Attachment 1
Accident 1.0 Benefit Summary
Accident 1.0
Colonial Life’s voluntary accident insurance policy is a medical indemnity plan that
provides employees and their families with hospital, doctor, accidental death and
catastrophic accident benefits in the event of a covered accident.
This policy offers six plan choices with varying benefit amounts and three optional
riders:
• Basic
• Basic with Health Screening Benefit
• Preferred
• Preferred with Health Screening Benefit
• Premier
• Premier with Health Screening Benefit
Each of the plans listed above may be offered as On/Off-Job or Off-Job Only.
Optional Riders:
• Off-Job Only or On/Off-Job Accident Disability Rider
• Off-Job Only or On/Off-Job Accident/Sickness Disability Rider
• Sickness Hospital Confinement Rider
Benefits
Base Policy Benefits
Basic
Preferred
Premier
$75
$125
$125
$50/visit up to 2
visits per accident
$50/visit up to 3
visits per accident
$50/visit up to 4
visits per accident
Accidental Death
$20,000 Employee
$20,000 Spouse
$4,000 Child(ren)
$25,000 Employee
$25,000 Spouse
$5,000 Child(ren)
$50,000 Employee
$50,000 Spouse
$10,000 Child(ren)
Accidental Death:
Common Carrier
$80,000 Employee
$80,000 Spouse
$16,000 Child(ren)
$600- $12,000
$100,000
Employee
$100,000 Spouse
$20,000 Child(ren)
$750- $15,000
$200,000
Employee
$200,000 Spouse
$40,000 Child(ren)
$1,200-$24,000
$1,200
$2,000
$2,000
Ambulance - Ground
$120
$200
$200
Appliances
(such as wheelchair, crutches)
$75
$100
$100
Accident Emergency Treatment
For treatment in a doctor’s office,
urgent care facility or emergency room
within the first 72 hours of the accident.
If initially treated after 72 hours, please
see Accident Follow-up Doctor’s Visit
Accident Follow-Up Doctor Visit
Accidental Dismemberment:
(Loss of Finger/Toe/Hand/Foot or
Sight)
Ambulance - Air
Applicable to AZ
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the
marketing brand.
2009 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210 PS01358
Base Policy Benefits
Basic
Preferred
Premier
Blood/Plasma/Platelets
$300
$300
$300
Burns
(based on size and degree)
$1,000- $12,000
$1,000- $12,000
$1,000- $12,000
Burns - Skin Graft
50% of burn
benefit
$10,000 EE/SP
$5,000 CH
50% of burn
benefit
$25,000 EE/SP
$12,500 CH
50% of burn
benefit
$25,000 EE/SP
$12,500 CH
$7,500
$10,000
$12,500
$60
$90-$3,600
$60
$110 - $4,400
$60
$120 - $4,800
$200 (crown,
implant or denture)
or $50 (extract)
$200
$300 (crown,
implant or denture)
or $75 (extract)
$300
$400 (crown,
implant or denture)
or $100 (extract)
$300
Fractures (Based on bone and if
repaired by open or closed reduction)
$90 - $4,500
$110 - $5,500
$120 - $6,000
Hospital Admission*
$750/accident
$1,000/accident
$1,250/accident
$175
$225
$250
$1,500/accident
$2,000/accident
$2,500/accident
$350
$450
$500
$500
$500
$750
$30-$500
$30-$500
$30-$500
$100 per day
up to 30 days
$100 per accident
$125 per day
up to 30 days
$150 per accident
$150 per day
up to 30 days
$200 per accident
Catastrophic Accident –
prior to 65
(For severe injuries that result in the
total and irrevocable: loss of one hand
and one foot; loss of both hands or both
feet; loss of sight in both eyes; loss of
hearing of both ears; loss of the ability
to speak.)
365 day elimination period
Amounts reduced for covered persons
over age 65
Coma (duration of at least 7 days)
Concussion
Dislocation (Based on joint and if
repaired by open or closed reduction)
Emergency Dental Work
Eye Injury
Hospital Confinement
(Per day up to 30 days)
Hospital ICU Admission*
Hospital ICU Confinement
(Up to 15 days per accident)
Knee Cartilage - Torn
Laceration
(based on size and repair)
Lodging (Companion)
Medical Imaging Study
Limit one accident per year
Prosthetic Device/Artificial Limb
$500 (1);
$500 (1);
$750 (1);
$1,000 (2 or more) $1,000 (2 or more)
$1,500 (2 or more
* We will pay either the Hospital Admission or Hospital ICU Admission benefit, but not both.
Applicable to AZ
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the
marketing brand.
2009 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210 PS01358
Base Policy Benefits
Basic
Preferred
Premier
$100/day
$100/day
$150/day
$500
$1,000:
$500
$1,500
$750
$1,500
Surgery- Hernia
$100
$150
$150
Surgery – Exploratory or
Arthroscopic
Tendon/Ligament/Rotator Cuff
$150
$200
$200
$500 (1);
$1,000 (2 or more)
$25 per day (10
visits/accident)
$500 (1);
$1,000 (2 or more)
$25 per day (10
visits/accident)
$750 (1);
$1,500 (2 or more)
$35 per day (10
visits/accident)
Transportation
up to 3 trips per accident
X-Ray Benefit
$400 per trip
$500 per trip
$600 per trip
$20
$30
$40
Home Health Services
Maximum of 30 days per covered
person per covered accident.
$50 per day
$50 per day
$50 per day
Rehabilitation Unit Confinement
Up to 15 days per confinement per
covered accident.
Maximum of 30 days per calendar year.
Ruptured Disc
Surgery-Cranial, Open
Abdominal, Thoracic
Therapy - Occupational and
Physical Therapy Benefit
Health Screening Benefit
Available on selected plans
• $50 per covered person per calendar year.
• Provides a benefit if the covered person has one of the health screening tests
performed. This benefit is payable once per calendar year per covered person
and is subject to a 30-day waiting period. Available to each covered person.
Tests include:
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Blood test for
triglycerides
Bone marrow testing
Breast ultrasound
CA 15-3 (blood test for
breast cancer)
CA125 (blood test for
ovarian cancer)
Carotid doppler
CEA (blood test for
colon cancer)
Chest x-ray
Colonoscopy
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Echocardiogram
(ECHO)
Electrocardiogram
(EKG, ECG)
Fasting blood glucose
test
Flexible sigmoidoscopy
Hemoccult stool analysis
Mammography
Pap smear
PSA (blood test for
prostate cancer)
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•
•
Serum cholesterol test to
determine level of HDL
and LDL
Serum protein
electrophoresis (blood
test for myeloma)
Stress test on a bicycle or
treadmill
Skin cancer biopsy
Thermography
ThinPrep pap test
Virtual colonoscopy
Applicable to AZ
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the
marketing brand.
2009 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210 PS01358
Optional Riders
A choice of optional riders are available and can be purchased at an additional cost to
provide extra coverage and benefits.
Off-Job Only or On/Off-Job Accident Disability Income Rider
• Employee: $400-$2,500 Off-Job monthly benefit. On-job amount is 50% of Off-Job
benefit.
• Spouse: $400 - $1,500 monthly benefit amounts (off job only available for spouse)
• Sold in $50 on-job and $100 off-job increments
• 0, 7, 14 or 30 day elimination period
• 6 or 12 month benefit period
• Up to 50% of income for employee or spouse
• Guaranteed Renewable to age 70
Off-Job Only or On/Off-Job Accident/Sickness Disability Income Rider
• Employee: $400-$2,500 Off-Job monthly benefit. On-job amount is 50% of Off-Job
benefit.
• Spouse: $400 - $1,500 monthly benefit amounts (off-job only available for spouse)
• Sold in $50 on-job and $100 off-job increments
• 0/7, 7/7, 0/14, 14/14, 0/30, 30/30, 60/60, 90/90 or 180/180 day elimination periods
based on benefit period selected
• 3, 6, 12 or 24 month benefit periods (24 month not available for spouse)
• Up to 50% of income for employee or spouse
• A 12/12 pre-existing condition limitation.
• Guaranteed Renewable to age 70
Sickness Hospital Confinement Rider
• Pays if an insured is confined as an overnight resident bed patient in a hospital
because of covered sickness
• $100 per day
• 0 day elimination period
• 30 day benefit period
• 12/12 pre-existing conditions limitation
• Rider is guaranteed renewable for life
• Available to employee, spouse and children
• Home Health Services-$50 Per Day Benefit Period. Up To 30 Days Per Confinement
Features
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Base plans are guaranteed issue so there is no health underwriting.
Benefits are paid directly to the insured unless specified otherwise.
Benefits are paid in addition to other insurance your employees may have.
Applicable to AZ
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the
marketing brand.
2009 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210 PS01358
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•
Benefits are level for employee, spouse and children except for accidental death and
catastrophic accident benefits.
Base coverage and sickness hospital confinement rider are guaranteed renewable for
life as long as premiums are paid when they are due.
Coverage is portable. An employee can take this coverage with him if he changes
jobs or leaves your company.
Spouse and/or dependent children can purchase coverage without the employee
having to purchase coverage. Premiums are payroll deducted through employee’s
paycheck.
Spouse can purchase optional accident only disability rider or accident/sickness
disability rider coverage.
The spouse’s signature is not required on the application in most states.
Coverage is worldwide. The Disability riders are subject to the Geographical
Limitations provision.
Disability riders provide Total Disability and Partial Disability benefits.
If a disability rider is purchased, the Waiver of Premium benefit applies after 90
continuous days of disability or the elimination period has been satisfied whichever is
greater.
Eligibility Requirements
Accident Base Plans
• Permanent benefit-eligible employees between the ages of 17-80, working
20 hours per week.
• Employee’s spouse between the ages of 17-80.
• Child(ren) between the ages of 0-25*. (May vary by state)
Optional Riders
• Disability Income Riders: Permanent benefit-eligible employees and spouses between
the ages of 17-69, working 20 or more hours per week.
• Sickness Hospital Confinement Rider: Permanent benefit eligible employees between
the ages of 0-69. Spouse must be age 0-69. Child(ren) must be age 0-25.
Health questions apply to the Accident/Sickness Disability Income Riders and the Sickness
Hospital Confinement Rider.
Participation Requirements
To offer this plan, we require that only 3 eligible employees apply.
Definitions
Totally Disabled* means you are: unable to perform the material and substantial duties
of your job; not, in fact, working at any job; and under the regular and appropriate care of
a doctor.
Applicable to AZ
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the
marketing brand.
2009 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210 PS01358
Partially Disabled* means you are unable to perform the material and substantial
duties of your job for 20 hours or more per week; you are able to work at your job or your
place of employment for less than 20 hours per week; your employer will allow you to
return to your job or place of employment for less than 20 hours per week; and you are
under the regular and appropriate care of a doctor.
Waiver of Premium Benefit*: After you have been totally disabled or qualify for
Partial Disability benefits as the result of a covered accident or a covered sickness for
more than 90 consecutive days while this rider is in effect, or after the elimination period
shown on the Rider Schedule, whichever is greater, we will waive the premium
beginning on the next premium due date for the policy and any attached rider(s) for as
long as you remain disabled, up to the benefit period shown on the Rider Schedule.You
must pay all premiums to keep the policy and any attached rider(s) in force until you have
been totally disabled or qualify for Partial Disability benefits for 90 consecutive days
while this rider is in effect, or for the elimination period shown on the Rider Schedule,
whichever is greater.
Geographical Limitations*: If you become totally disabled as the result of a covered
accident or a covered sickness while you are outside the covered geographical areas and
you are totally disabled longer than the elimination period shown on the Rider Schedule,
your maximum benefit period for total disability and partial disability combined while
outside the covered geographical areas will be limited to 60 days.
Covered geographical areas are less than 40 miles outside the territorial limits of the
United States, Canada, Mexico, Puerto Rico, the Bahama Islands, the Virgin Islands,
Bermuda or Jamaica.
Pre-existing Condition** means a sickness or physical condition for which you were
treated, received medical advice or had taken medication within 12 months before the
effective date of this rider.
If you become disabled or hospital confined because of a pre-existing condition, we will
not pay for any disability period or hospital confinement if it begins during the first 12
months the rider is in force. After this rider has been in force for 12 months from the
effective date of this rider, we will pay benefits for any pre-existing condition not
otherwise excluded by name or specific description if the covered confinement began
more than 12 months after the effective date of the rider.
Any recurrent disability caused by a pre-existing condition will not be covered if it is
treated as a continuation of the previous disability.
*Applicable to the Disability Income Riders only.
**Applicable to the Accident/Sickness Disability Income Rider and the Sickness Hospital
Confinement Riders only.
Applicable to AZ
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the
marketing brand.
2009 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210 PS01358
What is Not Covered
Accident Base Plans will not provide benefits for losses that are caused by or are the
result of any insured’s:
• Hazardous avocations
• Sickness
• Felonies or illegal occupations
• Suicide or self-inflicted injuries
• Racing
• War or armed conflict
• Semi-professional or professional
• Intoxicants and Narcotics
sports
In addition to the exclusions listed above, we also will not pay the Catastrophic
Accident benefit for injuries that are caused by or are the result of:
• Birth
In addition to the base plan exclusions listed above, the Accident Only Disability Rider
will not provide benefits for losses that are caused by or which occur as the result of:
• Intoxicants and Narcotics
• Psychiatric or Psychological Conditions
In addition to the base plan exclusions listed above, the Accident/Sickness Disability
Rider will not provide benefits for losses that are caused by or which occur as the result
of:
• Intoxicants and Narcotics
• Pre-Existing Conditions
• Giving Birth within the first nine months
• Psychiatric or Psychological
after the effective date of this rider as the
Conditions
result of a normal pregnancy, including
Cesarean.
The Sickness Hospital Confinement Rider will not provide benefits for a hospital
confinement caused by or occurring as the result of:
• Accidental Injuries
• Giving Birth Limitation. We will
not pay benefits for hospital
• Intoxicants and Narcotics
confinement due to any covered
• Dental Care
person giving birth within the
• Elective Procedures
first nine (9) months after the
• Pre-existing Conditions
effective date of this rider as a
• Psychiatric or Psychological Conditions
result of a normal pregnancy.
• Well Baby Care Exclusion
Applicable to AZ
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the
marketing brand.
2009 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210 PS01358
Premium Information
•
•
Premiums for the base plans and all riders except the Accident/Sickness rider are not
age banded. Premiums for the Accident/Sickness rider are age banded.
Premium levels are available for Employee, Spouse or Child as the Named Insured,
Employee/Spouse, One-Parent and Two-Parent family coverage.
Sample Monthly Premiums
Coverage
Type
Plan
Optional
Rider(s)
Disability
Benefit Amount
Monthly
Premium
Employee
Only
Basic
Off-Job Only Coverage
None
None
$11.98 (base)
Employee
Only
Preferred with Health
Screening
On- & Off- Job
Coverage
On/Off-Job
Accident
Disability Income
Rider
6 month benefit
0 day elimination
$1,000 per
month for
employee
$21.15 (base)
$22.00 (DI rider)
Premier with Health
Screening
On- & Off-Job Only
Coverage
Off-Job
Accident
Disability
Income Rider for
Spouse
12 month benefit
14 elimination
Off Job Accident
& Sickness
Disability Income
Rider
3 month benefit
0/14 day
elimination
$800 per month
for
spouse
Employee/
Spouse
Two-Parent
Family
Preferred
Off-Job Only Coverage
Sickness
Hospital
Confinement
Rider
for 2 Parent
Family
Total Monthly
Premium
$43.15
$36.32 (base)
$8.00 (DI rider)
Total Monthly
Premium
$44.32
$1,000 per
month
for spouse
(age 25)
$1,500 per
month employee
(age 30)
$100 per
sickness
confinement per
family member
$29.31(base)
$24.00
(SP DI Rider)
$36.00
(EE DI Rider)
$9.00 (SHC
Rider)
Total Monthly
Premium
$98.31
Applicable to AZ
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the
marketing brand.
2009 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210 PS01358
Attachment 2
Accident 1.0 Outline of Coverage
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY
1200 Colonial Life Boulevard, P.O. Box 1365, Columbia, South Carolina 29202
1.800.325.4368 www.coloniallife.com
A Stock Company
ACCIDENT ONLY INSURANCE COVERAGE
THE POLICY PROVIDES LIMITED BENEFITS
BENEFITS PROVIDED ARE SUPPLEMENTAL AND NOT INTENDED TO COVER ALL MEDICAL EXPENSES.
OUTLINE OF COVERAGE (Applicable to Policy Form Accident 1.0-HS-AZ)
THE POLICY IS NOT A MEDICARE SUPPLEMENT POLICY. If you are eligible for Medicare, review the Guide to Health
Insurance for People with Medicare available from the Company.
Please Read The Policy Carefully. This outline provides a very brief description of the important features of the policy. This is not
an insurance contract and only the actual policy provisions will control. The policy sets forth in detail the rights and obligations of
both you and us. It is, therefore, important to READ THE POLICY CAREFULLY.
Renewability. The policy is guaranteed renewable as long as premiums are paid when they are due or within the grace period. The
premium can be changed only if we change it on all policies of this kind in force in the state where the policy was issued.
Coverage Provided by The Policy. The policy is designed to provide to covered persons coverage for losses resulting from injuries
received from a covered accident only, subject to any limitations or exclusions. It does not provide coverage for basic hospital, basic
medical-surgical or major medical expenses.
BENEFITS - All benefits are payable once per covered person per covered accident unless specified otherwise. We will
pay these benefits for any covered person who receives injuries as the result of a covered accident:
Accident Emergency Treatment - $125
Benefit payable if, as the result of a covered accident, a covered person is injured and requires examination and treatment by a doctor
in a hospital emergency room, urgent care center, or doctor’
s office (other than acupuncturist or occupational or physical therapist)
within 72 hours after covered accident. A charge must be incurred for the treatment. We will not pay the Accident Emergency
Treatment and the Accident Follow-Up Doctor Visit benefits for visits on the same day.
Accident Follow-Up Doctor Visit - $50, Maximum of three visits per covered person per covered accident
Benefit payable in the amount and up to the maximum number of visits for initial treatment more than 72 hours after the covered
accident or follow-up treatment (other than occupational or physical therapy) provided by a doctor in a doctor’
s office, urgent care
facility or emergency room for injuries received due to a covered accident. Treatment must begin within 60 days of the covered
accident, be completed with 365 days of the covered accident, not be for routine examination or preventative testing and a charge
must be incurred. We will not pay the Accident Emergency Treatment and the Accident Follow-Up Doctor Visit benefits for visits on
the same day.
Accidental Death - Named Insured $25,000 Spouse $25,000 Children $5,000
Benefit payable if a covered person is injured in a covered accident and the injury causes the covered person to die within 90 days
after the accident. If we pay this benefit, we will not pay the Accidental Death-Common Carrier benefit.
Accidental Death - Common Carrier - Named Insured $100,000 Spouse $100,000 Children $20,000
Benefit payable if, as the result of a covered accident, a covered person is injured while a fare-paying passenger on a common carrier
and the injury causes the covered person to die within 90 days after the accident. Common carrier means: commercial airplanes, trains,
buses, trolleys, subways, ferries and boats that operate on a regularly scheduled basis between predetermined points or cities. Taxis and
privately chartered vehicles are not common carriers. If we pay this benefit, we will not pay the Accidental Death benefit.
Accident 1.0-HS-O-AZ
1
Preferred with Health Screening 74115
Accidental Dismemberment (Loss of Finger, Toe, Hand, Foot or Sight of An Eye)
$750 Payable for loss of: one finger or one toe
$1,500 Payable for loss of: two or more fingers, or two or more toes or any combination of two or more fingers or toes.
$7,500 Payable for loss of: one hand, or one foot, or sight of one eye.
$15,000 Payable for loss of: both hands, or both feet, or the sight of both eyes, any combination of two or more hands, feet, or the
sight of an eye.
Benefit payable if the insured loses a finger, toe, hand, foot or sight of an eye within 90 days after the covered accident and a charge is
incurred, as the result of a covered accident. If the covered person loses a finger or toe and later loses a hand or foot on the same side
of the body as a result of the same covered accident, the amount paid for the loss of a finger or toe benefit will be subtracted from the
amount paid for the loss of a hand or foot. Loss of a hand means that the hand is cut off through or above the wrist joint or the use
of the hand is permanently lost. Loss of a foot means that the foot is cut off through or above the ankle joint or the use of the foot is
permanently lost. Loss of a finger means that the finger is cut off at the joint proximate to the first interphalangeal joint where it is
attached to the hand. Loss of a toe means that the toe is cut off at the joint proximate to the first interphalangeal joint where it is
attached to the foot. Loss of sight of an eye means that at least 80 percent of vision is permanently lost.
Air Ambulance - $2,000
Benefit payable if a licensed professional air ambulance company transports by air any covered person to or from a hospital or
between medical facilities for treatment for injuries received in a covered accident and a charge is incurred. Transportation must occur
within 48 hours after the covered accident.
Ambulance -$200
Benefit payable if a licensed professional ambulance company transports any covered person by ground transportation to or from a
hospital or between medical facilities for treatment for injuries received in a covered accident and a charge is incurred. Transportation
must occur within 90 days after the covered accident.
Appliance - $100
Benefit payable if, as the result of a covered accident, an appliance is prescribed by a doctor to aid in personal locomotion or mobility;
use must begin within 90 days after covered accident and a charge must be incurred. For purposes of this benefit, appliance means a
back brace, cane, crutches, leg brace, walker and wheelchair.
Blood/Plasma/Platelets - $300
Benefit payable if, as the result of a covered accident, a covered person requires the transfusion, administration, cross matching, typing
and processing of blood/plasma/platelets, they are administered within 90 days after the covered accident, and a charge is incurred.
Burn - Benefit payable if, as the result of a covered accident, a covered person is treated by a doctor within 72 hours after the accident
for burns as described below, and a charge must be incurred.
$1,000 - Second degree burns covering a total of at least 36% of the body surface
$2,000 - Third degree burns covering at least 9 square inches but less than 18 square inches
$4,000 - Third degree burns covering at least 18 square inches but less than 35 square inches
$12,000 - Third degree burns covering 35 or more square inches
Burn - Skin Graft - 50% of applicable burn benefit
Payable only for a skin graft for a burn for which a burn benefit was received under the policy and for which a charge is incurred.
Catastrophic Accident - payable once per lifetime per covered person
Accident Occurs:
Covered Person
Prior to the covered person’
s attaining age 65
Named Insured
Spouse
Child(ren)
After the covered person’
s attaining age 65 and
prior to the covered person’
s attaining age 70
After the covered person’
s attaining age 70
Accident 1.0-HS-O-AZ
Benefit Amount
$25,000
$25,000
$12,500
Named Insured
$12,500
Spouse
Child(ren)
$12,500
$6,250
Named Insured
Spouse
Child(ren)
$6,250
$6,250
$3,125
2
Preferred with Health Screening 74115
Benefit payable if any covered person sustains a catastrophic loss as the result of a covered accident and is under the appropriate care
of a doctor during the elimination period and remains alive at the end of the elimination period.
