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.