LOYAL AMERICAN LIFE INSURANCE COMPANY A Stock Insurance Company P.O. Box Austin, Texas

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1 THIS 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. LOYAL AMERICAN LIFE INSURANCE COMPANY A Stock Insurance Company P.O. Box Austin, Texas ACCIDENT EXPENSE INSURANCE POLICY This policy does not pay for losses resulting from sickness. This policy 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 a non-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. Guaranteed Renewable for Life This policy is guaranteed renewable for life as long as premiums are paid when they are due. Premiums can be changed, but only on a class basis. A class may be defined by age, sex, occupation, premium payment method, issue state, elimination period, benefit period, etc. Important Notice Please read Your application attached to this policy. This policy was issued based on Your responses to the questions on Your application. If Your answers are incorrect or untrue, We may have the right to deny benefits or terminate Your policy. The best time to clear up any questions is now, before a claim arises! If for any reason, any of Your answers are incorrect, contact Us at this address: P.O. Box Austin, Texas Please Read This Policy Carefully This policy is a legal contract between You and Us. Please read it carefully. We want You to be pleased with the coverage it provides. To understand the coverage, please read this policy as a whole. In this policy, the words "You" or "Your" refer to the person or persons insured by the policy. The words "We," "Us," or "Our" refer to Loyal American Life Insurance Company. The Right to Return This Policy Within 10 Days Within 10 days from receipt of the policy, You may return it for any reason. If returned, this policy is void. Any premiums paid on this policy will be refunded. This policy may be returned to Us or to Your agent. IN WITNESS THEREOF, We have caused this policy to be signed by Our President and Our Secretary. This policy takes effect at 12:01 a.m. at Your residence on the Effective Date. This policy terminates at 12:01 a.m. on the date any renewal premium is due and not paid, subject to the Grace Period. SECRETARY PRESIDENT

2 POLICY GUIDE Guaranteed Renewable for Life...1 Important Notice...1 Please Read This Policy Carefully...1 The Right to Return This Policy Within 10 Days...1 POLICY GUIDE...2 POLICY SCHEDULE BENEFITS SCHEDULE YOUR CONTRACT WITH US...4 Coverage Provided by This Policy...4 This Policy is a Contract...4 Entire Contract...4 PREMIUM PAYMENTS...4 When to Pay Premiums...4 Grace Period...4 Reinstatement...4 Our Right to Change Premium...4 IMPORTANT WORDS IN THIS POLICY...5 Benefits Schedule...5 Child or Children...5 Confined or Confinement...5 Covered Accident...5 Doctor...5 Effective Date...5 Family Member...5 Hospital...5 Hospital Intensive Care Unit...5 Hospital Intensive Care Unit - sub-acute...6 Injury...6 Insured...6 Loss of Arm...6 Loss of Finger...6 Loss of Foot...6 Loss of Hand...6 Loss of Leg...6 Loss of Sight of Eye...6 Loss of a Toe...6 Physical Therapist...6 Policy Schedule...6 Prosthetic Device or Artificial Limb...6 ELIGIBILITY FOR COVERAGE...7 INJURY...8 Burn...8 Dislocation (Separated Joint)...8 Eye Injury...8 Fracture (Broken Bone)...8 Knee Cartilage - Torn...9 Laceration...9 Prosthetic Device or Artificial Limb...9 Tendon, Ligament, Rotator Cuff...9 HOSPITAL AND SERVICES...9 Accident Follow-Up Treatment...9 Air Ambulance...9 Ambulance...10 Appliance...10 Blood, Plasma, Platelets...10 Emergency Room Treatment...10 Family Lodging...10 Hospital Confinement...10 Hospital Intensive Care Unit Confinement...11 Initial Accident Hospitalization...11 Physical Therapy...11 Transportation...11 ACCIDENTAL DEATH AND DISMEMBERMENT...11 Accidental Death - Common Carrier...11 Accidental Death - Other Accidents...11 Accidental Dismemberment...11 WHAT IS NOT COVERED BY THIS POLICY...12 YOUR CLAIM FOR BENEFITS...12 Notice of Claim...12 Proof of Loss...12 Claim Form...12 Payment of Claim...12 How to Change the Beneficiary...13 Physical Examinations and Autopsy...13 Legal Action...13 IMPORTANT PROVISIONS...14 Error in Age...14 Other Accident Policies With Us...14 State Laws...14 Time Limit...14 Transfer of Rights...14 The Right to Continue Coverage...14 TERMINATION, TRANSFER, AND CONVERSION OF COVERAGE...7 Child Termination of Coverage...7 Spouse Termination of Coverage...7 Conversion Policy...7 Page 2

