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; or 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-33412(FL)-0522 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. Policy Form AO22 Series 013-810, 013-811, 013-812 American Fidelity Assurance Company americanfidelity.com Accident Insurance