ACCIDENT INSURANCE. Quick Reference Guide

A

I

Quick Reference Guide

Underwritten by the following subsidiary of UnumProvident Corporation: Provident Life and Accident Insurance Company

1 Fountain Square, Chattanooga, TN 37402 www.unumprovident.com

©2004 UnumProvident Corporation. UnumProvident represents the marketing brand of UnumProvident Corporation’s insuring subsidiaries. All rights reserved.

VB-596 (Rev. 6-04)

Accident Insurance

UnumProvident’s supplemental accident insurance provides benefi ts for covered injuries1 _and accident-related expenses for an individual or family. This individual policy is designed to help cover expenses that result from accidents occurring on or off the job, depending on the plan design selected.

Product Overview

Plan design options

• Base plan covers a wide variety of injuries and accident-related expenses such as hospitalization, physical therapy, hospital intensive care, transportation, lodging and more. • Three base plan options available:

1. On and off-job accident coverage 2. Off-job accident coverage

3. On and off-job accident coverage without catastrophic accident or accidental death benefi ts and with reduced hospital benefi ts

Policy ownership

• individual policy sold at the worksite • premiums paid through payroll deduction

• employees can keep their coverage if they leave their current employer for any reason

Family coverage options2

• individual coverage: employee, spouse or child • employee and spouse

• one-parent family (where only one parent is covered) • two-parent family

Guaranteed renewable

Coverage is guaranteed renewable for life (except on disability riders) as long as premiums are paid.

Base plan eligibility

• Employee:

– issue ages 17 - 80

– must be actively at work3 _{with 20 hours per week}

minimum

• Spouse:

– issue ages 17 - 80 – must not be disabled • Children:

– issue ages 14 days - 24 years4

– must be dependent child of employee – must not be disabled

• Riders:

– Refer to the rider descriptions for eligibility

Effective date of coverage

Coverage becomes effective no earlier than the date the application is signed5 _{and no later than the date payroll}

deductions begin.

Riders available

The employee must be covered under the accident insurance base plan to apply for riders.

• sickness hospital confi nement rider (on- and off-job coverage)

– Benefi ts are paid if the insured is confi ned to a hospital due to a covered sickness

– Benefi t amounts: up to $100 per day for employee or spouse; up to $75 per day for children

– Eligibility: employee and spouses ages 17 - 67; children ages 14 days - 24 years

– Rider coverage is available to, and must match, those that are covered by the base accident plan

– Certain health questions will be asked when applying for employee or spouse coverage

– Includes a 12-month pre-existing condition provision and a nine-month pregnancy exclusion

• accident only disability income rider (off-job coverage) – Benefi ts are paid for covered accidents resulting in a

disability that occur off the job

– Available monthly benefi ts: $400 to $1,500, in $100 increments, up to a maximum of 40% of income for employees; spouses are eligible for a fl at $500 monthly benefi t

– Eligibility: employee and spouse ages 17 - 67 who are actively at work and not disabled

– Zero day elimination period with a six- or 12-month benefi t period

– Rider coverage is offered on a guaranteed issue basis – Coverage terminates at age 72

The policy or its provisions may vary or be unavailable in some states. See the actual policy or your UnumProvident representative for specifi c provisions and details of availability.

UnumProvident Corporation’s insuring subsidiaries comply with Act 91, the Vermont Civil Union Endorsement Law.

1 Covered accident means an accident that occurs after the policy effective date; occurs while the policy is in force; is of a coverage type listed on the policy schedule; and is not excluded by name or specifi c description in this policy. Injury or injuries means accidental bodily injury that is the direct result of a covered accident. Injuries must be independent of sickness, disease, bodily infi rmity and other causes. Carpal tunnel syndrome is considered to be a sickness.

2 One or two-parent family plans include all unmarried children ages 14 days to 25 years old and is dependent upon the employee for at least 50% support.

3 Being actively at work means that on the day the employee applies for coverage, he/she is working at one of his/ her company’s business locations, or is working at a location where he/she is required to represent his/her company. If he/she is applying for coverage on a day that is not a scheduled workday, then he/she will be considered actively at work if he/she meets this defi nition as of the last scheduled workday. Employees are not considered actively at work if their normal duties are limited or altered due to health, or if they are on a leave of absence. 4 Children covered at birth for the following states: AZ, CO, FL, GA, ID, IN, KS, LA, MN, MT, NC, NM, OK, OR, SC, SD, TX, UT, WA, and WI. In the following states, children are covered until age 26: ND and UT 5 The employee will receive the plan and coverage amount applied for on the application, unless it is determined to be unacceptable under UnumProvident’s rules, limits or standards. In such event, the plan and coverage amount may be modifi ed or declined.