3 YOUR CONTRACT WITH US Coverage Provided by This Policy This Policy is a Contract According to all of the provisions of this policy, You are insured against losses resulting from Injuries received in a Covered Accident. This policy is a legal contract between You and Us. We provide the insurance coverage stated in this policy, subject to the terms of this policy. We do this in return for the application and the first payment called a premium. The premium for this policy is shown in the Policy Schedule. Entire Contract Whenever We use the word policy, We mean the entire contract. The entire contract consists of: the basic policy, including the Policy Schedule; the attached copy of the application; and any attached riders or endorsements. Riders and endorsements add provisions or change the terms of the basic policy. Any change to this policy must be attached in writing and signed by one of Our executive officers. No agent or anyone else can change this policy or waive any of its provisions. PREMIUM PAYMENTS When to Pay Premiums Grace Period Reinstatement The premiums for this policy must be paid to Us in advance. After the first premium, if a 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 this period, the policy will stay in force. If a premium is not paid by the end of the Grace Period, this policy will terminate. If terminated, this policy can be put back in force. This is called reinstatement. Ask Us or one of Our agents about reinstating this policy. If We accept premium and do not require a reinstatement application, this policy will be reinstated on the date the premium is paid. If We accept premium and require a reinstatement application, We will provide a receipt for the premium. If We approve the reinstatement application, this policy will be reinstated on the date We approve it. If We do not provide notification that We have approved or disapproved the reinstatement application, this policy will be reinstated on the 45th day after the payer receives the receipt. The reinstated policy will only cover losses that result from Injuries which occur after the reinstatement date. We have the right to make changes in this policy before We reinstate it. Any changes will be made in or attached to the reinstated policy. In every other way, Your rights and Our rights will be the same. Our Right to Change Premium We have the right to change the premium We charge. However, We cannot single out anyone for a premium change. Premium can be changed only on a class basis. A class may be defined by age, sex, occupation, premium payment method, issue state, elimination period, benefit period, etc. If We plan to make a premium change, We will send a notice at least 31 days before We make it. We will not change the premium more than once in a 12 month period. Page 4

4 IMPORTANT WORDS IN THIS POLICY Benefits Schedule Child or Children Confined or Confinement Covered Accident Doctor Pages 3.01 and 3.02 of this policy. Child or Children, unless excluded from coverage, means Your unmarried Children, stepchildren and adopted Children who are dependent on You. Children must also be: under age twenty-five (25). Children also include any Children for whom You must provide medical support under a court order. An adopted Child is considered Your Child if You are a party in a suit in which adoption of the Child by You is sought. Also included as Children are grandchildren whom You claim as dependents for federal income tax purposes. Confined or Confinement means the assignment to a bed as an overnight resident patient in a Hospital on the advice of a Doctor. An accident which: occurs after the Effective Date of this policy, occurs while this policy is in force, and is not excluded by specific description in this policy. A Doctor means a person, other than You or a Family Member, who: is licensed by the state to practice a healing art, performs services which are allowed by his/her license, and performs services for which benefits are provided by this policy. Effective Date Effective Date means the date on which the coverage under this policy begins. The Effective Date is shown on the Policy Schedule. Family Member Hospital Family Member means Your spouse and the following relatives of You or Your spouse: parents, grandparents, brothers, sisters, Children and grandchildren. A Hospital means a place which: is legally operated for the care and treatment of sick and injured persons at their expense; is primarily engaged in providing medical, diagnostic and surgical facilities either on its premises or in facilities available to the Hospital on a formal pre-arranged basis; provides twenty-four (24) hour-a-day nursing services by or under the supervision of a graduate registered nurse (R.N.); and has a staff of one or more Doctors available at all times. Hospital as herein defined shall not include any institution which is principally an institution for the care and treatment of alcoholics or drug addicts. Hospital Intensive A Hospital Intensive Care Unit means a place which: Care Unit is a specifically designated area of the Hospital called an Intensive Care Unit that provides the highest level of medical care. A Hospital Intensive Care Unit 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; and is under constant and continuous observation by a specially trained nursing staff. This staff must be assigned exclusively to the intensive care unit on a 24 hour basis. Page 5

