coverage effective date during which no benefits are payable. States without a waiting period will have a pre-existing condition limitation. Product has exclusions and limitations that may affect benefits payable. Benefits vary by state and may not be available in all states. Applicable to policy form CanAssist (and state abbreviations where applicable, for example: CanAssist-TX).

See your Colonial Life benefits representative for complete details.

ColonialLife.com

Radiation/chemotherapy Injected chemotherapy by medical personnel: $250-$1,000 once per calendar week Radiation delivered by medical personnel: $250-$1,000 once per calendar week Self-injected chemotherapy: $150-$400 once per calendar month Topical chemotherapy: $150-$400 once per calendar month Chemotherapy by pump: $150-$400 once per calendar month Oral hormonal chemotherapy (1-24 months): $150-$400 once per calendar month Oral hormonal chemotherapy (25+ months): $75-$200 once per calendar month Oral non-hormonal chemotherapy: $150-$400 once per calendar month Anti-nausea medication $25-$60 per day, up to $100-$240 per calendar month Medical imaging studies $75-$225 per study, up to $150-$450 per calendar year Outpatient surgical center $100-$400 per day, up to $300-$1,200 per calendar year Skin cancer initial diagnosis $300-$600 payable once per lifetime Surgical procedures Inpatient and outpatient surgeries: $40-$70 per surgical unit, up to $2,500-$6,000 per procedure Reconstructive surgery $40-$60 per surgical unit, up to $2,500-$3,000 per procedure including 25% for general anesthesia Anesthesia General: 25% of surgical procedures benefit Local: $25-$50 per procedure Hospital confinement 30 days or less: $100-$350 per day 31 days or more: $200-$700 per day Family care Inpatient and outpatient treatment for a covered dependent child: $30-$60 per day, up to $1,500-$3,000 per calendar year Second medical opinion on surgery or treatment $150-$300 once per lifetime Home health care services Examples include physical therapy, speech therapy, occupational therapy, prosthesis and orthopedic appliances, durable medical equipment: $50-$150 per day, up to the greater of 30 days per calendar year or twice the number of days hospitalized per calendar year Hospice care Initial: $1,000 once per lifetime Daily: $50 per day ($15,000 maximum for initial and daily hospice care per lifetime) Transportation and lodging Transportation for treatment more than 50 miles from covered person’s home: $0.50 per mile, up to $1,000-$1,500 per round trip Companion transportation (for any companion, not just a family member) for commercial travel when treatment is more than 50 miles from covered person’s home: $0.50 per mile, up to $1,000-$1,500 per round trip Lodging for the covered person or any one adult companion or family member when treatment is more than 50 miles from the covered person’s home: $50-$80 per day, up to 70 days per calendar year Benefits also included in each plan Air ambulance, ambulance, blood/plasma/platelets/immunoglobulins, bone marrow or peripheral stem cell donation, bone marrow donor screening, bone marrow or peripheral stem cell transplant, cancer vaccine, egg(s) extraction or harvesting/sperm collection and storage (cryopreservation), experimental treatment, hair/external breast/voice box prosthesis, private full-time nursing services, prosthetic device/artificial limb, skilled nursing facility, supportive or protective care drugs and colony stimulating factors Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

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6-19 | 101478-2

Cancer Insurance Wellness Benefits

To encourage early detection, our cancer insurance offers benefits for wellness and health screening tests.

Part one: Cancer wellness/health screening Provided when one of the tests listed below is performed after the waiting period and while the policy is in force. Payable once per calendar year, per covered person.

Cancer wellness tests

Health screening tests

■ Bone marrow testing

■ Blood test for triglycerides

■ Breast ultrasound

■ Carotid Doppler

■ CA 15-3 (blood test for breast cancer)

■ Echocardiogram (ECHO)

■ CA 125 (blood test for ovarian cancer)

■ Electrocardiogram (EKG, ECG)

■ CEA (blood test for colon cancer)

■ Fasting blood glucose test

■ Chest X-ray

■ Serum cholesterol test for HDL

and LDL levels

■ Colonoscopy ■ Flexible sigmoidoscopy

■ Stress test on a bicycle or treadmill

■ Hemoccult stool analysis ■ Mammography ■ Pap smear ■ PSA (blood test for prostate cancer) ■ Serum protein electrophoresis

(blood test for myeloma)

■ Skin biopsy ■ Thermography ■ ThinPrep pap test ■ Virtual colonoscopy

For more information, talk with your benefits counselor.

Part two: Cancer wellness — additional invasive diagnostic test or surgical procedure Provided when a doctor performs a diagnostic test or surgical procedure after the waiting period as the result of an abnormal result from one of the covered cancer wellness tests in part one. We will pay the benefit regardless of the test results. Payable once per calendar year, per covered person.

Waiting period means the first 30 days following the policy’s coverage effective date during which no benefits are payable.

The policy has exclusions and limitations which may affect any benefits payable. For cost and complete details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states.

Applicable to policy form CanAssist (and state abbreviations where applicable, for example: CanAssist-TX).

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

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CANCER ASSIST WELLNESS | 6-19 | 101486-2

Individual Cancer Insurance Description of Benefits The policy and its riders may have additional exclusions and limitations. For cost and complete details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states. Coverage is dependent on answers to health questions. Applicable to policy forms CanAssist-IL and CanAssist-SC, and rider forms R-CanAssistIndx-IL, R-CanAssistProg-IL, R-CanAssistSpDis-IL, R-CanAssistIndxSC, R-CanAssistProg-SC and R-CanAssistSpDis-SC. Cancer Insurance Benefits Air Ambulance, per trip Maximum trips per confinement Ambulance, per trip Maximum trips per confinement Anesthesia, General Anesthesia, Local, per procedure Anti-Nausea Medication, per day Maximum per month Blood/Plasma/Platelets/Immunoglobulins, per day Maximum per year Bone Marrow or Peripheral Stem Cell Donation, per lifetime Bone Marrow or Peripheral Stem Cell Transplant, per transplant Maximum transplants per lifetime Companion Transportation, per mile Maximum per round trip Egg(s) Extraction or Harvesting or Sperm Collection, per lifetime Egg(s) or Sperm Storage, per lifetime Experimental Treatment, per day Maximum per lifetime Family Care, per day Maximum per year Hair/External Breast/Voice Box Prosthesis, per year Home Health Care Services, per day Maximum per year Hospice, Initial, per lifetime Hospice, Daily Maximum combined Initial and Daily per lifetime Hospital Confinement, 30 days or less, per day Hospital Confinement, 31 days or more, per day Lodging, per day Maximum days per year Medical Imaging Studies, per study Maximum per year Outpatient Surgical Center, per day Maximum per year Private Full-time Nursing Services, per day Prosthetic Device/Artificial Limb, per device or limb Maximum per lifetime

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Level 1 Level 2 Level 3 Level 4 $2,000 $2,000 $2,000 $2,000 2 2 2 2 $250 $250 $250 $250 2 2 2 2 25% of Surgical Procedures Benefit $25 $30 $40 $50 $25 $40 $50 $60 $100 $160 $200 $240 $150 $150 $175 $250 $10,000 $10,000 $10,000 $10,000 $500 $500 $750 $1,000 $3,500 $4,000 $7,000 $10,000 2 2 2 2 $0.50 $0.50 $0.50 $0.50 $1,000 $1,000 $1,200 $1,500 $500 $700 $1,000 $1,500 $175 $200 $350 $500 $200 $250 $300 $300 $10,000 $12,500 $15,000 $15,000 $30 $40 $50 $60 $1,500 $2,000 $2,500 $3,000 $200 $200 $350 $500 $50 $75 $100 $150 30 days or twice the days confined $1,000 $1,000 $1,000 $1,000 $50 $50 $50 $50 $15,000 $15,000 $15,000 $15,000 $100 $150 $250 $350 $200 $300 $500 $700 $50 $50 $75 $80 70 70 70 70 $75 $125 $175 $225 $150 $250 $350 $450 $100 $200 $300 $400 $300 $600 $900 $1,200 $50 $75 $125 $150 $1,000 $1,500 $2,000 $3,000 $2,000 $3,000 $4,000 $6,000

Individual Cancer Insurance Description of Benefits The policy and its riders may have additional exclusions and limitations. For cost and complete details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states. Coverage is dependent on answers to health questions. Applicable to policy forms CanAssist-IL and CanAssist-SC, and rider forms R-CanAssistIndx-IL, R-CanAssistProg-IL, R-CanAssistSpDis-IL, R-CanAssistIndxSC, R-CanAssistProg-SC and R-CanAssistSpDis-SC. Cancer Insurance Benefits Radiation/Chemotherapy Injected chemotherapy by medical personnel, per week Radiation delivered by medical personnel, per week Self-Injected Chemotherapy, per month Pump Chemotherapy, per month Topical Chemotherapy, per month Oral Hormonal Chemotherapy (1-24 months), per month Oral Hormonal Chemotherapy (25+ months), per month Oral Non-Hormonal Chemotherapy, per month Reconstructive Surgery, per surgical unit Maximum per procedure, including 25% for general Second Medical Opinion, per lifetime Skilled Nursing Care Facility, per day, up to days confined Skin Cancer Initial Diagnosis, per lifetime Supportive/Protective Care Drugs/Colony Stimulating Factors, per Maximum per year Surgical Procedures, per surgical unit Maximum per procedure Transportation, per mile Maximum per round trip Waiver of Premium Policy-Wellness Benefits Bone Marrow Donor Screening, per lifetime Cancer Vaccine, per lifetime Part 1: Cancer Wellness/Health Screening, per year Part 2: Cancer Wellness/Health Screening, per year

Level 1

Level 2

Level 3

Level 4

$250 $250 $150 $150 $150 $150 $75 $150 $40 $2,500 $150 $75 $300 $50 $400 $40 $2,500 $0.50 $1,000 Yes

$500 $500 $200 $200 $200 $200 $100 $200 $40 $2,500 $200 $100 $300 $100 $800 $50 $3,000 $0.50 $1,000 Yes

$750 $750 $300 $300 $300 $300 $150 $300 $60 $3,000 $300 $100 $400 $150 $1,200 $60 $5,000 $0.50 $1,200 Yes

$1,000 $1,000 $400 $400 $400 $400 $200 $400 $60 $3,000 $300 $150 $600 $200 $1,600 $70 $6,000 $0.50 $1,500 Yes

$50 $50 $50 $50 $50 $50 $50 $50 One amount per account: $0, $25, $50, $75 or $100 Same as Part 1

Additional Riders may be available at an additional cost WAITING PERIOD The policy and its riders may have a waiting period. Waiting period means the first 30 days following the policy’s coverage effective date during which no benefits are payable. If your cancer has a date of diagnosis before the end of the waiting period, coverage for that cancer will apply only to losses commencing after the policy has been in force for two years, unless it is excluded by name or specific description in the policy.

EXCLUSIONS We will not pay benefits for cancer or skin cancer: Ŷ ,I WKH GLDJQRVLV RU WUHDWPHQW RI FDQFHU LV UHFHLYHG RXWVLGH RI WKH WHUULWRULDO OLPLWV RI WKH 8QLWHG 6WDWHV DQG LWV possessions; or Ŷ )RU RWKHU FRQGLWLRQV RU GLVHDVHV H[FHSW ORVVHV DJJUDYDWHG E\ FDQFHU RU UHVXOWLQJ IURP FDQFHU RU WUHDWPHQW RI cancer. ©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

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CANCER BENEFIT PREMIUMS LEVEL 1 - Composite Rates Employee

Employee/Spouse

One-Parent Family

Two-Parent Family

$8.42

$13.27

One-Parent Family

Two-Parent Family

$10.13

$15.76

One-Parent Family

Two-Parent Family

$12.51

$20.70

One-Parent Family

Two-Parent Family

$16.71

$27.69

One-Parent Family

Two-Parent Family

$0.81

$0.58

$0.81

$1.15

$0.74

$1.20

$3.60

$7.87

Level 1 with $100 Cancer Wellness/Health Screening 26-Pay Premium

$8.35

$13.20 LEVEL 2 - Composite Rates

Employee

Employee/Spouse

Level 2 with $100 Cancer Wellness/Health Screening 26-Pay Premium

$9.99

$15.62 LEVEL 3 - Composite Rates

Employee

Employee/Spouse

Level 3 with $100 Cancer Wellness/Health Screening 26-Pay Premium

$12.30

$20.49 LEVEL 4 - Composite Rates

Employee

Employee/Spouse

Level 4 with $100 Cancer Wellness/Health Screening 26-Pay Premium

$16.43

$27.42 OPTIONAL RIDERS

Employee

Employee/Spouse

Specified Disease Hospital Confinement Rider 26-Pay Premium

$0.58

Initial Diagnosis of Cancer Rider (per $1,000) 26-Pay Premium

$0.69

Initial Diagnosis of Cancer Progressive Payment Rider 26-Pay Premium

$3.60

$7.87

Sample rates only. Multiple choices and options available and rates may vary.

