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TimeInsuranceCompany

501WestMichigan
Milwaukee,WI53203

OutlineofCoverage
for
AccidentMedicalExpenseInsurancePolicyForm8227.POLLA
WithTermAccidentalDeathandDismembermentBenefitsandOptionalRiders

Notice:ThecoverageappliedforisanAccidentonlyPolicyanditdoesnotpaybenefitsforloss
fromSickness[,exceptasprovidedforunderoptionalRider[s]].ThePolicy[andoptional
Rider[s]]provide[s]limitedbenefits.Benefitsprovidedaresupplementalandarenotintended
tocoverallmedicalexpenses.

TobeeligibleforanybenefitsunderthisPolicy,anAccidentmustoccuronoraftertheCovered
PersonsEffectiveDateandwhilethisPolicyisineffect.Tobeeligibleforanybenefitsunder
theSicknessIndemnityRider,theConfinementPeriodforHospitalizationduetoSicknessmust
occuronoraftertheCoveredPersonsEffectiveDateandwhiletheRiderisineffect.Tobe
eligibleforanybenefitsundertheCancerandHeartStrokeRiderthefirsteverDiagnosisofa
SpecifiedDiseasemustoccuronoraftertheCoveredPersonsEffectiveDateandwhilethe
Riderisineffect.

AccidentmedicalexpensesareeligibleforbenefitsonlyuptotheamountofCoveredTreatment
ofanAccidentforwhichnoOtherBenefitsarereceivedunderanyothercoverage,suchas
benefitsunderanothermedicalplan,hospitalindemnitypolicy,medicalpaymentsunderan
motorvehicle,orotherliabilitypolicy.

THISISNOTMEDICARESUPPLEMENTINSURANCECOVERAGE.

THEPLANHASLIMITEDBENEFITSANDANNUALMAXIMUMS.PLEASEREADYOUR
POLICYCAREFULLYTOUNDERSTANDPLANLIMITATIONS.

ConditionallyRenewablePlan:ReadtheTerminationDateprovisionofYourPolicycarefully.We
reservetherighttochangepremiumsbyclassuponanyrenewaldateaftertheinitial12months
coverageisinforce.

ThisoutlineofcoverageprovidesabriefdescriptionoftheimportantfeaturesofYourPolicy.This
isnottheinsurancecontract.ThePolicyitselfsetsforthindetailthelimitsandconditionsof
coverageaswellastherightsandobligationsofbothYouandtheinsurancecompany.ThePolicy
provideslimitedbenefitsonlyandcontainsMaximumBenefitLimitations.Itisimportantthat
YouREADYOURPOLICYANDBENEFITSCHEDULECAREFULLY.

8227.OOCR.LA Page1OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.

SECTION1:SCHEDULEDBENEFITS

AccidentBenefits
WewillpaythebenefitsshownbelowonlyasdescribedintheAccidentBenefitssectionofthe
Policy.AllbenefitsandlimitationsstatedbelowarestatedperCoveredPerson.

AccidentMedicalExpenseBenefits
AccidentMedicalExpense AMEMaximumBenefitLimitation:$__________per
Benefit: Accident
DeductibleperAccident:$250
BenefitPercentage:100%
BenefitPeriod:thefirst365daysafterthedatetheAccident
occurs.
InitialTreatmentPeriod:Initialtreatmentorevaluationof
theAccidentalInjurymustbereceivedwithinthefirst7
daysafterthedatetheAccidentoccurs.
TreatmentSpecificLimitations:
Benefitsforgroundambulanceservicesarelimitedto
$300perAccident.
PhysicalMedicineislimitedtoamaximumbenefitof
$25pervisitdayupto$250perAccident.
DurableMedicalEquipmentandPersonalMedical
Equipmentbenefitsarelimitedtoamaximumbenefitof
$100perAccident.

AccidentalDeathandDismembermentBenefits
AccidentalDeathand AllAccidentalDismembermentBenefitsandtheAccidentalDeath
DismembermentMaximum Benefitscombinedarelimitedto$__________perAccident.
BenefitLimitation:
AccidentalDismemberment InitialTreatmentPeriod:Initialtreatmentorevaluationofthe
Benefit: AccidentalDismembermentmustbereceivedwithinthefirst7days
afterthedatetheAccidentoccurs.

Accidental BenefitAmount
Dismemberment
Lossofonehand. 50%oftheAccidentalDeathand
DismembermentMaximumBenefit
Limitation
Lossofonefoot. 50%oftheAccidentalDeathand
DismembermentMaximumBenefit
Limitation
LossofSightofone 25%oftheAccidentalDeathand
eye. DismembermentMaximumBenefit
Limitation

8227.OOCR.LA Page2OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.

LossofHearinginone 25%oftheAccidentalDeathand
ear. DismembermentMaximumBenefit
Limitation
LossofSpeech. 50%oftheAccidentalDeathand
DismembermentMaximumBenefit

Limitation
AccidentalDeathBenefit: CoveredPerson BenefitAmount
Policyholder: $__________
CoveredDependentSpouse/Domestic $__________
Partner:
CoveredDependentChild(ren): $__________


CANCERANDHEARTSTROKERIDER
LimitedSpecifiedDiseaseRiderBenefits

BenefitswillbepaidforSpecifiedDiseasesfirsteverDiagnosedwhilethisRiderisinforce.
Paymentofbenefitsissubjecttoalltheterms,limitsandconditionsintheRider.

WewillpaytheScheduledBenefitshownbelowonlyfortheSpecifiedDiseaseslistedbelow.
AllbenefitsandlimitationsarestatedperCoveredPerson.
CancerBenefit BenefitWaitingPeriodforCancer:Canceriseligibleforbenefits
underthisplanonlyifDiagnosedafterthefirst90calendardays
fromtheEffectiveDate.