6 The premium rate for this policy can be changed only if UnumProvident changes it on all similar inforce policies.

Base plan is an accident-only policy.

THIS IS A LIMITED POLICY.

Signifi cant Exceptions

UnumProvident’s Accident Coverage Insurance Policy and its provisions may vary by state. Below is a list of those states which have signifi cant exceptions. Please contact your UnumProvident representative for complete details for your state. State exceptions are subject to change.

State Exception

California Maximum policy issue age is 64. Premium rates vary for the disability riders.

Colorado Higher Benefi t Schedule. Reduced 1st year compensation.

Florida Higher Benefi t Schedule. Massachusetts Policy is non-cancelable

New Hampshire Higher Benefi t Schedule. Reduced 1st year compensation.

New Jersey CAT benefi t paid immediately upon written proof of loss. Loss of Sight, Hearing and Speech are not covered. Pennsylvania Off-job only (Plan 2) is NOT available.

CAT benefi t paid immediately upon written proof of loss. Loss of Sight, Hearing and Speech are not covered. Washington Lower Benefi t Schedule. All benefi ts include

A

I

Quick Reference Guide

Underwritten by the following subsidiary of UnumProvident Corporation: Provident Life and Accident Insurance Company

1 Fountain Square, Chattanooga, TN 37402 www.unumprovident.com

©2004 UnumProvident Corporation. UnumProvident represents the marketing brand of UnumProvident Corporation’s insuring subsidiaries. All rights reserved.

VB-596 (Rev. 6-04)

Accident Insurance

UnumProvident’s supplemental accident insurance provides benefi ts for covered injuries1 _and accident-related expenses for an individual or family. This individual policy is designed to help cover expenses that result from accidents occurring on or off the job, depending on the plan design selected.

Product Overview

Plan design options

• Base plan covers a wide variety of injuries and accident-related expenses such as hospitalization, physical therapy, hospital intensive care, transportation, lodging and more. • Three base plan options available:

1. On and off-job accident coverage 2. Off-job accident coverage

3. On and off-job accident coverage without catastrophic accident or accidental death benefi ts and with reduced hospital benefi ts

Policy ownership

• individual policy sold at the worksite • premiums paid through payroll deduction

• employees can keep their coverage if they leave their current employer for any reason

Family coverage options2

• individual coverage: employee, spouse or child • employee and spouse

• one-parent family (where only one parent is covered) • two-parent family

Guaranteed renewable

Coverage is guaranteed renewable for life (except on disability riders) as long as premiums are paid.

Base plan eligibility

• Employee:

– issue ages 17 - 80

– must be actively at work3 _{with 20 hours per week}

minimum

• Spouse:

– issue ages 17 - 80 – must not be disabled • Children:

– issue ages 14 days - 24 years4

– must be dependent child of employee – must not be disabled

• Riders:

– Refer to the rider descriptions for eligibility

Effective date of coverage

Coverage becomes effective no earlier than the date the application is signed5 _{and no later than the date payroll}

deductions begin.

Riders available

The employee must be covered under the accident insurance base plan to apply for riders.

• sickness hospital confi nement rider (on- and off-job coverage)

– Benefi ts are paid if the insured is confi ned to a hospital due to a covered sickness

– Benefi t amounts: up to $100 per day for employee or spouse; up to $75 per day for children

– Eligibility: employee and spouses ages 17 - 67; children ages 14 days - 24 years

– Rider coverage is available to, and must match, those that are covered by the base accident plan

– Certain health questions will be asked when applying for employee or spouse coverage

– Includes a 12-month pre-existing condition provision and a nine-month pregnancy exclusion

• accident only disability income rider (off-job coverage) – Benefi ts are paid for covered accidents resulting in a

disability that occur off the job

– Available monthly benefi ts: $400 to $1,500, in $100 increments, up to a maximum of 40% of income for employees; spouses are eligible for a fl at $500 monthly benefi t

– Eligibility: employee and spouse ages 17 - 67 who are actively at work and not disabled

– Zero day elimination period with a six- or 12-month benefi t period

– Rider coverage is offered on a guaranteed issue basis – Coverage terminates at age 72

The policy or its provisions may vary or be unavailable in some states. See the actual policy or your UnumProvident representative for specifi c provisions and details of availability.

