Common use of Loss of Life Clause in Contracts

Loss of Life. Loss of Speech and Loss of Hearing Loss of Speech and one of Loss of Hand, Loss of Foot or Loss of Sight of One Eye Loss of Hearing and one of Loss of Hand, Loss of Foot or Loss of Sight of One Eye Benefit Amounts (Percentage of Principal Sum) 100% 100% 100% 100% Loss of Hands(Both), Loss of Feet(Both), Loss of Sight or a combination of any two of Loss100% of Hand, Loss of Foot or Loss of Sight of One Eye Quadriplegia 100% Paraplegia 75% Hemiplegia 50% Loss of Hand, Loss of Foot or Loss of Sight of one Eye (Any one of each) 50% Loss of Speech or Loss of Hearing 50% Uniplegia 25% Loss of Thumb and Index Finger of the same Hand 25% E) ADDITIONAL BENEFITS CLASS BENEFIT BENEFIT AMOUNT 1 Child Care Expense 5% of the Principal Sum up to a maximumof $5,000 for each Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 1 Education Expense 5% of the Principal Sum up to a maximumof $5,000 for each eligible Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 1 Home Alteration or Vehicle Modification Benefit Amount for Home Alteration 10%of Principal SumBenefit Amount for Vehicle Modification 10% of Principal SumMaximum Benefit Amount 20% of the Principal Sum to a maximum of $50,000 1 Medical Evacuation And Repatriation Maximum Benefit Amount UnlimitedMedical Expense Amount $100,000 Benefit Amount for Hospital Admission Guaranty $5,000 Family Travel Expense Maximum per Day $100 Maximum Number of Days 5 1 Psychological Therapy 5% of Principal SumMaximum Benefit Amount $25,000 1 Rehabilitation Expense 5% of Principal SumMaximum Benefit Amount $25,000 1 Seatbelt Occupant Protection Device 10% of Principal SumAlternate Benefit Amount $1,000 Occupant Protection Device Benefit Amount 10% of Principal Sum Maximum Benefit Amount 20% of Principal Sum up to $50,000 2 Child Care Expense 5% of the Principal Sum up to a maximumof $5,000 for each Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 2 Education Expense 5% of the Principal Sum up to a maximumof $5,000 for each eligible Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 2 Home Alteration or Vehicle Modification Benefit Amount for Home Alteration 10%of Principal SumBenefit Amount for Vehicle Modification 10% of Principal SumMaximum Benefit Amount 20% of the Principal Sum to a maximum of $50,000 2 Medical Evacuation And Repatriation Maximum Benefit Amount UnlimitedMedical Expense Amount $100,000 Benefit Amount for Hospital Admission Guaranty $5,000 Family Travel Expense Maximum per Day $100 Maximum Number of Days 5 2 Psychological Therapy 5% of Principal SumMaximum Benefit Amount $25,000 2 Rehabilitation Expense 5% of Principal SumMaximum Benefit Amount $25,000 2 Seatbelt Occupant Protection Device 10% of Principal SumAlternate Benefit Amount $1,000 Occupant Protection Device Benefit Amount 10% of Principal Sum Maximum Benefit Amount 20% of Principal Sum up to $50,000 3 Child Care Expense 5% of the Principal Sum up to a maximumof $5,000 for each Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 3 Education Expense 5% of the Principal Sum up to a maximumof $5,000 for each eligible Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 3 Home Alteration or Vehicle Modification Benefit Amount for Home Alteration 10%of Principal SumBenefit Amount for Vehicle Modification 10% of Principal SumMaximum Benefit Amount 20% of the Principal Sum to a maximum of $50,000 3 Medical Evacuation And Repatriation Maximum Benefit Amount UnlimitedMedical Expense Amount $100,000 Benefit Amount for Hospital Admission Guaranty $5,000 Family Travel Expense Maximum per Day $100 Maximum Number of Days 5 3 Psychological Therapy 5% of Principal SumMaximum Benefit Amount $25,000 3 Rehabilitation Expense 5% of Principal SumMaximum Benefit Amount $25,000 3 Seatbelt Occupant Protection Device 10% of Principal SumAlternate Benefit Amount $1,000 Occupant Protection Device Benefit Amount 10% of Principal Sum Maximum Benefit Amount 20% of Principal Sum up to $50,000 4 Home Alteration or Vehicle Modification Benefit Amount for Home Alteration 10%of Principal SumBenefit Amount for Vehicle Modification 10% of Principal SumMaximum Benefit Amount 20% of the Principal Sum to a maximum of $50,000 4 Medical