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