.~~~
~~
/~
~ ~ ~
r
~ fir" ~ ~ ~ ~ c ~-e ~ 1 C~ ~ ~ ~ ~ ~ /s a ~s ~ v ~ 7`~ l
~ti , ~ D d ~~
~~
~~
ll-13-~~7
~,~f~~~~ ~ ~-~ ~~ s ~f ~
~7~~ ~~~~
y
,. ,~
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;~~.
Kerr County
Specific and Aggregate Stop Loss Insurance
Third Party Medical Claims Administration
Group Term Life and AD&D
Health Reimbursement Arrangement
Cafeteria Plan (IRS code 125) Administration
Prescription Benefit Management
PLEASE FILL IN THE FOLLOWING INFORMATION NEEDED AND
SUBMIT WITH PROPOSAL.
The undersigned proposer, by signing and executing this proposal, certifies and represents to Kerr
County that proposer has not offered, conferred or agreed to confer any pecuniary benefit, as
defined by (l .07 (a) (6) of the Texas Penal Code, or any other thing of value as consideration for
the receipt of information or any special treatment of advantage relating to this proposal; the
proposer also certifies and represents that the proposer has not offered, conferred or agreed! to
confer any pecuniary benefit or other thing of value as consideration for the recipient's decision,
opinion, recommendation, vote or other exercise of discretion concerning this proposal, the
proposer certifies and represents that proposer has neither coerced nor attempted to influence the
exercise of discretion by any officer, trustee, agent or employee of Ken County concerning this
proposal on the basis of any consideration not authorized by law; the proposer also certifies and
represents that proposer has not received any information not available to other proposers so as to
give the undersigned a preferential advantage with respect to this proposal; the proposer further
certifies and represents that proposer has not violated any state, federal, or local law, regulation or
ordinance relating to bribery, improper influence, collusion or the like and that proposer will not
in the future offer, confer, or agree to confer any pecuniary benefit or other thing of value of any
oflcer, trustee, agent or employee of Kerr County in return for the person having exercised their
person's official discretion, power or duty with respect to this proposal; the proposer certifies and
represents that it has not now and will not in the future offer, confer, or agree to confer a pecuniary
benefit or other thing of value to any officer, trustee, agent, or employee of Kerr County in
connection with information regarding this proposal, the submission of this proposal, the award
of this proposal or the performance, delivery or sale pursuant to this proposal. The Proposer
represents that he, his agent(s), nor any corporate employee has contacted any officer, trustee,
elected County official or any other County employee with the intent to discuss, influence, or in
any manner affect the outcome of the bid process.
The proposer shall defend, indemnify, and hold harmless Kerr County, all of its officers, agents and
employees from and against all claims, actions, suits, demands, proceeding, costs, damages, and
liabilities, arising out of, connected with, or resulting from any acts or omissions of contractor or
any agent, employee, subcontractor, or Supplier of contractor in the execution or performance of
this RFP.
I have read all of the specifications and general proposal requirements and do hereby certify that
all items submitted meet specifications. ' A ) /
COMPANY: ~6 r-~ ~ ~ Vyl~ 1 DID e ~
AGENT NAME: W ~ I r ~C.- ~ °~ ~~ ~ e
AGENT SIGNATURE: ~ ~
ADDRESS: (Q~.4~ ~/ ~Z ~ i~ ~/ f'' ~S5 #3
cITY: ~..5~ V v~
STATE: ZIP CODE: i~~S S
TELEPHONE: ~j,3~ `3 ~Z- ~U ~Z FAX:g~~'~C~-~ ~ ~~~
FEDERAL TIN#: ANED/OR SOCIAL SECURITY #: ~,~~- 7 ~ "~'Z l U
Page 5 of 29
Kerr County
Specific and Aggegate Stop Loss Insurance
Third Party Medical Claims Administration
Group Term Life and AD&D
Health Reimbursement Arrangement
Cafeteria Plan (IRS code 125) Administration
Prescription Benefit Management
PLEASE ACKNOWLEDGE RECEIVING THIS RFP BY RETURNING THIS FORM
In order to allow a fair and competitive bid process proposer will not be allowed to access markets prior to
the release date of this RFP. The official date and time of release is Tuesday October 30, 2007, 10:00 AM.
[t is your responsibility to return this intent to bid with the proper means of contacting you or your
organization. Communicating any questions, answers, or amendments to this RFPwill be made through the
process you provide on this form.
FAX or Mail TO: Gary Looney REec
Insurance Consultant
3201 Cherry Ridge Dr
Suite D 405
San Antonio, Texas 78230
Fax:210-930-1838
WILL RESPOND*
WILL NOT RESPOND
COMMENTS:
AGENT NAME: l ,f'S K ~ Tl I/l.%/~'/l>4 C ~
Agent Phone: Agent Email:
Agent Signature Print Agent Name
COMPANY NAME: aVj{-l~t~C-~' `~ ~-s.~C) ~ _ _ -~ Z..
COMPANY FAX ~ Company Phone
COMPANY CONTACT EMAIL ~~~ Cc,)A- l /~-~ ~- (% S~~X ' ~'/'rr Cdlur
~~ _
SIGNATURE
Page 4 of 29
Michelle Burnett
From: Hector_Licon@BCBSTX.COM
Sent: Thursday, November 08, 2007 4:24 PM
To: Michelle Burnett
Subject: Re: FW: Kerr County
Michelle, I have just been advised by TAC, that after evaluating the most current
experience, they are opting to "NO BID" the case. The County has already been informed of
their decision. We appreciate you thinking of us and hope that we get to work on other
opportunities in the future.
Regards,
Hector Licon
Regional Sales Executive
Mid-Market Croup Sales
Blue Cross Blue Shield of Texas
8200 IH-10 West, Suite 420
San Antonio, Texas 78230
Direct: 210-357-5204
Fax: 210-357-5216
hector licon@bcbstx.com

The information contained in this communication is confidential, private, proprietary, or
otherwise privileged and is intended only for the use of the addressee. Unauthorized use,
disclosure, distribution or copying is strictly prohibited and may be unlawful. If you
have received this communication in error, please notify the sender immediately at
(312)653-6000 in Illinois; (800)835-8699 in New Mexico; (918)560-3500 in Oklahoma; or
(972)766-6900 in Texas.

1
,.
Page 1 of 1
Michelle Burnett
From: Mike Wilson [MWitson@sbsadmin.com]
Sent: Thursday, September 06, 2007 1:26 PM
To: Michelle Burnett
Subject: Kerr County
Michelle,
Attached are the requested quotes for Kerr County.
Thanks,
Mike Wilson
President
SBS Administrative Services, LLC
210-659-8100
1-888-659-8151
Fax 210-659-8171
433 Kitty Hawk Rd. Suite 217
Universal City, Texas 78148
This email transmission, including any attachments, is intended only for the use of the individual or entity named above
and may contain information that is confidential, privileged and or exempt from disclosure under applicabale law. If you
are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or use of any of the
information contained in this transmission is strictly PROHIBITED.
9/6/2007
~ ~~.- Administrative
Services, LLC
COBRA QUOTE FOR SERVICES
Date: 9/6/2007	Company Name: Kerr County
Below is a breakdown of charges that would be incurred as a result of SBS Administrative Services, LLC providing
COBRA Administrative Services as of the effective date of the contract.
Contract Effective Date:
Administration and Development
• Take-over of all existing COBRA Participants
• Access to Online Cobra Notification System on SBS Web Site
• Qualifying Event Forms
• Initial HIPAA Pre-Existing Conditions Notice and COBRA Rights Notice to all new insurance enrollees and spouse
adds, upon notification
• Termination Packet
• Notification of Rights to Elect COBRA Continuation
• Cobra Continuation Coverage Election Forms
• Certificates of Group Health Plan Coverage, as required by HIPAA
• Coupons, with 102% calculation
• Retrieval of COBRA Premiums, (payable to the Employer)
• Notice ofNon-Commencement
• Notice of Termination with HIPAA Certificates
• State Continuation Administration for active COBRA participants
• Monthly COBRA logs to Employer
• Customer service for Employer and COBRA Participants
• Notification to Employer and eligible Participants of changes in COBRA regulations, as needed
Schedule of Charges
Set-Up Fee:	Monthly Fee:
$150.00	$1.50 Per Active Benefit Participant
	Minimum Monthl Fee $125.00
Signature of Company Representative	Date
Signature of SBS Administrative Services, LLC Representative	Date
P.O. Box 3102, Universal City, Texas 78148
Phone (210) 659-8100
Toll Free (888) 659-8151
Fax (210) 659-8171
www.sbsadmin.com
~ ` Administrative
ser..~~es, ~~c
SECTION 125 F[JLL FLEX Q~T4TE WITH FLEX CONVENIENCE CARD
Date:	Company Name:
9/6/2007	Kerr County
Below is a breakdown of charges that would be incurred as a result of
SBS Administrative Services, LLC providing a Section 125 Full Flex Cafeteria Plan with
the Flex Convenience Card as of the effective date of the contract.
Contract Effective Date:
Administration and Development
• Development of Enrollment Forms
• Group Enrollment Presentation
• Development of Summary Plan Descriptions to be distributed to all eligible plan participants
• Confirmation Letters to be mailed to all Flex Plan Participants including Claim Forms and
Retum Envelopes
• Model Plan Documents ready for signature
• Completion ofNon-Discrimination Testing
• Premium Deduction Recording per Pay Cycle
• Flex Convenience Cards for all Flex Plan Participants
• Online Access for Account Participants which shows balances and claims paid to date.
• Daily Reimbursement Claims Payment
• Account Status Balance Report for Employer
• Annual Reporting
• 5500 Tax Form Completion if required by ERISA
P.O. Box 3101, Universal City, Texas 78148
Phone (210) 659-8100
Toll Free (888) 659-8151
Fax (L10) 659-8171
www.sbsadmin.com
~ ~ Administrati~
Services, LL
Each question below must be answered at the time of signature.
If you need any clarification on the following please contact
SBS Administrative Services, LLC for assistance prior to signing this quote.
APPROVAL METHOD FOR REVIEW OF FLEX CARD TRANSACTIONS: (You must check one.)
^ I authorize SBS Administrative Services, LLC to REVIEW ALL Flex Card transactions that are not pre-set
for Automatic Register Review, such as Wal-Mart, Sam's Club and Walgreens, and request ALL receipts from EACH
plan participant as the expenses are incurred. This means SBS will review all Hospital Charges, Doctor Charges, Vision
Charges, Dental Charges and Pharmacy Charges. NO EXCEPTIONS. (Recommended based on IRS regulation).
^ I authorize SBS Administrative Services, LLC to only review Pharmacy and Grocery Store/Pharmacy
Flex Card transactions that are not pre-set for Automatic Register Review, such as Wal-Mart, Sam's Club and
Walgreens, and request ALL receipts from EACH plan participant for these given expenses as they are incurred. This
means SBS will not request receipts for Hospital Charges, Doctor Charges, Vision Charges and Dental Charges.
^ I authorize SBS Administrative Services, LLC to automatically approve ALL Flex Card transactions as incurred
WITHOUT REVIEWING any receipts including all pharmacy transactions that are not pre-set for Automatic Register
Review, such as Wal-Mart, Sam's Club and Walgreens from each plan participant. NO EXCEPTIONS.
I understand that SBS Administrative Services, LLC cannot be held Responsible or Liable for any abuse
pertaining to the Medical Spending Account if SBS Administrative Services LLC does not review each receipt
after the time of purchase/transaction.
Signature of Company Representative Date
2'/: MONTH EXTENSION FOR MEDICAL SPENDING ACCOUNT: (You must check one.)
^ I authorize SBS Administrative Services, LLC to add the 2 `/Z month extension of time to incur expenses for the
Medical Spending Account for this new plan year. I understand that by adding this extension, the plan may end
in a deficit (negative) at the close of the 2 '/Z month extension.
^ I do not authorize SBS Administrative Services, LLC to add the 2 '/z month extension of time to incur expenses
for the Medical Spending Account.
Signature of Company Representative
Date
P.O. Box 310L, Universal City, Texas 78148
Phone (210) 659-8100
Toll Free (888) 659-8151
Fax (210) 669-8171
www.sbsadmin.com
~ ` Administrative
Serv~ces_ LLC
COORDINATION WITH A HEALTH SAVINGS ACCOUNT: (You must check one.)
We offer a Health Savings Account,
We do not offer a Health Savings Account.
I understand that if we offer a Health Savings Account, SBS Administrative Services, LLC does NOT accept any
liability or responsibility for coordinating any Plan Documents or Claims between our FSA and our HSA.)
Signature of Company Representative Date

	Monthly Fee:
Set-Up Fee:	
$6.00 Per Reimbursement Account Plan Participant Only
$500.00	(Minimum Monthly Fee $125.00)
Si nature of Com any Re resentative	Date
Si ature of SBS Administrative Services, LLC Re resentative	Date
P.O. Box 310L, Universal City, Texas 78148
Phone (210) 639-8100
Toll Free (888) 659-8151
Fax ('L 10) 659-8171
www.sbsadmin.com
!, 'k
~~ VERITY
NATIONAL
November 13, 20Q7
Mr. Don Wallace
WALLACE & ASSOCIATES
628` North 123 Bypass #3
Seguin, TX 78155
Dear Dan:
The purpose of this letter Is to confirm that Verity National Group`s reuised
figures of iQ/7/2007 (copy attached} will stand as our final numbers for the
second RFP round for Kerr County, due tomorrow in Gary Looney`s office.
Should you have. any questions ar concerns please feel free to contact me at
(214} 442-4642 or uia e-mail at jreidCa~ueritynational.com
SiflCErel}!r
1im Reid
Managing Partner -Operations
VERITY i~t~1~'IC)NAL C~Rf_IC~I?, I~~,
Corpc~tate Qffice
1~oi3? Hire 3rtPC Rcz.r,', Sta 3(}0, Sin Ar~tc~riir~. (X rt3~3i~
~i.0E3~p J77
paftas Office
~95~ Shea; Lar7e. `~t~: 1G~;°3. Cta(ias. T;X ;'5~2~
2IEl.~i51_e98t
~ai~ftYnati~ina .corn
E
KERB COUNTY 08
revised 1(I-07-~7
Benefit Plan	CURRENT	CURRENT	CURRENT
TpA	VERITY	VERITY	VERITY
Carrier	MOO	MOO	MOO
Specific Level	$40,000	$50,000	$60,000

Specific Contract	15112' 15112	15112
A re ate Contract	15112 15112	~-5112

Annual Fixed Gost	496,369.08	$ 428,21.16	$ 376,095.96
			
Maximum Giaims ~	$ 1';600,211.52	$ 1,650,707.20	$ 1,703,430.00
(Maximum Annual plan Cost ~ $ 2,096,580.60 ~ $ 2,086,920.36 ~ $ 2,079,534.96
$ 1,755,178,92 j $ 1„738,647.18
plan Cost
Specific Rates:							
	Employee Only	~	92.75.	' $	75.34	$	62.16
	Dependant{s}	$	118.05	$	99.13	$	84.51
							
Aggregate Premium		$	7.58	$	7.69.	$	7.69
							
Administration:							
	Medical. Adm.	$	17.00	$	17,00	$	1:7.00
	Dental	$	2.00	$	2,00	~+	2'AO
	COBRA	$	2.00	~	2.00	$	2.00
	Pre-Cert1UR	$	2,25	$	2.25	$	2,25
	PPO	$	5.75	. $	5.75	° $	5.75
	Broker Fee	$	3.00	$	3.00	$	3.00
	TotaE Admin	$	32.00	$	32.00	$	32.00
Aggregate Factors:							
	MediealJRX						
	Employee Only	$	424.04	$'	438.82	$	450.09.
	Dependent{s)	$	388.58.	$	405.03	$	417.71
							
Enrollment:							
	Employee Only		243		Z43		243
	Sp		21		21		21
	Ctt		31		31		31
	Fam		20		26		26
	Dependent{s}		78		78		T8
wnuctpatea runamg			
EE	$431.74	$426.55	$422.58
Sp	$5'1.8.09	$511.86	$507.10
Gfe	$388.57	$383.90	3380.33
Fa	$777.14	$767.79	$760.85
Maximum Funding			
r,=	$509.52	$507.17	$505.38
Su	$611.43	$608.61..	$606.46
Ct'	$458.57	$456.46	$454.8$
EaE,i	$917.14	3912.91	3908.68
Kerr Coui>tty
Self=Funded Welfare Plan Step-Loss Pt~opos~E ComparisoT~
Insurance Cak•rier -Third. Party Administra#ot•		lj~„ty Nationat
I2ciitsurartce Carrier		Mfutua! of (}mat~a
		
Insursrtcc ~onrparty		G
		
		
Setup Fee *:	$	1,000.06
Itenewat Fee	S	500.00
Itun-Inftttm-f~ut: t~duli~7iskratian Fee		IO°f°
Estimated run out claun iiabililiy		
Specific Liietinte ]viaximum	~	950,000
Aggregate flan Yea#• annual \daximum	$	1x000,000
		
		
* Nate: T~rese r•cttes U1•e r:vt hrclzrded in tatt~ts below.		
STQP-Lt3SS IiA'~IS		