5 Notwithstanding the above, a Hospital Intensive Care Unit is not any of the following step down units: progressive care unit; intermediate care unit; private monitored room; Hospital Intensive Care Unit - sub-acute; observation unit; or any facility not meeting this policy's definition of a Hospital Intensive Care Unit. Hospital Intensive Care A Hospital Intensive Care Unit - sub-acute means a place which: Unit - sub-acute is a specifically designated area of the Hospital that provides a level of medical care below intensive care but above a regular private or semi-private room or ward; is separate and apart from the surgical recovery room and from rooms, beds, and wards customarily used for patient Confinement; is permanently equipped with special lifesaving equipment for the care of the critically ill and injured; and is under constant and continuous observation by a specially trained nursing staff. A Hospital Intensive Care Unit - sub-acute may be referred to by other names such as progressive care, intermediate care, or a step-down unit. A Hospital Intensive Care Unit - sub-acute is not a regular private or semi-private room or a ward, with or without monitoring equipment. Injury Insured Loss of Arm Loss of Finger Loss of Foot Loss of Hand Loss of Leg Loss of Sight of Eye Loss of a Toe Physical Therapist Policy Schedule Prosthetic Device or Artificial Limb An Injury to Your body which is caused by a Covered Accident. Insured means the person shown on the policy application as the applicant. Loss of Arm means that the arm is cut off through or above the elbow joint or the use of the arm is permanently lost. Loss of Finger means that a finger is cut off at the joint (proximate to the first interphalangeal joint) where it is attached to the hand. Loss of 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 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 Leg means that the leg is cut off through or above the knee joint or the use of the leg is permanently lost. Loss of Sight of Eye means that at least eighty percent of vision is permanently lost. 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. 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/her 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. Page 3.00 of this policy. A Prosthetic Device or Artificial Limb is an artificial device designed to replace a missing limb. It must be prescribed by a Doctor for functional use. Page 6

6 ELIGIBILITY FOR COVERAGE If this is an Individual Plan, covered person means only the Insured. If this is a Husband/Wife Plan, covered persons include the Insured and the Insured's spouse. If this is a Single Parent Plan, covered persons include: the Insured and the dependent, unmarried Children of the Insured on the Effective Date. If this is a Family Plan, covered persons include the Insured, the Insured's spouse, and the dependent, unmarried Children of the Insured or Insured's spouse on the Effective Date. In all cases, a Child born to the Insured while this policy is in force automatically becomes insured on the date of birth. If this is an Individual Plan, upon addition of a Child born to the Insured, the coverage will become a Single Parent Plan and the premium will be adjusted accordingly. If this is a Single Parent or a Family Plan, the coverage for a newly adopted Child is effective upon the earlier of the date: of placement for the purpose of adoption; or of the entry of an order granting custody of the Child. Coverage will continue for the Child unless the Child is removed from placement prior to the legal adoption. We must receive written notification within 31 days after the adoption of the Child in order to have the coverage continue beyond the 31 day period. TERMINATION, TRANSFER, AND CONVERSION OF COVERAGE Child Termination of Coverage A Child shall cease to be covered on the premium due date on or next following the earlier of such Child's 25th birthday or date of marriage. The coverage of a Child will not terminate if the Child is both: incapable of self-sustaining employment because of mental retardation or physical handicap; and currently dependent upon the Insured. Proof of continued incapacity and dependency must be furnished to Us by the Insured within thirty-one (31) days of the Child's twenty-fifth (25th) birthday. Afterwards, proof of continued incapacity and dependency must be furnished to Us, at Our request, by the