Catastrophic loss means an injury that within 365 days of the covered accident results in total and irrecoverable:
• Loss of both hands or both feet; or
• Loss of the sight of both eyes; or
• Loss or loss of use of both arms or both legs; or
• Loss of the hearing of both ears; or
• Loss of one hand and one foot; or
• Loss of the ability to speak.
• Loss or loss of use of one arm and one leg; or
For purposes of this benefit, the following definitions apply. Loss of a hand means that the hand is cut off through or above the wrist
joint. Loss of a foot means that the foot is cut off through or above the ankle joint. Loss of an arm means the arm is cut off above the
elbow. Loss of a leg means the leg is cut off above the knee. Loss of use of an arm means the loss of function of the entire arm from
the shoulder to the hand. Loss of use of a leg means the loss of function of the entire leg from the hip to the foot. Loss of sight of
both eyes means at least 80 percent of vision is permanently lost in both eyes, such that it cannot be corrected to any functional degree
by any procedure, aid or device. Loss of hearing of both ears means deafness in both ears, such that it cannot be corrected to any
functional degree by any procedure, aid or device. Loss of the ability to speak means loss of audible communication, such that it
cannot be corrected to any functional degree by any procedure, aid or device.
Elimination period means the period of 365 days after the date of a covered accident. The catastrophic accident benefit will be payable
once per lifetime for each covered person in this policy.
Coma - $10,000
Benefit payable if any covered person is diagnosed with or treated for a coma lasting for a period of at least seven consecutive days
resulting from a covered accident. The condition must require intubation for respiratory assistance, be diagnosed or treated by a
doctor within 90 days after the covered accident, and a charge must be incurred. For purposes of this benefit, coma means a
continuous state of profound unconsciousness characterized by the absence of eye opening, motor response and verbal response. The
term “coma”does not include any medically induced coma.
Concussion - $60
Benefit payable if any covered person sustains a concussion diagnosed by a doctor within 72 hours from date of covered accident as
the result of a covered accident and a charge is incurred.
Dislocation (Separated Joint)
Complete Dislocation of Joint
Hip
Knee (except patella)
Ankle - bone or bones of the foot (other than toes)
Collarbone (sternoclavicular)
Lower jaw, shoulder (glenohumeral), elbow, wrist
Bone or bones of the hand (other than fingers)
Collarbone (acromioclavicular and separation),
one toe or finger
Incomplete dislocation
Closed Reduction
(with Anesthesia)
$2,200
$1,100
$880
$550
$330
$330
$110
Open Reduction
(with Anesthesia)
$4,400
$2,200
$1,760
$1,100
$660
$660
$220
25% of applicable amount for closed reduction of joint involved or
dislocation reduction without anesthesia.
Benefit payable if, as the result of a covered accident, any covered person has a dislocation diagnosed by a doctor within 90 days after
the accident; reduction must require correction with anesthesia by a doctor, for which a charge is incurred. Benefit payable for more
than one dislocation (requiring open or closed reduction) is no more than two times the amount for the joint involved which has the
highest benefit amount. An incomplete dislocation is a dislocation in which the joint is not completely separated. Benefit payable only
for the first dislocation of a joint after the policy coverage effective date. Subsequent dislocations of the same joint after the policy
coverage effective date will not be covered under this benefit.
Emergency Dental Work - $300 - Broken tooth repaired with a crown, dentures or implant
$75 - Broken tooth resulting in extraction
The specified dental services must be required by a covered person as the result of injuries received in an accident, must begin within
60 days of the covered accident and a charge must be incurred for the services. Each Emergency Dental Work benefit is payable only
once per covered person per covered accident, regardless of the number of teeth involved.
Accident 1.0-HS-O-AZ
3
Preferred with Health Screening 74115
Eye Injury - $300
Benefit payable if, as the result of a covered accident, a covered person requires surgery on or the removal of a foreign object from the
eye by a doctor within 90 days after the covered accident and a charge is incurred. An examination with anesthesia will not be
considered surgery.
Fracture (Broken Bone)
Skull (except bones of face or nose)
depressed skull fracture
Skull (except bones of face or nose)
non-depressed skull fracture
Hip, thigh (femur)
Vertebrae, body of (excluding vertebral
processes), pelvis (except coccyx), leg
Bones of face or nose (except mandible or
maxilla)
Upper jaw, maxilla (except alveolar process),
upper arm between elbow and shoulder
Lower jaw, mandible (except alveolar process),
kneecap, foot (except toes), ankle
Shoulder blade, collarbone, vertebral processes,
forearm, hand, wrist (except fingers)
Rib
Coccyx
Finger, Toe
Chip Fracture
Closed reduction
$2,750
Open reduction
$5,500
$1,100
$2,200
$1,650
$825
$3,300
$1,650
$385
$770
$385
$770
$330
$660
$330
$660
$275
$550
$220
$440
$110
$220
25% of the applicable amount for closed reduction for the bone involved as
listed above.
Benefit payable if, as the result of a covered accident, a covered person has a fracture diagnosed by a doctor within 90 days after the
accident. The fracture must require open (surgical) or closed (non-surgical) reduction by a doctor, and a charge is incurred for the
reduction. Benefit payable for more than one fracture (open or closed reduction) is no more than two times the amount for the bone
involved which has the highest benefit amount. If a covered person has a fracture and a dislocation in a covered accident, maximum
benefit payable will be two times the amount for the bone or joint involved with the highest benefit amount. A chip fracture is a
fracture in which a piece of the bone is broken off near a joint at a place where a ligament is usually attached.
Health Screening - $50 per covered person per calendar year
Benefit payable once per calendar year for one of the health screening tests defined in this outline performed after the waiting period
and while coverage under the policy is in force. Health screening test is defined as: blood test for triglycerides, bone marrow testing,
breast ultrasound, CA 15-3 (blood test for breast cancer), CA125 (blood test for ovarian cancer), carotid doppler, CEA (blood test for
colon cancer), chest x-ray, colonoscopy, echocardiogram (ECHO), electrocardiogram (EKG, ECG), fasting blood glucose test, flexible
sigmoidoscopy, hemoccult stool analysis, mammography, pap smear, PSA (blood test for prostate cancer), serum cholesterol test to
determine level of HDL and LDL, serum protein electrophoresis (blood test for myeloma), stress test on a bicycle or treadmill, skin
cancer biopsy, thermography, ThinPrep pap test, virtual colonoscopy. Waiting Period means the first 30 days following any covered
person’
s policy coverage effective date during which time this benefit is not payable.
Home Health Services - $50 per day, Maximum of 30 days per covered person per covered accident
Benefit payable if a covered person receives treatment in the home as part of the home health services prescribed by a doctor in lieu of
hospital confinement for injuries received in a covered accident. The covered person must receive home health services within six
months after the covered accident.
We will pay this amount up to 30 days per covered accident.
Home health services shall be deemed in lieu of hospital confinement, regardless of any prior hospitalization, subject to the following:
• the home health services are prescribed by a doctor in place of what otherwise, out of medical necessity, would be hospital
inpatient care as certified by the prescribing doctor, and not for custodial care, and are reviewed and approved by a doctor at least
every 30 days; and
• the home health services are provided by a home health care agency licensed by the State Department of Health Services and
certified by the U.S. Department of Health and Human Services.
Accident 1.0-HS-O-AZ
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Preferred with Health Screening 74115
Hospital Admission - $1,000
Benefit payable if, as the result of a covered accident, a covered person is confined in a hospital within six months after the accident
and a charge is incurred. Payable once per covered accident. We will not pay this benefit for emergency room treatment, outpatient
treatment, or a stay of less than 20 hours in an observation unit. We will not pay the Hospital Admission benefit and the Hospital
Intensive Care Unit Admission benefit for the same covered accident.
Hospital Confinement - $225 per day up to 30 days per covered person per covered accident
Benefit payable if, as the result of a covered accident, a covered person is initially confined in a hospital or a hospital sub-acute
intensive care unit within six months after the covered accident, and a charge is incurred. We will not pay this benefit for emergency
room treatment, outpatient treatment, or confinement of less than 20 hours to an observation unit. We will not pay the Hospital
Confinement benefit and the Hospital Intensive Care Unit confinement benefit concurrently. If the covered person is confined in a
hospital intensive care unit for more than 15 days, the Hospital Confinement benefit will begin on the 16th day.
Hospital Intensive Care Unit Admission - $2,000 - one per covered person per covered accident
Benefit payable if, as the result of a covered accident, a covered person is admitted directly to a hospital intensive care unit within 30
days after the covered accident and a charge is incurred; payable once per covered accident. We will not pay this benefit for emergency
room treatment, outpatient treatment, or a stay of less than 20 hours in an observation unit. We will not pay the Hospital Intensive
Care Unit Admission benefit and the Hospital Admission benefit for the same covered accident.
Hospital Intensive Care Unit Confinement - $450 per day up to 15 days per covered person per covered accident
Benefit payable if, as the result of a covered accident, a covered person is confined to a hospital intensive care unit. Hospital intensive
care unit confinement must begin within 30 days after the accident, and a charge must be incurred. We will not pay the Hospital
Intensive Care Unit Confinement benefit and the Hospital Confinement benefit concurrently.
Knee Cartilage Torn - $500 - one per covered person per covered accident
Benefit payable if, as the result of a covered accident, a covered person is treated by a doctor for a torn knee cartilage within 60 days
after the covered accident. The torn knee cartilage must be repaired through surgery within 12 months after the covered accident, and
a charge must be incurred for the repair. If exploratory arthroscopic surgery is performed and no repair is done, or if the cartilage is
shaved (debridement), we will pay under the Surgery - Exploratory and Arthroscopic benefit.
Laceration
$60 - Total of all lacerations is less than two inches long (less than 5.08 centimeters) and repaired by stitches
$260 - Total of all lacerations is at least two but less than six inches long (5.08 to 15.23 centimeters) and repaired by stitches
$500 - Total of all lacerations is six inches or longer (15.24 centimeters or longer) and repaired by stitches
$30 - Laceration(s) with no repair
Benefit payable if, as the result of a covered accident, a covered person has a laceration that is repaired by a doctor within 72 hours
after the covered accident, and a charge must be incurred for the repair. If benefits are payable for a laceration on a finger, toe, hand,
foot or eye and the insured later loses that finger, toe, hand, foot, or eye as the result of the same covered accident, the amount we
paid under the Laceration benefit will be subtracted from the Accidental Dismemberment (Loss of a Finger, Toe, Hand, Foot or Sight
of an Eye) benefit.
Lodging - $125 per night up to 30 days per covered accident
Payable for a companion’
s motel/hotel stays during the period of time the covered person is confined to the hospital as the result of a
covered accident, and a charge is incurred. Hospital must be more than 50 miles from the residence of the covered person.
Medical Imaging Study - $150 payable once per covered person per covered accident and once per calendar year
Benefit payable if, as the result of a covered accident, a covered person receives one of the following imaging studies. Study must be
prescribed by a doctor and performed in an office or in a hospital on an inpatient or outpatient basis, and a charge must be incurred.
Studies include: Computed Tomography (CT) imaging or Computed Axial Tomography (CAT Scan), Electroencephalogram (EEG), or
Magnetic Resonance (MR) or Magnetic Resonance Imaging (MRI).
Occupational Or Physical Therapy - $25 per day up to 10 days per covered person per covered accident
Benefit payable if, as the result of a covered accident, a covered person requires occupational or physical therapy treatment. Therapy
must begin within 60 days after the covered accident and be completed within six months after the covered accident, and a charge
must be incurred. Must be prescribed by a doctor and rendered by a licensed physical or occupational therapist and performed in an
office or in a hospital on an inpatient or outpatient basis.
Accident 1.0-HS-O-AZ
5
Preferred with Health Screening 74115
Prosthetic Device/Artificial Limb
$500 - One prosthetic device or artificial limb
$1,000 - Two or more devices or artificial limbs.
Benefit payable if, as the result of a covered accident, a covered person requires a prosthetic device/artificial limb prescribed by a
doctor for functional use when the covered person loses a hand, foot, or sight of an eye. Must be received within one year of the
covered accident, and a charge must be incurred. This benefit is not payable for hearing aids, dental aids, including false teeth, eye
glasses or for cosmetic prosthesis such as hair wigs. We will not pay for joint replacement such as an artificial hip or knee.
Rehabilitation Unit Confinement - $100 per day, up to 15 days per covered person per covered accident, and a maximum of
30 days per calendar year
Benefit payable if, as the result of a covered accident, a covered person is transferred to a rehabilitation unit immediately after a period
of hospital confinement due to a covered accident, and a charge is incurred. We will not pay both the Rehabilitation Unit Confinement
benefit and the Hospital Confinement benefit concurrently.
Ruptured Disc - $500
Benefit payable if, as the result of a covered accident, a covered person receives a ruptured disc in his spine. The ruptured disc must
be treated by a doctor within 60 days after the covered accident and repaired through surgery within one year after the accident. A
charge must be incurred for the repair.
Surgery - Cranial, Open Abdominal and Thoracic - $1,500
Hernia - $150
Cranial, open abdominal and thoracic surgery benefit payable if as a result of a covered accident, a covered person undergoes cranial,
open abdominal or thoracic surgery other than hernia repair within 72 hours of a covered accident and a charge is incurred. Surgery
must be for repair of internal injuries. Hernia surgery benefit payable if, as the result of a covered accident, a covered person
undergoes hernia surgery. The hernia must be diagnosed within 30 days, and surgery must be performed within 60 days after the
covered accident. A charge must be incurred for the repair. If cranial, open abdominal or thoracic (other than hernia repair) surgery
and hernia surgery are performed as a result of the same covered accident, we will pay only the Cranial, Open Abdominal or Thoracic
benefit.
Surgery - Exploratory and Arthroscopic - $200
Payable if any covered person undergoes exploratory or arthroscopic surgery within 60 days of covered accident to explore or repair
injuries received as the result of a covered accident. Hernia repair is not covered under this benefit.
Tendon/Ligament/Rotator Cuff
$500 - Repair of one tendon, ligament or rotator cuff
$1,000 - Repair of two or more of the above.
Benefit payable if, as the result of a covered accident, a covered person receives a torn, ruptured or severed tendon/ligament/rotator
cuff. It must be treated by a doctor within 60 days, and repaired through surgery within one year after the covered accident, and a
charge must be incurred.
Transportation - $500 per round trip up to three round trips per covered person per covered accident
Benefit payable if, as the result of a covered accident, a covered person must travel more than 50 miles one way for special treatment
and confinement in a hospital, and a charge is incurred. Treatment must be prescribed by a doctor and not available locally. This
benefit is not payable for transportation by ambulance or air ambulance.
X-ray - $30
Payable if any covered person incurs a charge for and receives an x-ray as the result of a covered accident. The test must be prescribed
by a doctor and performed in a doctor’
s office or a hospital on an inpatient or outpatient basis and performed within 90 days of the
covered accident.
IMPORTANT WORDS IN THE POLICY
Accident means an unintended or unforeseen bodily injury sustained by a covered person, wholly independent of disease, bodily
infirmity, illness, infection, or any other abnormal physical condition.
Confined or Confinement means the assignment to a bed as a resident inpatient in a hospital on the advice of a doctor or
confinement in an observation unit within a hospital for a period of no less than 20 continuous hours on the advice of a doctor.
A Covered Accident is an accident which: occurs on or after the effective date of the policy; occurs while the policy is in force; is of
the Accident Type listed on the Policy Schedule page; and is not excluded by name or specific description in the policy.
Accident 1.0-HS-O-AZ
6
Preferred with Health Screening 74115
A Doctor or Physician means a person who: is licensed by the state to practice a healing art; and performs services for a covered
person which are allowed by his license. Doctor or physician does not include any covered person or anyone related to any covered
person by blood or marriage, a business or professional partner of any covered person, or any person who has a financial affiliation or
a business interest with any covered person.
An Emergency Room is a specified area within a hospital that is designated for the emergency care of accidental injuries. This area
must: be staffed and equipped to handle trauma; be supervised and provide treatment by doctors; and provide care seven days per
week, 24 hours per day.
A Hospital means a place which: is run according to law on a full-time basis; provides overnight care of injured and sick people; is
supervised by a doctor; has full-time nurses supervised by a registered nurse; and has at its locations or uses on a pre-arranged basis:
X- ray equipment, a laboratory and an operating room where surgical operations take place.
Notwithstanding the above, a hospital is not: a nursing home; an extended care facility; a skilled nursing facility; a rest home or home
for the aged; a rehabilitation center; a place for alcoholics or drug addicts; or an assisted living facility.
A Hospital Intensive Care Unit means a place which: is a specifically designated area of the hospital called an intensive care unit
that provides the highest level of medical care and is restricted to patients who are critically ill or injured and who require intensive
comprehensive observation and care; is separate and apart from the surgical recovery room and from rooms, beds and wards
customarily used for patient confinement; is permanently equipped with special lifesaving equipment for the care of the critically ill or
injured; is under constant and continuous observation by a specially trained nursing staff assigned exclusively to the intensive care unit
on a 24 hour basis; and has a doctor assigned to the intensive care unit on a full-time basis.
A hospital intensive care unit is not any of the following step down units: a progressive care unit; an intermediate care unit; a private
monitored room; sub-acute intensive care unit; an observation unit; or any facility not meeting the definition of a hospital intensive
care unit as defined in the policy.
A Hospital Sub-Acute Intensive Care Unit means a place which: is a specifically designated area of the hospital that provides a
level of medical care below intensive care, but above a regular private or semi-private room or ward; is separate and apart from the
surgical recovery room and from rooms, beds and wards customarily used for patient confinement; is permanently equipped with
special lifesaving equipment for the care of the critically ill or injured; and is under constant and continuous observation by a specially
trained nursing staff.
A hospital sub-acute intensive care unit may be referred to by other names such as progressive care, intermediate care, or a step-down
unit, but it is not a regular private or semi-private room, or a ward with or without monitoring equipment.
An Injury means a wound to a covered person’
s body that is caused solely by or is the result of a covered accident.
An Observation Unit is a specified area within a hospital, apart from the emergency room, where a patient can be monitored
following outpatient surgery or treatment in the emergency room by a doctor; and which: is under the direct supervision of a doctor or
registered nurse; is staffed by nurses assigned specifically to that unit; and provides care seven days per week, 24 hours per day.
An Occupational Therapist is a person, who: possesses the designation “Occupational Therapist Registered (OTR);”is licensed by
the state to practice occupational therapy; performs services which are allowed by his license and performs services for which benefits
are provided by the policy. For purposes of this definition, occupational therapist does not include any covered person or anyone
related to any covered person by blood or marriage.
An Off-Job Accident means an accident that occurs while a covered person is not working at any job for pay or benefits.
An On-Job Accident means an accident that occurs while a covered person is working at any job for pay or benefits.
A Physical Therapist is a person who: is licensed by the state to practice physical therapy; performs services which are allowed by his
license; performs services for which benefits are provided by the policy; and practices according to the Code of Ethics of the
American Physical Therapy Association. For purposes of this definition, physical therapist does not include any covered person or
anyone related to any covered person by blood or marriage.
A Rehabilitation Unit means an appropriately licensed facility that provides rehabilitation care services on an inpatient basis.
Rehabilitation care services consist of the combined use of medical, social, educational, and vocational services to enable patients
disabled by accidental injury to achieve the highest possible functional ability. Services are provided by or under the supervision of an
organized staff of physicians. The rehabilitation unit may be part of a hospital or a freestanding facility. A rehabilitation unit is not a
nursing home, an extended care facility, a skilled nursing facility, a rest home or home for the aged, a hospice care facility, a place for
alcoholics or drug addicts, or an assisted living facility.
An Urgent Care Facility means a place other than a doctor’
s office, hospital or emergency room that provides emergency care and
treatment for injured people.
WHAT IS NOT COVERED BY THE POLICY
We will not pay benefits for losses that are caused by or are the result of any covered person’
s:
• engaging in hang-gliding, bungee jumping, parachuting, sailgliding, parasailing, parakiting, jumping, parachuting, or falling from
any aircraft or hot air balloon, including those which are not motor-driven or any similar activities.
• committing or attempting to commit a felony or engaging in an illegal occupation.
• riding in or driving any motor-driven vehicle in a race, stunt show or speed test.
• being intoxicated or under the influence of any narcotic unless administered on the advice of a physician.
Accident 1.0-HS-O-AZ
7
Preferred with Health Screening 74115
•
•
•
•
practicing for or participating in any semi-professional or professional competitive athletic contests for which any type of
compensation or remuneration is received.
having any sickness or declining process caused by a sickness, including physical or mental infirmity. We also will not pay benefits
to diagnose or treat the sickness. Sickness means any illness, infection, disease or any other abnormal physical condition which is
not caused by an injury.
committing or trying to commit suicide or his injuring himself intentionally, whether he is sane or not.
being exposed to war or any act of war, declared or undeclared, or serving in the armed forces of any country or authority. Losses
as a result of acts of terrorism or nuclear release committed by individuals or groups will not be excluded from coverage unless
the covered person who suffered the loss committed the act of terrorism or nuclear release.
In addition to the exclusions listed above, we also will not pay the Catastrophic Accident benefit for injuries that are caused
by or are the result of:
• injuries to a dependent child received during his birth.
Accident 1.0-HS-O-AZ
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Preferred with Health Screening 74115
Attachment 3
Accident 1.0 Flyer
Accident Insurance
Accidents happen in places where you and your family spend
the most time – at work, in the home and on the playground – and
they’re unexpected. How you care for them shouldn’t be.
In your lifetime, which of these accidental injuries have happened to you or someone you know?
l
l
Sports-related accidental injury
Broken bone
Burn
Concussion
Laceration
l
Back or knee injuries
l
l
l
l
Car accidents
l Falls & spills
l Dislocation
l Accidental injuries that send you
to the Emergency Room, Urgent Care
or doctor’s office
Accident 1.0­-Preferred with Health Screening Benefit-AZ
Colonial Life’s Accident Insurance is designed to help you fill some of the gaps caused by increasing deductibles,
co-payments and out-of-pocket costs related to an accidental injury. The benefit to you is that you may not need
to use your savings or secure a loan to pay expenses. Plus you’ll feel better knowing you can have greater financial
security.
What additional features are
included?
l
Worldwide coverage
l
Portable
l
Compliant with Healthcare Spending
Account (HSA) guidelines
Will my accident claim
payment be reduced if I have
other insurance?
You’re paid regardless of any other insurance you
may have with other insurance companies, and the
benefits are paid directly to you (unless you specify
otherwise).
What if I change employers?
If you change jobs or leave your employer, you can
take your coverage with you at no additional cost.
Your coverage is guaranteed renewable as long as
you pay your premiums when they are due or within
the grace period.