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Click on the video below to learn more about Critical Illness Benefits!

CRITICAL ILLNESS BENEFITS

Group Critical Illness Insurance Plan 1

When life takes an unexpected turn due to a critical illness diagnosis, your focus should be on recovery — not finances. Colonial Life’s group critical illness insurance helps provide financial support by providing a lump-sum benefit payable directly to you for your greatest needs.

An unexpected moment changes life forever

Coverage amount: ____________________________

Chris was mowing the lawn when he suffered a stroke. His recovery will be challenging and he's worried, since his family relies on his income.

Critical illness benefit

HOW CHRIS’S COVERAGE HELPED

The lump-sum payment from his critical illness insurance helped pay for: Co-payments and hospital bills not covered by his medical insurance Physical therapy to get back to doing what he loves Household expenses while he was unable to work

For illustrative purposes only.

COVERED CONDITION¹

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Benign brain tumor

100%

Coma

100%

End stage renal (kidney) failure

100%

Heart attack (myocardial infarction)

100%

Loss of hearing

100%

Loss of sight

100%

Loss of speech

100%

Major organ failure requiring transplant

100%

Occupational infectious HIV or occupational infectious hepatitis B, C, or D

100%

Permanent paralysis due to a covered accident

100%

Stroke

100%

Sudden cardiac arrest

100%

Coronary artery disease

25%

20

GCI6000 – PLAN 1 – CRITICAL ILLNESS

KEY BENEFITS

Available coverage for spouse and eligible dependent children at 50% of your coverage amount Cover your eligible dependent children at no additional cost Receive coverage regardless of medical history, within specified limits Works alongside your health savings account (HSA) Benefits payable regardless of other insurance

For more information, talk with your benefits counselor.

Subsequent diagnosis of a different critical illness2 If you receive a benefit for a critical illness, and are later diagnosed with a different critical illness, 100% of the coverage amount may be payable for that particular critical illness.

Subsequent diagnosis of the same critical illness2 If you receive a benefit for a critical illness, and are later diagnosed with the same critical illness,3 25% of the coverage amount may be payable for that critical illness.

Additional covered conditions for dependent children PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

COVERED CONDITION¹

Cerebral palsy

100%

Cleft lip or palate

100%

Cystic fibrosis

100%

Down syndrome

100%

Spina bifida

100%

Preparing for the unexpected is simpler than you think.

With Colonial Life, youʼll have the support you need to face lifeʼs toughest challenges.

1. Refer to the certificate for complete definitions of covered conditions.

2. Dates of diagnoses of a covered critical illness must be separated by more than 180 days.

3. Critical illnesses that do not qualify include: coronary artery disease, loss of hearing, loss of sight, loss of speech, and occupational infectious HIV or occupational infectious hepatitis B,C,or D. THIS INSURANCE PROVIDES LIMITED BENEFITS Insureds in MA must be covered by comprehensive health insurance before applying for this coverage.

EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS

We will not pay the Critical Illness Benefit, Benefits Payable Upon Subsequent Diagnosis of a Critical Illness or Additional Critical Illness Benefit for Dependent Children that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a critical illness.

ColonialLife.com

PRE-EXISTING CONDITION LIMITATION

We will not pay a benefit for a pre-existing condition that occurs during the 12-month period after the coverage effective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date.

This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

21

5-20 | 385403

Group Critical Illness Insurance Plan 2

When life takes an unexpected turn, your focus should be on recovery — not finances. Colonial Life’s group critical illness insurance helps relieve financial worries by providing a lump-sum benefit payable directly to you to use as needed.

Preparing for a lifelong journey Rebecca was born with Down syndrome.

Her parents’ critical illness coverage provided a benefit that can help cover expenses related to Rebecca’s care and her changing needs.

HOW THEIR COVERAGE HELPED

The lump-sum amount from the family coverage benefit helped pay for:

A hospital stay and treatment for corrective heart surgery Physical therapy to build muscle strength

Special needs daycare

Coverage amount: ____________________________

Critical illness and cancer benefits COVERED CRITICAL ILLNESS CONDITION¹

Benign brain tumor

100%

Coma

100%

End stage renal (kidney) failure

100%

Heart attack (myocardial infarction)

100%

Loss of hearing

100%

Loss of sight

100%

Loss of speech

100%

Major organ failure requiring transplant

100%

Occupational infectious HIV or occupational infectious hepatitis B, C, or D

100%

Permanent paralysis due to a covered accident

100%

Stroke

100%

Sudden cardiac arrest

100%

Coronary artery disease

25%

COVERED CANCER CONDITION¹ For illustrative purposes only.

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Invasive cancer (including all breast cancer)

100%

Non-invasive cancer

25%

Skin cancer initial diagnosis ............................................................ $400 per lifetime 22

GCI6000 – PLAN 2 – CRITICAL ILLNESS AND CANCER

KEY BENEFITS

Available coverage for spouse and eligible dependent children at 50% of your coverage amount Cover your eligible dependent children at no additional cost Receive coverage regardless of medical history, within specified limits Works alongside your health savings account (HSA) Benefits payable regardless of other insurance

Subsequent diagnosis of a different critical illness2 If you receive a benefit for a critical illness, and are later diagnosed with a different critical illness, 100% of the coverage amount may be payable for that particular critical illness.

Subsequent diagnosis of the same critical illness2 If you receive a benefit for a critical illness, and are later diagnosed with the same critical illness,3 25% of the coverage amount is payable for that critical illness.

Reoccurrence of invasive cancer (including all breast cancer) If you receive a benefit for invasive cancer and are later diagnosed with a reoccurrence of invasive cancer, 25% of the coverage amount is payable if treatment-free for at least 12 months and in complete remission prior to the date of reoccurrence; excludes non-invasive or skin cancer.

Additional covered conditions for dependent children PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

COVERED CONDITION¹

Cerebral palsy

100%

Cleft lip or palate

100%

Cystic fibrosis

100%

Down syndrome

100%

Spina bifida

100%

Preparing for the unexpected is simpler than you think.

With Colonial Life, youʼll have the support you need to face lifeʼs toughest challenges.

1. Refer to the certificate for complete definitions of covered conditions.

2. Dates of diagnoses of a covered critical illness must be separated by more than 180 days.

3. Critical illnesses that do not qualify include: coronary artery disease, loss of hearing, loss of sight, loss of speech, and occupational infectious HIV or occupational infectious hepatitis B,C,or D.

For more information, talk with your benefits counselor.

THIS INSURANCE PROVIDES LIMITED BENEFITS Insureds in MA must be covered by comprehensive health insurance before applying for this coverage.

EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS

We will not pay the Critical Illness Benefit, Benefits Payable Upon Subsequent Diagnosis of a Critical Illness or Additional Critical Illness Benefit for Dependent Children that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a critical illness.

EXCLUSIONS AND LIMITATIONS FOR CANCER

We will not pay the Invasive Cancer (including all Breast Cancer) Benefit, Non-Invasive Cancer Benefit, Benefit Payable Upon Reoccurrence of Invasive Cancer (including all Breast Cancer) or Skin Cancer Initial Diagnosis Benefit for a covered person’s invasive cancer or non-invasive cancer that: is diagnosed or treated outside the territorial limits of the United States, its possessions, or the countries of Canada and Mexico; is a pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is initially diagnosed as having invasive or non-invasive cancer. No pre-existing condition limitation will be applied for dependent children who are born or adopted while the named insured is covered under the certificate, and who are continuously covered from the date of birth or adoption.

PRE-EXISTING CONDITION LIMITATION

We will not pay a benefit for a pre-existing condition that occurs during the 12-month period after the coverage effective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date.

ColonialLife.com

This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

23

5-20 | 387100

Group Critical Illness Insurance First Diagnosis Building Benefit Rider

The first diagnosis building benefit rider provides a lump-sum payment in addition to the coverage amount when you are diagnosed with a covered critical illness or invasive cancer (including all breast cancer). This benefit is for you and all your covered family members.

First diagnosis building benefit Payable once per covered person per lifetime

¾ Named insured ............................................................ Accumulates $1,000 each year ¾ Covered spouse/dependent children ............................... Accumulates $500 each year The benefit amount accumulates each rider year the rider is in force before a diagnosis is made, up to a maximum of 10 years.

For more information, talk with your benefits counselor.

If diagnosed with a covered critical illness or invasive cancer (including all breast cancer) before the end of the first rider year, the rider will provide one-half of the annual building benefit amount.

Coronary artery disease is not a covered critical illness. Non-invasive and skin cancer are not covered cancer conditions.

ColonialLife.com

THIS INSURANCE PROVIDES LIMITED BENEFITS. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX) and rider form R-GCI6000-BB. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

24

GCI6000 – FIRST DIAGNOSIS BUILDING BENEFIT RIDER | 5-20 | 387381

Group Critical Illness Insurance Infectious Diseases Rider

The sudden onset of an infectious or contagious disease can create unexpected circumstances for you or your family. The infectious diseases rider provides a lump sum which can be used toward health care expenses or meeting day-today needs. These benefits are for you as well as your covered family members.

Payable for each covered infectious disease once per covered person per lifetime COVERED INFECTIOUS DISEASE¹

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Hospital confinement for seven or more consecutive days for treatment of the disease

For more information, talk with your benefits counselor.

ColonialLife.com

Antibiotic resistant bacteria (including MRSA)

50%

Cerebrospinal meningitis (bacterial)

50%

Diphtheria

50%

Encephalitis

50%

Legionnaires’ disease

50%

Lyme disease

50%

Malaria

50%

Necrotizing fasciitis

50%

Osteomyelitis

50%

Poliomyelitis

50%

Rabies

50%

Sepsis

50%

Tetanus

50%

Tuberculosis

50%

Hospital confinement for 14 or more consecutive days for treatment of the disease Coronavirus disease 2019 (COVID-19)

25

25%

GCI6000 – INFECTIOUS DISEASES RIDER

1. Refer to the certificate for complete definitions of covered diseases.

THIS INSURANCE PROVIDES LIMITED BENEFITS.

EXCLUSIONS AND LIMITATIONS FOR INFECTIOUS DISEASES RIDER

ColonialLife.com

We will not pay benefits for a covered infectious disease that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a covered infectious disease.

PRE-EXISTING CONDITION LIMITATION

We will not pay a benefit for a pre-existing condition that occurs during the 12-month period after the coverage effective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date.

This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX) and rider form R-GCI6000-INF. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

26

5-20 | 387523

Group Critical Illness Insurance Progressive Diseases Rider

The debilitating effects of a progressive disease not only impact you physically, but financially as well. Changes in lifestyle may require home modification, additional medical treatment and other expenses. These benefits are for you as well as your covered family members.

Payable for each covered progressive disease once per covered person per lifetime PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

COVERED PROGRESSIVE DISEASE¹

This benefit is payable if the covered person is unable to perform two or more activities of daily living2 and the 90-day elimination period has been met.

For more information, talk with your benefits counselor.

ColonialLife.com

Amyotrophic Lateral Sclerosis (ALS)

25%

Dementia (including Alzheimer’s disease)

25%

Huntington’s disease

25%

Lupus

25%

Multiple sclerosis (MS)

25%

Muscular dystrophy

25%

Myasthenia gravis (MG)

25%

Parkinson’s disease

25%

Systemic sclerosis (scleroderma)

25%

1. Refer to the certificate for complete definitions of covered diseases.

2. Activities of daily living include bathing, continence, dressing, eating, toileting and transferring.

THIS INSURANCE PROVIDES LIMITED BENEFITS.

