Personal Sickness Indemnity Plan

1 Personal SicknessIndemnity PlanHospital Confinement Sickness IndemnityLimited Benefit InsurancePlan Benefits Physician Visits Initial Hospitalization Hospital Confinement Major Diagnostic Exams Surgical Plus .. moreForm A45075B1 PAIC(2/08) Personal Sickness Indemnity PlanPolicies A-45100-PA, A-45200-PA, and A-45300-PA Policy A-45100-PA (Level 1) Policy A-45200-PA (Level 2) Policy A-45300-PA (Level 3) Physician Visits BenefitAflac will pay the amount for the level chosenwhen a coveredperson incurs a charge for a physician visit.

2 Services must beunder the supervision of a physician. This is a healthmaintenance benefit; the Sickness of a covered person is notrequired for this benefit to be payable. No lifetime 1 Level 2 Level 3A-45100-PAA-45200-PAA-45300-PABenefit Amount$15$20$25 Number of Visits per Year:Individual344 Family*688 Covered physician visits include, but are not limited to, eyeexams, well-baby visits, immunizations, periodic healthexams, and routine physicals. The following benefits are payable for a covered Sickness thatoccurs while coverage is in force.

3 Treatment or confinement in government hospital does not require a charge for benefits tobe payable. All of the benefits listed below, except for theHospital Confinement Benefit, are the same for Levels 1, 2, and 3 (Policies A-45100-PA, A-45200-PA, and A-45300-PA).Hospital Confinement BenefitAflac will pay the amount per dayfor the level chosen when acovered person requires hospital confinement for 14 or morehours for a covered Sickness or for rehabilitory care as a resultof Sickness and incurs a charge. Benefits are not payable fordays beyond the 180th day in a period of hospitalconfinement.

4 ** No lifetime 1 Level 2 Level 3A-45100-PAA-45200-PAA-45300-PABenefit Amount:Days 1 15$ 50$ 75$ 100 Days 16 180$100$150$200 Initial Hospitalization BenefitAflac will pay $250per period of hospital confinement** whena covered person is confined to a hospital for at least 24 hoursfor a covered Sickness . This benefit is limited to one paymentper calendar year, per covered person. No lifetime Diagnostic ExamsAflac will pay $150when a covered person requires one of thefollowing exams for a covered Sickness : CT scan MRI (magnetic resonance imaging) EEG (electroencephalogram) Thallium stress test Myelogram Angiogram ArteriogramThese exams must be performed in a hospital, doctor s office,or ambulatory surgical center, and a charge must be benefit is limited to one payment per calendar year, percovered person.

5 No lifetime BenefitAflac will pay $100 $2,000when a covered person has surgeryperformed for a covered Sickness in a hospital or ambulatorysurgical center based upon the Schedule of Operations in thepolicy. Only one benefit is payable per 24-hour period forsurgery even though more than one surgical procedure may beperformed. We will pay the highest eligible benefit. Benefitsare not payable for cosmetic or elective surgery that is not dueto Sickness . Surgical Benefits are not payable for surgeryperformed in a doctor s or dentist s office, clinic, or other suchlocation.

6 Surgery performed but not listed in the schedule willbe paid according to the amount shown for the surgery mostsimilar in severity and gravity. No lifetime BenefitAflac will pay $100 for ground ambulance and $1,000 for airambulanceif, because of a covered Sickness , a covered personrequires transportation to or from a hospital. A licensedprofessional ambulance company must provide the ambulanceservice. This benefit is limited to two trips per calendar year,per covered person. No lifetime maximum.* Family includes two-parent family, one-parent family, and named insured/spouse only.

7 **A period of hospital confinement is the time period of hospital confinement that starts while the policy is in force. If the confinement follows a previously covered confinement, it will be deemed a continuation of the first confinement unless the later confinement is the result of an entirely unrelated Sickness or the confinements are separated by 30 days or Family Life Assurance Company of Columbus ( aflac ) aflac s Personal Sickness Indemnity Plan pays cash benefitsdirectly to you, unless assigned, regardless of any other insuranceyou may of Coverage BenefitAflac will waive all monthly premiums due for the policy andriders for up to two months if you meet all of the followingconditions: (1) Your policy has been in force for at least sixmonths; (2) we have received premiums for at least sixconsecutive months; (3) your premiums have been paidthrough payroll deduction and you leave your employer forany reason.

8 (4) you or your employer notifies us in writingwithin 30 days of the date your premium payments ceasebecause of your leaving employment; and (5) you re-establishpremium payments through your new employer s payrolldeduction process or direct payment to aflac . You will againbecome eligible to receive this benefit after you re-establishyour premium payments through payroll deduction for aperiod of at least six months and we receive premiums for atleast six consecutive months. Payroll deduction means yourpremiums are remitted to aflac for you by your employerthrough a payroll deduction policy is guaranteed-renewable for your lifetime, subjectto aflac s right to change the applicable table of premiumrates by class upon any renewal DateThe effective date is the date shown in the Policy Schedule, notthe date the application is signed.

9 Payroll rates may be retainedafter one month s premium payment on payroll CoverageFamily coverage includes the insured; spouse; and dependent,unmarried children under age 19 (or 23 if they are enrolled asfull-time students). Newborns are automatically covered underthe terms of the policy from the moment of birth. One-parentfamily coverage includes the insured and all of the insured sunmarried, dependent children under age 19 (or 23 if they areenrolled as full-time students). A dependent child must be underthe age of 19 at the time of application to be eligible forcoverage.

10 Please refer to the policy regarding eligibility forcoverage for a full-time student who is called or ordered toactive duty as a member of the Pennsylvania National Guard ora Reserve Component of the Armed Forces of the United States. Pre-Existing ConditionsA pre-existing condition is a Sickness for which, within the12-month period before the effective date of coverage, medicaladvice or treatment was medically recommended by orreceived from a physician. Care or treatment caused by a pre-existing condition will not be covered unless it beginsmore than six months after the effective date of Sickness is an illness, disease, or disorder medically diagnosedor treated 30 days or more after the effective date of coverageand while coverage is in force.