cancer & specified disease insurance with optional ... · pdf filecancer & specified...

CANCER & SPECIFIED DISEASE INSURANCE

WITH OPTIONAL INTENSIVE CARE RIDER

Underwritten by Humana Insurance Company

John D. Webb

Salina, Kansas 67401

(888)756-6670

[email protected]

Form Number: HIC-IND-CAN-SB-KS rev. 11/15

Individual Cancer and Specified Disease InsurancePOLICY FORM HIC-CAN-POL-KS 5/09Underwritten by Humana Insurance Company

► Plan Features• DonorBenefits• WellnessBenefits• ManyBenefitshaveNoLifetimeMaximum• CoversCertainLodgingandTransportation

• RenewableforLife• InandOutofhospitalbenefits• Paysregardlessofothercoverage

Benefit BBAC-0001 BBAC-0352WellnessBenefit.For Cancer screening tests such as mammogram, flexible sigmoidoscopy, pap smear, chest X-ray, hemocult stool specimen, or prostate screen. No Lifetime Maximum

Up to $50 percalendar year

Up to $100 per calendar year

PositiveDiagnosisTest. Payable for a test that leads to positive diagnosis of Cancer or Specified Disease within 90 days. This benefit is not payable if the same Cancer or Specified Disease recurs.



FirstDiagnosisBenefit. One-time benefit payable when a Covered Person is first diagnosed with Cancer (other than Skin Cancer) or a Specified Disease. Must occur after the Policy Effective Date. $2,500 $7,500

SecondandThirdSurgicalOpinions.Covers written opinions received after a Positive Diagnosis and before surgery. No Lifetime Maximum Actual Charges Actual Charges

Non-LocalTransportation.Payable for transportation to a Hospital, clinic or treatment center which is more than 60 miles and less than 700 miles from a Covered Person’s home. No Lifetime Maximum

Actual charges by a common carrier or 50 cents per mile if apersonal vehicle is used.

Actual charges by a common carrier or50 cents per mile if a personal vehicle is used.

AdultCompanionLodgingandTransportation. Payable for one adult companion to stay with a Covered Person who is confined in a Hospital that is more than 60 miles and less than 700 miles from his or her home. Covered expenses include a single room in a motel or hotel up to 60 days per confinement; and the actual charge of round trip coach fare by a common carrier or a mileage allowance for the use of a personal vehicle. This benefit is not payable for lodging expense incurred more than 24 hours before the treatment nor for lodging expense incurred more than 24 hours following treatment. No Lifetime Maximum

Up to $75 per day for lodging. 50 cents permile if a personal vehicle is used.

Up to $75 per day for lodging. 50 cents per mile if a personal vehicle is used.

Ambulance. For ambulance service if the Covered Person is taken to a Hospital and admitted as an inpatient. No Lifetime Maximum Actual Charges Actual Charges

Surgery. Covers actual surgeon’s fee for an operation up to the amount listed on the schedule. Benefits for surgery performed on an outpatient basis will be 150% of the schedule benefit amount, not to exceed the actual surgeon’s fees. No Lifetime Maximum

Up to $1,500 Up to $4,500

DonorBenefitBoneMarrowandStemCellTransplant.We will pay the following expenses incurred by the Covered Person and his or her live donor:(a) Medical expense allowance of two times the selected Hospital Confinement benefit. (b) Actual charges for round trip coach fare on a Common Carrier to the city where the transplant is performed; or personal automobile expense allowance of 50 cents per mile. Mileage is measured from the home of the Donor or Covered Person to the Hospital in which the Covered Person is staying. We will pay for up to 700 miles per Hospital stay. (c) Actual Charges up to $50 per day for lodging and meals expense for donor to remain near Hospital.

(a) $200 per day(b) Actual charges for round trip coach fare; or personal automobile expense of 50 cents per mile.(c) Actual charges up to $50 per day

(a) $400 per day(b) Actual charges for round trip coach fare;or personal automobile expense of 50 cents per mile.(c) Actual charges up to $50 per day

BoneMarrowandStemCellTransplant. We will pay Actual Charges per Covered Person for surgical and anesthetic charges associated with bone marrow transplant and/or peripheral stem cell transplant

Actual charges to a combined lifetime maximum of $15,000

Actual charges to a combined lifetime maximum of $15,000


Benefit BBAC-0001 BBAC-0352Anesthesia. For services of an anesthesiologist during a Covered Person’s surgery. No Lifetime Maximum

For anesthesia in connection with the treatment of skin Cancer. No Lifetime Maximum

Up to 25% of surgical benefit paid.$100 maximum per Covered Person

Up to 25% of surgical benefit paid.

$100 maximum per Covered Person

AmbulatorySurgicalCenter.We will pay the expense incurred at an Ambulatory Surgical Center. No Lifetime Maximum $250 Per Day $250 Per Day

DrugsandMedicines. Payable for drugs and medicine received while the Covered Person is Hospital confined. No Lifetime Maximum

Up to $25 per day, $600 per calendar year

Up to $25 per day, $600 per calendar year

OutpatientAnti-NauseaDrugs. Payable for drugs prescribed by a Physician to suppress nausea due to Cancer or Specified Disease. No Lifetime Maximum



Radiation,RadioactiveIsotopesTherapy,Chemotherapy,orImmunotherapy. Covers treatment administered by a Radiologist, Chemotherapist or Oncologist on an inpatient or outpatient basis. No Lifetime Maximum

Actual charges up to $1,000 per day

Actual charges up to $5,000 per month

MiscellaneousTherapyCharges.Covers charges for lab work or x-rays in connection with radiation and chemotherapy treatment. Service must be performed while receiving treatment(s) in Item 15 or within 30 days following a covered treatment.

Actual charges up toa lifetime maximum of $10,000

Actual charges up to a lifetime maximum of $10,000

Self-AdministeredDrugs.We will pay the actual expenses incurred for self-administered chemotherapy, including hormone therapy, or immunotherapy agents. This benefit is not payable for planning, monitoring, or other agents used to treat or prevent side effects, or other procedures related to this therapy treatment. No Lifetime Maximum



ColonyStimulatingFactors. We will pay expenses incurred for: [a] cost of the chemical substances and [b] their administration to stimulate the production of blood cells. Treatment must be administered by an Oncologist or Chemotherapist. No Lifetime Maximum

Actual charges up to $500 per month


Blood,PlasmaandPlatelets.For blood, plasma and platelets, and transfusions: including administration. No Lifetime Maximum

Actual charges up to $200 per day

Actual charges up to $200 per day

Physician'sAttendance. For one visit per day while Hospital confined. No Lifetime Maximum Up to $35 per day Up to $35 per day

PrivateDutyNursingService.For private nursing services ordered by the Physician while Hospital confined. No Lifetime Maximum Up to $100 per day Up to $100 per day

NationalCancerInstituteDesignatedComprehensiveCancerTreatmentCenterEvaluation/ConsultationBenefit. We will pay the expense incurred if an Covered Person is diagnosed with Internal Cancer and seeks evaluation or consultation from a National Cancer Institute designated Comprehensive Cancer Treatment Center. If the Comprehensive Cancer Treatment Center is located more than 30 miles from the Covered Person’s place of residence, We will also pay the transportation and lodging expenses incurred. This benefit is not payable on the same day a Second or Third Surgical Opinion Benefit is payable and is in lieu of the Non-Local Transportation Benefits of the policy.

Expenses incurred limited to a lifetime maximum up to $750 for evaluation.Expenses incurred limited to a lifetime maximum up to $350 for transportation and lodging.

Expenses incurred limited to a lifetime maximum up to $750 for evaluation.Expenses incurred limited to a lifetime maximum up to $350 for transportation and lodging.

BreastProsthesis.Covers the prosthesis and its implantation if it is required due to breast cancer. No Lifetime Maximum Actual Charges Actual Charges

ArtificialLimborProsthesis.Covers implantation of an artificial limb or prosthesis when an amputation is performed.

$1,500 lifetime maximum per amputation.

$1,500 lifetime maximum per amputation.

PhysicalorSpeechTherapy.Payable when therapy is needed to restore normal bodily function. No Lifetime Maximum Up to $35 per session Up to $35 per session

ExtendedBenefits. If a Covered Person is confined in a Hospital for 60 continuous days We will pay three times the selected Hospital Confinement Benefit beginning on the 61st day for Hospital Confinement. This benefit is payable in place of the Hospital Confinement Benefit. No Lifetime Maximum

$300 per day $600 per day

ExtendedCareFacility. Limited to number of days of prior Hospital confinement. Must begin within 14 days after Hospital confinement, and be at the direction of the attending Physician.No Lifetime Maximum

Up to $50 per day Up to $50 per day

AtHomeNursing. Limited to number of days of prior Hospital confinement. Must begin immediately following a Hospital confinement, and be authorized by the attending Physician. No Lifetime Maximum

Up to $100 per day Up to $100 per day

NeworExperimentalTreatment.We will pay the expenses incurred by a Covered Person for New or Experimental Treatment judged necessary by the attending Physician and received in the United States or in its territories. No Lifetime Maximum

Up to $7,500per calendar year

Up to $7,500per calendar year

HospiceCare. If a Covered Person elects to receive hospice care, We will pay the expenses incurred for care received in a Free Standing Hospice Care Center. No Lifetime Maximum Up to $50 per day Up to $50 per day

GovernmentorCharityHospital. Payable if the Covered Person is confined in a U. S. Government Hospital or a Hospital that does not charge for its services. Paid in place of all other benefits under the Policy. No Lifetime Maximum

$200 per day $200 per day


Other Specified Diseases Covered:

• Addison’s Disease • Meningitis (epidemic cerebrospinal) • Scarlet Fever• Amyotrophic Lateral Sclerosis • Multiple Sclerosis • Sickle Cell Anemia• Cystic Fibrosis • Muscular Dystrophy • Tay-Sachs Disease• Diphtheria • Myasthenia Gravis • Tetanus• Encephalitis • Niemann-Pick Disease • Toxic Epidermal Necrolysis• Epilepsy • Osteomyelitis • Tuberculosis• Hansen’s Disease • Poliomyelitis • Tularemia• Legionnaire’s Disease • Rabies • Typhoid Fever• Lupus Erythematosus • Reye’s Syndrome • Undulant Fever• Lyme Disease • Rheumatic Fever • Whipple’s Disease• Malaria • Rocky Mountain Spotted Fever

Benefit BBAC-0001 BBAC-0352

Hairpiece. We will pay the actual expense incurred per Covered Person for a hairpiece when hair loss is a result of Cancer Treatment.

Actual charge up to a lifetime maximum of $150

Actual charge up to a lifetime maximum of $150

RentalorPurchaseofDurableGoods. We will pay the actual expenses incurred for the rental or purchase of the following pieces of durable medical equipment: a respirator or similar mechanical device, brace, crutches, Hospital bed, or wheelchair. No Lifetime Maximum

Actual charges up to $1,500 per calendar year

Actual charges up to $1,500 per calendar year

WaiverofPremium.After 60 continuous days of disability due to Cancer or Specified Disease, We will waive premiums starting on the first day of policy renewal. After 60 days After 60 days

HospitalConfinement.Payable for each day a Covered Person is charged the daily room rate by a Hospital, for up to 60 days of continuous stay. The benefit for covered children under age 21 is two times the Covered Person’s daily benefit. No Lifetime Maximum $100 per day $200 per day

RenewabilityAs long as premiums are paid on time, you have the right to renew your policy and riders.

PremiumsPremiums for this policy are calculated at age at issue class as of the effective date of the policy. You lock in your age class for the life of the policy. The premium for this policy and rider if selected may change but will not change because you attain the next premium rate age classification. Any change in premium will apply to all policies and riders of this form number issued in your State of residence.

Payment Of BenefitsBenefits are payable for a Covered Person’s Positive Diagnosis of a Cancer or Specified Disease that begins after the Policy Effective Date and while this Policy has remained in force.

Exceptions and Other LimitationsThe Policy pays benefits only for diagnoses resulting from Cancer or Specified Diseases, as defined in the Policy. It does not cover:1. any other disease or sickness;2. injuries;3. any disease, condition, or incapacity that has been caused, complicated,

worsened, or affected by: a. Specified Disease or Specified Disease treatment; or b. Cancer or Cancer treatment, or unless otherwise defined in the Policy4. care and treatment received outside the United States or its territories;5. treatment not approved by a Physician as medically necessary;6. Experimental Treatment by any program that does not qualify as

Experimental Treatment as defined in the Policy.