Insured but not more frequently than annually after the two-year period following the Child's twenty-fifth (25th) birthday, unless such information is requested as a part of Our claim processing. If a claim is denied under this policy because the Child has attained the limiting age, the burden is on the Insured to establish that the Child is and has continued to be handicapped and dependent as defined. Proof of continued incapacity and dependency must be furnished at Our request, but not more frequently than annually, unless such information is requested as a part of Our claim processing. Spouse Termination of Coverage Conversion Policy If this is a Husband/Wife Plan or a Family Plan, the coverage of the Insured's spouse shall cease on the premium due date on or next following the date of entry of a valid judgment of dissolution of marriage. A covered person may apply for a policy (hereinafter called Conversion Policy) if coverage under this policy ends as set forth in the Child Termination of Coverage or the Spouse Termination of Coverage provisions. The Conversion Policy will be issued without proof of good health, subject to the following conditions: A written application for the Conversion Policy is sent to Us no later than the date on which such person's coverage under this policy ends. The Effective Date of the Conversion Policy shall be the date such person's coverage ends. The premium for the Conversion Policy will be the premium payable on the Effective Date of the Conversion Policy for the form and amount of coverage provided. The Conversion Policy will be a form currently in use by Us. It will provide similar coverage as provided under this policy. The Conversion Policy may exclude any condition excluded by this policy at the time of the termination of this policy. We will not pay benefits under the Conversion Policy for expenses incurred while this policy is in force. Page 7

7 INJURY Please refer to the Benefits Schedule for specific benefit amounts. Burn Dislocation (Separated Joint) We will pay this benefit if You receive burns which require medical treatment due to a Covered Accident. The burns must be second degree burns which cover at least 36% of the body surface or third degree burns which cover at least 9 square inches of the body surface. They must be treated by a Doctor within 72 hours after the accident. After all of these things occur, We will pay the amount shown for each Covered Accident. We will pay this benefit if You receive a dislocation in a Covered Accident. A dislocation is a completely separated joint. It must be diagnosed by a Doctor within 90 days after the accident. The dislocation must require correction with anesthesia by a Doctor. It can be corrected by open (surgical) or closed (non-surgical) reduction. After all of these things occur, We will pay the amount shown for the joint which requires closed reduction. If the dislocation requires open reduction, We will pay 150% of the amount shown. If You receive more than one dislocation in a Covered Accident, and they require open or closed reduction, We will pay for all dislocations. However, We will pay no more than 150% of the amount for the joint involved which has the highest benefit amount. If the dislocation requires reduction without anesthesia by a Doctor, We will pay 25% of the amount shown for the joint involved. If a Doctor diagnoses the dislocation as an incomplete dislocation, We will pay 25% of the amount shown for the joint involved. An incomplete dislocation is a dislocation in which the joint is not completely separated. If You receive a fracture and a dislocation in the same Covered Accident, We will pay for both. However, We will pay no more than 150% of the amount for the bone or joint involved which has the highest benefit amount. We will pay this benefit only for the first dislocation of a joint after the Effective Date. Subsequent dislocations of the same joint will not be covered. Eye Injury Fracture (Broken Bone) We will pay this benefit if You receive an eye Injury in a Covered Accident. The eye Injury must require surgery or the removal of a foreign object by a Doctor within 90 days after the accident. After all of these things occur, We will pay the amount shown for each Covered Accident. An examination with anesthesia will not be considered surgery. We will pay this benefit if You receive a fracture in a Covered Accident. A fracture is a break in a bone which can be seen by X-ray. It must be diagnosed by a Doctor within 90 days after the accident. The fracture must require open (surgical) or closed (non-surgical) reduction by a Doctor. After all of these things occur, We will pay the amount shown for the bone which requires closed reduction. If the fracture requires open reduction, We