Number ofErnployees:		_
~~~
'Number of Spouse t7nly		_
2t
Number ofChild{ren} onty		3i
Number ofl~amily units		2G
Number of Dependent Units:		78
Speci~ic:I3eductible:

~;pc.cifc Contract [ncltides

;YfaXlmttrTl A.~regate Li~~t In	S	50,000
t5/12
died ~~ Ira
ISl12
t~ regate Carrtraet fnClttde9		~~~ ~ RY
~'~iON'['HLY I•IYL~D C©STS		
Streciftc Preruiuur		
Ftt~pioyee:	~	75.31
Etttp!©yee and Spouse		
En~playet: and Cltild{ren)		
Dependent Unit:	$	~`~.l~
Family:		
Cam asite. Pox G€>n~parisan Only		
Ag re refs. Fremtuan		
Composite:	~~	~.~~
tvontlal ~ Ga		
Adutinisfeattart atI fees er uuit er rncrath)		
Claims Cast Per• Ernptoyee ;	$	t ~:U$`
Claims Cast t'ee' Dependent :	~	-
t.?tlllLation Itev[eti4 pct" I'.I''.	~	~.?~
PPC) Nttvor>l Per EE:
ILY Program Fees{Describe)
CnI3RA per EE	~

$	5.75

?.tTO
fflPAfi e'er GE		Inct
l~idut;iaty f.iabflit?s t^ce		
62-63°fo off AL+VP, ?fi°Io Rebates Returned
`~~I'att9 )lent ~eneitt -	1	
Eml~layee/Mth		
©epende~rt U17it/Mth:		
Cafeteria P[an		
FSA Account Per Participant	~	S.UU
Chita Care Per Participant	~	
Debit card expense	~	-
Stalrt 711) expense		
Other Cafeteria P{an Fees:		
HRA		
Start up expense	~+	~t1U.U0
Per Account Fee	S	_
4.O1?
Debit s:ard expense		
Otfror I1RA Pian tees;		
Wellness Plan Cost Per EEtMth		
~4ellness flan Cost Per IElil~lti~	~	3.QU
Disease ~~lanagen7ent ~'	$	3.UU
Dental		
Dental fldn7in Fee per FE/Mti7		
Dental Acimin Fee per Depil~lti7		
L?ental NettvorlC Access-Fee		
Banlcin ~aysten7 Motes		
Positi~re Pa}=lEilMt#t		
Positive Pay ~8t up ~'~~ ~~t1C tone SGt up tee		
Araker Fee:		
Fee	S	2.fN)
AGCRF.GATE FACTORS		
Canployee C)nly:	$	438.$2
Dependent Unit:	~	405.Q3
Employee and Sl7ouse		
Emplo}gee and Child(ren)		
Family:		
Cfln7 asite:	~	568.83
Attachment Points		
I<~fantl7iti~:	$	138,226
Am7ua1:	~	1,658,7t)~
TOTAL. AN~lI3AL COSTS		
Spectic 3tap Lass Pren7iun7	~	31.2.477,12
r~egregate Premium	$	22.=t~ 1.074
Administration	fi	~S'~;4Q4.U0
k1d1717n7StrattUn a5 ~ffl UI VIi1x 1.1771Fn7 Annual CUSt		
Ult., PPO; Itx, HrolCer, a[7d all other		$29,1ti4.()G
		
Total Fixed	~	419,~tfi~.i6
1>xpected:	~	1,7417,430:92
i~ilakimum:	~	2,078,172.36
HItA Estitrtatell Claim ExC-ensc ~ 5 1411,©II@.lIO
:`+ates: ''
IIRA Estlrrlatetl Adn7inist-~aton Fxpettse $ '11,664,0Q
FSi1 Estinuttecl Expense
Inoludes Debit Card
PROPOSAL
FOR
PRESENTED BY: CATHY CLEVELAND
COLONIAL SUPPLEMENTAL INSURANCE
11503 JONES MALTSBERGER, SUITE 225
SAN ANTONIO, TEXAS 78216
210-602-6042
DATE PREPARED: NOVEMBER 12, 2007
DATE THROUGH: 3 MONTHS FROM CURRENT DATE
UNDERWRITTEN BY:
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY
POST OFFICE BOX 1365
COLUMBIA, SOUTH CAROLINA 29202
Colonial is committed to helping working Americans and their families minimize personal financial
risk with a comprehensive offering of voluntary benefits through the workplace. Colonial
compensates producers to facilitate the sale and delivery of these valuable benefits. This
compensation might include commissions as well as various incentives and awards.
We support disclosure of compensation programs for our products, and your insurance advisor can
provide you with complete information about these programs. You may also learn additional
information about our compensation programs by contacting our Plan Administrator Service Center
at 1-800-256-7004.
Colonial Supplemental Insurance is the marketing brand of Colonial Life & Accident Insurance
Company.
HISTORY '
An Industry Original
for 65 Years
c~
COLONIAL
SUPPLEMENTAL I N S U R A N C E
for what happens next®
In 1937, Colonial founders Edwin F. Averyt and J. Clifton Judy started a company to sell a
small accident insurance polity. In 1939, that company was incorporated as Colonial Life &
Accident Insurance Company. Our mission was and remains to help working Americans and
their families lessen their financial risk.
For 65 years, Colonial has perfected our ability to develop, communicate and enroll, and
administer voluntary benefits to support this mission. It's not a sideline for us -it's all we
do. From flexible rycles for payroll deductions .., to easy online billing and reconciliation ...
to seamless interface between our enrollment systems and home office processing capabilities -
we know how to do it right.
Innovation, Not Imitation
We're proud of our history, but longevity is not what makes
us a leader in voluntary benefits. We're an innovator. In
1955, we pioneered worksite marketing of voluntary benefits
through payroll deduction. And that first payroll-deduction
account remains a Colonial customer to this day.
In the 1970s, we implemented computer technology long
before most companies did. In the 1980s, we began marketing
our products through Section 125 and introduced electronic
enrollment capabilities nationwide. Today, we continue
to add innovative enrollment technologies, including call
centers and our new web-based enrollment platform.
It's the People Primarily
All of our accomplishments and innovations result from the
quality, expertise and dedication of our people.
Based in South Carolina, Colonial is known as a premiere
employer, and we're Fortunate to be able to attract and retain
high-quality employees. Currently, nearly 1,000 employees
work at our home office in Columbia. Many of our employees
have have been with us for 20 to 30 years and longer.
Our sales organization consists of nearly 6,000 career sales
representatives, aswell asmore than 5,000 active brokers.
In 1955, we pioneered
worksite marketing
of voluntary benefits
through payroll
deduction. And
that first payroll-
deductionaccount
remains a Colonial
customer to this day.
From Single Line to Single Source
More than 65 years ago, Colonial found opportunity in a
single line of insurance. Today, the context is broader, the
needs greater, and the issues more complex.
We've grown from a company that offers a single product to
an industry leader that offers a single source for broad-based
benefits solutions. That's The Colonial Advantage.
Colonial Life & Accident Insurance Company
1200 Colonial Life Boulevard • Columbia, South Carolina 29210 • www.coloniallife.com
©2005 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 the Togo, separately and in combination, are registered service marks of
Colonial Life & Accident Insurance Company. All rights reserved. ,,,~ ,,,,,,
Colonial representatives provide benefits communication,
enrollment and service to our more than 50,000 accounts
and 2 million poliryholders. Using advanced technology, our
representatives can communicate and enroll a company's core
as well as voluntary employee benefits.
The Strength
of a Leader
When choosing an insurance company, people want a
company that is both stable and financially sound. You can
count on that fact with Colonial.
Along with its parent company, Unum Group, Colonial is a
strong industry leader with a secure future. The company's
financial position remains solid and well positioned to serve
customers' needs and deliver on promises now and in the
future.
Colonial operates as a stand-alone entity of Unum Group, a
Fortune 500 company. Colonial's entire operation-customer call
centers, underwriting, claims processing, product development
and marketing activities - is managed independently at its
headquarters in Columbia, S.C.
Strong Financial Background
Colonial has a long tradition of consistent, profitable
financial performance, prudent investment strategies and
financial integrity. The results are evident in the quality of
the company's investment portfolio and the strength of its
balance sheet.
Since 1939:
• Colonial's statutory assets have grown at an average
compound annual rate of 18 percent.
• Statutory premiums have grown at an average compound
annual rate of 15 percent.
• Total statutory liabilities have grown at an average
compound annual growth rate of 19 percent.
Over the last 10 yeazs, policyholder reserves, which exceed
90 percent of liabilities, have grown at a compound annual
growth rate of 8 percent.
We take pride in the overall financial strength of our company,
and we want you to know about our:
• Consistently strong industry ratings.
• Strong investment portfolio.
• Long-term profitable growth.
Colonial has the resources and the integrity to meet its
obligations to customers and continue to grow the company.
You can count on Colonial - a proven industry leader with a
strong financial background.
c~
COLONIAL
SUPPLEMENTAL INSURANCE
for what happens next
• Headquartered in Columbia, S.C.
• Founded in 1939.
• 1,000 employees.
• 6,500-member independent contractor sales
organization nationwide.
• 5,000 active Colonial-contracted brokers.
• Offers a broad portfolio of insurance coverages,
such as disability, life, and supplemental accident
and health insurance policies.
• Colonial continues to be a leader in benefits
communication, enrollment and customer service
while providing essential voluntary benefits to
employees and their families through the
workplace.
• Operates in 49 states, the District of Columbia
and Puerto Rico. In New York, similar products, if
approved, aze underwritten by a Colonial affiliate,
The Paul Revere Life Insurance Company.
• More than 2.5 million policies in force.'
• Serves more than 50,000 businesses
and organizations.'
• Is a stand-alone subsidiary of Unum Group,
a Fortune 500 company. Through its insuring
subsidiaries, Unum is a leader in employee benefits
and the No. 1 provider of group and individual
disability income protection insurance.2
• Named one of the top four best lazge companies
to work for in S.C.
' Colonial Life & Accident Insurance Company corporate
records as of year-end 2006.
' Unum represents the multiple insuring subsidiaries of
Unum Group, including the #1 group and individual income
protection carriers in the United States and United Kingdom,
according to the JHA 2005 U.S. Group and Individual
Disability Market Surveys, 2006, and GE Frankona Re 2006.
Fast Facts About Colonial
Consistently Strong Industry Ratings3
While the ultimate judge of an insurance company is the customer, independent rating agencies also judge, or rate, insurance
companies. These ratings can help you determine the financial strength and liquidity of a company The Unum Group's primary
subsidiaries4 consistently earn strong financial strength ratings from the four major rating agencies.
A.M. BEST COMPANY
Colonial
Unum America
First Unum
Provident Life and
Accident
Provident Life and
Casualty
Paul Revere Life
A- Excellent
A- Excellent
A- Excellent
A- Excellent
A- Excellent
A- Excellent
A Best's Rating is an independent
opinion based on a comprehensive
quantitative and qualitative evaluation
of a company's balance sheet strength,
operating performance and business
profile. A Best's financial strength
rating is an opinion as to an insurer's
financial strength and ability to
meet its ongoing obligations to
poliryholders.
MOODY'S INVESTORS SERVICES
Colonial Baal Adequate
Unum America Baal Adequate
First Unum Baal Adequate
Provident Life and
Accident Baal Adequate
Paul Revere Life Baal Adequate
Moody's applies numerical modifiers 1, 2 and 3 in each
rating classification: the modifier 1 indicates that the
insurance company tanks in the higher end of its generic
rating category; the modifier 2 indicates a mid-range
ranking; and the modifier 3 indicates that the company
ranks in the lower end of izs generic rating category.
STANDARD BL POOR'S
Colonial	BBB+ Good
Unum Ameriuz	`BBB+ Good
First Unum	BBB+ Good
Provident Lifeand	
Accident	BBB+ Good
Paul-Revere Life	BBB+ Good
Plus (+) or minus (-) signs folio	ratings fmm AA
to CCC show relative standing. withi	n the major rating
categories.	
FITCH
Colonial
Unum America
First Unum
Provident Life and
Accident
Paul Revere Life
Plus (+) or (-) may be ap
A- Strong
A- Strong
A- Strong
A- Strong
A- Strong
vended to a rating to indicate the
Moody's Insurance Financial Strength
Ratings are opinions of the ability
of insurance companies to repay
punctually senior policyholder claitns
and obligations.
A Standard & Poor's Insurer Financial
Strength Rating is a ctu~rent opinion
of the financial security characteristics
of an insurance organization with
respect to its ability to pay under its
insurance. policies and contracts in
accordance with their terms.
A Fitch Insurer Financial Strength
Rating provides an assessment of the
financial strength of an insurance
organization and its capacity to meet
senior obligations to poliryholders
and contractholders on a timely
j basis.
relative position of a credit within the rating category. Such
suffixes aze not added to radn in the `AAA"sate o or to
A.M. BEST
Fi¢vANCIAL STRENGTH. RATINGS
Secure Ratings
A++, A+	Superior
A, A-	Excellent
B++, B+	Very Good
Vulnerable	Ratings
B, B-	Fair
C++, C+	Margt'nal
G G	Weak
D	Poor
E	Under Regulatory
	Supervision
F	In Liquidation
S	Suspended
MooD~s
FINANCIAL STRENGTH RATINGS
Secure Ratings
Aaa	Exceptional
Aa	Excellent
A	Good
Baa	Adequate
Vulnerable Ratings
Ba	Questionable
B	Poor
Caa	Very Poor
Ca	Extremely Poor
C	Lowest
STANDARD & 1 VOR'S .INSURER
FINANCIAL STRENGTH RATINGS
AAA	Extremely Sttong
AA	Very Strong
A	Sttong
BBB	Good
BB	
a~
B	
CCC	Very Weak
CC	Extremely Weak
R	Regulatory Action
NR	Not Rared
FrrcH
FINANCIAL STRENGTH RATINGS
Secure Ratings
AAA	Exceptionally Strong
AA	Very Sttong
A	Strong
BBB	Good
Vulnerable Ratings
BB	Moderately Weak
B	Weak
CCC, CG C	Very Weak
DDD, DD, D	Disttessed
I~ g ry
ratings below the "CCC" category.
s Industry ratings are not a warranty of an insurer's financial strength, current or future ability to meet its obligations to policyholders nor a
recommendation of a specific policy form, contract, rate or claim practice. In addition, industry ratings do not address the suitability of a particular
insurance policy or contract for a specific purpose or purchaser.
The Unum Group's primary subsidiaries are Unum Life Insurance Company of America, Provident Life and Accident Insurance Company, The Paul
Revere Life Insurance Company, and Colonial Life & Accident Insurance Company.
_ ;;, ~,~ 3
~~~' ~:
~" fk~a F'~ ~t
i~: i ~,
~.. ~ * d '~'~~
? j. s~!'.
: , ~iA

Colonial was just chosen a ~~ ~~~~°`rt~ _,_ in
Benefits Selling magazine's 2007 Readers' Choice Awards!
Brokers industrywide put us first in five out of eight categories in the Benefits Selling 2007 Readers' Choice Awards, which
were announced in the publication's November issue. For the second year in a row, Colonial was the only carrier to win more
than one top award.
To spotlight the hottest products, best carriers and latest trends, Benefits Selling magazine asks brokers each year to name their
choice in response to eight questions, and brokers selected Colonial as their top pick in the following categories:
The best c~°it~~al ~~~ pia~°~ in the marketplace
~'~„ The ost i ~.w,.An.~.~~.4e arriew in the marketplace
~.. The carrier that offers the ha~~~t h~~k~"o:: ~.: p~~,
The carrier that c n°~nicats e~i~ ~iti~ poke,
The est oie iie ins~a~°t~~,~~ ~°o tac in the marketplace
Thank you to Benefits Selling magazine's national readership of brokers and advisors for this great endorsement. We promise to
continue providing the voluntary benefits, innovation, service, and communication that win your trust.
Ask your Colonial contact TODAY about
Colonial's award-winning eapabilities.
Colonial Supplemental Insurance products are underwritten by
Colonial Life & Accident Insurance Company
1200 Colonial Life Boulevard, Columbia, South Carolina 29210
www.col on is I life.com
®2007 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 the logo, separately and in combination, are registered service marks of Colonial Life & Accident
COLONIAL
SUPPLEMENTAL INSURANCE
for what happens next
_____ -._
ELECTRONIC SERVICES
d ~ ~~
COLONIAL
5 UPf'LEMEPITAL INSURANCE
for what happens next
Does the idea of simplified billing sound good to you? How about spending less time on the
tasks with even less hassle? Colonial's E-Services are designed to save time, trouble and paper
- but still provide you with professional, courteous service, your way.
Our web-based billing and administration services for Colonial products are designed with our
plan administrators in mind. We want to help save you valuable time and energy so you can
focus on the other important aspects of your job.
ColonialConnectfnr Plan AdministratorsSM Web Site
~ ~ ~ coFomal p
~ ' C ' f~https l/planadministrator.colonlallife.com/home/default.asp <~`~	All of our E-Services are
COndtiCted through th1S
Hymn	®.~~,~„ ~~~~aGaT	secure web site, which our
•		
		account plan administrators
ter cocoNUt AccauNT	-~	may join at no charge. The
#BOUT E-8ERYICEB	of ~
"	site allows you to view your
snurlo nPS	- " ~`'
~ COLONIAL	bill and conduct the online

noMtNtsTRanvE rlnta	.~ ~ .....

„~.	
billing services, find helpful
DOWNIOADFORMB		
Colonial administrative
r,, ~ : ~ ~,~V
,~, ~ -
- -	
tips, download claim and
What's New E	I~ You Can Count On Coionial	service forms, e-mail key
In our Whets New section find the
Mast news and information m		
account service areas, and
CokxridComect. the currant
issue or the CebnialCannact	
^"''°°s'' "`° "a"' ~°r"" s1B °°k'n'~
i
t
d
65
f	
enjoy free access to the
Newsbtler. as wet as updates to
the Service Goal Report Card	ntlus
ry
or more
er
years. we
~n~s
contnuey seek ways to provide vdue end
'	
CCH HRAnswersNow
.	hassb•hee services 1
or You and Your	
Comoettsatbn Dtsclasure	°"~'°Y~~	Web Site.
IMaamatbn	Last ta0. we conducted a research study to	
	enswe that we are providieg the 6anefts	
	comrtwnication and enrotrrbnt services that
empbyers want and need m today's marketplace. The survey prompted us b devabp	
One of the reasons Colonial
	customer commiNrents to help us rennin focused an priorities that wi 6e of me	
	~r'a'BSth°"etrt°°'~°ust°m°rs.	developed this secure web
	Ae a vaWad Cokmiei cusmmer, we want you to know that you can count on Cobnial [o	
i
h
l
t
	provde you.	your
te was to
e
p protec
s
	. Haea~-rrea ~a~,ntary ha,~etda aeai~ned w he amore a~ aaaY ror y°e.	privacy. We are committed
	trofore. dtasq aid after the emdlnenL
a Roressional, remob haneIIs erroNnwtt and communication, so you can	
to adhering to all legal
	count on Colonial to get me yw twos and acne wee	
	. Proaucis aid services to help Y~ t»neR do/ars go fuAMr ^ taaaya wend	requirements so we can
	of rising hearth care costs and aural Human Resource stabs.
Long-term leadeashp and fnancial statxtily that provide you with the shength	
rotect the I1Va Of Our
P c3'
	aid expertlse of a baser.	P
	• New krsighis and empayee beneR soWaons that are ml.,ad b meet your	customers
as defined by
	needs, not ass.	,
	cobnial B so convnited>D mesa prsncipba mat we unveibd a new prof adven"sing	the Gramm-Leach-Blilely
	van otl~voa~inea°s°ara u~btMr°eaasesnta~uc~toma~c"'«e~nentt °rft	Aa (GLB) of 1999, HIPAA
	Watch for tlretn n empbyee lbnafss ana human resowce publcaUOrts. But rtast of at,
ha aaeured mat when ~ comes m voluntary hanaRa. You and Your erryrloyees can	
Privary Rule, and various
	count on Colonial. fa what happens nett.	
other Federal and State
		Insurance Privacy Laws.
E-Services
These web-based services are designed to provide you a paperless billing process -all available
at no charge. That's the premise of all of our services: to provide what is most convenient for
you, not what is easiest for us.
Ez Billing
,r ~ ~ ;
This quick and easy service enables us to reconcile your
Colonial bill electronically. All you have to do is submit an
electronic file of your deduction information, and we do the
rest - no more hours of reconciling paper bills! It not only
saves you time but you can also expect greater bill accuracy
and quicker application of your premiums.
Send Premium Data to Colonial
,I r _~n,'. ~~_ `,7 ~~~ ,r, lit/
File EdR View F,~+orites Tools H~~
Back - ~ ~ r. ~; ~ 'Search 4 ; Favor~es ~?" ~ a~:+<
addrE~s ~ https:(lp~nadmr+istra[or.colona~fe.com(Appkatiw»sJEBi'/OpenBis.asp
NY' COLOMIIAL ACGAUNT
y;
ACOUT @•fERVICEQ
BILLIN9 TIPS
AONINIBTRATIVE Ties
nownLOat7 FonMs
`•l
COLONIAL
F,..a.ra.~p....,~•
You can view your
Colonial bill online
whenever you want. Our
E-Bill Notification Service
will send you an e-mail
each time your new bill
information is posted on
ColonialConnect.
~E~~
Open Biils -Summary Information
As Of 1f20/2006
ABC COMPANY
E1004235
,ece. szis.ao ~ ,_ ooaolras +.+onn+w
~'=

This simple function enables you to pay your Colonial bills at
the touch of a button. It is a secure service, conduced from
the ColonialConnect web site through an agreement we have
with SameDayPay online payments service.
~ii,~~l
E-Bill Summary
Flexible Billing Features
Speaking of simplified billing, did you know that
you can pay all of your Colonial premiums through
one payroll slot? And that you can select your billing
frequenry to suit your business needs? Again, you
choose what works best for you.
Ez Administration allows plan administrators to "search" at
the employee level and view employee level information such
as polity status, coverage effective dates and policy/coverage
type. It also includes the ability to make necessary adjustments
to employee level data such as: name/address changes, polity
cancellations and policy reinstatements.
CCH HRAnswersNow
Web Site Access
Through an agreement with CCH (Commerce Clearing
House) Inc., ColonialConnect provides you direct, free ac-
cess to the CCH HRAnswersNow web site. This valuable site
includes information on HR policies and guidelines, tools and
checklists, and the most up-to-date state and federal laws and
regulations, explained in everyday language.
F~ '@
I-
~https: J /hranswersnow.com/
H~11$W4CS~oW
Employee Information and Records -Select All '
_' Records i3 q r
'_' Personnel files iisi
_' Reports psi
. , ~~: ~~rdr ~f
~ : c~l#S1~~5
'~IEal~3~}~«
G
- - --~ -
-' Posters and notices I•~s~
HRIS isi
Issues and answers in employee information and
- records [il
Staffing -- Select All '~ '
Determining your staffing needs ii 1i _ Pre-employment inquiries ,~ ai
_' Planning for diversity (~zi _' Hiring ilsi
Workforce reduction hai ;! Issues and answers in staffing ifl
'_' Recruiting 1311
r_-- HRAnswersNow ... .._4._.._-...-_ -
=1
,~.,.w,...~.,.f.a,,- r -
hwim,
Enter your search teml(s) tx type YWr question ...
.z :A
News and Information
{AA+aC• -aM1w - Wy 2005
u ales coven those hot to cs'.
Chsdk out the t,le ns ra'rdn9
• Hft seN-wrrias appicatio 9
• Ghecx5ol for a„pNrr+enhnq a Cnmgtal dankground chac0.
• Form 1-9 curerage expanded
• Stale Daposn Chad revised
• Fnai EEOC regutat.uns on rataee health benefds stopped
i
ari taf~ nd-80iwan i.fYr~1SY '~..-t