Evacuation And Repatriation Maximum Benefit Amount UnlimitedMedical Expense Amount $100,000 Benefit Amount for Hospital Admission Guaranty $5,000 Family Travel Expense Maximum per Day $100 Maximum Number of Days 5 4 Psychological Therapy 5% of Principal SumMaximum Benefit Amount $25,000 4 Rehabilitation Expense 5% of Principal SumMaximum Benefit Amount $25,000 4 Seatbelt Occupant Protection Device 10% of Principal SumAlternate Benefit Amount $1,000 Occupant Protection Device Benefit Amount 10% of Principal Sum Maximum Benefit Amount 20% of Principal Sum up to $50,000 Aggregate Limit of Insurance The Aggregate Limit of Insurance applies: $1,000,000 Premium Amount Due Due Date per Accident $5,808 06/01/2022 Employee Retirement Income Security Act Is this plan subject to Employee Retirement Income Security Act (ERISA) regulations? (Y/N) Policy Acceptance The undersigned declares that all information provided in this application and any attachments hereto is true and correct. The undersigned understands that all information provided in this application and any attachments hereto is material to the insurer's decision to provide this insurance, and that insurance will be provided, at the insurer's sole discretion, in reliance upon the truth of such information. It is hereby agreed and understood this insurance is provided by the Company in consideration of payment of the required premium. The insurance under the policy begins on the Effective Date shown in the Insuring Agreement of the policy. The acceptance of the policy terminates any prior policy of the same policy number, effective with the inception of the policy. Fraud Warning Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Name of Policyholder: Date Signature Title

Loss of Life. Loss of Speech and Loss of Hearing Loss of Speech and one of Loss of Hand, Loss of Foot or Loss of Sight of One Eye Loss of Hearing and one of Loss of Hand, Loss of Foot or Loss of Sight of One Eye Benefit Amounts (Percentage of Principal Sum) 100% 100% 100% 100% Loss of Hands(Both), Loss of Feet(Both), Loss of Sight or a combination of any two of Loss100% of Hand, Loss of Foot or Loss of Sight of One Eye Quadriplegia 100% Paraplegia 75% Hemiplegia 50% Loss of Hand, Loss of Foot or Loss of Sight of one Eye (Any one of each) 50% Loss of Speech or Loss of Hearing 50% Uniplegia 25% Loss of Thumb and Index Finger of the same Hand 25% E) ADDITIONAL BENEFITS CLASS BENEFIT BENEFIT AMOUNT 1 Child Care Expense 5Carjacking 10% of the Principal Sum up to a maximumof $5,000 for each Dependent Child Alternate Benefit Amount $2,000 Maximum SumMaximum Benefit Amount $25,000 1 Education Expense 5Coma 1% of the Principal SumMaximum Benefit Amount 100% of Principal Sum up to a maximumof $5,000 for each eligible Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 1 Home Alteration or Vehicle Modification Benefit Amount for Home Alteration 10%of Principal SumBenefit Amount for Vehicle Modification 10% of Principal SumMaximum Benefit Amount 20% of the Principal Sum to a maximum of $50,000 1 Medical Evacuation And Repatriation Maximum Benefit Amount UnlimitedMedical Expense Amount $100,000 Benefit 250,000Benefit Amount for Hospital Admission Guaranty $5,000 Family Travel Expense Maximum per Day $100 Maximum Number of Days 5 Evacuation Expense Amount $100,000 1 Psychological Therapy 5% of Principal SumMaximum Benefit Amount $25,000 1 Rehabilitation Expense 5% of Principal SumMaximum Benefit Amount $25,000 1 Seatbelt Occupant Protection Device 10% of Principal SumAlternate Benefit Amount $1,000 2,000 Occupant Protection Device Benefit Amount 10% of Principal Sum Maximum Benefit Amount 20% of Principal Sum up to $50,000 2 Child Care Expense 5Carjacking 10% of the Principal Sum up to a maximumof $5,000 for each Dependent Child Alternate Benefit Amount $2,000 Maximum SumMaximum Benefit Amount $25,000 2 Education Expense 5Coma 1% of the Principal SumMaximum Benefit Amount 100% of Principal Sum up to a maximumof $5,000 for each eligible Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 2 Home Alteration or Vehicle Modification Benefit Amount for Home Alteration 10%of Principal SumBenefit Amount for Vehicle Modification 10% of Principal SumMaximum Benefit Amount 