Pre-Existing Condition LimitationDuring the first 12 months of a Covered Person’s insurance, losses incurred for Pre-Existing Conditions are not covered. During the first 12 months following the date a Covered Person makes a change in coverage that increases his or her benefits, the increase will not be paid for Pre-Existing Conditions. After this 12 month period, however, benefits for such conditions will be payable unless specifically excluded from coverage. This 12 month period is measured from the Policy Effective Date for each Covered Person. If this policy replaces or is in addition to an existing specified disease policy, We will give credit for the expired portion of any waiting period, elimination period, probationary period or any similar provision.

Pre-ExistingCondition means Cancer or a Specified Disease, for which a Covered Person has received medical consultation, treatment, care, services, or for which diagnostic test(s) have been recommended or for which medication has been prescribed during the 12 months immediately preceding the effective date of coverage.

Right to Examine PolicyIf You decide not to keep this Policy, send it to Us or Our agent within 10 days after You receive it. We will treat the Policy as though it had never been issued. We will refund any premiums paid.

Covered PersonsCoveredPersonmeans any of the following:a. the Named Insured; orb. any eligible Spouse or Child, as defined and as indicated on the

Policy Schedule whose coverage has become effective;c. any eligible Spouse or Child, as defined and added to this Policy by

endorsement after the Policy Effective Date whose coverage has become effective; or

d. a newborn child (as described in the Eligibility Section).


Child(Children)means the Named Insured’s unmarried child, stepchild, legally adopted newborn child from the moment of birth if a petition for adoption of a child is filed within 31 days of the birth of such child, or adopted children from the date the petition for adoption of a child is filed who is:a. not yet age 21; orb. not yet age 25 if a full time student at an accredited school.

Option To Add Additional BenefitsHospital Intensive Care Insurance Rider

Form Number HIC-ICR-KS 5/09

In consideration of additional premium, this coverage will provide you with benefits if you go into a Hospital Intensive Care Unit (ICU).

BenefitsYour benefits start the first day you go into ICU. The benefit is payable for up to 45 days per ICU stay.

HospitalIntensiveCareConfinementBenefitYou may choose the benefit of $325, $625, $725, or $825 per day. It is reduced by one-half at age 75.

DoubleBenefitsWe will double the daily benefits for each day you are in an ICU as a result of Cancer or a Specified Disease. We will also double the benefit for an injury that results from: being struck by an automobile, bus, truck, motorcycle, train, or airplane; or being involved in an accident in which the named insured was the operator or was a passenger in such vehicle. ICU confinement must occur within 48 hours of the accident.

EmergencyHospitalizationandSubsequentTransfertoanICUWe will pay the benefit selected by you for the highest level of care in a hospital that does not have an ICU, if you are admitted on an emergency basis, and you are transferred within 48 hours to the ICU of another Hospital.

StepDownUnitWe will pay a benefit equal to one half the chosen daily benefit for confinement in a Step Down Unit.

ExceptionsandOtherLimitationsExcept as provided in Step Down Unit and Emergency Hospitalization and Subsequent Transfer to an ICU, coverage does not provide benefits for: surgical recovery rooms; progressive care; intermediate care; private monitored rooms; observation units; telemetry units; or other facilitieswhich do not meet the standards for a Hospital Intensive Care Unit.

Benefits are not payable: if you go into an ICU before the Policy Effective Date; if you go into an ICU for intentionally self-inflicted bodily injury or suicide attempts; if you go into an ICU due to being intoxicated or under the influence of alcohol, drugs or any narcotics, unless administered on the advice of a Physician and taken according to the Physician’s instructions. The term “intoxicated” refers to that condition as defined by law in the jurisdiction where the accident or cause of loss occurred.

Uponreceiptofyourpolicy,pleasereviewitandyourapplication.Thisisnotamedicaresupplementpolicy.Ifyouareeligibleformedicare,seethemedicaresupplementbuyer’sguideAvailablefromthecompany.ThispolicyonlycoverscancerandtheDiseasesspecifiedabove,unless

Thehospitalintensivecareriderisselected.Ifanyinformationisincorrect,pleasecontact:

BayBridgeAdministratorsP.O.Box161690|Austin,Texas78716|1-800-845-7519

P.O. Box 16190 ‐ Austin, Texas 78716 ‐ (800) 845‐7519

Wellness $50 $100

Administered by:

Intensive Care Rider ‐ $325Coverage 0 ‐ 29 30 ‐ 44 45 ‐ 59 60 +

Employee Only $1.48 $2.59

Radiation/Chemotherapy $1,000 per day $5,000 per monthFirst Diagnosis $2,500 $7,500

Colony Stimulating Factors $500 $1,000

Variable Benefit Elections

Hospital Confinement $100 $200BBAC ‐ 01 BBAC ‐ 352

Surgical $1,500 $4,500

Two Parent Family $27.67 $51.09 $105.94 $157.14One Parent Family $23.97 $35.85 $63.97 $88.47Employee Only $13.09 $24.96 $52.86 $79.11

Coverage 0 ‐ 29 30 ‐ 44 45 ‐ 59 60 +

OFG BlockIndividual Cancer Plan ‐ Monthly Rates

BBAC ‐ 01Coverage 0 ‐ 29 30 ‐ 44 45 ‐ 59 60 +

BBAC ‐ 352

Employee Only $7.49 $15.26 $32.35 $47.03One Parent Family $13.84 $21.60 $38.83 $52.60Two Parent Family $15.94 $30.94 $64.38 $93.15

Two Parent Family $3.70 $5.78 $6.89 $6.53

$3.24 $3.61One Parent Family $3.02 $4.13 $4.80 $5.18

Employee Only $2.85 $4.99 $6.22 $6.95


Two Parent Family $7.12 $11.12 $13.25 $12.56One Parent Family $5.80 $7.94 $9.23 $9.96

Employee Only $3.30 $5.79 $7.22 $8.06



Employee Only $3.76 $6.58 $8.21 $9.17



INDIVIDUAL ACCIDENT INSURANCE

Underwritten by Humana Insurance Company

John D. Webb

Salina, KS 67401

(888)756-6670

[email protected]

Form Number: HIC-ACC-SB-KS

Individual Accident InsurancePOLICY FORM HIC-ACC-POL-KS 7/09Underwritten by Humana Insurance Company

► Plan Features• Onandoffthejobbenefits• Paysregardlessofothercoverage

BenefitsFor:

• AccidentMedicalExpenseBenefit• AccidentHospitalIndemnity• DislocationsandFractures• AccidentalDeathandDismemberment

Bronze1Unit

Silver2Units

Gold3Units

AccidentMedicalExpenseBenefitWe will pay the Actual Charges incurred up to $250 per unit if, as a result of Injury, a Covered Person requires medical or surgical treatment.

$250 $500 $750

AccidentHospitalIndemnityBenefitWe will pay for each day a Covered Person is Confined during one or more periods of Hospital Confinement if: a) the Confinement is due to Injury; or b) the first day of Confinement occurs within 90 days after the accident.

$100 $200 $300

AmbulanceServiceBenefitWe will pay for regular ambulance service and for air Ambulance if as a result of an injury,a Covered Person requires ambulance service for transfer; a) to a Hospital; or b) from a Hospital.

Regular Ambulance / Air Ambulance

$100 / $200 $200/$400 $300/ $600

DislocationandFractureBenefit

We will pay the following amount shown based on Your selection of coverage:

For Fracture of Bone or Bones of: Bronze1Unit

Silver2Units

Gold3Units For Complete Dislocation of: Bronze

1UnitSilver2Units

Gold3Units

Skull (except Bones of Face or Nose) $1,900 $3,800 $5,700 Hip Joint $2,000 $4,000 $6,000Hip, Thigh (Femur) $2,000 $4,000 $6,000 Knee Joint (Except Patella) $ 800 $1,600 $2,400Pelvis (Except Coccyx) $2,000 $4,000 $6,000 Bone or Bones of the Foot, Other than Toes $ 800 $1,600 $2,400Arm, Between Shoulder and Elbow (Shaft) $1,100 $2,200 $3,300 Ankle Joint $ 800 $1,600 $2,400Shoulder Blade (Scapula) $1,100 $2,200 $3,300 Wrist Joint $ 700 $1,400 $2,100Leg (Tibia or Fibula) $1,100 $2,200 $3,300 Elbow Joint $ 600 $1,200 $1,800Ankle $ 800 $1,600 $2,400 Shoulder Joint $ 400 $ 800 $1,200Knee Cap (Patella) $ 800 $1,600 $2,400 Bone or Bones of the Hand, Other than Fingers $ 300 $ 600 $ 900Collar Bone (Clavicle) $ 800 $1,600 $2,400 Collar Bone $ 300 $ 600 $ 900Forearm (Radius or Ulna) $ 800 $1,600 $2,400 Two or More Fingers $ 140 $ 280 $ 420Foot (Except Toes) $ 700 $1,400 $2,100 Two or More Toes $ 140 $ 280 $ 420Hand or Wrist (Except Fingers) $ 700 $1,400 $2,100 One Finger or One Toe $ 60 $ 120 $ 180Lower Jaw (Except Alveolar Process) $ 400 $ 800 $1,200Two or More Ribs, Fingers or Toes $ 300 $ 600 $ 900Bones of Face or Nose $ 300 $ 600 $ 900 Primary Insured Coverage 100%/Spouse Coverage 50%/ Child Coverage 25%One Rib, Finger or Toe $ 140 $ 280 $ 420Coccyx $ 140 $ 280 $ 420


AccidentalDeathandDismembermentBenefit

We will pay the following amount shown based on Your selection of coverage:

For Loss of: Bronze1Unit

Silver2Units

Gold3Units

Bronze1Unit

Silver2Units

Gold3Units

Life $20,000 $40,000 $60,000 One Hand or One Arm $10,000 $20,000 $30,000Both Hands or Both Feet or Sight of Both Eyes $20,000 $40,000 $60,000 One Foot or One Leg $10,000 $20,000 $30,000Both Arms or Both Legs $20,000 $40,000 $60,000 One or More Entire Toes $ 1,000 $ 2,000 $ 3,000One Hand or Arm and One Foot or Leg $20,000 $40,000 $60,000 One or More Entire Fingers $ 800 $ 1,600 $ 2,400Sight of One Eye $10,000 $20,000 $30,000

Primary Insured Coverage 100%/Spouse Coverage 50%/ Child Coverage 25%

Lossmeans with regard to: a) hands and feet--actual severance through or above wrist or ankle joints; b) sight, entire and irrecoverable loss thereof;c) toes and fingers--actual severance through or above the metacarpophalangeal joints.

If loss is sustained by a Covered Person while riding as a fare-paying passenger on a scheduled Common Carrier, We will pay three times the amount payable under the Accidental Death and Dismemberment Benefit.

Covered PersonsFamily plan coverage may include the following: You; Your spouse; Your unmarried dependent children under age 21 (25 if full-time student); grandchildren dependent upon you for income tax purposes; and children required to be insured under a medical support order by a court. Incapacitated children are covered in accordance with the incapacitated child continuation provision in the policy.

Termination of Covered Persons: Yourcoverageterminatesontheearliestof:a) the date the Policy is terminated; b) the date of Your death; c) Your attainment of the Policy Age Limit; or d) Your failure to pay the required premium, subject to the Grace Period. Your spouse, if covered under the policy, becomes the new insured upon Your death or the date Your coverage terminates because You reached the Policy Age Limit.

CoverageforYourspousewillterminateonthefirsttooccurof:a) the termination of this Policy: b) the date following your divorce, legal separation or annulment of marriage; c) Your spouse’s attainment of the Policy Age Limit; d) the date of Your spouse’s death; or e) failure to pay the required premium, subject to the Grace Period.

CoverageforYourdependentchild(ren)willterminateonthefirsttooccurof:a) the termination of this Policy; b) the policy anniversary date after he or she ceases to be a Dependent; or c) failure to pay the required premium, subject to the Grace Period.Termination will be without prejudice to a claim that begins before termination.