AllCancerBenefitsarelimitedtoaMaximumLifetimeBenefitof
$__________.
HeartStrokeBenefit BenefitWaitingPeriodforHeartStroke:HeartStrokeiseligible
forbenefitsunderthisplanonlyifDiagnosedafterthefirst30
calendardaysfromtheEffectiveDate.

AllHeart/StrokeBenefitsarelimitedtoaMaximumLifetime
Benefitof$__________.
SpecifiedDisease ScheduledBenefit
Cancer $__________
CoronaryArteryDiseaseorCardiacArrhythmiaresultinginHeartAttack $__________
CoronaryArteryDiseaseorCardiacArrhythmiaresultinginCoronary 25%ofHeartAttack
ArteryBypass Benefit
CoronaryArteryDiseaseresultinginCoronaryAngioplasty 10%ofHeartAttack
Benefit
CerebrovascularDiseaseresultinginStroke $__________

8227.OOCR.LA Page3OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.

SICKNESSINDEMNITYRIDER
HospitalConfinementFixedIndemnityBenefit
WewillpaytheScheduledBenefitshownbelowonlyforHospitalizationsduetoSicknessasdefined
intheRider.Paymentofbenefitsissubjecttoallterms,limitsandconditionsintheRider.
BenefitsstatedbelowareperCoveredPersonexceptfortheMaximumHospitalizationBenefit.
InpatientHospitalizationfor BenefitWaitingPeriodforInpatientHospitalizationfor
SicknessBenefit: Sickness:HospitalizationiseligibleforbenefitsunderthisRider
onlyifitoccursafterthefirst30calendardaysfromthe
EffectiveDate.
InpatientHospitalizationScheduledBenefit:$__________per
ConfinementPeriod
MaximumCalendarYearBenefitPerCoveredPerson:
$__________
MaximumCalendarYearBenefitCombined:2Inpatient
HospitalizationforSicknessBenefits

SECTION2:BENEFITDESCRIPTIONS:
AccidentMedicalExpenseBenefitDescription:
AfterYouhavesatisfiedpaymentoftheDeductibleamount,WewillpaytheBenefitPercentage
shownaboveforchargesforCoveredTreatmentIncurredbyaCoveredPersonforthetreatmentof
AccidentalInjuriesifallofthefollowingaremet:

1. ThechargesforCoveredTreatmentsofanAccidentalInjuryareIncurredwithintheBenefit
PeriodshownontheBenefitSchedule.

2. ThefirsttreatmentormedicalevaluationfortheAccidentalInjuryisIncurredwithinthe
InitialTreatmentPeriodshownabove;ifnotreatmentfortheAccidentalInjuryisrendered
withintheInitialTreatmentPeriod,anysubsequentchargesfortreatmentoftheAccidental
InjuryarenoteligibleforbenefitsunderthisPolicy.

3. YoudonotreceivebenefitsequaltosuchchargesunderanyOtherBenefits.

4. Thetotalchargesforthemedicaleventortreatmentrenderedarenotinexcessofthe
MaximumAllowableAmountshownabove.Anyportionofsuchchargesinexcessofthe
MaximumAllowableAmountwillnotbeconsideredwhendeterminingbenefitsunderthis
Policy.

AccidentalDismembermentBenefitDescription:
WewillpayanAccidentalDismembermentBenefitifallofthefollowingrequirementsaremet:

1. TheAccidentandAccidentalDismembermentoccurwhiletheAccidentalDismemberment
Benefitprovisionisinforce.

8227.OOCR.LA Page4OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.

2. ThefirsttreatmentormedicalevaluationfortheAccidentalDismembermentorAccidental
InjuryresultinginsuchdismembermentisIncurredwithintheInitialTreatmentPeriod.If
notreatmentormedicalevaluationfortheAccidentalDismemberment,orcausalAccidental
Injury,isrenderedwithintheInitialTreatmentPeriod,noAccidentalDismemberment
BenefitwillbepaidunderthePolicy.

3. TheAccidentalDismembermentoccurswithin90daysofthedatetheAccidentoccurred.

TheAccidentalDismembermentBenefitwillnotbepaidiftheseveredbodypartissubsequently
reattached.TheAccidentalDismembermentBenefitpayableforeachtypeofdismembermentis
shownontheBenefitSchedule.OnlyAccidentalDismembermentsshownontheBenefitSchedule
areeligibleforbenefitsunderthisprovision.AccidentalDismembermentBenefitsaresubjecttothe
AccidentalDeathandDismembermentMaximumBenefitLimitation.

AccidentalDeathBenefitDescription:
IftheCoveredPersondiesasadirectresultoftheAccident,Wewillpaythecorresponding
AccidentalDeathBenefittotheBeneficiaryifallofthefollowingrequirementsaremet:
1. WereceivelegalproofoftheCoveredPersonsdeath;and
2. TheproofshowsthatdeathresulteddirectlyfrombodilyAccidentalInjurycausedsolelyas
aresultofanAccidentandindependentofdisease,physicalcondition,bodilyinfirmityor
anyothercause;
3. AccidentalDeathoccurredwithinthefirst90daysaftertheAccident,exceptthat,incases
whenattheendofthe90dayperiodaCoveredPersoniscomatoseorisbeingkept
clinicallyalivebyanartificiallifesupportsystem,the90daylimitwillbeextendedto365
days;and
4. AccidentalDeathoccurredpriortothedatetheCoveredPersonattainsage75.

WereservetherighttohaveanautopsyperformedatOurexpensewhereitisnotprohibitedby
lawbeforebenefitsareconsidered.

WewillnotpayanyAccidentalDeathBenefitsfordeathoccurringbetweenthedatethecoverage
lapsesandthedatecoverageisreinstated.