20% of the Principal Sum to a maximum of $50,000 2 Medical Evacuation And Repatriation Maximum Benefit Amount UnlimitedMedical Expense Amount $100,000 Benefit 250,000Benefit Amount for Hospital Admission Guaranty $5,000 Family Travel Expense Maximum per Day $100 Maximum Number of Days 5 Evacuation Expense Amount $100,000 2 Psychological Therapy 5% of Principal SumMaximum Benefit Amount $25,000 2 Rehabilitation Expense 5% of Principal SumMaximum Benefit Amount $25,000 2 Seatbelt Occupant Protection Device 10% of Principal SumAlternate Benefit Amount $1,000 2,000 Occupant Protection Device Benefit Amount 10% of Principal Sum Maximum Benefit Amount 20% of Principal Sum up to $50,000 3 Child Care Expense 5Carjacking 10% of the Principal Sum up to a maximumof $5,000 for each Dependent Child Alternate Benefit Amount $2,000 Maximum SumMaximum Benefit Amount $25,000 3 Education Expense 5Coma 1% of the Principal SumMaximum Benefit Amount 100% of Principal Sum up to a maximumof $5,000 for each eligible Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 3 Home Alteration or Vehicle Modification Benefit Amount for Home Alteration 10%of Principal SumBenefit Amount for Vehicle Modification 10% of Principal SumMaximum Benefit Amount 20% of the Principal Sum to a maximum of $50,000 3 Medical Evacuation And Repatriation Maximum Benefit Amount UnlimitedMedical Expense Amount $100,000 Benefit 250,000Benefit Amount for Hospital Admission Guaranty $5,000 Family Travel Expense Maximum per Day $100 Maximum Number of Days 5 Evacuation Expense Amount $100,000 3 Psychological Therapy 5% of Principal SumMaximum Benefit Amount $25,000 3 Rehabilitation Expense 5% of Principal SumMaximum Benefit Amount $25,000 3 Seatbelt Occupant Protection Device 10% of Principal SumAlternate Benefit Amount $1,000 2,000 Occupant Protection Device Benefit Amount 10% of Principal Sum Maximum Benefit Amount 20% of Principal Sum up to $50,000 4 Carjacking 10% of Principal SumMaximum Benefit Amount $25,000 4 Coma 1% of Principal SumMaximum Benefit Amount 100% of Principal Sum 4 Home Alteration or Vehicle Modification Benefit Amount for Home Alteration 10%of Principal SumBenefit Amount for Vehicle Modification 10% of Principal SumMaximum Benefit Amount 20% of the Principal Sum to a maximum of $50,000 4 Medical Evacuation And Repatriation Maximum Benefit Amount UnlimitedMedical Expense Amount $100,000 Benefit 250,000Benefit Amount for Hospital Admission Guaranty $5,000 Family Travel Expense Maximum per Day $100 Maximum Number of Days 5 Evacuation Expense Amount $100,000 4 Psychological Therapy 5% of Principal SumMaximum Benefit Amount $25,000 4 Rehabilitation Expense 5% of Principal SumMaximum Benefit Amount $25,000 4 Seatbelt Occupant Protection Device 10% of Principal SumAlternate Benefit Amount $1,000 2,000 Occupant Protection Device Benefit Amount 10% of Principal Sum Maximum Benefit Amount 20% of Principal Sum up to $50,000 Aggregate Limit of Insurance The Aggregate Limit of Insurance applies: $1,000,000 5,000,000 Premium Amount Due Due Date per Accident $5,808 06/01/2022 Employee Retirement Income Security Act Is this plan 112,605, payable in three annual installments of $37,535 War Risk premium is included in the policy premium and is not subject to Employee Retirement Income Security Act (ERISA) regulations? (Y/N) Policy Acceptance The undersigned declares that all information provided in this application and any attachments hereto is true and correct. The undersigned understands that all information provided in this application and any attachments hereto is material to the insurer's decision to provide this insurance, and that insurance will be provided, at the insurer's sole discretion, in reliance upon the truth of such information. It is hereby agreed and understood this insurance is provided by the Company in consideration of payment of the required premium. The insurance under the policy begins on the Effective Date shown in the Insuring Agreement of the policy. The acceptance of the policy terminates any prior policy of the same policy number, effective with the inception of the policy. Fraud Warning Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Name of Policyholder: Date Signature Titleaudit.