Q
and child support t~~i
lion i~]
laat»a and /ufa+wro°
• Nay 76. 2005: Can an offshore oonbaciar re wa credit medral exarra?
• AAay 9. 2i105~. PTO fans he ease edmcrisVative burdens ~
en Flit outsourm rovider
• enay 2. 2005~Se1ecln ooreraas --- •_
_.
bensiRsd n`tt ear COBRH __ __.--- .
• gprd 25, 2065 {>seh
- - - - ------ - -- - - .E+y . s.,u~~r~:i~.
- --------- r',.
..~>' -. -
HRAnswersNow
o.iw e.~u ar+~bal ~ ~ ~.
• ~ahh coYareya wntinuation padod ardanded
• Yidaa wrva~anca n the woa~taoe ratatiation
• Implied Prrvafa dphl of action under Tina IX foe
• Supreme ['quit OKs disparate mpad theory for a9s bps
claims
~ F1 °e Customer Forms ~
~ ~ ~ ~ C ~ (~https /Jcustamer.coloniallife.comiForms/CustomerForms.asp
f it,rr ~ : Farm, ~ IAGpeT _-
dAIM~
nsour-,~
s <:
Forms in English
Formularios en Espattot
Acrobat Reader requited;
please click on the anage bcbw
to downkrad d needed. Need
Helo?
lldeM .ter
at,
:i
Download Forms
` ~- ,,~
rk,.. ~''v',i
To make d easy for you to access the
forms you need, our commonly used
service forms are boated here.
These forms are available in Adobe
Acrobat PDF format. The PDF forms
must be printed out and then completed;
they cannot be completed onikte. Once
you have printed and completed the
form, maf or fax the form to Cobnial as
stated on the Corm.
Always with. a
Personal Touch
It's important to enjoy the
ease and automation that
technology provides, but
we never underestimate
the need for personal,
courteous service. That's
why we back each of these
services with experienced
specialists who are available
by phone daily to provide
assistance to you and your
employees.
„~. - >
..
Colonial Life & Accident Insurance Company
1200 Colonial Life Boulevard • Columbia, South Carolina 29210 • www.coloniallife.com
c~~2005 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 the logo, separately and in combination, are registered service marks of
Colonial Life & Accident Insurance Company. All rights reserved.
~~
COLONIAL
jot tr~G.tt hrepprwr next'
CLAIM FORMS
Cokmial Supplemental Insurance
Processing Center
P.O. Box 100195
Cdumbia, SC 29202-3 7 95
FAX: 1.800-880.5325
OTHER FORMS
Cobnial Supplemental Insurance
Processing Center
P.O. Box 1365
Cdumbia. SC 29202.1365
:u
Bottom
~~~~~~~C~~~~i~ f~°
~d~h~~i~~l"~~i~t
~ 1~
~i Through this secure web
~ site, your employees have
24/7 access to claim
forms and claim status
~ information and can e-mail
our customer service area.
'~
BENEFITS COMMUNICATION '
The Advantage of
Benefits Communication
As health care costs continue to rise, it's more important than
ever that your employees understand and appreciate the ben-
efits you provide for them. With these increasing costs, come
increasing competition for quality employees -and you want
to ensure you attract and retain the best.
A sound benefits package is a plus but only if employees know
and understand what you make available to them. Colonial
provides professional, consistent communications throughout
the entire enrollment process to help your employees not only
understand their benefits but also appreciate them.
And the best part? We can
provide the communications
for you, so you can focus on
other important aspects of
your job.
c~
COLONIAL
SUPPLEMENTAL I N S U R A N C E
for what happens next
The average turnover rate oftop-performing employees is 17 percent
at companies that offer rich benefit programs but poorly communicate
them to workers, as opposed to 12 percent at businesses with less
comprehensive programs but better communication strategies'
Colonial can. provide quality enrollment communications -letters, fliers, powerl'oint
Y'
presentations; brochures, e-majls, .posters, tent cards -whatever works best to ensure your
employees are aware of the de~aiLs of your upcoming enrollment and the key details of
your benefits offerings. ~:
r'
Group Meetings '4
.,
To help provide background on the overall benefits program, highlight any major changes ,;
in the program and introduce any new offerings, we recommend that you begin your en- `•:
rollment process witha group.employee meeting. We can communicate whatever benefits ~,
you wish to highlight in a concise, professional manner. ~;;
Pre-Enrollment Communications
S
Custom {ommunications ~~'
,,
;>
.. ~ .~ ~v~...~
... ,:, r
1 Taken from WorkUSAP' 2004/2005: Effective Employee Driven Financial Results©2005 Watson Wyatt Worldwide.
For more information, visit www.watsonwyatt.com.
THE ~yApTCAGE
°F CI~OZG~
'~° ' ;~~.
~~_~'
~ •,.
~ ~:
t~ 4
Enrollment Communications
One-on-One Meetings ~;
While we take pride in our enrollment technology, we have
learned that nothing can replace the value of meeting with •'`
employees individually to review and enroll their benefits.
Our representatives are trained to communicate your benefits ~:
program consistently and thoroughly in a way that your
employees can understand. They then help the employees 4'
enroll in the benefits they select through our own electronic '=
enrollment system.
				r
				
Electronic Enrollment System
Through our own electronic laptop enrollment system, we can help employees consider their
personal benefits situation and see the impact of their benefit selections on their paycheck. The
system enables us to provide numerous communication services, such as the following:
ABC
COMPANY J
sSN: 111-223333
Lasl Name: EMPLOYEE
First Name: JANE
Addressl: 123 ANY STREET
Addresa2:
cay: col_uMala
state: sc
Birthdate: 0);15.'1958
Home Phone: (8041763.7789
Department: d20
EEC Update Employee Data
MI: M
~ Help verify and update basic
Lp case: nzlo_ employee data.
sax: F
Emp Date: 10.N5'1980
cross Pay. Staas4 Pry Permes ax vDOr za -~-----_
a of r'sa. oaaEm.,; zc ~+~ ~> sc
tMOtlion Plods ri Hertel°r~'s:
r~rnra~---- _ E:~s: z
awtrslm,: t7uaralsa Usenet.
Ezemptlmc =
Ownca QntaE,«IglOea.aolry ,
LDeel7az Miovt Omer
t7,--
Review Existing Benefits
Highlight each employee's existing
benefits, pointing out what the
employee contributes and what
you, the employer, contribute.
	JAPE M. EMPLOYEE	
ee RR
®
~	ttt,xzaaas		
AL/
COMPANY ~	Gm"D"	aemsel	
u Srw- E%rrRg er~rnD	E-Ner EmPlo	r	
P OOaPe x D.OMIIrr	t1a2	SI.Oa	
A iaCA	6151	0.00	
A NOl1DAY5
A PTO	6M
10M
Am	0.00
0.00
O
a	
SID Canere.n
A UNEODMS	lOAB	.
O.Oe	
P VMew Ca.	15M	BAN	
P.a.... I		u.r Pq	-lw.n
			
	tUIP	ysn	P+9•d	er.n.	Heat
					
COLONIAL SUPPLEMENTAL IN)URANCE
ENROLLMENT ELECTION FORM
Election form
Provide a detailed listing
ofthe cmploye~~s selections
and tontrihuriwls as one last
verii'ication gfplan informa-
tion and premiums. Ynu carti
also receive a copy o£this
Election For1n so you can
have each employee's elco-
bons and signanue on #iIL•.
-. _ ~ + _ _ ~
ABC Ctxnpgny
ear.: EMPLOYEE, JANE M.
le r:
~~' t1t~22-3333 CIrWkNlon: F7
~: a2o a~ F
~,:
,,,,~_ 123 ANY STREET
~r COLUMBIA sue. SC ac: 12345
„r,,, a,q,.,,
.m~. (803)888-8689 ~ (803)888-8888 a<:
~~a.~:2s „~,,,,,: taos,lsfio
..,r~.r,,:2s a~om, o7ns~lssB
L Co7reraae
COREHD Heatthl0ental Insurance
(HUS)JOE EMPLOYEE
(SON) JIM EMPLOYEE
(DAU)JEANNA EMPLOYEE
UNIFORM UNIFORMS
VISION Vision Care
VPRODI Accident - Disat>:liry 1000
VPRODIB Universal Life - ChoicePlus
VPROD22 hbsp Inc -Medical Bridge 1000
Policv pey
Plan Irdonnatk,..
------~.~ Tvoe ~ Prctax AfteiYax P i
Employee antl Family, 5100 part N 26 35.00 ~~
o.o0 740.00
SSN: 43203.3/32 DOB: 10/01/1960
$SN: 234-340324 DOB: 12/07Y2000
SSN: 856-66-$545 DOB: 03r20/199g
Sez: M
Sex: M
Sex: F
E 26
E 26
N 26
N 26
N 26
Totals:
,-Polley Type Legend...._-_--- --
Total Deductions:
N - ~' Colonial Life 8 Aotident Totals:
'E' - E7clatfng Non-Colonial Life 8 Aceldent Totals:
8/30/2004 71:37 AM Arx,n+~a..w c:_____
Two-Way Communication
0.00	0.00	70.00
0.00	0.00	75.00
9.42	0.00	0,00
0.00	20.00	0.00
16.15	0.00	0.00
60.57	20.00	165.00
$80.57
$25.57 $20.00
$35.00 $0.00 $165.00
You know what's best for your business and for your employees. That's why our first step in
benefits communication is to communicate with you. We will work with you to determine
what you want to communicate and when and how to do it. With Colonial, you can count on
professional, consistent benefits communication, tailored to meet your needs, not ours.
So what's the advantage of benefits communication? Save costs, save time,
save energy -and gain greater employee satisfaction through personal,
quality benefits communication.
Colonial Life & Accident Insurance Company
1200 Colonial Life Boulevard • Columbia, South Carolina 29210 • www.coloniallife.com
©2005 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 the logo, separately and in combination, are registered service marks of Colonial Life & Accident
Insurance Company. All rights reserved.
.~~ r,4., ~_... r..r-
ABC Company
Benefits Statement
JANE M EMPLOYEE
123 ANY STREET
COLUMBIA, SC 12345
Dear JANE:
This benefit statement is a brief outline of your 2004 company provided benefits. It is our way of showing you how
much we appreciate your contribution to the success of ABC Company.
Annual Summary of Benefits Costs
Benefit	Employer Cost	
Employee Cost
Health~Dental Insurance	~ 640 ~	
STD Contribution		$910.00
Vision Care	$780'00	$0.00
401(K) % Deduction	~~•~	$0•~
UNIFORMS	$702'42	$1,404.84
FICA	$260.00	$0.00
Total Benefits Cost	$.756.05	$0.00
-Annual income	$7.528.47	$2,314.84
	$23,414.04	
Actual Realized Income	~-	
	$30,942.51	
Your total benefit cost equals an additional 32.15% of your annual salary. Annual summary costs and
income may vary slightly due to rounding.
Time-Off Compensation
Based on your current service, you are eligible for the following leave annually:
Holidays: 6 Dollar Value:
Paid Time Off: $540.32
10 Dollar Value: $900.54
Total value of time off; St qqp ~
Errors occasionally occur in the calculation of benefit amounts. If you should discover errors in this statement or if
you have questions, contact your supervisor or person responsible for benefits administration.
This statement is only an overview of your benefits and has been prepared by Colonial Life & Accident insurance
Company based on information provided by your employer. It is not legally binding and should not be considered a
contract. This information does not alter or amend any original plan documents.
Benefits Statement
-.\
Show the employee his or her entire benefits package, includ- ~;
ing paid time od, uniform Costs or any. specific benefits yoti, `%
would like to highlight. The employee -can see, again, the w
employee and employer contributions to the beneiirs package.: ~'
We can rovide a a er co of this statement for the em to ee ~
P, P P PY P Y
r'
tn;keep. f~

ENROLLMENT SERVICES
A Spectrum of
Enrollment Solutions
c~
COLONIAL
SUPPLEMENTAL I N S U R A N C E
for what happens next
Colonial will work with you to provide reliable, efficient
enrollments to meet your business needs.
"One-size-fits-all" is not in our vocabulary. We understand
the importance of providing the services our customers need
in the way that they need them.
That rings especially true for benefit enrollments. We strive to
provide you with hassle-free, professional enrollment services
so you can focus on other aspects of your employee benefits
program.
Through our 50-plus years of experience in worksite market-
ing, we've gained the expertise to provide quality enrollment
services to accounts of all sizes -from five employees to
100,000; in one location or across the United States. Bottom
line: We have a spectrum of enrollment solutions, ready to
provide you with a professional, reliable enrollment from
beginning to end.
"Employers feel that
employee meetings
would be a must.
Most indicate two
types of meetings
would be required: a
small group meeting
to introduce the plan,
followed by one-on-
onemeetings with
employees to provide
individual coaching
and assistance:'
Enrollment Communications
GROUP MEETTNGS, during which our representatives give a
short presentation to employees to explain how the enroll-
ment process works, what's new about their benefits - virtu-
ally anything you want to highlight regarding your benefits
program.
ONE-ON-ONE MEETINGS, during which our representatives
meet with each employee one-on-one, provide an individual
overview of the benefits package, and enroll the employee.
PERSONALIZED SALARY ILLUSTRATIONS, BENEFITS STATEMENTS
nND ELECTION FORMS can be provided to each employee.
These forms provide the employees a tangible snapshot of the
elections they have chosen, reflecting the employee's benefit
elections, employee deductions and even the employer-pro-
vided amounts, if you wish.
~:r .- -
~~ w
-®
~~
`-`~~a~"' ENROLLMEM'ELEC170N FORM
~:z_ ~ ._-.,-m4-,ero
~ _.e._..,.~...._ ~r .m ..~m
David Hekeler, Ph.D, _""M'
"Consumer-Driven Medical .._ -"`,,;; r,,~ ----~~""` ~..
Insurance: A New Day '"""~
Dawning?"2003 LIMRA study. ~ , `.~.,
Enrollment Technology
Colonial's Electronic
Enrollment System
We have successfully and accurately enrolled
millions of employees in their benefits program
using this laptop system, which Colonial de-
veloped and owns. With this system, you car
have a virtually paperless enrollment, usin,
its technology to provide each employee wii
personal benefits and salary illustrations, captt
signatures, provide benefits statements, and subs
applications and enrollment data electronically
We also have other technological solutions to h
your employees' enrollment needs and work
such as:
• WEB-BASED ENROLLMENT: HarmoriysM, OUI next gen-
eration enrollment platform, is a web-based system that
provides self-service capabilities that complement our
representative-assisted processes.
• TELEPHONIC ENROLLMENT SUPPORT: We Can aISO prOVlde
options for telephonic enrollment support, depending on
your account size and your needs.
.Broad Spectrum, Simple Theory
We're proud of the broad spectrum of enrollment ser-
vices and innovations we've developed over the years.
But enrollment expertise is quite simple, really All the
capabilities in the world. are useless if you don't tailor
them to meet the business needs. At Colonial, we focus
on ensuring we not only meet your needs but surpass
.your expectations.

Enrollment Expertise
local Point of Contact
When planning and conducting your enrollment, you will
have a central point of contact. A Colonial representative will
work with you to develop an enrollment strategy that meets
your business needs and expectations. We will then implement
that strategy, providing tailored enrollment communications,
and work to ensure the entire enrollment process is handled
efficiently and successfully.
Qualified Enrollers
Most of our enrollers have long-term relationships with us
and are highly trained to provide quality and consistency in
their enrollments. We invest a great deal of resources to ensure
that our representatives are thoroughly trained on Colonial's
products, flexible benefit programs, technology, processes
and services.
Our representatives receive standard training through Colonial
College, our national educational and testing program, to
ensure they have the necessary skills to provide an effective
enrollment. Curriculum ranges from market conduct to prod-
uct enrollments to consumer-driven health care trends.
Spanish-Speaking Representatives
If you have employees who speak Spanish, we have Spanish-
speaking enrollers and enrollment materials to accommodate
them.
Colonial Life & Accident Insurance Company
1200 Colonial Life Boulevard • Columbia, South Carolina 29210 • www.coloniallife.com
©2005 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 the logo, separately and in combination, are registered service marks of
Colonial Life & Accident Insurance Company. "Harmony" is a service mark of Colonial Life & Accident Insurance Company. All rights reserved.
sic nn na n.... -i inc
AM E R I ~LEXo I FLEXIBLE SPENDING ACCOUNTS
v~r~f.flex' 25.car,?
PREPARED FOR: Kerr County
PREPARED BY: Don Wallace November 12, 2007
EFFECTIVE DATE: January 1, 2008
Flexible
~i~£'ndint,~
ACCOUn#S
administered with the
Ameri Flex
Convenience
Card®
,~
'AF
TABLE OF CONTENTS
COMPANY PROFILE 3
WHAT IS A FLEXIBLE SPENDING ACCOUNT?	4
EMPLOYER ADVANTAGES	8
EMPLOYEE ADVANTAGES	9
THE AMERIFLEX CONVENIENCE CARDSM	10
ADMINISTRATIVE SERVICES	13
IMPLEMENTATION PROCESS	14
FUNDING OPTIONS	15
ADMINISTRATIVE FEES	16
SUMMARY OF SAVINGS	17
OTHER PRIORITY SERVICES	18
2
AF
COMPANY PROFILE
Established as a Third-Party Administrator in 1998, AmeriFlex is an
independent benefits administrator providing technology-based, consumer-
driven benefits and compliance solutions to clients throughout the United
States. AmeriFlex is headquartered in Mount Laurel, N.J., and serves more
than 4,400 clients that represent over 1,750,000 employees.
AmeriFlex's commitment to innovative technology delivers a wealth of
consumer-driven benefit options, as well as a robust, liability-free, web-
based COBRA administration system. These turnkey solutions provide our
clients with the ability to remain strategically competitive in the ever-
changing landscape of employee benefits, consumer-driven healthcare, and
compliance.
In 1999, AmeriFlex and our banking intermediary, MBI, helped pioneer the
FSA debit card. As a result, AmeriFlex gained immediate and substantial
market share and used this momentum to further enhance our technological
capabilities, including the development of a consolidated debit card platform
combining FSA, HRA, HSA, and CRA into one debit card, the AmeriFlex
Convenience Cardsm. This singular approach provides simplification and ease
of use for both employer and employee. The employer is rewarded with the
savings derived from per participant rather than per account pricing, as well
as real-time balances and user-friendly consolidated reporting. The
employee is unencumbered with the confusion and frustration inherent in
the understanding and use of multiple cards. Many TPAs who were late
adopters of debit card technology continue to face the obstacles associated
with dual processing platforms and data interface challenges. Seven years of
refining the AmeriFlex Convenience Cardsm system has allowed us to take
full advantage of the potential inherent in this technology.
The power and simplicity of the complete AmeriFlex suite of services with
particular emphasis on our utilization of a single debit card platform and
web-based COBRA administration have positioned AmeriFlex as the industry
leader.
Benefits Selling Magazine's 2005 and 2006 'Readers' Choice Award" named
AmeriFlex as the national TPA deli~~ost comprehensive services.
3
'AF
WHAT IS A FLEXIBLE SPENDING ACCOUNT?
Flexible Spending Accounts (FBAs), commonly referred to as ~~Section 125"
plans or "Cafeteria" plans, were developed as part of Internal Revenue Code
Section 125 to provide employees with tax relief for their un-reimbursed
medical and dependent day-care costs. FBAs enable employees to utilize pre-
tax dollars and save Federal, FICA, and, in most cases, state taxes when paying
for eligible expenses not covered by traditional insurance plans.
Although FBAs have been available for many years, the emergence of
consumer-driven healthcare and increased employee cost-sharing has made
them an integral benefits solution that provides substantial tax savings to both
employers and employees.
There are three types of Flexible Spending Accounts: 1) Medical Reimbursement
Accounts: Accounts used to pay for eligible un-reimbursed medical expenses
such as co-pays, deductibles, dental, vision, prescription, over-the-counter
drugs, and more; 2) Dependent Day-Care Reimbursement Accounts: Accounts
used to pay for the daily care of an eligible child or adult dependent as defined
by the IRS; and 3) Commuter Reimbursement Accounts: Accounts used to pay
for eligible transportation and parking expenses.
To further enhance the benefits of implementing FBAs, AmeriFlex offers the
AmeriFlex Convenience Cardsm MasterCard°. This single-platform debit card
allows for the automatic electronic transfer of pre-tax dollars from an FSA when
paying for qualified expenses. Most importantly, the AmeriFlex Convenience
Cardsm can accommodate and administer all three accounts on the same card
without an incremental fee.
AmeriFlex leverages the purchasing power of your FSA even further by
providing AmeriFlex Rx, AmeriFlex's online drugstore. AmeriFlex Rx clearly
identifies FBA-eligible products for employees, combining the ease of online
shopping with the assurance of an automated system for substantiation of
FSA claims..
4

IAF
Medical Reimbursement Accounts -These accounts offer employees the
opportunity to utilize pre-tax dollars to pay for eligible out-of-pocket and un-
reimbursed medical expenses.
Medical Reimbursement Spending Accounts cover an endless list of eli ible
expenses for which an employee can seek reimbursement. Some examples
include:
• Deductibles
• Co-insurance and office visit co-pays
• Prescriptions and eligible over-the-counter drugs
• Dental and orthodontia services
• Durable medical equipment
• Infertility treatments
• Psychiatric services
• Eyeglasses and contact lenses
• Visit www.flex125.com for a complete list of eli _ ible expenses
Key Elements
/ Employees may only use their funds for eligible expenses as determined by
the IRS.
/ Employers are required to fund the reimbursement of an eligible expense
up to the full amount of an employees' annual election, regardless of the
funds contributed to date by the employee.
/ The IRS 'Use it or Lose it" rule states that the employee forfeits any
unused funds at the end of the plan year.* Conversely, the employer
cannot require an employee who terminates with a negative account
balance to pay back the funds.
/ To mitigate this risk, employers set the maximum annual contribution in
the Medical Flexible Spending Account as well as the employee eligibility
period.
/ AmeriFlex offers funding options that eliminate the need for employers to
pre-fund their account.
/ Employers can elect to make contributions to their employees' accounts
provided they satisfy all non-discrimination requirements.
*IRS Ruling 2005-42 allows employers to extend the claims reimbursement cycle by 2.5 .months
beyond the close of the plan year.
5
AF
Dependent Care Reimbursement Accounts -These accounts utilize pre-tax
dollars to pay for dependent day-care expenses for an eligible child or adult
dependent up to $5,000 per family per year. Some qualified expenses include:
• Before- and after-school programs
• Nursery school or pre-school tuition
• Summer day camp
• Care in a home by a licensed provider
Key Elements
/ Employees may contribute up to a maximum of $5,000 per family per year.
This option replaces the Federal Childcare Tax Credit.
/ Unlike the medical spending account, funds are only available once they
are deducted from the employee's payroll and deposited into their account.
/ An e/igib/e dependent is defined as a child under the age of 13 who bears a
specified relationship to the employee and has the same principal place of
residence as the employee for more than one-half of the year.
/ An eligible dependent can also include a spouse, parent, or child of any age
who is physically or mentally incapable of caring for themselves, who has