AccidentalDeathBenefitsaresubjecttotheAccidentalDeathandDismembermentMaximum
BenefitLimitationshownontheBenefitSchedule.

CancerandHeartStrokeRider
SpecifiedDiseaseBenefitDescription:
IfthisRiderispurchasedandifaCoveredPersonhasafirsteverDiagnosisofaSpecified
DiseasewhileinsuredunderthisRider,WewillpaythecorrespondingScheduledBenefitshown
intheBenefitSchedule.

8227.OOCR.LA Page5OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.

WewillnotpaybenefitsforanySpecifiedDiseaseiftheCoveredPersonhasreceivedthat
DiagnosisatanytimepriortotheCoveredPersonsEffectiveDateofcoverageunderthisRider.

SicknessIndemnityRider
InpatientCoveredHospitalizationforSicknessBenefitDescription:
IfthisRiderispurchasedand,WewillpaytheScheduledBenefitamountperConfinementPeriod
foraCoveredHospitalizationasaresultofSickness.

BenefitsarelimitedtotheMaximumCalendarYearBenefitsshownontheBenefitSchedule.]

SECTION3:DEFINITIONS:
AsusedinthisOutlineofCoverage,capitalizedterms(otherthanheadingsandtitles)aredefined
asfollows.ConsultthePolicyforafulllistofalldefinedtermsusedinthePolicydocuments.

Accident
Anyeventthatmeetsallofthefollowingrequirements:
1. Itcausesharmtothephysicalstructureofthebody.
2. Itisthedirectcauseofaloss,independentofdisease,bodilyinfirmityoranyothercause.
3. Itisdefiniteastoasingletimeandplace.
4. Ithappensinvoluntarily.

AnAccidentdoesnotincludeharmresulting,whetherdirectlyorindirectly,fromsickness,cerebral
vascularaccident(stroke),orexposuretosickness,toxin,aninfectiousagent,orcommunicable
disease.Accidentdoesnotincludeanyoverdoseofcontrolledsubstance,drug,ornarcotic.
Accidentdoesnotincludebug/insectbitesorstings.

AccidentalDeath
DeathcausedbyanAccidentandindependentandexclusiveofallothercauses.Tobeeligiblefor
benefitsunderthePolicy,suchdeathmustoccurwithin90daysaftertheAccidentinitially
occurred,exceptthat,incaseswhenattheendofthe90dayperiodaCoveredPersoniscomatose
orisbeingkeptclinicallyalivebyanartificiallifesupportsystem,the90daylimitwillbeextended
to365days.

AccidentalDismemberment
Completeseveranceofabodypartfromtherestofthebody,includingamputation,asaresult,
whetherdirectorindirect,ofanAccidentandindependentofallothercauses.Partial
dismembermentwherethebodypartisrippedortornbutnotcompletelyseveredisnotconsidered
AccidentalDismembermentforpurposesofthePolicy.Forpurposesofthisplan,uncorrectable
LossofSpeech,LossofHearing,orLossofSight,duetoanAccidentiseligibleforAccidental
DismembermentBenefitsasshownontheBenefitSchedule.

AccidentalDismembermentseligibleforbenefitsunderthisplanandthecorrespondingbenefit
percentageamounttobepaidforeachtypeofAccidentalDismembermentareshownonthe
BenefitSchedule.AnyotherdismembermentsnotlistedontheBenefitSchedulearenoteligiblefor
AccidentalDismembermentBenefitsunderthisPolicy.

8227.OOCR.LA Page6OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.


AccidentalInjury
BodilydamageoccurringunexpectedlyandunintentionallyastheresultofanAccident,
independentofallothercauses.

BenefitPercentage
ThepercentageofchargesforCoveredTreatmentsWewillpayforAccidentMedicalExpense
BenefitsaftersatisfactionoftheDeductibleuptotheAMEMaximumBenefitLimitation.

BenefitWaitingPeriod
TheperiodofconsecutivedaysthatmustpassaftertheEffectiveDatebeforeaCoveredPersonis
eligibleforScheduledBenefitsunderthetermsofthisplan.

Cancer
1. Amalignanttumor,includinganinsitu,andhematopoieticmalignancyforwhichanyof
thefollowingisrecommendedbyYourHealthCarePractitioner:
a.Radiation;
b.Chemotherapy;or
c.Immunotherapy;or
d.Completeexcisionofaninternalorganwithoutneedforfurthertreatment
2. Anymetastaticcancerforwhichnotherapyisrecommended.

ForpurposesofthisPolicy,Cancerdoesnotinclude:
1. Noninvasivedermatologiccarcinomas(basalcellcarcinoma(BCC),squamouscell
carcinomas(SCC),melanomainsitu),cervicalcarcinomainsituorotherpremalignant
conditionssuchasmyelodysplasticandmyeloproliferativedisorders,leukoplakia,
hyperplasia;or
2. Anincidentalpathologicaldiagnosisfoundfollowingsurgicalexcisionofanorganunless
additionalchemotherapy,radiationtherapyand/orimmunotherapyisrecommended.

CardiacArrhythmia
Cardiacdysrhythmias,paroxysmalsupraventriculartachycardia,paroxysmalventricular
tachycardia,atrialfibrillationandflutter,andventricularfibrillationandflutter.

CerebrovascularDisease
Subarachnoidhemorrhage,intracerebralhemorrhage,occlusionandstenosisofprecerebral
arteries,andocclusionofcerebralarteries.

ConfinementPeriod
Acontinuousanduninterruptedperiodofatleast24hoursduringwhichaCoveredPersonisadmittedtoa
HospitaltoobtainMedicallyNecessaryInpatienttreatmentofaSicknesswhileundertheregularcareand
attendanceofaHealthCarePractitioner.