Can my premium change?
Colonial Life can change your premium only if we
change it on all policies of this kind in the state
where your policy was issued.
How do I file a claim?
Visit coloniallife.com or call our Customer Service
Department at 1.800.325.4368 for additional
information.
Benefits listed are for each covered person per covered accident unless otherwise specified.
Initial Care
l
Accident Emergency Treatment........... $125
l
Ambulance........................................$200
l
X-ray Benefit................................................... $30
lAir
Ambulance.............................. $2,000
Common Accidental Injuries
Dislocations (Separated Joint)
Hip
Knee (except patella)
Ankle – Bone or Bones of the Foot (other than Toes)
Collarbone (Sternoclavicular)
Lower Jaw, Shoulder, Elbow, Wrist
Bone or Bones of the Hand
Collarbone (Acromioclavicular and Separation)
One Toe or Finger
Fractures
Depressed Skull
Non-Depressed Skull
Hip, Thigh
Body of Vertebrae, Pelvis, Leg
Bones of Face or Nose (except mandible or maxilla)
Upper Jaw, Maxilla
Upper Arm between Elbow and Shoulder
Lower Jaw, Mandible, Kneecap, Ankle, Foot
Shoulder Blade, Collarbone, Vertebral Process
Forearm, Wrist, Hand
Rib
Coccyx
Finger, Toe
Non-Surgical
Surgical
$2,200
$1,100
$880
$550
$330
$330
$110
$110
$4,400
$2,200
$1,760
$1,100
$660
$660
$220
$220
Non-Surgical
Surgical
$2,750
$1,100
$1,650
$825
$385
$385
$385
$330
$330
$330
$275
$220
$110
$5,500
$2,200
$3,300
$1,650
$770
$770
$770
$660
$660
$660
$550
$440
$220
Your Colonial Life policy also provides benefits for the following injuries received as a result of a covered accident.
l
Burn (based on size and degree).....................................................................................$1,000 to $12,000
l
Coma..............................................................................................................................................................$10,000
l
Concussion.......................................................................................................................................................... $60
Emergency Dental Work........................................$75 Extraction, $300 Crown, Implant, or Denture
l Lacerations (based on size)............................................................................................................$30 to $500
l
Requires Surgery
l
Eye Injury............................................................................................................................................................$300
l
Tendon/Ligament/Rotator Cuff...........................................................$500 - one, $1,000 - two or more
l
Ruptured Disc...................................................................................................................................................$500
l
Torn Knee Cartilage........................................................................................................................................$500
Surgical Care
Surgery (cranial, open abdominal or thoracic)................................................................................. $1,500
l
l
Surgery (hernia)...............................................................................................................................................$150
l
Surgery (arthroscopic or exploratory).....................................................................................................$200
l
Blood/Plasma/Platelets.................................................................................................................................$300
Transportation/Lodging Assistance
If injured, covered person must travel more than 50 miles from residence to receive special treatment
and confinement in a hospital.
Transportation..............................................................................$500 per round trip up to 3 round trips
l
Lodging (family member or companion)................................................$125 per night up to 30 days for
a hotel/motel lodging costs
l
Accident Hospital Care
Hospital Admission*......................................................................................................... $1,000 per accident
l
Hospital ICU Admission*................................................................................................. $2,000 per accident
* We will pay either the Hospital Admission or Hospital Intensive Care Unit (ICU) Admission, but not both.
l
l
Hospital Confinement.......................................................................................$225 per day up to 30 days
l
Hospital ICU Confinement ....................................................$450 per day up to 15 days per accident
Accident Follow-Up Care
l
Accident Follow-Up Doctor Visit........................................................... $50 (up to 3 visits per accident)
Medical Imaging Study.......................................................................................................$150 per accident
(limit 1 per covered accident and 1 per calendar year)
l
l
Occupational or Physical Therapy...................................................... $25 per treatment up to 10 days
l
Appliances ........................................................................................... $100 (such as wheelchair, crutches)
l
Prosthetic Devices/Artificial Limb .....................................................$500 - one, $1,000 - more than 1
Rehabilitation Unit..................................................$100 per day up to 15 days per covered accident,
and 30 days per calendar year.
Maximum of 30 days per calendar year
l
l
Home Health Services.......$50 per day up to 30 days per covered person per covered accident
Accidental Dismemberment
l
Loss of Finger/Toe..................................................................................$750 – one, $1,500 – two or more
l
Loss or Loss of Use of Hand/Foot/Sight of Eye......................$7,500 – one, $15,000 – two or more
Catastrophic Accident
For severe injuries that result in the total and irrecoverable:
l
Loss of one hand and one foot
l
Loss of the sight of both eyes
l
Loss of both hands or both feet
l
Loss of the hearing of both ears
l
Loss or loss of use of one arm and one leg or
l
Loss of the ability to speak
l
Loss or loss of use of both arms or both legs
Named Insured................. $25,000Spouse...............$25,000Child(ren)..........$12,500
365-day elimination period. Amounts reduced for covered persons age 65 and over.
Payable once per lifetime for each covered person.
Accidental Death
Accidental Death
Common Carrier
l
Named Insured
$25,000
$100,000
l
Spouse
$25,000
$100,000
l
Child(ren)
$5,000
$20,000
Health Screening Benefit
l
$50 per covered person per calendar year
Provides a benefit if the covered person has one of the health screening tests performed.
This benefit is payable once per calendar year per person and is subject to a 30-day waiting period.
Tests include:
l.
Blood test for triglycerides
l.
Hemoccult stool analysis
l.
Bone marrow testing
l.
Mammography
l.
Breast ultrasound
l.
Pap smear
l.
CA 15-3 (blood test for breast cancer)
l.
PSA (blood test for prostate cancer)
l.
CA125 (blood test for ovarian cancer)
l.
l.
Carotid doppler
Serum cholesterol test to determine level of HDL and LDL
l.
CEA (blood test for colon cancer)
l.
l.
Chest x-ray
Serum protein electrophoresis
(blood test for myeloma)
Colonoscopy
l.
l.
Stress test on a bicycle or treadmill
Echocardiogram (ECHO)
l.
l.
Skin cancer biopsy
Electrocardiogram (EKG, ECG)
l.
l.
Thermography
Fasting blood glucose test
l.
l.
ThinPrep pap test
Flexible sigmoidoscopy
l.
l.
Virtual colonoscopy
My Coverage Worksheet (For use with your Colonial Life benefits counselor)
Who will be covered? (check one)
Employee Only Spouse Only One-Parent Family, with Spouse
Employee & Spouse
Two-Parent Family
When are covered accident benefits available? (check one)
On and Off -Job Benefits Off -Job Only Benefits
We will not pay benefits for losses that are caused by or are the result of: intoxicants and narcotics; hazardous
avocations; felonies or illegal occupations; racing; semi-professional or professional sports; sickness; suicide or
self-inflicted injuries; war or armed conflict; in addition to the exclusions listed above, we also will not pay the
Catastrophic Accident benefit for injuries that are caused by or are the result of: birth.
For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form Accident 1.0-HS-AZ.
This is not an insurance contract and only the actual policy provisions will control.
Colonial Life
1200 Colonial Life Boulevard
Columbia, South Carolina 29210
coloniallife.com
10/11
©2011 Colonial Life & Accident Insurance Company.
Colonial Life products are underwritten by Colonial Life & Accident
Insurance Company, for which Colonial Life is the marketing brand.
Colonial Life and Making benefits count are registered service marks
of Colonial Life & Accident Insurance Company.
74252-2
Accident 1.0­-Preferred with Health Screening Benefit-AZ
One-Parent Family, with Employee
One Child Only
Attachment 4
Cancer 1000 Benefit Summary
Cancer 1000
Colonial's Cancer 1000 insurance helps employees and their families maintain financial security
in the event of a cancer diagnosis. Employees can choose from four levels of coverage amounts.
Employee; Employee and Dependent Children; and Employee, Spouse, and Dependent Children
plans are available.
Benefits
Base
Level 1
Level 2
Level 3
Level 4
Cancer Screening Benefits
Part I. Cancer Screening/Wellness Benefit per calendar
year
Part II. Additional Invasive Diagnostic Test or Surgical
Benefit per calendar year
$25
$75
$100
$125
$25
$75
$100
$125
$1,000
$1,000
$1,000
$1,000
Ambulance per trip limit 2 trips per confinement
Anesthesia-Benefit for General is 25% of Surgical
Procedures
$200
$200
$200
$200
Per procedure for local anesthesia
Antinausea Medication per day administered or per
prescription filled
$25
$30
$40
$50
$20
$40
$50
$60
$80
$160
$200
$240
$200
$200
$200
$200
Bone Marrow Stem Cell Transplant per lifetime
Bone Marrow Stem Cell Donation Benefit
per lifetime
Companion Transportation ($ per mile) up to $1,500
per round trip
Experimental Treatment per day up to $10,000 per
lifetime
$10,000
$10,000
$10,000
$10,000
$1,000
$1,000
$1,000
$1,000
0.50
0.50
0.50
0.50
$300
$300
$300
$300
Family Care per day
Hair/External Breast/Voice Box Prosthesis per calendar
year
Home Health Care Services per day up to greater of 30
days/calendar year or
2 times the days confined to hospital
$60
$60
$60
$60
$200
$200
$200
$200
$75
$75
$75
$75
Cancer Benefits
Air Ambulance per trip limit 2 trips per confinement
Maximum per month
Blood/Plasma/Platelets/Immunoglobulins per day up to
$10,000 per cal year
Hospice per day, no lifetime limit
Hospital Confinement, Days 1-30,
benefit per day
$70
$70
$70
$70
$100
$200
$300
$400
Hospital Confinement, Days 31+, benefit per day
$200
$400
$600
$800
Cancer 1000 Available in AZ
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing
brand.
2008 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210
PS00708
Hospital Confinement in a US Government Hospital
Days 1-30, benefit per day
Hospital Confinement in a US Government Hospital
Days 31+, benefit per day
$100
$200
$300
$400
$200
$400
$600
$800
Lodging per day up to 70 days per calendar year
Medical Imaging Studies per study, $500 calendar year
max
$75
$75
$75
$75
$250
$250
$250
$250
Outpatient Surgical Center per day
$200
$200
$300
$400
Calendar year maximum
$600
$600
$900
$1,200
Peripheral Stem Cell Transplant lifetime maximum
$5,000
$5,000
$5,000
$5,000
$150
$150
$150
$150
$3,000
$3,000
$3,000
$3,000
$100
$200
$300
$300
Self Injected
$800
$1,600
$2,400
$2,400
Pump
$400
$800
$1,200
$1,200
Topical
$400
$800
$1,200
$1,200
Oral
$400
$800
$1,200
$1,200
Any Other Method Not Listed
$400
$800
$1,200
$1,200
$40
$40
$60
$60
$2,500
$2,500
$3,000
$3,000
$300
$300
$300
$300
$100
$100
$100
$100
$300
$300
$300
$300
$50
$100
$150
$200
$400
$800
$1,200
$1,600
$40
$50
$60
$70
$2,500
$3,000
$5,000
$6,000
0.50
0.50
0.50
0.50
Yes
Yes
Yes
Yes
Private Full Time Nursing Services per day
Prosthesis/Artificial Limb per device, limit 1 per site,
$6,000 lifetime
Radiation/Chemotherapy per day
(no monthly limit for chemotherapy
injected or radiation delivered by medical
personnel)
Monthly Maximum
Reconstructive Surgery per unit value
Maximum per procedure for Surgery and
Anesthesia,
limit 2 per site
Second Medical Opinion
limit once per malignant condition
Skilled Nursing Care Facility per day up to days
confined in hospital
Skin Cancer Initial Diagnosis
once per lifetime
Supportive or Protective Care Drugs &
Colony Stimulating Factors
per day
calendar year maximum
Surgical Procedures-Unit Value
maximum per procedure
Transportation (per mile) up to $1,500 per
trip
Waiver of Premium
Cancer 1000 Available in AZ
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing
brand.
2008 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210
PS00708
Optional Riders
A choice of optional riders is available and can be purchased at an additional cost to provide extra
coverage and benefits.
Specified Disease
• Paid for hospital confinement for covered specified diseases.
• $300 per day when hospitalized
• $125,000 lifetime maximum
The specified diseases covered under this rider are:
Adrenal Hypofunction
(Addison’s Disease)
Botulism
Bubonic Plague
Cerebral Palsy
Cholera
Cystic Fibrosis
Diphtheria
Encephalitis, including
Encephalitis contracted
from West Nile Virus.
Huntington’s Chorea
Legionnaires Disease
Lou Gehrig’s Disease
(Amyotrophic Lateral
Sclerosis)
Lyme Disease
Malaria
Meningitis (bacterial)
Multiple Sclerosis
Muscular Dystrophy
Myasthenia Gravis
Necrotizing Fasciitis
Osteomyelitis
Poliomyelitis
Rabies
Reye’s Syndrome Scleroderma
Scarlet Fever
Sickle Cell Anemia Systemic
Lupus
Tetanus
Toxic Epidermal Necrolysis
Toxic Shock Syndrome
Tuberculosis (Mycobacterial)
Tularemia
Typhoid Fever
Variant Creutzfeldt- Jakob Disease
(Mad Cow)
Yellow Fever
Initial Diagnosis
• Paid for the first diagnosis of internal (not skin) cancer.
• Available in $1,000 units from $1,000 - $5,000
• Pays 1.5 times amount for children on family coverage.
Progressive Payment
• Paid for the first diagnosis of internal (not skin) cancer. The progressive payment
accumulates $50 per month for each month the policy has been in force.
• Issue age for Progressive Payment rider is 17-64.
Cancer 1000 Available in AZ
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing
brand.
2008 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210
PS00708
Features
•
•
•
•
•
•
•
Benefits are paid directly to the insured unless they specify otherwise.
Benefits are paid in addition to other insurance your employees may have with other
insurance companies.
The policy is guaranteed renewable.
Coverage is portable. An employee can take this coverage with him if he changes jobs or
leaves your company.
The spouse may be listed as the primary insured on a Cancer policy if the employee is not
eligible for coverage
Cancer 1000 coverage offers innovative benefits to help address current treatment costs for
the care of cancer
All eligible applicants in an account have the same premium, regardless of risk class or age
Eligibility Requirements
•
•
•
•
Issue ages 17-69 for both the employee and spouse.
The employee must be permanent and full time working 20 hours per week.
The employee must be actively at work at the time of application.
Dependent children (as defined in the policy).
Participation Requirements
To offer this plan, we require only 3 eligible participants apply.
Premium Information
•
•
•
•
Premiums are based on level of coverage chosen.
Premium levels are available for Employee; Employee and Dependent Children; and
Employee, Spouse and Dependent Children plans.
Premiums are not age banded.
Premiums are not based on occupational risk
Cancer 1000 Available in AZ
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing
brand.
2008 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210
PS00708
Sample Monthly Premiums
Coverage Description
Employee coverage without Optional riders
Employee and Dependent Children coverage
with Progressive Payment Rider
Employee, Spouse and Dependent Children
coverage with $5,000 Initial Diagnosis Rider
Level
1
3
Monthly Premium
3
$58.00
$12.25
$35.85
Definitions
Cancer: means a disease which is identified by the presence of malignant cells or a malignant
tumor characterized by the uncontrolled and abnormal growth and spread of invasive malignant
cells. Pre-malignant conditions or conditions with malignant potential are not defined as cancer.
Skin Cancer: means melanoma of Clark’s level I or II (Breslow less than .75mm); basal cell
carcinoma; or squamous cell carcinoma of the skin.
Pre-existing condition: means a condition for which the insured received medical advice, was
given treatment, or treatment was recommended by or received from a doctor within six months
immediately preceding the effective date of this policy and which is not excluded by name or
specific description in this policy.
What is Not Covered
• If cancer is not pathologically or clinically diagnosed until after death, we will pay benefits
for the treatment of cancer or specified disease (if applicable) performed during the forty-five
day period before death.
• We will not pay the Reconstructive Surgery Benefit for melanoma diagnosed as Clarks Level
I or II or Breslow less than .75 mm.
• We will not cover cancer which is a pre-existing condition during the first six months after the
effective date of coverage.
Cancer 1000 Available in AZ
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing
brand.
2008 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210
PS00708
Attachment 5
Cancer 1000 Flyer
Cancer Insurance
If diagnosed with cancer,
how will you pay for what your health insurance won’t?
The risk of developing cancer, unfortunately, is very real.
Nearly everyone has experienced or knows somebody who has experienced a cancer diagnosis in their family.
The good news is that cancer screenings and cancer-fighting technologies have gotten a lot better in recent years.
However, with advanced technology come high costs. Major medical health insurance is a great start, but even with
this essential safety net, cancer sufferers can still be hit with unexpected medical and non-medical expenses.
Cancer coverage from Colonial Life offers the protection
you need to concentrate on what is most important — your care.
Features of Colonial Life’s Cancer Insurance:
1. Pays benefits to help with the cost of cancer screening and cancer treatment.
2. Provides benefits to help pay for the indirect costs associated with cancer, such as:
l
Loss of wages or salary
and coinsurance
Travel expenses to and from treatment centers
Lodging and meals
Child care
l Deductibles
l
l
l
3. Pays regardless of any other insurance you have with other insurance companies.
4. Provides a cancer screening benefit that you can use even if you are never diagnosed with cancer.
5. Guaranteed renewable as long as premiums are paid when due.
Cancer 1000-No waiting
6. Benefits paid directly to you unless you specify otherwise.
7. You can take your coverage with you even if you change jobs or leave your employer.
8. Flexible coverage options for employees and their families.
This is a brief description of some available
benefits.
Treatment Benefits (In-or Outpatient)
Radiation/Chemotherapy
Antinausea Medication
l Blood/Plasma/Platelets/Immunoglobulins
l Experimental Treatment
l Hair Prosthesis/External Breast/Voice Box Prosthesis
l Supportive/Protective Care Drugs and Colony
Stimulating Factors
l Medical Imaging Studies
l Bone Marrow Stem Cell Transplant
l Peripheral Stem Cell Transplant
l
l
We will pay benefits if certain routine cancer
screening tests are performed or if cancer is
diagnosed while your policy is in force.
Cancer Screening Benefit Tests
l
Pap Smear
ThinPrep Pap Test 1
l CA125 (Blood test for ovarian cancer)
l Mammography
l Breast Ultrasound
l CA 15-3 (Blood test for breast cancer)
l PSA (Blood test for prostate cancer)
l Chest X-ray
l Biopsy of Skin Lesion
l Colonoscopy
l Virtual Colonoscopy
l Hemoccult Stool Analysis
l Flexible Sigmoidoscopy
l CEA (Blood test for colon cancer)
l Bone Marrow Aspiration/Biopsy
l Thermography
l Serum Protein Electrophoresis
(Blood test for Myeloma)
l
Transportation/Lodging Benefits
l
Transportation
Companion Transportation
l Lodging
l
Surgical Procedures Benefits
Surgical Procedures (including skin cancer)
Anesthesia (including skin cancer)
l Second Medical Opinion
l Reconstructive Surgery
l Prosthesis/Artificial Limb
l Outpatient Surgical Center
l
l
Extended Care Benefits
To file a claim for a Cancer Screening Benefit test, it is not
necessary to complete a claim form. Call our toll-free Customer
Service number, 800.325.4368, with the medical information.
l
Family Care
Hospice
l Home Health Care Service
l Waiver of Premium
l
Additional Invasive Diagnostic Procedure
If abnormal results are received from a Cancer Screening
Benefit test.
Inpatient Benefits
Hospital Confinement
l Ambulance
l Air Ambulance
l Private Full-Time Nursing Services
Cancer 1000-No waiting
l
Initial Diagnosis of Skin Cancer
We will pay this benefit for the first diagnosis of skin cancer.
THIS IS A CANCER ONLY POLICY.
This policy has exclusions and limitations. For cost and
complete details of the coverage, see your Colonial Life
benefits counselor. Coverage may vary by state and may not
be available in all states. Applicable to policy form C1000
(and state abbreviations where used).
ThinPrep is a registered trademark of Cytyc Corporation.
1
Colonial Life
1200 Colonial Life Boulevard
Columbia, South Carolina 29210
coloniallife.com
5/11
©2011 Colonial Life & Accident Insurance Company.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company,
for which Colonial Life is the marketing brand.
Colonial Life and Making benefits count are registered service marks of Colonial Life &
Accident Insurance Company.
61599-4
Attachment 6
Specified Critical Illness Outline of Coverage
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY
1200 Colonial Life Boulevard, P.O. Box 1365, Columbia, South Carolina 29202
1.800.325.4368 www.coloniallife.com
A Stock Company
LIMITED BENEFIT HEALTH COVERAGE FOR SPECIFIED CRITICAL ILLNESS
OUTLINE OF COVERAGE (Applicable to Policy Form CI-1.0-AZ)
PRE-EXISTING CONDITIONS - PLEASE READ CAREFULLY
If you received treatment, testing or medical advice or took medication for a sickness or physical condition within 12 months before
the effective date of this policy, we will not pay a benefit for a Specified Critical Illness that occurs as a result of that sickness or
physical condition if the Specified Critical Illness has a Date of Diagnosis within the first 12 months after the effective date of the
policy.
THE POLICY IS NOT A MEDICARE SUPPLEMENT POLICY. If you are eligible for Medicare, review the Guide to
Health Insurance for People with Medicare available from the Company.
Please Read The Policy Carefully. This outline provides a very brief description of the important features of the policy. This is not
an insurance contract and only the actual policy provisions will control. The policy sets forth in detail the rights and obligations of
both you and us. It is, therefore, important to READ THE POLICY CAREFULLY.
Guaranteed Renewable Subject to Payment of the Maximum Benefit Amount for Specified Critical Illness. The policy is
guaranteed renewable as long as you pay the premiums when they are due or within the grace period, up to the date of payment of the
Maximum Benefit Amount for Specified Critical Illness as shown on the Policy Schedule. Your premium can be changed only if we
change it on all policies of this kind in force in the state where the policy was issued.
Coverage Provided by The Policy. The policy is designed to provide coverage ONLY for Specified Critical Illnesses and for certain
health screening tests, subject to any limitations or exclusions in your policy. It does not provide coverage for basic hospital, basic
medical-surgical or major medical expenses.
The policy provides benefits only if the Date of Diagnosis of Specified Critical Illness or the performance of a health screening test or
Cancer Vaccine is while your policy is in force. Any health screening test or Cancer Vaccine performed before the Policy Coverage
Effective Date will not be covered.
Premiums vary depending on the amount of coverage you chose at time of application.
The amount of coverage you chose is shown on the Policy Schedule.
BENEFITS
Specified Critical Illness Benefit
Face Amount for Named Insured
Face Amount for Spouse (if covered)
Face Amount for Dependent Children (if covered)
$_____________
50% of face amount for Named Insured
25% of face amount for Named Insured
The Face Amount(s) and the Maximum Benefit Amount for Specified Critical Illness will reduce by 50% on the first Policy
Anniversary Date after the named insured attains age 75.
