Accident Insurance Overview Level 4

ACCIDENTAL DEATH & DISMEMBERMENT LEVEL 4 PRIMARY/SPOUSE CHILD Common Carrier $250,000 $125,000 Other Accident $100,000 $50,000 Dismemberment $7,000 to $100,000 $3,500 to $50,000 Plan Benefit Highlights ACCIDENT SCREENING BENEFIT This benefit is paid directly to you once per policy per calendar year and covers several tests, including, but not limited to: Are you financially prepared for an accident? Accidents can happen to anyone. And even though you can’t plan for an accident, you can help prepare for unexpected medical costs. Limited Benefit Accident Only Insurance provides coverage to help with unforeseen accident costs. 1Hypothetical example of a covered accident based on the AO22 policy. Accident is defined as an event which results in bodily Injury that is independent of disease or bodily infirmity or any other cause, and which occurs while the policy is active. LEVEL 4 Initial Treatment $300 X-Rays (two different days) $400 Anesthesia $300 Hospital Admission (day 1) $2,000 Hospital Confinement (days 2 through 4) $1,200 Concussion $350 Open Reduction Tibia Fracture Repair $6,000 Appliance - Crutches $250 Follow-up Treatment (3 visits) $150 TOTAL $10,950 A bad fall from a ladder leads to a broken lower leg and head injury, resulting in a fractured tibia and concussion. Treatment is received within 3 days. • Sports Physical Exam • Stress Test • Routine Physical Exam • Bone Density Screening LEVEL 4 $75 ACCIDENTAL INJURY Hypothetical Example 1 Accident Insurance Accident Insurance

ALL COVERAGE LEVELS Plan Benefit Highlights BENEFITS LEVEL 4 TREATMENTS Initial Treatment $300 Follow-up Treatment Up to six treatments $50 MEDICAL IMAGING CT, CAT, MRI, PET, US, SPECT $200 X-Rays Up to two days $200 HOSPITAL ICU Admission $2,500 Hospital Admission $2,000 ICU Confinement Up to 30 days $1,600 Hospital Confinement Up to 365 days $400 Rehabilitation Up to 30 days $200 AMBULANCE Ground/Water $500 Air $1,500 SURGICAL Anesthesia $300 Exploratory Surgery $400 Internal Injuries Surgery Open abdominal/thoracic surgery $2,500 Miscellaneous Surgery $250 Outpatient Hospital or Ambulatory Surgical Center $450 Ruptured Disc or Torn Knee Cartilage Surgery $500 Tendons, Ligaments, and Rotator Cuff Surgery One tendon, ligament, or rotator cuff More than one tendon, ligament, or rotator cuff $500 $750 FAMILY SUPPORT Transportation Up to 3 round trips per Covered Person per Covered Accident $300 Family Member Lodging and Meals Per day per accident; Up to 30 days per Covered Accident $100 ALL COVERAGE LEVELS MONTHLY PREMIUMS LEVEL 4 Individual $41.80 Individual & Spouse $48.90 Individual & Child(ren) $63.10 Family $71.10 BENEFITS LEVEL 4 INJURY TREATMENTS Fractures Depending on open or closed reduction and bone involved Chip fracture - 25% of closed reduction amount $375 to $10,000 Dislocations Depending on open or closed reduction and joint involved With local or no anesthesia - 25% of closed reduction amount $375 to 10,000 Lacerations Not requiring sutures Sutured lacerations less than two inches Sutured lacerations totaling two but less than six inches Sutured lacerations totaling six inches or more $100 $250 $350 $700 2nd & 3rd Degree Burns Skin grafts are 50% of benefit $150 to $15,000 Appliances Crutches, leg braces, etc. $250 Blood, Plasma, and Platelet $400 Concussion $350 Coma $20,000 Emergency Dental Work Broken teeth repaired with crown or extraction of a broken natural tooth $300 Epidural Pain Management $250 Eye Injury Injury with surgical repair or removal of foreign body by physician, for one or both eyes $350 Gunshot Wound $2,000 Paralysis Paraplegia/Uniplegia Quadriplegia $25,000 $50,000 Physical, Occupational, or Speech Therapy Per day of treatment up to eight days combined $25 Prosthesis Up to two devices $500 Traumatic Brain Injury $2,500

Emergency Dental Work Benefit Payable for repair to natural teeth, free of decay, when treated by a Physician or dentist. Initial dental treatment must be received within 3 days of the Accident. Epidural Pain Management Benefit Payable when a Person receives an epidural injection into the epidural space for management of pain due to an Injury. This benefit is not payable for an epidural administered before a surgical procedure. Exploratory Surgery Benefit Payable when an exploratory surgical operation without surgical repair is performed. Eye Injury Benefit Payable for one or both eyes requiring treatment by a Physician due to an Accident. Family Member Lodging and Meals Benefit Payable for lodging and meals for a family member to be near a Person who is Hospital Confined in a non-local Hospital. The Hospital must be at least 50 miles away, one way, using the most direct route from the family member’s residence. Fractures Benefit Varies based on the bone involved, type of fracture and type of treatment. If the Person fractures more than one bone, payment is made for all fractures up to two times the amount for the bone involved that has the highest benefit amount. Gunshot Wound Benefit Payable if gunshot wound does not cause Person to die; is