Loss of Life. Loss of Speech and Loss of Hearing Loss of Speech and one of Loss of Hand, Loss of Foot or Loss of Sight of One Eye Loss of Hearing and one of Loss of Hand, Loss of Foot or Loss of Sight of One Eye Benefit Amounts (Percentage of Principal Sum) 100% 100% 100% 100% Loss of Hands(Both), Loss of Feet(Both), Loss of Sight or a combination of any two of Loss100% of Hand, Loss of Foot or Loss of Sight of One Eye Quadriplegia 100% Paraplegia 75% Hemiplegia 50% Loss of Hand, Loss of Foot or Loss of Sight of one Eye (Any one of each) 50% Loss of Speech or Loss of Hearing 50% Uniplegia 25% Loss of Thumb and Index Finger of the same Hand 25% E) ADDITIONAL BENEFITS CLASS BENEFIT BENEFIT AMOUNT 1 Child Care Expense 5% of the Principal Sum up to a maximumof $5,000 for each Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 1 Education Expense 5% of the Principal Sum up to a maximumof $5,000 for each eligible Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 1 Home Alteration or Vehicle Modification Benefit Amount for Home Alteration 10%of Principal SumBenefit Amount for Vehicle Modification 10Coma 1% of Principal SumMaximum Benefit Amount 20100% of the Principal Sum to a maximum of $50,000 1 Medical Evacuation And Repatriation Maximum Benefit Amount UnlimitedMedical Expense Amount $100,000 25,000 Benefit Amount for Hospital Admission Guaranty $5,000 Family Travel Expense Maximum per Day $100 Maximum Number of Days 5 1 Psychological Therapy 5% of Principal SumMaximum Benefit Amount $25,000 1 Rehabilitation Expense 5% of Principal SumMaximum Benefit Amount $25,000 1 Seatbelt Occupant Protection Device 10% of Principal SumAlternate Benefit Amount $1,000 2,000 Occupant Protection Device Benefit Amount 10% of Principal Sum Maximum Benefit Amount 20% of Principal Sum up to $50,000 2 Child Care Expense 5% of the Principal Sum up to a maximumof $5,000 for each Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 2 Education Expense 5% of the Principal Sum up to a maximumof $5,000 for each eligible Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 2 Home Alteration or Vehicle Modification Benefit Amount for Home Alteration 10%of Principal SumBenefit Amount for Vehicle Modification 10Coma 1% of Principal SumMaximum Benefit Amount 20100% of the Principal Sum to a maximum of $50,000 2 Medical Evacuation And Repatriation Maximum Benefit Amount UnlimitedMedical Expense Amount $100,000 25,000 Benefit Amount for Hospital Admission Guaranty $5,000 Family Travel Expense Maximum per Day $100 Maximum Number of Days 5 2 Psychological Therapy 5% of Principal SumMaximum Benefit Amount $25,000 2 Rehabilitation Expense 5% of Principal SumMaximum Benefit Amount $25,000 2 Seatbelt Occupant Protection Device 10% of Principal SumAlternate Benefit Amount $1,000 2,000 Occupant Protection Device Benefit Amount 10% of Principal Sum Maximum Benefit Amount 20% of Principal Sum up to $50,000 3 Child Care Expense 5% of the Principal Sum up to a maximumof $5,000 for each Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 3 Education Expense 5% of the Principal Sum up to a maximumof $5,000 for each eligible Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 3 Home Alteration or Vehicle Modification Benefit Amount for Home Alteration 10%of Principal SumBenefit Amount for Vehicle Modification 10Coma 1% of Principal SumMaximum Benefit Amount 20100% of the Principal Sum to a maximum of $50,000 3 Medical Evacuation And Repatriation Maximum Benefit Amount UnlimitedMedical Expense Amount $100,000 Benefit UnlimitedBenefit Amount for Hospital Admission Guaranty $5,000 Family Travel Expense Maximum per Day $100 Maximum Number of Days 5 3 Psychological Therapy 5% of Principal SumMaximum Benefit Amount $25,000 3 Rehabilitation Expense 5% of Principal SumMaximum Benefit Amount $25,000 3 Seatbelt Occupant