We will pay this benefit if a covered person is diagnosed with one of the Specified Critical Illnesses shown below if: the Date of
Diagnosis is while coverage under the policy is in force; and the Specified Critical Illness is not excluded by name or specific
description in the policy.
CI-1.0-O-AZ
1
CI With Cancer, Subsequent Diagnosis, Health Screening (HSA)
PL10
72984
Cancer
Heart Attack (Myocardial Infarction)
Stroke
End Stage Renal (Kidney) Failure
Major Organ Failure
Permanent Paralysis due to a Covered Accident
Coma
Blindness
Occupational Infectious HIV or Occupational Infectious Hepatitis B, C or D
Coronary Artery Disease
Carcinoma in Situ
100%
100%
100%
100%
100%
100%
100%
100%
100%
25%
25%
Maximum Benefit Amount for Specified Critical Illness: $_____________
We will pay the percentage of the Face Amount shown on the Policy Schedule for the Specified Critical Illness diagnosed, up to the
Maximum Benefit Amount for Specified Critical Illness shown on the Policy Schedule.
We will pay the benefit for Coronary Artery Disease only once per lifetime per covered person.
If, on the same day, a covered person is placed on the UNOS list for a transplant of two or more major organs listed in the definition
of Major Organ Failure (example: heart and lungs), a single benefit will be paid.
We will pay the benefit for Occupational Infectious HIV or Occupational Infectious Hepatitis B, C or D only once per lifetime per
covered person.
We will pay the benefit for Carcinoma in Situ only once per lifetime per covered person.
We will pay the benefit for Cancer only once per lifetime per covered person.
If the Date of Diagnosis of two or more Specified Critical Illnesses is the same day, we will pay only one Specified Critical Illness
benefit. We will pay the larger of the Specified Critical Illness benefits.
No benefits are payable for conditions other than the Specified Critical Illnesses defined in the policy.
Benefits Payable Upon Subsequent Diagnosis.
If a covered person has been diagnosed with and received a benefit for a Specified Critical Illness and is subsequently diagnosed with
a different Specified Critical Illness, we will pay the Specified Critical Illness benefit as shown on the Policy Schedule, up to the
Maximum Benefit Amount for Specified Critical Illness, if: the Date of Diagnosis of the subsequent Specified Critical Illness is more
than 180 days after any previous Date of Diagnosis for a Specified Critical Illness; and the subsequent Date of Diagnosis is while
coverage under this policy is in force; and the Specified Critical Illness is not excluded by name or specific description in this policy.
If a covered person has been diagnosed with and received a benefit for a Specified Critical Illness and is subsequently diagnosed with
the same Specified Critical Illness (other than Coronary Artery Disease, Cancer, Carcinoma in Situ, and Occupational Infectious HIV
or Occupational Infectious Hepatitis B, C or D), we will pay an amount equal to 25% of the Face Amount for the covered person as
shown on the Policy Schedule, up to the Maximum Benefit Amount for Specified Critical Illness, if: the Date of Diagnosis of the
subsequent Specified Critical Illness is more than 180 days after any previous Date of Diagnosis for the same Specified Critical Illness;
and the covered person has not received treatment during the 180 days between the Dates of Diagnosis for the same Specified Critical
Illness. For purposes of the preceding sentence, treatment does not include medications and follow-up visits to the covered person’
s
Doctor; the subsequent Date of Diagnosis is while coverage under this policy is in force; and the Specified Critical Illness is not
excluded by name or specific description in this policy.
We will not pay more than the Maximum Benefit Amount for Specified Critical Illness as shown on the Policy Schedule.
This policy will terminate when the Maximum Benefit Amount for Specified Critical Illness as shown on the Policy Schedule has been
paid.
CI-1.0-O-AZ
2
CI With Cancer, Subsequent Diagnosis, Health Screening (HSA)
PL10
72984
Benefit Reduction
The Face Amount(s) and the Maximum Benefit Amount for Specified Critical Illness will reduce by 50% on the first Policy
Anniversary Date after the named insured attains age 75. All Specified Critical Illness benefits payable after that date will be based on
the reduced Face Amount and the reduced Maximum Benefit Amount.
Cancer Vaccine Benefit
Amount: $50
We will pay this benefit if a covered person incurs a charge for and receives any cancer vaccine that is FDA approved for the
prevention of Cancer. The vaccine must be administered by licensed medical personnel while coverage under the policy is in force.
Payment of this benefit will not reduce the Maximum Benefit Amount for Specified Critical Illness. This benefit is limited to one
payment per covered person, per lifetime.
Health Screening Benefit
Amount: $50/Year
We will pay this benefit if any covered person incurs a charge for and has one of the following screening tests performed while
coverage under the policy is in force. We will pay the amount shown for one of the following screening tests. Payment of this benefit
will not reduce the Maximum Benefit Amount for Specified Critical Illness. This benefit is payable once per calendar year for each
covered person.
Health screening test is defined as: stress test on a bicycle or treadmill, fasting blood glucose test, blood test for triglycerides, serum
cholesterol test to determine level of HDL and LDL, bone marrow testing, carotid doppler, electrocardiogram (EKG, ECG),
echocardiogram (ECHO), skin cancer biopsy, breast ultrasound, CA 15-3 (blood test for breast cancer), CA125 (blood test for ovarian
cancer), CEA (blood test for colon cancer), chest x-ray, colonoscopy, flexible sigmoidoscopy, hemoccult stool analysis, mammography,
pap smear, PSA (blood test for prostate cancer), serum protein electrophoresis (blood test for myeloma), thermography, thinprep pap
test, and virtual colonoscopy.
DEFINITIONS
Accident means an unintended or unforeseen bodily injury sustained by a covered person, wholly independent of disease, bodily
infirmity, illness, infection, or any other abnormal physical condition.
Blindness means clinically proven irreversible reduction of sight in both eyes that has persisted for a period of at least 180
consecutive days. Sight must be reduced to a corrected visual acuity of less than 6/60 (Metric Acuity) or 20/200 (Snellen or E-Chart
Acuity), or visual field restriction to 20º or less in both eyes. The following are not to be construed as blindness for purposes of the
policy: if in general medical opinion any procedure, device, or implant could result in the partial or total restoration of sight; if the
covered person has not attained age three or above on the Date of Diagnosis, and if the covered person’
s reduction of sight as defined
above occurs prior to the Policy Coverage Effective Date of the covered person’
s coverage under this policy.
Calendar Year means the period beginning on the Policy Coverage Effective Date of coverage shown on the Policy Schedule and
ending on December 31 of the same year. Thereafter, it is the period beginning on January 1 and ending on December 31 of each
following year.
Cancer means a disease that is identified by the presence of malignant cells or a malignant tumor characterized by the uncontrolled
and abnormal growth and spread of invasive malignant cells. The following are not to be construed as Cancer for purposes of this
policy: pre-malignant conditions or conditions with malignant potential; Carcinoma in Situ; basal cell carcinoma and squamous cell
carcinoma of the skin; and melanoma that is diagnosed as Clark’
s Level I or II or Breslow less than .75mm.
Carcinoma in Situ means Cancer that is in the natural or normal place, confined to the site of origin without having invaded
neighboring tissue.
Cancer and/or Carcinoma in Situ must be diagnosed in one of two ways:
A Pathological Diagnosis of Cancer or Carcinoma in Situ is based on a microscopic study of fixed tissue or preparations from the
hemic (blood) system. This type of diagnosis must be done by a certified Pathologist, whose diagnosis of malignancy is in keeping
with the standards set up by the American Board of Pathology.
A Clinical Diagnosis of Cancer or Carcinoma in Situ is based on the study of symptoms. We will pay benefits for a clinical diagnosis
only if:
• a Pathological Diagnosis cannot be made because it is medically inappropriate or life-threatening; and
• there is medical evidence to support the diagnosis; and
CI-1.0-O-AZ
3
CI With Cancer, Subsequent Diagnosis, Health Screening (HSA)
PL10
72984
•
a Doctor is treating the covered person for Cancer and/or Carcinoma in Situ.
Cardiologist means a Doctor who is licensed to practice medicine and who is also licensed to practice by the American Board of
Internal Medicine in the subspecialty of cardiovascular disease.
Coma means a continuous state of profound unconsciousness resulting from a Covered Accident or a Covered Sickness,
characterized by the absence of: eye opening, motor response, and verbal response. The condition must require intubation for
respiratory assistance. The term “Coma”does not include any medically induced coma.
A Covered Accident is an accident that occurs on or after the Policy Coverage Effective Date of the policy; occurs while the policy is
in force; and, is not excluded by name or specific description in the policy.
A Covered Sickness means an illness, infection, disease or any other abnormal physical condition, not caused by an accident, that
occurs on or after the Policy Coverage Effective Date of the policy; occurs while the policy is in force; and is not excluded by specific
name or specific description in the policy.
Coronary Artery Bypass Graft Surgery means undergoing open heart surgery to correct narrowing or blockage of one or more
coronary arteries utilizing venous or arterial grafts, excluding procedures such as, but not limited to, balloon angioplasty, valve
replacement surgery, laser relief, stents or other non-surgical procedures.
Coronary Artery Disease means a narrowing or blockage of one or more coronary arteries for which a Cardiologist recommends that
Coronary Artery Bypass Graft Surgery occur within 60 days following the date of the recommendation.
Date of Diagnosis
• for Heart Attack (Myocardial Infarction), the date that the ischemic death of a portion of the heart muscle occurred based on the
applicable criteria listed under the Heart Attack (Myocardial Infarction) definition;
• for Stroke, the date a Stroke occurred based on neuroimaging or other neurodiagnostic study consistent with an acute or subacute
infarction, hemorrhage, embolism, thrombosis and presence of neurological deficits persisting for a period of 30 days or greater;
• for End Stage Renal (Kidney) Failure, the date that regular hemodialysis or peritoneal dialysis begins;
• for Major Organ Failure, the date that the covered person is placed on the UNOS list for transplantation;
• for Permanent Paralysis due to a Covered Accident, the date the Doctor confirms the Permanent Paralysis due to a Covered
Accident has continued for a period of 180 consecutive days;
• for Coma, the date a Doctor confirms a coma resulting from a Covered Accident or a Covered Sickness has lasted seven or more
consecutive days;
• for Blindness, the date the Doctor confirms the irreversible reduction of sight has continued for a period of 180 consecutive days;
• for Occupational Infectious HIV or Occupational Infectious Hepatitis B, C or D, the date of a positive antibody test for HIV or
Hepatitis B, C or D subsequent to a prior negative test for the same condition with a lapse of between 90 and 180 days between
the two tests;
• for Coronary Artery Disease, the date the Cardiologist recommends the covered person undergo Coronary Artery Bypass Graft
Surgery within the 60 days following the date of the recommendation; and
• for Cancer or Carcinoma in Situ, the date the tissue specimen, blood samples or titer(s) are taken upon which the first diagnosis of
Cancer or Carcinoma in Situ is based.
Dependent Children means any natural children, step-children, legally adopted children, foster children or children placed into your
custody for adoption who are unmarried; chiefly dependent on you or your spouse for support; and younger than age 26.
A Doctor or Physician means a person who: is licensed by the state to practice a healing art; and performs services for a covered
person that are allowed by his license. For purposes of this definition, Doctor or Physician does not include any covered person or
anyone related to any covered person by blood or marriage, a business or professional partner of any covered person, or any person
who has a financial affiliation or a business interest with any covered person.
End Stage Renal (Kidney) Failure means chronic irreversible failure of the function of both kidneys such that the covered person
must undergo at least weekly hemodialysis or peritoneal dialysis.
Heart Attack (Myocardial Infarction) means the ischemic death of a portion of heart muscle as a result of obstruction of one or more
of the coronary arteries. A positive diagnosis must be supported by three or more of the following: atypical chest pain;
electrocardiographic (EKG) changes indicative of myocardial infarction; elevation of biochemical markers of myocardial necrosis; and
CI-1.0-O-AZ
4
CI With Cancer, Subsequent Diagnosis, Health Screening (HSA)
PL10
72984
confirmatory imaging studies. In the event of death, an autopsy, medical examiner’
s confirmation or death certificate identifying Heart
Attack (Myocardial Infarction) as the cause of death will be accepted.
A Heart Attack (Myocardial Infarction) is not congestive heart failure, atherosclerotic heart disease, angina, coronary artery disease,
cardiac arrest, or any other dysfunction of the cardiovascular system.
Occupational Infectious HIV or Occupational Infectious Hepatitis B, C or D means diagnosis of Human Immunodeficiency
Virus (HIV) infection or Hepatitis B, C or D resulting from exposure to HIV-contaminated or Hepatitis B-, C- or D-contaminated
body fluids as the result of a Covered Accident during the normal course of performing an occupation for which remuneration is
earned.
We will pay this benefit if: within five days of the Covered Accident, it is reported and recorded by the appropriate person according
to the legislation, regulations, standards or guidelines that apply to the covered person’
s occupation or profession; the Covered
Accident is investigated and a written investigation report is provided to us by the covered person’
s employer; a confirmatory antibody
HIV or Hepatitis B, C or D test is taken within five days of the Covered Accident and HIV or Hepatitis B, C or D is not present; all
HIV or Hepatitis B, C or D tests are performed by a state certified and licensed laboratory; and a follow-up confirmatory antibody
HIV or Hepatitis B, C or D test is taken between 90 days and 180 days after the Covered Accident, and the result is positive.
Occupational HIV or Hepatitis B, C or D excludes: HIV or Hepatitis B, C or D infection as the result of IV drug use; HIV or
Hepatitis B, C or D infection as the result of sexual transmission; and HIV or Hepatitis B, C or D infection determined not to have
been the result of a Covered Accident.
Major Organ Failure means diagnosis of major organ failure of the heart, kidney, liver, lung, or pancreas resulting in the covered
person being placed on the UNOS (United Network for Organ Sharing) list for a transplant.
A Pathologist means a Doctor who is licensed to practice medicine and who is also licensed to practice pathologic anatomy by the
American Board of Pathology. A Pathologist also means an Osteopathic Pathologist who is certified by the Osteopathic Board of
Pathology.
Permanent Paralysis due to a Covered Accident means the complete and permanent loss of the use of two or more limbs through
paralysis as the result of a Covered Accident as defined in the policy for a continuous period of 180 days, as confirmed by a Doctor.
Loss of use of two or more limbs through paralysis as the result of a Stroke will not be construed as Permanent Paralysis due to a
Covered Accident for purposes of the policy.
Policy Anniversary Date occurs annually on the same date and in the same month as the date for which we first received premium.
Pre-existing Condition means having a sickness or physical condition for which any covered person was treated, had medical testing,
received medical advice or had taken medication within 12 months before the Policy Coverage Effective Date of this policy.
Specified Critical Illness means one of the Specified Critical Illnesses shown on the Policy Schedule.
Stroke means an acute or subacute cerebrovascular incident, including infarction of brain tissue, cerebral and subarachnoid
hemorrhage, cerebral embolism and cerebral thrombosis.
The diagnosis must be supported by: evidence of persistent neurological deficits confirmed by a neurologist at least 30 days after the
event; and confirmatory neuroimaging studies consistent with the diagnosis of a new Stroke.
The following are not to be construed as a Stroke for purposes of the policy: transient ischemic attack; brain injury related to trauma
or infection; brain injury associated with hypoxia/anoxia or hypotension; vascular disease affecting the eye or optic nerve; and
ischemic disorders of the vestibular system. In the event of death, an autopsy confirmation identifying Stroke as the cause of death will
be accepted.
WHAT IS NOT COVERED BY THE POLICY
We will not pay benefits for a Specified Critical Illness that occurs as a result of a covered person’
s:
1. Committing or attempting to commit a felony or engaging in an illegal occupation.
2. Being intoxicated or under the influence of any narcotic unless administered on the advice of his Doctor.
3. Having a pre-existing condition as defined in the policy and limited by the Time Limits on Certain Defenses provision of the
policy.
CI-1.0-O-AZ
5
CI With Cancer, Subsequent Diagnosis, Health Screening (HSA)
PL10
72984
4. Having a psychiatric or psychological condition including, but not limited to affective disorders, neuroses, anxiety, stress and
adjustment reactions. However, Alzheimer’
s disease and other organic senile dementias are covered under the policy.
5. Committing or trying to commit suicide, or his injuring himself intentionally, while he is sane or insane.
6. Being exposed to war or any act of war, declared or undeclared, or serving in the armed forces of any country or authority.
Losses as a result of acts of terrorism or nuclear release committed by individuals or groups will not be excluded from
coverage unless the covered person who suffered the loss committed the act of terrorism or nuclear release.
CI-1.0-O-AZ
6
CI With Cancer, Subsequent Diagnosis, Health Screening (HSA)
PL10
72984
Attachment 7
Specified Critical Illness Flyer
Specified Critical Illness
Insurance
How will you pay for what your health insurance won’t?
Even those of us who plan for the unexpected with life, disability and medical insurance may discover
that some expenses can still remain unpaid. Without adequate protection, sufferers of critical illnesses
might have to pull from their savings or rely on other financial sources in their time of need.
Specified Disease Insurance helps fill the gaps in your health insurance.
With Colonial Life’s Specified Critical Illness Insurance, you’re paid a benefit that can help you cover:
Deductibles, co-pays and co-insurance of your health insurance
l Home health care needs and household modifications
l Travel expenses to and from treatment centers
l Lost income
l Rehabilitation
l Child care expenses
l Everyday living expenses
l
You’re free to use the benefit however you choose.
And coverage is available for you and your eligible family members.
Critical Illness 1.0 with Health Screening
Covered Specified Critical Illnesses
For this illness…
We will pay this percentage
of the face amount:
Heart Attack (Myocardial Infarction)
100%
Stroke
100%
Major Organ Failure
100%
End Stage Renal (Kidney) Failure
100%
Permanent Paralysis due to a Covered Accident
100%
Coma
100%
Blindness
100%
Occupational Infectious HIV or Occupational Infectious Hepatitis B, C or D
100%
Coronary Artery Bypass Graft Surgery
25%
The Maximum Benefit Amount for this policy is 100% of the face amount for each covered person. We will not
pay more than 100% of the face amount for all covered Specified Critical Illnesses combined. The policy will
terminate when the Maximum Benefit Amount for Specified Critical Illness has been paid.
Health Screening Benefit
New technology can help improve your chances of surviving a serious illness through early detection and
treatment. We will pay this benefit if any covered person incurs a charge for and has any of the following
screening tests performed while your policy is in force.
l
Stress test on a bicycle or treadmill
Serum cholesterol test to determine levels of HDL and LDL
Carotid doppler
Electrocardiogram (ECG/EKG)
Echocardiogram (ECHO)
Chest x-ray
Colonoscopy
Mammography
Pap smear
l
PSA (blood test for prostate cancer)
l
l
l
l
l
l
l
l
Critical Illness 1.0 with Health Screening
24 tests included - No Lifetime Limit
This policy has exclusions and limitations. Premium will vary based on plan chosen. This is not an insurance contract and
only the actual policy provisions will control. For cost and complete details of the coverage, see your Colonial Life benefits
counselor. Applicable to policy form CI-1.0 or CI-1.0-PL2 (including state abbreviations where used, such as CI-1.0-TX).
Colonial Life
1200 Colonial Life Boulevard
Columbia, South Carolina 29210
coloniallife.com
6/11
©2011 Colonial Life & Accident Insurance Company.
Colonial Life products are underwritten by Colonial Life & Accident
Insurance Company, for which Colonial Life is the marketing brand.
Colonial Life and Making benefits count are registered service marks
of Colonial Life & Accident Insurance Company.
71756-2
Attachment 8
Whole Life Benefit Summary
Whole Life
Colonial Life’s Whole Life 1000 is an individually owned, whole life insurance plan with
guaranteed level premiums, guaranteed cash values and a guaranteed death benefit. Coverage is
permanent and is guaranteed for the life of the policy (to age 100), provided premiums are paid when
due.
Base Plan Benefits
Two Plan Options
Available for employee and spouse.
 Paid-Up at Age 65 Plan
The policy is paid-up at the original face amount when the insured
reaches age 65, with no additional premiums due.
 Paid-Up at Age 95 Plan
The policy is paid-up at the original face amount when the insured
reaches age 95, with no additional premiums due.
Death Benefit
$5,000 to $300,000
Guaranteed
Purchase Option
 Provides the policyowner the right to buy additional insurance on the
life of the insured without providing evidence of insurability if the
policy is purchased before age 55.
 There are three option dates to purchase additional insurance; the
second, fifth and eighth policy anniversary dates. A life event option
can be exchanged for an anniversary option.
 Life event options are the date of the insured’s marriage, birth of a
living child, adoption of a child or a legal divorce.
 Additional amounts of insurance of the same plan may be purchased
on each option date up to the initial face amount not to exceed a total
combined maximum of $100,000 for all Guaranteed Purchase Options.
Immediate Claims
Payment
Helps meet immediate needs with a payment of $3,000 to the designated
beneficiary upon certification of the insured’s death. The remainder of
the claim will be processed and the balance provided to the designated
beneficiary.
Accelerated Death
Benefit Provision
 If the insured is diagnosed with a terminal illness and has a life
expectancy of 12 months or less, the policyowner can request up to 75
percent of the death benefit, to a maximum of $150,000.
 A $200 one time administrative fee will be charged.
Endows
The policy endows at age 100.
Applicable to AZ
PS01632
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
11/2013 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210
Coverage Options
If the policy ends due to unpaid premiums, the policyowner has several
options:
 Extended Term Insurance Option – the policyowner can use the
accumulated net cash surrender value as a net single premium to
purchase term life insurance.
 Reduced Paid-Up Life Insurance Option – the policyowner can use the
accumulated net cash surrender value as a net single premium to
purchase a smaller amount of fully paid-up life insurance.
 Automatic Premium Loan Provision – If this provision is in effect,
Colonial Life will lend the policyowner the amount needed to pay an
overdue premium provided the cash surrender value is great enough to
pay the premiums plus interest.
Optional Riders
Policyowners may select to enhance their whole life policy by adding optional rider(s) at an
additional premium.
Spouse Term Riders
Choice of 10-year or 20-year Spouse Term Riders
•
•
•
•
•
•
•
•
•
Provides a level death benefit for the designated 10- or 20-year term period with
guaranteed level premiums.
No spouse signature required.
Minimum death benefit - $5,000
Maximum death benefit - $50,000
Rates are level, uni-tobacco and unisex.
May not exceed face amount of base plan.
Conversion available to a cash value plan without evidence of insurability.
May be added to a spouse base policy.
Can be added after purchase of the base plan.
Children's Term Rider
• One premium provides level term coverage for all eligible dependent children of the
primary insured who are at least 14 days of age, unmarried, under age 19, and living with
the insured in a regular parent-child relationship.