UnumProvident Corporation’s insuring subsidiaries comply with Act 91, the Vermont Civil Union Endorsement Law.

1 Covered accident means an accident that occurs after the policy effective date; occurs while the policy is in force; is of a coverage type listed on the policy schedule; and is not excluded by name or specifi c description in this policy. Injury or injuries means accidental bodily injury that is the direct result of a covered accident. Injuries must be independent of sickness, disease, bodily infi rmity and other causes. Carpal tunnel syndrome is considered to be a sickness.

2 One or two-parent family plans include all unmarried children ages 14 days to 25 years old and is dependent upon the employee for at least 50% support.

3 Being actively at work means that on the day the employee applies for coverage, he/she is working at one of his/ her company’s business locations, or is working at a location where he/she is required to represent his/her company. If he/she is applying for coverage on a day that is not a scheduled workday, then he/she will be considered actively at work if he/she meets this defi nition as of the last scheduled workday. Employees are not considered actively at work if their normal duties are limited or altered due to health, or if they are on a leave of absence. 4 Children covered at birth for the following states: AZ, CO, FL, GA, ID, IN, KS, LA, MN, MT, NC, NM, OK, OR, SC, SD, TX, UT, WA, and WI. In the following states, children are covered until age 26: ND and UT 5 The employee will receive the plan and coverage amount applied for on the application, unless it is determined to be unacceptable under UnumProvident’s rules, limits or standards. In such event, the plan and coverage amount may be modifi ed or declined.

6 The premium rate for this policy can be changed only if UnumProvident changes it on all similar inforce policies.

Base plan is an accident-only policy.

THIS IS A LIMITED POLICY.

Signifi cant Exceptions

UnumProvident’s Accident Coverage Insurance Policy and its provisions may vary by state. Below is a list of those states which have signifi cant exceptions. Please contact your UnumProvident representative for complete details for your state. State exceptions are subject to change.

State Exception

California Maximum policy issue age is 64. Premium rates vary for the disability riders.

Colorado Higher Benefi t Schedule. Reduced 1st year compensation.

Florida Higher Benefi t Schedule. Massachusetts Policy is non-cancelable

New Hampshire Higher Benefi t Schedule. Reduced 1st year compensation.

New Jersey CAT benefi t paid immediately upon written proof of loss. Loss of Sight, Hearing and Speech are not covered. Pennsylvania Off-job only (Plan 2) is NOT available.

CAT benefi t paid immediately upon written proof of loss. Loss of Sight, Hearing and Speech are not covered. Washington Lower Benefi t Schedule. All benefi ts include

A

I

Quick Reference Guide

Underwritten by the following subsidiary of UnumProvident Corporation: Provident Life and Accident Insurance Company

1 Fountain Square, Chattanooga, TN 37402 www.unumprovident.com

©2004 UnumProvident Corporation. UnumProvident represents the marketing brand of UnumProvident Corporation’s insuring subsidiaries. All rights reserved.

VB-596 (Rev. 6-04)

Accident Insurance

UnumProvident’s supplemental accident insurance provides benefi ts for covered injuries1 _and accident-related expenses for an individual or family. This individual policy is designed to help cover expenses that result from accidents occurring on or off the job, depending on the plan design selected.

Product Overview

Plan design options

• Base plan covers a wide variety of injuries and accident-related expenses such as hospitalization, physical therapy, hospital intensive care, transportation, lodging and more. • Three base plan options available:

1. On and off-job accident coverage 2. Off-job accident coverage

3. On and off-job accident coverage without catastrophic accident or accidental death benefi ts and with reduced hospital benefi ts

Policy ownership

• individual policy sold at the worksite • premiums paid through payroll deduction

• employees can keep their coverage if they leave their current employer for any reason

Family coverage options2

• individual coverage: employee, spouse or child • employee and spouse

• one-parent family (where only one parent is covered) • two-parent family

Guaranteed renewable

Coverage is guaranteed renewable for life (except on disability riders) as long as premiums are paid.

Base plan eligibility

• Employee:

– issue ages 17 - 80

– must be actively at work3 _{with 20 hours per week}

minimum

• Spouse:

– issue ages 17 - 80 – must not be disabled • Children:

– issue ages 14 days - 24 years4

– must be dependent child of employee – must not be disabled

• Riders:

– Refer to the rider descriptions for eligibility

Effective date of coverage

Coverage becomes effective no earlier than the date the application is signed5 _{and no later than the date payroll}

deductions begin.