Exclusions and Other LimitationsThis Policy does not cover any loss resulting from:

a. intentionally self-inflicted injury;b. suicide or attempted suicide, whether sane or insane;c. injury incurred prior to the effective date of coverage; d. war or act of war, whether declared or undeclared;e. injury sustained while in the armed forces of any country or international authority;f. injury sustained while riding On any aircraft except a Civil or Public Aircraft, or Military Transport Aircraft;g. injury sustained while riding On any aircraft except as a fare-paying passenger in an aircraft provided by a licensed Common Carrier;h. injury sustained while voluntarily taking drugs which federal law prohibits dispensing without a prescription, including sedatives, narcotics, barbiturates, amphetamines, or hallucinogens, unless the drug is taken as prescribed or administered by a licensed physician;i. injury sustained while committing or attempting to commit a felony; j. injury sustained while the Covered Person is operating any motor vehicle while legally intoxicated from the use of alcohol;k. hernia, including complications due to hernia; l. driving in any organized or scheduled race or speed test or while testing an automobile or any vehicle on any racetrack or speedway;m. voluntarily taking poison;n. asphyxiation from voluntarily inhaling gas or fumes.

Pre-Existing Condition LimitationIf a Covered Person has a pre-existing condition, We will not pay benefits for such condition during the 2 year period beginning on the policy date.

Pre-existingCondition means a condition [a] which manifested itself prior to the effective date of coverage; or [b] for which medical advice or treatment was recommended by or received from a physician in the 5years prior to the effective date of coverage.

Right to Return PolicyIf You are not satisfied with this Policy for any reason, You may return it to us or to the agent from whom it was purchased within 10 days. We will consider it void from the Policy Date and any premium paid will be returned.

RenewabilityYour Policy is Guaranteed Renewable until age 70, by payment of premiums as they become due. This Policy will terminate on the last day of the period for which premium is paid unless continued in force during a Grace Period.


Premium ChangeWe have the right to change the table of premium rates for this Policy. The change in premium will apply to all policies of this form number issued to insureds in Your state of residence. Premiums will be charged in accordance with the table of premium rates using the original classification.

Additional Benefits Rider HIC-ACC-ABR-KS 7/09

In consideration of an additional premium, We will pay the benefits listed below. Coverage for Primary Insured, Spouse and Child/Children based on

Your selection of coverage.

BenefitScheduleBronze, Silver and Gold Options 1 Unit of Coverage

AbdominalorThoracicSurgeryBenefit - We will pay $1,000 if a covered person undergoes abdominal or thoracic surgery to repair internal injuries as a result of a covered injury. The surgery must be performed within 3 days of the covered accident. For exploratory surgery done with no surgical repair, We will pay $100.

AccidentFollow-UpTreatmentBenefit - We will pay $50 per day a covered person receives a follow-up treatment provided that a benefit has been paid under the Medical Expense Benefit of the policy. This benefit is limited to 2 treatments per covered accident per covered person. Treatments must be administered by a physician in the physician’s office or a hospital on an outpatient basis. Follow-up treatments must begin within 90 days of the covered accident and not take place longer than 6 months after the covered accident. This Benefit is not payable at the same time a benefit is payable under the Physical Therapy Benefit.

ApplianceBenefit - We will pay $125 for prescribed medical appliances that aid in personal mobility including wheelchair, crutches or walker. Use of these devices must begin within 90 days after a covered accident and the Benefit is payable only once per covered person per covered accident.

BloodandPlasmaBenefit- We will pay $300 for blood or plasma for a transfusion required for a covered accident. The transfusion must be within 3 days of the covered accident and is payable only once per covered person per accident.

BrainInjuryDiagnosisBenefit- We will pay $150 for the first diagnosis of the following traumatic brain injuries: cerebral contusion; cerebal laceration; concussion; or intercranial hemorrage. The covered person must be treated within 3 days of a covered accident; and diagnosis made by computed tomography (CT) scan, electroencephalogram (EEG), magnetic resonance imaging (MRI), positron emission tomography (PET) scan or X-ray must occur within 30 days of the accident. This benefit is payable only once per covered person.

BurnBenefit- We will pay $100 if burns cover less than 15% of the body surface and $500 if burns cover more than 15% of the body surface for one or more second or third degree burns other than sunburn. Treatment must be within 3 days of the covered accident and the benefit is payable only once per covered person per covered accident.

ComaBenefit - We will pay $15,000 if a covered person is in a Coma as defined in this rider which lasts 5 or more consecutive days as a result of a covered accident. This benefit is payable only once per covered person.

EyeInjuryBenefit- We will pay $100 for surgery or the removal of a foreign object from the eye. Treatment must be performed by a physician and occur within 90 days of the accident. An examination without anesthesia is not considered a surgery. This benefit is payable only once per covered person per covered accident.

FamilyMemberLodgingBenefit - We will pay $100 per day for lodging of one adult member of a covered person’s family when a covered person is confined in a non-local hospital or speciality free standing treatment center while undergoing treatment for a covered accident. This benefit is payable for 30 days for each covered accident. This benefit is payable only if the Non-local Transportation Benefit is payable under the covered accident. This benefit will not be paid if the family member lives within 60 miles of the treatment facility.

HospitalIntensiveCareConfinementBenefit- We will pay $400 per day that a covered person is confined to a hospital Intensive Care Unit. Confinement must begin within 3 days after a covered accident and is payable for up to 60 days of continuous confinement in the Intensive Care Unit. For a partial day confinement, the daily benefit will be pro-rated based on the number of hours confined divided by 24 hours.

ImmediateHospitalizationBenefit- We will pay $1,000 upon the first confinement to a hospital during a calendar year for a covered accident providing that a benefit is payable under the Hospital Confinement Benefit of the policy. The covered person must be confined to the hospital within 3 days of a covered accident and is payable only once per covered person per hospital confinement and only once per calendar year.

LacerationBenefit- We will pay $50 for lacerations or cuts treated by a physician within 3 days of a covered accident. This benefit is only payable once per covered person per calendar year.

NonLocalTransportationBenefit- We will pay $300 per trip for non-local treatment at a hospital or speciality free-standing treatment center nearest the covered person’s home. Treatment must be prescribed by a physician and the same treatment or care cannot be obtained locally. Non-local is treatment that is 60 miles or more one way from the covered person’s home. We do not pay for visits to a physician’s office or clinic or for services other than actual treatment. This benefit is payable 3 times per covered accident. This benefit does not cover ground or air ambulance.

ParalysisBenefit- We will pay $10,000 for paraplegia and $20,000 for quadriplegia if a covered person receives a spinal cord injury resulting in complete and permanent loss of use of two or more limbs. An attending physician must confirm the paralysis within 3 days of a covered accident and the paralysis must last for at least 90 consecutive days. This benefit is payable only once per covered person.

PhysicalTherapyBenefit- We will pay $30 per day a covered person receives physical therapy treatment. This benefit is only payable if a benefit has been paid under the Medical Expense Benefit of the policy. We will pay for a maximum of one treatment per day with a maximum of 6 treatments per covered accident per covered person. This benefit is only payable for injuries resulting from a covered accident where benefits begin within 90 days of the covered accident. Treatments after 6 months after a covered accident are not covered. This benefit is not payable for a same visit for which a benefit is payable under the Accident Follow-Up Treatment Benefit.


ProsthesisBenefit-We will pay $500 for one device and $1,000 for 2 or more devices for a prosthetic hand, foot, or eye that is prescribed by a physician. This benefit is payable if a benefit is paid for the loss of hand, foot, or eye under the Accidental Dismemberment benefit of the policy. The device or devices must be received within 180 days of a covered accident. This benefit is payable only once per covered person per covered accident.

RupturedDiscBenefit - We will pay $500 for a ruptured disc of the spine. The ruptured disc must be diagnosed as a result of a covered accident and surgically repaired by a physician within 180 days of the date of the covered accident.

SkinGraftBenefit - We will pay 50% of the Burn Benefit under this rider if a covered person receives a skin graft for a burn for which a benefit is paid under the Burn Benefit. The skin graft must be performed by a physician to treat a covered burn within 90 days of a covered accident. This benefit is payable only once per covered person per covered accident.

Tendon,Ligament,RotatorCufforKneeCartilageBenefit- We will pay $500 per injury for an injured tendon, ligament, rotator cuff or knee cartliage. The injury site must be torn, ruptured, or severed and surgically repaired by a physician within 180 days of a covered accident. If exploratory surgery. using arthroscopy is done and no surgical repair is done, we will pay $150 for the exploratory surgery. This benefit is not paid if a benefit is paid under the Ruptured Disc Benefit of the rider for the same covered accident.

The benefits under this rider are subject to the Pre-existing Condition Limitation of the policy. All other general provisions of the Policy to which this rider is attached apply to this rider.

RIDERRENEWALPROVISIONThis rider is renewable in the same manner as the Policy to which it is attached.

TERMINATIONThis rider terminates:a) when coverage terminates under the Policy to which this rider is attached;b) when the premium for this rider is not paid before the end of the Grace Period; or c) when the Insured Person gives Us Written Notice to terminate this rider.

Uponreceiptofyourpolicy,pleasereviewitandyourapplication.

Ifanyinformationisincorrect,pleasecontact:

BayBridgeAdministratorsP.O.Box161690|Austin,Texas78716|1-800-845-7519

Coverage TierBase Policy

Per UnitAdditional

Benefits Rider

Individual $9.40 $3.29

Ind + Spouse $16.82 $6.57

Ind + Child(ren) $17.46 $7.36

Family $24.89 $10.64

Effective Date - 1/1/2013

Administered by:

P.O. Box 16190 - Austin, Texas 78716 - (800) 845-7519

Underwritten by:Humana Insurance Company

Monthly Rates

OFG BlockIndividual Accident Plan

USD 405 Aflac Representative

Randy Fry

Alfac Agent

1201 Bradley

Great Bend, KS 67530

620-786-4307

[email protected]

To schedule your time

Cancer Insurance

Hospital Confinement Insurance

AFLACCANCER CARE CANCERINDEMNITYINsuRANCE

CLAssiCWe’ve been dedicated to helping provide

peace of mind and financial security for

nearly 60 years.

A78375RKS IC(10/12)

Chances are you know someone who’s been affected, directly or indirectly, by

cancer. You also know the toll it’s taken on them—physically, emotionally, and

financially. That’s why we’ve developed the Aflac Cancer Care insurance policy.

The plan pays a cash benefit upon initial diagnosis of a covered cancer, with a

variety of other benefits payable throughout cancer treatment. You can use these

cash benefits to help pay out-of-pocket medical expenses, the rent or mortgage,

groceries, or utility bills—the choice is yours.

And while you can’t always predict the future, here at Aflac we believe it’s good to

be prepared. The Aflac Cancer Care plan is here to help you and your family better

cope financially—and emotionally—if a positive diagnosis of cancer ever occurs.

That way you can worry less about what may be ahead.

Aflac herein means American Family Life Assurance Company of Columbus.

Added Protection for You and Your Family

AFLAC CANCER

CARE - CLAssiC coverage is selected.

Policyholder suffers from

frequent infections & high fevers.

Physician visit & bone marrow biopsy reveals diagnosis of leukemia.

AFLAC CANCER

CARE - CLAssiC

insurance policy provides the

following:

how I T w o Rks

$33,175ToTAlBENEfITs

The above example is based on a scenario for Aflac Cancer Care – Classic that includes the following benefit conditions: Physician visit (Cancer Wellness Benefit) of $75, bone marrow biopsy (Surgical/Anesthesia Benefit) of $125, NCI Evaluation/Consultation Benefit of $500, Initial Diagnosis Benefit of $4,000, venous port

(Surgical/Anesthesia Benefit) of $125, Injected Chemotherapy Administration Benefit (10 weeks) of $4,000, Immunotherapy Benefit (3 months) of $1,050, Antinausea Benefit (3 months) of $300, Hospital Confinement Benefit (10-week hospitalization) of $22,000, Blood/Plasma Benefit (10 transfusions) of $1,000.

1Cancer Facts & Figures 2012, American Cancer Society.

The policy has limitations and exclusions that may affect benefits payable. For costs and complete details of the coverage, contact your Aflac insurance agent/producer. This brochure is for illustrative purposes only. Refer to the policy for benefit details, definitions, limitations, and exclusions.