• Face amounts: $1,000 to $10,000 in $1,000 increments.
• Rates are level, uni-tobacco and unisex.
• Coverage is convertible without evidence of insurability to a cash value life insurance plan
for up to five times the rider's face amount.
• If the main insured dies before the child is age 25, paid-up insurance will be provided for
each child until the child's 25th birthday.
• No health questions.
• Can be added after the purchase of the base plan.
Applicable to AZ
PS01632
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
11/2013 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210
Waiver of Premium Rider
• Available on employee and spouse policies.
• Waives the total premium if the insured is totally disabled due to an accidental bodily
injury or sickness before age 65.
• Must meet the elimination period of 6 months continuous total disability. Premiums paid
during this period will be refunded when the claim is approved.
• Terminates on the policy anniversary following the insured’s 65th birthday.
• Rates are level, uni-tobacco and unisex.
• Available only at purchase of base plan.
Features
•
•
•
•
•
•
•
•
Individual whole life insurance plan that provides cash value protection with guarantees to
individuals in the payroll deduction market.
Guaranteed level premiums, guaranteed cash value and a guaranteed death benefit.
Tax-free benefits are paid to the beneficiary, regardless of other life insurance and Social
Security.
Family Coverage available through a separate spouse policy or term rider for the spouse and a
term rider for the dependent children.
$3,000 immediate claims payment provides immediate funds to the designated beneficiary.
No spouse signature required on spouse policies or riders with face amounts up to $50,000.
Automatic Premium Loan for non-payment of premiums available.
Portable Coverage – Insured can keep his policy if he changes jobs or retires.
Eligibility Requirements
Employee
• Must be actively at work at the date of enrollment.
• Must be working full-time (20+ hours per week).
• Must have been employed with present employer for at least 90 days.
• Paid-Up at Age 65 plan issue ages: 16-45.
• Paid-Up at Age 95 plan issue ages: 16-79.
Spouse (for policy)
• Must be the spouse of an employee.
• Paid-Up at Age 65 plan issue ages: 16-45.
• Paid-Up at Age 95 plan issue ages: 16-79.
Spouse (for Term Riders)
10-Year Spouse Term Rider
• Available with both the Life Paid-Up at Age 65 plan and Life Paid-Up at Age 95 plan.
• Issue Ages: 16-55.
• Can be added after purchase of base plan.
Applicable to AZ
PS01632
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
11/2013 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210
20-Year Spouse Term Rider
• Available with both the Life Paid-Up at Age 65 plan and Life Paid-Up at Age 95 plan.
• Spouse Issue Ages for Life Paid-Up at Age 65 plan: 16-45.
• Spouse Issue Ages for Life Paid-Up at Age 95 plan: 16-50.
• Can be added after purchase of base plan.
Dependent (for Children's Term Rider)
• Issue ages: 14 days -18 years.
• Primary insured issue ages: 16-65.
• Can be added after purchase of base plan.
Waiver of Premium Rider
• Issue ages: 16-55 for employee and spouse policies.
• May be added only at purchase of base policy.
Participation Requirements
To offer this plan, we require only 3 eligible applicants.
Premium Information
Employee and Spouse Policy
•
•
Level, tobacco-distinct, unisex premiums.
Two rate bands based on face amount: $5,000 - $50,000 / $50,001 - $300,000
What Is Not Covered
If the insured commits suicide within two years from the coverage effective date or the date of
reinstatement, we will not pay the death benefit. We will terminate this policy and return the
premiums paid, minus any loans and loan interest.
Whole Life 1000 Sample Premium and Rider Rates
Paid-Up at Age 65 Plan
 Sample Non-Tobacco Monthly Premiums and Guaranteed Cash Values at Age 65
$5/wk-$21.67/mo
$6/wk-$26/mo
$10/wk$43.33/mo
Guar.
Face
Amt.
Cash
Value
$16/wk$69.33/mo
Guar.
Face
Amt.
Cash
Value
Face
Amt.
Guar.
Cash
Value
Face
Amt.
Guar.
Cash
Value
25
22,512
10,716
27,738
13,203
48,643
23,154
91,284
35
14,368
6,839
17,703
8,427
31,045
14,777
45
7,562
3,600
9,318
4,435
16,340
7,778
Issue
Age
$24/wk-$104/mo
Face
Amt.
Guar.
Cash
Value
43,451
138,990
66,159
54,297
25,845
82,673
39,352
26,873
12,792
40,918
19,477
Applicable to AZ
PS01632
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
11/2013 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210
 Sample Tobacco Monthly Premiums and Guaranteed Cash Values at Age 65
Issue
Age
$5/wk$21.67/mo
Guar.
Face
Amt.
Cash
Value
$6/wk-$26/mo
Face
Amt.
Guar.
Cash
Value
$10/wk$43.33/mo
Guar.
Face
Amt.
Cash
Value
$16/wk$69.33/mo
Guar.
Face
Amt.
Cash
Value
$24/wk-$104/mo
Face
Amt.
Guar.
Cash
Value
25
16,816
9,064
20,720
11,168
36,336
19,585
72,827
39,254
110,887
59,768
35
10,058
5,421
12,393
6,680
21,733
11,714
35,743
19,265
66,338
35,756
45
5,797
3,125
7,142
3,850
12,525
6,751
20,600
11,103
31,366
16,906
Paid-Up at Age 95 Plan
 Sample Non-Tobacco Monthly Premiums and Guaranteed Cash Values at Age 65
Issue
Age
$5/wk$21.67/mo
Guar.
Face
Amt.
Cash
Value
$6/wk-$26/mo
Face
Amt.
Guar.
Cash
Value
$10/wk$43.33/mo
Guar.
Face
Amt.
Cash
Value
$16/wk-$69.33/mo
$24/wk-$104/mo
Face
Amt.
Guar.
Cash
Value
Face
Amt.
Guar.
Cash
Value
25
26,571
10,655
32,740
13,129
64,190
25,740
105,570
42,334
160,742
64,458
35
17,270
6,234
21,279
7,682
37,316
13,471
66,947
24,168
101,934
36,798
45
10,831
3,163
13,346
3,897
23,404
6,834
38,491
11,239
63,856
18,646
55
6,256
1,064
7,709
1,311
13,519
2,298
22,234
3,780
33,854
5,755
7,182
1,738
11,811
2,858
17,984
4,352
5,399
1,911
8,221
2,910
65
75
 Sample Tobacco Monthly Premiums and Guaranteed Cash Values at Age 65
Issue
Age
$5/wk$21.67/mo
Guar.
Face
Amt.
Cash
Value
$6/wk-$26/mo
Face
Amt.
Guar.
Cash
Value
$10/wk$43.33/mo
Guar.
Face
Amt.
Cash
Value
$16/wk-$69.33/mo
$24/wk-$104/mo
Face
Amt.
Guar.
Cash
Value
Face
Amt.
Guar.
Cash
Value
25
18,682
8,444
23,019
10,405
40,366
18,245
80,000
36,160
121,809
55,058
35
11,746
4,769
14,472
5,876
25,380
10,304
41,740
16,946
78,193
31,746
45
7,726
2,503
9,520
3,084
16,695
5,409
27,457
8,896
41,807
13,545
5,077
919
8,903
1,611
14,643
2,650
22,295
4,035
7,774
1,920
11,838
2,924
6,412
2,174
55
65
75
Applicable to AZ
PS01632
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
11/2013 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210
Sample Rider Monthly Premiums
 10-Year Spouse Term Rider
Issue Age
$10,000
$20,000
$25,000
$30,000
$40,000
$50,000
25
2.70
5.40
6.75
8.10
10.80
13.50
35
4.00
8.00
10.00
12.00
16.00
20.00
45
5.80
11.60
14.50
17.40
23.20
29.00
55
15.00
30.00
37.50
45.00
60.00
75.00
 20-Year Spouse Term Rider
Issue Age
$10,000
$20,000
$25,000
$30,000
$40,000
$50,000
25
2.80
5.60
7.00
8.40
11.20
14.00
35
4.20
8.40
10.50
12.60
16.80
21.00
45
7.40
14.80
18.50
22.20
29.60
37.00
 Waiver of Premium Rider Monthly Rate
Issue Age
Sample Rates per $1,000
25
$.02
35
$.03
45
$.07
55
$.30

Children’s Term Rider
Face Amount
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
$9,000
$10,000
Monthly Rate
$.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
4.50
5.00
Applicable to AZ
PS01632
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
11/2013 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210
Attachment 9
Whole Life LTC Rider
Whole Life
Long-Term Care Benefit Rider
This rider is available and can be purchased at an additional cost to provide for flexible use of
the Whole Life policy’s death benefit.
Colonial Life’s Long-Term Care Benefit Rider provides your employees with two kinds of
insurance protection in one convenient Whole Life policy – life insurance benefits and long-term
care benefits.
The Long-Term Care Benefit Rider reduces the Whole Life policy death benefit to provide
monthly indemnity payments to help pay for the insured’s long-term care services needed as a
result of a chronic illness, serious accident, sudden illness, or cognitive impairment. The
maximum benefit amount is equal to the policy death benefit, less any indebtedness.
Benefits
Care Setting
Long-Term Care Facility or Assisted
Living Facility
Monthly Benefit
Monthly indemnity benefit of 4% of the Death
Benefit, less any policy debt, after the 90-day
elimination period.
Home Health Care by Licensed Home
Health Care Agency or Licensed Home
Health Care Professional
Monthly indemnity benefit of 4% of the Death
Benefit, less any policy debt, after the 90-day
elimination period.
Adult Day Care Benefit
Monthly indemnity benefit of 4% of the Death
Benefit, less any policy debt, after the 90-day
elimination period.
Features
• Benefit Payment Structure allows the employee to protect their savings and assets and have
more choice in where long-term care is received. It provides coverage for all care settings,
including the home.
• Advances the Whole Life death benefit in monthly indemnity payments to help pay for the
long-term care services needed as a result of the insured’s inability to perform at least two of
the six Activities of Daily Living (ADLs), or the insured’s requiring substantial supervision
due to severe cognitive impairment.
• Claim payments are made monthly and are a percentage of the death benefit.
• Terminates on the first to occur: base policy terminates; when the owner requests termination
of the rider; or the date the death benefit is exhausted from long-term care benefit payments.
• 90-day elimination period.
• Six-month pre-existing conditions limitation period.
• Built-in Waiver of Monthly Deductions due to payments of the long-term care benefit.
Waives all monthly deductions for the rider and the Whole life policy, when long-term care
benefits are being paid.
Applicable to AZ
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
6/14 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210
PS01944
Eligibility Requirements
• Issue ages for employees and spouses:
• Paid-Up at Age 65: 16-45
• Paid-Up at Age 95: 16-79
• May be added to a Whole Life plan during the initial sale.
Premium Information
•
Premiums are per thousand, unisex, uni-tobacco, and based on face amount and age.
What Is Not Covered
Preexisting Conditions Limitation- No benefits will be paid for any benefit period that
results from a preexisting condition and that starts during the first six months after the effective
date of this rider.
Other Limitations or Conditions on Eligibility for Benefits
We will not pay benefits for confinement or services:
• resulting from mental or nervous disorder; however, Alzheimer’s Disease and related
degenerative and dementing illnesses are covered;
• resulting from alcoholism, and drug addiction;
• for which there is no charge in the absence of insurance;
• provided by a family member;
• received while residing or confined outside the United States and Canada; and
• due to chronic illnesses resulting from;
• war or any act of war, whether declared or undeclared, or service in any armed forces or
auxiliary units thereto;
• intentionally self-inflicted injuries, attempted suicide or suicide;
• participation in a felony, riot, or insurrections; and
• aviation (if a non-fare paying passenger).
Non-Duplication of Benefits
Qualified long-term care services do not include services for which charges are covered under
any of the following:
• Medicare (including amounts that would be reimbursable but for the application of a
deductible or coinsurance amounts);
• any other government program or facility (except Medicaid); and
• any state or federal worker’s compensation, employer’s liability or occupational disease law,
or under any motor vehicle no-fault law.
Applicable to AZ
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
6/14 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210
PS01944
Definitions
Elimination Period – means the first 90 days of the Benefit Period. No benefits are payable for
care or service received during this time.
Pre-existing Condition – means a condition for which medical advice or treatment was
recommended by, or received from, a provider of health care services, within the six months
preceding the effective date of this rider.
Long-Term Care Rider Sample Monthly Premiums
Paid-Up at Age 65 Plan
Issue Age
Monthly Sample Premium per $1,000 Death Benefit
Uni-tobacco
25
$0.01
35
0.02
45
0.03
Long-Term Care Rider Sample Monthly Premiums
Paid-Up at Age 95 Plan
Issue Age
Monthly Sample Premium per $1,000 Death Benefit
Uni-Tobacco
25
$0.01
35
0.02
45
0.03
55
0.05
65
0.12
Applicable to AZ
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
6/14 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210
PS01944
Attachment 10
Whole Life Flyer
Whole Life Insurance
You can’t predict your family’s future, but you
can be prepared for it.
You like to think that you’ll be there for your family in the years to come. But
if something happened to you, would your family have the income it needs?
It’s not easy to think about such serious circumstances, but it’s important
to make sure your family is financially protected. You can gain peace of
mind with Colonial Life’s Whole Life Insurance.
50% of U.S. households
(58 million) say they need
more life insurance.
Facts About Life, LIMRA 2013
What is whole life insurance?
Whole life insurance can help provide protection for you and those who depend
on you. You won’t have to worry about becoming uninsurable later in life, and
your premiums won’t increase as you get older.
With whole life insurance, you receive a guaranteed death benefit, which can
help with funeral costs and other immediate expenses. Also, throughout the
life of the policy, you can access its cash value through a policy loan, and use
the money for emergencies.
What are the advantages of Colonial Life’s Whole Life Insurance?
„„ Your premiums will never increase because of changes in your
health or age.
Your cost will vary based on the
level of coverage you select.
Talk with your Colonial Life
benefits counselor for information
about what level of coverage
would work best for you.
„„ You can take the policy with you even if you change jobs or retire,
with no increase in premium.
„„ A guaranteed purchase option means you can purchase additional
whole life coverage — without having to answer health questions —
at three different points in the future.
„„ With the accelerated death benefit, you can request 75 percent of your
policy’s death benefit if you are diagnosed with a terminal illness.
„„ An immediate $3,000 claim payment can help your designated
beneficiary pay for funeral costs or other expenses.
WHOLE LIFE 1000
Benefits worksheet
For use with your Colonial Life
benefits counselor
HOW MUCH COVERAGE
DO YOU NEED?
£ YOU $ __________________
FACE AMOUNT
Select the option:
£ Paid-Up at Age 65
£ Paid-Up at Age 95
£ SPOUSE $ ______________
FACE AMOUNT
Select the option:
£ Paid-Up at Age 65
£ Paid-Up at Age 95
Select any optional riders:
£ Spouse Term Life Rider
$ _____________ face amount
for ________-year term period
£ Children’s Term Life Rider
$ _____________ face amount
£ Waiver of Premium Benefit Rider
Product options
Paid-Up at Age 65 or Paid-Up at Age 95
These two plan design options allow you to select what age your premium payments
will end. You can choose to have your policy paid up when you reach age 65 or 95.
Accelerated Death Benefit
If you are diagnosed with a terminal illness, you can request up to 75 percent of the
policy’s death benefit, up to $150,000.
Guaranteed Purchase Option
If you are age 55 or younger when you purchase the policy, you have the option to
purchase additional whole life coverage – without having to answer health questions –
at three different points in the future. You may purchase up to your initial face amount,
not to exceed a total combined maximum of $100,000 for all options.
$3,000 Immediate Claim Payment
This payment can help meet immediate needs, such as funeral costs, by providing an
initial death benefit payment of $3,000 to the designated beneficiary.
Additional coverage options
Spouse Whole Life Policy
This policy offers a guaranteed death benefit, guaranteed level premiums and guaranteed
cash value accumulation – whether or not you buy a policy on yourself.
Spouse Term Life Rider
You can purchase term life coverage for your spouse, with a maximum death benefit of
up to $50,000. 10-year and 20-year coverage periods are available, based on the policy
you select. You can choose to convert this coverage to a cash value policy within certain
time periods later on – without having to answer health questions.
Dependent Coverage
You may purchase up to $10,000 in term life coverage for each of your eligible dependent
children and pay one premium. You can later convert this coverage to a cash value life
insurance policy – without having to answer health questions – upon your 70th birthday
or the child’s 25th birthday, whichever comes first. You can add this additional coverage
to either the primary or the spouse policy, but not both.
Waiver of Premium Benefit Rider
Your premiums on the whole life policy and any riders attached to it will be waived
if you become totally disabled before the policy anniversary following your 65th
birthday and you satisfy the six-month elimination period (the amount of time until
benefits are payable).
To learn more,
talk with your Colonial Life
benefits counselor.
EXCLUSIONS AND LIMITATIONS
If the insured commits suicide within two years (one year in ND) from the coverage effective date or the date of
reinstatement (not applicable in AR), whether he is sane or insane (not applicable in AZ), we will not pay the death
benefit. We will terminate this policy and return the premiums paid, minus any loans and loan interest to you.
Product may vary by state. For costs and complete details of the coverage, call or write your Colonial Life benefits
counselor or the company.
ColonialLife.com
This product is underwritten by Colonial Life & Accident Insurance Company. This brochure is applicable to
policy forms ICC07-WL-NGPO-65/WL-NGPO-65, ICC07-WL-NGPO-95/WL-NGPO-95, ICC08-WL-GPO-65/WL-GPO-65,
ICC08-WL-GPO-95/WL-GPO-95 and rider forms ICC07-R-WL-CTR/R-WL-CTR, ICC07-R-WL-STR-10/R-WL-STR-10,
ICC07-R-WL-STR-20/R-WL-STR-20, ICC07-R-WL-WOP/R-WL-WOP and applicable state variations.
©2014 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are
underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
7-14 | 69596-6
Attachment 11
Universal Life Benefit Summary
Universal Life
Colonial Life’s Universal Life 1000 is a flexible premium, adjustable death benefit life insurance
plan that accumulates cash value, based on current interest rates. Employees can purchase
individually owned life insurance coverage that is theirs to keep, even if they change jobs or retire.
Base Plan Benefits
Coverage
Available for the employee, spouse and juvenile.
Two Plan Options
Offers a choice of two plan options:
ƒ
Option A - establishes a basic program of cash value life insurance
– offers a stable death benefit at a low cost and builds cash value at
current credited interest rates.
ƒ
Option B - offers life insurance benefits that increase as the policy’s
cash value increases – provides you and your family inflation protection
as needs change over time.
Death Benefit
Employees can change the death benefit to adapt to changing needs,
subject to IRS and underwriting guidelines.
Minimum issue amount: $5,000 or $3.00 weekly target premium.
Maximum issue amount: unlimited, based on underwriting.
Cash Value
Premiums build cash value based on current interest rates, (which are
subject to change).
Guaranteed Interest
Rate
Family Coverage
Interest rates are guaranteed to be no lower than 4 percent.
Accelerated Death
Benefit Provision
If the insured is diagnosed with a terminal illness and has a life
expectancy of 12 months or less, the policyowner can request up to 75
percent of the death benefit, to a maximum of $150,000. There is no
additional premium charged for this provision. A $200 one time
administrative fee will be charged.
Premiums
Tobacco distinct/unisex premiums. Lower premiums at face amounts
over $150,001.
Withdrawals
$250 minimum with a $50 withdrawal charge.
Endows
Endows at age 100, based on target premium and assumed credited
interest rate.
Additional Benefits
Additional benefits are available through optional riders (at an
additional cost).
Available through separate policies or Spouse and Children’s Term
Riders.
Applicable to AZ
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
2008 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210 PS01269
Juvenile Policy
Same as the adult plan, with these differences:
Coverage
Employees do not have to purchase coverage on themselves to
purchase policies for their children or grandchildren.
Premiums
Uni-tobacco/unisex premiums.
Death Benefit
Minimum death benefit of $25,000.
Maximum death benefit – unlimited, based on underwriting.
Guaranteed Purchase
Option
Allows the policyowner the right to purchase additional amounts of
insurance without providing evidence of insurability.
The option may be exercised at ages 18, 21, and 24.
Maximum amount for all options is either the initial face amount of
the policy, or $100,000, whichever is less.
Dependent Children
Ages 18-24
Dependent children ages 18-24 who are full-time students, may be
issued a tobacco distinct adult policy.
Optional Riders
Policyowners may select to enhance their universal life policy by adding an optional rider(s) at an
additional premium.
Accidental Death Benefit Rider
• Benefit equal to the death benefit of the policy, not to exceed $150,000.
• Pays an additional death benefit if the primary insured dies as a result of an accidental bodily
injury before age 70.
• Benefit amount doubles if the accidental bodily injury occurs while the insured is a fare-paying
passenger within a public conveyance, such as a subway or city bus.
• An additional 25 percent of the accidental death benefit will be paid if the insured dies due to
an accidental bodily injury sustained while driving or riding in a private passenger vehicle and
wearing a seatbelt.
Additional Coverage Term Rider
• Face amounts: $5,000 minimum, up to 100 percent of base plan’s face amount applied for on
the primary insured.
• Provides additional 20-year level term insurance coverage on the primary insured.
• Premiums are level for the duration of the term, based on issue age, tobacco use, and premium
per thousand of coverage purchased.
• Conversion is available to a cash value plan without evidence of insurability, on or after the
first policy anniversary date.
Applicable to AZ
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
2008 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210 PS01269
Children’s Term Rider
• Face amounts - $1,000 to $10,000 in $1,000 increments.
• Provides level term insurance for one premium for all eligible dependent children of the primary
insured who are at least 14 days of age, under age 19, unmarried, and living in a regular parentchild relationship with the insured.
• Eligible children are covered until the policy anniversary after their 25th birthday or the
insured’s 70th birthday, whichever occurs first. Conversion is then available to a cash value
plan without evidence of insurability, for up to five times the rider amount.
• Should the primary insured die while eligible children are still covered by the rider, each
dependent child will be provided a paid-up term policy until age 25.
• Premiums are level, uni-tobacco and unisex.
P
P
P
P
Guaranteed Purchase Option Rider
• Maximum amount for each option is the initial face amount of the policy not to exceed a total
combined maximum of $100,000 for all options.
• Allows the policyowner to purchase additional coverage, up to the initial face amount of the
policy, at three specified option dates — the second, fifth and eighth policy anniversary dates
— or for a specified life event.
• On the second, fifth, and eighth policy anniversary dates, insured’s can purchase additional
face amounts without evidence of insurability. They may also exercise a life event option on
the date of the insured’s marriage, birth of a living child, adoption of a child, or legal divorce.
(Exercising a life event option date cancels out the next policy anniversary option date.)
• Rates are based on issue age, tobacco use, and rate per thousand of coverage purchased.