EXCLUSIONS AND LIMITATIONS FOR PROGRESSIVE DISEASES RIDER

We will not pay benefits for a covered progressive disease that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the preexisting condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a covered progressive disease.

PRE-EXISTING CONDITION LIMITATION We will not pay a benefit for a pre-existing condition that occurs during the 12-month period after the coverage effective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date.

This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX) and rider form R-GCI6000-PD. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

27

GCI6000 – PROGRESSIVE DISEASES RIDER | 5-20 | 387594

CRITICAL ILLNESS BENEFIT PREMIUMS

Plan 1 - Critical Illness Rates illustrated per unit. Named Insured unit value = $1000

Issue Age

Deduction

Named Insured

Employee & Spouse

One-Parent Family

Two Parent Family

Non-Tobacco 17-24

26-Pay Premium

$0.10

$0.14

$0.10

$0.14

25-29

26-Pay Premium

$0.14

$0.20

$0.14

$0.20

30-34

26-Pay Premium

$0.18

$0.25

$0.18

$0.25

35-39

26-Pay Premium

$0.26

$0.39

$0.26

$0.39

40-44

26-Pay Premium

$0.36

$0.53

$0.36

$0.53

45-49

26-Pay Premium

$0.50

$0.76

$0.50

$0.76

50-54

26-Pay Premium

$0.66

$1.03

$0.66

$1.03

55-59

26-Pay Premium

$0.88

$1.36

$0.88

$1.36

60-64

26-Pay Premium

$1.20

$1.86

$1.20

$1.86

65-69

26-Pay Premium

$1.31

$2.02

$1.31

$2.02

70-74

26-Pay Premium

$1.51

$2.33

$1.51

$2.33

One-Parent Family $3.07

Two Parent Family $4.78

Wellbeing Assistance Benefit Rates by wellbeing amount = 1 unit Wellbeing Amount $100

26-Pay Premium

Named Insured $3.07

Employee & Spouse $4.78

Sample rates only. Multiple choices and options available and rates may vary.

28

CRITICAL ILLNESS BENEFIT PREMIUMS Plan 2 - Critical Illness & Cancer Benefits Rates illustrated per unit. Named Insured unit value = $1000

Issue Age

Deduction

Named Insured

Employee & Spouse

One-Parent Family

Two Parent Family

Non-Tobacco 17-24

26-Pay Premium

$0.18

$0.26

$0.18

$0.26

25-29

26-Pay Premium

$0.26

$0.38

$0.26

$0.38

30-34

26-Pay Premium

$0.35

$0.50

$0.35

$0.50

35-39

26-Pay Premium

$0.53

$0.78

$0.53

$0.78

40-44

26-Pay Premium

$0.72

$1.06

$0.72

$1.06

45-49

26-Pay Premium

$1.02

$1.53

$1.02

$1.53

50-54

26-Pay Premium

$1.32

$2.00

$1.32

$2.00

55-59

26-Pay Premium

$1.74

$2.64

$1.74

$2.64

60-64

26-Pay Premium

$2.37

$3.60

$2.37

$3.60

65-69

26-Pay Premium

$2.90

$4.42

$2.90

$4.42

70-74

26-Pay Premium

$2.90

$4.42

$2.90

$4.42

One-Parent Family $3.07

Two Parent Family $4.78

Wellbeing Assistance Benefit Rates by wellbeing amount = 1 unit Wellbeing Amount $100

26-Pay Premium

Named Insured $3.07

Employee & Spouse $4.78

Sample rates only. Multiple choices and options available and rates may vary.

29

Click on the video below to learn more about Short-Term Disability Benefits!

SHORT-TERM DISABILITY BENEFITS

Individual Short-Term Disability Insurance

You never know when a disability could impact your way of life. Fortunately, there’s a way to help protect your income. If a covered accident or sickness prevents you from earning a paycheck, disability insurance can provide a monthly benefit to help you cover your ongoing expenses.

Can you afford to not protect your income?

You don’t have the same lifestyle expenses as the next person. That’s why you need disability coverage that can be customized to fit your specific needs.

After calculating your monthly expenses, your benefits counselor can help you complete the benefits worksheet.

MONTHLY EXPENSES Round to the nearest hundred.

ColonialLife.com

1

Rent or mortgage

$

2

Transportation (gas, car, bus, etc.)

$

3

Utilities (phone, internet, tv, electricity/gas, water, etc.)

$

4

Food and necessities

$

5

Other expenses

$

Total monthly expenses (add lines 1-5 together)

$

Benefits worksheet How much coverage do I need?

Monthly benefit amount for off-job accident and off-job sickness: ______________ Choose a monthly benefit amount between $400 and $6,500.* If your plan includes on-job accident/sickness benefits, the benefit is 50% of the off-job amount.

How long can I receive benefits?

Benefit period: _______ months The partial disability benefit period is three months.

When may my total disability benefits start?

After an accident: _______ days *Subject to income requirements

31

After a sickness: _______ days ISTD3000 BASE

Product information Total disability definition If the benefit period shown on the policy schedule is 12 months or less, totally disabled or total disability means you are: unable to perform the material and substantial duties of your occupation; and not, in fact, working at any occupation for wage or profit; and under the regular and appropriate care of a physician.

After the first year of disability, total disability means you are unable to engage in any employment or occupation for which you are qualified by reason of education, training or experience and under the regular and appropriate care of a physician.

How partial disability works If you are able to return to work part time after at least 14 days of being paid for a total disability, you may be able to still receive 50% of your total disability benefit.

Waiver of premium We will waive your premium payments after 90 consecutive days of a covered disability.

Geographical limitations If you are disabled while outside of the United States, Canada or Mexico, you may receive benefits for up to 60 days before you have to return to the U.S. in order to continue receiving benefits.

Issue age Coverage is available from ages 17 to 74.

Keep your coverage You can keep your coverage to age 75 at no additional cost, even if you change jobs, as long as you pay your premiums when they are due.

For more information, talk with your benefits counselor.

EXCLUSIONS AND LIMITATIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of: cosmetic surgery, felonies or illegal occupations, flying, hazardous avocations, intoxicants and narcotics, psychiatric or psychological conditions, racing, semi-professional or professional sports, substance abuse, suicide or injuries which you intentionally do to yourself, war or armed conflict. We will not pay for losses due to you giving birth within the first nine months after the coverage effective date of the policy. We will not pay for loss when the disability is a pre-existing condition as described in the policy.

PRE-EXISTING CONDITIONS LIMITATION Pre-existing condition means a sickness or physical condition, whether diagnosed or not, for which you were treated, had medical testing, received medical advice or had taken medication within 12 months before the policy coverage effective date shown on the policy schedule.

After this policy has been in force for 12 months from the policy coverage effective date shown on the policy schedule, we will pay benefits for any pre-existing condition not excluded by name or specific description if the covered disability began at least 12 months after the policy coverage effective date and the elimination period has been satisfied.

For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form ISTD3000-SC and rider form ISTD3000-ADIB. This is not an insurance contract and only the actual policy and rider provisions will control.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

32

12-19 | 101629-2-SC

Individual Short-Term Disability Insurance Psychiatric and Psychological Benefit

Although illnesses and accidents are often associated with disabilities, mental disorders can also leave you unable to earn an income.

If you’re disabled with a covered mental or nervous condition, disability insurance from Colonial Life & Accident Insurance Company offers a monthly benefit that can help provide financial support while you focus on recovery.

Psychiatric and psychological benefit There is a maximum six-month benefit period limitation for any one occurrence of a psychiatric or psychological condition. There is a three-month benefit period limitation if you have a three-month benefit period.

For more information, talk with your benefits counselor.

There is a 24-month cumulative lifetime maximum benefit period for all psychiatric or psychological conditions. This maximum includes a combination of total disability and partial disability occurrences.

ColonialLife.com

The psychiatric and psychological benefit is only applicable when combined with the ISTD3000 base policy. The exclusions listed on the ISTD3000 base policy apply, except for the psychiatric or psychological conditions exclusion. For cost and complete details, talk with your Colonial Life benefits counselor. Applicable to policy form ISTD3000 and rider form ISTD3000-ADIB (plus state abbreviations where applicable, for example: ISTD3000-TX and ISTD3000-ADIB-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy and rider provisions will control.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

33

ISTD3000 – PSYCHIATRIC AND PSYCHOLOGICAL BENEFIT | 1-19 | 101630-2

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SHORT-TERM DISABILITY PREMIUMS On/Off-Job Accident and On/Off-Job Sickness Coverage $400 monthly benefit amount Benefit Period: 3 Months Elimination Ages: 17-49 26-Pay Premum Ages: 50-64 26-Pay Premum Ages: 65-74 26-Pay Premum

0/7 $7.11 $8.23 $9.62

7/7 $6.41 $7.70 $9.10

7/14 $4.91 $5.80 $6.85

0/14 $5.19 $6.20 $7.70

14/14 $4.58 $5.30 $6.42

0/30 $4.21 $4.82 $5.61

30/30 $2.97 $4.06 $5.15

0/14 $6.92 $8.68 $11.17

14/14 $5.80 $7.62 $10.02

0/30 $5.32 $6.92 $8.75

30/30 $3.97 $5.41 $6.89

0/14 $9.93 $12.33 $19.48

14/14 $8.20 $10.39 $16.56

0/30 $7.46 $9.45 $14.01

30/30 $5.89 $7.86 $11.69

0/14 $13.53 $18.78 $32.27

14/14 $11.50 $15.56 $27.23

0/30 $9.95 $13.53 $23.21

30/30 $8.38 $11.78 $20.23

Benefit Period: 6 Months Elimination Ages: 17-49 26-Pay Premum Ages: 50-64 26-Pay Premum Ages: 65-74 26-Pay Premum

0/7 $9.25 $10.93 $15.49

7/7 $8.12 $10.67 $14.55

7/14 $6.33 $8.31 $10.49

Benefit Period: 12 Months Elimination Ages: 17-49 26-Pay Premum Ages: 50-64 26-Pay Premum Ages: 65-74 26-Pay Premum

0/7 $12.96 $15.54 $24.66

7/7 $11.41 $14.25 $22.58

7/14 $8.75 $11.28 $17.80

Benefit Period: 24 Months Elimination Ages: 17-49 26-Pay Premum Ages: 50-64 26-Pay Premum Ages: 65-74 26-Pay Premum

0/7 $18.22 $24.66 $42.55

7/7 $16.38 $22.21 $38.23

7/14 $12.07 $16.87 $28.98

Sample rates only. Multiple choices and options available and rates may vary.

35

Click on the video below to learn more about Accident Benefits!

ACCIDENT BENEFITS

Accident Insurance Preferred Plan

Our coverage includes:

If you are in an accident, your focus should be on recovery, not how you’re going to pay your bills. Colonial Life Accident Insurance can pay benefits directly to you to use however you like — from medical costs to everyday expenses — offering financial support when you need it.

• Benefits payable directly to you • No medical questions to qualify for coverage • Coverage for simple and complex injuries • Benefits payable regardless of other insurance • Worldwide coverage • Works alongside your Health Savings Account (HSA)

BENEFITS STORY

Jacob was running on the playground when he tripped and injured his hand.

With Colonial Life accident benefits, Jacob’s parents were able to pay the annual deductible and co-payments.

JACOB’S ACCIDENT BENEFITS Jacob went to an urgent care facility and received immediate care.

Accident emergency treatment

$125

The doctor ordered an X-ray and discovered Jacob had fractured his hand.

• X-ray • Fracture (hand)

$40 $475

The doctor also found that Jacob had a cut on his hand.

Laceration (no stitches)

$30

Jacob was discharged with a splint.

Medical equipment (splint)

$40

Over the next several weeks, Jacob had three follow-up appointments with his doctor.

Accident follow-up treatment (3 visits)

$165

Total

$875

For illustrative purposes only for covered accidents. Benefit amounts may vary and may not cover all expenses.

