Williamsburg County School District 2022 Booklet 23PY

ARRANGED BY: www.piercegroupbenefits.com BENEFITSEMPLOYEEPLAN PLAN YEAR: January 1, 2023 through WILLIAMSBURG COUNTY December 31, 2023 SCHOOL DISTRICT

Accident

Welcome to the Williamsburg County School District comprehensive benefits program. This booklet highlights the benefits offered to all eligible employees for the plan year listed below. Benefits described in this booklet are voluntary, employee-paid benefits unless otherwise noted.

Disability

page 23 page 30 Bridge Beneﬁts Insurance page 19Beneﬁts

Life

page 34 page 32 page 33 Form

Medical

EFFECTIVE DATES: JANUARY 1, 2023 - DECEMBER 31, 2023

EMPLOYEE BENEFITS GUIDE TABLE OF CONTENTS

ENROLLMENT PERIOD: SEPTEMBER 15, 2022 - OCTOBER 31, 2022

Cancer Benefits Critical Illness Benefits page 15Benefits

Rev. 09/14/2022

Authorization

ContinuationInformationInsurancePracticesOfCoverageforBeneﬁtsForm

Online Enrollment Instructions Beneﬁts Plan Overview page 7 page 12

Notice Of page 2 page 5

ENROLLMENT PERIOD: SEPTEMBER 15, 2022 - OCTOBER 31, 2022 EFFECTIVE DATES: JANUARY 1, 2023 - DECEMBER 31, 2023 Life Insurance Colonial Life • Whole Life Insurance WILLIAMSBURG COUNTY SCHOOL DISTRICT PRE-TAX & POST-TAX BENEFITS PRE-TAX POST-TAXBENEFITSBENEFITS Please note existing insurance products will remain in effect unless you speak with a representative to change them. BenefitsCancer Colonial Life BenefitsAccident Colonial Life Medical Bridge Benefits Colonial Life BenefitsDisability Colonial Life IllnessCriticalBenefits Colonial Life PEBA BENEFITS PEBA information is included in this booklet for informational purposes only. Please see the following page for ways to access your benefits and enrollment information. VisionDentalHealth MoneyPlus Health Savings Accounts Life Insurance 2

QUALIFICATIONS:

• Please be aware there are certain coverages that may be subject to federal and state tax when premium is paid by pretax deduction or employee contribution.

• You must work 30 hours or more per week.

• Elections made during this enrollment period CANNOT BE CHANGED AFTER THE ENROLLMENT PERIOD unless there is a family status change as deﬁned by the Internal Revenue Code. Examples of a family status change are: marriage, divorce, death of a spouse or child, birth or adoption of a child, termination or commencement of a spouse's employment, or the transition of spouse's employment from full-time to part-time, or vice-versa. Once a family status change has occurred, an employee has 30 days to notify the Pierce Group Beneﬁts Service Center at 1-833-556-0006 to request a change in elections.

QUALIFICATIONS & IMPORTANT INFO THINGS YOU NEED TO KNOW

https://www.peba.sc.gov/oe

PEBA administers the state’s employee insurance programs for South Carolina’s public workforce. PEBA benefit elections are processed through PEBA’s MyBenefits and Member Access portals. Learn more about the benefits available to employees by visiting the link below or scanning the QR code.

• Additionally, some policies may include a pre-existing condition clause. Please read your policy carefully for full details.

PEBA BENEFITS & ENROLLMENT:

IMPORTANT FACTS:

• If signing up for any coverage on your spouse and/or children, please have their dates of birth and social security numbers available when speaking with the Beneﬁts Representative.

•

To view the PEBA Insurance Summary, click on the link below and, once the new page loads, click on '2023 Insurance Summary'. 3

• Deductions for Colonial Insurance products will begin December 2022.

• The Colonial Cancer plan and the Health Screening Rider on the Colonial Accident and Colonial Medical Bridge plan have a 30-day waiting period for new enrollees. Coverage, therefore, will not begin until January 31, 2023.

• The plan year for Colonial Insurance products lasts from January 1, 2023 through December 31, 2023.

During your open enrollment period, a Pierce Group Beneﬁts representative will be available by appointment to answer any questions you may have and to assist you in the enrollment process.

Beneﬁts Details | Educational Videos | Download Forms | Online Chat with Service Center

this

This is neither an insurance contract nor a Summary Plan Description and only the actual policy provisions will prevail. information in this booklet including premiums quoted is subject to change. All policy descriptions are for information purposes only. Your actual policies may be diﬀerent than those in booklet.

To view your website, go to:

You may enroll or make changes online to your beneﬁts plan. To enroll online, please see the information below and on the following pages.

EMPLOYEE BENEFITS GUIDE ENROLLMENT PERIOD: SEPTEMBER 15, 2022 - OCTOBER 31, 2022 ACCESS YOUR BENEFITS ONLINE WHENEVER, WHEREVER.

www.piercegroupbenefits.com/WilliamsburgCountySchoolDistrict or piercegroupbenefits.com and click “Find Your Benefits”. WILLIAMSBURG COUNTY SCHOOL DISTRICT YOU CAN MAKE THE FOLLOWING BENEFIT ELECTIONS ONLINE DURING THE ENROLLMENT PERIOD: • Enroll in, change or cancel Colonial coverage (see the following pages for enrollments/changes that can be completed online).

4

All

personalized beneﬁts

IN PERSON

ONLINE

IMPORTANT NOTE & DISCLAIMER

• If you are an existing employee and unable to log into the online system, please contact the Harmony Help Desk at 866-875-4772 between 8:30am and 6:00pm, or speak with the Beneﬁts Representative assigned to your location.Go to https://harmonyenroll.coloniallife.com

The screen shows updated personal information. Verify that the information is correct and make changes if necessary. Click ‘Continue’.

The screen allows you to add family members. It is only necessary to enter family member information if adding or including family members in your coverage. Click ‘Continue’.

Click on ‘I Agree’ and then “Enter My Enrollment”.

<<< enrollment instructions continued on next page >>> 5

• Enter your Password: Four digit Year of Birth and then Last 4 of Social Security Number (19766789)

COMPLETE THE STEPS BELOW TO BEGIN THE ONLINE ENROLLMENT PROCESS

The screen shows ‘My Beneﬁts’. Review your current beneﬁts and make changes/selections for the upcoming plan year.

8.6.5.4.3.2.1.7.

HELPFUL TIPS:

• If you are a new employee and unable to log into the online system, please speak with the Beneﬁts Representative assigned to your location, or contact Human Resources.

Choose a security question and enter answer [______________________________________].

The screen shows ‘Me & My Family’. Verify that the information is correct and enter the additional required information (title, marital status, work phone, e-mail address). Click ‘Save & Continue’ twice.

HARMONY ONLINE ENROLLMENT:

• Enter your User Name: WLMSBRG and then Last Name and then Last 4 of Social Security Number (WLMSBRGSMITH6789)

The screen prompts you to create a NEW password [____________________________]. Your password must have: 1 lowercase letter, 1 uppercase letter, 1 number and 8 characters minimum Your password cannot include: ﬁrst name, last name, spaces, special characters (such as ! $ % &) or User ID

• CANCER ASSIST

• DISABILITY - EDUCATOR DISABILITY ADVANTAGE (EDA1100)

• ACCIDENT 1.0

HARMONY ONLINE ENROLLMENT CONT.:

You may enroll online in Cancer Assist coverage.

• WHOLE LIFE 5000 Plus

Click ‘Finish’.

You may enroll online in EDA1100 coverage.

• MEDICAL BRIDGE

You may enroll online in Critical Illness 1.0 coverage.

You may enroll online in Whole Life 5000 Plus; however, employees wishing to purchase an individual policy for their spouse should speak with the Beneﬁts Representative.

Click ‘Log out & close your browser window’ and click ‘Log Out’.

12.10.9.11.

• CRITICAL ILLNESS 1.0

You may enroll online in Accident 1.0; however, persons over age 64 applying for coverage and employees wishing to purchase an individual policy for their spouse should speak with the Beneﬁts Representative.

Click ‘I Agree’ to electronically sign the authorization for your beneﬁt elections.

Click ‘Print a copy of your Elections’ to print a copy of your elections, or download and save the document. Please do not forget this important step!

6

You may enroll online in Medical Bridge coverage.

