Voluntary Accident

Voluntary Accident Insurance Don’t let an accident catch you off guard. Protect your family’s finances with Accident Insurance from United of Omaha Life Insurance Company. An accident insurance policy supplements your medical coverage and provides a cash benefit for injuries you or an insured family member sustain from an accident. This benefit can be used to pay out-of- pocket medical expenses, help supplement your daily living expenses and cover unpaid time off work. As an active employee of ACME, you may purchase this coverage for yourself and your family members, and premiums can be deducted from your paycheck. It’s a simple and affordable way for your family to receive added financial protection. Coverage guidelines and benefits are outlined below. This insurance offers financial protection by paying a cash benefit if you or an insured dependent are injured as a result of a covered accident. Unless otherwise stated, the benefit amount payable is the same for you and your insured dependent(s). ELIGIBILITY - VACC Eligibility Requirement You must be actively working a minimum of 30 hours per week to be eligible for coverage. Dependent Eligibility To be eligible for coverage, your dependents must be able to perform Requirement normal activities, and not be confined (at home, in a hospital, or in any other care facility), and any child(ren) must be under age 26. In order for your spouse and/or children to be eligible for coverage, you must elect coverage for yourself. Premium Payment The premiums for this insurance are paid in full by you. PLAN INFORMATION INFORMATION / AMOUNT(S) Coverage Type 24-hour (On and off-job) Express Benefit $0 Annual Benefit Maximum Not Included (ABM) Portability Included 45106

BENEFITS AMOUNTS 1 Initial Care & Emergency – Most treatment / service required within 72 hours of accident; Once per accident per insured person Emergency Room $0 Urgent Care Center $0 Initial Physician Office Visit $0 Ambulance Up to $0 Specified Injuries1,2 Fractures (Surgical / Non-surgical) Up to $0 Dislocations (Surgical / Non-surgical) Up to $0 Lacerations Up to $0 Burns Up to $0 Dental Up to $0 Hospital, Surgical & Diagnostic1,3 Admission $0 Daily Confinement (Up to 365 days per accident) $0 per day ICU Confinement (Up to 15 days per accident) $0 per day Rehab. Facility Confinement (Up to 30 days per $0 per day accident) Surgical Up to $0 Diagnostic Up to $0 Follow-Up Care1 – Treatment / service required within 365 days of accident; Medical device is once per accident per insured person Physician Follow-Up Office Visit $0; Up to 6 per accident Therapy Services $0; Up to 6 per accident Medical Device $0 Prosthetic Device(s) $0; Up to 2 per accident 1 Additional Benefits – Benefits are payable within 365 days of accident; Health screening benefit is payable once per calendar year Transportation (Up to 3 trips per accident) $0 per trip Lodging (Up to 30 nights per accident) $0 per night Childcare (Up to 30 days per accident) $0 per day Health Screening $0 Catastrophic Benefits1,4 – Benefits are payable within 365 days of accident; Once per accident per insured person Principal Sum (PS) You: $0 Spouse: $0 Child(ren): $0 Common Carrier Accidental Death 0% of PS Transportation of Remains Up to $0 Dismemberment & Paralysis Up to 0% of PS Reasonable Modifications Up to 0% of PS Coma 0% of PS SERVICES Hearing Discount Program The Hearing Discount program provides you and your family discounted hearing products, including hearing aids and batteries. Call 1-888-534-1747 or visit www.amplifonusa.com/mutualofomaha to learn more. 1Additional limitations apply as described in the certificate. 2Fractures and dislocations require treatment within 90 days of accident, burns and lacerations within 72 hours of an accident, and dental care within 30 days. If an insured person sustains both a fracture and dislocation as the result of the same accident, the maximum amount payable is up to 200% of the amount payable for the injury with the highest applicable benefit amount. 3Daily confinement must begin with 90 days of accident and ICU confinement within 30 days. Surgical treatment timeframes vary. If applicable, diagnostic services must be received within 90 days of accident. Except for confinement benefits, most benefits are payable once per accident per insured person. If any surgery occurs concurrently with an open reduction for a fracture or dislocation of the same bone or joint as a result of the same accident, only the highest applicable benefit is payable. 4The principal sum for you and your spouse reduces by 50% when you reach the age of 70.