37

IAC4000 – PREFERRED PLAN

BENEFITS STORY

Olivia was driving to the store when she got into a car accident.

Olivia’s accident benefits helped cover her annual deductible and co-payments.

OLIVIA’S ACCIDENT BENEFITS Olivia arrived by ambulance at the nearest emergency room and received immediate care.

• Ambulance • Accident emergency treatment • Injury due to auto accident

$250 $125 $250

The doctor ordered an X-ray and discovered Olivia had fractured her thigh (femur). He also ordered a CT scan of her head to check for a brain injury.

• X-ray • Medical imaging (CT) • Thigh fracture — femur (surgical)

$40 $250 $5,600

Olivia was admitted to the hospital for surgery on her leg. She was confined for three days.

• Hospital admission • Surgery (exploratory/arthroscopic) • Hospital confinement (3 days)

$1,250 $350 $900

Olivia had eight sessions of physical therapy to help regain the strength in her leg.

• Physical therapy (8 days) • Medical equipment (crutches)

$360 $125

Over the next several weeks, she had six follow-up appointments with her doctor.

Accident follow-up treatment (6 visits)

$330

Total

For illustrative purposes only for covered accidents. Benefit amounts may vary and may not cover all expenses.

$9,830

Summary of Benefits Benefits are per covered person per covered accident unless stated otherwise.

Initial care

Dislocation — separated joint • Non-surgical — repair . . . . . . . . . . . . . . . . . . . . . . . $125–$2,750 Examples: elbow: $600 | ankle: $1,250 | hip: $2,750

Accident emergency treatment. . . . . . . . . . . . . . . . . . . . . . . . . $125 Hospital emergency room, urgent care facility or physician’s office

• Incomplete dislocation — or dislocation without anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25% (payable as a % of the applicable dislocation benefit)

Accidental injury due to an automobile accident1 . . . . . . . . $250 Air ambulance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $2,400 Ambulance — ground or water . . . . . . . . . . . . . . . . . . . . . . . . . $250

• Surgical — repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250–$5,500 Examples: elbow: $1,200 | ankle: $2,500 | hip: $5,500

Observation room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$175 per day (up to two days per calendar year)

Emergency dental work . . . . . . . . . . . . . . . . . . . . . . . . . . $125–$350 Dental extraction or dental crown, denture or implant

X-ray. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40

Common accidental injuries

Eye injury — with surgical repair or removal of a foreign object . . . . . . . . . . . . . . . . . . . . . . . . . . . . $350

Burn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,000–$15,000 (based on size and degree)

Fracture — complete

Burn — skin graft . . . . . . . . . . . . . .50% of applicable burn benefit

• Non-surgical — repair . . . . . . . . . . . . . . . . . . . . . . . $300–$3,750 Examples: hand/foot: $475 | collarbone: $775 | leg: $1,250

Coma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $15,000 (lasting for seven or more consecutive days)

• Chip fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25% (payable as a % of the applicable fracture benefit )

Concussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200

• Surgical — repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . $600–$7,500 Examples: hand/foot: $950 | collarbone: $1,550 | leg: $2,500

38

Follow-up care Accident follow-up treatment, including transportation/telemedicine . . . . . . . . . . . . . . . . . . . . . . . . . . . .$55 (up to six benefits per covered person per covered accident and up to 12 benefits per covered person per calendar year) Medical equipment • Tier 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40 Arm sling, cane, medical ring cushion, neck brace or wrist/ankle splint • Tier 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $125 Bedside commode, cold therapy system (cryotherapy), crutches, leg brace, shower chair, walker or walking boot • Tier 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250 Back brace, body jacket, continuous passive movement (CPM), halo, electric scooter, hospital bed (including rental), knee scooter, stair lift chair or wheelchair Medical imaging study — CT, CAT scan, EEG, EMG, MR or MRI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250 (one per calendar year) Pain management for epidural anesthesia — non-surgical . . $125 Post-traumatic stress disorder (PTSD) . . . . . . . . . . . . . . . . . $250 Prosthetic device/artificial limb Hearing-loss injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$140

• One . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $950

Knee cartilage — torn — with surgical repair . . . . . . . . . . . . . $800

• More than one . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,900

Laceration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $30–$750 (based on repair and length)

• Repair/replacement3 . . . . . . . . . . . . . . . . . . . . . . . . . . $475/$950

2

Rehabilitation unit confinement . . . . . . . . . . . . . . . . .$175 per day (up to 15 days, not to exceed 30 days per calendar year)

Ruptured disc — with surgical repair . . . . . . . . . . . . . . . . . . . $950 Tendon/ligament/rotator cuff — with surgical repair

Therapy — occupational, physical or speech . . . . . . $45 per day (up to 10 days)

• One . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $800 • Two or more . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,600

Accidental dismemberment

Hospital care

Accidental dismemberment . . . . . . . . . . . . . . . . . . .$600–$25,000 • Loss, loss of use or paralysis – hand, arm, foot, leg, sight of eye • Loss, loss of use – finger, toe, partial dismemberment of finger or toe

Hospital admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,250 Hospital confinement . . . . . . . . . . . . . . . . . . . . . . . . . $300 per day (up to 365 days)

Accidental dismemberment due to a catastrophic accident

Hospital sub-acute intensive care unit confinement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $400 per day (up to 30 days)

• Named insured, spouse or child . . . . . . . . . . . . . . . . . .$30,0004 • Total and irrecoverable loss, loss of use or paralysis – 180-day elimination period • Loss of both hands, arms, feet, legs or the sight of both eyes; or any combination; or • Loss of hearing in both ears, or loss of ability to speak

Intensive care unit admission . . . . . . . . . . . . . . . . . . . . . . . .$2,500 Intensive care unit confinement . . . . . . . . . . . . . . . . $550 per day (up to 15 days)

Surgical care

Accidental death

Blood/plasma/platelets — transfusion . . . . . . . . . . . . . . . . . $400

Accidental death

Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250–$1,900 (based on type of repair and surgery)

• Named insured, spouse . . . . . . . . . . . . . . . . . . . . . . . . . . $40,000 • Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$10,000

Transportation and lodging

Accidental death common carrier Examples of common carriers are mass transit trains, buses and planes

Transportation for hospital confinement . . $700 per round trip (up to three round trips, 50+ miles from home)

• Named insured, spouse . . . . . . . . . . . . . . . . . . . . . . . . . .$160,000

Lodging–companion . . . . . . . . . . . . . . . . . . . . . . . . . . $150 per day (up to 30 days)

• Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $30,000

39

For more information, contact your Colonial Life benefits counselor.

1 Requires transportation by a licensed professional air ambulance or ambulance (ground or water).

STATE VARIATIONS FOR EXCLUSIONS AND LIMITATIONS

2 One benefit for each injured ear per covered person per lifetime.

3 One repair or replacement per prosthetic device/artificial limb per covered person per lifetime.

MI: Not applicable to “suicide or injuries which any covered person intentionally does to himself” or for injuries that are the result of intoxication or use of narcotics.”

4 Payable once per lifetime per covered person.

OR: Replace “felonies or illegal occupations” with “felonies.”

HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLE

PA: Not applicable to “injuries a child sustains during birth” or “injuries that are the result of intoxication or use of narcotics.”

KS: Not applicable to “for injuries a child sustains during birth.”

This plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be offered to employees who do not have HSAs.

SC: Not applicable to “hazardous avocations, racing, semi-professional or professional sports.”

VT: Not applicable to “hazardous avocations, racing, semi-professional or professional sports.” The additional exclusions for Accidental Dismemberment due to Catastrophic Accident “for injuries a child sustains during birth, or for injuries that are the result of intoxication or use of narcotics” do not apply.

THIS POLICY PROVIDES LIMITED BENEFITS. This coverage is a supplement to health insurance. It is not a substitute for essential health benefits or minimum essential coverage as defined in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this coverage.

This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy form IAC4000 (including state abbreviations where used, for example: IAC4000-SC). For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company.

EXCLUSIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of a covered personʼs felonies or illegal occupations, hazardous avocations, racing, semi-professional or professional sports, sickness, suicide or injuries which any covered person intentionally does to himself, war or armed conflict. In addition, we will not pay Accidental Dismemberment Due to Catastrophic Accident benefits for injuries a child sustains during birth, or for injuries that are the result of intoxication or use of narcotics.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ColonialLife.com

© 2024 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

FOR EMPLOYEES 7-24 | 101954-3

40

Accident Insurance Active Lifestyles Benefit

This benefit increases the amount you receive by 20% for your covered eligible benefits, giving you more financial protection for the unexpected.

The active lifestyles benefit is available to you with accident coverage, as well as all your covered family members.

Example of a benefits calculation

Eligible benefits1

$2,500

Eligible benefits

$2,500

Eligible benefit amount

x 20%

Active lifestyles benefit

$500

Active lifestyles benefit calculation

$2,500

Eligible benefit amount

+ $500

Active lifestyles benefit

• Concussion • Dislocation • Emergency dental work • Eye injuries • Fractures • Knee cartilage (torn) • Laceration • Medical imaging study • Ruptured disc with surgical repair • Surgery ‐ cranial, open abdominal, thoracic/hernia

$3,000

‐ exploratory and arthroscopic

Total

• Tendon/ligament/rotator cuff with surgical repair • X-ray

For illustrative purposes only

To learn more, talk with your Colonial Life benefits counselor.

41

IAC4000 – ACTIVE LIFESTYLES BENEFIT

1 Active lifestyles benefit applies to any combination of these injuries or services due to a covered accident.

HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLE This plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate.

It may also be offered to employees who do not have HSAs. THIS POLICY PROVIDES LIMITED BENEFITS. This coverage is a supplement to health insurance. It is not a substitute for essential health benefits or minimum essential coverage as defined in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this coverage.

ADDITIONAL DISCLOSURES FOR KENTUCKY Eligibility for benefits: We will pay benefits for a covered accident if any covered person sustains an injury as a result of a covered accident if: • the covered accident occurs while the policy is in force; • the covered accident occurs on or after the policy coverage effective date; • the covered accident is an accident type listed on the policy schedule; and • the covered accident is not excluded by name or specific description in the policy.

Noncancellable: This policy is noncancellable. We have no right to change the premiums we charge on this policy. Any riders attached to this policy may be subject to a change in premium. The premium can be changed following the approval of the Commissioner of Insurance only if we change it on all riders of the same kind in force in the state where the policy was issued.

What is not covered by this policy: We will not pay benefits for losses that are caused by, contributed to by or occur as a result of the covered person’s felonies or illegal occupations, hazardous avocations, racing, semi-professional or professional sports, sickness or injuries which any covered person intentionally does to himself, war or armed conflict.

In addition, we also will not pay the Accidental Dismemberment due to Catastrophic Accident benefit for injuries that are caused by or are the result of birth or intoxicants, narcotics and hallucinogencis.

This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy form IAC4000 (including state abbreviations where used, for example: IAC4000-TX).

For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. An insurance producer may contact you.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2024 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

ColonialLife.com

42

FOR EMPLOYEES

3-24 | 101778-3

Accident Insurance Sickness Hospital Confinement Rider

These benefits can help with medical costs related to a hospital stay for a covered sickness, including costs that your health insurance may not cover, such as co-pays and deductibles.

The sickness hospital confinement rider is optional coverage available to you and all your covered family members.

Daily sickness hospital confinement . . . . . . . . . . . . . . . . . . . . . . . $100 per day

To learn more, talk with your Colonial Life benefits counselor.

Up to 30 days per covered person per confinement for a covered sickness Re-confinement for the same or related condition within 90 days of discharge is considered a continuation of a previous confinement.

43

IAC4000 – SICKNESS HOSPITAL CONFINEMENT RIDER

HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLE This plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be offered to employees who do not have HSAs. THIS POLICY PROVIDES LIMITED BENEFITS. This coverage is a supplement to health insurance. It is not a substitute for essential health benefits or minimum essential coverage as defined in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this coverage.