ThE fACT s sAY You NEED ThE pR oTECT IoN of AflAC ’s CANCER CARE plAN :

1-in-2 1-in-3FA C t N o . 0 1 FA C t N o . 0 2

LIFETIME RISK OF DEvELOPINg CANCER.1 LIFETIME RISK OF DEvELOPINg CANCER.1

IN THE UNITED STATES, WOMEN HAvE SLIgHTLY MORE THAN AIN THE UNITED STATES, MEN HAvE SLIgHTLY LESS THAN A

AflACCANCERCARECANCERINDEMNITYINsuRANCE CCPolicy Series A78000

C l A s s I C

Classic Cancer Care Benefit Overview

Benefit name Benefit amount

Cancer Wellness Benefit $75 per year, per Covered Person

Mammography Benefit $70 per year, per Covered Person

Cancer Diagnosis Benefits:

Initial Diagnosis Benefit Insured/Spouse: $4,000; Dependent Child: $8,000; payable once per Covered Person

Medical Imaging With Diagnosis Benefit $135; two payments per year, per Covered Person; no lifetime max

NCI Evaluation/Consultation Benefit $500 payable only once per Covered Person

Cancer Treatment Benefits:

Injected Chemotherapy Administration Benefit $400 per week; no lifetime max

Nonhormonal Oral/Injected Chemotherapy Benefit $250 per prescription, per month up to $750 max per month for Chemotherapy Benefits2

Hormonal Oral/Injected Chemotherapy Benefit $250 per prescription, per month up to 24 months; after 24 months $75 per month up to $750 max per month for Chemotherapy Benefits2

Topical Chemotherapy Benefit $150 per prescription, per month up to $750 max per month for Chemotherapy Benefits2

Radiation Therapy Benefit $350 per week; no lifetime max

Experimental Treatment Benefit $350 per week if charged; $100 per week if no charge; no lifetime max

Immunotherapy Benefit $350 once per month; $1,750 lifetime max per Covered Person

Antinausea Benefit $100 per month; no lifetime max

Stem Cell Transplantation Benefit $7,000; lifetime max $7,000 per Covered Person

Bone Marrow Transplantation Benefit $7,000; $7,000 lifetime max per Covered Person; $750 to donor

Blood and Plasma Benefit Inpatient: $100 times the number of days paid under the Hospital Confinement Benefit; Outpatient: $175 per day; no lifetime max

Surgical/Anesthesia Benefit $100–$3,400 (Anesthesia: additional 25% of Surgical Benefit); maximum daily benefit not to exceed $4,250; no lifetime max on number of operations

Skin Cancer Surgery Benefit $35–$400; no lifetime max on number of operations

Additional Surgical Opinion Benefit $200 per day; no lifetime max

Hospitalization Benefits:

Hospital Confinement Benefit:

• Hospitalization for 30 days or less Insured/Spouse: $200 per day; Dependent Child: $250 per day; no lifetime max

• Hospitalization for Days 31+ Insured/Spouse: $400 per day; Dependent Child: $500 per day; no lifetime max

Outpatient Hospital Surgical Room Charge Benefit $200 (payable in addition to Surgical/Anesthesia Benefit); no lifetime max on number of operations

Continuing Care Benefits:

Extended-Care Facility Benefit $100 a day, limited to 30 days per year, per Covered Person

Home Health Care Benefit $100 per day; limited to 30 days per year, per Covered Person

Hospice Care Benefit $1,000 for the 1st day; $50 per day thereafter; $12,000 lifetime max per Covered Person

Nursing Services Benefit $100 per day; no lifetime max

Surgical Prosthesis Benefit $2,000; lifetime max $4,000 per Covered Person

Nonsurgical Prosthesis Benefit $175 per occurrence; lifetime max $350 per Covered Person

Reconstructive Surgery Benefit $220–$2,000 (Anesthesia: 25% of Reconstructive Surgery Benefit); no lifetime max on number of operations

Egg Harvesting and Storage (Cryopreservation) Benefit $1,000 to have oocytes extracted; $350 for storage; $1,350 lifetime max per Covered Person

Ambulance, Transportation, Lodging, and Other Benefits:

Ambulance Benefit $250 ground or $2,000 air; no lifetime max

Transportation Benefit $.40 per mile; max $1,200 per round trip; no lifetime max

Lodging Benefit $65 per day; limited to 90 days per year

Bone Marrow Donor Screening Benefit $40; limited to one benefit per Covered Person, per lifetime

REFER TO THE FOLLOWINg OUTLINE OF COvERAgE FOR BENEFIT DETAILS, DEFINITIONS, LIMITATIONS, AND EXCLUSIONS.

2Up to three different chemotherapy medicines per calendar month.

1Cancer Facts & Figures 2012, American Cancer Society.

The policy has limitations and exclusions that may affect benefits payable. For costs and complete details of the coverage, contact your Aflac insurance agent/producer. This brochure is for illustrative purposes only. Refer to the policy for benefit details, definitions, limitations, and exclusions.

A78325KS

american family Life assurance Company of Columbus(herein referred to as aflac)

Worldwide Headquarters • 1932 Wynnton Road • Columbus, Georgia 31999 toll-free 1.800.99.afLaC (1.800.992.3522)

the policy described in this outline of Coverage provides supplemental coverage and will be issued only to supplement insurance already in force.

L I M I T E D B E N E F I T

S P E C I F I E D - D I S E A S E I N S U R A N C E

O U T L I N E O F C O v E R A g E F O R P O L I C y F O R M S E R I E S A 7 8 3 0 0

tHiS iS not meDiCaRe SuPPLement CoVeRaGe.

if you are eligible for medicare, review the medicare Supplement Buyer’s Guide furnished by aflac.

(10/12)A78325KS.1

© 2011 Aflac All Rights Reserved

(10/12)A78325KS.1


1. Read Your Policy Carefully: This Outline of Coverage provides a very brief description of some of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth, in detail, the rights and obligations of both you and Aflac. It is, therefore, important that you ReaD YouR PoLiCY CaRefuLLY.

2. Cancer insurance Coverage is designed to supplement your existing accident and sickness coverage only when certain losses occur as a result of the disease of Cancer or an Associated Cancerous Condition. Coverage is provided for the benefits outlined in Part (3). The benefits described in Part (3) may be limited by Part (5).

3. All treatments below, except prescription drugs, must must be NCI or Food and Drug Administration (FDA) approved for the treatment of Cancer or Associated Cancerous Condition, as applicable. Prescription drugs will be covered if the prescription drug is recognized for treatment of the indication in one of the standard reference compendia or in substantially accepted peer-reviewed medical literature. The prescribing Physician shall submit to the insurer documentation supporting the proposed off-label use or uses if requested by the insurer.

a. CanCeR WeLLneSS BenefitS: 1. CanCeR WeLLneSS: Aflac will pay $75 per Calendar Year when

a Covered Person receives one of the following:

• breast ultrasound

• breast MRI

• CA15-3 (blood test for breast Cancer tumor)

• Pap smear

• ThinPrep

• biopsy

• flexible sigmoidoscopy

• hemoccult stool specimen (lab confirmed)

• chest X-ray

• CEA (blood test for colon Cancer)

• CA 125 (blood test for ovarian Cancer)

• PSA (blood test for prostate Cancer)

• testicular ultrasound

• thermography

• colonoscopy

• virtual colonoscopy

This benefit is limited to one payment per Calendar Year, per Covered Person. These tests must be performed to determine whether Cancer or an Associated Cancerous Condition exists in a Covered Person and must be administered by licensed medical personnel. No lifetime maximum.

2. mammoGRaPHY Benefit: Aflac will pay $70 (seventy dollars) per Calendar Year when charges are incurred for an annual screening by low dose mammography for the presence of occult breast Cancer. This benefit is limited to one payment per Calendar Year, per Covered Person. No lifetime maximum.

3. Bone maRRoW DonoR SCReeninG: Aflac will pay $40 when a Covered Person provides documentation of participation in a screening test as a potential bone marrow donor. This benefit is limited to one benefit per Covered Person per lifetime.

B. CanCeR DiaGnoSiS BenefitS: 1. initiaL DiaGnoSiS Benefit: Aflac will pay the amount listed

below when a Covered Person is diagnosed as having Internal Cancer or an Associated Cancerous Condition while this policy is in force, subject to Part 2, Limitations and Exclusions, Section B, of the policy.

Named Insured or Spouse $4,000 Dependent Child $8,000

This benefit is payable under the policy only once for each Covered Person. In addition to the Positive Medical Diagnosis, we may require additional information from the attending Physician and Hospital.

2. meDiCaL imaGinG WitH DiaGnoSiS Benefit: Aflac will pay $135 when a charge is incurred for a Covered Person who receives an initial diagnosis or follow-up evaluation of Internal Cancer or an Associated Cancerous Condition, using one of the following medical imaging exams: CT scans, MRIs, bone scans, thyroid scans, multiple gated acquisition (MUGA) scans, positron emission tomography (PET) scans, transrectal ultrasounds, or abdominal ultrasounds. This benefit is limited to two payments per Calendar Year, per Covered Person. No lifetime maximum.

3. nationaL CanCeR inStitute eVaLuation/ConSuLtation Benefit: Aflac will pay $500 when a Covered Person seeks evaluation or consultation at an NCI-Designated Cancer Center as a result of receiving a diagnosis of Internal Cancer or an Associated Cancerous Condition. The purpose of the evaluation/consultation must be to determine the appropriate course of treatment. This benefit is not payable the same day the Additional Surgical Opinion Benefit is payable. This benefit is also payable at the Aflac Cancer Center & Blood Disorders Service of Children’s Healthcare of Atlanta. This benefit is payable only once per Covered Person.

C. CanCeR tReatment BenefitS: 1. DiReCt nonSuRGiCaL tReatment BenefitS: all benefits

listed below are not payable based on the number, duration, or frequency of the medication(s), therapy, or treatment received by the Covered Person (except as provided in Benefit C1a). Benefits will not be paid under the experimental treatment Benefit or immunotherapy Benefit for any medications or treatment paid under the Chemotherapy Benefits, injected Chemotherapy administration Benefit, or the Radiation therapy Benefit.

A78325KS 6

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a. CHemotHeRaPY BenefitS:

(1) nonHoRmonaL oRaL/inJeCteD CHemotHeRaPY Benefit: Aflac will pay $250 per Calendar Month during which a Covered Person is prescribed, receives, and incurs a charge for Nonhormonal Oral/Injected Chemotherapy for the treatment of Cancer or an Associated Cancerous Condition.

(2) HoRmonaL oRaL/inJeCteD CHemotHeRaPY Benefit: Aflac will pay $250 per Calendar Month for up to 24 months during which a Covered Person is prescribed, receives, and incurs a charge for Hormonal Oral/Injected Chemotherapy for the treatment of Cancer or an Associated Cancerous Condition. After 24 months of paid benefits of Hormonal Oral/Injected Chemotherapy for a Covered Person, Aflac will pay $75 per Calendar Month during which a Covered Person is prescribed, receives, and incurs a charge for Hormonal Oral/Injected Chemotherapy for the treatment of Cancer or an Associated Cancerous Condition. Examples of Hormonal Oral Chemotherapy treatments include but are not limited to Nolvadex, Arimidex, Femara, and Lupron and their generic versions, such as tamoxifen.

(3) toPiCaL CHemotHeRaPY Benefit: Aflac will pay $150 per Calendar Month during which a Covered Person is prescribed, receives, and incurs a charge for a Topical Chemotherapy for the treatment of Cancer or an Associated Cancerous Condition.

Chemotherapy benefits are limited to the Calendar month in which the charge for the medication(s) or treatment is incurred. if the prescription is for more than one month, the benefit is limited to the Calendar month in which the charge is incurred. total benefits are payable for up to three different Chemotherapy medicines per Calendar month, up to a maximum of $750 per Calendar month. Refills of the same prescription within the same Calendar month are not considered a different Chemotherapy medicine. no lifetime maximum.

b. inJeCteD CHemotHeRaPY aDminiStRation Benefit: Aflac will pay $400 once per Calendar Week for administration fee for the treatment of Cancer or Associated Cancer Condition injected by medical personnel in a Physician’s office, clinic or a Hospital. The Surgical/Anesthesia Benefit provides amounts payable for insertion and removal of a pump. Benefits will not be paid for each week of continuous infusion of medications dispensed by a pump, implant, or patch. This benefit is limited to the Calendar Week in which the charge for the medication(s) or treatment is incurred. No lifetime maximum.

c. RaDiation tHeRaPY Benefit: Aflac will pay $350 once per Calendar Week during which a Covered Person receives and incurs a charge for Radiation Therapy for the treatment

of Cancer or an Associated Cancerous Condition. This benefit will not be paid for each week a radium implant or radioisotope remains in the body. This benefit is limited to the Calendar Week in which the charge for the therapy is incurred. No lifetime maximum.

d. eXPeRimentaL tReatment Benefit: Aflac will pay $350 once per Calendar Week during which a Covered Person receives and incurs a charge for Physician-prescribed experimental Cancer chemotherapy medications. Aflac will pay $100 once per Calendar Week during which a Covered Person receives Physician-prescribed experimental Cancer chemotherapy medications as part of a clinical trial that does not charge patients for such medications.