caused by a shot from a Conventional Firearm; requires treatment by a Physician within 24 hours of Accident; and requires Confinement. If Dismemberment occurs, only the highest benefit will be paid. The Dismemberment must occur within 90 days after the Accident. Hospital Admission Benefit Pays the first day a Person is Confined to a Hospital. Hospital Confinement Benefit Pays a daily benefit for a Hospital Confinement up to 365 days. This benefit does not pay on the same day a Hospital Admission or ICU Admission benefit is paid. Intensive Care Unit (ICU) Admission Benefit Pays the first day a Person is Confined to an ICU. If Hospital Admission and ICU Admission Benefits are payable for the same day, only the ICU Admission Benefit will be paid. Intensive Care Unit (ICU) Confinement Benefit Pays a daily benefit for an ICU Confinement up to 30 days. This benefit does not pay on the same day a Hospital Admission or ICU Admission benefit is paid. This benefit is payable in addition to the Hospital Confinement Benefit. Internal Injuries Benefit Payable for an open abdominal or thoracic surgery performed within 3 days of the Accident. Lacerations Benefit This benefit varies based on the method of repair and total length of all lacerations due to an Accident. Medical Imaging Benefit Payable for a Computerized Tomography (CT or CAT), Magnetic Resonance Imaging (MRI), Single-Photon Emission Computed Tomography (SPECT), Positron Emission Tomography (PET) or an ultrasound for diagnosing an Injury due to an Accident. Miscellaneous Surgery Benefit Payable when a Person receives a surgery requiring general anesthesia due to an Accident that is not payable under any other benefit. Epidural injections are not paid under this benefit. Outpatient Hospital or Ambulatory Surgical Center Benefit Pays when a surgical procedure is performed on an outpatient basis in a Hospital or Ambulatory Surgical Center. We will only pay one Outpatient Hospital or Ambulatory Surgical Center Benefit in a 24-hour period even if more than one surgical procedure is performed. This benefit will not be paid for surgery performed in an Emergency Room, Urgent Care Facility or in a Physician’s Office. Paralysis Benefit The duration of the Paralysis must be a minimum of 90 consecutive days. If more than one type of Paralysis occurs due to the same Accident, only the highest benefit will be paid. Paid once per lifetime per Person. A Covered Person (thereafter referred to as “Person”) under AF™ Limited Benefit Accident Only Insurance policy may be eligible for the following benefits when a Covered Accident (thereafter referred to as “Accident”) happens. All benefits are paid once per Person per Accident unless otherwise specified. All benefits are only paid as a result of Injuries received in an Accident that occurs while coverage is active. All treatment, procedures, and medical equipment must be diagnosed, recommended and treated by a Physician. These references are not intended to change or modify any definitions in the AO22 policy series. Initial Treatment Benefit Payable for the first treatment received within 30 days of the Accident. The initial treatment must be administered by a Physician or Medical Professional. Follow-Up Treatment Benefit Payable for up to six follow- up treatments when initial medical treatment was received within 30 days of the Accident. Not payable for a visit in which a Physical, Occupational, or Speech Therapy benefit is paid. Accident Screening Benefit Payable when a Person receives one of the following screenings rendered by a Physician: bone density screening; Epworth Sleepiness Scale for the purpose of diagnosing a sleeping disorder; hemoglobin A1C; routine physical exam; sports physicals; or stress test. This benefit is payable once per policy per Calendar Year. This benefit does not cover dental exams or eye exams. An Accident is not required for this benefit to be payable. This benefit is not payable for services performed as treatment for an Injury. Accidental Death and Dismemberment Benefit The applicable benefits apply when an Accidental Death or Dismemberment occurs within 90 days of an Accident. In the event that Accidental Death and Dismemberment result from the same Accident, only the Accidental Death Benefit will be paid. Ambulance Benefit If air and ground/water ambulance transportation is required for the same Accident, only the highest benefit will be paid. Anesthesia Benefit Payable for the services of an anesthesiologist for a surgery performed due to an Accident. Hospital Confinement is not required to receive this benefit. We will only pay one Anesthesia Benefit per Person in a 24-hour period even if more than one surgical procedure is performed. This benefit is not payable for local anesthesia. Appliances Benefit Payable for one of the following as prescribed by a Physician: wheelchair, motorized scooter, walker, walking boot, brace, cane, crutches, or any other medical device used for mobility. Not payable for Prosthetic Devices. Blood, Plasma and Platelets Benefit Payable for blood, plasma and