EXCLUSIONS AND LIMITATIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of accidental injuries, alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, psychiatric or psychological conditions, intoxicants and narcotics, psychiatric or psychological conditions, suicide or injuries which you intentionally do to yourself, war or armed conflict and well baby care.

PRE-EXISTING CONDITION LIMITATION Pre-existing condition means a sickness or physical condition, whether diagnosed or not, for which a covered person was treated, had medical testing, received medical advice, or had taken medication within 12 months before the rider coverage effective date shown on the rider schedule. After this rider has been in force for 12 months from the rider coverage effective date shown on the rider schedule, we will pay benefits as stated in the rider for any loss as the result of a pre-existing condition not excluded by name or specific description if the covered loss began at least 12 months after the rider coverage effective date.

STATE VARIATIONS FOR EXCLUSIONS AND LIMITATIONS AK: Replace “alcoholism or drug addiction” with “intoxicants or narcotics.”

DE: Replace “alcoholism or drug addiction” with “substance abuse.”

FL: Replace “psychiatric or psychological conditions” with “mental or nervous disorders.”

IL: Pre-existing Condition Limitation definition also includes “produced symptoms.”

LA: Replace “alcoholism or drug addiction” with “intoxicants and narcotics.”

ME: Pre-existing Condition Limitation definition does not include “had taken medication.”

MO: Replace “alcoholism or drug addiction” with “substance abuse.”

MT: Pre-existing Condition Limitation definition does not include “whether diagnosed or not” or “had medical testing.”

NC: Pre-existing Conditions Limitation definition also includes “If a covered person is 65 or older when this policy is issued, pre-existing conditions for that covered person will include only conditions specifically eliminated by rider.”

OK: Replace “psychiatric or psychological conditions” with “mental or emotional conditions.”

SC: Replace “psychiatric or psychological conditions” with “mental or emotional disorders.”

SD: Not applicable to “alcoholism or drug addiction.”

UT: Replace “psychiatric or psychological conditions” with “mental or nervous disorders.”

VT: Not applicable to “alcoholism or drug abuse, psychiatric or psychological conditions, well baby care,” or the limitation for giving birth within the first nine months after the rider coverage effective date.

ADDITIONAL DISCLOSURES FOR THE STATE OF KENTUCKY Eligibility for Benefits: We will pay the benefits for a covered accident if any covered person sustains an injury as a result of a covered accident if: • The covered accident occurs while the policy is in force; • The covered accident occurs on or after the policy coverage effective date; • The covered accident is on an accident type listed on the policy schedule; and • The covered accident is not excluded by name or specific description in the policy.

What is not covered by this policy: We will not pay benefits for losses that are caused by, contributed to by or occurs as a result of the covered person’s felonies or illegal occupations, hazardous avocations, racing, semi-professional or professional sports, sickness or injuries which any covered person intentionally does to himself, war or armed conflict.

In addition, we also will not pay the Accidental Dismemberment due to Catastrophic Accident benefit for injuries that are caused by or are the result of birth or intoxicants, narcotics, and hallucinogenics.

Termination of this Rider: This rider will terminate on the earliest of: the date the policy to which this rider is attached terminates; the date premium for this rider is not paid by the end of the grace period; or the date we receive your written request to terminate this rider.

Noncancellable: This policy is noncancellable. We have no right to change the premiums we charge on this policy. Any riders attached to this policy may be subject to a change in premium. The premium can be changed following the approval of the Commissioner of Insurance only if we change it on all riders of the same kind in force in the state where the policy was issued.

This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy form IAC4000 and rider form R-SHC4000 (including state abbreviations where used, for example: IAC4000-AL). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.

ColonialLife.com

© 2024 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

FOR EMPLOYEES 3-24 | 101785-5

44

Accident Insurance Wellbeing Assistance Standard Benefit

This benefit can help reduce the risk of serious illness through early detection of disease or other risk factors, giving you more protection from the unexpected.

Wellbeing assistance standard . . . . . . . . . . . . . . . . . . . . . .$____________________ Payable once per covered person per calendar year; subject to a 30-day waiting period1 • Blood test for triglycerides

• Hemoccult stool analysis

• Bone marrow testing

• Mammography

• Breast ultrasound

• Pap smear2

• CA 15-3 (blood test for breast cancer)

• PSA (blood test for prostate cancer)

• CA 125 (blood test for ovarian cancer)

• Serum cholesterol test for HDL and LDL levels

• Carotid Doppler • CEA (blood test for colon cancer)

• Serum protein electrophoresis (blood test for myeloma)

• Chest X-ray

• Skin cancer biopsy

• Colonoscopy

• Stress test on a bicycle or treadmill

• Echocardiogram (ECHO) • Electrocardiogram (EKG, ECG) • Fasting blood glucose test • Flexible sigmoidoscopy

To learn more, talk with your Colonial Life benefits counselor .

• Thermography • ThinPrep pap test2 • Virtual colonoscopy

45

IAC4000 – WELLBEING ASSISTANCE STANDARD BENEFIT

1 No waiting period in ID, MD, MO, VA and VT. 2 In WV only, benefit is also payable for human papillomavirus screening test.

THIS POLICY PROVIDES LIMITED BENEFITS .

This coverage is a supplement to health insurance. It is not a substitute for essential health benefits or minimum essential coverage as defined in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this coverage.

EXCLUSIONS FOR ARIZONA We will not pay benefits for losses that are caused by, contributed to by or occur as the result of a covered personʼs felonies or illegal occupations, hazardous avocations, racing, semi-professional or professional sports, sickness, suicide or injuries which any covered person intentionally does to himself, war or armed conflict. In addition, we will not pay Accidental Dismemberment Due to Catastrophic Accident benefit for injuries a child sustains during birth, or for injuries that are the result of intoxication or use of narcotics.

ADDITIONAL DISCLOSURES FOR KENTUCKY Waiting Period: Waiting period means the first 30 days following each covered person’s coverage effective date during which no benefits are payable.

Eligibility for Benefits: We will pay the benefits for a covered accident if any covered person sustains an injury as a result of a covered accident if: • The covered accident occurs while the policy is in force; • The covered accident occurs on or after the policy coverage effective date; • The covered accident is on an accident type listed on the policy schedule; and • The covered accident is not excluded by name or specific description in the policy.

What is not covered by this policy: We will not pay benefits for losses that are caused by, contributed to by or occurs as a result of the covered person’s felonies or illegal occupations, hazardous avocations, racing, semi-professional or professional sports, sickness or injuries which any covered person intentionally does to himself, war or armed conflict.

In addition, we also will not pay the Accidental Dismemberment due to Catastrophic Accident benefit for injuries that are caused by or are the result of birth or intoxicants, narcotics, and hallucinogencis.

Noncancellable: This policy is noncancellable. We have no right to change the premiums we charge on this policy. Any riders attached to this policy may be subject to a change in premium. The premium can be changed following the approval of the Commissioner of Insurance only if we change it on all riders of the same kind in force in the state where the policy was issued.

This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy form IAC4000 (including state abbreviations where used, for example: IAC4000-TX).

For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. An insurance producer may contact you.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2024 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

ColonialLife .com

46

FOR EMPLOYEES

6-24 | 101781-5

Accident Insurance Gunshot Wound Benefit

This benefit can help pay your medical expenses if you receive a non-fatal gunshot wound. It offers you a lump sum benefit for a covered injury that you can use where you need it the most.

Gunshot wound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $_____________________ Guaranteed issue You can get this coverage without answering any health questions.

On/off-job coverage You may receive benefits regardless of whether the injury occurs on or off the job.

Direct payment Benefits are payable directly to you regardless of any other insurance coverage you may have.

This policy covers a non-fatal gunshot wound from a conventional firearm that requires treatment by a doctor and overnight hospitalization within 24 hours of the injury. If you’re shot more than once in a 24-hour period, we can pay benefits only for the first wound.

47

For more information, talk with your Colonial Life benefits counselor.

IAC4000 – GUNSHOT WOUND BENEFIT

HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLE This plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be offered to employees who do not have HSAs. THIS POLICY PROVIDES LIMITED BENEFITS .

This coverage is a supplement to health insurance. It is not a substitute for essential health benefits or minimum essential coverage as defined in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this coverage.

EXCLUSIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of your felonies or illegal occupations, suicide or injuries which you do to yourself, war or armed conflict.

STATE VARIATIONS FOR EXCLUSIONS AND LIMITATIONS CT: Not applicable to “or illegal occupations”.

ID: This is a rider R-GSW4000-ID. MD: Not applicable to “or illegal occupations”. This is a rider R-GSW4000-MD. MI: Not applicable to “suicide or injuries which you do to yourself”.

MT: Not applicable to “suicide or injuries which you do to yourself”.

OH: This is a rider R-GSW4000.

OR: Not applicable to “or illegal occupations”.

ADDITIONAL DISCLOSURES FOR KENTUCKY: Eligibility for Benefits: We will pay the benefits for a covered accident if any covered person sustains an injury as a result of a covered accident if: • The covered accident occurs while the policy is in force; • The covered accident occurs on or after the policy coverage effective date; • The covered accident is on an accident type listed on the policy schedule; and • The covered accident is not excluded by name or specific description in the policy.

What is not covered by this policy: We will not pay benefits for losses that are caused by, contributed to by or occurs as a result of the covered person’s felonies or illegal occupations, hazardous avocations, racing, semi-professional or professional sports, sickness or injuries which any covered person intentionally does to himself, war or armed conflict.

In addition, we also will not pay the Accidental Dismemberment due to Catastrophic Accident benefit for injuries that are caused by or are the result of birth or intoxicants, narcotics, and hallucinogencis.

Noncancellable: This policy is noncancellable. We have no right to change the premiums we charge on this policy. Any riders attached to this policy may be subject to a change in premium. The premium can be changed following the approval of the Commissioner of Insurance only if we change it on all riders of the same kind in force in the state where the policy was issued.

This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy form IAC4000 (including state abbreviations where used, for example: IAC4000-TX).

For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. An insurance producer may contact you.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2024 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

ColonialLife .com

48

IAC4000 – GUNSHOT WOUND BENEFIT

2-24 | 101779-3

ACCIDENT BENEFIT PREMIUMS 3UHIHUUHG ZLWK $FWLYH /LIHVW\OHV 2Q 2II -RE $FFLGHQW &RYHUDJH DQG 6WDQGDUG :HOOEHLQJ $VVLVWDQFH *XQVKRW :RXQG &RYHUDJH

26-Pay Premium Named Insured

$12.60

Employee & Spouse

$19.25

One Parent Family Employee

$20.34

Two Parent Family

$26.76

Sample rates only. Multiple choices and options available and rates may vary.

49

Click on the video below to learn more about Medical Bridge Benefits!

MEDICAL BRIDGE BENEFITS

Hospital Confinement Indemnity Insurance Plan 1 Our Individual Medical BridgeSM insurance can help with medical costs that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children.

Hospital confinement ..................................................................... $__________________ Maximum of one benefit per covered person per calendar year

Observation room.................................................................................. $100 per visit Maximum of two visits per covered person per calendar year

Rehabilitation unit confinement ................................................................. $100 per day Maximum of 15 days per confinement with a 30-day maximum per covered person per calendar year

Waiver of premium Available after 30 continuous days of a covered hospital confinement of the named insured

Health savings account (HSA) compatible

For more information, talk with your benefits counselor.

ColonialLife.com

This plan is compatible with HSA guidelines. This plan may also be offered to employees who do not have HSAs. Colonial Life & Accident Insurance Company’s Individual Medical Bridge offers an HSA compatible plan in most states.

THIS POLICY PROVIDES LIMITED BENEFITS.

EXCLUSIONS We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, mental or emotional disorders, pregnancy of a dependent child, suicide or injuries which any covered person intentionally does to himself or herself, war, or giving birth within the first nine months after the effective date of the policy. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. A preexisiting condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the effective date of the policy.

For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000-SC. This is not an insurance contract and only the actual policy provisions will control. ©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

51

IMB7000 – PLAN 1 | 1-16 | 101576-SC

Hospital Confinement Indemnity Insurance Plan 3 Our Individual Medical BridgeSM insurance can help with medical costs that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children.