Specified disease hospital confinement rider provides $300 per day for confinement to a hospital for treatment of one of 34 specified diseases covered under the rider.

Individual, individual/spouse, one-parent and two-parent family policies

A benefit amount in $1,000 increments from $1,000-$10,000 may be chosen. The benefit for covered dependent children is two and a half times ($2,500-25,000) the chosen benefit amount.

Competitive advantages

Attractive features

This individual voluntary policy provides benefits that can be used for both medical and out-of-pocket, non-medical expenses traditional health insurance may not cover. Cancer Assist can enhance any competitive benefits package without adding costs to a company’s bottom line.

Indemnity-based benefits provide exactly what’s listed for the selected plan level.

Waiver of premium if named insured is disabled due to cancer for longer than 90 consecutive days and the date of diagnosis is after the waiting period and while the policy is in force

The plan’s family care benefit provides a daily benefit when a covered dependent child receives inpatient or outpatient cancer treatment.

Portable

Form 1099s may not be issued in most states because all benefits require that a charge is incurred.

There are four distinct plan levels, each featuring the same benefits with premiums and benefit amounts designed to meet a variety of budgets and coverage needs (benefits overview on reverse).

Flexible family coverage

Benefits that don’t coordinate with any other coverage from any other insurer renewable

HSA-compliant Guaranteed

Available for businesses with 3+ eligible employees

Cancer Insurance

Broad range of policy issue ages, 17-75

– Part Two covers an invasive diagnostic test or surgical procedure if an abnormal result from a Part One test requires additional testing. This benefit is payable once per calendar year per covered person and matches the Part One benefit.

Composite rates are available.

Discuss details with your benefits representative, or consult your tax adviser if you have questions.

CANCER ASSIST7

Initial diagnosis of cancer progressive payment rider provides a $50 lump-sum payment for each month the rider has been in force, after the waiting period, once cancer is first diagnosed. The issue ages for this rider are 17-64.

Optional riders (available at an additional cost/payable once per covered person)

Employer-optional cancer wellness/health screening benefits are available:

Full schedule of 30+ benefits and three optional riders (benefit amounts may vary based on plan level selected) with each plan level

Cancer Assist helps protect employees and their loved ones through diagnosis, treatment and recovery.

Initial diagnosis of cancer rider provides a one-time benefit for the initial diagnosis of cancer.

Family coverage that includes eligible dependent children (to age 26) for the same rate, regardless of the number of children covered

Part One covers 24 tests. If selected, the employer chooses one of four benefit amounts for employees: $25, $50, $75 or $100. This benefit is payable once per covered person per calendar year.

Transportation for treatment more than 50 miles from covered person’s home: $0.50 per mile, up to $1,000-$1,500 per round trip

THIS POLICY PROVIDES LIMITED BENEFITS.

6-19 | 101478-2

Hospital confinement

Hospice care

Radiation delivered by medical personnel: $250-$1,000 once per calendar week

Self-injected chemotherapy: $150-$400 once per calendar month

$40-$60 per surgical unit, up to $2,500-$3,000 per procedure including 25% for general anesthesia

Daily: $50 per day ($15,000 maximum for initial and daily hospice care per lifetime)

Inpatient and outpatient treatment for a covered dependent child: $30-$60 per day, up to $1,500-$3,000 per calendar year

Each benefit requires that charges are incurred for treatment. All benefits and riders are subject to a 30-day waiting period. Waiting period means the first 30 days following the policy’s coverage effective date during which no benefits are payable. States without a waiting period will have a pre-existing condition limitation. Product has exclusions and limitations that may affect benefits payable. Benefits vary by state and may not be available in all states. Applicable to policy form CanAssist (and state abbreviations where applicable, for example: CanAssist-TX). See your Colonial Life benefits representative for complete details.

Companion transportation (for any companion, not just a family member) for commercial travel when treatment is more than 50 miles from covered person’s home: $0.50 per mile, up to $1,000-$1,500 per round trip

Inpatient and outpatient surgeries: $40-$70 per surgical unit, up to $2,500-$6,000 per procedure

Home health care services

Chemotherapy by pump: $150-$400 once per calendar month

Injected chemotherapy by medical personnel: $250-$1,000 once per calendar week

$100-$400 per day, up to $300-$1,200 per calendar year

$300-$600 payable once per lifetime

Surgical procedures

Talk with your benefits representative to learn more. ColonialLife.com

Topical chemotherapy: $150-$400 once per calendar month

Anesthesia

Family care

Second medical opinion on surgery or treatment

$150-$300 once per lifetime

Lodging for the covered person or any one adult companion or family member when treatment is more than 50 miles from the covered person’s home: $50-$80 per day, up to 70 days per calendar year

Cancer Assist benefits overview

Oral non-hormonal chemotherapy: $150-$400 once per calendar month

Medical imaging studies

This overview shows benefits available for all four plan levels and the range of benefit amounts payable for most common cancer treatments.

Reconstructive surgery

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

Outpatient surgical center

Initial: $1,000 once per lifetime

8

Skin cancer initial diagnosis

Local: $25-$50 per procedure

General: 25% of surgical procedures benefit

Oral hormonal chemotherapy (1-24 months): $150-$400 once per calendar month

Oral hormonal chemotherapy (25+ months): $75-$200 once per calendar month

Radiation/chemotherapy

Air ambulance, ambulance, blood/plasma/platelets/immunoglobulins, bone marrow or peripheral stem cell donation, bone marrow donor screening, bone marrow or peripheral stem cell transplant, cancer vaccine, egg(s) extraction or harvesting/sperm collection and storage (cryopreservation), experimental treatment, hair/external breast/voice box prosthesis, private full-time nursing services, prosthetic device/artificial limb, skilled nursing facility, supportive or protective care drugs and colony stimulating factors

Anti-nausea medication

$75-$225 per study, up to $150-$450 per calendar year

31 days or more: $200-$700 per day

Each benefit is payable for each covered person under the policy. Actual benefits vary based on the plan level selected.

$25-$60 per day, up to $100-$240 per calendar month

Transportation and lodging

Examples include physical therapy, speech therapy, occupational therapy, prosthesis and orthopedic appliances, durable medical equipment: $50-$150 per day, up to the greater of 30 days per calendar year or twice the number of days hospitalized per calendar year

Benefits also included in each plan

30 days or less: $100-$350 per day

CANCER ASSIST WELLNESS | 6-19 | 101486-2

■ Thermography

■ ThinPrep pap test

■ Serum protein electrophoresis (blood test for myeloma)

■ Breast ultrasound

■ Hemoccult stool analysis

To encourage early detection, our cancer insurance offers benefits for wellness and health screening tests.

■ Chest X-ray

■ Pap smear

■ Blood test for triglycerides

■ CA 15-3 (blood test for breast cancer)

Health screening tests

■ Echocardiogram (ECHO)

Part two: Cancer wellness — additional invasive diagnostic test or surgical procedure

■ Skin biopsy

Cancer wellness tests

■ Fasting blood glucose test

■ Electrocardiogram (EKG, ECG)

Provided when one of the tests listed below is performed after the waiting period and while the policy is in force. Payable once per calendar year, per covered person.

Provided when a doctor performs a diagnostic test or surgical procedure after the waiting period as the result of an abnormal result from one of the covered cancer wellness tests in part one. We will pay the benefit regardless of the test results. Payable once per calendar year, per covered person.

9

■ CA 125 (blood test for ovarian cancer)

■ Serum cholesterol test for HDL and LDL levels

■ Bone marrow testing

Cancer Insurance Wellness Benefits

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

■ Colonoscopy

■ PSA (blood test for prostate cancer)

For more information, talk with your benefits counselor.

■ Carotid Doppler

■ Stress test on a bicycle or treadmill

Waiting period means the first 30 days following the policy’s coverage effective date during which no benefits are payable. The policy has exclusions and limitations which may affect any benefits payable. 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 CanAssist (and state abbreviations where applicable, for example: CanAssist-TX).

