G Bene昀椀ts Overview BENEFIT AMOUNT HI HOSPITAL ADMISSION BENEFIT per con昀椀nement (once per covered sickness or accident per calendar year for each insured) Payable when an insured is admitted to a hospital and con昀椀ned as an inpatient because of a covered accidental injury or covered sickness. We will not pay bene昀椀ts for con昀椀nement to an observation unit, or for emergency room treatment or outpatient treatment. $2,000 We will not pay bene昀椀ts for admission of a newborn child following his birth; however, we will pay for a newborn’s admission to a Hospital Intensive Care Unit if, following birth, he is con昀椀ned as an inpatient as a result of a covered accidental injury or covered sickness (including congenital defects, birth abnormalities, and/or premature birth). HOSPITAL CONFINEMENT per day (maximum of 31 days per con昀椀nement for each covered sickness or accident for each insured) Payable for each day that an insured is con昀椀ned to a hospital as an inpatient as the result of a covered accidental injury or covered sickness. If we pay bene昀椀ts for con昀椀nement and the insured becomes con昀椀ned $200 again within six months because of the same or related condition, we will treat this con昀椀nement as the same period of con昀椀nement. This bene昀椀t is payable for only one hospital con昀椀nement at a time even if caused by more than one covered accidental injury, more than one covered sickness, or a covered accidental injury and a covered sickness. HOSPITAL INTENSIVE CARE BENEFIT per day (maximum of 10 days per con昀椀nement for each covered sickness or accident for each insured) Payable for each day when an insured is con昀椀ned in a Hospital Intensive Care Unit because of a covered accidental injury or covered sickness. We will pay bene昀椀ts for only one con昀椀nement in a Hospital's Intensive $200 Care Unit at a time. Once bene昀椀ts are paid, if an insured becomes con昀椀ned to a Hospital's Intensive Care Unit again within six months because of the same or related condition, we will treat this con昀椀nement as the same period of con昀椀nement. This bene昀椀t is payable in addition to the Hospital Con昀椀nement Bene昀椀t. INTERMEDIATE INTENSIVE CARE STEP-DOWN UNIT per day (maximum of 10 days per con昀椀nement for each covered sickness or accident for each insured) Payable for each day when an insured is con昀椀ned in an Intermediate Intensive Care Step-Down Unit because of a covered accidental injury or covered sickness. We will pay bene昀椀ts for only one con昀椀nement in an Intermediate Intensive Care Step-Down Unit at a time. $100 Once bene昀椀ts are paid, if an insured becomes con昀椀ned to a Hospital's Intermediate Intensive Care Step- Down Unit again within six months because of the same or related condition, we will treat this con昀椀nement as the same period of con昀椀nement. This bene昀椀t is payable in addition to the Hospital Con昀椀nement Bene昀椀t. SUCCESSOR INSURED BENEFIT If spouse coverage is in force at the time of the employee’s death, the surviving spouse may elect to continue coverage. Coverage would continue according to the existing plan and would also include any dependent child coverage in force at the time. In order to receive bene昀椀ts for accidental injuries due to a covered accident, an insured must be admitted within six months of the date of the covered accident (in Washington, twelve months). LIMITATIONS AND EXCLUSIONS military, armed forces, or an auxiliary unit thereto. (We will return the prorated EXCLUSIONS premium for any period not covered by the certi昀椀cate when the insured is in We will not pay for loss due to: such service.) War does not include acts of terrorism. • War – voluntarily participating in war, any act of war, or military con昀氀icts, declared or • Suicide – committing or attempting to commit suicide, while sane or insane. undeclared, or voluntarily participating or serving in the military, armed forces, or an − In Missouri, Montana, and Vermont: committing or attempting to commit suicide, auxiliary unit thereto, or contracting with any country or international authority. (We while sane. will return the prorated premium for any period not covered by the certi昀椀cate when − In Minnesota: this exclusion does not apply. the insured is in such service.) War also includes voluntary participation (In North • Self-In昀氀icted Injuries – injuring or attempting to injure oneself intentionally. Carolina, active participation) in an insurrection, riot, civil commotion or civil state of − In Missouri: injuring or attempting to injure oneself intentionally which is belligerence. War does not include acts of terrorism (except in Illinois). obviously not an attempted suicide. − In Connecticut: a riot is not excluded. − In Vermont: injuring or attempting to injure oneself intentionally, while sane. − In Oklahoma: War, or any act of war, declared or undeclared, when serving in the