will pay 150% of the amount shown for the bone involved. If You receive more than one fracture in a Covered Accident, and they require open or closed reduction, We will pay for all fractures. However, We will pay no more than 150% of the amount for the bone involved which has the highest benefit amount. If a Doctor diagnoses the fracture as a chip fracture, We will pay 25% of the amount shown for the bone involved. A chip fracture is a fracture in which a piece of the bone is broken off near a joint at a place where a ligament is usually attached. If You receive a fracture and a dislocation in the same accident, We will pay for both. However, We will pay no more than 150% of the amount for the bone or joint involved which has the highest benefit amount. Page 8

8 Knee Cartilage - Torn Laceration We will pay this benefit if You receive a torn knee cartilage (meniscus) in a Covered Accident. It must be treated by a Doctor within 60 days after the Covered Accident. It must be repaired through surgery by a Doctor within 6 months after the accident. After all of these things occur, We will pay the amount shown for each Covered Accident. We will pay this benefit if You receive a laceration in a Covered Accident. A laceration is a cut. The laceration must be repaired by a Doctor within 72 hours after the accident. After all of these things occur, We will pay one of the amounts shown for each Covered Accident. The amount We pay will be based on the total length of all lacerations received in any one accident which require repair. If the laceration is severe enough to require stitches but the Doctor chooses to repair it in another way, We will treat it as if it were repaired without stitches. If You receive a laceration on Your finger or toe and later lose that finger or toe as a result of the same accident, We will subtract the amount We paid under the Laceration benefit from the Accidental Dismemberment benefit. If You receive a laceration on Your hand, foot or eye and later lose that hand, foot, or sight of the eye as a result of the same accident, We will subtract the amount We paid under the Laceration benefit from the Accidental Dismemberment benefit. Prosthetic Device or Artificial Limb Tendon, Ligament, Rotator Cuff We will pay this benefit for a Prosthetic Device or Artificial Limb which is prescribed by a Doctor for functional use when You lose a hand, foot, or sight of an eye due to a Covered Accident. The Prosthetic Device or Artificial Limb must be received within one year of the Covered Accident. We will pay this benefit once per Covered Accident. This benefit is not payable for hearing aids, dental aids, false teeth, or for cosmetic prosthesis (e.g. hair wigs). We will not pay for joint replacement (e.g. an artificial hip or knee). We will pay this benefit if You receive an injured tendon, ligament or rotator cuff in a Covered Accident. It must be torn, ruptured or severed. It must be repaired through surgery by a Doctor within 90 days after the accident. After all of these things occur, We will pay one of the amounts shown for each Covered Accident. The amount We pay will be based on the number repaired as a result of each accident. If You receive a fracture or a dislocation, and You also tear, rupture or sever a tendon, ligament or rotator cuff in the same accident, We will pay the largest benefit amount. HOSPITAL AND SERVICES Please refer to the Benefits Schedule for specific benefit amounts. Accident Follow-Up Treatment Air Ambulance We will pay this benefit if You need additional treatment of Injuries sustained in a Covered Accident over and above emergency treatment administered in the first 72 hours following the accident. Benefits will not exceed 3 treatments per Covered Accident. The treatment must begin within 30 days of the Covered Accident. Treatment must conclude within 6 months following the Covered Accident. Treatments must be furnished by a Doctor in a Doctor's office or in a Hospital on an outpatient basis. Benefits will not be paid for services rendered by a Family Member. We will pay this benefit if a licensed professional air ambulance company transports You. The transport must be to or from a Hospital or between medical facilities where treatment is received for Injuries as a result of a Covered Accident. The air ambulance transportation must be within 48 hours after the accident. We will pay this benefit once per Covered Accident. Page 9