■ CEA (blood test for colon cancer)

Part one: Cancer wellness/health screening

■ Mammography

■ Virtual colonoscopy

■ Flexible sigmoidoscopy

25% of Surgical Procedures Benefit

Level 1Level 2Level 3Level 4 $2,000$2,000$2,000$2,000 Maximum trips per confinement 2 2 2 2 $250$250$250$250 Maximum trips per confinement 2 2 2 2 $25$30$40$50$25$40$50$60 Maximum per month$100$160$200$240 $150$150$175$250 Maximum per year $10,000$10,000$10,000$10,000 $3,500$4,000$7,000$10,000$500$500$750$1,000 Maximum transplants per lifetime 2 2 2 2 $0.50$0.50$0.50$0.50 Maximum per round trip $1,000$1,000$1,200$1,500 $500$700$1,000$1,500$175$200$350$500$200$250$300$300 Maximum per lifetime $10,000$12,500$15,000$15,000 $30$40$50$60 Maximum per year $1,500$2,000$2,500$3,000 $200$200$350$500$50$75$100$150 Maximum per year $1,000$1,000$1,000$1,000$50$50$50$50 Maximum combined Initial and Daily per lifetime$15,000$15,000$15,000$15,000 $100$150$250$350$200$300$500$700$50$50$75$80 Maximum days per year 70707070 $75$125$175$225 Maximum per year $150$250$350$450 $100$200$300$400 Maximum per year $300$600$900$1,200 $1,000$1,500$2,000$3,000$50$75$125$150 Maximum per lifetime $2,000$3,000$4,000$6,000

policy and its riders may have additional exclusions and limitations. For cost and complete

Medical Imaging Studies, per study

Private Full-time Nursing Services, per day Prosthetic Device/Artificial Limb, per device or limb

Egg(s) Extraction or Harvesting or Sperm Collection, per lifetime Egg(s) or Sperm Storage, per lifetime Experimental Treatment, per day

Ambulance, per trip Anesthesia, Local, per procedure Anti-Nausea Medication, per Blood/Plasma/Platelets/Immunoglobulins,day per day

Bone Marrow or Peripheral Stem Cell Donation, per lifetime Bone Marrow or Peripheral Stem Cell Transplant, per transplant

Hospital Confinement, 30 days or less, per day Hospital Confinement, 31 days or more, per day Lodging, per day

Hospice, Initial, per lifetime Hospice, Daily

Cancer Insurance Benefits

Companion Transportation, per mile

30 days or twice the days confined

10

Hair/External Breast/Voice Box Prosthesis, per year Home Health Care Services, per day

The details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states. Coverage is dependent on answers to health questions. Applicable to policy forms CanAssist-IL and CanAssist-SC, and rider forms R-CanAssistIndx-IL, R-CanAssistProg-IL, R-CanAssistSpDis-IL, R-CanAssistIndxSC, R-CanAssistProg-SC and R-CanAssistSpDis-SC.

Individual Cancer Insurance Description of Benefits

Anesthesia, General Air Ambulance, per trip

Outpatient Surgical Center, per day

Family Care, per day

The policy and its riders may have additional 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. Coverage is dependent on answers to health questions. Applicable to policy forms CanAssist-IL and CanAssist-SC, and rider forms R-CanAssistIndx-IL, R-CanAssistProg-IL, R-CanAssistSpDis-IL, R-CanAssistIndxSC, R-CanAssistProg-SC and R-CanAssistSpDis-SC.

Radiation delivered by medical personnel, per week $250$500$750$1,000

Pump Chemotherapy, per month $150$200$300$400

Self-Injected Chemotherapy, per month $150$200$300$400

Cancer Insurance Benefits

Oral Non-Hormonal Chemotherapy, per month

Topical Chemotherapy, per month $150$200$300$400

Oral Hormonal Chemotherapy (25+ months), per month$75$100$150$200

Individual Cancer Insurance Description of Benefits

$150$200$300$400$40$40$60$60

Maximum per procedure, including 25% for general $150$200$300$300$75$100$100$150$300$300$400$600$50$100$150$200

Level 1Level 2Level 3Level 4

Maximum per round trip Stimulating Factors, per

$1,000$1,000$1,200$1,500 YesYesYesYes$50$50$50$50$50$50$50$50 WeEXCLUSIONSwillnotpay benefits for cancer or skin cancer: Supportive/Protective Care Drugs/Colony

Maximum per procedure $2,500$3,000$5,000$6,000 $0.50$0.50$0.50$0.50

ReconstructiveRadiation/ChemotherapySurgery,per surgical unit Second

$2,500$2,500$3,000$3,000

Oral Hormonal Chemotherapy (1-24 months), per month$150$200$300$400

coverage effective

The policy and its riders may have a waiting period. Waiting period means the first 30 days following the policy’s date during which no benefits are payable. If your cancer has a date of diagnosis before the end of the waiting period, coverage for that cancer will apply only to losses commencing after the policy has been in force for two years, unless it is excluded by name or specific description in the policy.

Skilled

Injected chemotherapy by medical personnel, per week$250$500$750$1,000

©2015 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. Transportation, per mile Waiver of Premium Bone Marrow Donor Screening, per lifetime Cancer Vaccine, per lifetime Part 1: Cancer Wellness/Health Screening, per year Part 2: Cancer Wellness/Health Screening, per year One amount per account: $0, $25, $50, $75 or Same$100 as Part 1 WAITING PERIOD Additional Riders may be available at an additional cost Policy-Wellness Benefits possessions; or cancer. 11

Skin

Maximum per year $400$800$1,200$1,600 $40$50$60$70

Surgical Procedures, per surgical unit Medical Opinion, per lifetime Nursing Care Facility, per day, up to days confined Cancer Initial Diagnosis, per lifetime

Subsequent diagnosis of the same critical illness3

For the diagnosis of this covered critical illness condition:1

Heart attack (myocardial infarction) 100%

Permanent paralysis due to a covered accident 100%

Occupational infectious HIV or occupational infectious hepatitis B, C or D 100%

Stroke 100%

Specified Critical Illness Insurance

12

End-stage renal (kidney) failure 100%

CRITICAL ILLNESS 1.0 WITH SUBSEQUENT DIAGNOSIS

Face amount: $_______________

ColonialLife.comcounselor.

Blindness 100%

Subsequent diagnosis of a different critical illness3

For more information, talk with your benefits

This percentage of the face amount is payable:

Major organ failure 100%

Critical illness benefit

If you receive a benefit for a specified critical illness, and later you are diagnosed with a different specified critical illness, the original percentage of the face amount is payable for that particular specified critical illness.

If you’re diagnosed with a covered critical illness, specified critical illness insurance from Colonial Life can help with your expenses, so you can concentrate on what’s most important – your treatment, care and recovery.

The maximum benefit amount for this policy is 3x the face amount for the named insured for all covered persons combined. The policy will terminate when the maximum benefit amount for specified critical illness has been paid.

If you receive a benefit for a specified critical illness, and later you are diagnosed with the same specified critical illness, 25% of the original face amount is payable. Critical illness conditions that do not qualify are: coronary artery bypass graft surgery/disease2 and occupational infectious HIV or occupational infectious hepatitis B, C or D.

Coma 100%

Coronary artery bypass graft surgery/disease2 25%

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.

2 Benefit for coronary artery disease applicable in lieu of benefit for coronary artery bypass graft surgery when health savings account (HSA) compliant plan is selected.

We will not pay benefits for a specified critical illness that occurs as a result of a covered person’s: felonies or illegal occupations; intoxicants and narcotics; mental or emotional disorders; pre-existing condition; suicide or self-inflicted injuries; or war or armed conflict.

THIS POLICY PROVIDES LIMITED BENEFITS.

3 Dates of diagnoses of a covered specified critical illness must be separated by at least 180 days.

This is not an insurance contract and only the actual policy provisions will control. Applicable to policy form CI-1.0-ID or CI-1.0-SC. Please see your Colonial Life benefits counselor for details.

4-19 | 101824-1-ID-SC

13

1 Please refer to the policy for complete definitions of covered conditions.

EXCLUSIONS AND LIMITATIONS FOR SPECIFIED CRITICAL ILLNESS

ColonialLife.com

Hemoccult

GROUP CRITICAL CARE, CRITICAL ILLNESS 1.0 – HEALTH SCREENING BENEFIT | 5-19 | 100355-3 ColonialLife.com

$ Maximum

Colonial

Breast

CA

Mammography

and

Colonoscopy Echocardiogram

Serum

a registered

CEA

14

Bone

Fasting

Blood

(blood

All

&

Chest

Carotid

CA

Critical Illness Insurance

Health Screening Benefit

Thermography ThinPrep

Virtual

The

PSA

of Colonial

Electrocardiogram

Underwritten

For more information, talk with your benefits counselor.