Hospital confinement ......................................................................... $_______________ Maximum of one benefit per covered person per calendar year

Observation room.................................................................................. $100 per visit Maximum of two visits per covered person per calendar year

Rehabilitation unit confinement ................................................................. $100 per day Maximum of 15 days per confinement with a 30-day maximum per covered person per calendar year

Waiver of premium

Available after 30 continuous days of a covered hospital confinement of the named insured

Diagnostic procedure Tier 1. . . . . . ......................................................................................... ................. $250 Tier 2. . . . . . ......................................................................................... ................. $500 Maximum of $500 per covered person per calendar year for all covered diagnostic procedures combined

Outpatient surgical procedure Tier 1. . . . . . ......................................................................................... . $_______________ Tier 2. . . . . . ......................................................................................... .. $_______________

For more information, talk with your benefits counselor.

Maximum of $___________ per covered person per calendar year for all covered outpatient surgical procedures combined

The following is a list of common diagnostic procedures that may be covered.

Tier 1 diagnostic procedures Breast – Biopsy (incisional, needle, stereotactic) Diagnostic radiology – Nuclear medicine test Digestive – Barium enema/lower GI series – Barium swallow/upper GI series – Esophagogastroduodenoscopy (EGD) Ear, nose, throat, mouth – Laryngoscopy Gynecological – Hysteroscopy – Amniocentesis – Loop electrosurgical – Cervical biopsy excisional procedure – Cone biopsy (LEEP) – Endometrial biopsy

Liver – biopsy Lymphatic – biopsy Miscellaneous – Bone marrow aspiration/biopsy Renal – biopsy Respiratory – Biopsy – Bronchoscopy – Pulmonary function test (PFT) Skin – Biopsy – Excision of lesion Thyroid – biopsy Urologic – Cystoscopy

Tier 2 diagnostic procedures Cardiac – Angiogram – Arteriogram – Thallium stress test – Transesophageal echocardiogram (TEE)

52

Diagnostic radiology – Computerized tomography scan (CT scan) – Electroencephalogram (EEG) – Magnetic resonance imaging (MRI) – Myelogram – Positron emission tomography scan (PET scan) IMB7000 – PLAN 3

The surgeries listed below are only a sampling of the surgeries that may be covered. Surgeries must be performed by a doctor in a hospital or ambulatory surgical center. For complete details and definitions, please refer to your policy.

Tier 1 outpatient surgical procedures Breast

Ear, nose, throat, mouth

– Axillary node dissection – Breast capsulotomy – Lumpectomy

– Adenoidectomy – Removal of oral lesions – Myringotomy – Tonsillectomy – Tracheostomy – Tympanotomy

Cardiac

– Pacemaker insertion

Digestive

Gynecological

– Colonoscopy – Fistulotomy – Hemorrhoidectomy – Lysis of adhesions

– Dilation and curettage (D&C) – Endometrial ablation – Lysis of adhesions

Musculoskeletal system

Skin

– Laparoscopic hernia repair – Skin grafting

Liver

– Paracentesis

– Carpal/cubital repair or release – Foot surgery (bunionectomy, exostectomy, arthroplasty, hammertoe repair) – Removal of orthopedic hardware – Removal of tendon lesion

Tier 2 outpatient surgical procedures Breast

Gynecological

Cardiac

Musculoskeletal system

– Breast reconstruction – Breast reduction

– Hysterectomy – Myomectomy

– Angioplasty – Cardiac catheterization

Digestive

– Exploratory laparoscopy – Laparoscopic appendectomy – Laparoscopic cholecystectomy

Ear, nose, throat, mouth – Ethmoidectomy – Mastoidectomy – Septoplasty – Stapedectomy – Tympanoplasty

– Arthroscopic knee surgery with meniscectomy (knee cartilage repair) – Arthroscopic shoulder surgery – Clavicle resection – Dislocations (open reduction with internal fixation) – Fracture (open reduction with internal fixation) – Removal or implantation of cartilage – Tendon/ligament repair

Thyroid

– Excision of a mass

Urologic

Eye

– Cataract surgery – Corneal surgery (penetrating keratoplasty) – Glaucoma surgery (trabeculectomy)

– Lithotripsy

– Vitrectomy

THIS POLICY PROVIDES LIMITED BENEFITS.

EXCLUSIONS

ColonialLife.com

We will not pay benefits for injuries received in accidents or for sicknesses which are caused by: (a) alcoholism or drug addiction, (b) dental procedures, (c) elective procedures and cosmetic surgery, (d) felonies or illegal occupations, (e) pregnancy of a dependent child, (f) psychiatric or psychological conditions, (g) suicide or injuries which any covered person intentionally does to himself or herself, or (h) war. We will not pay benefits for hospital confinement (i) due to giving birth within the first nine months after the effective date of the policy or (j) for a newborn who is neither injured nor sick. (k) The policy may have additional exclusions and limitations which may affect any benefits payable.

PRE-EXISTING CONDITION LIMITATION (l) We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. (m) A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the effective date of the policy. (n) This limitation applies to the following benefits, if applicable: Hospital Confinement, Daily Hospital Confinement, Enhanced Intensive Care Unit Confinement and Rehabilitation Unit Confinement.

This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy form IMB7000 (including state abbreviations where used, for example: IMB7000-TX).

For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

This form is not complete without form #562973.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2021 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

53

1-21 | 562942

Hospital Confinement Indemnity Insurance Exclusions and Limitations STATE-SPECIFIC EXCLUSIONS

AK: (a) Replaced by intoxicants and narcotics CA: (a) Replaced by intoxicants or controlled substances; (c) Replaced by cosmetic surgery CT: (a) Replaced by intoxication or drug addiction; (d) Replaced by felonies; (e) Exclusion does not apply DE: (a) Exclusion does not apply IL: (a) Replaced by alcoholism, intoxication, or drug addiction; (e) Exclusion does not apply; (g) Exclusion does not apply KS: (a) Replaced by intoxicants and narcotics; (f) Exclusion does not apply; (h) Replaced by war or armed conflict; (i) Exclusion does not apply; (j) or requires necessary care and treatment of medically diagnosed congenital defects, birth abnormalities or routine and necessary immunizations KY: (a) Replaced by intoxicants, narcotics and hallucinogenics LA: (a) Replaced by intoxicants and narcotics MN: (a) Replaced by narcotic addiction; (e) Exclusion does not apply; (g) Exclusion does not apply MO: (a) Replaced by drug addiction NC: (i) Exclusion does not apply OR: (a) Exclusion does not apply; (d) Replaced by felony; (i) Replace “nine months” with “six months” SC: (f) Replaced by mental or emotional disorders SD: (a) Exclusion does not apply TN: (a) Replaced by intoxicants and narcotics; (e) Exclusion does not apply TX: (a) Replaced by intoxicants and narcotics WA: (a) Only sicknesses caused by alcoholism or drug addiction are excluded, not accidents

STATE-SPECIFIC PRE-EXISTING CONDITION LIMITATIONS

NV, WY: (m) applies within the six months before the policy effective date.

CT: (m) Pre-existing Condition means having a sickness or physical condition for which any covered person was treated, received medical advice or had taken medication within 12 months before the effective date of this policy.

FL: (m) Pre-existing Condition means any covered person having a sickness or physical condition that during the 12 months immediately preceding the effective date of this policy had manifested itself in such a manner as would cause an ordinarily prudent person to seek medical advice, diagnosis, care, or treatment or for which medical advice, diagnosis, care, or treatment was recommended or received.

Routine follow-up care during the 12 months immediately preceding the effective date of this policy to determine whether a breast cancer has recurred in a covered person who has been previously determined to be free of breast cancer does not constitute medical advice, diagnosis, care, or treatment for purposes of determining pre-existing conditions, unless evidence of breast cancer is found during or as a result of the follow-up care.

GA: (m) Pre-existing Condition means having a sickness or physical condition for which any covered person was treated, had medical testing, received medical advice or had taken prescription medication within 12 months before the effective date of this policy.

IL: (m) Pre-existing Condition means having a sickness or physical condition for which any covered person was diagnosed, treated, had medical testing by a legally qualified physician, or received medical advice or had taken medication within 12 months prior to the effective date of this policy.

ME: (m) Pre-existing Condition means having a sickness or physical condition for which any covered person was treated, had medical testing, or received medical advice within 12 months before the effective date of this policy.

NC: (m) Pre-existing Condition means having those conditions whether diagnosed or not, for which any covered person received medical advice, diagnosis, care or treatment was received or recommended within one-year period immediately preceding the effective date of this policy.

If you are 65 or older when this policy is issued, pre-existing conditions will include only conditions specifically eliminated by rider.

OR: Pre-existing Condition means having a sickness or physical condition for which any covered person was diagnosed, received treatment, care or medical advice within the 6-month period immediately preceding the effective date of this policy.

This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states.

The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form IMB7000 (including state abbreviations where used, for example: IMB7000-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

This form is not complete without base form 562880, 562911, or 562942.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2021 Colonial Life & Accident Insurance Company. All rights reserved.

Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

54

IMB7000 – EXCLUSIONS AND LIMITATIONS | 1-21 | 562973

Hospital Confinement Indemnity Insurance Health Screening Individual Medical BridgeSM insurance’s health screening benefit can help pay for health and wellness tests you have each year.

Health screening .............................................................................. $_____________ Payable once per covered person per calendar year; subject to a 30-day waiting period.

Blood test for triglycerides Bone marrow testing Breast ultrasound CA 15-3 (blood test for breast cancer) CA 125 (blood test for ovarian cancer) CEA (blood test for colon cancer) Carotid Doppler

Serum protein electrophoresis (blood test for myeloma) Skin cancer biopsy Stress test on a bicycle or treadmill Thermography ThinPrep pap test Virtual colonoscopy

Chest X-ray Colonoscopy Echocardiogram (ECHO) Electrocardiogram (EKG, ECG) Fasting blood glucose test Flexible sigmoidoscopy

For more information, talk with your benefits counselor.

Hemoccult stool analysis Mammography Pap smear PSA (blood test for prostate cancer) Serum cholesterol test for HDL and LDL levels

ColonialLife.com MO & ND: Waiting period does not apply THIS POLICY PROVIDES LIMITED BENEFITS. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy form IMB7000 (including state abbreviations where used, for example: IMB7000-TX).

For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2021 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

55

IMB7000 – HEALTH SCREENING BENEFIT | 1-21 | 101579-4

MEDICAL BRIDGE BENEFIT PREMIUMS INDIVIDUAL MEDICAL BRIDGE Plan 1 Named Insured

Hospital Confinement Medical Treatment Pkg $100 Health Screening

Level 2

Level 3

$1,000.00

$1,500.00

$8.91 $11.12 $14.12 $18.25

$11.35 $14.49 $18.76 $24.44

Pay Premium Ages 17-49 Ages 50-59 Ages 60-64 Ages 65-75

26-Pay Premium 26-Pay Premium 26-Pay Premium 26-Pay Premium

INDIVIDUAL MEDICAL BRIDGE Plan 3 Named Insured Level 3

Level 4

Hospital Confinement Medical Treatment Pkg $100 Health Screening

$1,500.00

$2,000.00

Outpatient Surgical Procedure

Option 2 Tier 1 $750 Tier 2 $1,500 CY Max $2,500

Option 2 Tier 1 $750 Tier 2 $1,500 CY Max $2,500

$20.77 $26.63 $33.18 $41.19

$24.23 $31.38 $39.58 $49.78

Ages 17-49 Ages 50-59 Ages 60-64 Ages 65-75

Pay Premium 26-Pay Premium 26-Pay Premium 26-Pay Premium 26-Pay Premium

Sample rates only. Multiple choices and options available and rates may vary.

56

Click on the video below to learn more about Whole Life Insurance!

WHOLE LIFE INSURANCE

Whole Life Plus Insurance*

You can’t predict your family’s future, but you can prepare for it.

Advantages of Whole Life Plus insurance

Help give your family more peace of mind and coverage for final expenses with Colonial Life Individual Whole Life Plus insurance.