Protection Device 10% of Principal SumAlternate Benefit Amount $1,000 2,000 Occupant Protection Device Benefit Amount 10% of Principal Sum Maximum Benefit Amount 20% of Principal Sum up to $50,000 4 Home Alteration or Vehicle Modification Benefit Amount for Home Alteration 10%of Principal SumBenefit Amount for Vehicle Modification 10Coma 1% of Principal SumMaximum Benefit Amount 20100% of the Principal Sum to a maximum of $50,000 4 Medical Evacuation And Repatriation Maximum Benefit Amount UnlimitedMedical Expense Amount $100,000 Benefit UnlimitedBenefit Amount for Hospital Admission Guaranty $5,000 Family Travel Expense Maximum per Day $100 Maximum Number of Days 5 4 Psychological Therapy 5% of Principal SumMaximum Benefit Amount $25,000 4 Rehabilitation Expense 5% of Principal SumMaximum Benefit Amount $25,000 4 Seatbelt Occupant Protection Device 10% of Principal SumAlternate Benefit Amount $1,000 2,000 Occupant Protection Device Benefit Amount 10% of Principal Sum Maximum Benefit Amount 20% of Principal Sum up to $50,000 Aggregate Limit of Insurance The Aggregate Limit of Insurance applies: $1,000,000 Premium Amount Due Due Date per Accident $5,808 06/01/2022 Employee Retirement Income Security Act Is this plan subject to Employee Retirement Income Security Act (ERISA) regulations? (Y/N) Policy Acceptance The undersigned declares that all information provided in this application and any attachments hereto is true and correct. The undersigned understands that all information provided in this application and any attachments hereto is material to the insurer's decision to provide this insurance, and that insurance will be provided, at the insurer's sole discretion, in reliance upon the truth of such information. It is hereby agreed and understood this insurance is provided by the Company in consideration of payment of the required premium. The insurance under the policy begins on the Effective Date shown in the Insuring Agreement of the policy. The acceptance of the policy terminates any prior policy of the same policy number, effective with the inception of the policy. Fraud Warning Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Name of Policyholder: Date Signature Title:

Loss of Life. Loss of Speech and Loss of Hearing Loss of Speech and one of Loss of Hand, Loss of Foot or Loss of Sight of One Eye Loss of Hearing and one of Loss of Hand, Loss of Foot or Loss of Sight of One Eye Benefit Amounts (Percentage of Principal Sum) 100% 100% 100% Loss of Hearing and one of Loss of Hand, Loss of Foot or Loss of Sight of One Eye 100% Loss of Hands(Both), Loss of Feet(Both), Loss of Sight or a combination of any two of Loss100% of Hand, Loss of Foot or Loss of Sight of One Eye Quadriplegia 100% Paraplegia 75% Hemiplegia 50% Loss of Hand, Loss of Foot or Loss of Sight of one Eye (Any one of each) 50% Loss of Speech or Loss of Hearing 50% Uniplegia 25% Loss of Thumb and Index Finger of the same Hand 25% E) ADDITIONAL BENEFITS CLASS BENEFIT BENEFIT AMOUNT 1 Child Care Expense 5Burn 100% of the Principal Sum up to a maximumof $5,000 for each Dependent Child Alternate Benefit Amount $2,000 Maximum 1 Carjacking 10% of the Principal SumMaximum Benefit Amount $25,000 1 Education Child Abduction Medical Expense 5Benefit Amount$10,000Deductible $250Psychological Therapy Benefit Amount$10,000Lost Salary Benefit Amount $10,000 Other Child Abduction Expenses Benefit Amount $10,000 1 Coma 1% of the Principal SumMaximum Benefit Amount 100% of the Principal Sum up to a maximumof $5,000 for each eligible Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 1 Felonious Assault 20% of the Principal Sum 1 Home Alteration or Vehicle Modification Benefit Amount for Home Alteration 10%of the Principal SumBenefit Amount for Vehicle Modification 10% of the Principal SumMaximum Benefit Amount 