Health screening benefit of one screening test per covered person per calendar year. test for triglycerides marrow testing ultrasound 15-3 (blood test for breast cancer) 125 (blood test for ovarian cancer) Doppler (blood test for colon cancer) X-ray (ECHO) (EKG, ECG) blood glucose test sigmoidoscopy stool analysis Pap smear (blood test for prostate cancer) cholesterol test for HDL and LDL levels Serum protein electrophoresis test for myeloma) Skin cancer biopsy Stress test on a bicycle or treadmill pap test colonoscopy optional health screening benefit can help you reduce the risk of serious illness through early detection. by Colonial Life & Accident Insurance Company, Columbia, Life Accident Insurance Company. rights reserved. Life is trademark marketing brand Life Accident Insurance Company.

&

Flexible

For

The policy has exclusions and limitations which may affect any benefits payable. cost and complete details, see your Colonial Life benefits counselor. Applicable to form CI-1.0-P and GCC1.0-P (including state abbreviations where used, for example: CI-1.0-P-TX and GCC1.0-P-TX). may vary by state and may not be available in all states.

Coverage

• Waiver of premium: We will waive your premium payments after 90 consecutive days of a covered disability.

• Partial disability Up to 3 months $_____________/month

Educator Disability Advantage Short Term Disability

What additional features or benefits are included?

• Normal pregnancy is covered the same as any other covered sickness.

Educator Disability Advantage insurance1 from Colonial Life is designed to provide financial protection for all education workers with plans that can help supplement and/or complement the South Carolina Public Employee Benefit Authority (PEBA) plan. Educator Disability Advantage insurance provides flexible options for disability coverage and accidental injury benefits to help protect your income and maintain lifestyle needs if you become disabled due to a covered accident or sickness.

How much will it cost? Your cost will vary based on the level of coverage you select.

$_____________/month $_____________/month

• Goodwill child benefit: $1,000, up to two benefits per year for adoption or ward of a guardian

How long could you afford to go without a paycheck? Monthly expenses: Mortgage/rent $_____________ Groceries $_____________ Car $_____________ Medical bills $_____________ Utilities $_____________ Other $_____________ Total $ EDUCATOR DISABILITY ADVANTAGE (EDA1100) — MENTAL & NERVOUS 15

• After an accident: ___________ days After a sickness: ___________ days

• Total disability On-job accident/sickness Off-job accident/sickness

My disability coverage worksheet

Employee coverage (includes both on- and off-job benefits)

When will my benefits start?

(For use with your Colonial Life benefits counselor)

First 3 months $_____________/month $_____________/month

Next 9 months

$____________/month

How much coverage do I need?

• Mental or nervous disorders benefit

• X-ray $150

COMPLETE FRACTURES Nonsurgical Surgical

Anita teaches at a local community college and enjoys spending time on active hobbies and volunteering with nonprofits. When she was injured in a mountain biking accident, she worried that she might not be able to make ends meet for a while.

With her coverage, she received benefits for:

• Common carrier death (includes school bus for school activities) $50,000

...................................

• Accident treatmentemergency $400

• Hospital stay of 3 nights $150

• Upper arm, upper jaw $525 $1,050

• Coccyx $125 $250

• Accidental death $25,000

Disability benefits and more

• Foot, ankle, kneecap $750 .......... $1,500

• Hip, thigh $1,500 .......... $3,000

16

• Shoulder blade, collarbone $600 $1,200

...........

• Leg $900 $1,800

.............................................

• Collarbone fracture requiring surgery $1,200

• Loss of a finger or toe Single dismemberment $750 Double dismemberment $1,500

............................................

• Vertebrae $1,350 $2,700

• Pelvis $1,200 $2,400

In addition to disability coverage, this plan also provides employees with benefits related to accidental injuries, their treatment and more. Even if you’re not disabled, the following benefits are payable for covered accidental injuries or sickness:

• Elbow dislocation (nonsurgical) ....... $400

............................................

• Vertebral processes $300 $600

*For illustrative purposes only. Coverage amounts may vary based on injury, treatment, income and more.

HOSPITAL CONFINEMENT BENEFIT FOR ACCIDENT OR SICKNESS

Pays in addition to disability benefit. Benefits begin on the first day of confinement in a hospital. Up to 3 months .............................. $1,500/month ($50/day)

ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS

• Loss of a hand, arm, foot or sight of an eye Single dismemberment .................................................. $7,500 Double dismemberment $15,000

Total amount: ..... $3,700

• Accident follow-up treatment (including transportation)/telemedicine ..................................... $75 (up to 6 benefits per accident per person, up to 12/year per person)

...........

• Rib $300 $600

Additional employee coverage

• Finger, toe $175 $350

• Forearm, hand, wrist $750 $1,500

How Anita’s coverage helped*

ACCIDENTAL INJURIES BENEFITS

...................................

• Facial bones $450 $900

• Lower jaw $600 .......... $1,200

• X-ray $150

• Short-term disability benefits .......... $1,400

• Accident emergency treatment $400

• Skull (simple) $525 $1,050

• Skull (depressed) $1,500 $3,000

• Loss of a finger or toe Single dismemberment $75 Double dismemberment $150

• Knee $975 $1,950

• Common carrier death, spouse/dependent Includes school bus for school activities $20,000 / $10,000

• Hip ................................................. $1,500 .......... $3,000

ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS

Optional spouse and dependent child(ren) coverage

• Collarbone (sternoclavicular) $750 $1,500

• Accidental death, spouse/dependent $10,000 / $5,000

• Loss of a hand, arm, foot or sight of an eye Single dismemberment $750 Double dismemberment $1,500

. . . . . . . . . . . . . . . . . . . . . . . . .

• For multiple fractures or dislocations, we will pay for both, up to 2 times the highest amount.

.....................................

• One finger, toe $125 $250

Up to 3 months $1,500/month ($50/day)

• Hand $525 $1,050

• For your first dislocation, you would receive the amount shown; however, recurrent dislocations of the same joint are not covered.

ACCIDENTAL INJURIES BENEFITS

HOSPITAL CONFINEMENT BENEFIT FOR ACCIDENT OR SICKNESS

• Elbow $400 ........... $800

• For a chip fracture, your benefit would be 25% of the amount shown. Chip fractures are those in which a fragment of bone is broken off near a joint at a point where a ligament is attached.

• Ankle, foot $750 .......... $1,500

Nonsurgical Surgical

• Lower jaw $450 $900

• Wrist $400 $800

17

• Accident emergency treatment $400

• Shoulder $750 .......... $1,500

COMPLETE DISLOCATIONS

You may cover one or all of the eligible dependent members of your family for an additional premium. Eligible dependents include your spouse and ALL dependent children who are younger than age 26.

• Collarbone (acromioclavicular and separation) $675 $1,350

...............................................

• X-ray $150

• Accident follow-up treatment (including transportation)/telemedicine $75 (up to 6 benefits per accident per person, up to 12/year per person)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

More than 1 in 4 of 20-year-olds become disabled retirementbeforeage.2

............................................

..............................................

When do disability benefits end?

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:

What is a pre-existing condition?

• You are able to work at your job or your place of employment for less than half of your normally scheduled hours per week;

The total disability benefit must have been paid for at least 14 days immediately prior to your being partially disabled.

2. U.S. Social Security Administration, The Faces and Facts of Disability. https://www.ssa.gov/disabilityfacts/facts.html. Accessed April 2021.

This information is not intended to be a complete description of the insurance coverage available. The policy may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy form SCE1100. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

EXCLUSIONS AND LIMITATIONS

This benefit provides coverage for a disability due to a mental or nervous condition. Coverage provides a benefit up to three months per occurrence, with a cumulative lifetime maximum benefit of 24 months.

We will not pay benefits for losses that are caused by or are the result of: Cosmetic Surgery, Felonies and Illegal Occupations, Flying, Hazardous Avocations, Intoxicants and Narcotics, Racing, Semiprofessional or Professional Sports, Substance Abuse, Suicide or Self-Inflicted Injuries, and War or Armed Conflict.

The total disability benefit will end on the policy anniversary date on or next following your 70th birthday, or when you are no longer considered disabled as defined in the policy, whichever comes first.

• Under the regular and appropriate care of a doctor.

FOR EMPLOYEES 8-22 | 1172391-SCColonialLife com 18

• Not, in fact, working at any occupation; and

Can I keep my coverage if I change jobs?