CoronaryAngioplasty

8227.OOCR.LA Page7OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.

Aninterventionalproceduretowidenorunblocktherightcoronaryartery;leftmainstem;left
anteriordescending;orcircumflexartery.

CoronaryArteryBypass
Aprocedurewhichusesasaphenousveinorinternalmammaryarterygrafttosurgicallybypass
obstructionsinanativecoronaryarteryorarteriestotreatcoronaryarteryatherosclerosis.
CoronaryArteryBypassdoesnotinclude:balloonangioplasty,laserreliefofobstructionorany
otherintraarterialprocedures.

CoronaryArteryDisease
Acutecoronaryocclusion,coronaryatherosclerosis,aneurysmanddissectionoftheheart,and
coronaryatherosclerosisduetolipidrichplaque.

CoveredHospitalization
AHospitalizationforwhichthisplanprovidesaScheduledBenefitandthatmeetsallofthe
followingrequirements:
1. TheHospitalizationmeetstheConfinementPeriod.
2. ItisincurredbyaCoveredPersonwhilecoverageisinforceunderthisplanastheresultof
aSickness.
3. ItdoesnotoccurduringaBenefitWaitingPeriod.
4. ItisMedicallyNecessary.

CoveredPerson
Apersonwhoisenrolledandeligibletoreceivebenefitsunderthisplan,asshownontheBenefit
Schedule.

CoveredTreatment
ThatportionofmedicaltreatmentorevaluationofAccidentalInjuryforwhichaCoveredPerson
doesnotreceiveanyOtherBenefits,andthatmeetsallofthefollowingrequirements:

1. ItisIncurredformedicaltreatment,services,supplies,casts,bloodplasma,oxygen,
anesthesia,durablemedicalequipment,personalmedicalequipment,diagnosticimaging
andtesting,ordentalinjuryprovidedbyoratanappropriatelylicensed:Healthcare
practitioner,hospital,outpatientorsurgicalfacilityincludingafreestandingfacilityor
urgentcareclinic,retailhealthclinic,supplier,andairorgroundambulanceservices.

2. ItisIncurredbyaCoveredPersonwhilecoverageisinforceunderthisplanastheresultof
anAccidentthatisfirstsustainedonoraftertheCoveredPersonsEffectiveDate.

3. ItiseligibleforbenefitslistedintheAccidentBenefitssectionandnotexcludedunderthis
Policy.

Deductible
ThetotaldollaramountofchargesperAccidentthatmustbepaidbytheCoveredPersonbefore
AccidentMedicalExpenseBenefitsarepaidbyUs.IftheCoveredPersonreceivesanyOther

8227.OOCR.LA Page8OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.

BenefitsduetoAccidentalInjury,orrelatedsickness,sustainedduetotheAccident,suchamounts
arenotconsideredforpurposesofsatisfactionoftheDeductibleunderthePolicy.TheDeductibleis
shownontheBenefitSchedule.

Diagnosis/Diagnosed
IdentificationofaSpecifiedDiseasemadeduringtheCoveredPersonslifebyaHealthCare
Practitionerthatissupportedbyevaluations,clinicalorlaboratorytests,andobservations
documentedintheCoveredPersonsmedicalrecords.

HeartAttack
Amyocardialinfarctionresultinginthedeathofanareaoftheheartmuscleduetoinsufficient
bloodsupplytothatarea.ThebasisoftheDiagnosismustinclude:
1. serialmeasurementsofcardiacbiomarkersshowingapatternandlevelconsistentwithan
acutemyocardialinfarction;and
2. newelectrocardiographicchangesconsistentwithacutemyocardialinfarction.

ForthepurposesofthisPolicy,HeartAttackdoesnotinclude:
1. Anyotherdiseaseorinjuryinvolvingthecardiovascularsystem;
2. Acardiacarrestthatisnotcausedbymyocardialinfarction.

Hospitalization
AMedicallyNecessaryInpatientstayinaHospitalofatleast24hoursastheresultofaSickness.

InitialTreatmentPeriod
TheperiodimmediatelyfollowingthedateofanAccidentduringwhichaCoveredPersonmust
receivetreatmentorclinicalevaluationfromahealthcarepractitioneroftheAccidentalInjuryor
AccidentalDismembermentforAccidentMedicalExpenseBenefitsandAccidental
DismembermentBenefitstobeconsideredunderthisPolicy.TheInitialTreatmentPeriodduration
isshownontheBenefitSchedule.

MaximumAllowableAmount
ThemaximumamountofabilledchargeWewillconsiderwhendeterminingchargesforCovered
Treatments.AmountsbilledinexcessoftheMaximumAllowableAmountbyoronbehalfofa
healthcarepractitioner,facilityorsupplierarenotpayablebyUs.

Forgoodsandservicesprovidedbyahealthcarepractitioner,facilityorsupplierincluding,butnot
limitedto,professional,inpatientandoutpatientclaims,theMaximumAllowableAmountisthe
lesserof:
1. Billedcharges;or
2. TheamountnegotiatedbetweenUs,oronbehalfofUs,andthehealthcarepractitioner,
facilityorsupplierastotalpaymentfortheservicesorsuppliesprovided;or
3. InaccordancewithOurcurrentmethodologiesfordeterminingthereasonableand
customarychargeforservicesandsuppliesinaspecificregionandbyaparticulartypeof
provider.

8227.OOCR.LA Page9OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.

MaximumBenefitLimitation
ThisPolicycontainsvariousMaximumBenefitLimitations,asdescribedbelow.Theapplicable
MaximumBenefitLimitationsareshownontheBenefitSchedule.

1. AccidentalDeathandDismembermentMaximumBenefitLimitation
Themaximumamount,asshownintheBenefitSchedule,thatWewillpayfortheAccidental
DismembermentBenefitsandtheAccidentalDeathBenefitscombinedresultingfromthe
sameAccident.