Riders available

The employee must be covered under the accident insurance base plan to apply for riders.

• sickness hospital confi nement rider (on- and off-job coverage)

– Benefi ts are paid if the insured is confi ned to a hospital due to a covered sickness

– Benefi t amounts: up to $100 per day for employee or spouse; up to $75 per day for children

– Eligibility: employee and spouses ages 17 - 67; children ages 14 days - 24 years

– Rider coverage is available to, and must match, those that are covered by the base accident plan

– Certain health questions will be asked when applying for employee or spouse coverage

– Includes a 12-month pre-existing condition provision and a nine-month pregnancy exclusion

• accident only disability income rider (off-job coverage) – Benefi ts are paid for covered accidents resulting in a

disability that occur off the job

– Available monthly benefi ts: $400 to $1,500, in $100 increments, up to a maximum of 40% of income for employees; spouses are eligible for a fl at $500 monthly benefi t

– Eligibility: employee and spouse ages 17 - 67 who are actively at work and not disabled

– Zero day elimination period with a six- or 12-month benefi t period

– Rider coverage is offered on a guaranteed issue basis – Coverage terminates at age 72

The policy or its provisions may vary or be unavailable in some states. See the actual policy or your UnumProvident representative for specifi c provisions and details of availability.

UnumProvident Corporation’s insuring subsidiaries comply with Act 91, the Vermont Civil Union Endorsement Law.

1 Covered accident means an accident that occurs after the policy effective date; occurs while the policy is in force; is of a coverage type listed on the policy schedule; and is not excluded by name or specifi c description in this policy. Injury or injuries means accidental bodily injury that is the direct result of a covered accident. Injuries must be independent of sickness, disease, bodily infi rmity and other causes. Carpal tunnel syndrome is considered to be a sickness.

2 One or two-parent family plans include all unmarried children ages 14 days to 25 years old and is dependent upon the employee for at least 50% support.

3 Being actively at work means that on the day the employee applies for coverage, he/she is working at one of his/ her company’s business locations, or is working at a location where he/she is required to represent his/her company. If he/she is applying for coverage on a day that is not a scheduled workday, then he/she will be considered actively at work if he/she meets this defi nition as of the last scheduled workday. Employees are not considered actively at work if their normal duties are limited or altered due to health, or if they are on a leave of absence. 4 Children covered at birth for the following states: AZ, CO, FL, GA, ID, IN, KS, LA, MN, MT, NC, NM, OK, OR, SC, SD, TX, UT, WA, and WI. In the following states, children are covered until age 26: ND and UT 5 The employee will receive the plan and coverage amount applied for on the application, unless it is determined to be unacceptable under UnumProvident’s rules, limits or standards. In such event, the plan and coverage amount may be modifi ed or declined.

6 The premium rate for this policy can be changed only if UnumProvident changes it on all similar inforce policies.

Base plan is an accident-only policy.

THIS IS A LIMITED POLICY.

Signifi cant Exceptions

UnumProvident’s Accident Coverage Insurance Policy and its provisions may vary by state. Below is a list of those states which have signifi cant exceptions. Please contact your UnumProvident representative for complete details for your state. State exceptions are subject to change.

State Exception

California Maximum policy issue age is 64. Premium rates vary for the disability riders.

Colorado Higher Benefi t Schedule. Reduced 1st year compensation.

Florida Higher Benefi t Schedule. Massachusetts Policy is non-cancelable

New Hampshire Higher Benefi t Schedule. Reduced 1st year compensation.

New Jersey CAT benefi t paid immediately upon written proof of loss. Loss of Sight, Hearing and Speech are not covered. Pennsylvania Off-job only (Plan 2) is NOT available.

CAT benefi t paid immediately upon written proof of loss. Loss of Sight, Hearing and Speech are not covered. Washington Lower Benefi t Schedule. All benefi ts include

Coverage for accidents Accident insurance Accident insurance base plan plus optional occurring off the job base policy only rider for hospitalization due to sickness

Plan 1 Plan 2 Plan 3 Plan 1 Plan 2 Plan 3 Employee $3.78 $3.30 $2.61 $4.59 $4.11 $3.42 Employee and Spouse $5.40 $4.71 $3.75 $7.02 $6.33 $5.37 One-parent family $7.20 $6.72 $5.55 $8.58 $8.10 $6.93 Two-parent family $8.82 $8.13 $6.69 $11.01 $10.32 $8.88

Schedule of Benefi ts Riders available (cont.)

