Group Hospital Indemnity IN

AF™ Limited Bene昀椀t Hospital Indemnity Insurance Help pay for your stay. If you experienced a medical emergency, would you be prepared to cover the out-of-pocket medical expenses? And, what about everything else that adds up, like bills, groceries, and housing? Major medical insurance plans are designed to pay a large portion of your medical costs. But with rising deductibles and copays, you’re still paying out of your own pocket until you meet your deductible and plan maximum. That’s where AF™ Limited Benefit Hospital Indemnity Insurance, or AF Hospital Assist®, can help. It can be used with a low deductible or high deductible health plan (HDHP). Health Savings Account Qualified Plan Help offset high deductibles and copays, and give yourself a little protection for the unexpected . This Health Savings Account (HSA) qualified plan provides a way to help pay for large, out-of-pocket expenses, like a hospital ® stay, while also getting the tax benefit and potential savings from an HSA. AF Hospital Assist Plan Highlights • No health questions required to apply • Benefits paid directly to you • Portable so you can take it with you even if you leave employment • Coverage available for you, your spouse, and your children up to age 26 • Online claims filing process Did you know? The average cost for a 1 hospital stay is $11,728. They’re neither cheap nor predictable, but they happen. And often. In fact, over 36 million Americans were 2 hospitalized in 2018. ™ AF Hospital Assist Premiums* MONTHLY PREMIUM BASIC ENHANCED ENHANCED PLUS Employee $14.54 $24.54 $34.60 Employee + Spouse $27.76 $46.80 $65.90 Employee + Child $29.94 $49.66 $69.62 Family $43.16 $71.92 $100.92 * The premium and amount of benefits provided vary based upon the plan selected. EMPLOYER BENEFIT SOLUTIONS FOR EDUCATION This brochure highlights important features of the policy. Please refer to your certificate for complete details. If you reside in a state other than your employers state domicile, where required by law, policy provisions and benefits may vary.

Benefits ENHANCED Hospital Benefits BENEFITS BASIC ENHANCED PLUS If hospitalized, you can get paid directly for the costs. Basic HOSPITAL Enhanced Enhanced Plus Hospital Admission $500 $1,000 $1,500 Hypothetical Example with Enhanced Plan You have a car accident 1 day/Covered Person and are rushed to the ER. You’re admitted and stay 3 days for a back injury. Then, you complete 10 days of rehabilitation. The deductible Hospital Confinement Pays in this example is based on Preferred Provider Organization (PPO) plan up to 30 days/Covered Person $100 $150 $200 option Cost of Care Your Payable Plan Benefits Deductible 3 $11,728 ICU 10 days/Covered Person $200 $300 $400 Confinement $500 Admission $1,000 4 Rehab $1,620 Confinement $450 Rehab $750 Rehab 10 days/ $50 $75 $100 Total out of Total benefit Covered Person pocket cost7 payment to you Total $13,348 $3,069 $2,200 ACCIDENT Accident Treatment - ER Accident Benefits 3 days/Covered Person $200 $300 $400 Weekend warrior? Active family? Or a long daily commute? No matter your situation, accidents happen. Basic Accident Treatment - Enhanced Physician’s Office or Urgent $50 $75 $100 Enhanced Plus Care 6 days/Covered Person Hypothetical Example with Enhanced Plan You are traveling in Accident Surgery - Hospital your car and are hit by a driver running a red light. Your arm is or Ambulatory Surgical $1,000 $1,500 $2,000 broken and requires an ER visit, surgery, admission to the hospital, Center 3 days/Covered Person and two nights’ stay. The deductible in this example is based on a 2020 IRS minimum family medical HSA High Deductible Health Plan (HDHP). Cost of Care Your Payable Plan Benefits Accident Surgery - 5 Deductible Physician’s Office or Urgent $125 $125 $250 ER Visit $827 $2,800 ER Visit $300 6 Care 6 days/Covered Person Surgery $16,000 Surgery $1,500 Hospital Admission $1,000 Benefits are paid on a calendar year basis. Hospital Confinement $300 Refer to the Plan Benefit Highlights section for additional information. Total out-of- Total benefit Total Cost of Care pocket cost7 payment to you $16,827 $5,605 $3,100