A pre-existing condition means a sickness or physical condition for which any covered person was treated, received medical advice, or had taken medication within 12 months before the effective date of the policy. If you are age 65 or older when the policy is issued, pre-existing conditions include only conditions specifically excluded from coverage by the rider.

1. Educator Disability Advantage is the marketing name of the insurance product filed as “Disability Income Insurance Policy (SCE1100).”

Visit coloniallife.com or call our Policyholder Service Center at 1-800-325-4368 for additional information.

What is the mental or nervous disorder benefit?

• Unable to perform the material and substantial duties of your occupation;

What if I want to return to work part time after I am totally disabled?

If you become disabled due to 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.

If you change jobs or retire, you can take your coverage with you until age 70, as long as you pay your premiums when they are due or within the grace period.

• Your employer will allow you to return to your job or place of employment for less than half of your normally scheduled hours per week; and

How do I file a claim?

Frequently asked questions

• You are under the regular and appropriate care of a doctor.

Totally disabled means you are:

When am I considered totally disabled?

• You are unable to perform the material and substantial duties of your job for more than half of your normally scheduled hours per week;

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.

For more information, talk with your Colonial Life benefits counselor.

Benefits are payable regardless of workers’ compensation or any other insurance you may have with other insurance companies. Benefits are payable directly to you (unless you specify otherwise).

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, and the benefits are paid directly to you (unless you specify otherwise).

BenefitScreeningHealthwith-Preferred1.0Accident

and

Accident Insurance

and

19

the

Can my premium change?

Accidents in places where and your family spend most time – work, the home on the playground –they’re unexpected. How you care for them shouldn’t be. which have happened to you someone you

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.

or

of these accidental injuries

l Car accidents l Falls & spills l Dislocation l Accidental injuries that

Visit coloniallife.com or call our Customer Service Department at 1.800.325.4368 for additional information.

in

you

you to

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.

happen

know? l Sports-related accidental injury l Broken bone l Burn l Concussion l Laceration l Back or knee injuries

Will my accident claim payment be reduced if I have other insurance?

How do I file a claim?

In your lifetime,

included? l Worldwide coverage l Portable l Compliant with Healthcare Spending Account (HSA) guidelines

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. send the Emergency Room, Urgent tor’s office features are

at

What additional

What if I change employers?

Care or doc

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 l Emergency Dental Work ....................................... $75 Extraction, $300 Crown, Implant, or Denture l Lacerations (based on size) ........................................................................................................... $30 to $500 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 l Surgery (cranial, open abdominal or thoracic) ................................................................................ $1,500 l Surgery (hernia) ..............................................................................................................................................$150 l Surgery (arthroscopic or exploratory) ....................................................................................................$200 l Blood/Plasma/Platelets ................................................................................................................................$300 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 l Air Ambulance ............................. $2,000 Common Accidental Injuries Dislocations (Separated Joint)

Non-Surgical

Surgical Depressed Skull $2,750 $5,500 Non-Depressed Skull $1,100 $2,200 Hip, Thigh $1,650 $3,300 Body of Vertebrae, Pelvis, Leg $825 $1,650 Bones of Face or Nose (except mandible or maxilla) $385 $770 Upper Jaw, Maxilla $385 $770 Upper Arm between Elbow and Shoulder $385 $770 Lower Jaw, Mandible, Kneecap, Ankle, Foot $330 $660 Shoulder Blade, Collarbone, Vertebral Process $330 $660 Forearm, Wrist, Hand $330 $660 Rib $275 $550 Coccyx $220 $440 Finger, Toe $110 $220

Non-Surgical Surgical

20

Hip $2,200 $4,400 Knee (except patella) $1,100 $2,200 Ankle – Bone or Bones of the Foot (other than Toes) $880 $1,760 Collarbone (Sternoclavicular) $550 $1,100 Lower Jaw, Shoulder, Elbow, Wrist $330 $660 Bone or Bones of the Hand $330 $660 Collarbone (Acromioclavicular and Separation) $110 $220 One Toe or Finger $110 $220

Fractures

l Medical Imaging Study $150 per accident (limit 1 per covered accident and 1 per calendar year)

.....................................................

Eye .....................

l Spouse

l Loss of Finger/Toe $750 – one, $1,500 – two or more Loss or Loss of Use Hand/Foot/Sight of $7,500 – one, $15,000 – two or more

.................................................$100

l Rehabilitation Unit per day up to 15 days per covered accident, and 30 days per calendar year. Maximum of 30 days per calendar year

l

l Accident Follow-Up Doctor Visit $50 (up to 3 visits per accident)

l Hospital ICU Confinement $450 per day up to 15 days per 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 ................ $25,000 Spouse .............. $25,000 Child(ren) ......... $12,500 365-day elimination period. Amounts reduced for covered persons age 65 and over. Payable once per lifetime for each covered person.

l Occupational or Physical Therapy $25 per treatment up to 10 days

Accident Hospital Care

l Hospital Confinement $225 per day up to 365 days per accident

l Hospital ICU Admission* $2,000 per accident

of

Accidental Death Common Carrier Named Insured $25,000 $100,000 $25,000 $100,000 $5,000 $20,000

.................................................................................

Accidental Death

Catastrophic Accident

l

...................................................

..........................................................................................

Transportation/Lodging Assistance

l Lodging (family member or companion) $125 per night up to 30 days for a hotel/motel lodging costs

l Transportation $500 per round trip up to 3 round trips

If injured, covered person must travel more than 50 miles from residence to receive special treatment and confinement in a hospital.

l Hospital Admission* $1,000 per accident

l Prosthetic Devices/Artificial Limb $500 - one, $1,000 - more than 1

* We will pay either the Hospital Admission or Hospital Intensive Care Unit (ICU) Admission, but not both.

Accident Follow-Up Care

.........................................................

......................................................................................................

l Appliances $100 (such as wheelchair, crutches)

l Child(ren)

21

....................................................

Accidental Dismemberment

l Breast ultrasound

Health Screening Benefit

Colonial

We will not pay benefits for losses that are caused by or are the result of: felonies or illegal occupations; 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; intoxication.

l

l Serum protein electrophoresis

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.

l Bone marrow testing

l Flexible sigmoidoscopy

l PSA (blood test for prostate cancer)

l Pap smear

l CA 15-3 (blood test for breast cancer)

l CEA (blood test for colon cancer)

l Fasting blood glucose test

l Serum cholesterol test to determine level of HDL and LDL

l Carotid doppler

Colonial Life and Making benefits count are registered service marks of Colonial Life & Accident Insurance Company.

Tests include:

l Chest x-ray Colonoscopy

EXCLUSIONS

l CA125 (blood test for ovarian cancer)

l Hemoccult stool analysis

For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form Accident 1.0-HS-SC. This is not an insurance contract and only the actual policy provisions will control.

(blood test for myeloma) l Stress test on a bicycle or treadmill l Skin cancer biopsy l Thermography l ThinPrep pap test l Virtual colonoscopy Colonial Life 1200 Colonial Life Boulevard Columbia, South Carolina 29210 coloniallife.com

10/11 BenefitScreeningHealthwith-Preferred1.0Accident My Coverage Worksheet (For use with your Colonial Life benefits counselor) Who will be covered? (check one) Employee Only Spouse Only One Child Only Employee & Spouse One-Parent Family, with Employee One-Parent Family, with Spouse Two-Parent Family When are covered accident benefits available? (check one) On and Off -Job Benefits Off -Job Only Benefits 22

l $50 per covered person per calendar year

l Electrocardiogram (EKG, ECG)

l Echocardiogram (ECHO)

l Mammography

l Blood test for triglycerides

71740-2-SC

For more information, talk with your benefits counselor.

Rehabilitation unit confinement $100 per day

EXCLUSIONS

THIS POLICY PROVIDES LIMITED BENEFITS.

Observation room $100 per visit

©2016 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.

Hospital Confinement Indemnity Insurance

ColonialLife.com

We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, mental or emotional disorders, pregnancy of a dependent child, suicide or injuries which any covered person intentionally does to himself or herself, war, or giving birth within the first nine months after the effective date of the policy. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. A preexisiting condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the effective date of the policy.

Colonial Life & Accident Insurance Company’s Individual Medical Bridge offers an HSA compatible plan in most states.