• accident/sickness disability income rider (off-job coverage) – Benefi ts are paid for a covered sickness or off-job accident

resulting in a disability

– Available monthly benefi ts: $400 to $1,500, in $100 increments, up to a maximum of 40% of income for employees; spouses are eligible for a fl at $500 monthly benefi t – Eligibility: employee and spouse ages 17 - 67 who are

actively at work and not disabled

– Elimination periods (accident/sickness) combinations: 0/7, 7/7, 0/14, or 14/14 with a six- or 12-month benefi t period – Certain health questions will be asked when applying

for coverage

– Includes a 12-month pre-existing condition provision and a nine-month pregnancy exclusion

– Coverage terminates at age 72

Rates6

• Rates are level premium, unisex, uni-age with non-occupational classifi cations.

• Issue ages are based on the individual’s last birthday. • Rates vary by coverage type and coverage plan elected.

Underwriting guidelines

• Minimum case size requirements is 100 eligible lives. For cases with 25 - 99 eligible lives, refer to the WorkPack portfolio. • A minimum of 25 adult applications is required to establish

billing for the account.

• Guaranteed issue underwriting is available for all base plan types and for the accident only disability income rider. • Simplifi ed issue underwriting is required for the accident/

sickness disability income rider and the sickness hospital confi nement rider.

Terminations

This policy will terminate on the earliest of the following: • written request by the insured to terminate the policy;

• failure to pay the premiums for this policy, subject to the grace period allowed; and

• named insured’s death.

Exclusions

We will not pay benefi ts on any covered person for losses that are caused by or occur as the result of:

• war or act of war, whether declared or undeclared;

• riding in or driving any motor-driven vehicle in a race, stunt show or speed test;

• operating, learning to operate, serving as a crew member of or jumping, parachuting, or falling from any aircraft or hot air balloon, including those which are not motor-driven. This does not include fl ying as a fare paying passenger;

• engaging in hang-gliding, bungee jumping, parachuting, sailgliding, parasailing, parakiting or any similar activities; • participating or attempting to participate in an illegal activity

and/or being incarcerated in a penal institution;

• committing or trying to commit suicide or injuring oneself intentionally, whether sane or not;

• having any sickness or declining process caused by a sickness, including physical or mental infi rmity. We also will not pay benefi ts to diagnose or treat the sickness. Sickness means any illness, infection, disease or any other abnormal physical condition which is not caused by an injury;

• practicing for or participating in any semi-professional or professional competitive athletic contests for which any type of compensation or remuneration is received; or

• having a work related injury, unless an on-job accident coverage type is shown on the policy schedule.

* Catastrophic accident benefi ts are payable after fulfi lling a 365-day elimination period. See policy for details.

** Outline of Coverage is required at time of solicitation for the following states: CA, GA, ME, MT, NV, NH, OR, TX, WI and WV. Special Forms required at time of solicitation for the following states: MN, OR, SC and WI.

Benefi t amounts may vary by state.

Accident/Injury Benefi t Amount

Fractures

open up to $5,000 closed up to $2,500 chips 25% of closed amount

Hospital admission

(per admission) $750 (Plan 3 – $250)

Hospital confi nement

(per day up to 365 days) $200 (Plan 3 – $100)

Hospital intensive care unit

(per day up to 15 days) $400 (Plan 3 – $200)

Knee cartilage (torn) $500

exploratory $100

Laceration $25-$400

Lodging

(per night up to 30 days) $100

Loss of fi nger, toe, hand, foot or sight of an eye

Loss of both hands, feet, sight of both eyes, or any combination

of two or more losses $15,000 Loss of one hand, foot or sight

in one eye $7,500 Loss of two or more fi ngers, toes or

any combination of two or more losses $1,500 Loss of one fi nger or toe $750

Physical therapy (6 treatments) $25 per treatment

Prosthetic device or artifi cial limb

one $500 more than one $1,000

Ruptured disc $400

Surgery benefi t (open abdominal, thoracic) $1,000 exploratory $100

Tendon/ligament and rotator cuff

repair of one $400 repair of more than one $600 exploratory only $100

Transportation

(100+ miles up to 3 trips) $300

Accident/Injury Benefi t Amount

Accidental death (Plans 1 & 2 only)

employee $25,000 spouse $10,000 child $5,000 The accidental death benefi t doubles if the insured is injured as a fare-paying passenger on a common carrier. Employee – $50,000; Spouse – $20,000; Child – $10,000