Chemotherapy medications must be approved by the NCI as a viable experimental treatment for Cancer. This benefit does not pay for laboratory tests, diagnostic X-rays, immunoglobulins, Immunotherapy, colony-stimulating factors, and therapeutic devices or other procedures related to these experimental treatments. Benefits will not be paid for each week of continuous infusion of medications dispensed by a pump, implant, or patch. This benefit is limited to the Calendar Week in which the charge for the chemotherapy medications is incurred. No lifetime maximum.

Benefits will not be paid under the experimental treatment Benefit for any medications paid under the immunotherapy Benefit.

2. inDiReCt/aDDitionaL tHeRaPY BenefitS: the following benefits are not payable based on the number, duration, or frequency of immunotherapy or anti-nausea drugs received by the Covered Person.

a. immunotHeRaPY Benefit: Aflac will pay $350 per Calendar Month during which a Covered Person receives and incurs a charge for Physician-prescribed Immunotherapy as part of a treatment regimen for Internal Cancer or an Associated Cancerous Condition. This benefit is payable only once per Calendar Month. It is limited to the Calendar Month in which the charge for Immunotherapy is incurred. Lifetime maximum of $1,750 per Covered Person.

Benefits will not be paid under the immunotherapy Benefit for any medications paid under the experimental treatment Benefit.

b. antinauSea Benefit: Aflac will pay $100 per Calendar Month during which a Covered Person receives and incurs a charge for antinausea drugs that are prescribed in conjunction with Radiation Therapy Benefits, Chemotherapy Benefits, or Experimental Treatment Benefits. This benefit is payable only once per Calendar Month and is limited to the Calendar Month in which the charge for antinausea drugs is incurred. No lifetime maximum.

A78325KS 7

(10/12)A78325KS.1


c. Stem CeLL tRanSPLantation Benefit: Aflac will pay $7,000 when a Covered Person receives and incurs a charge for a peripheral Stem Cell Transplantation for the treatment of Internal Cancer or an Associated Cancerous Condition. This benefit is payable once per Covered Person. Lifetime maximum of $7,000 per Covered Person.

d. Bone maRRoW tRanSPLantation Benefit: (1) Aflac will pay $7,000 when a Covered Person receives and incurs a charge for a Bone Marrow Transplantation for the treatment of Internal Cancer or an Associated Cancerous Condition. (2) Aflac will pay the Covered Person’s bone marrow donor an indemnity of $750 for his or her expenses incurred as a result of the transplantation procedure. Lifetime maximum of $7,000 per Covered Person.

e. BLooD anD PLaSma Benefit: Aflac will pay $100 times the number of days paid under the Hospital Confinement Benefit when a Covered Person receives and incurs a charge for blood and/or plasma transfusions during a covered Hospital confinement. Aflac will pay $175 for each day a Covered Person receives and incurs a charge for blood and/or plasma transfusions for the treatment of Internal Cancer or an Associated Cancerous Condition as an outpatient in a Physician’s office, clinic, Hospital, or Ambulatory Surgical Center. This benefit does not pay for immunoglobulins, Immunotherapy, antihemophilia factors, or colony-stimulating factors. No lifetime maximum.

3. SuRGiCaL tReatment BenefitS:

a. SuRGiCaL/aneStHeSia Benefit: When a surgical operation is performed on a Covered Person for a diagnosed Internal Cancer or Associated Cancerous Condition, Aflac will pay the indemnity listed in the Schedule of Operations for the specific procedure when a charge is incurred. If any operation for the treatment of Internal Cancer or an Associated Cancerous Condition is performed other than those listed, Aflac will pay an amount comparable to the amount shown in the Schedule of Operations for the operation most nearly similar in severity and gravity.

eXCePtionS: Surgery for Skin Cancer will be payable under Benefit C3b. Reconstructive Surgery will be payable under Benefit e7.

Two or more surgical procedures performed through the same incision will be considered one operation, and benefits will be paid based upon the highest eligible benefit.

Aflac will pay an indemnity benefit equal to 25% of the amount shown in the Schedule of Operations for the administration of anesthesia during a covered surgical operation.

The maximum daily benefit will not exceed $4,250. No lifetime maximum on the number of operations.

b. SKin CanCeR SuRGeRY Benefit: When a surgical operation is performed on a Covered Person for a diagnosed skin Cancer, including melanoma or Nonmelanoma Skin Cancer, Aflac will pay the indemnity listed below when a charge is incurred for the specific procedure. The indemnity amount listed below includes anesthesia services. The maximum daily benefit will not exceed $400. No lifetime maximum on the number of operations.

Laser or Cryosurgery $ 35

Surgeries otHeR tHan Laser or Cryosurgery: Biopsy 70 Excision of lesion of skin without flap or graft 170 Flap or graft without excision 250 Excision of lesion of skin with flap or graft 400

c. aDDitionaL SuRGiCaL oPinion Benefit: Aflac will pay $200 per day when a charge is incurred for an additional surgical opinion, by a Physician, concerning surgery for a diagnosed Cancer or an Associated Cancerous Condition. This benefit is not payable on the same day the NCI Evaluation/Consultation Benefit is payable. No lifetime maximum.

D. HoSPitaLiZation BenefitS:1. HoSPitaL Confinement BenefitS:

a. HoSPitaLiZation foR 30 DaYS oR LeSS: When a Covered Person is confined to a Hospital for treatment of Cancer or an Associated Cancerous Condition for 30 days or less, Aflac will pay the amount listed below per day for each day a Covered Person is charged for a room as an inpatient. No lifetime maximum.

Named Insured or Spouse $200 Dependent Child $250

b. HoSPitaLiZation foR 31 DaYS oR moRe: During any continuous period of Hospital confinement of a Covered Person for treatment of Cancer or an Associated Cancerous Condition for 31 days or more, Aflac will pay benefits as described in Benefit D1a above for the first 30 days. Beginning with the 31st day of such continuous Hospital confinement, Aflac will pay the amount listed below per day for each day a Covered Person is charged for a room as an inpatient. No lifetime maximum.

Named Insured or Spouse $400 Dependent Child $500

2. outPatient HoSPitaL SuRGiCaL Room CHaRGe Benefit: When a surgical operation is performed on a Covered Person for treatment of a diagnosed Internal Cancer or Associated Cancerous Condition, and a surgical room charge is incurred, Aflac will pay $200. For this benefit to be paid, surgeries must be performed on an outpatient basis in a Hospital or an Ambulatory Surgical Center. This benefit is payable once per day and is

A78325KS 8

(10/12)A78325KS.1


not payable on the same day the Hospital Confinement Benefit is payable. This benefit is payable in addition to the Surgical/Anesthesia Benefit. The maximum daily benefit will not exceed $200. No lifetime maximum on number of operations.

this benefit is also payable for nonmelanoma Skin Cancer surgery involving a flap or graft. it is not payable for any surgery performed in a Physician’s office.

e. ContinuinG CaRe BenefitS:1. eXtenDeD-CaRe faCiLitY Benefit: When a Covered Person

is hospitalized and receives benefits under Benefit D1 and is later confined, within 30 days of the covered Hospital confinement, to an extended-care facility, a skilled nursing facility, a rehabilitation unit or facility, a transitional care unit or any bed designated as a swing bed, or to a section of the Hospital used as such, (collectively referred to as “Extended-Care Facility”), Aflac will pay $100 per day when a charge is incurred for such continued confinement. For each day this benefit is payable, benefits under Benefit D1 are NOT payable. Benefits are limited to 30 days in each Calendar Year per Covered Person.

If more than 30 days separates confinements in an Extended-Care Facility, benefits are not payable for the second confinement unless the Covered Person again receives benefits under Benefit D1 and is confined as an inpatient to the Extended-Care Facility within 30 days of that confinement.

2. Home HeaLtH CaRe Benefit: When a Covered Person is hospitalized for the treatment of Internal Cancer or an Associated Cancerous Condition and then has either home health care or health supportive services provided on his or her behalf, Aflac will pay $100 per day when a charge is incurred for each such visit, subject to the following conditions:

a. The home health care or health supportive services must begin within seven days of release from the Hospital.

b. This benefit is limited to ten days per hospitalization for each Covered Person.

c. This benefit is limited to 30 days in any Calendar Year for each Covered Person.

d. This benefit will not be payable unless the attending Physician prescribes such services to be performed in the home of the Covered Person and certifies that if these services were not available, the Covered Person would have to be hospitalized to receive the necessary care, treatment, and services.

e. Home health care and health supportive services must be performed by a person, other than a member of your Immediate Family, who is licensed, certified, or otherwise duly qualified to perform such services on the same basis as if the services had been performed in a health care facility.

this benefit is not payable the same day the Hospice Care Benefit is payable.

3. HoSPiCe CaRe Benefit: When a Covered Person is diagnosed with Internal Cancer or an Associated Cancerous Condition and therapeutic intervention directed toward the cure of the disease is medically determined to be no longer appropriate, and if the Covered Person’s medical prognosis is one in which there is a life expectancy of six months or less as the direct result of Internal Cancer or an Associated Cancerous Condition (hereinafter referred to as “Terminally Ill”), Aflac will pay a one-time benefit of $1,000 for the first day the Covered Person receives Hospice care and $50 per day thereafter for Hospice care. For this benefit to be payable, Aflac must be furnished: (1) a written statement from the attending Physician that the Covered Person is Terminally Ill, and (2) a written statement from the Hospice certifying the days services were provided. This benefit is not payable the same day the Home Health Care Benefit is payable. Lifetime maximum for each Covered Person is $12,000.

4. nuRSinG SeRViCeS Benefit: While confined in a Hospital for the treatment of Cancer or an Associated Cancerous Condition, if a Covered Person requires and is charged for private nurses and their services other than those regularly furnished by the Hospital, Aflac will pay $100 per day for full-time private care and attendance provided by such nurses (registered graduate nurses, licensed practical nurses, or licensed vocational nurses). These services must be required and authorized by the attending Physician. This benefit is not payable for private nurses who are members of your Immediate Family. This benefit is payable for only the number of days the Hospital Confinement Benefit is payable. No lifetime maximum.

5. SuRGiCaL PRoStHeSiS Benefit: Aflac will pay $2,000 when a charge is incurred for surgically implanted prosthetic devices that are prescribed as a direct result of surgery for Internal Cancer or Associated Cancerous Condition treatment. Lifetime maximum of $4,000 per Covered Person.

the Surgical Prosthesis Benefit does not include coverage for tissue expanders or a Breast transverse Rectus abdominis myocutaneous (tRam) flap.

6. nonSuRGiCaL PRoStHeSiS Benefit: Aflac will pay $175 per occurrence, per Covered Person when a charge is incurred for nonsurgically implanted prosthetic devices that are prescribed as a direct result of treatment for Internal Cancer or an Associated Cancerous Condition. Examples of nonsurgically implanted prosthetic devices include voice boxes, hair pieces, and removable breast prostheses. Lifetime maximum of $350 per Covered Person.

7. ReConStRuCtiVe SuRGeRY Benefit: Aflac will pay the specified indemnity listed below when a charge is incurred for a

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reconstructive surgical operation that is performed on a Covered Person as a result of treatment of Cancer or treatment of an Associated Cancerous Condition. The maximum daily benefit will not exceed $2,000. No lifetime maximum on number of operations.

Breast Tissue/Muscle Reconstruction Flap Procedures $2,000 Breast Reconstruction (occurring within five years of breast cancer diagnosis) 500 Breast Symmetry (on the nondiseased breast occurring within five years of breast reconstruction) 220 Facial Reconstruction 500

Aflac will pay an indemnity benefit equal to 25% of the amount shown above for the administration of anesthesia during a covered reconstructive surgical operation.

If any reconstructive surgery is performed other than those listed, Aflac will pay an amount comparable to the amount shown above for the operation most nearly similar in severity and gravity.