the same principal place of residence as the employee for more than one-
half of the year, and whose gross income is less than the exemption
amount in Code 151(d) and with respect to whom the employee provides
over one-half of the individual's support.
6
~AF
Commuter Reimbursement Accounts (CRAs) -This account is a tax-
favored program (Internal Revenue Code Section 132 and TEA-21) that allows
employees to benefit by setting aside pre-tax money from their paychecks to
pay for eligible transportation and parking expenses. Transportation and
Parking eligible expenses include:
• Mass transportation to your place of employment such as subway or
bus
• Transportation to your place of employment via a vanpooling
commuter vehicle (which seats at least six adults, not including the
driver). At least 80% of the vehicle's mileage must be used to
transport employees to and from their place of employment.
• Parking near your place of employment
• Parking at or near a location from which you commute to work via
mass transit or vanpool
Key Elements
/ For Plan years beginning in 2007, Qualified Parking expenses are limited to
$215 per month and Transit Pass & Commuter Highway Vehicle expenses
are collectively limited to $110 per month.
/ Key differences from traditional flexible spending accounts include no plan
documents, no SPD or discrimination testing is required, elections may be
changed at any time during the year, and unused elections can be rolled
forward to subsequent years.
/ Similar to the Dependent Day Care Reimbursement Account, only the
amount that has been deducted to date can be reimbursed to participants.
7
~}
EMPLOYER ADVANTAGES
IAF
Employee benefits purchased on a pre-tax basis reduce the employer wage
base for purposes of calculating payroll taxes. Employers can realize direct
bottom-line savings from the reduced employer F.I.C.A. taxes, F.U.T.A. taxes,
and disability and workers' compensation insurance premiums (varies state by
state). Total savings to the employer can represent as much as 10% and
typically cover the administrative costs associated with these plans.
Following is an illustration of the potential employer FICA savings when an
average number of participants is multiplied by average participation levels.
Eligible Employees: 245
Flexible Spending Accounts*:
49 MedFSA participants
20 DepFSA participants
37 CRA participants
FICA saved
Voluntary Benefit Premiums:
$6 Voluntary participants
FICA saved
Health Insurance Premiums:
172 Health participants
FICA saved
x $1000 per participant $
x $5,000 per participant $
x $1,200 per participant $
7.65% * * x $
x
x
$540 per participant $
7.65%** x $
49,000
100,0(0y
44p40®
193,400 $ 14,795
46,305
46,305 $ 3,542
$900 per participant $ 154,350
7.65% * * x $ 154,350 $ 11,808
*Participation assumes the AmeriFlex Convenience Cards'" is being used. If not, assume an average participation of 10% in
Medical Reimbursement accounts and 2% in Dependent Care Reimbursement accounts.
**Employers save 6.2% on pre-tax payroll deductions for employees who make less than the maximum Social Security wage
base ($94,200 for 2007; indexed annually) plus 1.45% on all pre-tax deductions under the plan.
cg
}
CAF
EMPi.YEE ADVANTAGES
When employees contribute pre-tax dollars to their FSA, their compensation
is reduced for purposes of calculating wages subject to Federal and F.I.C.A.
(Social Security & Medicare) taxes. Based on 2007 tax rates, potential
savings range from 17.65% to 35.65% depending on an employee's
individual tax bracket, and, in most states, employees can also save on their
state income tax.
Following is an example of how an average employee can increase their
monthly take home pay by $51 through a Flexible Spending Account:
	Without a	With a
	F/ex P/an	F/ex P/an
Monthly Compensation	$2,000	$2,000
Pre-tax Contributions	N A	-200
Taxable Salary	$2,000	$1,800
Federal Income Tax (15%)	-300	-270
State Income Tax (@3%)*	-60	-54
Social Security Tax (7.65%)**	-153	-138
Salary after Taxes	$1,487	$1,338
After-Tax Expenses	-200	N A
Net Take Home Pay	$1,287	$1,338
Net Individual Savings is $51/month ($1,338 vs. $1,287) or $612/year.
*State tax savings are estimated. Most state and local governments also treat cafeteria plan elections favorably
for purposes of state and local income taxes.
**Employees save 6.2% on pre-tax payroll deductions if they make less than the maximum Social Security wage
base ($94,200 for 2007; indexed annually) plus 1.45% on all pre-tax deductions under the plan.
9
~AF
THE AMERIFLEX CONVENIENCE CARDsm
In 1999, AmeriFlex introduced the AmeriFlex
Convenience Cards"' MasterCard°, creating a
clear win-win circumstance for both employer
and employee by providing an easier, more
convenient method for employees to utilize their
Flexible Spending Accounts. This debit card allows for the automatic
electronic transfer of pre-tax dollars from an employee account when paying
for qualified expenses. Employees are able to receive immediate
reimbursement of their medical and dependent care expenses simply by
using their card at the point of service. The normal paper claims process is
eliminated, as are worries of forgotten purchases or lost receipts.
A Concept Of Simplicity
The AmeriFlex Convenience Cards"' can be used wherever MasterCard° is
accepted, and all charges are paid electronically. The MasterCard® system
carves the world into more than 1,000 merchant category codes, each code
reflecting whether the merchant is a restaurant, department store, gas
station, pharmacy, doctor's office, etc. Therefore, the card will not work at
an unauthorized MasterCard° merchant (e.g. gas station, restaurant, etc.)
but it will recognize applicable healthcare, dependent care, and transit
MCC/SIC codes, allowing AmeriFlex to properly adjudicate claims according
to IRS guidelines.
When the debit card is swiped, the system qualifies the expense. Next, it
determines if there is an adequate/available balance in the employee FSA
account. Finally, pre-authorization occurs at the merchant POS terminal. At
this point, the merchant will get paid via ACH and the amount of charge is
deducted from the employee's FSA account. It is important for employees to
remember that back-up documentation may be required, so they should
save their receipts.
10
'AF
Capitalizing on Technology
Technological innovation has been a hallmark of AmeriFlex since its
inception: In 1999, AmeriFlex and MBI pioneered the debit card technology
that started a voluntary benefits revolution. With the emergence of
Consumer-Driven Benefits, AmeriFlex has recognized the need to deliver a
technology-based solution that enhances the common debit card platform.
Our unmatched industry experience and knowledge-based administrative
expertise once again enabled us to pioneer the development of a
consolidated FSA/HRA/HSA/CRA platform with single-participant pricing.
Emerging consumer-driven benefit strategies that seek to utilize multiple
accounts (HRA/FSA/HSA/CRA) have made the AmeriFlex Convenience
Cards"' an even more compelling innovation. We employ technology that
provides the flexibility to handle a multitude of variations in plan structure
on one card, which is a prerequisite to achieving seamless compatibility with
the electronic payment systems that are critical to these types of plans.
Service & Support
In addition to being a leader in debit card technology and electronic claims
processing, AmeriFlex recognizes that the key to exceptional administration
is service. From the beginning, you receive individualized attention from
account setup through end of year reporting. Upon receiving a new client
application, your group is assigned a dedicated Account Executive who is
responsible for the implementation and daily management of your plan, Your
Account Executive serves as your primary contact for all administrative
inquiries.
Your employees will enjoy exceptional customer service from AmeriFlex as
well. In addition to having a knowledgeable and courteous staff of customer
service representatives, we offer two other options for employees to access
account balances and transaction history: by Web or IVR, both available 24
hours a day, 7 days a week.
I
CAF
Benefits of the Card
/ One fee per card - no per-swipe or transaction fees
/ Single participant pricing, regardless of the number of accounts
selected
/ Low minimum monthly fee of $60 regardless of number of employees
/ Option to waive pre-fund with ACH election
/ Account history access and reporting online (www.flex125.com)
/ Real time balances and consolidated reporting
/ One card for all three Flexible Spending Accounts
/ Pay only once...no double outlay of funds
/ Universal acceptance of MasterCard®
/ Spouse and dependent cards provided at no additional fee
/ Claims account information provided real-time
/ No credit application needed from employees
/ Unlimited lost or stolen card fraud protection
/ Increased FSA utilization
/ Increased employer F.I.C.A. savings
/ Increased employee morale
12
CAF
ADMINISTRATIVE SERVICES
Plan Installation/Takeover
/ Flexible Spending Account Document Preparation
/ AmeriFlex Convenience Card° Account Setup and Installation
/ Summary Plan Description (SPD) and Plan Document Preparation
/ Online Enrollment Capabilities
/ Initial Enrollment Report
/ Coordination with the payroll supervisor to ensure proper deductions
Consulting
/ A dedicated Account Executive to manage all aspects of group
administration
/ Semiannual discrimination testing, which includes:
• 25% Concentration test for Medical and Dependent Day-Care
• 55% Average Benefits test for Dependent Day-Care
/ Preparation of Form 5500 -Signature Ready (if applicable)
/ Preparation of Schedule A and Schedule C attachments
/ Summary Annual Reports (SAR) - as required by the U.S. DOL
/ Electronic education and enrollment materials
Monthly/Annual Administration
/ Tracking of all FSA contributions
/ Daily claims processing and coordination with MasterCard
/ Online access to claim forms and service documentation
/ Paper claims submission via fax
/ Direct Deposit option for paper claims
/ Employee statement with each claim check
/ Online account access and reporting (www.flex125.com)
/ Balance memos for each plan participant provided to the employer
/ Monthly employer reports
/ Toll-free 24/7 interactive voice response (888-868-3539)
13
CAF
IMPLEMENTATION PROCESS
AmeriFlex has made implementing an FSA easy. It all starts with the client
~glication, which can be accessed on our web site at www.flexl25.com, or
requested via e-mail at info@flex125.com.
The application provides all information required to complete your plan
documents, set up your account, and ensure that your FSA plan is in
compliance with all IRS Regulations. Once your account is established, you
simply collect employee elections and fund your claims account.
ENROLLMENT OPTIONS
• One-on-One Enrollment: Generally the most effective method of
enrollment is to provide your employees with consultation and
education via a one-on-one meeting with your broker or other
benefits counselor. This method ensures that employees best
understand how to use the plan, recognize what expenses qualify,
and have the opportunity to get their individual questions
answered. Effective personal enrollments usually produce the
highest participation levels which, in turn, serve to enhance overall
tax savings.
• Online Enrollment: For subsequent plan years, AmeriFlex can
provide access to online enrollments. Employees will be given a
password to our secure system and can then enroll at their
convenience, during the specified open enrollment period 24 hours
a day.
• File Transfer Enrollment: If your company currently utilizes an
online enrollment software, AmeriFlex can automate your
enrollment process and continued plan maintenance by
automatically accepting data from your primary benefit enrollment
system .
These methods of enrollment can be combined to create the best
environment for you and your employees to enroll in your Flexible Benefit
Plan.
14
CAF
FUNDING OPTIONS
• Daily ACH/Debit:. Daily ACH, our most popular funding option,
requires no pre-fund! Each weekday, AmeriFlex will e-mail or fax a
daily claims register for the previous day's transactions. Within 24
hours, AmeriFlex will debit the employer's pre-designated claims
account for the required funds. Monthly Administrative fees can also
be debited via ACH.
• Weekly ACH/Debit: Employer pre-funds an amount equal to one-
twelfth (1/12) of the annual elections to the AmeriFlex Flex Claims
Account. Each week, AmeriFlex will e-mail or fax a weekly claims
register for the previous week's transactions. Within 24 hours,
AmeriFlex will debit the employer's pre-designated claims account
for the required funds. Monthly Administrative fees can also be
debited via ACH.
• Check or Wire Transfer: Employer pre-funds an amount equal to
one-sixth (1/6) of the annual elections to the AmeriFlex Flex Claims
Account. AmeriFlex will e-mail or fax a weekly claims register for
the previous week's transactions. The employer can then mail a
check or initiate a wire transfer for the required funds. Checks or
wire transfers must be received within five (5) business days of the
request. Manual (non-debit card) employee reimbursements will be
held until funds are received.
Please refer to the AmeriFlex Client Application for further details on funding
options.
15
CAF
ADMINISTRATIVE FEES
Flexible Spending Accounts with the AmeriFlex Convenience Cards"'
Account Setup
with HRA or COBRA administrative service
Monthly Fees
Minimum Monthly Fee
Additional cards for spouse or dependent
(must be over 18)
Annual Fees
Renewal Fee
IRS Form 5500 preparation (if applicable)
Enrollment materials (PDF via e-mail)
Integrated FSA online enrollment option
Enrollment materials (hard copy)
$650.00
Waived*
$5.25/p/m**
$60.00
Included
$170.00
Included
Included
Included
Cost of Printing
*Only one account setup fee. If multiple services are selected at the point of application, the lowest account setup fee will be
applied.
**The monthly fee is based on number of participants and is inclusive of all debit card charges incurred (no transaction fee per
swipe or incremental debit card charges).
FEE GUARANTEE
Fees are guaranteed for a period of 12 mont hs following the effective date of
the plan. AmeriFlex reserves the right to change fees/services without
notice after 30 days from the date of this proposal if an Administrative
Services Agreement has not been signed.
PERFORMANCE GUARANTEE
If AmeriFlex fails to provide Kerr County the services outlined in this
proposal and within the administrative services agreement on a timely basis
and without cause, AmeriFlex shall credit Kerr County's monthly
Administrative Fees equal to 25% of that month's charges.
16
,<
l
CAF
SUMMARY OF SAVINGS
Projected Annual F.I.C.A. Savings from Flexible Spending Accounts
Projected Annual MedFSA Administrative Fees
49 participants @ $5.25 per month $ 3,087
Projected Annual DepFSA Administrative Fees
20 participants @ $5.25 per month $ 1,260
Projected Annual CRA Administrative Fees
37 participants @ $5.25 per month $ 2,331
One Time Account Setup $ 650
Annual Renewal Fee $ 170
Total 1st Year Fees ~ $ 7,328
$ 1,795
Projected Net Em plover Savings 1st Year ~,4~7
Projected Net Fm plover Savings 2nd Year 7,9#7
17
~i
IAF
OTHER PRIORITY SERVICES PROVIDED BY AMERIFLEX
~~Y ?' Healthcare Reimbursement Accounts (HRAs)
~:
`f }~ -
~. Health insurance premiums are rising due to the ever increasing
cost of care. Employers and employees must cope with higher co-
payments, higher deductibles and increased provider restrictions. Many
employers are now exploring alternatives to standard medical care that
combine high-deductible health plans (HDHP) with an Healthcare
Reimbursement Account to ease this burden. HRAs are employer-funded
accounts that can be designed to help offset the increase in employees' out-
of-pocket expenses due to the implementation of the HDHP. HRA
administrative costs and HRA contributions can be deducted from taxes
without increasing FICA or FUTA taxes or disability or workers' compensation
insurance premiums. The "hat-trick" created by combining the savings from
LOW-COST, high-deductible health plans with the associated tax savings and
even the ability to deduct HRA administrative costs, make HRAs a valuable
option worth considering for your employee benefits package.
,,`~~, Health Savings Accounts (HSAs)
,.~ ,
~? Maybe you're a small business owner and you need a good
insurance plan to attract top-notch employees. Maybe you run a
multi-million-dollar company and are looking to provide better insurance for
your team -and cut costs. If you're offering a High Deductible Health Plan to
your employees, a HSA just might be the perfect solution for you. A HSA
makes health coverage more like insurance -what health care coverage
should be. After all, you buy car insurance to protect yourself in the event of
a catastrophe. You don't "insure" routine maintenance and minor repairs like
a flat tire or a new turn-signal bulb.
HSAs can be funded by either an employee or an employer. The savings roll
over into subsequent years, earning interest. This low-cost, tax-free
alternative to traditional insurance is the biggest change to health policy in
decades. Seize the HSA opportunity. Because taking control of how you or
your company spend health care dollars is just smart business.
18
,,
~AF
Mongooses COBRA/HIPAA Administration
The IRS claims that over 90% of all employers are out of
compliance with COBRA regulations. Penalties are substantial and
the active enforcement of regulations has been increased in recent years.
Mongoose° allows you to stay focused on business, confident that issues
relating to COBRA/HIPAA administration and compliance are being managed
in accordance with the ever-changing Federal regulatory environment.
Utilizing Mongoose® shifts your risks to AmeriFlex.
Outsourcing COBRA/HIPAA administration relieves Kerr County of burdensome
tracking, notification, and billing processes. AmeriFlex's Mongoose® system
delivers a fast, highly automated, easy-to-use, cost-effective method for
administration and compliance of your COBRA/HIPAA obligations. Mongoose®
provides more than just simple event tracking and letter generation:
19
. ,~
AFI
i
/ Assumption of Liability
/ Communication with Carriers
/ COBRA rights and HIPAA Certificates automatically sent
/ Online Employer access
/ Online Participant access
/ Direct to Carrier billing and eligibility option
Simply put, by selecting AmeriFlex's Mongoose° service as your outsourced
COBRA solution, you are designating AmeriFlex as your 'plan administrator"
and shifting all responsibilities and liabilities for COBRA administration and
compliance to us.
COBRA/HIPAA ADMINISTRATIVE FEES
Account Setup $350.00
with FSA or HRA administrative service Waived*
Monthly Administration $0.75**
Optional Initial Notification via USPS Proof of Mailing $5.00/notice
$3.00/notice if ASCII format
Minimum Monthly Fee $50.00
*Only one account setup fee. If multiple services are selected at the point of application, the lowest account setup fee
will be applied.
**The monthly fee is based on the number of insured employees.
20
Accidents happen in places where
you and your family spend the most
time - at work, in the home or
during sports and leisure activities.
Consider the following facts about
accidents.
• On the job, 3.7 million American
workers suffered disabling injuries
in 2004. A fatal injury occurs every
5 seconds and a disabling injury
occurs every second.
Source: Injury Facts, National Safety Council, 2005-
2006 edition
• Children ages 5 to 14 account
for nearly 40 percent of all sports-
related injuries treated in hospital
emergency departments.
Source: 2006 National Center for Sports Safety
Most traditional insurance doesn't
cover every medical expense,
leaving you to pay out-of-pocket
expenses such as deductibles,
office visit co-payments, and
transportation and lodging costs.
Can you afford to pay all the costs
related to caring for an accidental
injury?
Colonial's Accident Insurance is
designed to help see you through
the different stages of care, this
plan provides benefits for initial
care and treatment, in addition to
the follow-up care you may need.
ouo~
^ Initial Care
• About 35 percent of all hospital emergency department visits are injury related.
Source: Injury Facts, National Safety Council, 2005-2006 edition
When an accident happens, you don't want to worry about how you will pay for the
initial care, especially if you have to go to the emergency room for x-rays or ride in an
ambulance.
• Ambulance $100 per trip • Emergency Room Treatment $150 per accident
. Air Ambulance $500 per trip • Initial Doctor's Office Visit $ 50 per accident
^ Common Accidental Injuries
. The total cost of unintentional injuries in 2004 was $574.8 billion.
Source; Injury Facts, National Safety Council, 2005-2006 edition
Fractures and dislocations are frequent injuries common in both adults and children.
Dislocation (Separated Joint)	Closed Reduction
	(Non-Surgical)
Hip	$2,000
Knee	$1,000
Ankle -Bone or Bones of the Foot	$ 800
Collarbone (Sternoclavicular)	$ 500
Lower Jaw, Shoulder, Elbow, Wrist	$ 300
Bone or Bones of the Hand	$ 300
Cnllarhnne lArrnminclavicularsnd Seouation). Orie TOe	Or F1n~eT $ 100
Fracture (Broken-Bone). Closed Reduction
	(Non-Surgical)
Skull, Depressed Skull	$2,500
Skull, Simple Non-Depressed	$1,000
Hip, Thigh	$1,500
Body of Vertebrae, Pelvis, Leg	$ 800
Bones of Face or Nose	$ 350
Upper Jaw, Maxilla	$ 350
Upper Arm between Elbow. and Shoulder	$ 350
Lower Jaw, Mandible, Kneecap, Ankle, Foot	$ 300
Shoulder Blade, Collarbone, Vertebral Processes	$ 300
Forearm, Wrist, Hand	$ 300
Rib	$ 250
Coccyx. ~	$ 200
Finger, Toe	$ 50
Open Reduction
(Surgical)
$4,000
$2,000
$1,600
$1;000
$'600
boa
$ 200
Open Reduction
(Surgical)
$5,000
$2,000
$3,000
X1,600
$ 700
$ 700
$ 700
$ 600
$ 600
$ 600
$ 500
$ 400
100
Your Colonial policy also provides benefits for the following injuries received as a
result of a covered accident.
Burn (based on size and degree)	$750 to $10,000
Concussion	$100
Emergency Dental Worl<	$50 to $150
Eye Injury	$200
Torn Knee Cartilage	$500
Lacerations (based on size)	$25 to $400
Ruptured Disc	$400
Tendon/Ligament/Rotator Cuff	$400 to $600
...Colonial's Accident Insurance
- -. .
1 Surgical Care
43.8 million surgical procedures were performed in 2003.
ource: Injury Facts, National Safety Council, 2005-2006 edition
f your covered accidental injury is serious enough to require
urgical care or a transfusion, your Colonial policy provides
•ou benefits.
surgery (open abdominal or thoracic) $1,000
flood/Plasma/Platelets $300
1 Transportation/Lodging Assistance
f a covered person requires care or treatment at least 100 miles
way from his home, your Colonial policy provides benefits to
yelp with transportation and lodging costs.
'ransportation $300 per trip up to 3 trips
