Accident (New Brochure)

Accident Insurance 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. ACCIDENTAL INJURY 1 Hypothetical Example 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. 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 Accident Hospital Confinement (days 2 through 4) $300 $600 $900 Concussion $200 $250 $300 Insurance 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 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: • Routine • Sports LEVELS Physical Exam Physical Exam 1 & 2 LEVEL 3 • Bone Density • Stress Test $50 $75 Screening Plan Benefit Highlights 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 1 Hypothetical 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.

Plan Benefit Highlights ALL COVERAGE LEVELS BENEFITS LEVEL 1 LEVEL 2 LEVEL 3 BENEFITS LEVEL 1 LEVEL 2 LEVEL 3 TREATMENTS INJURY TREATMENTS ALL COVERAGE Initial Treatment $150 $200 $250 Fractures LEVELS Depending on open or closed $150 $225 $300 reduction and bone involved to $4,000 to $6,000 to $8,000 Follow-up Treatment $50 $50 $50 Chip fracture Up to six treatments - 25% of closed reduction amount Dislocations MEDICAL IMAGING Depending on open or closed $150 $225 $300 CT, CAT, MRI, PET, US, SPECT $200 $200 $200 reduction and joint involved to $4,000 to $6,000 to $8,000 X-Rays With local or no anesthesia Up to two days $50 $100 $150 - 25% of closed reduction amount Lacerations HOSPITAL Not requiring sutures $25 $50 $75 ICU Admission $1,000 $1,500 $2,000 Sutured lacerations less than two inches $100 $150 $200 Hospital Admission $500 $1,000 $1,500 Sutured lacerations totaling two ICU Confinement but less than six inches $200 $250 $300 Up to 30 days $400 $800 $1,200 Sutured lacerations totaling six $400 $500 $600 Hospital Confinement $100 $200 $300 inches or more Up to 365 days 2nd & 3rd Degree Burns $150 $150 $150 Rehabilitation Skin grafts are 50% of benefit to $15,000 to $15,000 to $15,000 Up to 30 days $50 $100 $150 Appliances $100 $150 $200 Crutches, leg braces, etc. SURGICAL Blood, Plasma, and Platelet $250 $300 $350 Anesthesia $150 $200 $250 Concussion $200 $250 $300 Coma $5,000 $10,000 $15,000 Exploratory Surgery $250 $300 $350 Emergency Dental Work Internal Injuries Surgery Broken teeth repaired with $150 $200 $250 Open abdominal/thoracic surgery $1,000 $1,500 $2,000 crown or extraction of a broken natural tooth Miscellaneous Surgery $250 $250 $250 Epidural Pain Management $100 $150 $200 Outpatient Hospital or Eye Injury Ambulatory Surgical Center $150 $250 $350 Injury with surgical repair or removal of foreign body by $200 $250 $300 Ruptured Disc or Torn Knee $500 $500 $500 physician, for one or both eyes Cartilage Surgery Gunshot Wound $500 $1,000 $1,500 Tendons, Ligaments, and Rotator Paralysis Cuff Surgery $500 $500 $500 Paraplegia/Uniplegia $10,000 $15,000 $20,000 One tendon, ligament, Quadriplegia $20,000 $30,000 $40,000 or rotator cuff Physical, Occupational, or More than one tendon, ligament, $750 $750 $750 Speech Therapy or rotator cuff Per day of treatment up to $25 $25 $25 AMBULANCE eight days combined Ground/Water $500 $500 $500 Prosthesis $500 $500 $500 Air $1,500 $1,500 $1,500 Up to two devices Traumatic Brain Injury $1,000 $1,500 $2,000 FAMILY SUPPORT Transportation MONTHLY LEVEL 1 LEVEL 2 LEVEL 3 Up to 3 round trips per Covered $300 $300 $300 PREMIUMS Person per Covered Accident Individual $19.90 $26.10 $33.40 Family Member Individual & Spouse $28.30 $34.90 $41.90 Lodging and Meals $100 $100 $100 Individual & Child(ren) $31.50 $41.00 $51.30 Per day per accident; Up to 30 days per Covered Accident Family $39.90 $49.80 $59.90