Our Individual Medical BridgeSM insurance can help with medical costs that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children.

Maximum of one benefit per covered person per calendar year

For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000-SC. This is not an insurance contract and only the actual policy provisions will control.

IMB7000 – PLAN 1 | 1-16 | 101576-SC

Waiver of premium Available after 30 continuous days of a covered hospital confinement of the named insured

Hospital confinement $

Maximum of 15 days per confinement with a 30-day maximum per covered person per calendar year

Maximum of two visits per covered person per calendar year

Plan 1

23

Health savings account (HSA) compatible

This plan is compatible with HSA guidelines. This plan may also be offered to employees who do not have HSAs.

..................................................................................

Rehabilitation unit confinement $100 per day

Maximum of 15 days per confinement with a 30-day maximum per covered person per calendar year

IMB7000 – PLAN 3

Available after 30 continuous days of a covered hospital confinement of the named insured

For more information, talk with your benefits counselor.

Diagnostic procedure Tier 1 $250 Tier 2 $500

Outpatient surgical procedure Tier 1 $ Tier 2 $

Maximum of two visits per covered person per calendar year

Maximum of $___________ per covered person per calendar year for all covered outpatient surgical procedures combined

Breast – Biopsy (incisional,

Diagnostic radiology – Nuclear medicine test Digestive – Barium enema/lower GI series – Barium swallow/upper GI series – Esophagogastroduodenoscopy (EGD) Ear, nose, throat, mouth – Laryngoscopy Gynecological – Amniocentesis – Cervical biopsy – Cone biopsy – Endometrial biopsy Tier 2 diagnostic procedures Cardiac – Angiogram – Arteriogram – Thallium stress test – Transesophageal echocardiogram (TEE) Liver – biopsy Lymphatic – biopsy Miscellaneous – Bone marrow aspiration/biopsy Renal – biopsy Respiratory – Biopsy – Bronchoscopy – Pulmonary function test (PFT) Skin – Biopsy – Excision of lesion Thyroid – biopsy Urologic – Cystoscopy Diagnostic radiology – Computerized tomography scan (CT scan) – Electroencephalogram (EEG) – Magnetic resonance imaging (MRI) – Myelogram – Positron emission tomography scan (PET scan) – Hysteroscopy – Loop (LEEP)excisionalelectrosurgicalprocedure 24

The following is a list of common diagnostic procedures that may be covered. 1 diagnostic procedures needle, stereotactic)

Our Individual Medical BridgeSM insurance can help with medical costs that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children.

Maximum of one benefit per covered person per calendar year

Observation room $100 per visit

Hospital confinement $

Tier

Hospital Confinement Indemnity Insurance

Waiver of premium

Maximum of $500 per covered person per calendar year for all covered diagnostic procedures combined

Plan 3

Tier 1 outpatient surgical procedures

– Arthroscopic shoulder surgery

– Arthroscopic knee surgery with meniscectomy (knee cartilage repair)

– Dislocations (open reduction with internal fixation)

–

Ear, nose, throat, mouth

(m)Apre-existingconditionisasicknessorphysicalconditionforwhichacoveredpersonwastreated,hadmedicaltesting, receivedmedicaladviceorhadtakenmedicationwithinthe12monthsbeforetheeffectivedateofthepolicy.(n)This limitationappliestothefollowingbenefits,ifapplicable:HospitalConfinement,DailyHospitalConfinement,Enhanced IntensiveCareUnitConfinementandRehabilitationUnitConfinement.

Cardiac – Angioplasty – Cardiac catheterization

Skin

Tier 2 outpatient surgical procedures

– Adenoidectomy

– Myomectomy

– Lysis of adhesions

Wewillnotpaybenefitsforinjuriesreceivedinaccidentsorforsicknesseswhicharecausedby:(a)alcoholismordrug addiction,(b)dentalprocedures,(c)electiveproceduresandcosmeticsurgery,(d)feloniesorillegaloccupations,(e) pregnancy ofadependentchild,(f)psychiatricorpsychologicalconditions,(g)suicideorinjurieswhichanycoveredperson intentionally doestohimselforherself,or(h)war.Wewillnotpaybenefitsforhospitalconfinement(i)duetogivingbirth withinthefirst ninemonthsaftertheeffectivedateofthepolicyor(j)foranewbornwhoisneitherinjurednorsick.(k)The policymayhave additionalexclusionsandlimitationswhichmayaffectanybenefitspayable.

1-21 | 562942

This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy form IMB7000 (including state abbreviations where used, for example: IMB7000TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. This form is not complete without form #562973.

–

Breast – Breast reconstruction – Breast reduction

(l)Wewillnotpaybenefitsforlossduringthefirst12monthsaftertheeffectivedateduetoapre-existingcondition.

Urologic – Lithotripsy

Musculoskeletal system

– Clavicle resection

– Myringotomy

ColonialLife.com

Ear, nose, throat, mouth – Ethmoidectomy – Mastoidectomy – Septoplasty – Stapedectomy – Tympanoplasty

–

– Endometrial ablation

–

– Fracture (open reduction with internal fixation)

EXCLUSIONS

– Removal or implantation of cartilage – Tendon/ligament repair

– Tonsillectomy

Digestive – Exploratory laparoscopy – Laparoscopic appendectomy – Laparoscopic cholecystectomy

–

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC

The surgeries listed below are only a sampling of the surgeries that may be covered. Surgeries must be performed by a doctor in a hospital or ambulatory surgical center. For complete details and definitions, please refer to your policy.

PRE-EXISTING CONDITION LIMITATION

Gynecological – Hysterectomy

Thyroid – Excision of a mass

Cardiac – Pacemaker insertion Digestive – Colonoscopy Fistulotomy Hemorrhoidectomy Lysis of adhesions – Laparoscopic hernia repair Skin grafting Liver Paracentesis

– Dilation and curettage (D&C)

–

25

Gynecological

– Removal of oral lesions

Eye – Cataract surgery – Corneal surgery (penetrating keratoplasty) – Glaucoma surgery (trabeculectomy) – Vitrectomy

THIS POLICY PROVIDES LIMITED BENEFITS.

– Tracheostomy Tympanotomy

Musculoskeletal system

Breast – Axillary node dissection – Breast capsulotomy – Lumpectomy

–

– Carpal/cubital repair or release Foot surgery (bunionectomy, exostectomy, arthroplasty, hammertoe repair) Removal of orthopedic hardware Removal of tendon lesion

CT: (a) Replaced by intoxication or drug addiction; (d) Replaced by felonies; (e) Exclusion does not apply

ME: (m) Pre-existing Condition means having a sickness or physical condition for which any covered person was treated, had medical testing, or received medical advice within 12 months before the effective date of this policy.

CA: (a) Replaced by intoxicants or controlled substances; (c) Replaced by cosmetic surgery

NC: (i) Exclusion does not apply

IL: (a) Replaced by alcoholism, intoxication, or drug addiction; (e) Exclusion does not apply; (g) Exclusion does not apply

LA: (a) Replaced by intoxicants and narcotics

If you are 65 or older when this policy is issued, pre-existing conditions will include only conditions specifically eliminated by rider.

KS: (a) Replaced by intoxicants and narcotics; (f) Exclusion does not apply; (h) Replaced by war or armed conflict; (i) Exclusion does not apply; (j) or requires necessary care and treatment of medically diagnosed congenital defects, birth abnormalities or routine and necessary immunizations

AK: (a) Replaced by intoxicants and narcotics

NC: (m) Pre-existing Condition means having those conditions whether diagnosed or not, for which any covered person received medical advice, diagnosis, care or treatment was received or recommended within one-year period immediately preceding the effective date of this policy.

OR: Pre-existing Condition means having a sickness or physical condition for which any covered person was diagnosed, received treatment, care or medical advice within the 6-month period immediately preceding the effective date of this policy.

MN: (a) Replaced by narcotic addiction; (e) Exclusion does not apply; (g) Exclusion does not apply

Exclusions and Limitations

STATE-SPECIFIC EXCLUSIONS

STATE-SPECIFIC PRE-EXISTING CONDITION LIMITATIONS

MO: (a) Replaced by drug addiction

TX: (a) Replaced by intoxicants and narcotics

SC: (f) Replaced by mental or emotional disorders

IL: (m) Pre-existing Condition means having a sickness or physical condition for which any covered person was diagnosed, treated, had medical testing by a legally qualified physician, or received medical advice or had taken medication within 12 months prior to the effective date of this policy.