2. AccidentMedicalExpense(AME)MaximumBenefitLimitation
Themaximumamount,asshownintheBenefitSchedule,thatWewillpayfortheAccident
MedicalExpenseBenefitperAccident.TreatmentSpecificLimitationsmayalsobeapplicable
asshownontheBenefitScheduleforspecifictypesoftreatment,suppliesorcharges.Benefits
withinthesetreatmentcategoriesarestillsubjecttotheoverallAMEMaximumBenefit
Limitation.

3. MaximumBenefitforCancerandHeartStrokeRider

AMaximumBenefitistheamountofbenefits,asshownintheBenefitsSchedule,thatWe
willpayforeachCoveredPersonunderthisplan.ThisplanhasvaryingtypesofMaximum
Benefitlimitations.EachMaximumBenefitlimitationisstatedontheBenefitSchedule
correspondingtotheapplicablebenefitprovision.AparticularMaximumBenefitonly
appliesifitisshownontheBenefitSchedule.

1. MaximumLifetimeBenefitforCancer:ThemaximumamountofbenefitsthatWewill
payforeachCoveredPersonforCanceroverthelifetimeofthatCoveredPerson.

2. MaximumLifetimeBenefitforHeartStroke:ThemaximumamountofbenefitsthatWe
willpaycombinedforallHeartStrokeSpecifiedDiseasesforthatCoveredPerson.]

4. MaximumCalendarYearBenefitforSicknessIndemnityRider

MaximumCalendarYearBenefitistheamountofbenefits,asshownintheBenefits
Schedule,thatWewillpayperCalendarYearunderthisRider.Therearetwotypesof
MaximumCalendarYearBenefits:

1. PerCoveredPerson:ThemaximumamountofInpatientHospitalConfinement
BenefitsthatWewillpayperCalendarYearforeachCoveredPersonunderthisRider.

2. Combined:ThemaximumamountofInpatientHospitalConfinementBenefitsthatwe
willpayperCalendarYearforallCoveredPersonscombined.WhentheMaximum
CalendarYearBenefitCombinedhasbeenpaidbyUs,nofurtherbenefitsarepayable
foranyCoveredPersonfortheremainderoftheCalendarYear.

OtherBenefits

8227.OOCR.LA Page10OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.

BenefitsYoureceiveforamedicaleventortreatmentduetoanAccidentunderanyofthe
following:
1. Aselffundedorselfinsuredemployeewelfarebenefitplanthatprovideshealthbenefits
andisestablishedinaccordancewiththeEmployeeRetirementIncomeSecurityActof1974
(ERISA);
2. Individualorgroupdisabilityorhealthinsurancecoverage,includingshorttermlimited
durationhealthcoverageorlimitedmedicalexpenseplans;
3. Individualorgrouphealthplancoverage,includingHMO,capitationarrangement,pre
paid,orservicebasisplans;
4. Workerscompensationprotectionbywhatevernamecalled;
5. Hospitalorotherfixedindemnity,oranyothersupplementalcoverage;
6. Medicalcoverageunderamotorvehicleinsurancecontract;
7. MedicarePartAorPartB(TitleXVIIIoftheSocialSecurityAct);
8. MedicaidpursuanttoTitleXIXoftheSocialSecurityAct,otherthancoverageconsisting
solelyofbenefitsundersection1928;
9. Militarysponsoredhealthcare(Chapter55oftitle10,UnitedStatesCode);
10. AmedicalcareprogramofIndianHealthServiceorofatribalorganization;
11. Astatehealthbenefitriskpool;
12. FederalEmployeeHealthBenefitPlan(FEHBP)(healthplanunderchapter89oftitle5,
UnitedStatesCode);
13. Anypublichealthplan;
14. Achurchplanorbenefitsreceivedfromaserviceorganization;
15. AhealthplanunderthePeaceCorpsAct(22U.S.C.Section2504(e)).

PreExistingConditionforCancerandHeartStrokeRider
ASpecifiedDisease:
1. Forwhichmedicaladvice,consultation,careortreatmentwassought,receivedor
recommendedfromaproviderorPrescriptionDrugswereprescribedduringthe24month
periodimmediatelypriortotheCoveredPersonsEffectiveDate,regardlessofwhetherthe
conditionwasdiagnosed,misdiagnosedornotdiagnosed;or
2. Thatproducedsignsorsymptomsduringthe24monthperiodimmediatelypriortothe
CoveredPersonsEffectiveDate.

Thesignsorsymptomsweresignificantenoughtoestablishmanifestationoronsetbyoneof
thefollowingtests:
a. Thesignsorsymptomsreasonablyshouldhaveallowedorwouldhaveallowedone
learnedinmedicinetodiagnosethecondition;or
b. Thesignsorsymptomsreasonablyshouldhavecausedorwouldhavecausedan
ordinarilyprudentpersontoseekdiagnosisortreatment.

PreExistingConditionforSicknessIndemnityRider
ASicknessandrelatedcomplications:

8227.OOCR.LA Page11OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.

1. Forwhichmedicaladvice,consultation,diagnosis,careortreatmentwassought,receivedor
recommendedfromaproviderorPrescriptionDrugswereprescribedduringthe12month
periodimmediatelypriortotheCoveredPersonsEffectiveDate,regardlessofwhetherthe
conditionwasdiagnosed,misdiagnosedornotdiagnosed;or
2. Thatproducedsignsorsymptomsduringthe12monthperiodimmediatelypriortothe
CoveredPersonsEffectiveDate.