20% of the Principal Sum up to a maximum of $50,000 1 Home Invasion Medical Evacuation And Repatriation Maximum Expense Benefit Amount UnlimitedMedical Expense $10,000Deductible $250Psychological Therapy Benefit Amount$10,000Lost Salary Benefit Amount $100,000 10,000 Residential Security Expense Benefit Amount for Hospital Admission Guaranty $5,000 Family Travel 1,000 Temporary Relocation Expense Maximum per Day Benefit Amount $100 Maximum Number of Days 5 1,000 1 Psychological Therapy 5% of Principal SumMaximum Benefit Amount $25,000 1 Rehabilitation Expense 5% of Principal SumMaximum Benefit Amount $25,000 1 Seatbelt Occupant Protection Device Seatbelt Benefit Amount 10% of Principal thePrincipal SumAlternate Benefit Amount $1,000 2,000 Occupant Protection Device Benefit Amount 10% of the Principal Sum Maximum Benefit Amount 20% of the Principal Sum up to $50,000 2 Burn 100% of the Principal Sum 2 Carjacking 10% of the Principal SumMaximum Benefit Amount $25,000 2 Child Abduction Medical Expense Benefit Amount$10,000Deductible $250Psychological Therapy Benefit Amount$10,000Lost Salary Benefit Amount $10,000 Other Child Abduction Expenses Benefit Amount $10,000 2 Child Care Expense 510% of the Principal Sum up to a maximumof amaximum of $5,000 10,000 for each Dependent Child Alternate ChildAlternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 50,000 2 Coma 1% of the Principal SumMaximum Benefit Amount 100% of the Principal Sum 2 Common Accident Maximum Benefit Amount $200,000 2 Education Expense 5% of the Principal Sum up to a maximumof $5,000 25,000 for each eligible Dependent Child Alternate ChildAlternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 100,000 2 Felonious Assault 20% of the Principal Sum 2 Home Alteration or Vehicle Modification Benefit Amount for Home Alteration 10%of the Principal SumBenefit Amount for Vehicle Modification 10% of the Principal SumMaximum Benefit Amount 20% of the Principal Sum up to a maximum of $50,000 2 Home Invasion Medical Evacuation And Repatriation Maximum Expense Benefit Amount UnlimitedMedical Expense $10,000Deductible $250Psychological Therapy Benefit Amount$10,000Lost Salary Benefit Amount $100,000 10,000 Residential Security Expense Benefit Amount for Hospital Admission Guaranty $5,000 Family Travel 1,000 Temporary Relocation Expense Maximum per Day Benefit Amount $100 Maximum Number of Days 5 1,000 2 Psychological Therapy 5% of Principal SumMaximum Benefit Amount $25,000 2 Rehabilitation Expense 5% of Principal SumMaximum Benefit Amount $25,000 2 Seatbelt Occupant Protection Device Seatbelt Benefit Amount 10% of Principal thePrincipal SumAlternate Benefit Amount $1,000 2,000 Occupant Protection Device Benefit Amount 10% of the Principal Sum Maximum Benefit Amount 20% of the Principal Sum up to $50,000 3 Child Care 2 Spouse Domestic Partner EmploymentTraining Expense 510% of the Principal Sum up to a maximumof $5,000 for each Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 3 Education Expense 5% of the Principal Sum up to a maximumof $5,000 for each eligible Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 3 Home Alteration or Vehicle Modification Benefit Amount for Home Alteration 10%of Principal SumBenefit Amount for Vehicle Modification 10% of Principal SumMaximum Benefit Amount 20% of the Principal Sum to a maximum of $50,000 3 Medical Evacuation And Repatriation Maximum Benefit Amount UnlimitedMedical Expense Amount $100,000 Benefit Amount for Hospital Admission Guaranty $5,000 Family Travel Expense Maximum per Day $100 Maximum Number of Days 5 3 Psychological Therapy 5% of Principal SumMaximum Benefit Amount $25,000 3 Rehabilitation Expense 5% of Principal SumMaximum Benefit Amount $25,000 3 Seatbelt Occupant Protection Device 10% of Principal SumAlternate Benefit Amount 50,000 Premium