TN: (a) Replaced by intoxicants and narcotics; (e) Exclusion does not apply

IMB7000 – EXCLUSIONS AND LIMITATIONS | 1-21 | 56297326

CT: (m) Pre-existing Condition means having a sickness or physical condition for which any covered person was treated, received medical advice or had taken medication within 12 months before the effective date of this policy.

DE: (a) Exclusion does not apply

OR: (a) Exclusion does not apply; (d) Replaced by felony; (i) Replace “nine months” with “six months”

GA: (m) 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 prescription medication within 12 months before the effective date of this policy.

WA: (a) Only sicknesses caused by alcoholism or drug addiction are excluded, not accidents

KY: (a) Replaced by intoxicants, narcotics and hallucinogenics

This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form IMB7000 (including state abbreviations where used, for example: IMB7000-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. This form is not complete without base form 562880, 562911, or 562942.

SD: (a) Exclusion does not apply

FL: (m) Pre-existing Condition means any covered person having a sickness or physical condition that during the 12 months immediately preceding the effective date of this policy had manifested itself in such a manner as would cause an ordinarily prudent person to seek medical advice, diagnosis, care, or treatment or for which medical advice, diagnosis, care, or treatment was recommended or received.

Routine follow-up care during the 12 months immediately preceding the effective date of this policy to determine whether a breast cancer has recurred in a covered person who has been previously determined to be free of breast cancer does not constitute medical advice, diagnosis, care, or treatment for purposes of determining pre-existing conditions, unless evidence of breast cancer is found during or as a result of the follow-up care.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2021 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

NV, WY: (m) applies within the six months before the policy effective date.

Hospital Confinement Indemnity Insurance

Fasting

Colonoscopy Echocardiogram

Hospital Confinement Indemnity Insurance Screening

Serum

MO & ND: Waiting period does not apply

per calendar year; subject to a

per

PSA

Underwritten

Hemoccult

Flexible

Thermography ThinPrep

For more information, talk with your benefits counselor.

THIS POLICY PROVIDES LIMITED BENEFITS. information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy form IMB7000 (including state abbreviations where used, for example: IMB7000-TX). cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. screening once covered person 30-day waiting period. test for triglycerides marrow testing ultrasound 15-3 (blood test for breast cancer) 125 (blood test for ovarian cancer) (blood test for colon cancer) Doppler X-ray (ECHO) (EKG, ECG) blood glucose test sigmoidoscopy stool analysis smear (blood test for prostate cancer) cholesterol test for HDL and LDL levels protein electrophoresis test for myeloma) cancer biopsy test on a bicycle or treadmill pap test colonoscopy

(blood

CA

Serum

Skin

Mammography Pap

27

CEA

Virtual

Chest

For

Breast

CA

This

&

IMB7000 – HEALTH SCREENING BENEFIT | 1-21 | 101579-4 ColonialLife.com Health

$_____________ Payable

Health

Bone

Stress

Electrocardiogram

Blood

Carotid

Individual Medical BridgeSM insurance’s health screening benefit can help pay for health and wellness tests you have each year. by Colonial Life & Accident Insurance Company, Columbia, SC Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life Accident Insurance Company.

Maximum of two visits per covered person per calendar year

...................................................................................

Appliance $100

Maximum of one benefit per covered person per calendar year

For more information, talk with your benefits counselor.

Hospital Confinement Indemnity Insurance Medical Treatment Package

The medical treatment package paired with Plan 3 provides the following benefits:

This information is not intended to be a complete description of the insurance coverage available. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form IMB7000-SC. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

Doctor’s office visit $25 per visit

Maximum of three visits per calendar year for named insured coverage or maximum of five visits per calendar year for all covered persons combined

THIS POLICY PROVIDES LIMITED BENEFITS.

EXCLUSIONS

Air ambulance $1,000

Maximum of one benefit per covered person per calendar year

Maximum of two benefits per covered person per calendar year

28

Ambulance $100

IMB7000-MEDICAL TREATMENT PACKAGE SOUTH CAROLINA EDUCATORS | 3-21 | NS-15014-SC ColonialLife.com

We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, mental or emotional disorders, suicide or injuries which any covered person intentionally does to himself or herself, or war.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2021 Colonial Life & Accident Insurance Company. All rights reserved Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

The medical treatment package for Individual Medical BridgeSM coverage can help pay for deductibles, co-payments and other out-of-pocket expenses related to a covered accident or covered sickness.

Emergency room visit $100 per visit

X-ray $25 per benefit

Daily hospital confinement rider

Per covered person per day of intensive care unit confinement

Enhanced intensive care unit confinement rider $500 per day

This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy form IMB7000 and rider forms R-DHC7000 and R-EIC7000 (including state abbreviations where used, for example: IMB7000-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

THIS POLICY PROVIDES LIMITED BENEFITS. EXCLUSIONS

For more information, talk with your benefits counselor.

Hospital Confinement Indemnity Insurance

We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, war, or giving birth within the first nine months after the effective date of the rider. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the effective date of the rider.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC

This form is not complete without a base form (101576, 101578, 101581, 562880, 562911 or 562942).

Maximum of 365 days per covered person per confinement

Maximum of 30 days per covered person per confinement

Re-confinement for the same or related condition within 90 days of discharge is considered a continuation of a previous confinement.

29

Optional Riders

Individual Medical BridgeSM offers two optional benefit riders – the daily hospital confinement rider and the enhanced intensive care unit confinement rider. For an additional cost, these riders can help provide extra financial protection to help with out-of-pocket medical expenses.

$100 per day

Per covered person per day of hospital confinement

IMB7000 – DAILY HOSPITAL CONFINEMENT AND ENHANCED INTENSIVE CARE UNIT CONFINEMENT RIDERS | 1-21 | 101582-5 ColonialLife.com

WHOLE LIFE PLUS INSURANCE

Immediate $3,000 claim payment that can help your designated beneficiary pay for funeral costs or other expenses

You can’t predict your family’s future, but you can be prepared for it.

Cover your spouse with a death benefit up to $50,000, for 10 or 20 years.

Purchase a policy (paid-up at age 70) while children are young and premiums are low — whether or not you buy a policy for yourself. You may also increase the coverage when the child is 18, 21 and 24 without proof of good health.

Whole Life Plus Insurance

Juvenile Whole Life Plus policy

• Permanent coverage that stays the same through the life of the policy

Your cost will vary based on the amount of coverage you select.

Give your family peace of mind and coverage for final expenses with Whole Life Plus insurance from Colonial Life.

WHOLE LIFE PLUS (IWL5000) 30

• Benefit for beneficiarythethat is typically tax-free

• Policy loans available, which can be used for emergencies

BENEFITS AND FEATURES

Spouse term rider

Provides cash surrender value at age 100 (when the policy endows)

ADVANTAGES OF

ADDITIONAL COVERAGE OPTIONS

Children’s term rider

Stand-alone spouse policy available even without buying a policy for Abilityyourselftokeep the policy if you change jobs or retire

You may purchase up to $20,000 in term life coverage for all of your eligible dependent children and pay one premium. The children’s term rider may be added to either your policy or your spouse’s policy — not both.

Built-in terminal illness accelerated death benefit that provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness2

• Premiums will not increase due to changes in health or age

• Accumulates cash value based on a non-forfeiture interest rate of 3.75%1

Choose the age when your premium payments end — Paid-Up at Age 70 or Paid-Up at Age 100

Select the option:  Paid-Up at Age 70

 Paid-Up at Age 70

 Children’s term rider

ColonialLife.com

1. Accessing the accumulated cash value reduces the death benefit by the amount accessed, unless the loan is repaid. Cash value will be reduced by any outstanding loans against the policy.

 Paid-Up at Age 100

 Critical illness accelerated death benefit rider

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.

To learn more, talk with your benefits counselor.

 SPOUSE $

The beneficiary may receive an additional benefit if the covered person dies as a result of an accident before age 70. The benefit doubles if the accidental bodily injury occurs while riding as a fare-paying passenger using public transportation, such as ride-sharing services. An additional 25% will be payable if the injury is sustained while driving or riding in a private passenger vehicle and wearing a seatbelt.

EXCLUSIONS AND LIMITATIONS: If the insured dies by suicide, whether sane or insane, within two years (one year in ND) 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 without interest, minus any loans and loan interest to you.