Thesignsorsymptomsweresignificantenoughtoestablishmanifestationoronsetbyoneof
thefollowingtests:
a. Thesignsorsymptomsreasonablyshouldhaveallowedorwouldhaveallowedone
learnedinmedicinetodiagnosethecondition;or
b. Thesignsorsymptomsreasonablyshouldhavecausedorwouldhavecausedan
ordinarilyprudentpersontoseekdiagnosisortreatment.

ApregnancythatexistsonthedaybeforetheCoveredPersonsEffectiveDatewillbe
consideredaPreExistingCondition.

ScheduledBenefitforCancerandHeartStrokeRider
ThefixedbenefitamountpayableupontheDiagnosisofaSpecifiedDiseaseunderthetermsof
thisplan.TheScheduledBenefitforaSpecifiedDiseaseisshownontheBenefitSchedule.

ScheduledBenefitforSicknessIndemnityRider
The fixed benefit amount payable upon occurrence of a Covered Event under the terms of this
Rider.TheScheduledBenefitforaCoveredHospitalizationisshownontheBenefitSchedule.

SpecifiedDisease
Any disease identified as a Specified Disease on the Benefit Schedule. Diseases first ever
Diagnosed anytime prior to the Covered Persons Effective Date under the Policy are not
consideredSpecifiedDiseasesforthepurposeofthisPolicy.

Sickness
A disease or illness of a Covered Person. Sickness does not include an illness or disease resulting,
whetherdirectlyorindirectly,fromanAccident.

Stroke
Braintissueinfarctionduetoacutecerebrovascularincident,embolism,thrombosisorhemorrhage.
ThebasisoftheDiagnosismustincludeimagingdocumentationofnewbraintissueinfarctionin
associationwithacuteonsetofsymptomsconsistentwithcentralnervoussystemneurological
damage.

ForthepurposesofthisPolicy,Strokedoesnotinclude:
1. TransientIschemicAttacks(TIAs).
2. TransientGlobalAmnesia(TGA).
3. ExternaltraumacausingAccidentalInjurytothebrain.
4. Braindamageduetoinfection,vasculitis,encephalopathyandinflammatorydisease.

8227.OOCR.LA Page12OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.

5. Ischemicdisordersofthevestibularsystem.]

SECTION4:EXCLUSIONSANDLIMITATIONS
NoBenefitforAccidentSustainedPriortoEffectiveDate
Wewillnotpaybenefitsforanycharges,dismembermentordeaththatresultfromorarerelatedto
anAccidentsustainedpriortotheEffectiveDateofthecoverageunderthisPolicy.

Exclusions
ThisPolicydoesnotpayanybenefitsforclaimsresultingfromorrelatedtoSickness,exceptwhen
suchSicknessisthedirectresultofanAccidentalInjuryorAccidentalDismembermentcovered
underthisPolicy.

Wewillnotpaybenefitsforchargesresultingfrom,whetherdirectlyorindirectly,anyofthe
following:

1. Medicalevent,treatment,servicesorsuppliesforwhichbenefitsequaltoorinexcessof
suchchargesarereceivedunderanyOtherBenefits.

2. ChargesinexcessoftheMaximumAllowableAmount.

3. Treatment,servicesorsuppliesthat:
a. ArenotincludedintheCoveredTreatmentdefinition.
b. Areduetocomplicationsofanoncoveredservice.
c. AreIncurredbeforetheCoveredPersonsEffectiveDateoraftertheterminationdate
ofcoverage.

4. DentaltreatmentexceptasotherwisecoveredforaDentalInjury.

5. Tendonitis,tenosynovitis,bursitis,overuse,strains,repetitivemotionsorstress,repetitiveor
cumulativetraumasincluding,butnotlimitedto,carpaltunnelsyndrome,tenniselbow,
andthoracicoutletsyndrome.

6. Herniaorheatexhaustion.

7. Treatmentofmentaloremotionaldisorders,alcoholism,substanceabuseanddrug
addiction,whetherorganicornonorganic,chemicalornonchemical,biologicalor
nonbiologicalinoriginandirrespectiveofcause,basisorinducement,including,butnot
limitedto,drugsandmedicinesforinpatientoroutpatienttreatmentofsuchdisordersor
abuse.

8. CosmeticService;treatmentthatisnotMedicallyNecessary;treatment,servicesand
suppliesforExperimentalorInvestigationalServices.

9. Treatment,services,andsuppliesprovidedfororby:
a. amasseur,masseuseormassagetherapist,arolfer;massagetherapy;

8227.OOCR.LA Page13OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.

b. Meditationorrelaxationtherapy;aromatherapy;holistictherapies.
c. Acupuncture,biofeedback,neurotherapy,andelectricalstimulation.

10. Servicesordered,directedorperformedbyaHealthCarePractitionerorsuppliespurchased
fromamedicalsupplyproviderwhoisaCoveredPerson,anImmediateFamilyMember,
employerofaCoveredPersonorapersonwhoordinarilyresideswithaCoveredPerson.

11. AnyamountinexcessoftheMaximumLifetimeBenefitoranyotherMaximumBenefit
Limitationforcoveredbenefits.

12. TreatmentincurredoutsideoftheUnitedStates,itspossessions,orCanada.

13. Allprescriptionandoverthecounterproducts,drugsormedicines.

WewillnotpaybenefitsforAccidentalInjury,AccidentalDismembermentorAccidentalDeath
resultingfromorrelatedto,whetherdirectlyorindirectly,anyofthefollowing:

1. AnAccidentthatoccurredbeforetheCoveredPersonsEffectiveDateorafterthe
terminationdateofcoverage.

2. Participationinthemilitaryserviceofanycountryorinternationalorganization,including
nonmilitaryunitssupportingsuchforces.