Ambulance $100

air $500

Appliance $100

Blood, plasma and platelets $300

Burns

Flat amount for 2nd degree for 36% or more of body $750 3rd degree for 36% or more

of body, 9-34 sq. in. $1,500 35 or more sq. in. $10,000 skin grafts 25% of burn benefi t

Catastrophic accident (loss of use of sight, hearing, speech, arms or legs – Plans 1 & 2 only)*

employee <65 years $100,000 spouse or child <65 years $50,000 age 65-69 Amount reduced 50% age 70+ Amount reduced 75%

Concussion $100

Dental work, emergency

extraction $50 crown $150

Dislocations

open up to $4,000 closed up to $2,000

Doctor’s offi ce initial visit $50

Emergency room treatment

(includes X-rays) $150

Eye injury

requires surgery or removal of foreign body $200

Follow-up treatment for accident

initial follow-up visit $50

Weekly Premium Rates

Plan 1: On- and off-job accident coverage includes catastrophic accident and accidental death benefi ts Plan 2: Off-job accident coverage includes catastrophic accident and accidental death benefi ts Plan 3: On- and off-job accident coverage with reduced hospital benefi ts

Coverage for accidents Accident insurance Accident insurance base plan plus optional occurring off the job base policy only rider for hospitalization due to sickness

Plan 1 Plan 2 Plan 3 Plan 1 Plan 2 Plan 3 Employee $3.78 $3.30 $2.61 $4.59 $4.11 $3.42 Employee and Spouse $5.40 $4.71 $3.75 $7.02 $6.33 $5.37 One-parent family $7.20 $6.72 $5.55 $8.58 $8.10 $6.93 Two-parent family $8.82 $8.13 $6.69 $11.01 $10.32 $8.88

Schedule of Benefi ts Riders available (cont.)

• accident/sickness disability income rider (off-job coverage) – Benefi ts are paid for a covered sickness or off-job accident

resulting in a disability

– Available monthly benefi ts: $400 to $1,500, in $100 increments, up to a maximum of 40% of income for employees; spouses are eligible for a fl at $500 monthly benefi t – Eligibility: employee and spouse ages 17 - 67 who are

actively at work and not disabled

– Elimination periods (accident/sickness) combinations: 0/7, 7/7, 0/14, or 14/14 with a six- or 12-month benefi t period – Certain health questions will be asked when applying

for coverage

– Includes a 12-month pre-existing condition provision and a nine-month pregnancy exclusion

– Coverage terminates at age 72

Rates6

• Rates are level premium, unisex, uni-age with non-occupational classifi cations.

• Issue ages are based on the individual’s last birthday. • Rates vary by coverage type and coverage plan elected.

Underwriting guidelines

• Minimum case size requirements is 100 eligible lives. For cases with 25 - 99 eligible lives, refer to the WorkPack portfolio. • A minimum of 25 adult applications is required to establish

billing for the account.

• Guaranteed issue underwriting is available for all base plan types and for the accident only disability income rider. • Simplifi ed issue underwriting is required for the accident/

sickness disability income rider and the sickness hospital confi nement rider.

Terminations

This policy will terminate on the earliest of the following: • written request by the insured to terminate the policy;

• failure to pay the premiums for this policy, subject to the grace period allowed; and

• named insured’s death.

Exclusions

We will not pay benefi ts on any covered person for losses that are caused by or occur as the result of:

• war or act of war, whether declared or undeclared;

• riding in or driving any motor-driven vehicle in a race, stunt show or speed test;

• operating, learning to operate, serving as a crew member of or jumping, parachuting, or falling from any aircraft or hot air balloon, including those which are not motor-driven. This does not include fl ying as a fare paying passenger;

• engaging in hang-gliding, bungee jumping, parachuting, sailgliding, parasailing, parakiting or any similar activities; • participating or attempting to participate in an illegal activity

and/or being incarcerated in a penal institution;

• committing or trying to commit suicide or injuring oneself intentionally, whether sane or not;

• having any sickness or declining process caused by a sickness, including physical or mental infi rmity. We also will not pay benefi ts to diagnose or treat the sickness. Sickness means any illness, infection, disease or any other abnormal physical condition which is not caused by an injury;

• practicing for or participating in any semi-professional or professional competitive athletic contests for which any type of compensation or remuneration is received; or

• having a work related injury, unless an on-job accident coverage type is shown on the policy schedule.