8. eGG HaRVeStinG anD StoRaGe (CRYoPReSeRVation) Benefit: Aflac will pay $1,000 for a Covered Person to have oocytes extracted and harvested. In addition, Aflac will pay, one time per Covered Person, $350 for the storage of a Covered Person’s oocyte(s) or sperm when a charge is incurred to store with a licensed reproductive tissue bank or similarly licensed facility. Any such extraction, harvesting, or storage must occur prior to chemotherapy or radiation treatment that has been prescribed for the Covered Person’s treatment of Cancer or an Associated Cancerous Condition. Lifetime maximum of $1,350 per Covered Person.

f. amBuLanCe, tRanSPoRtation, anD LoDGinG BenefitS:1. amBuLanCe Benefit: Aflac will pay $250 when a charge is

incurred for ambulance transportation of a Covered Person to or from a Hospital where the Covered Person receives treatment of Cancer or an Associated Cancerous Condition. Aflac will pay $2,000 when a charge is incurred for air ambulance transportation of a Covered Person to or from a Hospital where the Covered Person receives treatment for Cancer or an Associated Cancerous Condition. This benefit is limited to two trips per confinement. The ambulance service must be performed by a licensed professional ambulance company. No lifetime maximum.

2. tRanSPoRtation Benefit: Aflac will pay 40 cents per mile for transportation, up to a combined maximum of $1,200, if a Covered Person requires treatment that has been prescribed by the attending Physician for Cancer or an Associated Cancerous Condition. This benefit includes:

a. Personal vehicle transportation of the Covered Person limited to the distance of miles between the Hospital or medical facility and the residence of the Covered Person.

b. Commercial transportation (in a vehicle licensed to carry passengers for a fee) of the Covered Person and no more than one additional adult to travel with the Covered Person. If the treatment is for a covered Dependent Child and commercial transportation is necessary, Aflac will pay for up to two adults to travel with the covered Dependent Child. This benefit is limited to the distance of miles between the Hospital or medical facility and the residence of the Covered Person.

This benefit is payable up to a maximum of $1,200 per round trip for all travelers and modes of transportation combined. No lifetime maximum.

tHiS Benefit iS not PaYaBLe foR tRanSPoRtation to anY HoSPitaL/faCiLitY LoCateD WitHin a 50-miLe RaDiuS of tHe ReSiDenCe of tHe CoVeReD PeRSon oR foR tRanSPoRtation BY amBuLanCe to oR fRom anY HoSPitaL.

3. LoDGinG Benefit: Aflac will pay $65 per day when a charge is incurred for lodging, in a room in a motel, hotel, or other commercial accommodation, for you or any one adult family member when a Covered Person receives treatment for Cancer or an Associated Cancerous Condition at a Hospital or medical facility more than 50 miles from the Covered Person’s residence. This benefit is not payable for lodging occurring more than 24 hours prior to treatment or for lodging occurring more than 24 hours following treatment. This benefit is limited to 90 days per Calendar Year.

G. PRemium WaiVeR anD ReLateD BenefitS:1. WaiVeR of PRemium Benefit: If you, due to having Cancer

or an Associated Cancerous Condition, are completely unable to perform all of the usual and customary duties of your occupation [if you are not employed: are completely unable to perform two or more Activities of Daily Living (ADLs) without the assistance of another person] for a period of 90 continuous days, Aflac will waive, from month to month, any premiums falling due during your continued inability. For premiums to be waived, Aflac will require an employer’s statement (if applicable) and a Physician’s statement of your inability to perform said duties or activities, and may each month thereafter require a Physician’s statement that total inability continues.

If you die and your Spouse becomes the new Named Insured, premiums will resume and be payable on the first premium due date after the change. The new Named Insured will then be eligible for this benefit if the need arises.

Aflac may ask for and use an independent consultant to determine whether you can perform an ADL when this benefit is in force.

Aflac will also waive, from month to month, any premiums falling due while you are receiving Hospice Benefits.

A78325KS 10

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2. Continuation of CoVeRaGe Benefit: Aflac will waive all monthly premiums due for this policy and riders for up to two months if you meet all of the following conditions:

a. Your policy has been in force for at least six months;

b. We have received premiums for at least six consecutive months;

c. Your premiums have been paid through payroll deduction, and you leave your employer for any reason;

d. You or your employer notifies us in writing within 30 days of the date your premium payments ceased because of your leaving employment; and

e. You re-establish premium payments through: (1) your new employer’s payroll deduction process, or (2) direct payment to Aflac.

You will again become eligible to receive this benefit after:

a. You re-establish your premium payments through payroll deduction for a period of at least six months, and

b. We receive premiums for at least six consecutive months.

“Payroll deduction” means your premium is remitted to aflac for you by your employer through a payroll deduction process or any other method agreed to by aflac and the employer.

4. optional Benefits:

initiaL DiaGnoSiS BuiLDinG Benefit RiDeR: (Series a78050) applied for: Yes no

initiaL DiaGnoSiS BuiLDinG Benefit: This benefit can be purchased in units of $100 each, up to a maximum of five units or $500. all amounts cited in this rider are for one unit of coverage. if more than one unit has been purchased, the amounts listed must be multiplied by the number of units in force. The number of units you purchased is shown in both the Policy Schedule and the attached application.

The initiaL DiaGnoSiS Benefit, as shown in the policy, will be increased by $100 for each unit purchased on each rider anniversary date while this rider remains in force. (The amount of the monthly increase will be determined on a pro rata basis.) This benefit will be paid under the same terms as the Initial Diagnosis Benefit in the policy to which this rider is attached. This benefit will cease to build for each Covered Person on the anniversary date of this rider following the Covered Person’s 65th birthday or at the time Internal Cancer or an Associated Cancerous Condition is diagnosed for that Covered Person, whichever occurs first. However, regardless of the age of the Covered Person on the Effective Date of this rider, this benefit will accrue for a period of at least five years, unless Internal

Cancer or an Associated Cancerous Condition is diagnosed prior to the fifth year of coverage.

exceptions, Reductions, and Limitations of Rider a78050 Series:

The Initial Diagnosis Building Benefit is not payable for: (1) any Internal Cancer or Associated Cancerous Condition diagnosed or treated before the Effective Date of the rider and the subsequent recurrence, extension, or metastatic spread of such Internal Cancer or Associated Cancerous Condition; or (2) the diagnosis of Nonmelanoma Skin Cancer. any Covered Person who has had a previous diagnosis of internal Cancer or an associated Cancerous Condition will not be eligible for an initial Diagnosis Building Benefit under this rider for a recurrence, extension, or metastatic spread of that same internal Cancer or associated Cancerous Condition.

DePenDent CHiLD RiDeR: (Series a78051) applied for: Yes no

DePenDent CHiLD Benefit: Aflac will pay $10,000 when a covered Dependent Child is diagnosed as having Internal Cancer or an Associated Cancerous Condition while this rider is in force.

This benefit is payable under this rider only once for each covered Dependent Child. In addition to the Positive Medical Diagnosis, we may require additional information from the attending Physician and Hospital.

exceptions, Reductions, and Limitations of Rider a78051 Series:

The Dependent Child Benefit is not payable for: (1) any Internal Cancer or Associated Cancerous Condition diagnosed or treated before the Effective Date of this rider and the subsequent recurrence, extension, or metastatic spread of such Internal Cancer or Associated Cancerous Condition; or (2) the diagnosis of Nonmelanoma Skin Cancer. any Dependent Child who has had a previous diagnosis of internal Cancer or an associated Cancerous Condition will not be eligible for any benefit under this rider for a recurrence, extension, or metastatic spread of that same internal Cancer or associated Cancerous Condition.

SPeCifieD-DiSeaSe Benefit RiDeR: (Series a78052) applied for: Yes no

This rider is issued on the basis that the information shown on the application is correct and complete. If answers on your application for this rider are incorrect or incomplete, then this rider may be voided or claims may be denied. If voided, any premiums for this rider, less any claims paid, will be refunded to you.

SPeCifieD-DiSeaSe initiaL Benefit: While coverage is in force, if a Covered Person is first diagnosed, after the Effective Date of

A78325KS 11

(10/12)A78325KS.1


this rider, with any of the covered Specified Diseases, Aflac will pay a benefit of $1,000. This benefit is payable only once per covered disease per Covered Person. no otHeR BenefitS aRe PaYaBLe foR anY CoVeReD SPeCifieD DiSeaSe not PRoViDeD foR in tHiS RiDeR.

a. HoSPitaL Confinement BenefitS:

1. HoSPitaLiZation foR 30 DaYS oR LeSS: When a Covered Person is confined to a Hospital for 30 days or less, for a covered Specified Disease, Aflac will pay $200 per day.

2. HoSPitaLiZation foR 31 DaYS oR moRe: During any continuous period of Hospital confinement of 31 days or more for a covered Specified Disease, Aflac will pay benefits as described in Section A1 above for the first 30 days, and beginning with the 31st day of such continuous Hospital confinement, Aflac will pay $500 per day.

“Specified Disease,” as used under this benefit, means one or more of the diseases listed below. These diseases must be first diagnosed by a Physician on or after the Effective Date of this rider for benefits to be paid. The diagnosis must be made by and upon a tissue specimen, culture(s), and/or titer(s).

• adrenal hypofunction (Addison’s disease)

• amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease)

• botulism

• bubonic plague

• cerebral palsy

• cholera

• cystic fibrosis

• diphtheria

• encephalitis (including encephalitis contracted from West Nile virus)

• Huntington’s chorea

• Lyme disease

• malaria

• meningitis (bacterial)

• multiple sclerosis

• muscular dystrophy

• myasthenia gravis

• necrotizing fasciitis

• osteomyelitis

• polio

• rabies

• Reye’s syndrome

• scleroderma

• sickle cell anemia

• systemic lupus

• tetanus

• toxic shock syndrome

• tuberculosis

• tularemia

• typhoid fever

• variant Creutzfeldt-Jakob disease (mad cow disease)

• yellow fever

RetuRn of PRemium Benefit: (Series a78053) applied for: Yes no

Aflac will pay you a cash value based upon the annualized premium paid for this rider, the policy, and any other attached benefit riders (premium paid for the policy and other attached benefit riders will be calculated at the original premium in effect on the rider effective Date and will not include premium increases that may occur for the policy or other such riders). All Return of Premium Benefits/cash values paid will be less any claims paid. If you surrender this rider for its cash value after Cancer or an Associated Cancerous Condition is diagnosed but before claims are submitted, we will reduce subsequent claim payment(s) by the amount of the cash value paid. Both the policy and the rider must remain in force for 20 consecutive years for you to obtain a maximum refund of premiums paid. If this rider is added to the policy after the policy has been issued, only the premium paid for the policy after the Effective Date of this rider will be returned. When the rider is issued after the Effective Date of the policy, the 20-year period begins for both the policy and the rider on the rider Effective Date.

The cash value for premium paid for the policy and rider begins on the fifth rider anniversary date.

Your cash value is based upon annualized premium of $ . If you surrender this rider after its fifth anniversary and such surrender occurs between rider anniversaries, a prorated amount for the partial year will be paid. The proration will be calculated by taking the cash value difference between the last and next anniversary dates, dividing by 12, and multiplying by the number of months that premiums were earned in the partial year at the time of surrender. This proration will then be added to the cash value on the last rider anniversary date, and this will be the cash value paid.

imPoRtant! ReaD CaRefuLLY: This rider will terminate on the earlier of: its 20th anniversary date and payment of the cash value; your surrender of it for its cash value between the fifth and 20th anniversary dates; your death prior to its 20th anniversary date, in which case the cash value (if any) will be paid to your estate; your failure to pay the premium for this rider, in which case any cash values due will be paid; the policy’s termination, in which case any cash values due will be paid; or the time that claims paid equal or exceed the cash value that would be paid on the 20th policy anniversary. When this rider terminates (is no longer in force), no further premium will be charged for it.

A78325KS 12

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5. exceptions, Reductions, and Limitations of the Policy (this is not a daily hospital expense plan.):

a. We pay only for treatment of Cancer and Associated Cancerous Conditions, including direct extension, metastatic spread, or recurrence. Benefits are not provided for premalignant conditions or conditions with malignant potential (unless specifically covered); complications of either Cancer or an Associated Cancerous Condition; or any other disease, sickness, or incapacity.

B. The Initial Diagnosis Benefit is not payable for: (1) any Internal Cancer or Associated Cancerous Condition diagnosed or treated before the Effective Date of this policy and the subsequent recurrence, extension, or metastatic spread of such Internal Cancer or Associated Cancerous Condition; or (2) the diagnosis of Nonmelanoma Skin Cancer. any Covered Person who has had a previous diagnosis of internal Cancer or an associated Cancerous Condition will not be eligible for an initial Diagnosis Benefit under this policy for a recurrence, extension, or metastatic spread of that same internal Cancer or associated Cancerous Condition.

