917800 Accident Insurance (12) 01.01.2024

TierNameW Accident Insurance HELPS YOUR FINANCES AFTER A MISHAP. When you, your spouse or child has a covered accident, like a fall from a bicycle that requires medical attention, you can receive cash benefits to help cover the unexpected costs. HELPS COVER RELATED EXPENSES. While health plans may cover direct costs associated with an accident, you can use accident benefits to help cover related expenses like lost income, child care, deductibles and co-pays. You can purchase this coverage for you and PAYS CASH BENEFITS DIRECTLY TO YOU. your family. Child Accident Insurance can be used however you want, and it pays in coverage is available addition to any other coverage you may already have. Benefits to age 26. are payable directly to you. And get this – there are no health questions or pre-existing conditions limitations. What’s more, all family members on your plan are eligible for a wellness-screening benefit, also paid directly to you once each year per covered person. ACCIDENT FAST FACTS Falls This coverage pays are the leading cause of benefits whether your injuries treated in covered accident happens emergency rooms every at work, at home, or year, for people of away (also known as all ages.1 24-hour coverage). DEPAUW UNIVERSITY You also get Emergency Travel Assistance and All Eligible Employees Identity Theft Protection POLICY # 917800 Sun Life Assurance Company of Canada 2389889 ACC4 CL1 03/19/2024 07:50:07 800-247-6875 • sunlife.com/us Accident Insurance

What’s covered Once your coverage goes into effect, you can file a claim for covered accidents that occur after your insurance plan’s effective date. Unless otherwise specified, benefits are payable only once for each covered accident, as applicable. The full list of benefits is listed here. Choose the plan that best meets your needs and your budget. LOW PLAN HIGH PLAN DISLOCATIONS OPEN CLOSED OPEN CLOSED (SURGERY) (NO SURGERY) (SURGERY) (NO SURGERY) Hip $2,000 $1,000 $4,000 $2,000 Knee, ankle, or bones of the foot $1,000 $500 $2,000 $1,000 Elbow, wrist or Lower jaw $400 $200 $800 $400 Shoulder $500 $250 $1,000 $500 Collarbone or bones of the hand $800 $400 $1,600 $800 Finger(s) or toe(s) $100 $50 $200 $100 FRACTURES OPEN CLOSED OPEN CLOSED (SURGERY) (NO SURGERY) (SURGERY) (NO SURGERY) Hip or thigh $2,000 $1,000 $4,000 $2,000 Skull-depressed $3,000 $1,500 $6,000 $3,000 Skull-simple $1,500 $750 $3,000 $1,500 Vertebral processes, Bones of the face or Nose $350 $175 $700 $350 Leg $1,000 $500 $2,000 $1,000 Vertebrae, Sternum or Pelvis $800 $400 $1,600 $800 Upper jaw or upper arm $375 $190 $750 $375 Lower jaw, Collarbone, Shoulder, Forearm, Hand, Wrist, Foot, Ankle, $325 $170 $650 $325 Kneecap, Elbow or Heel Rib, Finger, Toe or Coccyx $175 $90 $350 $175 Multiple ribs $500 $250 $1,000 $500 ADDITIONAL INJURIES Eye Injury - surgical repair $125 $250 Eye Injury - object remove $125 $250 Gunshot wound $250 $500 Paralysis—paraplegia $12,500 $25,000 Paralysis—quadriplegia $25,000 $50,000 Coma $5,000 $10,000 Concussion $50 $100 BURNS 2ND DEGREE 3RD DEGREE 2ND DEGREE 3RD DEGREE 21-40 square centimeters $200 $500 $400 $1,000 41-65 square centimeters $400 $1,000 $800 $2,000 66-160 square centimeters $600 $3,000 $1,200 $6,000 161-225 square centimeters $800 $7,000 $1,600 $14,000 More than 225 square centimeters $1,000 $10,000 $2,000 $20,000 Skin graft 50% of the applicable Burn 50% of the applicable Burn Benefit Benefit LACERATIONS No sutures and treated by doctor $20 $35 Single laceration under 5 cm with sutures $35 $65 5-15 cm with sutures (total of all lacerations) $125 $250 Greater than 15 cm with sutures (total of all lacerations) $250 $500 800-247-6875 • sunlife.com/us Accident Insurance