* Catastrophic accident benefi ts are payable after fulfi lling a 365-day elimination period. See policy for details.

** Outline of Coverage is required at time of solicitation for the following states: CA, GA, ME, MT, NV, NH, OR, TX, WI and WV. Special Forms required at time of solicitation for the following states: MN, OR, SC and WI.

Benefi t amounts may vary by state.

Accident/Injury Benefi t Amount

Fractures

open up to $5,000 closed up to $2,500 chips 25% of closed amount

Hospital admission

(per admission) $750 (Plan 3 – $250)

Hospital confi nement

(per day up to 365 days) $200 (Plan 3 – $100)

Hospital intensive care unit

(per day up to 15 days) $400 (Plan 3 – $200)

Knee cartilage (torn) $500

exploratory $100

Laceration $25-$400

Lodging

(per night up to 30 days) $100

Loss of fi nger, toe, hand, foot or sight of an eye

Loss of both hands, feet, sight of both eyes, or any combination

of two or more losses $15,000 Loss of one hand, foot or sight

in one eye $7,500 Loss of two or more fi ngers, toes or

any combination of two or more losses $1,500 Loss of one fi nger or toe $750

Physical therapy (6 treatments) $25 per treatment

Prosthetic device or artifi cial limb

one $500 more than one $1,000

Ruptured disc $400

Surgery benefi t (open abdominal, thoracic) $1,000 exploratory $100

Tendon/ligament and rotator cuff

repair of one $400 repair of more than one $600 exploratory only $100

Transportation

(100+ miles up to 3 trips) $300

Accident/Injury Benefi t Amount

Accidental death (Plans 1 & 2 only)

employee $25,000 spouse $10,000 child $5,000 The accidental death benefi t doubles if the insured is injured as a fare-paying passenger on a common carrier. Employee – $50,000; Spouse – $20,000; Child – $10,000

Ambulance $100

air $500

Appliance $100

Blood, plasma and platelets $300

Burns

Flat amount for 2nd degree for 36% or more of body $750 3rd degree for 36% or more

of body, 9-34 sq. in. $1,500 35 or more sq. in. $10,000 skin grafts 25% of burn benefi t

Catastrophic accident (loss of use of sight, hearing, speech, arms or legs – Plans 1 & 2 only)*

employee <65 years $100,000 spouse or child <65 years $50,000 age 65-69 Amount reduced 50% age 70+ Amount reduced 75%

Concussion $100

Dental work, emergency

extraction $50 crown $150

Dislocations

open up to $4,000 closed up to $2,000

Doctor’s offi ce initial visit $50

Emergency room treatment

(includes X-rays) $150

Eye injury

requires surgery or removal of foreign body $200

Follow-up treatment for accident

initial follow-up visit $50

Weekly Premium Rates

Plan 1: On- and off-job accident coverage includes catastrophic accident and accidental death benefi ts Plan 2: Off-job accident coverage includes catastrophic accident and accidental death benefi ts Plan 3: On- and off-job accident coverage with reduced hospital benefi ts

A

I

Quick Reference Guide

Underwritten by the following subsidiary of UnumProvident Corporation: Provident Life and Accident Insurance Company

1 Fountain Square, Chattanooga, TN 37402 www.unumprovident.com

©2004 UnumProvident Corporation. UnumProvident represents the marketing brand of UnumProvident Corporation’s insuring subsidiaries. All rights reserved.

VB-596 (Rev. 6-04)

Accident Insurance

UnumProvident’s supplemental accident insurance provides benefi ts for covered injuries1 _and accident-related expenses for an individual or family. This individual policy is designed to help cover expenses that result from accidents occurring on or off the job, depending on the plan design selected.

Product Overview

Plan design options

• Base plan covers a wide variety of injuries and accident-related expenses such as hospitalization, physical therapy, hospital intensive care, transportation, lodging and more. • Three base plan options available:

1. On and off-job accident coverage 2. Off-job accident coverage

3. On and off-job accident coverage without catastrophic accident or accidental death benefi ts and with reduced hospital benefi ts

Policy ownership

• individual policy sold at the worksite • premiums paid through payroll deduction

• employees can keep their coverage if they leave their current employer for any reason

Family coverage options2

• individual coverage: employee, spouse or child • employee and spouse

• one-parent family (where only one parent is covered) • two-parent family

Guaranteed renewable

Coverage is guaranteed renewable for life (except on disability riders) as long as premiums are paid.