,odging (family member or companion) $100 per night up to 30 days
1 Accident Hospital Care
In 2003, the average length of stay in a hospital was 4.8 days.
ource: Injury Facts, National Safety Council, 2005-2006 edition
'raditional health insurance policies may have per admission
eductibles and copayments that must be satisfied prior to
overing benefits related to hospital stays. Your Colonial policy
rovides benefits to help with these costs.
(ospital Admission	$750 per admission per accident
[ospital Confinement	$200 per day up to 365 days
[ospital Intensive Care	$400 per day up to 15 days
1 Follow-up Care
ou may require follow-up care once you are discharged from
ie emergency room, hospital or doctor's office. You may have to
ndergo physical therapy, use crutches or a wheelchair or even
'quire the use of an artificial limb.
.ccident Follow-up $50 (Limit of one visit, payable after
~reatmerit Emergency Treatment or Initial
Doctor's Office Visit)
.ppliances $100 (wheelchair, crutches)
hysical Therapy $25 per treatment up to 6 treatments
rosthetic Devices $500 to $1,000
Benefit Worksheet /
~r use by Colonial representative
Coverage: ^ Employee Only
(check one) ^ Employee/Spouse
^ Accidental Death and Dismemberment
• Preliminary information indicates that in 2003, accidental
injuries remained the fifth leading cause of death.
Source: Injury Facts, National Safety Council, 2005-2006 edition
For injuries received as the result of a covered accident that lead
to an accidental death or dismemberment, this plan provides
benefits that can help see you and your family through the loss.
Loss of Finger/Toe/Hand/Foot/Sight of Eye $750 to $15,000
Accidental Death Common Carrier
Named Insured $25,000 $50,000
Spouse $10,000 $20,000
Child(ren) $ 5,000 $10,000
^ Catastrophic Accident
The severity of some accidents can result in life changing losses.
Colonial can help with such severe losses by providing a benefit
for a catastrophic loss that results from a covered accident.
Catastrophic loss is an injury that within 365 days of the covered
accident results in the total and irrecoverable:
• loss of both hands or both feet, or • loss of sight of both eyes, or
• loss of use of both arms or both legs, or • loss of hearing of both ears, or
• loss or loss of use of one arm and one leg,or • loss of the ability to speak.
• loss of one hand and one foot, or
The Catastrophic Accident benefit is payable after a 365 day
elimination period. The elimination period refers to the period
of 365 days after the date of the covered accident.
Accident Occurs: Covered Benefit Amount
Prior to age 65* Person Per Lifetime
Named Insured $100,000
Spouse $ 50,000
Child(ren) $ 50,000
*Amounts are reduced for insureds who are over the age of 65.
Please refer to the Outline of Coverage contained in this
brochure for complete details.
^ Flexible Benefit
Plan: ^ On and Off-Job Benefits
(check one)
Premium Per Pay Period $
^ Spouse Only
^ One-Parent Family
^ Off-Job Only Benefits
^ One Child Only
^ Two-Parent Family
The premium will vary based on benefits selected.
__ .. ~, 65623-I
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY
P.O. Box 1365, Columbia, South Cazolina 29202 (800) 325 - 4368
ACCIDENT ONLY INSURANCE COVERAGE
REQUIRED OUTLINE OF COVERAGE (Applicable to Policy Form ACCPOIrTX)
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.
(1) 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 polity 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.
THE POLICY IS NOT A POLICY OF WORKERS' COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER
TO THE WORKERS' COMPENSATION SYSTEM BY PURCHASING THE POLICY, AND IF THE EMPLOYER IS ANON-SUBSCRIBER, THE
EMPLOYER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS' COMPENSATION LAWS. THE
EMPLOYER MUST COMPLY WITH THE WORKERS' COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED
NOTIFICATIONS THAT MUST BE FILED AND POSTED.
(2) Accident only coverage 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. Coverage is provided for the benefits
outlined in paragraph (3). The benefits described in paragraph (3) maybe limited by paragraph (4).
(3) BENEFITS -All benefits aze payable once 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:
Accidental Death Named Insured $25,000 Spouse $10,000 Children $5,000
Benefit payable if a covered person is injured in a covered accident and the injury causes the insured to die within 90 days afer the accident. If we pay this benefit,
we will not pay the Accidental Death-Common Carrier benefit
Accidental Death-Common Cazrier: Named Insured $50,000 Spouse $20,000 Children $10,000
Benefit payable if a covered person is injured while afore-paying passenger on a common carrier and the injury causes the insured 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 chanered vehicles are not common carriers. If we pay this benefit, we will not pay the Accidental Death benefit.
Accident Follow-Up Treatrt~ent - $50: Benefit payable for follow-up treatment due to a covered accident recommended or advised by a doctor. Follow-up
treatment must occur after initial treatment in a doctor's office or emergency room and occur within 90 days of the covered accident.
Air Ambulance - $500: Benefit payable if a licensed professional air ambulance company transports by air any covered person to or from a hospital or between
medical facilities; transportation must occur within 48 hours after the covered accident
Ambulance - $100: Benefit payable if a licensed professional ambulance company transports any covered person by ground transportation to or from a hospital or
between medical facilities; transportation must occur within 90 days after the covered accident
Appliance - $100: Prescribed by a doctor to aid in personal locomotion or mobility; use must begin within 90 days after covered accident
Blood/Plasma/Platelets - $300: Must require the transfusion, administration, cross matching, typing and processing ofblood/plasma/platelets and be administered
within 90 days after the covered accident
Burn -Must be treated by a doctor within 72 hours after the accident
$ 750 -Second degree burns which cover at least 36% of the body surface
$ 1,500 -Third degree burns which cover at least 9 square inches but less than 35 squaze inches of body surface
$10,000 -Third degree burns which cover 35 or more square inches of the body surface
Catastrophic Accident -payable once per lifetime per covered person
Accident Occurs: Covered Person Benefit Amount Accident Occurs Covered Person Benefit Amount
Prior to age 65 Named Insured $100,000 Age 65-69 Named Insured $ 50,000
Spouse $ 50,000 Spouse $ 25,000
Child(ren) $ 50,000 Child(ren) $ 25,000
After Age 70 Named Insured $ 25,000
Spouse $ 12,500
Child(ren) $ 12,500
Benefit payable if any covered person sustains a catastrophic loss and is under the care of a doctor during the elimination period and remains alive at the end of the
elimination period. Injury must occur within 365 days of the covered accident
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
The loss of use of an arm means the loss of function of the entire arm from the shoulder to the hand. The loss of use of a leg means the loss of function of the entire
leg from the hip to the foot. The loss of sight means both eyes are totally blind and that no sight can be restored. The loss of hearing means deafness in both ears, '
such that it cannot be corrected to any functional degree by any procedure, aid or device. The 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.
Concussion - $100
Benefit payable if any covered person sustains a concussion as the result of a covered accident; must be diagnosed by a doctor using X-ray, CAT scan or MRI within
72 hours from date of covered accident
Dislocation (Sepazated Joint) Closed Reduction Open Reduction
Hip $2,000 $4,000
Knee (except Patella) 1,000 2,000
Ankle - Bone or bones of the Foot (other than Toes) 800 1,600
Collarbone (Sternoclavicular) 500 1,000
Lower Jaw, Shoulder (Glenohumeral), Elbow, Wrist 300 600
Bone or Bones of the Hand (other than Fingers) 300 600
Collarbone (Acromioclavicular and separation), One Toe or Finger 100 200
Must be diagnosed by a doctor as a dislocation within 90 days after the accident; reduction must require correction with anesthesia by a doctor; reduction without
anesthesia will pay 25 percent of amount shown above for closed reduction.
ACCPOL-O-TX
ayable 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
benefit amount. Benefit payable for incomplete dislocation is 25 percent of amount shown for closed reduction. Benefit payable for a fracture and a
'' tion in the same accident is no more than two times the amount for the bone or joint involved which has the highest benefit amount. Benefit payable only
~`-~1'fe first dislocation of a joint after the effective date. Subsequent dislocations of the same joint after the effective date will not be covered. Benefit payable
]~ir a fiactttre or a dislocation and a tear, rupture or sever of atendon/ligament/rotator cuff in the same covered accident is no more than the larger of either the
''=1'c~don/Ligament/Rotator Cuff benefit, the Fracture benefit or the Dislocation benefit.
"boctot's Office - $50: Initial treatment and/or advice must be in a doctor's office and must occur within 60 days of the covered accident
F¢ '-Emergenry Dental Work $150 -Broken teeth repaired with crown(s) $ 50 -Broken teeth resulting in extractions)
hmergenry Room Treatment - $150: Requires examination and treatment by a doctor in a hospital emergency room within 72 hours after covered accident
Eye Injury- $200: Must require surgery or the removal of a foreign object by a doctor within 90 days after the covered accident. An examination with anesthesia
will not be consiered surgery.
Fracture (Broken Bone) Closed Reduction Open Reduction
Skull (except bones of face or nose) depressed skull fracture $2,500 $5,000
Skull (except bones of Face or nose) simple non-depressed skull fracture 1,000 2,000
Hip, `Thigh (Femur) 1,500 3,000
Vertebrae, Body of (excluding Vertebral Processes), Pelvis (except Coccyx), Leg 800 1,600
Bones of Face or Nose (except Mandible or Maxilla) 350 700
Upper Jaw, Maxilla (except Alveolar Process), Upper Arm between Elbow and Shoulder 350 700
Lower Jaw, Mandible (except Alveolar Process), Kneecap, Foot (except Toes), Ankle 300 600
Shoulder Blade, Collarbone, Vertebral Processes, Forearm, Hand, Wrist (except Fingers) 300 600
Rib 250 500
Coccyx 200 400
Finger, Toe 50 100
Must be diagnosed by a doctor within 90 days after the accident. 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. Benefit payable for a chip fracture is 25 percent of the amount shown for closed
reduction for the bone involved. Benefit payable for a fracture and a dislocation in the same covered accident is no more than two times the amount for the bone
or joint involved which has the highest benefit amount. Benefit payable for a fracture or a dislocation and a tear, rupture or sever of a tendon/ligament/rotator cuff
in the same covered accident is no more than the largger of either the Tendon/Ligament/Rotator Cuff benefit, the Fracture benefit or the Dislocation benefit.
Hospital Admission - $750 per admission - Must be confined in a hospital within six months after the accident; payable once per covered accident.
Hospital Confinement - $200/day up to 365 days per covered accident: Must be confined in a hospital or a hospital sub-acute intensive care unit within six
months after the covered accident.
If the covered person is confined in a hospital and is confined again within 90 days for the same accident or related condition, we will treat this confinement as
a continuation of the prior confinement. If more than 90 days have passed between the periods of hospital confinement, we will treat this confinement as a new
confinement. 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 Confinement - $400/day up to 15 days per covered accident: Must be confined to a hospital intensive care unit within 30
days after the accident. If the covered person is confined in a hospital intensive care unit, and is confined to a hospital intensive care unit again within 90 days for
the same accident or related condition, we will treat this confinement as a continuation of the prior confinement. If more than 90 days have passed between the
periods of confinement in a hospital intensive care unit, we will treat this confinement as a new confinement. We will not pay the Hospital Intensive Care Unit
Confinement benefit and the Hospital Confinement benefit concurrently.
Knee Cartilage Torn - $500: Must be treated by a doctor within 60 days after the covered accident and repaired through surgery within six months after the
covered accident. If exploratory arthroscopic surgery is performed and no repair is done, or if the cartilage is shaved (debridement), we will only pay $100
Laceration
$ 50 -Total of all lacerations is less than two inches long (less than 5.08 centimeters) and repaired by stitches
$200 -Total of all lacerations is two to six inches long (5.08 to 15.24 centimeters) and repaired by stitches
$400 -Total of all lacerations is over six inches long (over 15.24 centimeters) and repaired by stitches
$ 25 -Laceration(s) are treated without stitches
Must be repaired by a doctor within 72 hours after the covered accident. 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 Loss of a Finger, Toe, Hand, Foot or Sight of an Eye benefit.
Lodging - $100/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. Hospital must be more than 100 miles from the residence of the covered person.
Loss of a Finger, Toe, Hand, Foot or Sight of an Eye
$15,000 Payable for loss of: both hands, or both feet, or the sight of both eyes, or a hand and a foot,
or a hand and the sight of one eye, or a foot and the sight of an eye.
$ 7,500 Payable for loss of: one hand, or one foot, or sight of one eye.
$ 1,500 Payable for loss of two or more fingers, or two or more toes or one finger and one toe.
$ 750 Payable for loss of: one finger or one toe.
Benefit payable if the insured loses a finger, toe, hand, foot or sight of an eye within 90 days after the 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.
Physical Therapy - $25/treaunent up to six treatments per accident: Must begin within 60 days after the covered accident and be completed within six months
after the covered accident. Must be prescribed by a doctor and rendered by a licensed physical therapist and performed in an office or in a hospital
Prosthetic Device/Artificial Limb: $ 500 -One prosthetic device or artificial limb $1,000 -More than one device or artificial limb
Must be prescribed by a doctor for functional use when a covered person loses a hand, foot, or sight of an eye. Must be received within one year of the covered
accident. 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.
Ruptured Disc - $400: Must be treated by a doctor within 60 days after the covered accident and repaired through surgery within one year after the accident
Skin Grafts - 25% of Applicable Burn benefit: Payable only for a skin graft for a burn for which a burn benefit was received under the polity
O
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ACCPOL-O-TX
Surgery - $1,000: Payable if any covered person undergoes open abdominal or thoracic surgery within 72 hours of covered accident. Surgery must be for repair of
internal injuries; For exploratory or other surgery without repair we will pay $100.
Hernia repair will not be covered under this benefit. Tendon/Li ent/Rotator Cuff:
$400 -Repair of one tendon, ligament or rotator cuff 600 -Repair of more than one of the above
Must be torn, ruptured or severed and be repaired through surgery within 90 days after the covered accident. If the covered person is in an accident and receives a
fracture or a dislocation and tears, ruptures or severs a tendon/ligament/rotator cull, benefits are only payable for the larger benefit. If exploratory arthroscopic surgery is
performed and no repair is done, we will pay $100.
Transportation - $300/trip up to 3 trips per covered accident: Travel must be more than 100 miles for special treatment and confinement in a hospital. Treatment
must be prescribed by a doctor and not available locally. This benefit is not payable for transportation by ambulance or air ambulance.
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.
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 after the effective date of the polity; occurs while the polity is in force; is of a type of accident listed on the Polity
Schedule page; and is not excluded by 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. An emergency room is a specified area within a hospital that is designated for the emergenry 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 afull-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 apre-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 center; or a place for alcoholics or
drug addicts. Alcoholism and drug addiction are not covered by this policy.
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 this polity.
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 orsemi-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, for which benefits are provided, means a condition sustained by the covered person which is the direct result of an accident, independent of disease or bodily
infirmity or any other cause and occurs while this polity is in force.
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 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, other than you or a family member, 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 this policy; and practices according to the Code of Ethics of the American Physical Therapy Association.
(4) EXCLUSIONS AND LIMITATIONS: ,
We will not pay benefits for losses that are caused by or are the result of any covered persons:
• operating, learning to operate, serving as a crew member of or jumping, parachuting, or falling from any aircraft or hot air balloon, including those which are not
motor-driven.
• engaging in hang-gliding, bungee jumping, parachuting, sailgliding, parasailing, parakiting 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.
• 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 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.
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.
• any covered person's being intoxicated or under the influence of any narcotics unless administered on the advice of his doctor.
(5) RENEWABILITY: Your policy is guaranteed renewable for life as long as premiums are paid when they are due or within the grace period.
(6) PREMIUMS: Premiums are subject to change. 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.
Monthly Premium: $ Annual Premium: $ Plan:
Coverage: Individual-Individual/spouseOne-parentTwo-parent
After the first premium, if the premium is not paid when it is due, it can be paid during the next 31 days. These 31 days are called the grace period. During the grace
period, the polity will stay in force. If the premium is not paid before the grace period ends, the coverage provided by the policy will terminate at the end of the grace
period.
ACCPOL-O-TX
According to the most recent
Centers for Disease Control and
Prevention/National Center for Health
Statistics computations, if all forms
of major cardiovascular disease were
eliminated, life expectancy would rise
by almost seven years. If all forms
of cancer were eliminated, the gain
would be three years.
Source: 2004 Heart and Stroke Statistical
Update -American Heart Association.
One way to reduce the risk of serious
illness is through early detection with
an annual health screening test.
Colonial's Health Screening Rider will
provide a benefit if one of the covered
persons has one of the screening tests
listed below while the rider and the
policy to which it is attached are in
force, and after the waiting period.
'This benefit is payable once per
calendar year. Waiting period means
the first 30 days following the effective
date of the rider.
Health Screening Benefit $50.00
• Blood Test for Triglycerides
• Bone Marrow Testing
• 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
• 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
• Thermography
Please refer to the Outline of Coverage on the back of this brochure for complete
details. -
To receive payment for your health screening benefit, it is not necessary to complete a
claim form. Just call our toll-free Customer Service number, 1-800-325-4368 with the
medical information or visit www.coloniallife.com.
Colonial insurance is too valuable to lose just because you change employers.
When you are covered under this plan, you may be able to keep this insurance if
you change employers with no increase in premium.
Benefit Worksheet
For use by Colonial representative ^ Flexible Benefit
Check One: ^ Employee Only ^ Spouse Only ^ One Child Only
^ Employee/Spouse ^ One-Parent Family ^ Two-Parent Family
Benefit Amount: $50.00 (payable once per calendar year for one covered person)
Premium Per Pay Period $ The premium will vary based on the plan selected.
- - ~ ~;,~~~~ ~~;:~~• ,. ~.,;;~~.t y~~,~. coloniallife.com
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY
P.O. Box 1365, Columbia, South Carolina 29202 (800) 325-4368
HEALTH SCREENING RIDER
REQUIRED OUTLINE OF COVERAGE (Applicable to Rider Form R-HSR-TX)
THE RIDER IS NOT A MEDICARE SUPPLEMENT RIDER
If you are eligible for Medicaze, review the Guide to Health Insurance
for People with Medicare available from the Company.
(1) PLEASE READ YOUR RIDER CAREFULLY. This outline provides a very brief description of the important features of your rider. This is not an
insurance contract and only the actual policy and rider provisions will control. The rider sets forth in detail the rights and obligations of both you and us. It is,
therefore, important that you READ YOUR RIDER CAREFULLY.
THE POLICY IS NOT A POLICY OF WORKERS' COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER
TO THE WORKERS' COMPENSATION SYSTEM BY PURCHASING THE RIDER, AND IF THE EMPLOYER IS ANON-SUBSCRIBER,
THE EMPLOYER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACRUE UNDER THE WORKERS' COMPENSATION LAWS.
THE EMPLOYER MUST COMPLY WITH THE WORKERS' COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE
REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.
(2) The health screening rider is designed to provide coverage ONLY for the benefit listed below. This coveragge is subject to any limitations or exclusions.
Coverage is provided for the benefits outlined in paragraph (3). The benefits described in paragraph (3) may be limited by paragraph (4).
(3) BENEFITS:
Health Screening Amount: $50/YEAR
We will pay this benefit if one of the covered persons has one of the health screening tests defined in this outline performed after the waiting period. This benefit
is payable once per calendar year. There is no limit to the number of years a covered person can receive benefits for health screening tests, as long as the rider and