• Permanent life insurance coverage that stays the same through the life of the policy

Benefits and features Choose the age when your premium payments end — Paid-Up at Age 70 or Paid-Up at Age 100 Stand-alone spouse policy available even without buying a policy for yourself

• Premiums will not increase due to changes in health or age.

Ability to keep the policy if you change jobs or retire

• Accumulates cash value based on a nonforfeiture interest rate of 3.75%2

Built-in terminal illness accelerated death benefit that provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness1

• Policy loans available, which can be used for emergencies

Immediate $3,000 claim payment that can help your designated beneficiary pay for funeral costs or other expenses

• Benefit for the beneficiary that is typically tax-free

Provides cash surrender value at age 100 (when the policy endows)

Additional coverage options Spouse term rider Cover your spouse with a death benefit up to $50,000, for 10 or 20 years.

Juvenile Whole Life Plus policy Purchase a policy (Paid-Up at Age 70) while children are young and premiums are low — whether or not you buy a policy for yourself. You may also increase the coverage when the child is 18, 21 and 24 without proof of good health.

Children’s term rider

Your cost will vary based on the amount of coverage you select.

You may purchase up to $20,000 in term life insurance coverage for all of your eligible dependent children and pay one premium. The children’s term rider may be added to either your policy or your spouse’s policy — not both.

58

WHOLE LIFE PLUS (IWL5000)

Benefits worksheet

Additional coverage options (Continued)

For use with your benefits counselor

Accelerated death benefit for long term care services rider3

How much coverage do you need?

Talk with your benefits counselor for more details.

 YOU $_______________________

Accidental death benefit rider

Select the option:

 Paid-Up at Age 70  Paid-Up at Age 100  SPOUSE $ __________________ Select the option:

 Paid-Up at Age 70  Paid-Up at Age 100  DEPENDENT STUDENT

$ ____________________________ Select the option:

 Paid-Up at Age 70  Paid-Up at Age 100 Select any optional riders:

 Spouse term rider

$ _____________face amount for _________-year term period

 Children’s term rider

$ ______________ face amount

 Accelerated death benefit for long term care services rider

 Accidental death benefit rider  Chronic care accelerated death benefit rider

 Critical illness accelerated death benefit rider

 Guaranteed purchase option rider

 Waiver of premium benefit rider

To learn more, talk with your benefits counselor.

An additional benefit may be payable if the covered person dies as a result of an accident before age 70, and doubles if the injury occurs while riding as a fare-paying passenger using public transportation. An additional 25% is payable if the injury occurs while driving or riding in a private passenger vehicle and wearing a seatbelt.

Chronic care accelerated death benefit rider If a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments.1 Talk with your benefits counselor for more details.

Critical illness accelerated death benefit rider If you suffer a heart attack, stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable.1 A subsequent diagnosis benefit is included.

Guaranteed purchase option rider This rider allows you to purchase additional whole life coverage — without having to answer health questions — at three different points in the future. The rider may only be added if you are age 50 or younger when you purchase the policy.

You may purchase up to your initial face amount, not to exceed a total combined maximum of $100,000 for all options.

Waiver of premium benefit rider Policy and rider premiums are waived if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period. Once you are no longer disabled, premiums will resume.

* Whole Life Plus is a marketing name of the insurance policy filed as “Whole Life Insurance” in most states.

1 Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits.

2 Accessing the accumulated cash value reduces the death benefit by the amount accessed, unless the loan is repaid. Cash value will be reduced by any outstanding loans against the policy.

3 The rider is not available in all states.

This life insurance does not specifically cover funeral goods or services and may not cover the entire cost of your funeral at the time of your death. The beneficiary of this life insurance may use the proceeds for any purpose, unless otherwise directed.

EXCLUSIONS AND LIMITATIONS: If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you.

This information is not intended to be a complete description of the insurance coverage available.

The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy forms ICC19-IWL5000-70/ IWL5000-70, ICC19-IWL5000-100/IWL5000-100, ICC19-IWL5000J/IWL5000J and rider forms ICC23IWL5000-LTC/IWL5000-LTC, ICC19-R-IWL5000-STR/R-IWL5000-STR, ICC19-R-IWL5000-CTR/RIWL5000-CTR, ICC19-R-IWL5000-WP/R-IWL5000-WP, ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD, ICC19-R-IWL5000-CI/R-IWL5000-CI, ICC19-R-IWL5000-CC/R-IWL5000-CC, ICC19-R-IWL5000GPO/R-IWL5000-GPO (including state abbreviations where applicable). For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2023 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

ColonialLife.com

59

FOR EMPLOYEES

8-23 | 642298-2

Chronic Care Accelerated Death Benefit Rider

The day you may need care due to a serious illness might seem hard to imagine, but challenging times could come at any point.

A little planning now could go a long way to help protect what you’ve worked so hard to build.

NATIONAL AVERAGE COSTS FOR DIFFERENT CARE SETTINGS:2 Private room in a nursing home:

HOW IT WORKS

$8,821

You may be eligible for benefits if you are diagnosed with a chronic illness, meaning you require substantial supervision due to severe cognitive impairment or you are unable to perform at least two of the six Activities of Daily Living (ADLs)1.

Claim payments are:

Private one-bedroom unit in an assisted living facility:

$4,300

OR Monthly, 6% of the death benefit

PER MONTH

PER MONTH

A one-time lump sum of 50% of the death benefit

KEY POINTS • Gives access to the death benefit to help with expenses while living if diagnosed with a chronic illness • Provides benefits regardless of care setting — money can be used for any need

Home health aide:

$4,576 PER MONTH

• Provides relief from a monthly bill by waiving premiums while benefits are being paid. If the one-time lump-sum payment option is chosen, premiums will be waived for one year.

60

CHRONIC CARE ACCELERATED DEATH BENEFIT RIDER

A LIVING BENEFIT AT ANY AGE: If you have a serious accident or illness, this benefit could be used to pay for needs like out-of-pocket treatment costs, mortgage or outstanding debt.

A living benefit may help you manage these expenses without having to pull from savings or rely on financial aid from others.5

SUPPORT DURING CHALLENGING TIMES Matt and his wife, Jennifer, both work full-time jobs to support their two children.

The couple recently purchased a new home to accommodate their growing family.

After a serious accident, Matt needed a home health care professional to provide medical assistance while he recovered. To cover these expenses, he was going to have to pull from savings or borrow money from family.

Fortunately, Matt had a Whole Life Plus3 insurance policy with a chronic care accelerated death benefit rider. His policy had a $100,000 death benefit, and he needed assistance for three months.

He was able to receive a 6% monthly payment from his whole life policy’s death benefit, which helped with his care costs.

BENEFITS PAYOUT EXAMPLE

To learn more, talk with your Colonial Life benefits counselor.

BENEFITS PAYMENT4

DEATH BENEFIT

Just before 1st payment

$0

$100,000

Just after 1st payment

$6,000

$94,000

Just after 2nd payment

$6,000

$88,000

Just after 3rd payment

$6,000

$82,000

For illustrative purposes only

1. Bathing, continence, dressing, eating, toileting, and transferring.

2. Genworth Cost of Care Survey 2019, conducted by CareScout®, June 2020.

3. Rider can also be included on Individual Term Life.

4. A 90-day elimination period begins the date the insured has been certified with a covered chronic illness. Monthly benefits (minus any policy loans) begin after the elimination period. On Whole Life Plus, the cash value also reduces by 6% each month.

5. The Chronic Care accelerated death benefit is not long term care, nursing home, or home care insurance.

Accelerated benefit payments will reduce the amount the policy pays upon the recipient’s death.

This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy forms ICC19-IWL5000-70/IWL5000-70, ICC19-IWL5000-100/IWL5000-100, ICC19IWL5000J/IWL5000J and rider forms R-IWL5000-CC, ICC19-R-IWL5000-CC, R-IWL5000-CC-FL, R-ITL5000-CC, ICC18R-ITL5000-CC and R-ITL5000-CC-FL. For cost and complete details of coverage, call or write your Colonial Life benefits representative or the company.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ColonialLife.com

© 2021 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

FOR EMPLOYEES 7-21 | 372163-1

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COLONIAL LIFE & ACCIDENT INSURANCE COMPANY REQUIRED DISCLOSURE FORM FOR CHRONIC CARE ACCELERATED DEATH BENEFIT Consequences of This Benefit: Receipt of accelerated death benefits MAY AFFECT MEDICAID AND SUPPLEMENTAL SECURITY INCOME (“SSI”) ELIGIBILITY. The mere fact that you own a policy with an accelerated death benefit may affect your eligibility for these government programs. In addition, exercising the option to accelerate death benefits and receiving those benefits before you apply for these programs, or while you are receiving government benefits, may affect your initial or continued eligibility.

Contact the Medicaid Unit of your local Division of Medical Assistance and the Social Security Administration for more information.

Medical condition allowing the Chronic Care Accelerated Death Benefit:

The Chronic Care Accelerated Death Benefit is a benefit which allows a portion of the death benefit to be advanced to you, the policyowner, if the insured has been certified with a chronic illness as defined in this rider if: • it is certified while this rider is in force; and • after the elimination period.

Chronic Illness or Chronically Ill means the insured has been certified within the last 12 months by a licensed health care practitioner as: • being unable to perform, without substantial assistance from another individual, at least two activities of daily living for a period of at least 90 days due to a loss of functional capacity; or • requiring substantial supervision to protect the individual from threats to health and safety due to severe cognitive impairment.

Benefit Amount

To File a Claim

Benefit Payment

Effect on Premium Payment/Monthly Deduction

This Disclosure Form highlights some of the information in the rider form. It is not an insurance contract. If there are any inconsistencies between this disclosure form and the rider, then the terms and conditions of the actual rider will control.

You, the policyowner, may request a monthly amount of 6% or a one-time lump sum of 50% of the policy face amount, per benefit period. The total amount that we pay you on a monthly or one-time lump sum basis will not exceed the applicable federal per diem limit, adjusted for the applicable payment period, as defined in Internal Revenue Code Section 7702B, as amended. If you elected to accelerate an amount that is more than the federal per diem limit, your benefit period will continue until the Chronic Care benefit is exhausted.

When we receive your notice of claim, we will provide the Accelerated Benefit Claim Form within 15 days. If you do not receive a claim form within 15 days, proof of eligibility may be submitted by giving us a written statement of the occurrence, the character and the extent of this occurrence for which a claim is made. On all claims, we must receive certification from a Licensed Health Care Practitioner certifying the named insured is chronically ill.

We will pay the Chronic Care Accelerated Death Benefit on a monthly basis, unless you select a one-time lump sum amount. The amount will be paid to you or your estate while the insured is living, unless the proceeds have been otherwise assigned or designated by you.

We will send you a policy schedule addendum along with the Chronic Care Accelerated Death Benefit payment specifying the amount of benefits paid and the effect of the payment on the death benefit amount.

If we pay a Chronic Care Accelerated Death Benefit, the premium payable for the Chronic Care Accelerated Benefit will not change.

We will waive premiums for the policy and any riders attached to the policy if the Chronic Care Accelerated Death Benefit is paid. To avoid duplication of benefits, no waiver of premium benefits described in this provision will be applicable during any period of total disability of the insured as defined in any other provision of the policy, or any rider attached to it, that provides a waiver of premium benefit.

Monthly Benefit Waiver will: • begin the first month benefits are paid; and • continue if the insured is still chronically ill after twelve months.

We reserve the right to investigate the insured’s health condition to determine if the policy should remain on waiver or if premium payments should resume.

ICC19-IWL5000-DFACC

62

83227

Effect on Premium Payment/Monthly Deduction (continued)

One-time Lump Sum Benefit Waiver will: • begin when the benefit is paid; and • continue for up to twelve months.

We reserve the right to investigate the insured’s health condition to determine if the policy should remain on waiver or if premium payments should resume.

Each monthly benefit or one-time lump sum benefit payment under this rider will reduce the following items under the policy, as applicable: • death benefit; • cash value; • any indebtedness; • amount available for policy loans; and • amount available for advance of any part of the death benefit under any provision of the policy or any rider other than this rider.

Effect on Policy Values

Each monthly benefit or one-time lump sum benefit payment will reduce each of the items listed above by a proportional amount. This proportion will equal the payment divided by the death benefit at that time.