9 Ambulance Appliance Blood, Plasma, Platelets We will pay this benefit if a licensed professional ambulance company transports You by ground transportation. The transport must be to or from a Hospital or between medical facilities where treatment is received for Injuries as a result of a Covered Accident. The ambulance transportation must be within 90 days after the accident. We will pay this benefit once per Covered Accident. We will pay this benefit if You are injured in a Covered Accident and a Doctor prescribes the use of a medical appliance as an aid in personal locomotion or mobility. Crutches and wheelchairs are examples of medical appliances. The use of an appliance must begin within 90 days after the accident. We will pay this benefit once per Covered Accident. We will pay this benefit if You are injured in a Covered Accident and require the transfusion, administration, cross matching, typing and processing of blood, plasma or platelets. The blood, plasma or platelets must be administered within 90 days after the Covered Accident. We will pay this benefit once per Covered Accident. Emergency Room We will pay this benefit if: Treatment You are injured in a Covered Accident; the Injury is of an emergent nature; and You require examination and treatment by a Doctor in a Hospital emergency room within 72 hours after the accident. If You receive treatment in an emergency room but no charges are submitted, We will only pay the amount shown in the Benefits Schedule. If charges are later submitted, We will pay the benefit amount shown on the Schedule of Benefits, minus the amount We have already paid. If you have been treated in an emergency room for a laceration that is repaired without stitches or the removal of a foreign object from the eye, We will pay the amount shown in the Benefits Schedule. Family Lodging If You require Hospital confinement for treatment of Injuries sustained in a Covered Accident, We will pay for one hotel or motel room for a Family Member to accompany You. This benefit is payable only during the same period of time You are confined to the Hospital. This benefit is not payable for the trip to the Hospital. The Hospital and hotel or motel must be more than 100 miles from Your residence. The local attending Doctor must prescribe the treatment. This benefit is not to exceed 30 days per Covered Accident. Hospital Confinement We will pay this benefit if You are Confined in a Hospital or a Hospital Intensive Care Unit - sub-acute because of Injuries received in a Covered Accident. You must become Confined within 6 months after the accident. We will pay benefits for only one Confinement at a time, even if it is caused by more than one Covered Accident. We will pay this amount per day not to exceed 180 days per Covered Accident. If You were Confined in a Hospital or a Hospital Intensive Care Unit - sub-acute and are 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 Confinement, We will treat this Confinement as a new Confinement. We will not pay this benefit for Confinement to an observation unit, emergency room treatment or outpatient treatment. We will not pay the Hospital Confinement benefit and the Hospital Intensive Care Unit Confinement benefit concurrently. If You are Confined in a Hospital Intensive Care Unit for more than 15 days, the Hospital Confinement benefit will begin on the 16th day. The total amount payable per Covered Accident will not exceed 180 days for Hospital Confinement and 15 days for Hospital Intensive Care Unit Confinement. Page 10

10 Hospital Intensive Care Unit Confinement We will pay this benefit if You are Confined to a Hospital Intensive Care Unit because of Injuries received in a Covered Accident. The Confinement must begin within 30 days after the accident. We will pay this amount per day not to exceed 15 days per Covered Accident. If You were Confined in a Hospital Intensive Care Unit and are 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 Confinement, We will treat this Confinement as a new Confinement. If You are Confined to a Hospital Intensive Care Unit that does not meet the policy's definition of a Hospital Intensive Care Unit, We will pay the Hospital Confinement benefit. We will not pay the Hospital Intensive Care Unit Confinement benefit and the Hospital Confinement benefit concurrently. Initial Accident Hospitalization We will pay this benefit if You are Confined to a Hospital because of injuries received in a Covered Accident. You must become Confined within 6 months after the accident. We will not pay this benefit for Confinement to an observation unit, emergency room treatment or outpatient treatment. This benefit is payable once per Covered Accident. Physical Therapy Transportation We will pay this benefit if You require physical therapy as a result of a Covered Accident. We will pay this amount per treatment with a maximum of 5 treatments per Covered Accident. The therapy must begin within 60 days after the accident. The treatment must be completed within 6 months after the accident. All services must be prescribed by a Doctor and rendered by