the policy to which it is attached are in force.
Important Words in the Rider
Health Screening Test means blood test for triglycerides> bone marrow testing, breast ultrasound, CA 15-3 (blood test for breast cancer), CA125 (blood test
for ovarian cancer), CEA (blood test for colon cancer), chest X-ray, colonoscopy, fasting blood glucose test, flexible sigmoidoscopy, hemocult stool analysis,
mammography, pap smear, PSA (blood test for prostate cancer), serum cholesterol test to determine level of HDL and LDL, serum protein electrophoresis
(blood test for myeloma), stress test on a bicycle or treadmill or thermography.
Waiting Period means the first 30 days following the effective date of the rider.
(4) EXCLUSIONS AND LIMITATIONS: No benefits will be paid for a health screening test performed during the waiting period.
(5) RENEWABILITY: The rider is guaranteed renewable for life as long as the policy to which it is attached is in force and premiums are paid when they are
due or within the grace period.
(6) PREMIUMS: Premiums are subject to change. The premium can be changed only if we change it on all riders of this kind in force in the state where the
rider was issued.
Monthly Premium:$ Annual Premium:$ Plan:
Coverage: Individual Individual/Spouse_One-Pazent Two-Parent
After the first premium, if the premium is not paid when it is due, it can be paid during the next 31 days. These 31 days are called the grace period. During the
grace period, the rider will stay in force. If the premium is not paid before the grace period ends, the coverage provided by the rider will terminate at the end of
the grace period.
R-HSR-O-TX
_.
1`he ~It~r~iali ;~d~~ntag~
~ A leader in the supplemental insurance industry.
^ Communications and benefits education to help you understand
the benefits you have -and the benefits you may need.
^ Protnpt, accurate and courteous customer service.
~ Broad selection of products to help meet your individual needs,
with premiums paid through convenient payroll deduction.
Learn more about these and all of the advantages Colonial has to offer
at 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 the logo, separately and in combination, are registered
service marks of Colonial Life & Accident Insurance Company. All rights reserved.
COLONIAL
SUPPI_EMENTA I_ INSURANCE
for what happens next®
Colonial Supplemental Insurance products are underwritten by:
Colonial Life & Accident Insurance Company
1200 Colonial Life Boulevard, Columbia, South Carolina 29210
www.coloniallife.com

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Help protect your income with Colonial's
Short Term Disability Income Protec
Colonial's Short Term Disability Income Protection
insurance replaces a portion of your income if you
become disabled because of a covered accident or a
covered sickness. This income can help you
continue paying:
• Mortgage or rent payments.
• Utility bills and other household expenses.
• Food, clothing and other necessities.
• Co-payments.
• Medical costs not covered under other plans.
• Travel and lodging expenses for treatment.
You and your family rely on your income.
So what would happen if you became ill
or suffered an accident and were unable to
work? Could you still pay everyday living
expenses?
Consider these statistics:
• 23.2 million disabling injuries were reported in 2004;
3.7 million of those were work related.l
• A fatal injury occurs every 5 seconds and a disabling
injury occurs every second.l
• The cost of unintentional injuries in 2004 was $574.8
billion.'
' Injury Facts, National Safety Council, 2005-2006 edition.
z Please refer to the Renewability"section on the Outline of Coverage.
s Please refer to the Geographical Limitations"section of the Outline of Coverage.
With Colonial's Short Term Disability
Income Protection Insurance:
1. You're paid regardless of any other
insurance you may have with other
insurance companies.
2. Benefits are paid directly to you, unless you
specify otherwise.
3. You may choose the amount of your
disability benefits to meet your needs,
subject to income.
~. Your coverage is guaranteed renewable
to age 70.2
,S. If you change jobs or leave your employer,
you can take your coverage with you.
V. You're covered worldwide for up to 60
days.3
7• Waiver of Premium is included
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY
P.O. Box 1365, Columbia, South Carolina 29202
(800) 325-43G8
DISABILITY INCOME PROTECTION COVERAGE
REQUIRED OUTLINE OF COVERAGE
(Applicable to Policy Form DIS 1000-'TX)
(1) READ YOUR POLICY CAREFULLY. This disclosure of coverage provides a very brief description of the important features
of your polity. This is not an insurance contract and only the actual polity provisions will control. The polity itself sets forth in
detail the rights and obligations of both you and us. It is, therefore, important that you READ YOUR POLICY CAREFULLY!
THIS IS NOT A POLICY OF WORKERS' COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME
A SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM BY PURCHASING THIS RIDER, AND IF THE
EMPLOYER IS ANON-SUBSCRIBER, THE EMPLOYER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE
ACCRUE UNDER THE WORKERS' COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH WORKERS'
COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT
MUST BE FILED AND POSTED.
(2) Disability Income Coverage is designed to provide you with 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 is provided for the benefits outlined in paragraph (3). The benefits described in paragraph
(3) may be limited by paragraph (4).
(3) BENEFITS
We will pay the total disability benefit shown in the Polity 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 you are totally disabled due to a mental or nervous disorder, we will pay the total disability benefit for as long as this coverage is
in force and you remain totally disabled, after the elimination period, up to a maximum benefit period of six months.
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 I/30th of the monthly amount.
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.
If, after you cease to be disabled, you become disabled again for the same or related condition, it 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.
• anew 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.
• anew 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.
• your employer will allow you to work for less than 20 hours per week; and
DIS 1000-O-TX 1 59095-1
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.
If you become disabled because of apre-existing condition, we will not pay for any disability period if it begins during the first 12
months (6 months if you are age 65 or older after the effective date of this rider) the polity is in force.
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 Polity 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 regular occupation; and
• during such time you are no longer qualified to receive total or partial disability benefits.
This coverage will end on the polity 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 Polity Schedule.
Time Limits
After the polity has been in force for 12 months from the effective date of the polity, we will pay benefits for any pre-existing
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 Polity 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 polity 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 Polity Schedule. We will pay the monthly benefit amount shown in the Polity
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 polity 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 polity 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 polity is in effect, or
for the elimination period shown in the Polity 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.
DIS 1000-O-TX 2 59095-1
You must pay all premiums to keep the polity 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.
Important Words in the Polity
A covered accident is an accident which:
• occurs after the effective date of the polity;
• is of a type listed on the Polity Schedule;
• occurs while the polity 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 polity;
• is of a type listed on the Polity Schedule;
• occurs while the polity is in force; and
• is not excluded by specific name or specific description in the polity.
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 Polity Schedule.
Material and substantial duties of your occupation are defined as those duties which:
• are normally required to perform your regular occupation; and
• cannot be reasonably modified or omitted.
Performing your occupation at a particular work site or in a particular building is not a material and substantial duty of your
occupation, provided that your employer will allow you to perform your occupation at a different work site or in a different
building.
Mental or nervous disorder means a neurosis, psychoneurosis, psychopathy, psychosis or mental or emotional disease or disorder of
any kind.
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 regular occupation for 20 hours or more per week;
• you are able to work at your regular occupation or any other occupation for less than 20 hours per week;
DIS 1000-O-TX 3 59095-1
• 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.
Regular occupation means the occupation you are routinely performing at the time your disability begins or if none, the last
occupation you had routinely performed prior to the time your disability began.
Totally disabled means you are:
• unable to perform the material and substantial duties of your regular occupation;
• not in fact, working at any occupation for wage or profit; and
• under the regular and appropriate care of a doctor, unless the doctor states that continued treatment in the future would be of
no benefit to you.
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.
(4) EXCLUSIONS AND LIMITATIONS
We will not pay benefits for losses that are caused by or are the result of your:
• 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 polity as the result of a normal pregnanry, including
Cesarean. Complications of pregnanry 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;
• committing or attempting to commit a felony or engaging in an illegal occupation and/or being incarcerated in a penal
institution due to a felony conviction;
• being intoxicated or under the influence of any narcotic unless administered on the advice of a doctor;
• having apre-existing condition as described and limited by 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.
(5) Renewability. Your policy is 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 polity was issued.
Policy anniversary date occurs annually at noon on the same date and in the same month as the date for which we first received
premium.
(6) Premiums:
Premiums are subject to change. The premium can only be changed if we change it on all policies of this kind in force in the state
where the polity was issued.
Monthly Premium: $ Annual Premium: $ Plan:
Coverage: Individual
After the first premium, is the premium is not paid when it is due, it can be paid during the next 31 days. These 31 days are
called the grace period. During the grace period, the policy will stay in force. If the premium is not paid before the grace period
ends, the coverage provided by the policy will terminate at the end of the grace period.
DIS 1000-O-TX 4 59095-1
ion Insurance.
Total Disability Definition
• Unable to perform the material and substantial duties of your regular occupation;
• Not, in fact, working at any occupation for wage or profit; and
• Under the regular and appropriate care of a doctor; unless the doctor states that continued treatment in the future
would be of no benefit to you.
Partial Disability* Definition
• You are unable to perform the material and substantial duties of your regular occupation for 20 hours or more per
week;
• You are able to work at your regular occupation or any other occupation 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.
Pre-Existing Condition
You have apre-existing condition if 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 apre-existing condition, Colonial will not pay for any disability period if it begins during the first
12 months the policy is in force.
Waiver of Premium
After you have been totally disabled or qualify for partial disability benefits as a result of a covered accident or a covered
sickness for more than 90 consecutive days while your policy is in effect, or after the elimination period, whichever is greater,
we will waive the premium for this policy up to the maximum benefit period as long as you remain disabled.
Please refer to the "What Is Not Covered by This Policy"section of the Outline of Coverage.
This brochure is not complete without the corresponding Outline of Coverage form DIS 1000-O-TX or DIS 1000-3M-O-TX,
whichever is applicable.
Benefit Worksheet For use by c°l°nZa~nepresentatZVe
Monthly BenefitAmount ^ Flexible Benefit
Total Disability
On-Job Accident and On-Job Sickness Amount $
Off-Job Accident and Off-Job Sickness Amount $
Partial Disability (SO% of Total Disability Amount)
Elimination Period
Sickness
Benefit Period
Total Disability: months
Partial Disability: 3 months
Premium Per Pay Period $
The premium will vary based on benefits selected.
The Colonial Adv~znt~zge
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> A leader in the supplemental insurance industry.
> Communications and benefits education to help you understand the benefits you have-and the benefits
you may need.
> Prompt, accurate and courteous customer service.
> Broad selection of products to help meet your individual needs, with premiums paid through convenient
payroll deduction.
Learn more about these and all of the advantages Colonial has to offer at www.coloniallife.com.
Colonial Supplemental Insurance products are underwritten by:
Colonial Life & Accident Insurance Company
1200 Colonial Life Boulevard, Columbia, South Carolina 29210
www. co to niallife. 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 fra~Pens next"and the logo, separately and in combination, are registered service marks of Colonial Life & Accident Insurance Company. All rights reserved.
I I /06
59212-4
~~~'
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...Colonial's Cancer Insurance
The risk of developing cancer, unfortunately, is very real.
In the U:S., men havea l in 2 lifetime risk of developing cancer, and for-women the risk is 1 in 3.1
As serious as the threat of .cancer may be, new and improved medical treatments are being
introduced, and studies are showing that regular screening tests can detect some cancers in the
early stages.'
The five-year relative survival rate for screening-accessible cancers is about 85 percent. If all
.Americans participated in regular cancer screenings, this rate could increase to 95 percent.l But
with high technology come high costs. The American Cancer Society reports that cancer costs
Americans mare than $172 billion annuallya And much of that amount is considered indirect or
hidden. costs. not covered by major medical plans.
Colonial Supplemental Insurance cancer
coverage offers the protection you need
to concentrate on what is most important -
your care.
Direct Costs
Features of Colonial's Cancer Insurance: Most Major Medical
Plans Cover:
1. Pays regardless of any other insurance you have with other .I
insurance companies.
2. Provides a cancer screening benefit that you can use even Y'
if you are never diagnosed with cancer. r
3. Guaranteed renewable as long as premiums are paid	Hospital charges
when due.	Surgeon fees
	• Physician fees
4. Benefits paid directly to you unless you specify otherwise.	Medication and
	drug costs
5. You can take your coverage with you even if you change	Radiological fees
• Loss of wages or
salary
• Deductibles or
coinsurance
• Travel expenses to
and from treatment
1
jobs or leave your employer. Nursing costs centers
• Lodging and meals
6. Flexible coverage options for employees and their families. Child care
Indirect Costs
You Pay:
- Rider Benefits
This rider pays a lump sum benefit for the initial (first) diagnosis of internal (not skin) cancer that occurs after
the waiting period. Use the benefit to help pay for deductibles and coinsurance on your major medical insurance
or settle any outstanding debts.
Rider Features
• Guaranteed renewable as long as your cancer insurance policy is in force and you pay your premiums for
your rider.
• Covers the same family members as your cancer insurance policy.
• Pays benefits regardless of any other insurance you have with other insurance companies.
• Pays benefits directly to you, unless you specify otherwise.
This flier is not complete without the C1000 (including state abbreviations where applicable) brochure.
Premium Per Pay Period _______________ Monthly Premium
Benefit Amount Selected
COLONIAL
SUPPLEMENTAL INSURANCE
for what happens next
61589- I -TX
The diagnosis of internal cancer can be an upsetting time. You do not need to add financial worry to what is
already a very difficult situation. When you add an Initial Diagnosis of Cancer rider to your Colonial cancer
insurance policy, you add a little more financial protection at the point you or an insured family member is
diagnosed with internal cancer-a time before many medical costs are incurred.
coloniallife.com
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY
P.O. Box 1365, Columbia, South Carolina 29202
SPECIFIED DISEASE COVERAGE
INITIAL DIAGNOSIS OF CANCER RIDER
OUTLINE OF COVERAGE
(Applicable to Rider Form R-C1000-Indx, including state abbreviations where applicable)
THIS RIDER IS NOT ATTACHED TO A MEDICARE SUPPLEMENT POLICY.
If you are eligible for Medicare, review the Guide to Health Insurance for
People with Medicare available from the Company.
(1) Read your rider carefully. This outline provides a very brief description of the important features of
your rider. This is not an insurance contract and only the actual policy and rider provisions will control.
The policy and rider set forth in detail the rights and obligations of both you and us. It is, therefore,
important that you READ YOUR POLICY AND RIDER CAREFULLY.
(2) Cancer. Your rider is designed to provide coverage ONLY for cancer, subject to any limitations
in your rider. The rider does not provide coverage for basic hospital, basic medical-surgical or major
medical expenses.
(3) BENEFIT:
Initial Diagnosis of Cancer
We will pay this benefit when you are diagnosed for the first time as having internal (not skin) cancer.
This benefit is payable once per person insured under the policy and identified on the Schedule Page.
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 to be construed as Cancer for the
purposes of this rider.
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.
Waiting Period: means the first 30 days following each insured person's coverage effective date
during which time no benefits are payable.
(4) LIMITATIONS: The rider provides benefits only if the date of diagnosis of cancer is while your rider
is in force and after the waiting period has been satisfied. We will not pay this benefit if the first date of
diagnosis of your cancer is before the end of the waiting period.
coloniallife.com
(5) Renewability. Your rider is guaranteed renewable for as long as the policy to which it is attached
is in force. This means you have the right to keep the policy in force with the same benefits, except
that we may discontinue or terminate the policy if: (1) You fail to pay premiums as required under the
policy; or (2) You have performed an act or practice that constitutes fraud, or have made an intentional
misrepresentation of material fact, relating in any way to the policy, including claims for benefits under
the policy.
(6) Premium: Premiums are subject to change. Your premium can be changed only if we change it
on all rider of this kind in force in the state where your rider was issued.
Monthly Premium $
Annual Premium $
Plan
Coverage: Individual
One-parent family
Two-parent family
Premiums must be paid to us at our home office when they are due. If you do not pay a premium when
it is due you can pay it during the next thirty-one days. These thirty-one days are called the grace
period; however, if premiums are not paid by the end of the grace period the rider will terminate and
your coverage will end.
R-C1000-Indx-O-TX
Rider Benefits
After the waiting period and when internal cancer is first diagnosed, we will pay a progressive payment
of $50 for each month your rider has been in force after the waiting period and before internal (not skin)
cancer is first diagnosed.
Rider Features
• Guaranteed renewable as long as your cancer insurance policy is in force and you pay your premiums
for your rider.
• Covers the same family members as your cancer insurance policy.
• Pays benefits regardless of any other insurance you have with other insurance companies.
• Pays benefits directly to you> unless you specify otherwise.
This flier is not complete without the C1000 (including state abbreviations where applicable)
brochure.
	Premium Per Pay Period _____________ Monthly Premium ________________
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COLONIAL
o	SUPPLEMENTAL INSURANCE
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61591-TX
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A diagnosis of cancer is not only emotionally draining, it can be financially draining as welt. to neap
ease your financial worries during a difficult period, the progressive payment rider is payable when
internal (not skin) cancer is first diagnosed. You get to choose how to use the money, whether it's to pay
for outstanding debts or to help protect your quality of life.
coloniallife.com
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY
P.O. Box 1365, Columbia, South Carolina 29202
SPECIFIED DISEASE COVERAGE
INITIAL DIAGNOSIS OF CANCER PROGRESSIVE PAYMENT RIDER
OUTLINE OF COVERAGE
(Applicable to Rider Form R-C1000-Prog, including state abbreviations where applicable)
THIS RIDER IS NOT ATTACHED TO A MEDICARE SUPPLEMENT POLICY.
If you are eligible for Medicare, review the Guide to Health Insurance for
People with Medicare available from the Company.
(1) Read your rider carefully. This outline provides a very brief description of the important features
of your rider. This is not an insurance contract and only the actual policy and rider provisions will
control. The policy and rider set forth in detail the rights and obligations of both you and us. It is,
therefore, important that you READ YOUR POLICY AND RIDER CAREFULLY.
(2) Cancer. Your rider is designed to provide coverage ONLY for cancer, subject to any limitations
in your rider. T#~e rider does not provide coverage for basic hospital, basic medical-surgical or major