MEDICAL SERVICES What’s covered Diagnostic Exam - Arteriogram, Angiogram, CT, CAT, EKG, EEG, or MRI (1 $100 $200 time per benefit year) Diagnostic Exam - X-ray (1 time per covered accident) $25 $30 Accident Emergency Treatment, non-emergency room (once per $25 $50 covered accident) Physician's Follow-up Treatment office visit (per visit, up to 6 times per $25 $25 covered accident) Physical Therapy (per visit up to 10 visits per covered accident) $25 $25 Medical Devices $100 $125 Epidural Pain Management (up to 2 times per covered accident) $25 $50 Prescription drug $15 $25 Prosthesis (one) $250 $500 Prosthesis (two) $500 $1,000 Blood, Plasma, or Platelet Transfusion $100 $200 HOSPITAL Hospital Admission (once per benefit year) $500 $1,000 Hospital Confinement (per day up to 365 days per covered accident) $150 $250 Intensive Care Unit Admission (once per Benefit Year; payable instead of $750 $1,500 Hospital Admission benefit if Confined immediately to ICU) Intensive Care Unit Confinement (per day up to 15 days, payable in $300 $500 addition to any Hospital Confinement benefit) Ambulance (Ground) $100 $200 Ambulance (Air) $750 $1,500 Emergency Room Admission $100 $150 Family Lodging (per day up to 30 days per benefit year) $50 $100 Transportation (100 or more miles up to 3 times per covered accident) $250 $500 Rehabilitation Unit (per day up to 30 days per covered accident) $50 $100 SURGERY Miscellaneous Surgery requiring general anesthesia (not covered by any $150 $300 other benefit) Open Surgery $625 $1,250 Exploratory Surgery or Debridement $125 $250 Tendon/Ligament/Rotator Cuff Tear $300 $625 Torn Knee Cartilage $300 $625 Ruptured/Herniated Disc $300 $625 EMERGENCY DENTAL Emergency Dental extraction $30 $65 Emergency Dental crown $100 $200 WELLNESS Wellness Screening Benefit $50 $50 (once per benefit year) LIFE AND DISMEMBERMENT LOSSES* LOW PLAN HIGH PLAN Accidental Death $15,000 $25,000 Accidental Death Common Carrier (pays an additional benefit if accidental death occurs while traveling as a fare- $30,000 $100,000 paying passenger on a public conveyance) Catastrophic Loss: Both arms or both hands, both legs or both feet, one hand and one foot or one arm and one leg, $7,500 $15,000 or irrecoverable loss of sight of both eyes Loss of one hand, foot, leg, or arm $3,750 $7,500 Loss of sight of one eye or loss of one eye $3,750 $7,500 Two or more fingers or toes $750 $1,500 One finger or one toe $375 $750 800-247-6875 • sunlife.com/us Accident Insurance

*Benefits displayed for life and dismemberment are for the employee only. Spouse benefits are 100% of the employee benefit amount for What’s covered death and 100% of the employee benefit amount for dismemberment. Dependent children benefits are 50% of the employee benefit amount for death and 50% of the employee benefit amount for dismemberment. 800-247-6875 • sunlife.com/us Accident Insurance

Frequently asked questions How do I file an accident claim? If you have an accident after the effective date of coverage, you can file a claim with us by downloading forms from our website. We’ll ask that you and your doctor provide information about the accident and the treatment provided. What happens once my claim is approved? The benefit amount you receive will depend on your injury and/or the treatment provided. Remember, benefits are payable only once for each covered accident, unless noted otherwise in the benefit schedule. Is there a time period that I need to follow? Injuries and other related benefits due to a covered accident must be diagnosed or treated within a defined period of time from the date of your accident. This could be as few as three days for certain benefits. Please refer to your Certificate for details. How do I get the Wellness Screening Benefit? You may be paid the benefit when you or a covered family member submit proof of a covered screening each year, like specific blood tests and cancer screenings, cardiac stress tests, immunizations, school sports exams and more (may vary by state). Our wellness screening benefit claim form can also be downloaded from our website. Can I take my insurance with me if I leave my employer? Depending upon state variations and your employer’s plan, you may have an option to continue group coverage when your employment terminates. Your employer can advise you about your options. Is my benefit taxable? If you or your employer pay for all or part of the cost of coverage on a pre-tax basis, some or all of your benefit amount will be tax reported on a Form 1099 as taxable income. Please reach out to a tax advisor or your employer if you have any questions. Accident insurance is a limited bene昀椀t policy. The Certi昀椀cate has exclusions that may affect any bene昀椀ts payable. Bene昀椀ts payable are subject to all terms and conditions of your Certi昀椀cate. 1. “Health, United States, 2016,” US Department of Health and Human Services, Table 75. Read the Important information section for more details including limitations and exclusions. 800-247-6875 • sunlife.com/us Acccident Insurance