Information Class 1 Rate 0.040 per $1,000 Occupant Protection Device Benefit Amount 10% of Principal Sum Maximum Benefit Amount 20% of Principal Sum up to $50,000 4 Home Alteration or Vehicle Modification Benefit Amount for Home Alteration 10%of Principal SumBenefit Amount for Vehicle Modification 10% of Principal SumMaximum Benefit Amount 20% of the Principal Sum to a maximum of $50,000 4 Medical Evacuation And Repatriation Maximum Benefit Amount UnlimitedMedical Expense Amount $100,000 Benefit Amount for Hospital Admission Guaranty $5,000 Family Travel Expense Maximum 2 0.060 per Day $100 Maximum Number of Days 5 4 Psychological Therapy 5% of Principal SumMaximum Benefit Amount $25,000 4 Rehabilitation Expense 5% of Principal SumMaximum Benefit Amount $25,000 4 Seatbelt Occupant Protection Device 10% of Principal SumAlternate Benefit Amount $1,000 Occupant Protection Device Benefit Amount 10% of Principal Sum Maximum Benefit Amount 20% of Principal Sum up to $50,000 Aggregate Limit of Insurance The Aggregate Limit of Insurance applies: $1,000,000 Premium Amount Due Due Date per Accident $5,808 06/01/2022 Employee Retirement Income Security Act Is this plan subject to Employee Retirement Income Security Act (ERISA) regulations? (Y/N) Policy Acceptance The undersigned declares that all information provided in this application and any attachments hereto is true and correct. The undersigned understands that all information provided in this application and any attachments hereto is material to the insurer's decision to provide this insurance, and that insurance will be provided, at the insurer's sole discretion, in reliance upon the truth of such information. It is hereby agreed and understood this insurance is provided by the Company in consideration of payment of the required premium. The insurance under the policy begins on the Effective Date shown in the Insuring Agreement of the policy. The acceptance of the policy terminates any prior policy of the same policy number, effective with the inception of the policy. Fraud Warning Any person who who, knowingly and with intent to defraud any insurance company or other person person, files an application for insurance or statement of claim containing any materially false information information, or conceals for the purpose of misleading, information concerning any material fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Name of Policyholder: Date GC3001 APP Signature Title

Loss of Life. Loss of Speech and Loss of Hearing Loss of Speech and one of Loss of Hand, Loss of Foot or Loss of Sight of One Eye Loss of Hearing and one of Loss of Hand, Loss of Foot or Loss of Sight of One Eye Benefit Amounts (Percentage of Principal Sum) 100% 100% 100% Loss of Hearing and one of Loss of Hand, Loss of Foot or Loss of Sight of One Eye 100% Loss of Hands(Both), Loss of Feet(Both), Loss of Sight or a combination of any two of Loss100% of Hand, Loss of Foot or Loss of Sight of One Eye Quadriplegia 100% Paraplegia 75% Hemiplegia 50% Loss of Hand, Loss of Foot or Loss of Sight of one Eye (Any one of each) 50% Loss of Speech or Loss of Hearing 50% Uniplegia 25% Loss of Thumb and Index Finger of the same Hand 25% E) ADDITIONAL BENEFITS CLASS BENEFIT BENEFIT AMOUNT 1 Burn 100% of the Principal Sum 1 Carjacking 10% of the Principal SumMaximum Benefit Amount $25,000 1 Child Care Abduction Medical Expense 5Benefit Amount$10,000Deductible $250Psychological Therapy Benefit Amount$10,000Lost Salary Benefit Amount $10,000 Other Child Abduction Expenses Benefit Amount $10,000 1 Coma 1% of the Principal SumMaximum Benefit Amount 100% of the Principal Sum 1 Felonious Assault 20% of the Principal Sum 1 Home Alteration Vehicle Modification Benefit Amount for Home Alteration 10%of the Principal SumBenefit Amount for Vehicle Modification 10% of the