medical expenses. Coverage is provided for the benefits outlined in paragraph (3). The benefits
described in paragraph (3) may be limited by paragraph (4).
(3) BENEFIT:
Initial Diagnosis of Cancer Progressive Payment Rider
Amount: $50 for each month in force after the waiting period
We will pay a progressive payment in the amount indicated above for each month the rider has been
in force after the waiting period and before internal (not skin) cancer is first diagnosed. A month is 30
days. We will not pay this benefit for skin cancer.
The Progressive Payment stops adding up for any person insured by the policy on the policy
anniversary after his 65th birthday. We will pay this benefit only once for each person insured by this
rider.
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 to be construed as Cancer for the
purposes of this rider.
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.
Waiting Period: means the first 30 days following each insured person's coverage effective date
during which time no benefits are payable.
R-C 1000-Prog-O-TX
Colonial Supplemental Insurance products are underwritten by:
Colonial Life & Accident Insurance Company
1200 Colonial Life Boulevard, Columbia, South Carolina 29210
www. coloniallife. com
©2004 Colonial Life & Accident Insurance Company.
Colonial Supplemental Insurance is the marketing brand of Colonial Life & Accident Insurance Company. "Colonial Supplemental Insurance," 'fnr what happeru next"and the logo, separately and in
combina[ion, are regis[ered service marks of Colonial Life & Acciden[ Insurance Company. All rights reserved.
coloniallife.com
(4) LIMITATIONS: The rider provides benefits only if the date of diagnosis of cancer is while your
rider is in force and after the waiting period has been satisfied. We will not pay this benefit if the first
date of diagnosis of your cancer is before the end of the waiting period.
(5) Renewability: Your rider is guaranteed renewable for as long as the policy to which it is
attached is in force. This means you have the right to keep the policy in force with the same benefits,
except that we may discontinue or terminate the policy if: (1) You fail to pay premiums as required
under the policy; or (2) You have performed an act or practice that constitutes fraud, or have made an
intentional misrepresentation of material fact, relating in any way to the policy, including claims for
benefits under the policy.
(6) Premium: Premiums are subject to change. Your premium can be changed only if we change it
on all rider of this kind in force in the state where your rider was issued.
Monthly Premium $
Annual Premium $
Plan
Coverage: Individual One-parent family Two-parent family
Premiums must be paid to us at our home office when they are due. If you do not pay a premium
when it is due you can pay it during the next thirty-one days. These thirty-one days are called the
grace period; however, if premiums are not paid by the end of the grace period the rider will terminate
and your coverage will end.
R-C 1000-Prog-O-TX
Specified Diseases
• 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
• 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 Disease)
• Yellow Fever
Rider Benefits
If you incur charges for and are confined to a hospital for treatment of one of the specified diseases listed
above, we will pay a benefit of $300 per day.
Rider Features
• Guaranteed renewable as long as your cancer insurance policy is in force and you pay your premiums for
your rider.
• Covers the same family members as your cancer insurance policy.
• Pays benefits regardless of any other insurance you have with other insurance companies.
• Pays benefits directly to you, unless you specify otherwise.
This flier is not complete without the C1000 (including state abbreviations where applicable) brochure
0
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Premium Per Pay Period
• 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
Monthly Premium
COLONIAL
SUPPLEMENTAL I N S U R A N C E
for what happens next
61590-TX
There are many types of diseases besides cancer that require hospital confinement for treatment. When
you add this rider to your Colonial cancer insurance policy, you add valuable coverage related to the
following specified diseases.
coloniallife.com
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY
P.O. Box 1365, Columbia, South Carolina 29202
SPECIFIED DISEASE COVERAGE
SPECIFIED DISEASE HOSPITAL CONFINEMENT RIDER
OUTLINE OF COVERAGE
(Applicable to Rider Form R-C1000-SpDis, including state abbreviations where applicable)
THIS RIDER IS NOT ATTACHED TO A MEDICARE SUPPLEMENT POLICY.
If you are eligible for Medicare, review the Guide to Health Insurance for
People with Medicare available from the Company.
(1) Read your rider carefully. This outline provides a very brief description of the important features of
your rider. This is not an insurance contract and only the actual policy and rider provisions will control.
The policy and rider set forth in detail the rights and obligations of both you and us. It is, therefore,
important that you READ YOUR POLICY AND RIDER CAREFULLY.
(2) Specified Disease. Your rider is designed to provide coverage ONLY for specified disease,
subject to any limitations in your rider. The rider does not provide coverage for basic hospital, basic
medical-surgical or major medical expenses.
(3) BENEFIT:
SPECIFIED DISEASE HOSPITAL CONFINEMENT $300/day
We will pay this benefit for hospital confinement if you incur charges for and are confined to a hospital
for the treatment of a specified disease listed below if:
• the first date of diagnosis of the specified disease is after the waiting period;
• the first date of diagnosis of the specified disease is while this rider is in force;
• you are confined to a hospital for treatment of a specified disease beginning while this rider is in
force; and -
• the specified disease is not excluded by name or specific description in this rider.
Covered Specified Diseases:
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
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 Disease)
Myasthenia Gravis Yellow Fever
R-C 1000-SpDis-O-TX
coloniallife.com
We will pay up to a maximum of $125,000 during your lifetime for hospital confinements related to the
treatment of the specified diseases listed above.
DEFINITIONS:
Confinement: means the assignment to a bed as a resident inpatient in a hospital on the advice of
a physician or confinement in an observation unit within a hospital for a period of no less than 20
continuous hours on the advice of a physician.
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 apre-arranged basis X-ray equipment, a laboratory, and an operating
room where surgical operations take place. A hospital does not include a nursing home, an extended
care facility, a rest home, a home for the aged, a skilled nursing facility, a rehabilitation center, or a place
for alcoholics or drug addicts.
Waiting Period: means the first 30 days following each insured person's coverage effective date during
which time no benefits are payable.
(4) LIMITATIONS:-The rider provides benefits only if the date of diagnosis of specified disease is while
your rider is in force and after the waiting period has been satisfied. We will not pay this benefit if the
first date of diagnosis of your specified disease is before the end of the waiting period.
(5) Renewability. Your rider is guaranteed renewable for as long as the policy to which it is attached
is in force. This means you have the right to keep the policy in force with the same benefits, except
that we may discontinue or terminate the policy if: (1) You fail to pay premiums as required under the
policy; or (2) You have performed an act or practice that constitutes fraud, or have made an intentional
misrepresentation of material fact, relating in any way to the policy, including claims for benefits under
the policy. -
(6) Premium: Premiums are subject to change. Your premium can be changed only if we change it on
all rider of this kind in force in the state where your rider was issued.
Monthly Premium $ Annual Premium $ Plan
Coverage: Individual One-parent family Two-parent family
Premiums must be paid to us at our home office when they are due. If you do not pay a premium
when it is due you can pay it during the next thirty-one days. These thirty-one days are called the
grace period; however, if premiums are not paid by the end of the grace period the rider will terminate
and your coverage will end.
R-C 1000-SpDis-O-TX
coloniallife.com
Colonial Supplemental Insurance products are underwritten by:
Colonial Life & Accident Insurance Company
1200 Colonial Life Boulevard, Columbia, South Carolina 29210
www. coloniallife. tom
©2004 Colonial Life & Accident Insurance Company.
Colonial Supplemental Insurance is the marketing brand of Colonial Life & Accident Insurance Company "Colonial Supplememal Insurance," for what happens next"and the logo, separately and in
combination, are registered service marks of Colonial Life & Accident Insurance Company All rights reserved.
coloniallife.com
.~ x #r
x" About 1,372,910 new cancer cases are expected
to be diagnosed in 2005.'
~~,.
Cancer Screening Benefit Tests*
• Pap Smear
• ThinPrep Pap Test
• CA125 (Blood test for ovarian cancer)
• Mammography
• Breast Ultrasound
• CA 15-3 (Blood test for breast cancer)
• PSA (Blood test for prostate cancer)
• Chest X-ray
• Biopsy of Skin Lesion
• Colonoscopy
• Virtual Colonoscopy
• Hemoccult Stool Analysis
• Flexible Sigmoidoscopy
• CEA (Blood test for colon cancer)
• Bone Marrow Aspiration/Biopsy
• Thermography
• Serum Protein Electrophoresis (Blood test for Myeloma)
See the Outline of Coverage for Cancer Screening Benefits
payable, as well as exclusions and limitations of this coverage.
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, 1-800-325-4368, with the medical information.
Additional Invasive Diagnostic Procedure
If abnormal results are received from a Cancer Screening Benefit
test.
Inpatient Benefits
• Hospital Confinement
. Hospital Confinement in a U.S. Government Hospital
. Ambulance
• Air Ambulance
• Private Full-Time Nursing Services
• Attending Physician
Treatment Benefits (In-or Outpatient)
. Radiation/Chemotherapy
. Antinausea Medication
• Blood/Plasma/Platelets/Immunoglobulins
• Experimental Treatment
• Hair Prosthesis/External Breast/Voice Box Prosthesis
• Supportive/Protective Care Drugs and Colony Stimulating Factors
. Medical Imaging Studies
• Bone Marrow Stem Cell Transplant
. Peripheral Stem Cell Transplant
Transportation/Lodging Benefits
. Transportation
• Companion Transportation
• Lodging
Surgical Procedures Benefits
• Surgical Procedures (including skin cancer)
• Anesthesia (including skin cancer)
• Second Medical Opinion
• Reconstructive Surgery
• Prosthesis/Artificial Limb
• Outpatient Surgical Center
Extended Care Benefits
• Skilled Nursing Care Facility
• Family Care
• Hospice
• Home Health Care Service
. Waiver of Premium
Initial Diagnosis of Skin Cancer
We will pay this benefit for the first diagnosis of skin cancer.
'Cancer Facts & Figures,American Cancer Society, 2005.
This policy has limitations that may affect benefits payable.
Most benefits require that a charge be incurred. See the Outline
of Coverage for complete details of benefits, exclusions and
limitations. Policy may not be available and may vary by state.
We will pay benefits if certain routine cancer screening tests
are performed or if cancer is diagnosed after the waiting
period and while your policy is in force.
coloniallife.com
Benefit Worksheet
rut uee vy ~,ucuricue re~re~erieuecve
^ Flexible Benefit
Coverage: (check one)
^ Employee ^ Employee and Dependent Children
(Individual) (One-Parent Family)
Premium per Pay Period $_ ________
The premium will vary based on level of coverage and
benefits selected.
^ Employee, Spouse and Dependent Children
(Two-Parent Family)
Monthly Premium for Policy $
This brochure highlights the benefits o f policy form C1000-TX.
This is not an insurance contract and only the actual policy
provisions will control. The policy sets forth in detail the rights
and obligations o f both you and us. It is, there fore, important
that you READ YOUR POLICY CAREFULLY.
This brochure is not complete without the Outline of Coverage
(form number C1000-O-TX).
The Colonial Advantage
A leader in the supplemental insurance industry.
Communications and benefits education to help you
understand the benefits you have -and the benefits you
may need.
Prompt, accurate and courteous customer service.
Broad selection of products to help meet your individual
needs, with premiums paid through convenient payroll
deduction.
Learn more about these and all of the advantages Colonial
has to offer at www.coloniallife.com.
COLONIAL
S•UPPLEM ENTAL INSURANCE
for what happens next °
^
©2005 Colonial Life & Accident Insurance Company. D
Colonial Supplementa( Insurance is the marketing brand of Colonial Life & [Zi
Accident Insurance Company. "Colonial Supplemental Insurance," far what hafpens a
next"and the logo, separately and in combination, are registered service marks of ~
Colonial Life & Accident Insurance Company. All rights reserved. ~
O
O~
to
Co
X
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY
P.O. Box 1365, Columbia, South Carolina 29202
1-800-325-4368
SPECIFIED DISEASE COVERAGE
OUTLINE OF COVERAGE (Applicable to Policy Form C1000-TX)
This is not a policy of workers' compensation insurance. The employer does not become a
subscriber to the workers' compensation system by purchasing this policy, and if the
employer is anon-subscriber, the employer loses those benefits which would otherwise
accrue under the workers' compensation laws. The employer must comply with the workers'
compensation law as it pertains to non-subscribers and the required notifications that must
be filed and posted.
THIS POLICY IS NOT A MEDICARE SUPPLEMENT POLICY.
If you are eFigible for Medicare, review the Guide to Health Insurance for
People with Medicare available from the Company.
(1) 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.
(2) Cancer. Your policy is designed to provide coverage ONLY for cancer and cancer screening
procedures, subject to any limitations in your policy. The policy does not provide coverage for basic
hospital, basic medical-surgical or major medical expenses. Coverage is provided for the benefits
outlined in paragraph (3). The benefits described in paragraph (3) may be limited by paragraph (4).
(3) CANCER SCREENING BENEFITS
Cancer Screening/ $75/year
Wellness Benefit -Part 1
We will pay this benefit once per calendar year for each insured that has a covered cancer screening
test performed. We will .pay this benefit regardless of the results of the test. No lifetime limit.
Cancer Screening/ $75/year
Wellness Benefit -Part II
We will pay this benefit for each insured that incurs charges for and has an additional invasive
diagnostic procedure performed as the result of an abnormal -cancer screening test as shown in Part
I. Invasive diagnostic means a diagnostic test which requires an incision or an insertion of an
instrument into the body. We will pay this benefit regardless of the outcome of tests in Part II. No
lifetime limit.
C1000-O-TX 1 60162
CANCER BENEFITS
AIR AMBULANCE $1,000/trip
We will pay this benefit if you incur charges for a professional air ambulance to transport you on the
advice of a doctor to or from a hospital where you are confined as an inpatient for the treatment of
cancer. No lifetime limit other than two trips each time you are confined as an inpatient for the
treatment of cancer.
AMBULANCE $200/trip
We will pay this benefit if you incur charges for and are transported by a professional ambulance
service to or from a hospital where you are confined as an inpatient for the treatment of cancer. No
lifetime limit other than two trips each time you are confined as an inpatient for the treatment of
cancer.
ANESTHESIA 25% of the amount of the Surgery benefit paid;
Local anesthesia: $30/procedure
We will pay 25% of the amount of the surgery benefit paid if you incur charges for and receive
general anesthesia administered by an anesthesiologist or Certified Registered Nurse Anesthetist
during a surgical procedure performed for the treatment of cancer. If you receive and incur charges
for local anesthesia during a surgical procedure performed for the treatment of cancer, we will pay the
amount indicated above. If you have more than one surgical procedure performed at the same time,
we will pay the benefit for the procedure performed which has the highest dollar value. No lifetime
limit.
ANTINAUSEA MEDICATION See below
$40/day up to $160/month for medication administered in a doctor's office, clinic or hospital;
$40/day up to $160/month for each day you have a prescription filled
We will pay this benefit if you incur charges for medication that is prescribed by your doctor for
nausea as a result of radiation and/or chemotherapy treatments. We will only pay one antinausea
medication benefit per day, regardless of the number of medications you receive in the same day. No
lifetime limit.
ATTENDING PHYSICIAN $20/day
We will pay this benefit for each day you use the services of and incur charges for an attending
physician while you are confined to the hospital for cancer. No lifetime limit.
BLOOD/PLASMA/ $200/day, up to $10,000/calendar year
PLATELETS/
IMMUNOGLOBULINS
We will pay this benefit for each day you incur charges for and receive a transfusion of
blood/plasma/platelets/immunuglobulins during the treatment of cancer. No lifetime limit.
BONE MARROW STEM See below
CELL TRANSPLANT
$10,000/lifetime if you incur charges for and receive a bone marrow stem cell transplant for the
treatment of cancer.
$ 1,000/lifetime if you incur charges for bone marrow stem cell donation in connection with the
transplant procedure.
We will pay these benefits only once per lifetime for each insured. Benefits for a peripheral stem cell
transplant are only available under the Peripheral Stem Cell Transplant benefit.
C1000-O-TX 2 60162
~i~
COMPANION $0.50/mile up to $1,500 per round trip
TRANSPORTATION
We will pay this benefit for one companion to accompany you to another city (more than 50 miles one
way from the city where you live) where you are receiving treatment for internal cancer on the advice
of a doctor. We will pay this benefit if your companion incurs charges for commercial travel (train,
plane, or bus) to and from this destination or for non-commercial travel (use of personal car). If the Air
Ambulance or Transportation benefit is paid, the Companion Transportation benefit will not exceed
the greater of the other two benefits paid. If you and your companion travel together in a personal car,
we will only pay the Transportation benefit or the Companion Transportation benefit, but not both. No
lifetime limit.
EXPERIMENTAL $300/day; up to lifetime maximum of $10,000
TREATMENT
We will pay this benefit if you incur charges for receiving hospital, medical or surgical care in
connection with experimental treatment of internal (not skin) cancer prescribed by a physician.
Treatment must be received in an experimental cancer treatment program within the United States.
Payment of this benefit is in place of payment of any other benefit for the same covered treatments.
FAMILY CARE $60/day
We will pay this benefit for each day your insured child incurs charges for receiving treatment for
internal (not skin) cancer on an inpatient or outpatient basis from a licensed medical practitioner. This
benefit is paid in addition to any other applicable benefits. Self-administered treatment or treatment
within the home is excluded. No lifetime limit.
HAIR/EXTERNAL BREAST/ $200/calendar year
VOICE°BOX PROSTHESIS
We will pay this benefit if you incur charges for receiving a Hair, External Breast, or Voice box
Prosthesis needed as a direct result of cancer. No lifetime limit.
HOME HEALTH CARE $75/day
SERVICES
We will pay this benefit if you incur charges for and receive covered services provided by a home
health agency when required by your doctor instead of confinement in a hospital. We will pay the
greater of: 1) 30 days per calendar year; or 2) twice the number of days you were confined to a
hosptal``during acalendar year for the treatment of cancer. We will not pay this benefit for
housekeeping services, childcare or food services other than dietary counseling. No lifetime limit.
HOSPICE $70/day
We will pay this benefit for each day you incur charges for and receive covered care provided by a
hospice as the result of cancer. We will pay this benefit if a doctor determines that cancer treatments
are no longer of benefit to you, and you are expected to live for 6 months or less. We will not pay this
benefit if you are confined to a hospital, to a U.S. Government Hospital or to a skilled nursing care
facility. No lifetime limit.
HOSPITAL CONFINEMENT $200/day for first 30 days; $400/day for 31st day thereafter
We will pay this benefit if you incur charges for confinement to a hospital (including intensive care) for
the treatment of cancer. If less than 30 days separates periods of confinement, we will consider
second and subsequent periods to be continuations of the prior period. We will not pay this benefit if
you are confined to a U.S. Government Hospital. No lifetime limit.
C 1000-O-TX 3 60162
~~~
HOSPITAL CONFINEMENT $200/day for first 30 days; $400/day for 31st day thereafter
IN A U.S. GOVERNMENT
HOSPITAL
We will pay this benefit if you are confined to a U. S. Government Hospital (including intensive care)
for the treatment of cancer. This benefit is payable in place of all other benefits except: Cancer
Screening, Air Ambulance, Ambulance, Companion Transportation, Family Care, Hair
Prosthesis/External Breast Prosthesis/Voice Box Prosthesis, Lodging, Skilled Nursing Care Facility,
Skin Cancer Initial Diagnosis, Transportation, and Waiver of Premium. If less than 30 days separates
periods of confinement, we will consider second and subsequent periods to be continuations of the
prior period. No lifetime limit.
LODGING $75/day up to 70 days per calendar year
We will pay this benefit for each day that you or your adult companion incurs charges for lodging
while you are being treated for cancer more than 50 miles from your residence. No lifetime limit.
MEDICAL IMAGING $250/study up to $500 per calendar year
STUDIES
We will pay this-benefit if you incur charges for having a covered medical image study performed that
was prescribed by your doctor for the treatment of internal (not skin) cancer and performed after the
initial diagnosis of cancer. No lifetime limit.
OUTPATIENT SURGICAL $200/day up to $600 per calendar year
CENTER
We will pay this benefit if you incur charges for having surgery performed at an outpatient surgical
center for the treatment of internal (not skin) cancer. This does not include surgery in the emergency
room or while confined to the hospital. No lifetime limit.