platelets. This benefit does not provide benefits for immunoglobulins. Burns Benefit Payable for 2nd and 3rd degree burns when treated by a Physician within 3 days of the Accident. Coma Benefit Must be diagnosed by a Physician and continue for at least 14 days. Coma does not include medically induced coma or a coma which results directly from alcohol or drug use. Concussion Benefit Payable for a Person who sustains a concussion and is diagnosed by a Physician within 7 days of the Accident. If both a Concussion and a Traumatic Brain Injury occur in the same Accident, only the highest benefit will be paid. Dislocations Benefit Amount payable varies by the joint involved, type of treatment, and type of anesthesia. If a Person receives more than one Dislocation in an Accident, we will pay for all Dislocations up to two times the amount shown in the Schedule of Benefits for the Dislocation involved that has the highest benefit amount. No other amount will be paid under this benefit. Benefits are payable only for the first dislocation of a joint which occurs while this policy is active. Plan Benefit Highlights

Physical, Occupational, or Speech Therapy Benefit Payable for one treatment per day for up to eight treatments by a licensed Physical, Occupational, or Speech Therapist for all therapies combined. If treatment in an Emergency Room, Physician’s Office, or Urgent Care Facility occurs in the same visit, only the highest applicable benefit is payable. Prosthesis Benefit Payable for up to two devices. This benefit is not payable for hearing aids; dental aids; eyeglasses; false teeth; cosmetic aids such as wigs; or joint replacements such as artificial hips or knees. Rehabilitation Benefit Payable for each day a Person is an inpatient in a Rehabilitation Unit. The treatment must begin immediately after the date of discharge from the Hospital. This benefit is payable for up to 30 days. This benefit is not payable for any day for which a Hospital Admission, Hospital Confinement, ICU Admission, ICU Confinement, or Physical, Occupational, and Speech Therapy benefit is payable. Tendons, Ligaments and Rotator Cuff Benefit Payable for the repair of one or more tendons, ligaments, or rotator cuffs. The tendons, ligaments, or rotator cuff must be repaired through surgery performed by a Physician, as a result of an Accident. Torn Knee Cartilage or Ruptured Disc Benefit Payable for surgical repair as a result of an Accident. Transportation Benefit Payable for the Person’s transportation when specialized treatment and Hospital Confinement in a non-local Hospital is required. A non-local Hospital must be at least 50 miles away, one way, using the most direct route, from the Person’s home. Travel must be by scheduled bus, plane, train, or by car. Ambulance service does not qualify for this benefit. The treatment must be prescribed by a Physician and not be available locally. This benefit is payable up to three round trips per Person per Accident. This benefit is not payable on any day that an Ambulance Benefit is payable. Traumatic Brain Injury (TBI) Benefit Payable for a Person who is Confined for at least 48 hours as the result of a TBI. Diagnosis by a Physician and Confinement must occur within 3 days of the Accident. If both a TBI and Concussion occur in the same Accident, only the highest benefit will be paid. X-Ray Benefit Payable once per day up to 2 days for an x-ray performed due to Injuries sustained in an Accident. The x-ray must be done at the request of a Physician. This benefit does not cover any tests payable under the Medical Imaging Benefit or any other screening or medical imaging tests. Plan Benefit Highlights (cont.) Limitations and Exclusions No benefits will be provided for an Accident that is caused by or occurs as a result of: (1) intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; (2) participation in any form of flight aviation other than as a fare- paying passenger in a fully licensed/passenger-carrying aircraft; (3) any act that was caused by war, declared or undeclared, or service in any of the armed forces; (4) participation in any activity or event while under the influence of any narcotic, drug, or controlled substance unless administered by a Physician or taken according to the Physician’s instructions; (5) voluntary ingestion, injection, inhalation or absorption of any narcotic, drug, controlled substance, poison, gas, or fume; (6) participation in, or attempting to participate in, a felony, riot or insurrection. (A felony is as defined by the law of the jurisdiction in which the activity takes place.); (7) participation in any sport for pay or profit; or sponsorship, in a professional or semi-professional capacity; (8) treatment received outside the United States and its territories, Canada, or Mexico; (9) participation in any contest of speed in a power driven vehicle for pay or profit; (10) participation in parachuting, bungee jumping, rappelling, mountain climbing or hang gliding. Benefits will not be paid for services rendered by a member of the immediate family of a Person. A Covered