Base plan eligibility

• Employee:

– issue ages 17 - 80

– must be actively at work3 _{with 20 hours per week}

minimum

• Spouse:

– issue ages 17 - 80 – must not be disabled • Children:

– issue ages 14 days - 24 years4

– must be dependent child of employee – must not be disabled

• Riders:

– Refer to the rider descriptions for eligibility

Effective date of coverage

Coverage becomes effective no earlier than the date the application is signed5 _{and no later than the date payroll}

deductions begin.

Riders available

The employee must be covered under the accident insurance base plan to apply for riders.

• sickness hospital confi nement rider (on- and off-job coverage)

– Benefi ts are paid if the insured is confi ned to a hospital due to a covered sickness

– Benefi t amounts: up to $100 per day for employee or spouse; up to $75 per day for children

– Eligibility: employee and spouses ages 17 - 67; children ages 14 days - 24 years

– Rider coverage is available to, and must match, those that are covered by the base accident plan

– Certain health questions will be asked when applying for employee or spouse coverage

– Includes a 12-month pre-existing condition provision and a nine-month pregnancy exclusion

• accident only disability income rider (off-job coverage) – Benefi ts are paid for covered accidents resulting in a

disability that occur off the job

– Available monthly benefi ts: $400 to $1,500, in $100 increments, up to a maximum of 40% of income for employees; spouses are eligible for a fl at $500 monthly benefi t

– Eligibility: employee and spouse ages 17 - 67 who are actively at work and not disabled

– Zero day elimination period with a six- or 12-month benefi t period

– Rider coverage is offered on a guaranteed issue basis – Coverage terminates at age 72

The policy or its provisions may vary or be unavailable in some states. See the actual policy or your UnumProvident representative for specifi c provisions and details of availability.

UnumProvident Corporation’s insuring subsidiaries comply with Act 91, the Vermont Civil Union Endorsement Law.

1 Covered accident means an accident that occurs after the policy effective date; occurs while the policy is in force; is of a coverage type listed on the policy schedule; and is not excluded by name or specifi c description in this policy. Injury or injuries means accidental bodily injury that is the direct result of a covered accident. Injuries must be independent of sickness, disease, bodily infi rmity and other causes. Carpal tunnel syndrome is considered to be a sickness.

2 One or two-parent family plans include all unmarried children ages 14 days to 25 years old and is dependent upon the employee for at least 50% support.

3 Being actively at work means that on the day the employee applies for coverage, he/she is working at one of his/ her company’s business locations, or is working at a location where he/she is required to represent his/her company. If he/she is applying for coverage on a day that is not a scheduled workday, then he/she will be considered actively at work if he/she meets this defi nition as of the last scheduled workday. Employees are not considered actively at work if their normal duties are limited or altered due to health, or if they are on a leave of absence. 4 Children covered at birth for the following states: AZ, CO, FL, GA, ID, IN, KS, LA, MN, MT, NC, NM, OK, OR, SC, SD, TX, UT, WA, and WI. In the following states, children are covered until age 26: ND and UT 5 The employee will receive the plan and coverage amount applied for on the application, unless it is determined to be unacceptable under UnumProvident’s rules, limits or standards. In such event, the plan and coverage amount may be modifi ed or declined.

6 The premium rate for this policy can be changed only if UnumProvident changes it on all similar inforce policies.

Base plan is an accident-only policy.

THIS IS A LIMITED POLICY.

Signifi cant Exceptions

UnumProvident’s Accident Coverage Insurance Policy and its provisions may vary by state. Below is a list of those states which have signifi cant exceptions. Please contact your UnumProvident representative for complete details for your state. State exceptions are subject to change.

State Exception

California Maximum policy issue age is 64. Premium rates vary for the disability riders.

Colorado Higher Benefi t Schedule. Reduced 1st year compensation.

Florida Higher Benefi t Schedule. Massachusetts Policy is non-cancelable

New Hampshire Higher Benefi t Schedule. Reduced 1st year compensation.

New Jersey CAT benefi t paid immediately upon written proof of loss. Loss of Sight, Hearing and Speech are not covered. Pennsylvania Off-job only (Plan 2) is NOT available.

CAT benefi t paid immediately upon written proof of loss. Loss of Sight, Hearing and Speech are not covered. Washington Lower Benefi t Schedule. All benefi ts include