3. BenefitsinexcessofanyapplicableMaximumBenefitLimitationandAccidentalDeathand
DismembermentMaximumBenefitLimitation.

4. Waroranyactofwar,whetherdeclaredorundeclared;foreignordomesticactsof
terrorism.

5. Voluntarilytaking,absorbing,orinhalinganynarcotic,exceptwhenadministeredin
accordancewiththeadviceoftheCoveredPersonsHealthCarePractitioner.

6. TheCoveredPersonsbeingintoxicatedorundertheinfluenceofanarcotic,exceptwhen
administeredinaccordancewiththeadviceoftheCoveredPersonsHealthCarePractitioner.

7. TheCoveredPersonsvoluntaryattempttocommitorparticipationinanassaultor
commissionofafelony,whetherornotcharged,resistingorfleeingfromarrest,orwhicha
contributingcausewastheInsuredsbeingengagedinanillegaloccupation.

8. Anyhazardousactivityincluding,butnotlimitedto:Participating,instructing,
demonstrating,guidingoraccompanyingothersinparachutejumping,hanggliding,bungee
jumping,airorspacetravelinanyvehicleotherthanaregularlyscheduledflightbyan
airline,racinganymotorizedornonmotorizedvehicle,includingapitcrew,rockor
mountainclimbing,mountaineering,spelunkingandcaveexploration,parkour,
intercollegiatesportsandextremesports.Alsoexcludedaretreatmentandservicesrequired

8227.OOCR.LA Page14OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.

duetoAccidentalInjuryreceivedwhilepracticing,exercising,undergoingconditioningor
physicalpreparationforanysuchactivity.

9.Anyhazardousoccupationorotheractivityforwhichcompensationisreceivedinanyform,
includingsponsorship,suchas,butnotlimitedto:Operatingataxiordeliveryservice;
participating,instructing,demonstrating,guidingoraccompanyingothersinskiing,horse
riding,rodeoactivities,professionalorsemiprofessionalsports,adultsportingcompetition
atanationalorinternationallevelandextremesports.Alsoexcludedaretreatmentand
servicesrequiredduetoAccidentalInjuryreceivedwhilepracticing,exercising,undergoing
conditioningorphysicalpreparationforanysuchcompensatedactivity.

10. Suicideorattemptedsuicide.

11.Intentionallyselfinflictedinjury.

ExclusionsforCancerandHeartStrokeRider
ThisRiderprovidesbenefitsonlyforSpecifiedDiseasesidentifiedintheBenefitSchedule.

Wewillnotpaybenefitsforclaimsresulting,whetherdirectlyorindirectly,fromSpecified
Diseasesthatarerelatedto,orareresultingfromanyofthefollowing:

1. AnydiseaseiftheCoveredPersonwaspreviouslyDiagnosedanytimepriortohisorher
EffectiveDateunderthisRider.

2. AnydiseasefirstDiagnosedwithintheapplicableBenefitWaitingPeriod,asshowninthe
BenefitSchedule,immediatelyfollowingtheRiderEffectiveDate.

3. AnydiseasefirstDiagnosedwithinthePreExistingConditionsLimitation.

4. ArrhythmiaresultinginHeartAttackthatoccursinassociationwithuseofanynarcotic,
exceptwhenadministeredinaccordancewiththeadviceoftheCoveredPersonsHealth
CarePractitioner.

5. AnyamountinexcessofanyMaximumBenefitforcoveredScheduledBenefits.

6. DiseasesorconditionsthatdonotmeetthedefinitionofaSpecifiedDiseaseinthisRider.

7. Suicideorattemptedsuicide.

8. SelfinflictedSickness.

TheExclusionssectionintheAccidentMedicalExpenseInsurancePolicyisnotapplicabletothis
RidersSpecifiedDiseasebenefits.

8227.OOCR.LA Page15OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.


ExclusionsforSicknessIndemnityRider
ThisRiderprovidesbenefitsonlyforHospitalizationsidentifiedintheHospitalConfinementFixed
IndemnityBenefitssection.

Wewillnotpaybenefitsforclaimsresulting,whetherdirectlyorindirectly,fromHospitalizations
orlossesthatarerelatedto,orareresultingfromanyofthefollowing:

1. AnytreatmentorservicesforBehavioralHealthorSubstanceAbuse.

2. Anytreatmentorserviceswhethermedicalorsurgical,forpurposesofcontrollingthe
CoveredPersonsweightorrelatedtoobesityormorbidobesity,whetherornotweight
reductionisMedicallyNecessaryorappropriateorregardlessofpotentialbenefitsforco
morbidconditions;weightreductionorweightcontrolsurgery,treatmentorprograms;any
typeofgastricbypasssurgery;suctionlipectomy.

3. Capsularcontraction,augmentationorreductionmammoplasty,exceptforallstagesand
revisionsofreconstructionofthebreastfollowingaMedicallyNecessarymastectomyfor
treatmentofcancer,includingreconstructionoftheotherbreasttoproduceasymmetrical
appearanceandtreatmentoflymphedemas.

4. OutpatientorInpatientconfinementinanEmergencyRoomorafacilityotherthana
Hospital.

5. OutpatientorInpatientconfinementprimarilyforrehabilitationorCustodialCare.

6. Prophylactictreatment,servicesorsurgeryincluding,butnotlimitedto,prophylactic
mastectomyoranyothertreatment,servicesorsurgeryperformedtopreventadisease
processfrombecomingevidentintheorganortissueatalaterdate.

7. Treatmentorservicesrelatedtothefollowingconditions,regardlessofunderlyingcauses:
sextransformation;genderdysphoricdisorder;genderreassignment;treatmentofsexual
function,dysfunctionorinadequacy;treatmenttoenhance,restoreorimprovesexualenergy,
performanceordesire.

8. Treatmentorservicesrelatedto:infertility;maternity;pregnancy(includingcomplicationsof
pregnancy);routinewellnewborncareatbirthincludingnurserycare;abortion;surrogate
pregnancy;fetalsurgery,treatmentorservices.