Chronic care accelerated death benefit rider

 Paid-Up at Age 70

Select any optional riders:

For use with your benefits counselor

How much coverage do you need?

$

Accidental death benefit rider

$ _____________face amount for _________-year term period

If a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments.2 A chronic illness means you require substantial supervision due to a severe cognitive impairment or you may be unable to perform at least two of the six Activities of Daily Living (bathing, continence, dressing, eating, toileting and transferring). Premiums are waived during the benefit period.

 Guaranteed purchase option rider

2. Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits.

 Paid-Up at Age 100

 Accidental death benefit rider

FOR EMPLOYEES 6-21 | 642298 31

 Chronic care accelerated death benefit rider

Select the option:

Waiver of premium benefit rider

$ ________ face amount

 Spouse term rider

ADDITIONAL COVERAGE OPTIONS (CONTINUED)

Select the option:

Critical illness accelerated death benefit rider

Benefits worksheet

Guaranteed purchase option rider

Premiums are waived (for the policy and riders) if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period. Once you are no longer disabled, premium payments will resume.

 Paid-Up at Age 100

If you suffer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable.2 A subsequent diagnosis benefit is included.

 DEPENDENT STUDENT

This rider allows you to purchase additional whole life coverage — without having to answer health questions — at three different points in the future. The rider may only be added if you are age 50 or younger when you purchase the policy. You may purchase up to your initial face amount, not to exceed a total combined maximum of $100,000 for all options.

 Waiver of premium benefit rider

This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy forms ICC19IWL5000-70/IWL5000-70, ICC19-IWL5000-100/IWL5000-100, ICC19-IWL5000J/IWL5000J and rider forms ICC19-R-IWL5000-STR/R-IWL5000-STR, ICC19-R-IWL5000-CTR/R-IWL5000-CTR, ICC19-R-IWL5000-WP/R-IWL5000-WP, ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD, ICC19-RIWL5000-CI/R-IWL5000-CI, ICC19-R-IWL5000-CC/R-IWL5000-CC, ICC19-R-IWL5000-GPO/RIWL5000-GPO. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company.

 YOU $

Health information may be disclosed by any health care provider or institution, health plan or health care clearinghouse that has any records or knowledge about me including prescription drug database or pharmacy benefit manager, or ambulance or other medical transport service. Health information may also be disclosed by any insurance company, Medicare or Medicaid agencies or the Medical Information Bureau (MIB). Health information includes my entire medical record, but does not include psychotherapy notes. Non-health information including earnings or employment history deemed appropriate by Colonial to evaluate my application may be disclosed by any person or organization that has these records about me, including my employer, employer representative and compensation sources, insurance company, financial institution or governmental entities including departments of public safety and motor vehicle departments.

(Printed name of individual (Social Security (Signature) (Date Signed) subject to this disclosure) Number)

If applicable, I signed on behalf of the proposed insured as __________________________ (indicate relationship). If legal Guardian, Power or Attorney Designee, or Conservator.

Any information Colonial obtains pursuant to this authorization will be used for the purpose of evaluating my application(s) for insurance or eligibility for benefits. Some information obtained may not be protected by certain federal regulations governing the privacy of health information, but the information is protected by state privacy laws and other applicable laws. Colonial will not disclose the information unless permitted or required by thoseThislaws.authorization is valid for two (2) years from its execution and a copy is as valid as the original. A copy will be included with my contract(s) and I or my authorized representative may request access to this information. This authorization may be revoked by me or my authorized representative at any time except to the extent Colonial has relied on the authorization prior to notice of revocation or has a legal right to contest coverage under the contract(s) or the contract itself. If revoked, Colonial may not be able to evaluate my application(s) for insurance or eligibility for benefits as necessary to issue my contract(s). I may revoke this authorization by sending written notice to: Colonial Life & Accident Insurance Company, Underwriting Department, P.O. Box 1365, Columbia, SC 29202.

For the purpose of evaluating my application(s) for insurance submitted during the current enrollment and eligibility for benefits under any insurance issued including checking for and resolving any issues that may arise regarding incomplete or incorrect information on my application(s), I hereby authorize the disclosure of the following information about me and, if applicable, my dependents, from the sources listed below to Colonial Life & Accident Insurance Company (Colonial) and its duly authorized representatives.

___________________ _____

You may refuse to sign this form; however, Colonial may not be able to issue your coverage. I am the individual to whom this authorization applies or that person’s legal Guardian, Power of Attorney Designee, or Conservator.

Authorization for Colonial Life & Accident Insurance Company

(Printed name of legal representative) (Signature of legal representative) (Date Signed)

32

33

1.800.561.3082 (fax)

Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

10-16 18514-16 34

M 1st-5th M 6th-10th M 11th-15th M 16th-20th M 21st-26th

Mailing Address: Social Security Number or Date of Birth:_____________________

______________________________________

M Quarterly

Please choose one of the following payment options:

Which Colonial Life & Accident Insurance do you want to continue? (check one or more)

1.800.325.4368 (phone)

My premiums are no longer being payroll-deducted.

(Submit a payment 3 times your monthly premium)

______________________,continued:______________________, ______________________, ______________________,

City: State:_______________________ Zip: _____________________ number(s) to be

M 1. Deduct premiums monthly from my bank account.

M Semi-annually (Submit a payment 6 times your monthly premium) M Annually (Submit a payment 12 times your monthly premium)

YES! I want to keep my Colonial Life Coverage.

Date: ____________________ Policy Owner’s Signature:______________________________________________

Name: ____________________________________ Daytime Telephone Number: (______) ________________________

Return ColonialTo:Life & Accident Insurance Company P.O. Box Columbia,1365South Carolina 29202

Complete this form and mail it today — along with a check for your premium payment.

Your draft will occur on one of the dates within the range you have selected. Please include a voided check or Routing #____________________________ and Account #________________________________ Signature of bank account owner

Policy

Accident Disability Hospital Income Cancer or Critical Illness Life

M 2. Bill me directly. (choose one of the following)

PEBA - SC RETIREMENT SYSTEMS AND STATE HEALTH PLAN

Please Note: If your cancer policy includes a second part to the screening benefit, bills for tests covered and a copy of the diagnostic report (reflecting the abnormal reading of your first test) must be mailed or faxed to us for benefits to be provided.

If you wish to file a Wellness/Cancer Screening claim for a test performed within the past 18 months, you need the name and date of the test performed as well as your doctor’s name and phone number. Colonial also needs to know if this is for you or another covered individual and their name and social security number. You may:

• Technical Help Desk: 1-866-875-4772

• SUBMIT ON THE INTERNET using the Wellness Claim Form at www.coloniallife.com, or

COLONIAL LIFE

• Claims Fax: 1-800-880-9325

HARMONY ONLINE ENROLLMENT

TO VIEW YOUR BENEFITS ONLINE

If your Wellness/Cancer Screening test was more than 18 months ago, you must fax or mail Colonial a copy of the bill or statement from your doctor indicating the type of procedure performed, the charge incurred and the date of service. Please write your full name, social security number, and current address on the bill.

• TDD for hearing impaired customers call: 1-800-798-4040

• FILE BY PHONE! Call 1-800-325-4368 and provide the information requested by Colonial’s Automated Voice Response System, 24 hours per day, 7 days a week, or

CONTACT INFORMATION:

• Website: www.peba.sc.gov

• Write your name, address, social security number and/or policy/certificate number on your bill and indicate “Wellness Test.” Fax this to Colonial at 1-800-880-9325 or MAIL to PO Box 100195, Columbia, SC 29202

When you terminate employment, you have the opportunity to continue your Colonial coverage either through direct billing or automatic payment through your bank account. Please contact Colonial at 1-800-325-4368 to request the continuation of benefits form.

• Customer Service & Wellness Screenings: 1-800-325-4368

• Website: www.coloniallife.com

VISIT COLONIALLIFE.COM TO SET UP YOUR PERSONAL ACCOUNT

For additional information concerning plans offered to employees of the Williamsburg County School District, please contact our Pierce Group Benefits Service Center at 1-833-556-0006

• Customer Service: 1-803-737-6800 or 1-888-260-9430

• See pages 5-6 for online enrollment instructions

Visit WilliamsburgCountySchoolDistrictwww.piercegroupbenefits.com/

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