C. Aflac will not pay benefits whenever coverage provided by this policy is in violation of any U.S. economic or trade sanctions. If the coverage violates U.S. economic or trade sanctions, such coverage shall be null and void.

D. Aflac will not pay benefits whenever fraud is committed in making a claim under this coverage or any prior claim under any other Aflac coverage for which you received benefits that were not lawfully due and that fraudulently induced payment.

6. Renewability: The policy is guaranteed-renewable for life by payment of the premium in effect at the beginning of each renewal period. Premium rates may change only if changed on all policies of the same form number and class in force in your state.

7. Cancellation By the insured: You may cancel this policy at any time by written notice delivered or mailed to Aflac, effective upon receipt of such notice or on such later date as may be specified in such notice. In the event of cancellation or your death, we will promptly return the pro-rated unearned portion of any premium paid. Cancellation shall be without prejudice to any claim originating prior to the Effective Date of cancellation.

8. Premiums: Your Premium for the policy is:

Annual Semiannual Quarterly Monthly

Policy: $______ $______ $______ $______

Rider:

A78050KS: $______ $______ $______ $______

A78051KS: $______ $______ $______ $______

A78052KS: $______ $______ $______ $______

A78053: $______ $______ $______ $______

Licensed Resident Agent __________________ Date _______

Retain foR YouR ReCoRDS.

tHiS outLine of CoVeRaGe iS onLY a BRief SummaRY of tHe CoVeRaGe PRoViDeD.

tHe PoLiCY itSeLf SHouLD Be ConSuLteD to DeteRmine GoVeRninG ContRaCtuaL PRoViSionS.

A78325KS 13

TER MS YOU NEED TO KNOWaCtiVitieS of DaiLY LiVinG (aDLs): BATHING: washing oneself by sponge bath or in either a tub or shower, including the task of getting into or out of the tub or shower; MAINTAINING CONTINENCE: controlling urination and bowel movements, including your ability to use ostomy supplies or other devices such as catheters; TRANSFERRING: moving between a bed and a chair, or a bed and a wheelchair; DRESSING: putting on and taking off all necessary items of clothing; TOILETING: getting to and from a toilet, getting on and off a toilet, and performing associated personal hygiene; EATING: performing all major tasks of getting food into your body.

aSSoCiateD CanCeRouS ConDition: Myelodysplastic blood disorder, myeloproliferative blood disorder, or internal carcinoma in situ (in the natural or normal place, confined to the site of origin without having invaded neighboring tissue). An Associated Cancerous Condition must receive a Positive Medical Diagnosis. Premalignant conditions or conditions with malignant potential, other than those specifically named above, are not considered associated Cancerous Conditions.

CanCeR: Disease manifested by the presence of a malignant tumor and characterized by the uncontrolled growth and spread of malignant cells, and the invasion of tissue. Cancer also includes but is not limited to leukemia, Hodgkin’s disease, and melanoma. Cancer must receive a Positive Medical Diagnosis.

1. inteRnaL CanCeR: All Cancers other than Nonmelanoma Skin Cancer (see definition of “Nonmelanoma Skin Cancer”).

2. nonmeLanoma SKin CanCeR: A Cancer other than a melanoma that begins in the outer part of the skin (epidermis).

Associated Cancerous Conditions, premalignant conditions, or conditions with malignant potential will not be considered Cancer.

CoVeReD PeRSon: Any person insured under the coverage type you applied for: individual (named insured listed in the Policy Schedule), named insured/Spouse only (named insured and Spouse), one-parent family (named insured and Dependent Children), or two-parent family (named insured, Spouse, and Dependent Children). “Spouse” is defined as the person to whom you are legally married and who is listed on your application. Newborn children are automatically insured from the moment of birth. If coverage is for individual or named insured/Spouse only and you desire uninterrupted coverage for a newborn child, you must notify Aflac in writing within 31 days of the birth of your child, and Aflac will convert the policy to one-parent family or two-parent family coverage and advise you of the additional premium due. Coverage will include any other Dependent Child, regardless of age, who is incapable of self-sustaining employment by reason of mental retardation or physical handicap and who became so incapacitated prior to age 26 and while covered under the policy. “Dependent Children” are your natural children, stepchildren, or legally adopted children who are under age 26.

effeCtiVe Date: The date coverage begins, as shown in the Policy Schedule. The Effective Date is not the date you signed the application for coverage.

PHYSiCian: A person legally qualified to practice medicine, other than you or a member of your immediate family, who is licensed as a Physician by the state where treatment is received to treat the type of condition for which a claim is made.

A DDITIONA L INFOR M ATIONAn Ambulatory Surgical Center does not include a doctor’s or dentist’s office, clinic, or other such location.

The term “Hospital” does not include any institution or part thereof used as an emergency room; an observation unit; a rehabilitation unit; a hospice unit, including any bed designated as a hospice or a swing bed; a convalescent home; a rest or nursing facility; a psychiatric unit; an extended-care facility; a skilled nursing facility; or a facility primarily affording custodial or educational care, care or treatment for persons suffering from mental disease or disorders, care for the aged, or care for persons addicted to drugs or alcohol.

A Bone Marrow Transplantation does not include Stem Cell Transplantations.

A Stem Cell Transplantation does not include Bone Marrow Transplantations.

If Nonmelanoma Skin Cancer is diagnosed during hospitalization, benefits will be limited to the day(s) the Covered Person actually received treatment for Nonmelanoma Skin Cancer.

If treatment for Cancer or an Associated Cancerous Condition is received in a U.S. government Hospital, the benefits listed in the policy will not require a charge for them to be payable.

aflac.com 1.800.99.AflAC (1.800.992.3522)

Underwritten by: American Family Life Assurance Company of ColumbusWorldwide Headquarters | 1932 Wynnton Road | Columbus, Georgia 31999

A fl Ac HospitA l A dvA ntAge

H o s p i t A l c o n f i n e M e n t i n d e M n i t Y i n s U R A n c e

p o l i c Y s e R i e s A 4 9 0 0 0

p R e f e R R e d

This brochure is for a hospital confinement indemnity policy providing limited benefits. Benefits provided are supplemental and are not intended to cover all medical expenses.

RC(2/13)A49275KS

Aflac Hospital AdvantageHOSPITAL CONFINEMENT INDEMNITY INSURANCEPolicy Series A49000

The policy has limitations and exclusions that may affect benefits payable. This schedule is for illustrative purposes only. Refer to the policy for benefit details, definitions, limitations, and exclusions.

OPTION 3 BENEFITSAll benefits of option 2 plus tHe folloWinG

SuRgiCAl $50–$1,000 SuRgiCAl SChedule ONe BeNeFiT PeR 24-hOuR PeRiOd

iNVASiVe diAgNOSTiC eXAMS $100ONe eXAM PeR COVeRed PeRSON, PeR 24-hOuR PeRiOd

OPTION 4 BENEFITSAll benefits of options 2 & 3 plus tHe folloWinG

dAilY hOSPiTAl CONFiNeMeNT$100 PeR dAY

uP TO 365 dAYSiN AddiTiON TO The hOSPiTAl CONFiNeMeNT BeNeFiT

hOSPiTAl iNTeNSiVe CARe uNiT CONFiNeMeNT

$100 PeR dAY uP TO 30 dAYS

iN AddiTiON TO hOSPiTAl CONFiNeMeNT & dAilY hOSPiTAl CONFiNeMeNT BeNeFiTS

OPTION 2 BENEFITS

hOSPiTAl CONFiNeMeNT $1000 PeR COVeRed PeRSON

RehABiliTATiON FACiliTY $100 PeR dAY

hOSPiTAl eMeRgeNCY ROOM $100uP TO 2 TiMeS PeR YeAR, PeR POliCY

hOSPiTAl ShORT-STAY $100uP TO 2 TiMeS PeR YeAR, PeR POliCY

MediCAl diAgNOSTiC & iMAgiNg $150 ONCe PeR YeAR, PeR COVeRed PeRSON

AMBulANCe $100 – gROuNd, $1,000 – AiR uP TO 2 TRiPS PeR YeAR, PeR COVeRed PeRSON

WAiVeR OF PReMiuM YeS

CONTiNuATiON OF COVeRAge YeS

Aflac will pay the following benefits, as applicable, for a covered sickness or injury that occurs while coverage is in force. Treatment or confinement in a U.S. government hospital does not require a charge for benefits to be payable.

B e n e f i tB e n e f i t A m o u n t

A d d i t i o n A l B e n e f i t i n f o r m At i o n

oPtion 2

HOSPITAL CONFINEMENT

$1,000

Aflac will pay a Hospital Confinement Benefit of $1,000 when a covered person requires hospital confinement for 23 or more hours for a covered sickness or injury and a charge is incurred. This benefit is payable once per period of hospital confinement, per covered person. Confinements must be separated by a minimum of 90 days from the previous covered hospital confinement for this benefit to be payable. No lifetime maximum.

REHABILITATION FACILITY

$100 per day

Aflac will pay $100 per day when a covered person is confined in a hospital and is transferred to a bed in a rehabilitation facility for a covered sickness or injury and a charge is incurred. This benefit is limited to 15 days per period of hospital confinement and is limited to a calendar year maximum of 30 days per covered person. No lifetime maximum.

HOSPITAL EMERGENCY

ROOM$100

Aflac will pay $100 when a covered person receives treatment for a covered sickness or injury in a hospital emergency room, including triage, and a charge is incurred. This benefit is payable twice per calendar year, per policy. The Hospital Emergency Room Benefit and the Hospital Short-Stay Benefit are not payable on the same day. No lifetime maximum.

HOSPITAL SHORT-STAY

$100

Aflac will pay $100 when a covered person receives treatment for a covered sickness or injury in a hospital, including an observation room or an ambulatory surgical center, for a period of less than 23 hours and a charge is incurred. This benefit is not payable for treatment received in a hospital emergency room. This benefit is payable twice per calendar year, per policy. The Hospital Short-Stay Benefit and the Hospital Emergency Room Benefit are not payable on the same day. No lifetime maximum.

MEDICAL DIAGNOSTIC

AND IMAGING$150

Aflac will pay $150 per calendar year when a covered person requires one of the following exams and a charge is incurred: CT scan, MRI (magnetic resonance imaging), EEG (electroencephalogram), thallium stress test, myelogram, angiogram, or arteriogram. These exams must be performed in a hospital or an ambulatory surgical center. This benefit is limited to one payment per calendar year, per covered person. No lifetime maximum.

AMBULANCE

$100 – ground ambulance

$1,000 – air ambulance

Aflac will pay the amount shown at left if, due to a covered sickness or injury, a covered person requires ground ambulance transportation or air ambulance transportation to or from a hospital due to a covered sickness or injury and a charge is incurred. A licensed professional ambulance company must provide the ambulance service. The Ambulance Benefit is limited to two trips per calendar year, per covered person. No lifetime maximum.

WAIVER OF PREMIUM

Upon written notice, Aflac will waive from month to month any premium(s) falling due during a continued period of hospital confinement for the named insured only. This benefit will begin after the period of hospital confinement for the named insured has exceeded 30 consecutive days. When such continued period of hospital confinement has ended, premium payments must be resumed. Once premium payments are resumed, any new period of hospital confinement must again satisfy the 30-day continued confinement for premiums to be waived.



CONTINUATION OF COVERAGE

Aflac will waive all monthly premiums due for the policy and riders, if any, for up to two months if you meet all of the following conditions:• The policy was in force for at least six months.• We received premiums for at least six consecutive months.• Your premiums were paid through payroll deduction, and you left your employer for any reason.• You or your employer notified us in writing within 30 days of the date your premium payments ceased

because of leaving employment.• You re-establish premium payments with Aflac.

You will again become eligible to receive this benefit after you re-establish your premium payments through payroll deduction for a period of at least six months, and we receive premiums for at least six consecutive months.

oPtion 3 All benefits of

option 2 plus the following

SURGICAL

$50–$1,000 (based on the Schedule of Operations listed in the

policy)

Aflac will pay according to the benefits listed in the Schedule of Operations in the policy when, due to a covered sickness or injury, a covered person has a surgical operation, including a vaginal or cesarean delivery, performed in a hospital or an ambulatory surgical center and a charge is incurred. If any operation for the treatment of the covered sickness or injury is performed other than those listed, Aflac will pay an amount comparable to the amount shown in the Schedule of Operations for the operation most nearly similar in severity and gravity. Only one benefit is payable per 24-hour period for surgery, even though more than one surgical procedure may be performed. The highest eligible benefit will be paid. Exams covered under the Invasive Diagnostic Exams Benefit are not payable under this benefit. The Surgical Benefit and the Invasive Diagnostic Exams Benefit are not payable on the same day. The highest eligible benefit will be paid. No lifetime maximum.