PERIPHERAL STEM $5,000/lifetime
CELL TRANSPLANT
We will pay this benefit if you incur charges for receiving a peripheral stem cell transplant for the
treatment of cancer. We will pay this benefit only once per lifetime for each person insured under the
policy.
PRIVATE FULL-TIME $150/day
NURSING SERVICES
We will pay this benefit if you use and incur charges for full-time nursing services (at least 8 hours
during any 24-hour period), required and authorized by your doctor and performed by a registered, a
licensed practical or a licensed vocational nurse while you are confined to a hospital for the treatment
of cancer. No lifetime limit.
PROSTHESIS/ $3,000/device or limb, up to $6,000/lifetime
ARTIFICIAL LIMBS
We will pay this benefit if you incur charges for a surgically implanted prosthetic device or artificial
limb received as a direct result of cancer surgery. We will pay for no more than one of the same type
of prosthetic device or artificial limb per site.
C1000-O-TX 4 60162
RADIATION/ See below
CHEMOTHERAPY
We will pay the amount indicated below if you incur charges for and receive covered radioactive or
chemical treatments which are approved for destruction of malignant cells during the treatment of
internal (not skin) cancer by the United States Food and Drug Administration and are prescribed by
your doctor for the treatment of cancer. No lifetime limit.
Chemotherapy:
• $200/day for each day you receive chemotherapy treatments injected by medical personnel in a
doctor's office, clinic or hospital.
• $200/day for each day you have a prescription filled for oral chemotherapy up to a monthly
maximum of $800.
• $200/day for each day you have a prescription filled for topical chemotherapy up to a monthly
maximum of $800.
• $200/day for each day you have a pump for chemotherapy initially filled and any day the pump is
refilled up to a monthly maximum of $800.
• $200/day for each day you have chemotherapy injected by yourself or someone other than
personnel in a doctor's office, clinic or hospital, up to a monthly maximum of $1,600.
• $200/day for_each day you receive chemotherapy by a delivery method other than the ones
mentioned above up to a monthly maximum of $800.
Radiation:
• $200/day for each day you receive radioactive treatments delivered by medical personnel in a
doctor's office, clinic or hospital.
• $200/day for each day you receive radioactive treatments by a delivery method other than the one
mentioned above up to a monthly maximum of $800.
We will only pay one radiation or chemotherapy benefit per day regardless of the number of
radioactive or chemotherapy treatments you receive on the same day.
RECONSTRUCTIVE $40/surgical unit up to a maximum of $2,500 per procedure
SURGERY including general anesthesia
We will pay this benefit if you incur charges for a reconstructive surgical procedure that requires an
incision, is performed by a doctor for the treatment of cancer and is due to internal (not skin) cancer.
We will pay up to 25% of the Reconstructive Surgery benefit if you have general anesthesia
administered during a reconstructive surgical procedure. We will pay no more than the maximum
amount indicated above per procedure. We will pay for no more than two procedures per site. No
lifetime limit.
SECOND MEDICAL $300/malignant condition
OPINION
We will pay this benefit if you choose to obtain and incur charges for the opinion of a second
physician on recommended cancer surgery or treatment following the positive diagnosis of internal
(not skin) cancer. We will pay this benefit only once for each cancerous condition. This benefit is not
payable for skin cancer treatment or reconstructive surgery.
C 1000-O-TX 5 60162
® ~ ~~~
SKILLED NURSING $100/day
CARE FACILITY
We will pay this benefit for each day you are confined and incur charges for a skilled nursing care
facility if your confinement begins within 14 days after you are released from a hospital. We will pay
this benefit for no more than the number of days we paid you the Hospital Confinement or Hospital
Confinement in a U.S. Government Hospital benefit for your most recent confinement. No lifetime
limit.
SKIN CANCER INITIAL $300/lifetime
DIAGNOSIS
We will pay this benefit when you are diagnosed for the first time as having skin cancer. We will pay
this benefit only once per lifetime for each person insured by this policy.
SUPPORTIVE OR $100/day up to $800 calendar year maximum
PROTECTIVE CARE
DRUGS AND
COLONY STIMULATING
FACTORS
We will pay this benefit if you incur charges for and receive supportive or protective care drugs and/or
colony stimulating factors prescribed by your doctor for the treatment of cancer. No lifetime limit.
SURGICAL $50/unit up to $3,000/procedure
PROCEDURES
We will pay this benefit if you incur charges for and receive surgical procedures performed for
treatment of cancer. If you have more than one surgical procedure performed at the same time and
through the same incision, we will consider them to be one procedure and pay the benefit that has the
highest dollar value. If you have more than one surgical procedure performed at the same time but
through different incisions, we will pay each one. No lifetime limit.
TRANSPORTATION $0.50/mile, up to $1,500 per round trip
We will pay this benefit if you incur charges for travel to another city (more than 50 miles one way
from the city where you live) to receive treatment for cancer on the advice of your doctor. We will pay
this for travel to and from your destination for commercial travel (train, plane or bus); or for
noncommercial travel (use of personal car). No lifetime limit.
WAIVER OF PREMIUM
If the named insured becomes disabled because of cancer for longer than 3 continuous months (90
days), and the first date of diagnosis is after the waiting period and while this policy is in force, you
will not be required to pay premiums to keep your policy in force as long as you are disabled. A month
is 30 days. Disabled means you are unable to work at any job for which you are qualified by reason of
education, training or experience; you are not, in fact, working at any job for pay or benefits; and you
are under the care of a doctor for the treatment of cancer. If you do not have a job, we will not require
you to pay premiums only as long as you are kept at home because of your cancer and are under the
care of a doctor. No lifetime limit.
DEFINITIONS
Bone Marrow Stem Cell Transplant: means the harvesting, storage, and reinfusion of bone marrow
stem cells from a matched donor or yourself, performed under general anesthesia or intravenous (IV)
sedation.
C 1000-O-TX 6 60162
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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 to be construed as cancer for the
purposes of this policy.
Cancer Screening Test: means a biopsy of skin lesion, bone marrow aspiration/biopsy, breast
ultrasound, CA 15-3 (blood test for breast cancer),CA-125 (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, or virtual colonoscopy.
Confined or Confinement: means the assignment to a bed as a resident inpatient in a hospital on
the advice of a physician or confinement in an observation unit within a hospital for a period of no less
than 20 continuous hours on the advice of a physician.
Date of Diagnosis: is the day the tissue specimen, blood sample(s), and/or titer(s) are taken upon
which the first diagnosis of cancer is based.
Dependent Children: means the named insured's natural children; step-children; grandchildren who
are dependents for income tax purposes; adopted children; children for whom he has filed a suit
seeking the adoption of the children; children whom he is required to insure under a medical support
order issued under Section 14.061, Family Code, or enforceable by a court in this state; or children in
his custody under a temporary court order that grants him conservatorship of the children. Such
children must be: unmarried; dependent on you or your spouse for support; and younger than age 25.
Doctor or Physician: means a person, other than yourself or a family member, who is licensed by
the state to practice a healing art, performs services for you which are allowed by his/her license and
performs services for which benefits are provided by this policy.
Experimental treatment: means drugs or chemical substances that are pending approval by the
United States Food and Drug Administration for use in the treatment of cancer and surgery or therapy
endorsed by either the National Cancer Institute or the American Cancer Society for experimental
studies.
Family Member: means your spouse, son, daughter, mother, father, sister or brother.
Hospice: means an organization that provides care for the terminally ill that is: licensed by a
governmental agency; accredited by the Joint Commission on Accreditation of Hospitals; or qualified
to receive benefit payments from Medicare or Medicaid. The organization must have on its staff at
least one doctor and one registered nurse and must keep complete medical records for each patient.
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 apre-arranged basis X-ray equipment, a laboratory, and an
operating room where surgical operations take place. A hospital does not include a nursing home, an
extended care facility, a skilled nursing care facility; a rest home, a home for the aged, an assisted
living center, a hospice care facility, a rehabilitation center, or a place for alcoholics or drug addicts.
Alcoholism and drug addiction are not covered by this policy.
C 1000-O-TX 7 60162
Oral Chemotherapy: means chemotherapy taken by mouth.
Outpatient Surgical Center: means a place that is equipped to perform outpatient surgical
procedures performed by qualified physicians; provides anesthesia, other than local, by a licensed
anesthesiologist or Certified Registered Nurse Anesthetist; and has written agreements with local
hospitals to accept patients immediately who develop complications.
Pathologist: means a doctor, other than yourself or family member, 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.
Peripheral Stem Cell Transplant: means the harvesting, storage, and reinfusion of peripheral stem
cells taken from yourself or a matched donor.
Reconstructive Surgery: means surgery for the purpose of reconstruction of anatomic defects that
result from treatment of internal (not skin) cancer.
Skilled Nursing Care Facility: means a place where you go to recover fram an illness and that: is a
legally operated facility that can be a wing or part of a hospital; operates 24 hours a day and will
accept inpatients on an overnight basis; is supervised by a doctor; has a 24-hour a day nursing staff
which is supervised by a registered nurse; and keeps written daily records for each patient.
Notwithstanding the above, a skilled nursing care facility is not a: rest home or home for the aged;
place that provides mostly custodial care; or place for alcoholics or drug addicts.
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.
Supportive or Protective Care Drugs and Colony Stimulating Factors: means bone marrow
growth factors, radiation and chemotherapy protectants, and medications that promote bone growth.
Topical Chemotherapy: means a chemotherapy drug placed directly onto the skin.
U.S. Government Hospital: means a hospital that is funded by the U.S. Government primarily for
military enlisted personnel and their families and military veterans.
Waiting Period: means the first 30 days following each insured person's coverage effective date
during which no benefits are payable.
(4) LIMITATIONS: This policy provides benefits if the first date of diagnosis of cancer or the
performance of a cancer screening test occurs: while your policy is in force; after the waiting period
has been satisfied; and if the cancer or treatment is not excluded by name or specific description in
the policy. Drugs received for the treatment of cancer must be approved by the United States Food
and Drug Administration and treatment for cancer must be received within the United States. If the
first date of diagnosis of your cancer is before the end of the waiting period, coverage for that cancer
will apply only to loss commencing after this policy has been in force two years. Any cancer screening
test performed before the end of the waiting period will not be covered. Cancer must be pathologically
or clinically diagnosed. If cancer is not diagnosed until after you die, we will only pay benefits for the
treatment of cancer performed during the 45 day period before your death.
C1000-O-TX 8 60162
~~~
(5) Renewability: Your policy is guaranteed renewable. This means you have the right to keep the
policy in force with the same benefits, except that we may discontinue or terminate this policy if: (1)
you fail to pay premiums as required under the policy; or (2) you have performed an act or practice
that constitutes fraud, or have made an intentional misrepresentation of material fact, relating in any
way to the policy, including claims for benefits under the policy.
(6) Premium: Premiums are subject to change. 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.
Monthly Premium $
Annual Premium $
Plan
Coverage:
Individual One-parent family
Two-parent family
Premiums must be paid to us at our home office when they are due. If you do not pay a premium
when it is due you can pay it during the next thirty-one days. These thirty-one days are called the
grace period; however, if premiums are not paid by the end of the grace period the policy will
terminate and your coverage will end.
C 1000-O-TX 9 60162
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Help preserve your lifestyle
Coloni,~l's
with
Cs^iticallllnes
Chances are, you know someone who has faced a critical illness, so you know the
physical and emotional drain an illness con impose. But have you thought about the
financial problems a critical illness can bring?
Fortunately, survival rates for critical illnesses are increasing every year. With survival comes changes, one of which could be the
impact to your financial situation. Would you be able to meet your financial obligations if a critical illness should strike?
Even those of us who carefully plan for the unexpected with life, disability and medical insurance may discover that some expenses
can still remain unpaid. The benefits you receive from Colonial's critical illness insurance can help provide financial protection,
whatever your situation. Here are some examples of how the benefit can help you:
The average
age at which
a critical
illness
strikes
is 43.'
> Do you use an HMO or PPO for your > Are you newly married? The insurance can
major medical insurance? Critical illness provide a financial cushion, because you may not
insurance can help fill the gaps in case your have had time to build up savings or other assets
major medical coverage doesn't provide the to help you get through tough financial times.
freedom of choice that you need.
> Do you have a family? If your family relies
> Are you single? The benefit can help on you for income and/or for the work you do
provide for caretakers, home maintenance inside the home-this benefit could provide a
and transportation, which you may need if supplement to help you handle your reduced
a critical illness strikes. ability to earn an income, pay bills or provide
household care and maintenance.
Covered Critical Illnesses
Benefits are payable if you are diagnosed with one of the
following critical illnesses and the date of diagnosis is after
the waiting period and while the policy is in force (see
definitions of diagnosis on the back of this brochure). We
will not pay for more than 100% of the face amount for
all covered critical illnesses, combined.
Heart Attack -the date that the death (infarction) of a
portion of the heart muscle occurred, based on the
criteria listed under the heart attack definition.
Stroke -the date a stroke occurred, based on docu-
~ ~ •.
mented neurological deficits and neuroimaging studies.
Major Organ Transplant -the date the surgery ~ ~ .
occurs for covered transplants.
End Stage Renal Failure -the date your doctor or
physician recommends that you begin renal dialysis. ~ ~ '
Coronary Artery Bypass Surgery* -the date the
surgery occurs for covered coronary artery bypass surgery.
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*If you receive the 25% benefit for coronary artery bypass surgery and are later diagnosed with a different covered critical
illness, we will pay the face amount less the amount you received for coronary artery bypass surgery. We will not pay more than
100% of the face amount for all covered critical illnesses, combined.
'i~
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Insurance
Use Benefits Where
They're Needed Most
Colonial's critical illness insurance pays a lump sum benefit upon diagnosis
of a covered critical illness for you to use where it's needed most. Coverage is
available for you and your spouse.
We will pay for the critical illnesses listed if the date of diagnosis is after the
waiting period and during the time the polity is in force. The face amount
reduces by 50% on the first policy anniversary after your 75`h birthday.
Please see definitions and exclusions on the back of this brochure.
Health Screening Benefit
$50 Per CalendarYear No Lifetime Limit
New technology can help improve your chances of surviving a serious
illness through early detection and treatment. We will pay benefits for these
screening tests if the test is performed or if critical illness is diagnosed after
the 30-day waiting period and while your policy is in force.
> Stress test on a bicycle or treadmill
> Fasting blood glucose test
> Bone marrow testing
> Blood test for triglycerides
> Serum cholesterol test to determine levels of HDL and LDL
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Premiums
~x:
~.:,~
1?rcinitun:, are l~a,~d oit ~ou~~.~~ at`~i~u~, and} ~'
.
~<~tir tul,.l~cc, 5tarti,.~'''ourpre~~iU ~o~s~n©z~ ,~
incr~atic ;i< vuu ~T-tr uldcr. Preiu~s rill ~ ~~ r ,~ ,,
based on rho amcnint ~f 4overag~: S'<tu yclc:4t;;°,~ '°2
The policy is ~~uaran~tced rrit~s~ahle <~~ lu~~b , ~`-
as the preir~iums arepaid when.the~ are due
or within the ~rac~ period, ul;~ Fo diedatc
of paymentoflUU oof ~helate:nnounttor~ -
specified critical illnc5s. Prcmium,~ can he
changed only if we ch~int~c rhen~ on -all
policies of this kind in ford in the gate
where. the policy is issued.
Your face amount $
Your premium,
per pay period $
'Global experience from insurance carriers. Data from the 1985 °G'ommissioners Individual Disability
Table A,"Transactions of the Society ofAcutaries, Vol. 37, pp 449-602.
Heart Disease and Stroke Statistics - 2005 Update, American Heart Association.
No Claim Form Needed
To receive payment for your health
screening benefit, you may simph° call
our toll-free Customer Service number,
1-800-325-4368,
with the medical information.
did you know?
THIS IS A LIMITED POLICY.
7lie Colonial
Advantage
> A leader in the supplemental
insurance industry.
> Communications and benefits
` education to help you
understand'the benefits you
have-and the benefits you
may need.
~ ~ •~
Heart Attack means the death (infarction) of a portion of heart muscle as a result of inadequate
blood supply "Ihe diagnosis must be based on all of the following criteria:
> associated new electrocardiographic (EKG) changes consistent with injury; and
> elevation of cardiac enzymes; and
> confirmatory imaging studies such as thallium scans, MUGA scans, or stress
echocardiograms. In the event of death, an autopsy confirmation and death certificate
identifying heart attack as the cause of death will be accepted.
Stroke means a cerebrovascular event resulting in permanent neurological damage, including
infarction, hemorrhage or embolization of brain tissue from an extracranial source. Transient
ischemic attacks are specifically excluded. The diagnosis must be based on:
> documented neurological deficits; and
> confirmatory neuroimaging sardies.
Major Organ Transplant means undergoing surgery as a recipient of a transplant of a human
heart, lung, liver, kidney, or pancreas.
End Stage Renal Failure means chronic irreversible failure of the function of both kidneys
such that }'ou must undergo regular hemodialysis or peritoneal dialysis (at least weekly).
Coronary Artery Bypass Surgery means undergoing open heart surgery to correct narrowing
or blockage of one or more coronary arteries with by ass grafts, but excluding procedures such
as, but not limited to: balloon angioplasty, laser relief, stents or other non-surgical procedures.
Doctor or Physician means a person or practitioner, other than yourself or a family member,
who:
> is legally licensed by the state to practice a healing art;
> performs services for you which are allowed by his/her license; and
> performs services for which benefits are provided by the policy.
Waiting Period means the first thirty days following each insured person's coverage effective
date during which time no benefits are payable.
We will not pay benefits for a specified critical illness or surgery that occurs as a result of the
following:
> your being diagnosed with a specified critical illness during the waiting period.
> your participating or attemptingg to participate in an illegal activity.
> your intentionally causing aself-inflicted injury.
> your committing or attempting to commit suicide, whether sane or insane.
> your involvement in any period of armed conflict, even if it is not declared.
> Prompt, accurate and	-
We will not pay the specified critical illness benefit for the following: transient ischemic attacks;
courteous customer service.	balloon angioplasty; laser relief or other like procedures; pre-malignant conditions or conditions
	with malignant potential; basal cell carcinoma and squamous cell carcinoma of the skin; or
	melanoma that is diagnosed as Clark's Level I or II or Breslow less than .75mm.
> Broad selection of products	This brochure highlights the benefits of policy form CI(98)-W (including state abbreviations,
to help meet your individual	where applicable). 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>
needs, with premiums paid	therefore, important that you READ YOUR POLICY CAREFULLY.
through convenient payroll	
Product riot available in all states.
deduction.	
Learn more about these and all	
of the advantages Colonial has to	
offer at www.coloniallife,com.	
	Colonial Supplemental lnsuranceptoducts are underwritten by:
	Colonial Life & Accident Insurance Company
	1200 Colonial Life Boulevard, Columbia, South Carolina 29210
	www.coloniallife.com
	Oc 2006 Colonial Life & Accident Insurance Company.
Colonial Supplemental Insurance is the marketing brand of Colonial Life & Accident Insurance Company. "Colonial Supplemental
	Insurance," frr what happenr next"and the Togo, separately and in combination, are registered service marks of Colonial Life & Accident
	Insurance Company. All rights reserved.
	O6/O6 52426-9