9. HospitalizationsorderedordirectedbyaHealthCarePractitionerorproviderwhoisa
CoveredPerson,anImmediateFamilyMember,employerofaCoveredPersonoraperson
whoordinarilyresideswithaCoveredPerson.

8227.OOCR.LA Page16OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.

10. HospitalizationthatdoesnotmeetthedefinitionofaCoveredHospitalizationinthisRider
including,butnotlimitedto,HospitalizationthatisnotMedicallyNecessaryorisfor
ExperimentalorInvestigationalServices.

11. Waroranyactofwar,whetherdeclaredorundeclared;foreignordomesticactsofterrorism
thatresultinanationwideepidemic;participationinthemilitaryserviceofanycountryor
internationalorganization,includingnonmilitaryunitssupportingsuchforces.

12. Cosmeticservices,includingbutnotlimitedto,reconstructiveorplasticsurgerythatdoesnot
alleviateafunctionalimpairment.

13. TheCoveredPersonsbeingintoxicatedorundertheinfluenceofanarcoticexceptwhen
administeredinaccordancewiththeadviceoftheCoveredPersonsHealthCarePractitioner;
voluntarilytaking,absorbing,orinhalinganynarcotic,exceptwhenadministeredin
accordancewiththeadviceoftheCoveredPersonsHealthCarePractitioner.

14. AnyamountinexcessoftheMaximumCalendarYearBenefitsshownontheBenefit
Schedule.

15. HospitalizationincurredoutsideoftheUnitedStates,itspossessions,itspossessions,or
Canada.

16. Suicideorattemptedsuicide.

17. SelfinflictedSickness.

18. AHospitalizationwhentheConfinementPeriodbeganbeforetheCoveredPersonsEffective
Date,aftertheterminationdateofcoverage,orduringtheBenefitWaitingPeriod.

19. AHospitalizationwhentheConfinementPeriodbeginsduringthePreExistingCondition
Limitation.

20. AHospitalizationresultingfrom,whetherdirectlyorindirectly,anAccident.

TheExclusionssectionintheAccidentMedicalExpenseInsurancePolicyisnotapplicabletothis
RidersInpatientHospitalizationforSicknessbenefits.]

SECTION5:RENEWABILITYPROVISIONS:
WewillrenewthePolicyissuedexceptthatthisPolicywillterminateat12:01a.m.localtimeatthe
Policyholdersstateofresidenceontheearliestofthefollowingdates:

1. thedateWereceivearequestinwritingorbytelephonetoterminatethisplanoronalater
datethatisrequestedbythePolicyholderfortermination.

8227.OOCR.LA Page17OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.

2. thedateWereceivearequestinwritingorbytelephonetoterminatecoveragefora
CoveredDependentoronalaterdatethatisrequestedbythePolicyholderfortermination
ofaCoveredDependent.

3. thedatethisplanlapsesfornonpaymentofpremiumpertheGracePeriodprovisioninthe
PremiumProvisionssection.

4. thedatethereisfraudormaterialmisrepresentationmadebyorwiththeknowledgeof
anyCoveredPersonapplyingforthiscoverageorfilingaclaimforbenefits.

5. thedateallpoliciesofthesameplanasthisPolicyarenonrenewedinthestateinwhich
thisPolicywasissuedorthestateinwhichthePolicyholderpresentlyresides.

6. thedateWeterminateornonrenewinsurancecoverageintheindividualmarketinthe
stateinwhichthisPolicywasissuedorthestateinwhichYoupresentlyreside.Wewill
giveYouadvancenotice,asrequiredbystatelaw,oftheterminationofYourcoverage.

7. thedatethePolicyholdermovestoastatewhereWedonotprovideinsurancecoverage
underthesameplanasthisPolicy,Wereservetherighttoterminatethiscoverage.

8. foraCoveredDependent:onthedateaCoveredDependentnolongermeetsthe
Dependentdefinitioninthisplan.

9. thedatethePolicyholderattainsage75years.

IfWeelecttonotrenewthisPolicyforareasonotherthannonpaymentofpremiumornon
renewalofallpolicieswiththesameformnumber,WewillsendYounoticeofthenonrenewal60
daysinadvanceofthedatethisPolicywillterminate.

IfYouatanytimechangeyouroccupationtooneclassifiedbyUsaslesshazardousthanthatstated
inthepolicy,We,uponyourwrittenrequest,andatyouroption,willeithercancelthepolicyupon
itssurrenderandrefundtheunearnedpremiumorwillreducethepremiumrateaccordinglyand
refundtheexcessprorataunearnedpremiumfromthedateofreceiptofproofofsuchchangeof
occupation.

Delayorfailuretoreportterminationofanyinsurancewillnotcontinuetheinsuranceinforce
beyondthedateitwouldhaveterminatedaccordingtothisPolicy.

CoverageundertheRider[s]terminate[s]withthePolicyorthedatetheCoveredPersonattainsage
65,orthedatebenefitsarenolongeravailableundertheCancerandHeartStrokeRider.


SECTION6:INITIALPREMIUMINFORMATION:
PremiumissubjecttochangeasprovidedinthePolicy.

8227.OOCR.LA Page18OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.


InitialPaymentOptionSelected:
________________
InitialPremium: Annual
AccidentMedicalExpensePlan $________ $________
CancerandHeartStrokeRider $________ $________
SicknessIndemnityRider $________ $________
InitialTotalPremium: $________ $________

______________________________ _______________________________
LicensedAgentsSignature Date

8227.OOCR.LA Page19OutlineofCoverage
Form 30796-LA (New. 9/2015)
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company 2015 Assurant, Inc. All Rights
Reserved.