We will send you a policy schedule addendum along with the Chronic Care Accelerated Death Benefit payment specifying the amount of benefits paid and the effect of the payment on the death benefit amount.

If a Chronic Care Accelerated Death Benefit is paid, the policy may not be converted, and no new coverage can be added to the policy.

See illustration below.

Cost of Insurance Example to show results of exercising the Chronic Care Accelerated Death Benefit on a $50,000 policy.                                       

                   

Taxability of Benefits

                    

                    

                   

                   

                   

                    

                   

The Accelerated Death Benefit paid may be taxable or may affect your eligibility for benefits under state of federal law. You or your beneficiary may incur a tax obligation. As with all tax matters, you should consult your personal tax advisor to assess the impact of this benefit.

Payments made under this rider are intended to qualify for favorable tax treatment under U.S. Code 101(g).

This rider is not intended to be federally tax-qualitifed long term care insurance under Internal Revenue Code Section 7702B.

ICC19-IWL5000-DFACC

63

83227

Signature of Policyowner

Signature of Agent

Date signed (MM/DD/YYYY)

Policyowner Social Security Number

ICC19-IWL5000-DFACC

64

83227

WHOLE LIFE INSURANCE PREMIUMS Adult Base Plan Paid-up to Age 70 Non-Tobacco Rates Issue Age 25 30 35 40 45 50

Pay Premium 26-Pay Premium 26-Pay Premium 26-Pay Premium 26-Pay Premium 26-Pay Premium 26-Pay Premium

$10,000.00 $4.31 $5.08 $6.24 $7.82 $10.34 $14.39

$25,000.00 $10.78 $12.70 $15.60 $19.56 $25.86 $35.98

$50,000.00 $21.56 $25.40 $31.19 $39.12 $51.71 $71.96

$100,000.00 $43.12 $50.81 $62.39 $78.23 $103.42 $143.92

$150,000.00 $64.68 $76.21 $93.58 $117.35 $155.14 $215.88

$100,000.00 $39.69 $45.69 $54.08 $65.31 $82.27 $105.92 $141.84 $190.08

$150,000.00 $59.54 $68.54 $81.12 $97.96 $123.41 $158.88 $212.77 $285.12

Adult Base Plan Paid-up to Age 100 Non-Tobacco Rates Issue Age 25 30 35 40 45 50 55 60

Pay Premium 26-Pay Premium 26-Pay Premium 26-Pay Premium 26-Pay Premium 26-Pay Premium 26-Pay Premium 26-Pay Premium 26-Pay Premium

$10,000.00 $3.97 $4.57 $5.41 $6.53 $8.23 $10.59 $14.18 $19.01

$25,000.00 $9.92 $11.42 $13.52 $16.33 $20.57 $26.48 $35.46 $47.52

$50,000.00 $19.85 $22.85 $27.04 $32.65 $41.14 $52.96 $70.92 $95.04

Sample rates only. Multiple choices and options available and rates may vary.

65

Colonial Life for Policyholders Portal A faster, simpler way to manage your benefits

THE PORTAL OFFERS YOU: Faster service than calling/emailing Confirmation when a claim has been submitted

Colonial Life for Policyholders is an online portal created with you in mind. It’s the most convenient and efficient way to file a claim and manage your benefits.

Here’s what you can do on Colonial Life for Policyholders:

Simplified bill payment and management Answers to frequently asked questions and live chat assistance if you don’t see what you are looking for.

LEARN MORE Find out how simple your claims and benefits experience can be by learning more about the Colonial Life for Policyholders portal. Just visit ColonialLife.com to see what this online account administration platform can do for you.

File claims with a simple, guided form

Set up direct deposit for approved payments

View claim status or policy details anytime

Opt for instant alerts by email or text

Update your personal info & preferences

BECOME A MEMBER TODAY: 1

Go to ColonialLife .com/access to register.

2

Click “create an account”, fill out the required information and click Submit.

3

Enjoy faster service and improved benefits awareness.

NEED TO FILE A CLAIM? Filing online means never waiting for mail or dealing with fax machines and complex paper forms . Our guided question wizard walks you through the process and checks for missing information that could cause delays. Opting for direct deposit can also get approved payments to you up to a week faster than paper check.

AFTER YOU FILE: Check your claim status by logging into your account at ColonialLife .com/access. You can also sign up for text or email alerts so you know instantly if status changes or more information is needed. For your convenience, you can login anytime with a mobile device to photograph and upload documents with your camera.

Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2022 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

66

43233-41

Authorization for Colonial Life & Accident Insurance Company For the purpose of evaluating my application(s) for insurance submitted during the current enrollment and eligibility for benefits under any insurance issued including checking for and resolving any issues that may arise regarding incomplete or incorrect information on my application(s), I hereby authorize the disclosure of the following information about me and, if applicable, my dependents, from the sources listed below to Colonial Life & Accident Insurance Company (Colonial) and its duly authorized representatives.

Health information may be disclosed by any health care provider or institution, health plan or health care clearinghouse that has any records or knowledge about me including prescription drug database or pharmacy benefit manager, or ambulance or other medical transport service. Health information may also be disclosed by any insurance company, Medicare or Medicaid agencies or the Medical Information Bureau (MIB). Health information includes my entire medical record, but does not include psychotherapy notes. Non-health information including earnings or employment history deemed appropriate by Colonial to evaluate my application may be disclosed by any person or organization that has these records about me, including my employer, employer representative and compensation sources, insurance company, financial institution or governmental entities including departments of public safety and motor vehicle departments.

Any information Colonial obtains pursuant to this authorization will be used for the purpose of evaluating my application(s) for insurance or eligibility for benefits. Some information obtained may not be protected by certain federal regulations governing the privacy of health information, but the information is protected by state privacy laws and other applicable laws. Colonial will not disclose the information unless permitted or required by those laws.

This authorization is valid for two (2) years from its execution and a copy is as valid as the original. A copy will be included with my contract(s) and I or my authorized representative may request access to this information. This authorization may be revoked by me or my authorized representative at any time except to the extent Colonial has relied on the authorization prior to notice of revocation or has a legal right to contest coverage under the contract(s) or the contract itself. If revoked, Colonial may not be able to evaluate my application(s) for insurance or eligibility for benefits as necessary to issue my contract(s). I may revoke this authorization by sending written notice to: Colonial Life & Accident Insurance Company, Underwriting Department, P.O. Box 1365, Columbia, SC 29202.

You may refuse to sign this form; however, Colonial may not be able to issue your coverage. I am the individual to whom this authorization applies or that person’s legal Guardian, Power of Attorney Designee, or Conservator. ________________________ (Printed name of individual subject to this disclosure)

_____________ (Social Security Number)

___________________ (Signature)

__________________ (Date Signed)

If applicable, I signed on behalf of the proposed insured as __________________________ (indicate relationship). If legal Guardian, Power or Attorney Designee, or Conservator.

________________________________ (Printed name of legal representative)

_____________________________ (Signature of legal representative)

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___________ (Date Signed)

PRIVACY NOTICES Non Public Information (NPI) We collect Non Public Information (NPI) about our customers to provide them with insurance products and services. This may include telephone number, address, date of birth, occupation, income and health history.

We may receive NPI from your applications and forms. medical providers, other insurers, employers, insurance support organizations, and service providers.

We share the types of NPI described above primarily with people who perform insurance, business, and professional services for us, such as helping us pay claims and detect fraud. We may share NPI with medical providers for insurance and treatment purposes. We may share NPI with an insurance support organization. The organization may retain the NPI and disclose it to others for whom it performs services. In certain cases, we may share NPI with group policy holders for reporting and auditing purposes. We may share NPI with parties to a proposed or final sale of insurance business or for study purposes. We may also share NPI when otherwise required or permitted by law, such as sharing with governmental or other legal authorities. When legal necessary, we ask your permission before sharing NPI about you our practices apply to our former, current and future customers.

Please be assured we do not share your health NPI to market any product or service. We also do not share any NPI to market non financial products and services. For example, we do not sell your name to catalog companies.

The law allows us to share NPI as described above (except health information) will affiliates to market financial products and services. The law does not allow you to restrict these disclosures. We may also share with companies that help us market our insurance products and services, such as vendors that provide mailing services to us. We may share with other financial institution to jointly market financial products and services. When required by law, we ask your permission before we share NPI for marketing purposes.

When other companies help us conduct business, we expect them to follow applicable privacy laws.

We do not authorize them to use or share NPI except when necessary to conduct the work they are performing for us or to meet regulatory or other governmental requirements.

Our affiliated companies, including insurers and insurance service providers, may share NPI about you with each other.

The NPI might not be directly related to our transaction or experience with you. It may include financial or other personal information such as employment history.

Consistent with the Fair Credit Reporting Act, we ask your permission before sharing NPI that is not directly related to our transaction or experience with you.

We have physical, electronic and procedural safeguards that protect the confidentiality and security of NPI. We give access only to employees who need to know the NPI to provide insurance products or services to you.

You may request access to certain NPI we collect to provide you with insurance products and services, You must make your request in writing and send it to the address, telephone number and policy number if we have issued a policy. If you request, we will send copies of the NPI to you. If the NPI includes health information, we may provide the health information to you through a health care provider you designate. We will also send you information related to disclosures. We may charge a reasonable fee to cover our copying costs. This section applies to NPI we collect tor provide you with coverage.

It does not apply to NPI we collect in anticipation of a claim or civil or criminal proceeding.

in our files. We will file your statement with the disputed NPI. We will include your statement any time we disclose the disputed NPI. We will also give the statement to any person designated by your if we may have disclosed the disputed NPI to that person int he past two years.

Disclosure Notice Concerning The Medical Information Bureau Information regarding your insurability will be treated as confidential. Colonial or its reinsure(s) may, however, make a brief report thereon to the Medical Information Bureau, a nonprofit membership organization of life insurance companies which operates an information exchange on behalf of its members. If you apply to another Bureau member company for life or health insurance coverage, or a claim for benefits is submitted to such company, the Bureau, upon request, will supply such company with the information in its file.

Upon receipt of a request from you, the Bureau will arrange disclosure of any information it may have in your file. If you question the accuracy of information in the Bureau’s file, you may contact the Bureau and seek a correction in accordance with the procedure set forth in the federal Fair If you believe NPI we have about you Credit Reporting Act. The address of is incorrect, please write us. Your letter the Bureau’s information office is: 50 should include your full name, address, Braintree Hill Park, Suite 400, Braintree, telephone number and policy number if we have issued a policy. Your letter should MA 02184-8734, telephone (617) 4263660. also explain why you believe the NPI is inaccurate. If we agree with you, we will Colonial or its reinsure may also correct the NPI and notify you of the release information in its file to other correction. We will also notify any person who may have received the incorrect NPI life insurance companies to whom you from us in the past two years if you ask us may apply for life or health insurance or to whom a claim for benefits may be to contact that person. submitted.

If we disagree with you, we will tell you we are not going to make the correction, We will give the reason(s) for our refusal. We will also tell you that you may submit a statement to us.

Your statement should include the NPI you believe is correct. It should also include the reasons(s) why you disagree with our decision not to correct the NPI 68

CONTINUATION OF COVERAGE We are committed to being there for you and your family at every stage of life.

Pierce Group Benefits makes it easy to stay protected!

SUPPLEMENTAL/VOLUNTARY POLICIES Your individual supplemental/voluntary policies through Colonial Life are portable!

To transfer your benefits from payroll deduction to direct billing or automatic bank draft, please call Employee Services at 833-556-0006 within 30 days of becoming unemployed, switching careers, or retiring.

TRANSFERRING EMPLOYERS? If you are transferring from a current PGB client to another, some benefits may be eligible for transfer. Please call Employee Services at 833-556-0006 for assistance.

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ABOUT PIERCE GROUP BENEFITS Pierce Group Benefits is a leading full-service employee benefits administration and consulting agency serving employer groups across the Southeast. By leveraging market strength, exclusive partnerships, and industry expertise, we deliver trusted advice, products, and solutions that benefit employers and employees alike; delivered by one team and driven by one purpose — together we can do more.

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