Accident is defined as an Injury caused by an Accident, for which benefits are provided, which is independent of any disease, illness, or bodily infirmity or any other cause and that takes place while the Person is covered under this policy. A hospital is not an institution, or part thereof, used as: a hospice unit, including any bed designated as a hospice or a swing bed; a convalescent home; a rest or nursing facility; a rehabilitative facility; an extended-care facility; a skilled nursing facility; or a facility primarily affording custodial, educational care, or care or treatment for persons suffering from mental diseases or disorders, or care for the aged, or drug or alcohol addiction. Eligibility includes you, your lawful spouse and each natural, adopted/foster or stepchild who is under 26 years of age. Guaranteed Renewable You cannot be singled out for a rate increase for any reason. The Insurer has the right to increase premium rates only if rates for all policies in this class change. Termination Notice Policy/rider(s) will terminate and coverage will end for all Covered Persons on the earliest of: the end of the grace period if the premium remains unpaid; the date on which we receive a written request from you to terminate this policy/rider(s) or upon the date specified in your written request if such date is specified; or the date of your death, if this is an Individual Plan. If the plan is other than Individual, the remaining Covered Persons may have the right to continue or convert their coverage. Coverage for any Covered Person will terminate when they no longer meet the eligibility requirements. Any unearned premium will be returned to You on a pro rata basis from the date of termination. SB-33440(FL)-0622 Policy Form AO22 Series 013-813 Underwritten by American Fidelity Assurance Company. This is a brief description of the coverage. This product contains limitations and exclusions. For complete benefits and other provisions, please refer to your policy, AO22. The premium and amount of benefits vary depending on the Plan level selected at the time of application. This coverage does NOT replace Workers’ Compensation Insurance. Availability of riders may vary by employer. This product is inappropriate for people who are eligible for Medicaid coverage. American Fidelity Assurance Company americanfidelity.com Accident Insurance

AO22OCFL 1 AMERICAN FIDELITY ASSURANCE COMPANY 9000 Cameron Parkway, Oklahoma City, Oklahoma 73114 800-662-1113 ACCIDENT ONLY COVERAGE Required Outline of Coverage for Accident Only Policy - Form Number AO22FL A. Read Your Policy Carefully - This outline of coverage provides a brief description of the important features of your policy. This is not the insurance contract and only the actual provisions of the policy will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY! B. Accident Only Coverage - Policies of this category are designed to provide, to persons insured, restricted coverage paying benefits ONLY when certain losses occur as a result of a Covered Accident. Coverage is not provided for basic hospital, basic medical-surgical or major medical expenses. C. Benefits - Your policy only pays benefits due to a Covered Accident. Benefits are provided to a Covered Person, after their effective date of coverage, while covered under the policy, and as a result of a Covered Accident. A brief description of benefits provided by the policy follows. Benefits are payable once per Covered Person per Covered Accident unless indicated otherwise. Please see the policy for detailed benefit information. The benefits described are subject to all other terms and provisions of the policy. The Accidental Death benefit pays an indemnity amount when Accidental Death occurs as a result of a Covered Accident. The Accidental Death must occur within 90 days of the Covered Accident. The Dismemberment benefit pays an indemnity amount when the Covered Person sustains a Dismemberment. The Dismemberment must occur within 90 days of the Covered Accident. The Internal Injuries Surgery benefit pays an indemnity amount when a Covered Person sustains internal Injuries which result in open abdominal or thoracic surgery. The surgery must occur within 3 days of the Covered Accident. The Exploratory Surgery benefit pays an indemnity amount when a Covered Person receives an exploratory surgery for Injuries sustained and no surgical repair is performed during such surgery. The Tendons, Ligaments, and Rotator Cuff Surgery benefit pays an indemnity amount if a Covered Person’s tendons, ligaments, or rotator cuff are torn, ruptured or severed and repaired through surgery. The Ruptured Disc or Torn Knee Cartilage Surgery benefit pays an indemnity amount if a Covered Person receives a ruptured disc or torn knee cartilage. The Covered Person must be treated by a Physician and the ruptured disc or torn knee cartilage must be repaired through surgery. The Miscellaneous Surgery benefit pays an indemnity amount if a Covered Person receives a surgery requiring general anesthesia that is not payable under any other benefit.