a licensed Physical Therapist. The services must be performed in an office or a Hospital on an inpatient or outpatient basis. We will pay this benefit if You require special treatment and Confinement for Injuries sustained in a Covered Accident. This benefit is payable for the trip to the Hospital. The local attending Doctor must prescribe the treatment. The treatment must not be available locally. This benefit is not payable for transportation to any Hospital within a 100-mile radius of the accident site or Your residence. This benefit will not exceed 3 trips per calendar year per covered person. ACCIDENTAL DEATH & DISMEMBERMENT Please refer to the Benefits Schedule for specific benefit amounts. Accidental Death - Common Carrier We will pay this benefit if You are injured in a Covered Accident while a fare paying passenger on a common carrier and the Injury causes You to die within 90 days after the accident. Common carrier vehicles are limited to commercial airplanes, trains, buses, trolleys, subways, ferries and boats that operate on a regularly scheduled basis between predetermined points or cities. Taxis and privately chartered vehicles are not included in this benefit. If We pay this benefit, We will not pay the Accidental Death - Other Accidents benefit. Accidental Death - Other Accidents We will pay this benefit if You are in a Covered Accident and the Injury causes You to die within 90 days after the accident. If We pay this benefit, We will not pay the Accidental Death - Common Carrier benefit. Accidental We will pay the applicable benefit for dismemberment due to a Covered Accident. Dismembermentmust occur within 90 days of the accident. The benefit amounts for specific Dismemberment dismemberments are shown in the Benefits Schedule. Page 11

11 We will not pay benefits for any Injury as a result of You(r): WHAT IS NOT COVERED BY THIS POLICY Operating, learning to operate, serving as a crew member of or jumping or falling from any aircraft. Aircraft includes those which are not motor-driven. Engaging in hang gliding, bungee jumping, parachuting, sailgliding, parakiting, or hot air ballooning. Participating or attempting to participate in an illegal activity. Riding in or driving any motor-driven vehicle in a race, stunt show or speed test. Intentionally causing a self-inflicted Injury. Having any sickness or declining process caused by a sickness, including physical or mental infirmity. We also will not pay benefits to diagnose or treat the sickness. Sickness means any disease or disorder that is not caused by an Injury. Practicing for or participating in any semi-professional or professional competitive athletic contest for which any type of compensation or remuneration is received. Committing or trying to commit suicide, whether sane or insane. Being in an accident which occurs more than 40 miles outside the territorial limits of the United States, Canada, Puerto Rico and Virgin Islands. Involvement in any period of armed conflict, even if it is not declared. YOUR CLAIM FOR BENEFITS Notice of Claim Proof of Loss A written statement describing Your loss must be given to Us within 90 days after the covered loss begins or as soon as it is reasonably possible. The notice given by or on behalf of the Insured, or beneficiary, to Us at Our home office, or to Our agent with information sufficient to identify the Insured, shall be deemed notice to Us. Notice should include the Insured's name and the policy number. Written proof of loss must be given within 90 days after the covered loss begins. Written proof of loss includes one or more of the following: an attending Doctor's statement, a Doctor's bill, a Hospital bill, an employer's statement, or Your statement. If written proof of loss is not given within 90 days, it will not have a bearing on the claim if proof is given to Us as soon as it is reasonably possible. In any event, proof must be given no later than one year from the time stated, unless You are legally unable to do so. Claim Form Payment of Claim When We receive a notice of claim, We will send a claim form within 15 days. A claim form must be completed within 90 days after the covered loss begins or as soon as it is reasonably possible. Send the claim form along with proof of loss to Us. If the claim form is not received within 15 days, a written statement along with the proof of loss will be used to process the claim. After We receive written proof of loss, We will immediately pay all benefits due, if any. Benefits will be paid to You. Benefits can be paid elsewhere, such as to a Hospital or a Doctor's office, if a written request is made by You. This is called assignment. Page 12