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

Accident Insurance Plan Benefit Highlights (cont.) Limitations and Exclusions Physical, Occupational, or Speech Therapy Benefit Payable No benefits will be provided for an Accident that is caused by or for one treatment per day for up to eight treatments by a occurs as a result of: licensed Physical, Occupational, or Speech Therapist for all (1) in tentionally self-inflicted bodily injury, suicide or therapies combined. If treatment in an Emergency Room, attempted suicide, whether sane or insane; Physician’s Office, or Urgent Care Facility occurs in the same (2) par ticipation in any form of flight aviation other than as a fare- visit, only the highest applicable benefit is payable. paying passenger in a fully licensed/passenger-carrying aircraft; Prosthesis Benefit Payable for up to two devices. This benefit is not (3) any act that was caused by war, declared or undeclared, or payable for hearing aids; dental aids; eyeglasses; false teeth; cosmetic service in any of the armed forces; aids such as wigs; or joint replacements such as artificial hips or knees. (4) participation in any activity or event while under the influence of any narcotic, drug, or controlled substance unless administered Rehabilitation Benefit Payable for each day a Person is an inpatient by a Physician or taken according to the Physician’s instructions; in a Rehabilitation Unit. The treatment must begin immediately after (5) voluntary ingestion, injection, inhalation or absorption of any the date of discharge from the Hospital. This benefit is payable for up narcotic, drug, controlled substance, poison, gas, or fume; to 30 days. This benefit is not payable for any day for which a Hospital (6) participation in, or attempting to participate in, a felony, riot or Admission, Hospital Confinement, ICU Admission, ICU Confinement, insurrection. (A felony is as defined by the law of the jurisdiction or Physical, Occupational, and Speech Therapy benefit is payable. in which the activity takes place.); (7) participation in any sport for pay or profit; or sponsorship, in a Tendons, Ligaments and Rotator Cuff Benefit Payable for the professional or semi-professional capacity; repair of one or more tendons, ligaments, or rotator cuffs. The (8) treatment received outside the United States and its territories, tendons, ligaments, or rotator cuff must be repaired through Canada, or Mexico; surgery performed by a Physician, as a result of an Accident. (9) participation in any contest of speed in a power driven vehicle for Torn Knee Cartilage or Ruptured Disc Benefit Payable pay or profit; for surgical repair as a result of an Accident. (10) participation in parachuting, bungee jumping, rappelling, mountain climbing or hang gliding. Transportation Benefit Payable for the Person’s transportation Benefits will not be paid for services rendered by a member of the when specialized treatment and Hospital Confinement in a non-local immediate family of a Person. 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. A Covered Accident is defined as an Injury caused by an Accident, Travel must be by scheduled bus, plane, train, or by car. Ambulance for which benefits are provided, which is independent of any service does not qualify for this benefit. The treatment must be disease, illness, or bodily infirmity or any other cause and that takes prescribed by a Physician and not be available locally. This benefit is place while the Person is covered under this policy. payable up to three round trips per Person per Accident. This benefit A hospital is not an institution, or part thereof, used as: a hospice is not payable on any day that an Ambulance Benefit is payable. unit, including any bed designated as a hospice or a swing bed; a Traumatic Brain Injury (TBI) Benefit Payable for a Person convalescent home; a rest or nursing facility; a rehabilitative facility; who is Confined for at least 48 hours as the result of a TBI. an extended-care facility; a skilled nursing facility; or a facility Diagnosis by a Physician and Confinement must occur within primarily affording custodial, educational care, or care or treatment 3 days of the Accident. If both a TBI and Concussion occur in for persons suffering from mental diseases or disorders, or care for the same Accident, only the highest benefit will be paid. the aged, or drug or alcohol addiction. X-Ray Benefit Payable once per day up to 2 days for an x-ray Eligibility includes you, your lawful spouse and each natural, performed due to Injuries sustained in an Accident. The adopted or stepchild who is under 26 years of age. x-ray must be done at the request of a Physician. This benefit Guaranteed Renewable You cannot be singled out for a rate does not cover any tests payable under the Medical Imaging increase for any reason. The Insurer has the right to increase Benefit or any other screening or medical imaging tests. 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 end of the Policy/Rider(s) Month in which we receive a written request from you to terminate this policy/rider(s); 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. 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 Policy Form AO22 Series SB-33412-0422 013-810, 013-811, 013-812