Spouse Term Rider
• Face amounts - $5,000 to $50,000 for all issue ages in $1,000 increments.
• Level premiums are based on issue age, uni-tobacco and premium per thousand of coverage
purchased.
• Face amount cannot exceed the base policy’s face amount.
• Conversion available to cash value plan without evidence of insurability.
• No spouse signature required.
Waiver of Monthly Deductions Rider
• Waives all monthly deductions for the policy and any riders if insured becomes totally disabled
due to an accidental bodily injury or sickness. Disability must begin after the rider effective
date and before the policy anniversary following the insured’s 65th birthday and continue
longer than the elimination period.
• An elimination period of six months applies. Premiums paid during this time are credited to the
fund value after the claim for waiver of monthly deductions is approved.
P
P
Applicable to AZ
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
2008 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210 PS01269
Features
• Individual universal life insurance plan that provides affordable, cash value insurance protection
•
•
•
•
•
•
to individuals in the payroll-deduction market.
Flexibility to adapt to a customer’s changing needs with adjustable death benefit amounts and
flexible premiums.
Premiums build cash value based on current interest rates, which are subject to change. (Interest
rates are guaranteed to be no lower than 4 percent).
Death benefit remains level until maturity at age 100.
Loans –6% loan interest rate; 4% guaranteed interest rate credited to the loaned cash value; net
charge on loan of 2%.
Death benefit paid tax-free to the beneficiary, regardless of other life insurance and Social
Security.
Portable coverage – Insureds may keep their policies if they change jobs or retire.
Eligibility Requirements
Employee
• Issue ages, 16-79.
• Employed full time (20+ hours per week).
• Actively at work on the date of enrollment.
• Employed with present employer for at least 90 days.
Spouse
Must be the spouse of an employee.
• Individual Policy
ƒ Issue ages, 16-79.
• Spouse Term Rider
ƒ Issue ages, 16-65.
ƒ May be added to an existing universal life plan.
Dependent
• Individual Policy
ƒ Issue ages, 0-17, (18-24 if a full-time student).
ƒ Dependent students ages 18-24 are issued adult plans and the tobacco question is
required on the application.
ƒ No additional benefit riders are available on juvenile policies for insured’s under the age
of 17.
• Children’s Term Rider
ƒ Issue ages: 14 days-18 years for children; 16-65 for the primary insured.
ƒ Meets the definition of an insured child.
ƒ May be added to an existing universal life plan.
Other Rider Eligibility
Applicable to AZ
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
2008 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210 PS01269
To purchase a policy rider, applicants must first qualify for a base Universal Life policy.
Accidental Death Benefit Rider:
• Issue ages, 16-65 for employees and spouses.
• May be added to an existing universal life plan when increasing the policy’s death benefit.
Additional Coverage Term Rider:
• Issue ages, 16-50 for employees and spouses.
• Only provides coverage for the main insured.
• May be added to an existing universal life plan.
Guaranteed Purchase Option Rider:
• Issue ages, 16-60 for employees and spouses.
• Available only when a Universal Life policy is initially purchased.
Waiver of Monthly Deductions Rider:
• Issue ages, 16-55 for employees and spouses.
• May be added to an existing universal life plan when increasing the policy’s death benefit.
Participation Requirements
To offer this plan, we require only 3 eligible applicants.
Premium Information
Employee and Spouse Policy
• Tobacco-distinct, unisex premiums
• Two face amount premium bands:
ƒ Band 1: $5,000 - $150,000
ƒ Band 2: $150,001 – unlimited.
What Is Not Covered
If the insured commits suicide, whether he is sane or insane, within two years from the coverage
effective date or the date of reinstatement, we will not pay the death benefit. We will terminate this
policy and return the premiums paid, minus any loans and loan interest.
Underwriting
Simplified Issue (SI)
• Available in all accounts with 100+ lives.
• Available for employee and spouse policies.
• Two questions—Eligibility and AIDS (knockout).
• One reflex health question—“Within the past 12 months, have you, or your spouse if
applying for spouse coverage, been hospitalized or missed 5 or more consecutive days of
work for any reason other than flu, pregnancy, accidents, allergies, back or knee disorder?” If
Applicable to AZ
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
2008 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210 PS01269
•
the “reflex” health question is answered “yes,” the applicant must automatically answer
the Simplified Issue Level 1 health questions.
SI Limits ─ Employee and spouse: $3 per week target premium or minimum $5,000 face
amount.
Simplified Issue Level One (SI1)
• Available in all accounts.
• Available for employee and spouse policies.
• Must answer Eligibility, AIDS, Height/Weight and five additional health questions.
• All Simplified Issue Level One health questions are “knockout.”
• SI1 limits – Employee: up to $20 per week target premium, to maximum $150,000; Spouse:
up to $10 per week target premium, to maximum $75,000.
• Applicant and benefit representative know at point-of-sale whether coverage will be issued.
Full Underwriting
• Available in all accounts.
• Available for employee, spouse and juvenile policies.
• Required on all face amounts above Simplified Issue Level 1 guidelines.
Applicable to AZ
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
2008 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210 PS01269
Universal Life 1000 Sample Monthly Premiums
Employee/Spouse, Option A
Sample Non-Tobacco Target Premiums
$3/wk13.00/mo
Issue
Age
25
35
45
55
65
Face
Amt.
22,674
13,928
8,405
$8/wk34.67/mo
Guar.
Cash
Value
4,748
3,224
1,800
$10/wk
43.33/mo-
$12/wk
52.00/mo
$16/wk
69.33/mo
$20/wk
86.67/mo
Face
Amt.
Guar.
Cash
Value
Face
Amt.
Guar.
Cash
Value
Face
Amt.
Guar.
Cash
Value
Face
Amt.
Guar.
Cash
Value
Face
Amt.
Guar.
Cash
Value
73,062
44,880
27,083
15,630
8,654
15,891
10,730
5,976
2,229
1,639
93,217
57,261
34,554
19,941
11,042
20,337
13,727
7,643
2,851
2,101
113,372
69,642
42,025
24,253
13,429
24,796
16,731
9,315
3,475
2,563
173,903
94,404
56,968
32,877
18,204
27,107
22,732
12,653
4,721
3,486
219,517
119,166
71,910
41,500
22,979
34,297
28,740
15,996
5,968
4,409
Sample Tobacco Target Premiums
$3/wk13.00/mo
Issue
Age
25
35
45
55
65
Face
Amt.
15,983
9,948
5,945
$8/wk34.67/mo
Guar.
Cash
Value
3,224
2,334
1,363
$10/wk
43.33/mo
$12/wk
52.00/mo
$16/wk
69.33/mo
$20/wk
86.67/mo
Face
Amt.
Guar.
Cash
Value
Face
Amt.
Guar.
Cash
Value
Face
Amt.
Guar.
Cash
Value
Face
Amt.
Guar.
Cash
Value
Face
Amt.
Guar.
Cash
Value
51,502
32,057
19,156
11,140
6,656
11,061
7,905
4,587
1,718
1,009
65,710
40,901
24,441
14,213
8,492
14,184
10,127
5,873
2,202
1,296
79,918
49,744
29,725
17,287
10,328
17,322
12,357
7,164
2,685
1,585
108,333
67,431
40,294
23,433
14,000
23,582
16,809
9,740
3,651
2,162
136,748
85,119
50,863
29,580
17,673
29,858
21,269
12,321
4,618
2,740
Juvenile Policy
Sample Target Premium (Uni-tobacco)
$25,000 Policy Face Amount, Option A
Issue Age
14 days
5 years
10 years
15 years
Weekly Target
Premium
$2.02
2.19
2.37
2.60
Monthly Target
Premium
$8.75
9.50
10.25
11.25
Guaranteed Cash Value
at Age 65
7,923
7,389
5,956
5,073
Applicable to AZ
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the
marketing brand.
2008 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210 PS01269
Dependent Student Policy
Sample Target Premiums
$35,000 Policy Face Amount, Option A
Non-Tobacco
Issue
Age
18
20
21
22
Weekly Target
Premium
Monthly Target
Premium
$3.33
3.58
3.66
3.82
$14.45
15.50
15.85
16.55
Guaranteed Cash Value at Age
65
6,744
7,167
7,011
7,343
$35,000 Policy Face Amount, Option A
Tobacco
Issue Age
Weekly Target
Premium
$4.38
4.71
4.87
5.03
18
20
21
22
Monthly Target
Premium
$19.00
20.40
21.10
21.80
Guaranteed Cash Value at
Age 65
6,221
6,609
6,672
6,681
Sample Rider Monthly Premiums
Spouse Term Rider
T
Sample Monthly Premiums
$20,000
$25,000
$30,000
T
Issue Age
T
25
T
35
T
T
45
T
T
55
T
T
65
T
T
T
T
$10,000
T
T
T
T
T
T
T
T
T
$40,000
T
T
$50,000
T
T
$3.50
$7.00
$8.75
$10.50
$14.00
$17.50
6.00
12.00
15.00
18.00
24.00
30.00
10.60
21.20
26.50
31.80
42.40
53.00
20.80
41.60
52.00
62.40
83.20
104.00
39.00
78.00
97.50
117.00
156.00
195.00
Children’s Term Rider
Sample Monthly Premiums
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
$9,000
$10,000
$0.45
$0.90
$1.35
$1.80
$2.25
$2.70
$3.15
$3.60
$4.05
$4.50
Applicable to AZ
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the
marketing brand.
2008 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210 PS01269
Accidental Death Benefit Rider
Issue Ages 16-65
Sample Monthly Premium per $1,000 Death Benefit
$0.12
Additional Coverage Term Rider
Issue Age
25
35
45
50
Sample Monthly Premium per $1,000 Death Benefit
Non-Tobacco
Tobacco
$0.15
$0.22
$0.19
$0.36
$0.47
$0.96
$0.74
$1.53
Guaranteed Purchase Option Rider
Issue Age
25
35
45
55
60
Sample Monthly Premium per $1,000 Death Benefit
Non-Tobacco
Tobacco
$0.02
$0.03
$0.03
$0.05
$0.11
$0.18
$0.20
$0.34
$0.28
$0.46
Waiver of Premium Rider Monthly Rate
Issue Age
T
25
T
T
T
T
T
T
T
35
T
45
T
55
$0.04
T
T
T
Sample Rates per $1,000
T
$0.06
T
$0.12
T
$0.15
T
T
Applicable to AZ
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the
marketing brand.
2008 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210 PS01269
Attachment 12
Universal Life LTC Rider
Universal Life
Long-Term Care Benefit Rider
This rider is available and can be purchased at an additional cost to provide extra coverage and
benefits with a Universal Life policy.
Colonial Life’s Long-Term Care Benefit Rider provides your employees with two kinds of
insurance protection in one convenient Universal Life policy – life insurance benefits and longterm care benefits.
The Long-Term Care Benefit Rider reduces the Universal Life policy death benefit to provide
monthly indemnity payments to help pay for the insured’s long-term care services needed as a
result of a chronic illness, serious accident, sudden illness, or cognitive impairment. The
maximum benefit amount is equal to the policy death benefit, less any indebtedness.
Benefits
Care Setting
Long-Term Care Facility or Assisted
Living Facility
Monthly Benefit
Monthly indemnity benefit of 4% of the Death
Benefit, less any policy debt, after the 90-day
elimination period.
Home Health Care by Licensed Home
Health Care Agency or Licensed Home
Health Care Professional
Monthly indemnity benefit of 4% of the Death
Benefit, less any policy debt, after the 90-day
elimination period.
Adult Day Care Benefit
Monthly indemnity benefit of 4% of the Death
Benefit, less any policy debt, after the 90-day
elimination period.
Features
• Benefit Payment Structure allows the employee to protect their savings and assets and have
more choice in where long-term care is received. It provides coverage for all care settings,
including the home.
• Advances the Universal Life death benefit in monthly indemnity payments to help pay for the
long-term care services needed as a result of the insured’s inability to perform at least two of
the six Activities of Daily Living (ADLs), or the insured’s requiring substantial supervision
due to severe cognitive impairment.
• Claim payments are made monthly and are a percentage of the death benefit.
• Terminates on the first to occur: base policy terminates; when the owner requests termination
of the rider; or the date the death benefit is exhausted from long-term care benefit payments.
• 90-day elimination period.
Applicable to AZ, MD, NV, RI
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing
brand.
2008 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210
PS01286
• Six-month pre-existing conditions limitation period.
• Built-in Waiver of Monthly Deductions due to payments of the long-term care benefit.
Waives all monthly deductions for the rider and the Universal life policy, when long-term
care benefits are being paid.
Eligibility Requirements
• Issue ages: 16-79 for employees and spouses.
• May be added to a Universal Life plan only during the initial sale or when increasing the
T
death benefit on the existing Universal Life policy.
Premium Information
•
Premiums are per thousand, unisex, tobacco distinct, and based on face amount and age.
What Is Not Covered
Pre-existing Condition Limitation:
• No benefits will be paid for any benefit period that results from a pre-existing condition and
that starts during the first six months after the effective date of the rider.
Other Limitations or Conditions on Eligibility for Benefits
We will not pay benefits for confinement or services:
• resulting from mental or nervous disorder; however, Alzheimer’s Disease and related
degenerative and dementing illnesses are covered;
• resulting from alcoholism, alcohol abuse, drug addiction or drug abuse;
• for which there is no charge in the absence of insurance;
• provided by a Family Member;
• received while residing or confined outside the United States and Canada; and
• due to Chronic Illnesses resulting from;
¾ war or any act of war, whether declared or undeclared, or service in any armed
forces or auxiliary units thereto;
¾ intentionally self-inflicted injuries or suicide;
¾ participation in a felony, riot or insurrections; and
¾ aviation (if a non-fare paying passenger).
Applicable to AZ, MD, NV, RI
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing
brand.
2008 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210
PS01286
Non-Duplication of Benefits
Qualified Long-Term Care Services do not include services for which charges are covered under
any of the following:
• Medicare (including amounts that would be reimbursable but for the application of
a deductible or co-insurance amounts);
• any other government program or facility (except Medicaid); and
• any state or federal worker’s compensation, employer’s liability or occupational
disease law, or under any motor vehicle no-fault law.
Definitions
Elimination Period – means the first 90 days of the Benefit Period. No benefits are payable for
care or service received during this time.
Pre-existing Condition – means a condition for which medial advice or treatment was
recommended by, or received from, a provider of health care services, within the six months
preceding the effective date of this rider.
Long-Term Care Rider Sample Monthly Premiums
Issue Age
25
35
45
55
65
Monthly Sample Premium per $1,000 Death
Benefit
Non-Tobacco
Tobacco
$0.01
$0.01
0.02
0.02
0.03
0.03
0.05
0.05
0.13
0.13
Applicable to AZ, MD, NV, RI
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing
brand.
2008 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210
PS01286
Restoration of Benefits Rider
This rider is available and can be purchased at an additional cost to provide extra coverage and
benefits with a Universal Life policy that includes a Long-Term Care Benefit rider.
Employees concerned about depleting their Universal Life insurance death benefit may also be
interested in purchasing the Restoration of Benefits Rider. This additional rider automatically
restores the death benefit on a monthly basis when a long-term care benefit is paid. The
maximum restoration amount is equal to the policy’s death benefit, so the rider will fully restore
the death benefit one time.
Features
• Terminates on the first to occur:
ƒ Universal Life policy terminates.
ƒ The date the full death benefit has been restored.
ƒ When the Long-Term Care Benefit Rider is terminated.
ƒ When the owner requests termination of the rider.
• Cannot be purchased unless the Long-Term Care Benefit Rider is purchased.
Eligibility Requirements
T
• Issue ages: 16-79 for employees and spouses.
• May only be added to a Universal Life plan during the initial sale when the Long Term Care
Benefit Rider is being purchased, or when increasing the death benefit on the existing
Universal Life policy and adding the Long-Term Care Benefit Rider.
• Cannot be added at subsequent enrollments, even if the Long-Term Care Rider is already in
force.
Premium Information
•
Premiums are per thousand, unisex, tobacco distinct, and based on face amount and age.
Restoration of Benefits Rider Sample Monthly Premiums
Issue Age
25
35
45
55
65
Monthly Sample Premium per $1,000 Death
Benefit
Non-Tobacco
Tobacco
$0.05
$0.06
0.07
0.08
0.12
0.14
0.30
0.32
1.03
1.16
Applicable to AZ, MD, NV, RI
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing
brand.
2008 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210
PS01286
Attachment 13
Universal Life Flyer
Universal Life
Insurance
Universal Life 1000
Financial flexibility
and protection ...
for whatever the
future brings
coloniallife.com
Life is always changing,
so you need life insurance that can change with it.
Universal Life Insurance
As time passes, we all face different challenges and opportunities –
getting married, buying a home, having children. But with each stage of
life, one thing stays the same: the need to protect the life you’re building
for you and your loved ones.
Whatever stage of life you’re in, life insurance can help you secure your family’s future. With Colonial Life
& Accident Insurance Company’s Universal Life Insurance, you have the flexibility you need to protect the
life you’re building – when your needs change, when you set or attain new goals, even when unexpected
challenges arise.
The Features of Universal Life Insurance
= Provides a death benefit (to age 100) that can be paid to your beneficiaries tax-free.
You can change your premium payments and/or death benefit amount to adapt to your changing needs
and goals with every life stage, subject to IRS and underwriting guidelines.
Cash value:
• Is guaranteed to be credited at a minimum guaranteed interest rate of 4 percent.
• Grows on a tax-deferred basis.
The typical married
couple would need to
= Offers two plan options from which to choose:
• Option A establishes a basic program of cash value life insurance – offers a level death
benefit; builds cash value at current credited interest rates.
= Provides access to the policy’s cash value when needed.
• You may borrow against your policy’s cash value or take cash withdrawals from the
cash value if needed. But keep in mind that loans and withdrawals can reduce the
cash value and death benefit and may even cause your policy to terminate.
= Includes an Accelerated Death Benefit.
• Allows you to be advanced up to 75 percent of the death benefit, not
- LIMRA, “Facts About Life” Fact Sheet,
September 2007
to exceed $150,000, upon diagnosis of a terminal illness of the insured.
(State variations exist for this benefit. Please refer to your policy for details.)
It is important to remember that, as with any universal life policy, your policy’s projected cash value
may change over time due to fluctuations in interest rates, changes in the cost of insurance, nonpayment of premiums, or certain policy changes. We encourage you to maintain consistent premium
payments and repay any outstanding loans in a timely fashion to help avoid an early termination of
coverage under your policy.
To provide you with a valuable record of your policy activity, Colonial Life mails you a universal life
annual report each year showing what you have paid, how much cash value you have, plus the status
of any loans, interest credited, administrative charges and projected termination dates. Be sure to
review the universal life annual report carefully.
of having enough
life
insurance to replace income
for 7 to 10 years.
• Option B offers a death benefit that increases as the policy’s cash value increases.
double itscurrent
coverage to meet
the expert
recommendation
= Builds cash value at current credited interest rates.
= Offers flexible premiums and death benefit amounts.
More than 1 in 3 parents without life
insurance say their children’s college
plans would end if their family’s
primary wage earner died.
- KRC Research, 2006, national telephone survey of Americans with children under age 18
Life insurance choices
for your family
life insurance policy with the same flexible features available to you –
whether or not you buy a policy on yourself.
Spouse Term Rider: Add term life insurance for your spouse to your policy.
• Choose a death benefit from $5,000 to $50,000.
• Choose to convert the term rider later to a cash value life insurance policy – without
providing proof of good health – if the rider terminates before the spouse’s 70th birthday.
Available at an additional cost
= Your Spouse
• Universal Life Policy: Provide your spouse a universal
•
•
•
•
•
= Your Children
• Universal Life Policy for Each Eligible Child:
Purchase a policy while children are young because premiums are lower.
They can keep the coverage even if health problems develop in the future.
Available whether or not you buy a policy on yourself.
Opportunity to increase coverage at the child’s ages 18, 21 and 24 without providing proof of good health.
• Children’s Term Rider:
• Add term life insurance to your policy to cover all your eligible children for one premium.
• Choose a death benefit from $1,000 to $10,000.
• Choose to convert the term rider later to a cash value life insurance policy – without providing proof of the child’s good health
– upon your 70th birthday or the child’s 25th birthday, whichever comes first.
Additional Coverage Options
Help meet your individual needs by adding one or more of these optional riders to your universal life policy at an additional cost.
Riders have limitations and exclusions that affect benefits payable and that may vary by state. Refer to the rider for your state for
complete details.
• Pays an additional benefit if you die as a result of an accidental bodily injury before age 70.
• Benefit doubles if the accidental bodily injury occurs while you are a fare-paying passenger within a public conveyance
such as a subway or city bus.
• An additional 25 percent of the accidental death benefit will be paid should the insured die due to an accidental bodily
injury sustained while driving or riding in a private passenger vehicle and wearing a seatbelt.
= Accidental Death Benefit Rider
• Increase your universal life coverage without providing proof of good health.
• Increase your coverage under your universal life policy at the second, fifth and eighth policy years or when specified life events occur.
• Premium determined by your age at the time of the increase and amount of insurance you choose.
= Guaranteed Purchase Option Rider
• Waives all monthly deductions (cost of insurance for your universal life policy and any riders) if you become totally disabled
before age 65 and you satisfy the six-month (180 days in MO) elimination period.
• Premiums waived by this provision don’t have to be repaid.
• Your policy’s cash value remains intact and continues earning interest.
= Waiver of Monthly Deductions Rider
• Add 20-year level term coverage of up to 100 percent of your policy’s death benefit.
• Choose to convert the additional coverage term rider to any new or existing cash value life insurance plan – without providing
proof of good health – if the universal life policy terminates or the additional coverage term rider terminates.
• Premiums remain level for the duration of the rider.
= Additional Coverage Term Rider
Your Universal Life Benefits Outline
$__________________
$__________________
$__________________
$__________________
$__________________
$__________________
$__________________
Death Benefit at Age 65 Based on
Guaranteed Rate of 4%
$__________________
Cash Value at Age 65 Based on
Guaranteed Rate of 4%
$__________________
Initial Death Benefit
Name-Primary _________________________________________________ Age ________ Tobacco / Nontobacco
Name-Spouse _________________________________________________ Age ________ Tobacco / Nontobacco
Name-Juvenile _________________________________________________ Age ________ Tobacco / Nontobacco*
Primary
Spouse
Juvenile*
Option A
Option A
Option A
Option B
Option B
Option B
*Only applies to full-time dependent students aged 18-24 who are issued an adult policy
Your Universal Life Premiums
$__________________
$__________________
$__________________
$__________________
$__________________
$__________________
$__________________
$__________________
$__________________
$__________________
$__________________
$__________________
Spouse Term Rider
$___________Death Benefit
Children’s Term Rider
$___________Death Benefit
Accidental Death Benefit Rider
Additional Coverage Term Rider
$___________Death Benefit
Guaranteed Purchase Option Rider
Waiver of Monthly Deductions Rider
$__________________
Weekly
Monthly
Policy Premium
$__________________
$__________________
$__________________
$__________________
$__________________
$__________________
$__________________
TOTAL PREMIUM
$__________________
$__________________
This worksheet assumes that illustrated interest and cost of insurance rates remain unchanged. Current interest rates may be
changed by the company on a monthly basis. Current cost of insurance rates is lower than or equal to the maximum cost of
insurance rates for your current age. We cannot change your rates due to a deterioration of your health. Any rate change must be
made on everyone your age in your state.