IMPORTANT: Surgical Benefits are not payable for surgery performed in a physician’s or dentist’s office, a clinic, or other such location.

INVASIVE DIAGNOSTIC

EXAMS$100

Aflac will pay $100 when a covered person requires one of the following exams, with or without biopsy, and a charge is incurred: arthroscopy, bronchoscopy, colonoscopy, cystoscopy, gastroscopy, laparoscopy, laryngoscopy, sigmoidoscopy, or esophagoscopy. These exams must be performed in a hospital or an ambulatory surgical center. This benefit is limited to one exam per covered person, per 24-hour period. The Invasive Diagnostic Exams Benefit and the Surgical Benefit are not payable on the same day. The highest eligible benefit will be paid. No lifetime maximum.

oPtion 4All benefits of

options 2 & 3 plus the following

DAILY HOSPITAL

CONFINEMENT

$100 per day

Aflac will pay $100 per day for the period of hospital confinement when a covered person requires hospital confinement for a covered sickness or injury and a charge is incurred. This benefit is payable in addition to the Hospital Confinement Benefit. The maximum benefit period for any one period of hospital confinement is 365 days. No lifetime maximum.

HOSPITAL INTENSIVE CARE UNIT

CONFINEMENT

$100 per day

Aflac will pay $100 per day when a covered person incurs a charge for a period of hospital intensive care unit confinement for a covered sickness or injury. This benefit is payable in addition to the Hospital Confinement Benefit and the Daily Hospital Confinement Benefit. Confinements must be separated by a minimum of 90 days from the previous covered period of hospital intensive care unit confinement for this benefit to be payable. The maximum benefit period for any one period of hospital intensive care unit confinement is 30 days. No lifetime maximum.



CONTINUATION OF COVERAGE

Aflac will waive all monthly premiums due for the policy and riders, if any, for up to two months if you meet all of the following conditions:• The policy was in force for at least six months.• We received premiums for at least six consecutive months.• Your premiums were paid through payroll deduction, and you left your employer for any reason.• You or your employer notified us in writing within 30 days of the date your premium payments ceased

because of leaving employment.• You re-establish premium payments with Aflac.

You will again become eligible to receive this benefit after you re-establish your premium payments through payroll deduction for a period of at least six months, and we receive premiums for at least six consecutive months.

oPtion 3 All benefits of

option 2 plus the following

SURGICAL

$50–$1,000 (based on the Schedule of Operations listed in the

policy)

Aflac will pay according to the benefits listed in the Schedule of Operations in the policy when, due to a covered sickness or injury, a covered person has a surgical operation, including a vaginal or cesarean delivery, performed in a hospital or an ambulatory surgical center and a charge is incurred. If any operation for the treatment of the covered sickness or injury is performed other than those listed, Aflac will pay an amount comparable to the amount shown in the Schedule of Operations for the operation most nearly similar in severity and gravity. Only one benefit is payable per 24-hour period for surgery, even though more than one surgical procedure may be performed. The highest eligible benefit will be paid. Exams covered under the Invasive Diagnostic Exams Benefit are not payable under this benefit. The Surgical Benefit and the Invasive Diagnostic Exams Benefit are not payable on the same day. The highest eligible benefit will be paid. No lifetime maximum.

IMPORTANT: Surgical Benefits are not payable for surgery performed in a physician’s or dentist’s office, a clinic, or other such location.

INVASIVE DIAGNOSTIC

EXAMS$100

Aflac will pay $100 when a covered person requires one of the following exams, with or without biopsy, and a charge is incurred: arthroscopy, bronchoscopy, colonoscopy, cystoscopy, gastroscopy, laparoscopy, laryngoscopy, sigmoidoscopy, or esophagoscopy. These exams must be performed in a hospital or an ambulatory surgical center. This benefit is limited to one exam per covered person, per 24-hour period. The Invasive Diagnostic Exams Benefit and the Surgical Benefit are not payable on the same day. The highest eligible benefit will be paid. No lifetime maximum.

oPtion 4All benefits of

options 2 & 3 plus the following

DAILY HOSPITAL

CONFINEMENT

$100 per day

Aflac will pay $100 per day for the period of hospital confinement when a covered person requires hospital confinement for a covered sickness or injury and a charge is incurred. This benefit is payable in addition to the Hospital Confinement Benefit. The maximum benefit period for any one period of hospital confinement is 365 days. No lifetime maximum.

HOSPITAL INTENSIVE CARE UNIT

CONFINEMENT

$100 per day

Aflac will pay $100 per day when a covered person incurs a charge for a period of hospital intensive care unit confinement for a covered sickness or injury. This benefit is payable in addition to the Hospital Confinement Benefit and the Daily Hospital Confinement Benefit. Confinements must be separated by a minimum of 90 days from the previous covered period of hospital intensive care unit confinement for this benefit to be payable. The maximum benefit period for any one period of hospital intensive care unit confinement is 30 days. No lifetime maximum.

W H A t i s n o t c o v e R e d

l i M i t A t i o n s A n d e x c l U s i o n s

Aflac will not pay benefits for care or treatment that is: (1) caused by a pre-existing condition, unless it begins more than 12 months after the effective date of coverage, or (2) received prior to the effective date of coverage.

Aflac will not pay benefits whenever coverage provided by the policy is in violation of any U.S. economic or trade sanctions. If the coverage violates U.S. economic or trade sanctions, such coverage shall be null and void.

Aflac will not pay benefits whenever fraud is committed in making a claim under this coverage or any prior claim under any other Aflac coverage for which you received benefits that were not lawfully due and that fraudulently induced payment.

The policy does not cover losses caused by or resulting from:

• Receiving routine nursing or routine well-baby care for a newborn child;

• Using any drug, narcotic, hallucinogen, or chemical substance (unless administered by a physician and taken according to the physician’s instructions), or voluntarily taking any type of poison or inhaling any type of gas or fumes;

• Participating in, or attempting to participate in, an illegal activity that is defined as a felony, whether charged or not (felony is as defined by the law of the jurisdiction in which the activity takes place); or being incarcerated in any detention facility or penal institution;

• Being intoxicated or under the influence of alcohol, drugs, or any narcotic, unless administered on the advice of a physician and taken according to the physician’s instructions (the term intoxicated refers to that condition as defined by the law of the jurisdiction in which the cause of the loss occurred);

• Intentionally self-inflicting a bodily injury, or committing or attempting suicide, while sane or insane;

• Having dental treatment except as a result of injury or having cosmetic surgery that is not medically necessary;

• Having elective surgery;

• Being exposed to war or any act of war, declared or undeclared, or actively serving in any of the armed forces, or units auxiliary thereto, including the National Guard or Reserve;

• Donating an organ;

• Having mental or emotional disorders, including but not limited to the following: bipolar affective disorder (manic-depressive syndrome), delusional (paranoid) disorders, psychotic disorders, somatoform disorders (psychosomatic illness), eating disorders, schizophrenia, anxiety disorders, depression, stress, or post-partum depression. The policy will pay, however, for covered losses resulting from Alzheimer’s disease, or similar forms of senility or senile dementia, first manifested while coverage is in force.

An ambulatory surgical center does not include a physician’s or dentist’s office, a clinic, or other such location.

Complications of pregnancy do not include any of the following: premature delivery, multiple gestation pregnancy, false labor, occasional spotting, prescribed rest during pregnancy, morning sickness, and similar conditions associated with the management of a difficult pregnancy not constituting a classifiably distinct pregnancy complication. Cesarean deliveries are not considered complications of pregnancy.

The term hospital does not include any institution or part thereof used as an emergency room; a rehabilitation facility; a hospice unit, including any bed designated as a hospice or a swing bed; a convalescent home; a rest or nursing facility; a psychiatric unit; an extended-care facility; a skilled nursing facility; or a facility primarily affording custodial or educational care, care or treatment for persons suffering from mental disease or disorders, care for the aged, or care for persons addicted to drugs or alcohol. Benefits for confinement in a rehabilitation facility are payable under the Rehabilitation Facility Benefit.

The term hospital emergency room does not include urgent care centers.

Benefits are not payable for confinement in a hospital intensive care unit under the Hospital Intensive Care Unit Confinement Benefit for confinement in units such as telemetry or surgical recovery rooms, postanesthesia care units, progressive care units, intermediate care units, private monitored rooms, observation units located in emergency rooms or outpatient surgery units, step-down intensive care units, or other facilities that do not meet the standards for a hospital intensive care unit.

A physician does not include you or a member of your immediate family.

The term rehabilitation facility does not include a hospice unit, including any bed designated as a hospice or a swing bed; a convalescent home; a rest or nursing facility; a psychiatric unit; an extended-care facility; a skilled nursing facility; or a facility primarily affording custodial or educational care, care or treatment for persons suffering from mental disease or disorders, care for the aged, or care for persons addicted to drugs or alcohol.

Pre-existing Condition Limitations: A pre-existing condition is an illness, disease, infection, disorder, condition, or injury for which, within the 12-month period before the effective date of coverage, prescription medication was taken or medical testing, medical advice, consultation, or treatment was recommended or received, or for which symptoms existed that would ordinarily cause a prudent person to seek diagnosis, care, or treatment. Care or treatment caused by a pre-existing condition, including deliveries for children conceived prior to the effective date of coverage, will not be covered unless it begins more than 12 months after the effective date of coverage. Deliveries for children conceived prior to the effective date of coverage will not be covered.

t e R M s Y o U n e e d t o K n o W

CoVered Person: any person insured under the coverage type that you applied for on the application: individual (named insured listed in the Policy Schedule), named insured/spouse only (named insured and spouse), one-parent family (named insured and dependent children), or two-parent family (named insured, spouse, and dependent children). spouse is defined as the person to whom you are legally married and who is listed on your application. Newborn children are automatically insured from the moment of birth. If coverage is for individual or named insured/spouse only and you desire uninterrupted coverage for a newborn child, you must notify Aflac in writing within 31 days of the child’s birth, and Aflac will convert the policy to one-parent family or two-parent family coverage and advise you of the additional premium due. Coverage will include any other dependent child, regardless of age, who is incapable of self-sustaining employment by reason of mental retardation or physical handicap and who became so incapacitated prior to age 26 and while covered under the policy. Dependent children are your natural children, stepchildren, or legally adopted children who are under age 26.

eFFeCtiVe date: the date(s) coverage begins as shown in the Policy Schedule or on any attached endorsements or riders. The effective date is not the date you signed the application for coverage.

guaranteed-renewabLe: the right to renew the policy by payment of the premium due on or before the renewal date. The policy is guaranteed-renewable for your lifetime, subject to Aflac’s right to change premiums by class upon any renewal date.

HosPitaL ConFinement: a stay of a covered person confined to a bed in a hospital for 23 or more hours for which a room charge is made. The hospital confinement must be on the advice of a physician, medically necessary, and the result of a covered sickness or injury. The term hospital confinement does not include emergency rooms.

inJurY: a bodily injury caused directly by an accident, independent of sickness, bodily infirmity, or any other cause, occurring on or after the effective date of coverage and while coverage is in force. See the Limitations and Exclusions section for injuries not covered by the policy.

Period oF HosPitaL ConFinement: the number of days a covered person is assigned to and incurs a charge for a bed in a hospital. Confinements must begin while coverage under the policy is in force. Covered confinements not separated by 90 days or more from a previously covered confinement are considered a continuation of the previous period of hospital confinement. Hospitalization that begins prior to the end of one calendar year and continues into the next calendar year will be considered one confinement.

Period oF HosPitaL intensiVe Care unit ConFinement: the number of days a covered person is assigned to and incurs a charge for a bed in a hospital intensive care unit. Confinements must begin while coverage under the policy is in force. Covered confinements not separated by 90 days or more from a previously covered confinement are considered a continuation of the previous period of hospital intensive care unit confinement. Hospitalization that begins prior to the end of one calendar year and continues into the next calendar year will be considered one confinement.

siCKness: an illness, disease, infection, or disorder, independent of injury, medically evaluated, diagnosed, or treated by a physician after the effective date of coverage and while coverage is in force.

underwritten by: American Family life Assurance Company of ColumbusWorldwide headquarters | 1932 Wynnton Road | Columbus, georgia 31999 aflac.com 1.800.99.AflAC (1.800.992.3522)

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