12 If You receive medical assistance from the Texas Department of Human Resources, then any benefits payable under this coverage will be paid to the Texas Department of Human Resources. If You are receiving financial and medical benefits through the Texas Department of Human Services, benefits payable under this policy will be paid to the Texas Department of Human Services whenever: (1) The Texas Department of Human Services is paying benefits pursuant to Chapters 31 and 32 of the Human Resources Code, i.e., financial and medical assistance programs administered pursuant to the Human Resources Code; (2) We are notified at the time of claim that You are receiving financial and medical assistance; and (3) The parent who purchased the policy has possession or access to the child pursuant to a court order, or is not entitled to access or possession of the child and is required by the court to pay child support. Benefits and premiums under the policy shall be suspended at the request of the policyholder for the period (not to exceed 24 months) in which the policyholder has applied for and is determined to be entitled to medical assistance under Title XIX of the Social Security Act, but only if the policyholder notifies the insurer of such policy within 90 days after the date the individual becomes entitled to such assistance. Upon receipt of timely notice, the insurer shall return to the policyholder that portion of the premium attributable to the period of Medicaid eligibility, subject to adjustment for paid claims. Any benefits unpaid at death may be paid to the designated beneficiary. The beneficiary is the person named in the application as the beneficiary, unless it was changed at a later date. This is the person who will receive any benefits due at Your death. If a beneficiary was not named or, if the person named is not living at Your death, any benefits due will be paid in this order to Your: spouse; children; parents; brothers and sisters; or estate. If benefits are payable to the estate or to someone who cannot give a binding release, We can pay benefits up to $1,000 to someone related to You by blood or marriage who We feel is fairly entitled to them. If We do this, We will have no responsibility for this payment because We made it in good faith. How to Change the Beneficiary Physical Examinations and Autopsy Legal Action The beneficiary can be changed at any time. Notify Us, and We will send the form for completion. The request must be signed, dated, witnessed by someone other than You or the present or proposed beneficiary, and returned to Us. The change must be approved by Us. If approved, it will go into effect the day the request was signed. The change will not have a bearing on any payment We make before We receive it. We can require You to have a physical examination as often as reasonably necessary while a claim is pending. We can also require an autopsy in the event of Your death in those states where this is allowed. Either or both of these will be done at Our expense. We cannot be sued for benefits under this policy: until 60 days after written proof of loss is received or after 3 years from the time We required written proof of loss. Page 13

13 IMPORTANT PROVISIONS Error in Age Other Accident Policies With Us State Laws Time Limit If Your age was stated incorrectly in the application and, if, based on the correct age: We would not have issued this policy, then Our only responsibility will be to refund the premiums paid for the period not covered, if any. We would have issued a different policy, then Our responsibility will be to adjust the premium and benefits payable. If You are covered by more than one of Our accident policies, We will pay benefits under only one of the accident policies. You, the beneficiary, or the estate may choose which policy to keep in force by sending Us written notice. We will return the premium paid for any of Our other accident policies during the time You had more than one policy in force. Any provision of this policy that, on the Effective Date, does not agree with state laws where You reside will be amended to conform to the minimum requirements of those laws. We rely on the statements made in the application to issue this policy and to pay benefits. After this policy has been in force for 2 years, We cannot cancel it or refuse to pay benefits because of any untrue statement in the application unless a fraudulent statement was made. Transfer of Rights The Right to Continue Coverage Any rights You have under this policy can be assigned. However, no assignment is binding on Us until We receive a copy of it. We are not responsible for the soundness of any assignment. We guarantee that this policy will be in force as long as the premiums are paid when they are due. They can be paid: anytime before they are due or within the Grace Period. Page 14