This brochure is applicable to policy forms ICC07-UL1000 / UL1000 and rider forms ICC07-R-UL-ACDTH / R-UL-ACDTH, ICC07-R-ULACR / R-UL-ACR, ICC07-R-UL-CTR / R-UL-CTR, ICC08-R-UL-GPO / R-UL-GPO, ICC07-R-UL-STR / R-UL-STR, ICC07-R-UL-WOMD / R-ULWOMD and applicable state versions.
Exclusions and Limitations
If the insured commits suicide within two years (one year in Missouri and North Dakota) from the coverage effective date or the date
of reinstatement (not applicable in Louisiana), whether he is sane or insane, we will not pay the death benefit. We will terminate this
policy and return the premiums paid minus any loans, loan interest and withdrawals to you. We will not pay any increases in death
benefits if the insured commits suicide, whether he is sane or insane, within two years (one year in Missouri and North Dakota) from
the coverage effective date of the increase. Our only obligation will be to refund the premiums paid for the increase in the event of
suicide. You will receive a policy summary or illustration (whichever is applicable in your state) when your policy is issued. This policy
has exclusions, reductions of benefits and terms under which the policy may be continued in force or discontinued. For costs and
complete details of the coverage, call or write your insurance agent or the company.
Universal Life 1000
Colonial Life
1200 Colonial Life Boulevard
Columbia, South Carolina 29210
coloniallife.com
Colonial Life products are underwritten by Colonial Life & Accident
Insurance Company, for which Colonial Life is the marketing brand.
69577
05/08 Rev. -0
Attachment 14
Disability 1000 Benefit Summary
Disability 1000
Colonial Life’s supplemental short-term disability insurance policy is an individual plan that is
sold via payroll deduction at the workplace. It replaces a portion of your employee’s income if
he becomes unable to work because of a covered accident or sickness.
This policy offers two plan choices that provide off-job and on- and off-job coverage options.
•
Off-Job Accident/Off-Job Sickness—Disability benefits for off-job covered accidents and
off-job covered sicknesses.
•
On/Off-Job Accident/ Sickness—Disability benefits for on-job and off-job covered
accidents and on-job and off-job covered sicknesses.
Benefits
Plan Structure



Benefit Amount

Off-Job Accident and Off-Job Sickness
On/Off-Job Accident / Sickness
Please note that the on-job benefit is 50% of the off
job benefit.
$400 to $6,500 (offered in $100 increments)
Maximum income replacement is 60% of income.
Benefit Periods
Elimination Periods





3 months
6 months
12 months
24 months
0/7, 7/7, 0/14, 14/14, 0/30, 30/30 60/60, 90/90, and
180/180
Choice of elimination periods based on benefit periods
selected.
Elimination period means the number of days following a
disability before benefits begin. The first number
represents accident elimination period /the second number
represents sickness.
If $3,100 to $6,500 in monthly benefits is selected, a 3, 6, 12
or 24 month benefit period with a 14/14, 30/30, 60/60,
90/90 or 180/180 elimination period is available.
Applicable to AK, AL, AZ, CO, DC, DE, HI, IN, KY, ME, ND, NE, NV, OH, RI, WI
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing
brand.
3/14 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210 PS00084
Optional Rider
An optional rider is available and can be purchased at an additional cost to provide extra
coverage and benefits.
Health Screening Rider
• $50 per calendar year for one of 18 health screening tests
• 30 day waiting period
• Rider is guaranteed renewable for life
Features
•
•
•
•
•
•
•
•
•
Benefits are paid directly to the insured unless they specify otherwise.
Benefits are paid in addition to other insurance your employees may have with other
insurance companies.
Total and partial disability benefits. Pays partial benefits after total disability benefits are
paid, if the insured returns to work less than 20 hours per week.
Guaranteed renewable. This policy is guaranteed renewable to the policy anniversary date on
or next following the policyholder’s 70th birthday. Premiums can be changed only if we
change them on all policies of this kind in the state where the policy is issued.
Coverage is portable. An employee can take this coverage with him if he changes jobs or
leaves your company.
Worldwide coverage. The policyholder is covered for disabilities occurring outside the
regularly covered geographical areas for up to 60 days.
Unisex rates. Premiums are the same for males and females.
Waiver of premium after insured is disabled for 90 consecutive days.
No integration. There is no integration with other coverages. Benefits are paid regardless of
benefits received from other sources. For benefit amounts over $4,000 per month, offsetting
occurs during the application process.
Eligibility Requirements
Disability 1000 Base Policy
• Offered to all permanent, benefit-eligible employees up to age 69 who work at least 20 hours
per week on a regular basis
Participation Requirements
To offer this plan, we require only 3 eligible applicants.
Premium Information
•
•
•
•
Age-banded and one blended risk.
Premiums are based on the account’s industry risk classification.
Age bands of 17-49, 50-69.
Premiums do not increase as the policyholder ages.
Applicable to AK, AL, AZ, CO, DC, DE, HI, IN, KY, ME, ND, NE, NV, OH, RI, WI
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing
brand.
3/14 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210 PS00084
Definitions
Total Disability: means you are unable to perform the material and substantial duties of your
job; not, in fact, working at any job; and under the regular and appropriate care of a doctor.
Partial Disability: means you are unable to perform the material and substantial duties of your
job for 20 hours or more per week; you are able to work at your job or any other job for less than
20 hours per week; your employer will allow you to work for less than 20 hours per week and
you are under the regular and appropriate care of a doctor. To qualify for partial disability, total
disability benefit must have been paid for one month. Partial disability pays 50% of the total
disability benefit.
Pre-existing Condition: means your having a sickness or physical condition for which you
were treated, received medical advice, or had taken medication within 12 months before the
effective date of this policy. If the policyholder becomes disabled because of a pre-existing
condition, the policy does not pay for any disability period if it begins during the first 12 months
the policy is in force. Any recurrent disability caused by a pre-existing condition will not be
covered if it is treated as a continuation of the previous disability.
Waiver of Premium Benefit: After you have been totally disabled or qualify for partial
disability benefits as the result of a covered accident or covered sickness for more than 90
consecutive days (while your policy is in effect), or after the elimination period shown in your
policy (whichever is greater), we will waive the premium for as long as you remain disabled.
The premium will be waived up to the maximum benefit period shown in your policy.
There is no limit to the number of times you can receive the Waiver of Premium benefit. This
Waiver of Premium benefit does not apply to any period that you are totally disabled due to an
accident or condition which is excluded by name or specific description in the policy.
Worldwide Coverage: If the policyholder becomes totally disabled as the result of a covered
accident or a covered sickness while outside the covered geographical areas, the Geographical
Limitations provision may allow us to provide benefits. The policyholder must be totally
disabled longer than the elimination period, and the maximum benefit period for total disability
and partial disability combined while outside the covered geographical areas will be limited to 60
days. Covered geographical areas are less than 40 miles outside the territorial limits of the
United States, Canada, Mexico, Puerto Rico, the Bahama Islands, the Virgin Islands, Bermuda,
or Jamaica
Applicable to AK, AL, AZ, CO, DC, DE, HI, IN, KY, ME, ND, NE, NV, OH, RI, WI
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing
brand.
3/14 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210 PS00084
What is Not Covered
General Exclusions and Limitations:
•
•
•
Alcoholism or Drug Addiction
Flying
Giving Birth: Giving birth within the
first nine months after the effective date
of this policy as the result of a normal
pregnancy, including Cesarean.
Complications of pregnancy will be
covered to the same extent as any other
covered sickness.
•
•
•
•
•
•
•
•
Hazardous Avocations
Illegal Activities
Pre-Existing Conditions
Psychiatric or Psychological Conditions
Racing
Semi-professional or Professional Sports
Suicide or Self-inflicted Injuries
War or Armed Conflict
The above list does not include a complete description of each limitation and exclusion. To
obtain a complete description, please refer to an outline of coverage, sample policy, or see your
Colonial Life representative.
Applicable to AK, AL, AZ, CO, DC, DE, HI, IN, KY, ME, ND, NE, NV, OH, RI, WI
This information is only intended for proposal use with employers.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing
brand.
3/14 Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210 PS00084
Attachment 15
Disability 1000 Outline of Coverage
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY
P.O. Box 1365, Columbia, South Carolina 29202
(800) 325-4368
DISABILITY INCOME COVERAGE
OUTLINE OF COVERAGE
(Applicable to Policy Form DIS 1000,
including state abbreviations where used)
Read your policy carefully. This outline provides a very brief description of the important features of your policy. This is
not an insurance contract and only the actual policy provisions will control. The policy sets forth in detail the rights and
obligations of both you and us. It is, therefore, important that you READ YOUR POLICY CAREFULLY.
Renewability. Your policy is guaranteed renewable to the policy anniversary date on or next following your 70th birthday.
Your premium can be changed only if we change it on all policies of this kind in force in the state where your policy was
issued. Policy anniversary date occurs annually on the same date and in the same month as the date for which we first
received premium.
Disability Income Coverage. Your policy is designed to provide coverage for disabilities that result from covered
accidents or covered sicknesses subject to any limitations or exclusions. It does not provide coverage for basic hospital,
basic medical-surgical or major medical expenses.
Coverage Provided by the Policy. We will pay the total disability benefit shown in the Policy Schedule if you become
totally disabled and are totally disabled longer than the elimination period as the result of a covered accident or covered
sickness while the policy is in force.
If benefits are payable for less than a full month, we will pay the appropriate benefits on a daily basis. A month is 30 days.
The daily amount is 1/30th of the monthly amount.
If you do not have a job when you become totally disabled, we will pay the total disability benefit only as long as you are
kept at home and cannot perform two of five Activities of Daily Living and you are under the regular and appropriate care
of a doctor.
If you become partially disabled as a result of a covered accident or a covered sickness, we will pay up to the benefit
period and in the amount shown for a partial disability in the Policy Schedule, except as described in the Geographical
Limitations provision, for as long as this coverage is in force and you remain partially disabled, subject to the following
conditions:
• the total disability benefit must have been paid for at least one full month immediately prior to your being partially
disabled; and
• for a given period of disability, you may receive either a partial disability benefit or a total disability benefit, but not
both.
Recurrent Disability: A recurrent disability will be treated as:
• a continuation of the previous disability, not a new disability, if you have returned to work for less than six months.
• a new disability, if you have returned to work for six months or more, working at least the same number of hours you
were working before the previous disability began.
• a new disability, if you did not have a job before the previous disability began and you have ceased to be disabled for
six months or more.
• a continuation of the previous disability for any circumstances not specifically listed above.
A new disability is subject to a new elimination period, and a new benefit period applies. A disability that is considered a
continuation of a previous disability is not subject to a new elimination period, and a new benefit period does not apply.
Any recurrent disability caused by a pre-existing condition will not be covered if it is treated as a continuation of the
previous disability.
If you become disabled because of a pre-existing condition, we will not pay for any disability period if it begins during the
first 12 months the policy is in force.
DIS 1000-O
1
58701
Concurrent or Subsequent Disability: During any period in which you are disabled due to more than one condition,
whether the conditions are related or unrelated, benefits will be paid as if you are disabled due to only one condition. In
no event will your being disabled due to more than one condition extend the benefit period beyond the benefit period
shown in the Policy Schedule. Separate periods of disability resulting from unrelated conditions are considered a
continuation of the previous disability, not a new disability, unless:
• they are separated by a minimum of 10 calendar days;
• during such time you returned to work performing the material and substantial duties of your job; and
• during such time you are no longer qualified to receive total or partial disability benefits.
This coverage will end on the policy anniversary date on or next following your 70th birthday. Coverage ending at age 70
will not affect any disability that began while the policy was in force. The disability benefit will be limited to the payment of
the applicable monthly benefit amount for the length of the applicable benefit period shown on the Policy Schedule.
Time Limits
After the policy has been in force for 12 months from the effective date of the policy, we will pay benefits for any preexisting condition not excluded by name or specific description if the covered disability began 12 months after the effective
date and the elimination period has been satisfied.
Geographical Limitations
If you become totally disabled as the result of a covered accident or a covered sickness while you are outside the covered
geographical areas and you are totally disabled longer than the elimination period shown in the Policy Schedule, your
maximum benefit period for total disability and partial disability combined while outside the covered geographical areas
will be limited to 60 days. Covered geographical areas are less than 40 miles outside the territorial limits of the United
States, Canada, Mexico, Puerto Rico, the Bahama Islands, the Virgin Islands, Bermuda or Jamaica.
After the 60-day period, benefits will not be paid until you return to the covered geographical areas.
If you are still totally or partially disabled as defined in the policy when you return from outside the covered geographical
areas, we will determine your remaining applicable benefit period by subtracting the time period for which we have already
paid you benefits from the benefit period shown in the Policy Schedule. We will pay the monthly benefit amount shown in
the Policy Schedule for up to the remaining applicable benefit period.
Waiver of Premium Benefit
After you have been totally disabled or qualify for partial disability benefits as the result of a covered accident or a covered
sickness for more than 90 consecutive days while the policy is in effect, or after the elimination period shown in the Policy
Schedule, whichever is greater, we will waive the premium for the policy and any attached rider(s) for as long as you
remain disabled, up to the benefit period shown in the Policy Schedule. You must pay all premiums to keep the policy and
any attached rider(s) in force until you have been totally disabled or qualify for partial disability benefits for 90 consecutive
days while the policy is in effect, or for the elimination period shown in the Policy Schedule, whichever is greater.
You must send us written notice as soon as you are no longer disabled. We will assume you are no longer disabled if:
• You do not send us satisfactory proof of loss when we request it; or
• You notify us that you are no longer disabled.
You must pay all premiums to keep the policy and any attached rider(s) in force beginning with the first premium due after
you are no longer disabled.
The Waiver of Premium Benefit does not apply to any period that you are totally or partially disabled due to an accident or
condition which is excluded by specific name or specific description in the policy.
There is no limit to the number of times you can receive the Waiver of Premium benefit.
DIS 1000-O
2
58701
Important Words in the Policy
Activities of Daily Living mean the following:
1. Dressing – the ability to put on and take off all garments and medically necessary braces or artificial limbs usually
worn
2. Transferring – the ability to move in or out of a chair or bed
3. Eating – the ability to get nourishment into the body once it has been prepared
4. Preparing meals
5. Toileting – the ability to get on and off the toilet, to maintain a reasonable level of personal hygiene and to care for
clothing
A covered accident is an accident which:
• occurs after the effective date of the policy;
• is of a type listed on the Policy Schedule;
• occurs while the policy is in force; and
• is not excluded by name or specific description in the policy.
A covered sickness means an illness, infection, disease or any other abnormal physical condition, not caused by an injury,
which:
• occurs after the effective date of the policy;
• is of a type listed on the Policy Schedule;
• occurs while the policy is in force; and
• is not excluded by specific name or specific description in the policy.
A doctor means a person, other than you or a family member, who is licensed by the state to practice a healing art, and
performs services for you which are allowed by his license. For the purposes of this definition, family member means your
spouse, son, daughter, mother, father, sister or brother.
Elimination period means the period of time during which no benefits are payable, as shown in the Policy Schedule.
Material and substantial duties of your job are defined as those job duties which:
• are normally required to perform your regular job; and
• cannot be reasonably modified or omitted.
Performing your job at a particular work site or in a particular building is not a material and substantial duty of your job,
provided that your employer will allow you to perform your job at a different work site or in a different building.
Off-job accident means an accident that occurs while you are not working at any job for pay or benefits.
Off-job sickness means a sickness that was not caused by or contributed to by your working at any job for pay or benefits.
On-job accident means an accident that occurs while you are working at any job for pay or benefits.
On-job sickness means a sickness that was caused by or contributed to by your working at any job for pay or benefits.
Partially disabled means:
• you are unable to perform the material and substantial duties of your job for 20 hours or more per week;
• you are able to work at your job or any other job for less than 20 hours per week;
• your employer will allow you to work for less than 20 hours per week; and
• you are under the regular and appropriate care of a doctor.
Pre-existing condition means your having a sickness or physical condition for which you were treated, received medical
advice or had taken medication within 12 months before the effective date of the policy.
Recurrent disability means your becoming disabled, ceasing to be disabled, then becoming disabled again for the same or
related condition. The latter disability will be considered a recurrent disability.
DIS 1000-O
3
58701
Totally disabled means you are:
• unable to perform the material and substantial duties of your job;
• not in fact, working at any job; and
• under the regular and appropriate care of a doctor.
Under the regular and appropriate care of a doctor means you are being cared for on a regular basis by a doctor and the
care you are receiving is appropriate for the condition(s) which disable(s) you.
What Is Not Covered by the Policy
We will not pay benefits for losses that are caused by or are the result of your:
• addiction to alcohol or drugs, except for drugs taken as prescribed by your doctor;
• operating, learning to operate, or serving as a crew member of or jumping or falling from any aircraft or hot air balloon,
including those which are not motor-driven. This does not include flying as a fare paying passenger.
• giving birth within the first nine months after the effective date of the policy as the result of a normal pregnancy,
including Cesarean. Complications of pregnancy will be covered to the same extent as any other covered sickness;
• engaging in hang gliding, bungee jumping, parachuting, sailgliding, parasailing or parakiting or any similar activities;
• participating or attempting to participate in an illegal activity and/or being incarcerated in a penal institution;
• having a pre-existing condition as described and limited by the policy;
• having a psychiatric or psychological condition including, but not limited to, affective disorders, neuroses, anxiety,
stress and adjustment reactions. However, Alzheimer’s Disease and other organic senile dementias are covered
under the policy;
• riding in or driving any motor-driven vehicle in a race, stunt show or speed test;
• practicing for or participating in any semi-professional or professional competitive athletic contest for which you
receive any type of compensation or remuneration;
• committing or trying to commit suicide or your injuring yourself intentionally, whether you are sane or not; or
• being exposed to war or any act of war, declared or undeclared, or serving in the armed forces of any country or
authority.
DIS 1000-O
4
58701
Attachment 16
Disability 1000 Flyer
Short-Term
Disability Insurance
How long could you afford to go
without a paycheck?
Help protect your paycheck with Colonial Life’s short-term disability insurance.
You use your paycheck mainly to pay for your home, your car, groceries, medical bills and utilities. What if you
couldn’t go to work due to an accident or sickness?
Monthly Expenses:
$_________________
$_________________
$_________________
$_________________
$_________________
$_________________
Total $_________________
My Coverage Worksheet (For use with your Colonial Life Benefits Counselor)
How much coverage do I need?
On-Job Accident and On-Job Sickness $________ Off-Job Accident and Off-Job Sickness $________
How long will I receive benefits?
Total Disability: ___________ months
Partial Disability: 3 months*
*Partial Disability is 50% of the Total Disability Amount
When will my benefits start?
After an Accident: ___________ days
After a Sickness: ___________ days
How much will it cost?
Disability 1000
Your cost will vary based on the level of coverage you select.
What additional features are included?
O
O
Waiver of Premium
Worldwide Coverage
Here are some
frequently asked questions about Colonial Life’s
disability insurance:
Will my disability income payment be
reduced if I have other insurance?
You’re paid regardless of any other insurance you may have
with other insurance companies. Benefits are paid directly
to you (unless you specify otherwise).
When am I considered totally disabled?
Totally disabled means you are:
O Unable to perform the material and substantial duties
of your job;
O Not working at any job; and
O Under the regular and appropriate care of a doctor.
What if I want to return to work
part-time after I am totally disabled?
You may be able to return to work part-time and still receive
benefits. We call this “Partial Disability.” This means you may
be eligible for coverage if:
O
O
O
O
You are unable to perform the material and substantial
duties of your job 20 hours or more per week,
You are able to work at your job or any other job for less
than 20 hours per week,
Your employer will allow you to work for less than 20
hours per week, and
You are under the regular and appropriate care of
a doctor.
The total disability benefit must have been paid for at least
one full month immediately prior to your being partially
disabled
What if I change employers?
Disability 1000
If you change jobs or leave your employer, you can take
your coverage with you at no additional cost. Your coverage
is guaranteed renewable to age 70 as long as you continue
to pay your premiums when they are due.
What is a pre-existing condition?
A pre-existing condition is when you have a sickness or
physical condition for which you were treated, received
medical advice, or had taken medication within 12 months
before the effective date of your policy.
If you become disabled because of a pre-existing condition,
Colonial Life will not pay for any disability period if it begins
during the first 12 months the policy is in force.
Can my premium change?
You may choose the amount of coverage to meet your
needs (subject to your income). You can elect more or
less coverage which will change your premium. Colonial
Life can change your premium only if we change it on all
policies of this kind in the state where your policy was
issued.
What is a covered accident or a
covered sickness?
A covered accident is an accident. A covered sickness
means an illness, infection, disease or any other abnormal
physical condition, not caused by an injury.
A covered accident or covered sickness:
O Occurs after the effective date of the policy;
O Is of a type listed on the Policy Schedule;
O Occurs while the policy is in force; and
O Is not excluded by name or specific description in
the policy.
How do I file a claim?
Visit coloniallife.com or call our Policyholder Service Center
at 1.800.325.4368 for additional information.
EXCLUSIONS
We will not pay benefits for losses that are caused by or are the result of: alcoholism or drug addiction; flying; giving
birth within the first nine months after the effective date of the policy; hazardous avocations; illegal activities; having a
pre-existing condition as described and limited by the policy; psychiatric or psychological conditions; racing;
semi-professional or professional sports; suicide or self-inflicted injuries; war or armed conflict.
For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form DIS1000 (state
abbreviations where applicable). This is not an insurance contract and only the actual policy provisions will control.
Colonial Life
1200 Colonial Life Boulevard
Columbia, South Carolina 29210
coloniallife.com
4/11
©2011 Colonial Life & Accident Insurance Company.
Colonial Life products are underwritten by Colonial Life & Accident
Insurance Company, for which Colonial Life is the marketing brand.
Colonial Life and Making benefits count are registered service marks
of Colonial Life & Accident Insurance Company.
59013-9
Attachment 17
Medical Bridge 3000 Hospital Confinement
Outline of Coverage
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY
1200 Colonial Life Boulevard, P.O. Box 1365 Columbia, South Carolina 29202 (800) 325 - 4368
A Stock Company
LIMITED BENEFIT HOSPITAL CONFINEMENT INDEMNITY INSURANCE
OUTLINE OF COVERAGE (Applicable to Policy form MB3000-AZ)
BENEFITS PROVIDED ARE SUPPLEMENTAL AND NOT INTENDED TO COVER ALL MEDICAL EXPENSES.