AO22OCFL 2 The Outpatient Hospital or Ambulatory Surgical Center benefit pays an indemnity amount when a Covered Person undergoes a surgical procedure, without Confinement, at a Hospital or Ambulatory Surgical Center. This benefit is payable only once per Covered Person in a 24-hour period even if more than one surgical procedure is performed. The Anesthesia benefit pays an indemnity amount for the services of an anesthesiologist received as a result of surgery performed due to Injuries sustained by a Covered Person. This benefit is payable only once per Covered Person in a 24-hour period even if more than one surgical procedure is performed. The Hospital Admission benefit pays an indemnity amount for the first day a Covered Person is Confined. If both the Hospital Admission benefit and ICU Admission benefit are payable for the same day, only the ICU Admission Benefit Amount will be paid. The Hospital Confinement benefit pays an indemnity amount for each day a Covered Person is Confined. This benefit is payable once per day up to 365 days per Covered Person per Covered Accident. If both the Hospital Confinement benefit and Hospital Admission benefit are payable for the same day, only the Hospital Admission Benefit Amount will be paid. If both the Hospital Confinement benefit and ICU Admission benefit are payable for the same day, only the ICU Admission Benefit Amount will be paid. The ICU Admission benefit pays an indemnity amount for the first day a Covered Person is Confined in an Intensive Care Unit (ICU). This benefit is payable once per Covered Person per Covered Accident. If both the ICU Admission benefit and Hospital Admission benefit are payable for the same day, only the ICU Admission Benefit Amount will be paid. The ICU Confinement benefit pays an indemnity amount for each day a Covered Person is Confined in an Intensive Care Unit (ICU). This benefit is payable once per day up to 30 days per Covered Person per Covered Accident. If both the ICU Confinement benefit and ICU Admission benefit are payable for the same day, only the ICU Admission Benefit Amount will be paid. If both the ICU Confinement benefit and Hospital Confinement benefit are payable for the same day, the ICU Confinement Benefit Amount will be paid in addition to the Hospital Confinement Benefit Amount. The Rehabilitation benefit pays an indemnity amount for each day a Covered Person is an inpatient in a Rehabilitation Unit following a Hospital admission. The treatment must begin immediately after the date of discharge from the Hospital. This benefit is payable once per day up to 30 days per Covered Person per Covered Accident. The Initial Treatment benefit pays an indemnity amount for the first treatment a Covered Person receives for Injuries sustained. Initial treatment must be received within 30 days of the Covered Accident. The Follow-Up Treatment benefit pays an indemnity amount for additional treatment over and above the initial medical treatment a Covered Person receives for Injuries sustained. The Follow- Up Treatment Benefit Amount will only be payable if the initial treatment was received within 30 days of the Covered Accident. This benefit is payable up to 6 follow-up treatments per Covered Person per Covered Accident. The Eye Injury benefit pays an indemnity amount for surgery of the eye or removal of a foreign object from the eye of a Covered Person that is a result of an Injury to one or both eyes. The Dislocation benefit pays an indemnity amount for a Covered Person who receives a Dislocation and requires Open or Closed Reduction. The amount payable for this benefit will be based on the joint Dislocated. We will pay the Open or Closed Reduction Benefit Amount as shown in the Schedule of Benefits if the Dislocation is repaired by a Physician under general anesthesia.

AO22OCFL 3 We will pay a percentage of the Closed Reduction Benefit Amount as shown in the Schedule of Benefits if the Dislocation is repaired by a Physician with local anesthesia or no anesthesia. We will pay no more than one Dislocation benefit per joint per Covered Person while this policy is in force. The Fracture benefit pays an indemnity amount for a Covered Person who receives a Fracture and requires Open or Closed Reduction. If the Fracture cannot be repaired by Open or Closed Reduction, the Closed Reduction Benefit Amount will be paid. The amount payable for this benefit will be based on the bone Fractured. We will pay a percentage of the Closed Reduction Benefit Amount as shown in the Schedule of Benefits for the bone involved if the Fracture is a Chip Fracture. The Severe Burns benefit pays an indemnity amount if a Covered Person suffers a 2nd degree or 3rd degree burn. The amount payable will be based on the degree of burn and amount of the body surface burned. Treatment for the burn must occur within 3 days of the Covered Accident. The Skin Graft benefit pays an indemnity amount for a Covered Person who receives a skin graft for a burn for which benefits were paid under the Severe Burn Benefit. The Laceration benefit pays an indemnity amount for a Covered Person who suffers a laceration that must be repaired or treated by a Physician. The amount payable will be based on the method of repair and the total length of all lacerations. The Ambulance benefit pays an indemnity amount for a Covered Person who requires ambulance transportation en route to or between a Hospital, emergency center, or medical facility due to Injuries sustained. The Emergency Dental Work benefit pays an indemnity amount if a Covered Person requires repair by crown or extraction of a broken natural tooth, free of decay, by a Physician or dentist and that is the result of Injuries sustained. The dental repair must occur within 3 days of the Covered Accident. The Physical, Occupational, or Speech Therapy benefit pays an indemnity amount for each day a Covered Person receives Physical, Occupational, or Speech Therapy from a Physical, Occupational, or Speech Therapist. This benefit is payable up to 8 days per Covered Person per Covered Accident for all therapies combined. The Blood, Plasma, and Platelets benefit pays an indemnity amount for blood, plasma, and platelets needed. The X-ray benefit pays an indemnity amount for each day a Covered Person undergoes an x-ray for the purpose of diagnosing an Injury. This benefit is payable once per day up to 2 days per Covered Person per Covered Accident. The Medical Imaging benefit pays an indemnity amount if a Covered Person undergoes a Computerized Tomography (CT or CAT), Magnetic Resonance Imaging (MRI), Single-Photon Emission Computed Tomography (SPECT), Positron Emission Tomography (PET) scan, or an ultrasound, for the purpose of diagnosing an Injury. The Gunshot Wound benefit pays an indemnity amount if a Covered Person receives a gunshot wound and the gunshot wound does not cause the Covered Person to die; is caused by a shot from a Conventional Firearm; requires treatment by a Physician within 24 hours of the Covered Accident; and requires a Confinement. The Epidural Pain Management benefit pays an indemnity amount if a Covered Person receives an epidural injection into the epidural space for management of pain due to an Injury.