Important information The following coverage(s) do not constitute work-related illness or injuries unless you are enrolled in 24- comprehensive health insurance (often referred to as hour coverage. “major medical coverage”). They do NOT provide basic Information about services offered hospital, basic medical, or major medical insurance. Value-added services are not insurance, are offered only on To become insured, you must meet the eligibility specific lines of coverage and carry a separate charge, which requirements set forth by your employer. Your coverage is added to the cost of the insurance. The cost is included in effective date will be determined by the Policy and may be the total amount billed. Emergency Travel Assistance is pro- delayed if you are not actively at work on the date your vided by Assist America®. Identity Theft Protection is pro- coverage would otherwise go into effect. Similarly, vided by SecurAssist®, an Assist America program. The enti- dependent coverage, if offered, may be delayed if your ties that provide the value-added services are not subcon- dependents are in the hospital (except for newborns) on the tractors of Sun Life and Sun Life is not responsible or liable date coverage would otherwise become effective. Refer to for the care, services, or advice provided by them. Sun Life your Certificate for details. reserves the right to discontinue any of the Services at any time. Limitations and exclusions The below exclusions and limitations may vary by state This Overview is preliminary to the issuance of the law and regulations. This list may not be comprehensive. Policy. Refer to your Certificate for details. Receipt of Please see your Certificate or ask your benefits administrator this Overview does not constitute approval of coverage for details. under the Policy. In the event of a discrepancy between this Overview, the Certificate and the Policy, the terms Accident of the Policy will govern. Product offerings may not be We will not pay a benefit that is due to or results from: available in all states and may vary depending on state suicide while sane or insane; intentionally self-inflicted laws and regulations. injuries; committing or attempting to commit an assault, felony or other criminal act; war or an act of war; active participation in a riot, rebellion or insurrection; voluntary use of any controlled substance/illegal drugs; operation of a motorized vehicle while intoxicated; if you do not submit proof of your loss as required by us (this covers medical examination, continuing care, death certificate, medical records, etc.); incarceration; engaging in hang-gliding, bungee jumping, parachuting, sail gliding, parasailing, parakiting or mountaineering; participating in or practicing for any semi- professional or professional competitive athletic contest in which any compensation is received, including coaching or officiating; injuries sustained from commercial air transportation other than riding as a fare paying passenger; Sun Life companies include Sun Life and Health Insurance Company (U.S.) and Sun Life Assurance Company of Canada (collectively, “Sun Life”). Group insurance policies are underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) in all states, except New York, under Policy Form Series 12-GP-01, 12-AC-C-01, 15-GP-01 and 16-AC-C-01. © 2019 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. Sun Life and the globe symbol are trademarks of Sun Life Assurance Company of Canada. Visit us at www.sunlife.com/us. GVBH-EE-8384 SLPC 29579 800-247-6875 • sunlife.com/us Accident Insurance

Rates Coverage andmonthly cost for Accident. Rates are effective as of January 1, 2024. Accident coverage is contributory. You are responsible for paying for all or a part of the cost through payroll deduction. Lowplan Coverage Cost per pay period* Employee $9.65 Employee+Spouse $13.86 Employee+Child(ren) $15.09 Employee+Family $19.30 High plan Coverage Cost per pay period* Employee $13.21 Employee+Spouse $20.50 Employee+Child(ren) $23.02 Employee+Family $30.30 *Contact your employerto confirm your part of thecost. 800-247-6875 · sunlife.com/us Accident Insurance