THIS IS NOT MEDICARE SUPPLEMENT COVERAGE. If you are eligible for Medicare, review the Guide To Health
Insurance for People with Medicare available from the company. Premiums vary depending on your level of coverage.
Read your policy carefully. Your outline provides a very brief description of the important features of your policy. This is not an
insurance contract and only the actual policy provisions will control. The policy sets forth in detail the rights and obligations of both
you and us. It is, therefore, important that you READ YOUR POLICY CAREFULLY.
Renewability. Your policy is guaranteed renewable as long as you pay the premiums when they are due or within the grace period.
The premium can be changed only if we change it on all policies of this kind in force in the state where the policy was issued.
Limited Benefit Coverage. Your policy does not provide coverage for basic hospital, basic medical-surgical or major medical
expenses.
Benefits
Hospital Confinement Benefit Amount: $________ per confinement We will pay this benefit if any covered person incurs
charges for and is confined due to a covered accident or covered sickness. The confinement to a hospital must begin while the policy
is in force. We will pay this benefit once per confinement. If a covered person is confined and is discharged and confined again for
the same or related condition within 90 days of discharge, we will treat this later confinement as a continuation of the previous
confinement. If more than 90 days have passed between the periods of hospital confinement, we will treat this later confinement as a
new and separate confinement.
Surgical Procedure Benefit
General Requirements for Surgical Procedure Benefit
The following requirements apply to both the Outpatient Surgical Procedure Benefit and the Inpatient Surgical Procedure Benefit:
Surgical Procedure means the cutting into the skin or other organ to accomplish any of the following goals:
• remove diseased tissues or organs; • redirect channels;
• repair an area that has been injured
• remove an obstruction;
• transplant tissue or whole organs;
or affected by trauma, overuse, or
• reposition structures to their
• implant mechanical or electronic devices;
disease; or
normal position;
• restore proper function.
The following will not be considered a surgical procedure for the purposes of the policy:
• Venipuncture (drawing blood);
• Epidural steroid injections;
• Foreign body removal from the eye.
• Lumbar puncture;
• Removal of skin tags;
• Biopsies; or
• Procedures for: angiogram, arteriogram, thallium stress test, transesophageal echocardiogram (TEE), barium enema/lower
GI series, barium swallow/upper GI series, esophagogastroduodenoscopy (EGD), laryngoscopy, hysteroscopy, loop
electrosurgical excisional procedure (LEEP), computerized tomography scan (CT scan), electroencephalogram (EEG),
magnetic resonance imaging (MRI), myelogram, nuclear medicine test, positron emission tomography scan (PET scan),
bone marrow aspiration, bronchoscopy, pulmonary function test (PFT), excision of lesion, and urinary cystoscopy.
We will pay for only one surgical procedure for the same covered accident or covered sickness in a 90-day time period. If a covered
person receives a subsequent surgical procedure for the same covered accident or same covered sickness, we will pay an additional
benefit only if the subsequent procedure was performed more than 90 days after the last covered procedure was performed.
We will pay no more than the Calendar Year Maximum for the Surgical Procedure Benefit shown on the Policy Schedule.
We will also pay this benefit for reconstructive surgical procedures performed following a covered mastectomy on one breast or both
breasts to reestablish symmetry between the two breasts, prostheses and treatment of physical complications for all stages of the
mastectomy, including lymphedemas subject to all of the terms and conditions of this policy.
Outpatient Surgical Procedure Benefit
Tier 1 Surgical Procedures $________ per covered procedure
Tier 2 Surgical Procedures $________ per covered procedure
We will pay this benefit if any covered person incurs charges for and requires a surgical procedure due to a covered accident or
covered sickness, and he is not confined in a hospital at the time of the procedure (outpatient surgical procedure). The procedure must
be performed by a doctor. We will pay this benefit once per covered outpatient surgical procedure. We will pay this benefit for only
one outpatient surgical procedure performed at the same time even if caused by more than one accident or sickness. In that event, we
will pay the benefit that has the highest dollar value. The outpatient surgical procedure must occur while this policy is in force. To
determine the amount payable for an outpatient surgical procedure, locate the procedure in one of the tiers shown in the Outpatient
Surgical Procedure Schedule below and refer to the benefit amount on the Policy Schedule for the tier in which the procedure appears.
MB3000-O-AZ
1
Plan 2
65811-1
If the specific procedure is not listed in the Outpatient Surgical Procedure Schedule, we will use the Current Procedural Terminology
(CPT) Code provided by the covered person’
s doctor and a current relative value scale to determine the tier of the procedure.
Tier 1 Surgical Procedures
Breast
Ear/Nose/Throat/Mouth
Musculoskeletal System
Axillary node dissection
Adenoidectomy
Carpal/cubital repair or release
Breast capsulotomy
Removal of oral lesions
Dislocation (closed reduction treatment)
Breast reconstruction
Myringotomy
Foot surgery (bunionectomy, exostectomy,
Lumpectomy
Tonsillectomy
arthroplasty, hammertoe repair)
Cardiac
Tracheostomy
Fracture (closed reduction treatment)
Pacemaker insertion
Gynecological
Removal of orthopedic hardware
Digestive
Dilation & Curettage (D&C)
Removal of tendon lesion
Colonoscopy
Endometrial ablation
Skin
Fistulotomy
Lysis of adhesions
Laparoscopic hernia repair
Hemorrhoidectomy (external)
Liver
Skin grafting
Lysis of adhesions
Paracentesis
Tier 2 Surgical Procedures
Breast
Ear/Nose/Throat/Mouth cont.
Musculoskeletal System
Breast reduction
Septoplasty
Arthroscopic knee surgery w/menisectomy
Cardiac
Stapedectomy
(knee cartilage repair)
Angioplasty
Tympanoplasty
Arthroscopic shoulder surgery
Cardiac catherization
Tympanotomy
Clavicle resection
Digestive
Eye
Dislocations (ORIF - open reduction with
Exploratory laparoscopy
Cataract surgery
internal fixation)
Laparoscopic appendectomy
Corneal surgery (penetrating keratoplasty)
Fracture (ORIF - open reduction with internal
Laparoscopic cholecystectomy
Glaucoma surgery (trabeculectomy)
fixation)
Ear/Nose/Throat/Mouth
Vitrectomy
Removal or implantation of cartilage
Ethmoidectomy
Gynecological
Tendon/ligament repair
Mastoidectomy
Myomectomy
Thyroid
Excision of a mass
Inpatient Surgical Procedure Benefit $________ per covered procedure
We will pay this benefit if any covered person incurs charges for and requires a surgical procedure due to a covered accident or
covered sickness and he is confined in a hospital at the time of the procedure (inpatient surgical procedure). The procedure must be
performed by a doctor using general anesthesia. We will pay this benefit once per covered inpatient surgical procedure. We will pay
this benefit for only one inpatient surgical procedure performed at the same time even if caused by more than one accident or
sickness. The inpatient surgical procedure must occur while this policy is in force. General anesthesia means the induction of a balanced
state of unconsciousness, accompanied by the absence of pain sensation and the paralysis of skeletal muscle over the entire body. We
will pay the amount shown on the Policy Schedule. We will also pay the Hospital Confinement Benefit.
Calendar Year Maximum $________ per covered person for all covered surgical procedures combined
The calendar year maximum shown applies to the Outpatient Surgical Procedure Benefit and the Inpatient Surgical
Procedure Benefit combined.
External Breast Prosthesis Benefit $50 per prosthesis, maximum of two prostheses per covered person We will pay this
benefit if any covered person requires a postoperative external breast prosthesis as the result of a mastectomy for which a surgery
benefit is payable under the terms of this policy. We will pay for a maximum of two external breast prostheses per covered person.
The prosthesis must be obtained while this policy is in force.
Wellness Benefit Amount: $50 per test, one test per calendar year if named insured coverage; two tests per calendar year if
named insured and spouse coverage, one-parent family coverage or two-parent family coverage We will pay this benefit if
any covered person incurs charges for and has one of the wellness tests listed below performed while the policy is in force. We will
pay the amount shown for one of the following wellness tests:
• Blood test for triglycerides
• Colonoscopy or Virtual
• PSA (blood test for prostate cancer)
• Breast ultrasound
Colonoscopy
• Serum protein electrophoresis (blood test
• CA 15-3 (blood test for breast cancer) • Fasting blood glucose
for myeloma)
• CA 125 (blood test for ovarian cancer) • Flexible sigmoidoscopy
• Serum cholesterol test for HDL and LDL
• CEA (blood test for colon cancer)
• Hemoccult stool analysis
• Stress test on a bicycle or treadmill
• Chest x-ray
• Mammography
• Thermography
• Pap smear or Thin Prep Pap
MB3000-O-AZ
2
Plan 2
65811-1
We will pay up to the maximum number of tests shown.
Rehabilitation Unit Benefit Amount: $100 per day up to 15 days per confinement with a 30 day maximum per covered
person per calendar year We will pay this benefit if any covered person incurs charges for and is transferred to a rehabilitation unit
immediately after a period of hospital confinement due to a covered accident or covered sickness. We will pay the amount shown for
each day of confinement in a rehabilitation unit, up to the maximum number of days shown. Confinement to a rehabilitation unit must
begin while the policy is in force.
Waiver of Premium Benefit After you have been confined to a hospital due to a covered accident or covered sickness for more than
30 continuous days while the policy is in force, we will waive the premium for the policy and any attached riders for as long as you
remain confined to a hospital or rehabilitation unit. You must pay all premiums to keep the policy and any attached rider(s) in force
until you have been confined to a hospital for more than 30 continuous days and the waiver becomes effective. You must send us
written notice as soon as you are no longer confined to a hospital or rehabilitation unit. We will assume you are no longer confined to
a hospital or rehabilitation unit if:
• You do not send us satisfactory proof of loss when we request it; or
• You notify us that you are no longer confined to a hospital or rehabilitation unit.
You must pay all premiums to keep the policy in force beginning with the first premium due after you are no longer confined to a
hospital or rehabilitation unit. The Waiver of Premium Benefit does not apply to any period that you are confined to a hospital or
rehabilitation unit due to an accident, sickness or condition which is excluded by name or specific description. This benefit does not
apply to your spouse or to your children. We will waive premiums only if you, the named insured, are confined to a hospital for more
than 30 continuous days. However, if this is a named insured and spouse, one-parent family policy or a two-parent family policy, we
will waive premiums on all family members insured by the policy.
Definitions
Accident means an unintended or unforeseen bodily injury sustained by a covered person, wholly independent of disease, bodily
infirmity, illness, infection, or any other abnormal physical condition.
Calendar Year means the period beginning on the effective date of coverage shown on the Policy Schedule and ending on December
31 of the same year. Thereafter, it is the period beginning on January 1 and ending on December 31 of each following year.
Confined or Confinement means the assignment to a bed as a resident inpatient in a hospital on the advice of a physician or, for
purposes of the hospital confinement benefit only, confinement in an observation unit within a hospital for a period of no less than 20
continuous hours on the advice of a physician.
Covered Accident means an accident which occurs on or after the effective date of the policy, occurs while the policy is in force, and
is not excluded by name or specific description in the policy.
Covered Sickness means an illness, infection, disease or any other abnormal physical condition, not caused by an accident, which
occurs on or after the effective date of the policy, occurs while the policy is in force, and is not excluded by name or specific
description in the policy.
Dependent Children means any natural children, step-children, legally adopted children or children placed into your custody for
adoption who are unmarried, chiefly dependent on you or your spouse for support and younger than age 26.
Doctor or Physician means a person who is licensed by the state to practice a healing art and performs services for a covered person
which are allowed by his license. For purposes of this definition, Doctor or Physician does not include any covered person or anyone
related to any covered person by blood or marriage, a business or professional partner of any covered person, or any person who has a
financial affiliation or a business interest with any covered person.
Emergency Room means a specified area within a hospital which is designated for the emergency care of accidental injuries or
sicknesses. This area must be staffed and equipped to handle trauma, be supervised and provide treatment by physicians and provide
care seven days per week, 24 hours per day.
Hospital means a place that is run according to law on a full-time basis, provides overnight care of injured and sick people, is
supervised by a doctor, has full-time nurses supervised by a registered nurse, and has at its locations or uses on a pre-arranged basis:
X-ray equipment, a laboratory and an operating room where surgical operations take place.
A hospital is not a nursing home, an extended care facility, a skilled nursing facility, a rest home or home for the aged, a rehabilitation
unit, a place for alcoholics or drug addicts or an assisted living facility.
Observation Unit means a specified area within a hospital, apart from the emergency room, where a patient can be monitored
following outpatient surgery or treatment in the emergency room by a physician and which is under the direct supervision of a
physician or registered nurse, is staffed by nurses assigned specifically to that unit and provides care seven days per week, 24 hours per
day.
Pre-existing Condition means any covered person having a sickness or physical condition for which he was treated, had medical
testing, received medical advice or had taken medication within 12 months before the effective date of the policy.
Rehabilitation Unit means an appropriately licensed facility that provides rehabilitation care services on an inpatient basis.
Rehabilitation care services consist of the combined use of medical, social, educational, and vocational services to enable patients
disabled by sickness or accidental injury to achieve the highest possible functional ability. Services are provided by or under the
supervision of an organized staff of physicians. The rehabilitation unit may be part of a hospital or a freestanding facility.
MB3000-O-AZ
3
Plan 2
65811-1
A rehabilitation unit is not a nursing home, an extended care facility, a skilled nursing facility, a rest home or home for the aged, a
hospice care facility, a place for alcoholics or drug addicts, or an assisted living facility.
What is Not Covered We will not pay benefits for injuries received in accidents or for sicknesses which are caused by:
• Any covered person’
s treatment for dental care or dental procedures, unless treatment is the result of a covered accident.
• Any covered person undergoing elective procedures or cosmetic surgery. This includes procedures for complications arising from
elective or cosmetic surgery. This does not include congenital birth defects or anomalies of a child or reconstructive surgery related
to a covered sickness or injuries received in a covered accident.
• Any covered person participating or attempting to participate in an illegal activity.
• Any covered person being intoxicated or under the influence of any narcotic unless administered on the advice of a physician.
• Any pregnancy of a dependent child, including services rendered to her child after birth.
• Any covered person having a psychiatric or psychological condition including but not limited to affective disorders, neuroses,
anxiety, stress and adjustment reactions. However, Alzheimer’
s Disease and other organic senile dementias are covered under the
policy.
• Any covered person committing or trying to commit suicide or injuring himself intentionally, whether he is sane or not.
• Any covered person’
s involvement in any period of armed conflict, even if it is not declared.
Well Baby Care Limitation We will not pay benefits for hospital confinement of a newborn child following his birth unless he is
injured or sick.
Pre-existing Condition Limitation We will not pay benefits for Hospital Confinement, Rehabilitation Unit Confinement or
Outpatient Surgical Procedure for any covered person when such loss results from a pre-existing condition, unless the covered person
has satisfied the pre-existing condition limitation period shown on the Policy Schedule.
Birth Limitation We will not pay benefits for hospital confinement due to any covered person giving birth within the first nine (9)
months after the effective date of the policy as a result of a normal pregnancy, including Cesarean. Complications of pregnancy will be
covered to the same extent as any other covered sickness.
MB3000-O-AZ
4
Plan 2
65811-1
Attachment 18
Medical Bridge 3000 Hospital Confinement
Flyer
Medical Bridge 3000
SM
What’s missing in your
health plan?
What’s missing is a solution that can help minimize the impact of first
dollar claims to your employees.
It’s no secret where health care costs impact employees the most…
•
•
•
Deductibles
Out-of-pocket maximums
Co-payments
And as employers struggle every year to provide affordable coverage, where are the
gaps widening?
•
•
Deductibles
Out-of-pocket maximums
Co-payments may rise, but are generally to a manageable level. Although more frequent, these are
typically lower-dollar claims that employees expect to pay.
While hospital stays are less frequent, medical treatment is increasingly trending toward outpatient
services such as:
•
•
Diagnostic testing
Outpatient surgeries
These expenses are traditionally high-dollar claims which have a high potential to cause financial
hardship if employees don’t have secondary coverage to offset the gaps in their health plans.
Employees are very sensitive about losing coverage for routine health care. Therefore to provide
affordable health care as costs continue to rise, employers raise annual deductibles and out-of-pocket
maximums, increasing the employees’ share of first-dollar expenses.
Hospital
Surgical
Rising Annual Deductible and
Out-of-Pocket Maximums
Gaps Increase...
Diagnostic
Tests
Office Visits
Urgent Care
Emergency Room
Prescriptions
Rising Co-Payments
Colonial Life’s Medical Bridge 3000 is what’s missing.
Employers can continue to offer affordable health care and still help limit their employees’ first
dollar expenses.
Medical Bridge 3000 helps fill the gaps which can be
financially devastating when unexpected health care
expenses occur.
can’t stop medical
• You
costs from rising.
How can it help?
•
•
•
Hospital confinement indemnity plan
Offers employees the option to buy additional protection
Targets the gaps in high-priced claims areas including:
•
•
•
•
can help employees
• You
manage those costs and
Hospitalization
Outpatient surgeries
Diagnostic testing
Emergency room visits
As employers weigh the costs associated with annual health
coverage renewals, selecting Medical Bridge 3000 to offset
the increase in the deductibles may well be a less expensive
alternative than the original renewal.
Employees are still protected and employer costs are controlled.
Hospital
can’t prevent gaps in
• You
coverage from occuring.
Surgical
Diagnostic
Tests
Rising Annual Deductible and
Out-of-Pocket Maximums
Medical Bridge 3000
cover those gaps by
providing them with
additional protection
to help them in the
areas where they need
it the most.
Office Visits
Urgent Care
Emergency Room
Prescriptions
Rising Co-Payments
How does it work?
Five plan designs are available allowing employers flexibility to choose the one that works
best with their health plan.
Plan 1
Plan 2
Plan 3
Plan 4
Plan 5
(HSA-Compliant)
Hospital Confinement
Rehabilitation Unit
Wellness Benefit
Waiver of Premium
Outpatient Surgical Procedure
Diagnostic/ER
Doctor’s Office Visit
Benefits
•
•
•
•
Designed to fit your preferred renewal options
Helps employees manage first dollar expenses
Easy to understand indemnity schedule of benefits
Fast and direct claims payment to the employee; not tied to major medical claims decisions
Guaranteed Issue Underwriting with no Pre-Existing Conditions Option
•
•
•
•
Available for employees only
Works best with employer contribution
Greater of 15 participants or 50% participation
Up to $3,000 hospital confinement benefit
Colonial Life has what’s missing…ask your benefits representative how
Medical Bridge 3000 can help your employees today.
Applicable to policy form MB3000. This coverage has exclusions and limitations that may affect
benefits payable. Coverage type and benefits vary by state and may not be available in all states. See
the outline of coverage for complete details.
Colonial Life
1200 Colonial Life Boulevard
Columbia, South Carolina 29210
coloniallife.com
4/08
©2008 Colonial Life & Accident Insurance Company.
Colonial Life products are underwritten by Colonial Life & Accident
Insurance Company, for which Colonial Life is the marketing brand.
66660-3
Attachment 19
Public Safety Gunshot Safety Rider
Benefit Summary
G)
Public Safety
COLONIAL
Employees
SUPPLEMENTAL
INSURANCE
for what happens next®
AB a Public Safety Employee you are exposed to situations
where a gunshot wound could occur. A gunshot wound may
not be fatal and yet it can inflict serious physical and/ or
emotional damage.This benefit is designed to pay a lump-sum
benefit regardless of any other insurance you may have.
Expand Your Present Coverage
With a benefit designed to help meet the hazards faced by the
professional Public Safety Employee.
NON-FATAL GUNSHOTWOUND
$1,000 BENEFIT PAYMENT
for a gunshot wound requiring overnight hospitalization within
THE COLONIAL ADVANTAGE
>- A leader in the supplemental
insurance industry.
24 hours after the accident. If you are shot more than once in a
>- Communications and benefits
twenty-four hour period, we will pay benefits only for the first
education to help you
understand the benefits you
have-and the benefits you
may need.
wound.
These are the highlights of your benefit. Please see the Outline
>-
Prompt, accurate and
courteous customer service.
>-
Broad selection of products
to help meet your individual
needs, with premiums paid
through convenient payroll
deduction.
of Coverage contained in this brochure and the policy for
complete details.
Your Representative
Learn more about these and all
of the advantages Colonial has to
offer at www.coloniallife.com.
Colonial Suppkmental Insurance products are underwritten by:
Colonial Life & Accident Insurance Company
1200 Colonial Life Boulevard, Columbia, Souch Carolina 292 10
www.coloniallife.com
©2006 Colonial Life & Accident Insurance Company.
Colonial Supplemental Insurance is the marketing brand of Colonial Life & Accident Insurance Company. "Colonial Supplemental Insurance,"
for what happens next" and rhe logo, separnrely and in combinarion, are regisrered service marks of Colonial Life & Accident Insurance Company. All righcs reserved.
04/06
43200-7
Colonial Life & Accident Insurance Company
Columbia, South Carolina 29202
OUTLINE OF COVERAGE
(Applicable to Policy Form PYWOL
including state abbreviations where used)
MONTHLY PREMIUM
PLAN PS01
Premium $1.00
TOTAL PREMIUM
PER PAY PERIOD
$ _ _ __
Read your policy carefully. This outline provides a very brief description
of the important features of your policy. This is not an insurance contract
and only the actual policy provisions will control. The policy sets forth
in detail the rights and obligations of both you and us. It is, therefore,
important that you READ YOUR POLICY CAREFULLY.
Renewability: Your policy is guaranteed renewable. Your premium can
be changed only if we change it on all policies of this kind in force in
the state where you live.
Accident Coverage. Your policy is designed to provide coverage for
certain losses which result from covered accidents only subject to any
limitations in your policy. It does not provide coverage for basic hospital,
basic medical-surgical or major medical expenses.
We will pay this benefit if you receive a gunshot wound in a covered
accident in which you did not intentionally shoot yourself and which does
not cause you to die. It must be caused by a shot from a conventional
firearm. It must require treatment by a doctor, including overnight care in
a hospital, within twenty-four hours after the accident. After all of these
things occur, we will pay this amount for each covered accident.
Gunshot Wound
$1,000
If you are shot more than once in a twenty-four hour period, we will pay
benefits only for the first wound.
WHAT IS NOT COVERED BY THIS POLICY
We will not pay benefits for an injury which is caused by or occurs as
the result of: (1) your involvement in any period of armed conflict (war);
(2) your participating or attempting to participate in any illegal activity;
(3) your committing or trying to commit suicide or your injuring yourself
intentionally, whether you are sane or not.
PYWOLO
43200-7