AO22OCFL 4 The Coma benefit pays an indemnity amount if a Covered Person is rendered Comatose. The Coma must be diagnosed by a Physician and continue for at least 14 consecutive days. The Paralysis benefit pays an indemnity amount if a Covered Person suffers Paralysis. The amount paid will be based on the type of Paralysis. The Paralysis must be diagnosed by a Physician and continue for at least 90 consecutive days. This benefit is payable only once per lifetime per Covered Person. The Appliance benefit pays an indemnity amount for a wheelchair, motorized scooter, walker, walking boot, brace, cane, crutches, or any other medical device used for mobility to aid a Covered Person. The Prosthesis benefit pays an indemnity amount if a Covered Person requires the use of a prosthesis as a result of Injuries sustained. This benefit is payable per device up to two devices per Covered Person per Covered Accident. The Transportation benefit pays an indemnity amount for transportation of a Covered Person who requires treatment and is Confined in a non-local Hospital due to Injuries sustained. This benefit is payable only once per round trip up to 3 round trips per Covered Person per Covered Accident. Transportation benefits will only be provided for the Injured Covered Person. The Family Member Lodging and Meals benefit pays an indemnity amount, up to 30 days, for lodging and meals for a family member to be near a Covered Person who has been Confined in a Hospital. The Concussion benefit pays an indemnity amount for a Covered Person that suffers a Concussion. The diagnosis must be made within 7 days of the Covered Accident. The Traumatic Brain Injury benefit pays an indemnity amount for a Covered Person that is Confined for at least 48 hours as a result of a Traumatic Brain Injury (TBI). The diagnosis and Confinement must occur within 3 days of the Covered Accident. The Accident Screening benefit pays an indemnity amount if a Covered Person receives one of the following screenings rendered by a Physician: bone density screening; Epworth Sleepiness Scale for the purpose of diagnosing a sleeping disorder; hemoglobin A1c; routine physical exam; sports physicals; or stress test. This benefit is payable once per policy per Calendar Year. THE REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK Continued on next page

Benefit Schedule (Refer to your application for the Level elected.) Level 1 Level 2 Level 3 Level 4 AO22OCFL 5 Accidental Death and Dismemberment Benefits Primary Insured: 100% of Benefit Amount Spouse: 100% of Benefit Amount Dependent Child: 50% of Benefit Amount Accidental Death $40,000 $60,000 $80,000 $100,000 Common Carrier Accidental Death $100,000 $150,000 $200,000 $250,000 Dismemberment Both Arms and Both Legs $40,000 $60,000 $80,000 $100,000 Both Eyes / Both Arms / Both Legs / Both Hands / Both Feet / One Arm and One Leg / One Hand and One Foot $20,000 $30,000 $40,000 $50,000 One Eye / One Arm / One Leg / One Hand / One Foot $10,000 $15,000 $20,000 $25,000 One or More Fingers or Toes $2,800 $4,200 $5,600 $7,000 Internal Injuries Surgery $1,000 $1,500 $2,000 $2,500 Exploratory Surgery $250 $300 $350 $400 Tendons, Ligaments, and Rotator Cuff Surgery Repair of One Tendon / Ligament / Rotator Cuff $500 $500 $500 $500 Repair of Multiple Tendon / Ligament / Rotator Cuff $750 $750 $750 $750 Ruptured Disc or Torn Knee Cartilage Surgery $500 $500 $500 $500 Miscellaneous Surgery $250 $250 $250 $250 Outpatient Hospital or Ambulatory Surgical Center $150 $250 $350 $450 Anesthesia $150 $200 $250 $300 Hospital Admission $500 $1,000 $1,500 $2,000 Hospital Confinement $100 $200 $300 $400 ICU Admission $1,000 $1,500 $2,000 $2,500 ICU Confinement $400 $800 $1,200 $1,600 Rehabilitation $50 $100 $150 $200 Initial Treatment $150 $200 $250 $300 Follow-Up Treatment $50 $50 $50 $50 Eye Injury $200 $250 $300 $350 Dislocation (Open Reduction) Hip $4,000 $6,000 $8,000 $10,000 Knee (except Patella) $2,400 $3,600 $4,800 $6,000 Ankle / Bones of the Foot (excluding toes) $800 $1,200 $1,600 $2,000 Collarbone (Clavicle, Sternum) $800 $1,200 $1,600 $2,000 Elbow $600 $900 $1,200 $1,500 Lower Jaw $600 $900 $1,200 $1,500 Bones of the Hand (excluding fingers) $600 $900 $1,200 $1,500 Shoulder (Glenohumeral) $600 $900 $1,200 $1,500 Wrist $600 $900 $1,200 $1,500 Collarbone (Acromioclavicular and Separation) $600 $900 $1,200 $1,500 One Finger or Toe $300 $450 $600 $750 Dislocation (Closed Reduction) Hip $2,000 $3,000 $4,000 $5,000 Knee (except Patella) $1,200 $1,800 $2,400 $3,000 Ankle / Bones of the Foot (excluding toes) $400 $600 $800 $1,000 Collarbone (Clavicle, Sternum) $400 $600 $800 $1,000

Benefit Schedule (Refer to your application for the Level elected.) Level 1 Level 2 Level 3 Level 4 AO22OCFL 6 Elbow $300 $450 $600 $750 Lower Jaw $300 $450 $600 $750 Bones of the Hand (excluding fingers) $300 $450 $600 $750 Shoulder (Glenohumeral) $300 $450 $600 $750 Wrist $300 $450 $600 $750 Collarbone (Acromioclavicular and Separation) $300 $450 $600 $750 One Finger or Toe $150 $225 $300 $375 With Local Anesthesia or No Anesthesia 25% of Closed Reduction amount Fracture (Open Reduction) Skull, except Bones of the Face or Nose $4,000 $6,000 $8,000 $10,000 Hip, Thigh (Femur) $4,000 $6,000 $8,000 $10,000 Vertebrae $2,400 $3,600 $4,800 $6,000 Pelvis except Coccyx $2,400 $3,600 $4,800 $6,000 Leg (Fibula or Tibia) $2,400 $3,600 $4,800 $6,000 Ankle or Wrist $800 $1,200 $1,600 $2,000 Bones of the Face or Nose (except Mandible or Maxilla) $800 $1,200 $1,600 $2,000 Upper Jaw (Maxilla) except Alveolar Process $800 $1,200 $1,600 $2,000 Lower Jaw (Mandible) except Alveolar Process $800 $1,200 $1,600 $2,000 Arm (Radius, Ulna and/or Humerus) $800 $1,200 $1,600 $2,000 Collarbone (Clavicle or Sternum) $800 $1,200 $1,600 $2,000 Shoulder Blade (Scapula) $800 $1,200 $1,600 $2,000 Kneecap (Patella) $800 $1,200 $1,600 $2,000 Hand / Foot (except fingers / toes) $800 $1,200 $1,600 $2,000 Rib $800 $1,200 $1,600 $2,000 Coccyx $600 $900 $1,200 $1,500 One Finger or Toe $300 $450 $600 $750 Fracture (Closed Reduction) Skull, except Bones of the Face or Nose $2,000 $3,000 $4,000 $5,000 Hip, Thigh (Femur) $2,000 $3,000 $4,000 $5,000 Vertebrae $1,200 $1,800 $2,400 $3,000 Pelvis except Coccyx $1,200 $1,800 $2,400 $3,000 Leg (Fibula or Tibia) $1,200 $1,800 $2,400 $3,000 Ankle or Wrist $400 $600 $800 $1,000 Bones of the Face or Nose (except Mandible or Maxilla) $400 $600 $800 $1,000 Upper Jaw (Maxilla) except Alveolar Process $400 $600 $800 $1,000 Lower Jaw (Mandible) except Alveolar Process $400 $600 $800 $1,000 Arm (Radius, Ulna and/or Humerus) $400 $600 $800 $1,000 Collarbone (Clavicle or Sternum) $400 $600 $800 $1,000 Shoulder Blade (Scapula) $400 $600 $800 $1,000 Kneecap (Patella) $400 $600 $800 $1,000 Hand / Foot (except fingers / toes) $400 $600 $800 $1,000 Rib $400 $600 $800 $1,000 Coccyx $300 $450 $600 $750 One Finger or Toe $150 $225 $300 $375 Chip Fracture 25% of Closed Reduction Amount

Benefit Schedule (Refer to your application for the Level elected.) Level 1 Level 2 Level 3 Level 4 AO22OCFL 7 Severe Burns 2nd Degree less than 10% of the body surface $150 $150 $150 $150 10% to less than 25% of the body surface $450 $450 $450 $450 25% to less than 35% of the body surface $750 $750 $750 $750 35% or more of the body surface $1,500 $1,500 $1,500 $1,500 3rd Degree less than 10 sq. in. of the body surface $2,250 $2,250 $2,250 $2,250 10 sq. in. to less than 25 sq. in. of the body surface $3,750 $3,750 $3,750 $3,750 25 sq. in. to less than 35 sq. in. of the body surface $7,500 $7,500 $7,500 $7,500 35 sq. in. or more of the body surface $15,000 $15,000 $15,000 $15,000 Skin Graft 50% of