Accident Insurance Overview Levels 1-3

ACCIDENTAL DEATH & DISMEMBERMENT LEVEL 1 PRIMARY/SPOUSE CHILD Common Carrier $100,000 $50,000 Other Accident $40,000 $20,000 Dismemberment $2,800 to $40,000 $1,400 to $20,000 LEVEL 2 PRIMARY/SPOUSE CHILD Common Carrier $150,000 $75,000 Other Accident $60,000 $30,000 Dismemberment $4,200 to $60,000 $2,100 to $30,000 LEVEL 3 PRIMARY/SPOUSE CHILD Common Carrier $200,000 $100,000 Other Accident $80,000 $40,000 Dismemberment $5,600 to $80,000 $2,800 to $40,000 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 1 LEVEL 2 LEVEL 3 Initial Treatment $150 $200 $250 X-Rays (two different days) $100 $200 $300 Anesthesia $150 $200 $250 Hospital Admission (day 1) $500 $1,000 $1,500 Hospital Confinement (days 2 through 4) $300 $600 $900 Concussion $200 $250 $300 Open Reduction Tibia Fracture Repair $2,400 $3,600 $4,800 Appliance - Crutches $100 $150 $200 Follow-up Treatment (3 visits) $150 $150 $150 TOTAL $4,050 $6,350 $8,650 ACCIDENTAL INJURY Hypothetical Example 1 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 3 LEVELS 1 & 2 $50 $75 Accident Insurance Accident Insurance

ALL COVERAGE LEVELS Plan Benefit Highlights BENEFITS LEVEL 1 LEVEL 2 LEVEL 3 TREATMENTS Initial Treatment $150 $200 $250 Follow-up Treatment Up to six treatments $50 $50 $50 MEDICAL IMAGING CT, CAT, MRI, PET, US, SPECT $200 $200 $200 X-Rays Up to two days $50 $100 $150 HOSPITAL ICU Admission $1,000 $1,500 $2,000 Hospital Admission $500 $1,000 $1,500 ICU Confinement Up to 30 days $400 $800 $1,200 Hospital Confinement Up to 365 days $100 $200 $300 Rehabilitation Up to 30 days $50 $100 $150 AMBULANCE Ground/Water $500 $500 $500 Air $1,500 $1,500 $1,500 SURGICAL Anesthesia $150 $200 $250 Exploratory Surgery $250 $300 $350 Internal Injuries Surgery Open abdominal/thoracic surgery $1,000 $1,500 $2,000 Miscellaneous Surgery $250 $250 $250 Outpatient Hospital or Ambulatory Surgical Center $150 $250 $350 Ruptured Disc or Torn Knee Cartilage Surgery $500 $500 $500 Tendons, Ligaments, and Rotator Cuff Surgery One tendon, ligament, or rotator cuff More than one tendon, ligament, or rotator cuff $500 $750 $500 $750 $500 $750 FAMILY SUPPORT Transportation Up to 3 round trips per Covered Person per Covered Accident $300 $300 $300 Family Member Lodging and Meals Per day per accident; Up to 30 days per Covered Accident $100 $100 $100 ALL COVERAGE LEVELS MONTHLY PREMIUMS LEVEL 1 LEVEL 2 LEVEL 3 Individual $19.90 $26.10 $33.40 Individual & Spouse $28.30 $34.90 $41.90 Individual & Child(ren) $31.50 $41.00 $51.30 Family $39.90 $49.80 $59.90 BENEFITS LEVEL 1 LEVEL 2 LEVEL 3 INJURY TREATMENTS Fractures Depending on open or closed reduction and bone involved Chip fracture - 25% of closed reduction amount $150 to $4,000 $225 to $6,000 $300 to $8,000 Dislocations Depending on open or closed reduction and joint involved With local or no anesthesia - 25% of closed reduction amount $150 to $4,000 $225 to $6,000 $300 to $8,000 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 $25 $100 $200 $400 $50 $150 $250 $500 $75 $200 $300 $600 2nd & 3rd Degree Burns Skin grafts are 50% of benefit $150 to $15,000 $150 to $15,000 $150 to $15,000 Appliances Crutches, leg braces, etc. $100 $150 $200 Blood, Plasma, and Platelet $250 $300 $350 Concussion $200 $250 $300 Coma $5,000 $10,000 $15,000 Emergency Dental Work Broken teeth repaired with crown or extraction of a broken natural tooth $150 $200 $250 Epidural Pain Management $100 $150 $200 Eye Injury Injury with surgical repair or removal of foreign body by physician, for one or both eyes $200 $250 $300 Gunshot Wound $500 $1,000 $1,500 Paralysis Paraplegia/Uniplegia Quadriplegia $10,000 $20,000 $15,000 $30,000 $20,000 $40,000 Physical, Occupational, or Speech Therapy Per day of treatment up to eight days combined $25 $25 $25 Prosthesis Up to two devices $500 $500 $500 Traumatic Brain Injury $1,000 $1,500 $2,000

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; 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