Plan Benefit Highlights Hospital Admission Benefit: We will not pay this benefit for (j) experimental treatment, drugs, or surgery, except in connection outpatient treatment, emergency room treatment, or a stay of with an approved cancer clinical trial; less than 18 hours in an observation unit. Successive hospital (k) performance of military, naval, or air force service of any admissions will be considered as one admission if they are due country; to the same or related accident or sickness and separated by less (l) dental or routine vision services, unless: than 90 days. (1) resulting from an Accident occurring while the Covered Hospital Confinement Benefit: We will not pay this benefit for Person’s coverage is in force and if performed within 12 months of outpatient treatment or a hospital stay of less than 18 hours. the date of such Accident; or Hospital shall not include an institution used by you as a place (2) due to congenital disease or anomaly of a covered newborn for rehabilitation; a place for rest or for the aged; a nursing child; or convalescent home; a long-term nursing unit or geriatric (m) immunizations, sports and routine annual physicals; ward; or an extended care facility for the care of convalescent, (n) services, treatment or loss rendered in any Physician’s office, rehabilitative, or ambulatory patients. Veterans Administration or Federal Hospital or any other Hospital, except if there is a legal obligation to pay; Rehabilitation Facility Confinement Benefit: Confinement to the (o) artificial insemination, in vitro fertilization, test tube facility must be physician authorized for at least 18 continuous fertilization, sterilization, tubal ligation, or vasectomy, and reversal hours and begin immediately following a hospital confinement. thereof; Successive rehabilitation facility stays will be considered as one (p) loss that takes place outside of North America; confinement if they are due to the same or related accident or (q) participation in any sport for pay or profit; sickness and separated by less than 30 days. (r) alcoholism or drug use, unless such drugs were taken on the Outpatient Accident Treatment Benefit: Pays a benefit when any advice of a Physician and taken as prescribed; covered person incurs an expense and receives treatment by a (s) mental or emotional disorders without demonstrable organic physician in an emergency room, physician’s office or urgent care disease; facility due to a covered accident. Accident means an event which (t) air or ground ambulance; results in bodily injury that is independent of disease or bodily (u) Pre-Existing Conditions, unless the Covered Person has satisfied infirmity or any other cause. the Pre-Existing Condition Exclusion period of 12 months. Accident Surgical Procedure Benefit: Pays a benefit when Pre-Existing Condition: means a disease, Sickness, Accident, any covered person incurs an expense and requires a surgical or physical condition for which you: had treatment; incurred procedure due to a covered accident. The procedure must be expense; took medication; or received a diagnosis or advice from performed by a Physician in a hospital, ambulatory surgical center, a physician, during the 12 month period immediately before your urgent care facility, or physician’s office. We will pay for only one effective date of coverage. The term pre-existing condition will accident surgical procedure performed on the same day even if also include conditions which are related to such disease, Sickness, caused by more than one accident. We will not pay this benefit for Accident, or physical condition. colonoscopy or flexible sigmoidoscopy. Pregnancy Limitation: Exclusions: We will not pay benefits resulting from or caused by: For the Pregnancy Limitation Period, 10 months, the Company will (a) suicide or any attempt, while sane or insane; not pay benefits due to any Covered Person giving birth as a result (b) any intentionally self-inflicted injury or Sickness; of a normal pregnancy, including cesarean section. Complications (c) voluntary abortion except, with respect to You or Your covered of Pregnancy will be covered to the same extent as any other Dependent Spouse; covered benefit. Complications of Pregnancy includes but is not (1) where You or Your Dependent Spouse’s life would be limited to, conditions requiring Confinement (when pregnancy is endangered if the fetus were carried to term; or not terminated), whose diagnoses are distinct from pregnancy but (2) where medical complications have arisen from abortion; are adversely affected by pregnancy or are caused by pregnancy, (d) pregnancy of a Dependent child; such as acute nephritis, nephrosis, cardiac decompensation, (e) participation in a riot, civil commotion, civil disobedience, or missed abortion and similar medical and surgical conditions of unlawful assembly. This does not include a loss which occurs while comparable severity, ectopic pregnancy which is terminated, acting in a lawful manner within the scope of authority; spontaneous termination of pregnancy which occurs during (f) commission of a felony; a period of gestation in which a viable birth is not possible, (g) participation in a contest of speed in power driven vehicles, puerperal infection, eclampsia and toxemia. parachuting, or hang gliding; Complications of Pregnancy shall not include false labor, (h) air travel, except: occasional spotting, Physician prescribed rest during the period (1) as a fare-paying passenger on a commercial airline on a of pregnancy, morning sickness, hyperemesis gravidarum, regularly scheduled route; or preeclampsia and similar conditions associated with the (2) as a passenger for transportation only and not as a pilot or management of a difficult pregnancy not constituting a crew member; classifiable or distinct Complication of Pregnancy. (i) elective procedures or cosmetic surgery, including complications of elective procedures or cosmetic surgery; This product may contain limitations, exclusions and waiting periods. This product is inappropriate for people who are eligible for Medicaid coverage. 1AHRQ Healthcare Cost and Utilization Project, National Inpatient Sample as of February 5, 2019. 2American Hospital Association: Fast Facts on U.S. Hospitals, January 2020. 3AHRQ 4 Healthcare Cost and Utilization Project, National Inpatient Sample as of February 5, 2019. MD Save: Procedures A to Z; accessed 10/3/2018 from 5 MDsave.com. Healthcare Bluebook: Emergency Room Visit – Moderate Problem; Accessed from www.healthcarebluebook.com on April 6 3, 2020. Figures from Oklahoma City, OK. https://www.healthcarebluebook.com/ui/proceduredetails/239. CostHelper: How Much Does a 7 Broken Arm Cost?; accessed 10/3/2018 from health.costhelper.com. CostHelper: How Much Does a Broken Arm Cost? Total out of pocket costs assumes a 20% coinsurance amount.

AF™ Group Limited Bene昀椀t Hospital Indemnity Insurance Plan Benefit Highlights (cont.) Termination of Insurance Coverage for you and your covered dependent(s) may be continued during a layoff or leave of absence for up to a maximum period of 3 months. Coverage will continue as long as the group policy remains in force, the premiums are paid and you remain eligible for the coverage under the policy. Your coverage will end when you no longer qualify as an insured, you retire, you are not on active employment, or your employment terminates. Your coverage can be terminated or premiums may be increased on any premium due date with 31 days advance notice. American Fidelity Assurance Company 9000 Cameron Parkway, Oklahoma City, Oklahoma 73114 800-662-1113 • americanfidelity.com SB-32381(IN)(AFES)-0720 Policy Form Series: G1402