Burn Benefit Laceration Not requiring sutures $25 $50 $75 $100 Requiring sutures Lacerations totaling less than 2 inches in length $100 $150 $200 $250 Lacerations totaling 2 inches to less than 6 inches in length $200 $250 $300 $350 Lacerations totaling 6 inches or more in length $400 $500 $600 $700 Ambulance Air Ambulance $1,500 $1,500 $1,500 $1,500 Ground or Water Ambulance $500 $500 $500 $500 Emergency Dental Work $150 $200 $250 $300 Physical, Occupational, or Speech Therapy $25 $25 $25 $25 Blood, Plasma, and Platelets $250 $300 $350 $400 X-ray $50 $100 $150 $200 Medical Imaging $200 $200 $200 $200 Gunshot Wound $500 $1,000 $1,500 $2,000 Epidural Pain Management $100 $150 $200 $250 Coma $5,000 $10,000 $15,000 $20,000 Paralysis Uniplegia $10,000 $15,000 $20,000 $25,000 Paraplegia $10,000 $15,000 $20,000 $25,000 Quadriplegia $20,000 $30,000 $40,000 $50,000 Appliance $100 $150 $200 $250 Prosthesis (per device) $500 $500 $500 $500 Transportation $300 $300 $300 $300 Family Member Lodging and Meals $100 $100 $100 $100 Concussion $200 $250 $300 $350 Traumatic Brain Injury $1,000 $1,500 $2,000 $2,500 Accident Screening $50 $50 $75 $75 THE REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK Continued on next page

AO22OCFL 8 E. Limitations and Exclusions. No benefits will be payable for death, Dismemberment, surgery, Confinement, treatment, diagnosis, screening or any other care or service incurred during any period the Covered Person’s coverage is not in effect. Additionally, no benefits will be paid for an Injury that occurs prior to a Covered Person being covered under the policy. Benefits will also not be paid for services rendered by a Covered Person or immediate family member of a Covered Person. No benefits will be provided for an Accident that is caused by or occurs as a result of: 1. intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; 2. participation in any form of flight aviation other than as a fare-paying passenger in a fully licensed/passenger-carrying aircraft; 3. any act that was caused by war, declared or undeclared, or service in any of the armed forces; 4. participation in any activity or event while under the influence of any narcotic, drug, or controlled substance unless administered by a Physician or taken according to the Physician's instructions; 5. voluntary ingestion, injection, inhalation or absorption of any narcotic, drug, controlled substance, poison, gas, or fume; 6. participation in, or attempting to participate in, a felony, riot or insurrection; (A felony is as defined by the law of the jurisdiction in which the activity takes place.) 7. participation in any sport for pay, profit, or sponsorship, in a professional or semi-professional capacity; 8. treatment received outside the United States and its territories, Canada, or Mexico; 9. participation in any contest of speed in a power driven vehicle for pay or profit; or 10. participation in parachuting, bungee jumping, rappelling, mountain climbing or hang gliding. F. Renewability - The policy is guaranteed renewable for life, as long as you pay premiums before the date due or within the next 31 days. Premium rates may be changed, but only on a class basis. G. Optional Benefit Riders: Please refer to your application to see if your coverage includes this optional rider. AMDI551FL Organized Sports Benefit Rider The Organized Sports Benefit Rider pays an indemnity amount if a Covered Person, while a Participant in an Organized Sport, suffers an Injury for which a benefit is payable under this policy. The benefit payable under the policy will be increased by the Organized Sports benefit percentage. Level 1 Level 2 Level 3 Level 4 Additional 25% of the benefit payable This Outline of Coverage Is Only A Summary Of The Coverage Provided. Only The Actual Policy Provisions Will Control.