Accident Coverage This insurance pays a benefit for each injury, treatment or service included in the BENEFITS AMOUNT policy that occurs as the result of a covered accident. Ambulance $0 For example, Jeff’s son, Jake, was playing soccer during recess at school. He was ER Visit $0 tripped and falls hard, injures his shoulder, and is transported by ambulance to CT Scan $0 the ER due to concerns of head trauma. The ER doctor orders a CT scan to check X-ray $0 for any facial or head injuries and a shoulder X-ray. Concussion $0 Jake was diagnosed with a concussion and a broken collarbone. His arm was set Broken Collarbone $0 in a sling, and he was released to his pediatrician for follow-up care. Jake visits Follow-Up Visit 1 $0 his pediatrician at two weeks and one month after the accident to make sure he’s healing well. Follow-Up Visit 2 $0 In the meantime, Jeff starts receiving bills for the care Jake received. The Total Benefit $0 ambulance bill alone was $556. He’s a pretty healthy kid, so a health insurance Note: The benefits shown in this deductible of $1,500 had to be met before Jeff’s health insurance would begin example are for a sample design covering Jake’s care, and after that, there’s a 20% copay. and may vary from the benefits Accident benefits pay in addition to other insurance, and can be used to help that are available to you. cover gaps in health insurance or other expenses if the unexpected happens. Voluntary Accident Premium Rates The amounts shown below are WEEKLY amounts (52 payments / deductions per year). You may elect insurance for you only, or for your family. Premiums will be automatically deducted from your paychecks as authorized by you during the enrollment process. Premiums must be paid by you to the policyholder. COVERAGE TIER PREMIUM AMOUNT Employee/Member $0 ($0 per day) Employee/Member + Spouse $0 ($0 per day) Employee/Member + Child(ren) $0 ($0 per day) Employee/Member + Family $0 ($0 per day) Note: The amount(s) above may vary due to rounding and are subject to change based on the final terms of the policy.

Who is eligible for this insurance? · You must be actively working (performing all normal duties of your job) at least 30 hours per week and be under age 80 · Your dependent(s) must be performing normal activities and not be confined (at home or in a hospital / care facility) and any child(ren) must be under age 26 What is the “Express Benefit”? This benefit is payable upon notification of an accident in which an insured person is injured. It can be paid in a short time frame with minimal information (compared to a typical claim). Can I take this insurance with me if I change jobs / am no longer a member of this group? In the event this insurance ends due to a change in your employment / membership status with the group, or for certain other reasons, you or your insured spouse have the right to continue this insurance under the Portability provision, subject to certain conditions. When does this insurance end? Insurance will end on the last day of the month in which an insured person no longer satisfies the applicable eligibility conditions, or when you reach the age of 80. Additional circumstances under which insurance will end are described in the certificate. Are there any exclusions or limitations? The benefits payable are based on the insurance in effect on the date of the covered accident, subject to the definitions, limitations, exclusions and other provisions of the policy. The exclusions and limitations are summarized in the outline of coverage and detailed in the certificate. Please contact your benefits administrator for a copy of the outline of coverage or if you have questions prior to enrolling. This information describes some of the features of the benefits plan. Benefits may not be available in all states. Please refer to the certificate booklet for a full explanation of the plan's benefits, exclusions, limitations and reductions. Should there be any discrepancy between the certificate booklet and this summary, the certificate booklet will prevail. Availability of benefits is subject to final acceptance and approval of the group application by the underwriting company. Accident insurance is underwritten by United of Omaha Life Insurance Company, 3300 Mutual of Omaha Plaza, Omaha, NE 68175, 1-800-769-7159. United of Omaha Life Insurance Company is licensed nationwide, except in New York. Policy form number 7000GM-U-EZ 2010. This policy provides accident insurance only. It does not provide basic hospital, basic medical or major medical insurance. It is not a Medicare supplement policy. The insurance is designed to pay you a fixed dollar amount regardless of the amount any provider charges. VOLUNTARY ACCIDENT INSURANCE