Principal SumMaximum Benefit Amount 20% of the Principal Sum up to a maximumof $5,000 50,000 1 Home Invasion Medical Expense Benefit Amount $10,000Deductible $250Psychological Therapy Benefit Amount$10,000Lost Salary Benefit Amount $10,000 Residential Security Expense Benefit Amount $1,000 Temporary Relocation Expense Benefit Amount $1,000 1 Psychological Therapy $25,000 1 Rehabilitation Expense $25,000 1 Seatbelt Occupant Protection Device Seatbelt Benefit Amount 10% of thePrincipal SumAlternate Benefit Amount $2,000 Occupant Protection Device Benefit Amount 10% of the Principal Sum Maximum Benefit Amount 20% of the Principal Sum up to $50,000 2 Burn 100% of the Principal Sum 2 Carjacking 10% of the Principal SumMaximum Benefit Amount $25,000 2 Child Abduction Medical Expense Benefit Amount$10,000Deductible $250Psychological Therapy Benefit Amount$10,000Lost Salary Benefit Amount $10,000 Other Child Abduction Expenses Benefit Amount $10,000 2 Child Care Expense 10% of the Principal Sum up to amaximum of $10,000 for each Dependent Child Alternate ChildAlternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 1 50,000 2 Coma 1% of the Principal SumMaximum Benefit Amount 100% of the Principal Sum 2 Common Accident Maximum Benefit Amount $200,000 2 Education Expense 5% of the Principal Sum up to a maximumof $5,000 25,000 for each eligible Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 1 100,000 2 Felonious Assault 20% of the Principal Sum 2 Home Alteration or Vehicle Modification Benefit Amount for Home Alteration 10%of the Principal SumBenefit Amount for Vehicle Modification 10% of the Principal SumMaximum Benefit Amount 20% of the Principal Sum up to a maximum of $50,000 1 2 Home Invasion Medical Evacuation And Repatriation Maximum Benefit Amount UnlimitedMedical Expense Amount $100,000 Benefit Amount for Hospital Admission Guaranty $5,000 Family Travel Expense Maximum per Day $100 Maximum Number of Days 5 1 Psychological Therapy 5% of Principal SumMaximum Benefit Amount $25,000 1 Rehabilitation Expense 5% of Principal SumMaximum 10,000Deductible $250Psychological Therapy Benefit Amount$10,000Lost Salary Benefit Amount $10,000 Residential Security Expense Benefit Amount $1,000 Temporary Relocation Expense Benefit Amount $1,000 2 Psychological Therapy $25,000 1 2 Rehabilitation Expense $25,000 2 Seatbelt Occupant Protection Device Seatbelt Benefit Amount 10% of Principal thePrincipal SumAlternate Benefit Amount $1,000 2,000 Occupant Protection Device Benefit Amount 10% of the Principal Sum Maximum Benefit Amount 20% of the Principal Sum up to $50,000 2 Child Care Spouse Domestic Partner EmploymentTraining Expense 510% of the Principal Sum up to a maximumof $5,000 for each Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 2 Education Expense 5% of the Principal Sum up to a maximumof $5,000 for each eligible Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 2 Home Alteration or Vehicle Modification Benefit Amount for Home Alteration 10%of Principal SumBenefit Amount for Vehicle Modification 10% of Principal SumMaximum Benefit Amount 20% of the Principal Sum to a maximum of $50,000 2 Medical Evacuation And Repatriation Maximum Benefit Amount UnlimitedMedical Expense Amount $100,000 Benefit Amount for Hospital Admission Guaranty $5,000 Family Travel Expense Maximum per Day $100 Maximum Number of Days 5 2 Psychological Therapy 5% of Principal SumMaximum Benefit Amount $25,000 2 Rehabilitation Expense 5% of Principal SumMaximum Benefit Amount $25,000 2 Seatbelt Occupant Protection Device 10% of Principal SumAlternate Benefit Amount 50,000 Premium Information Class 1 Rate 0.040 per $1,000 Occupant Protection Device Benefit Amount 10% of Principal Sum Maximum Benefit Amount 20% of Principal Sum up to $50,000 3 Child Care Expense 5% of the Principal Sum up to a maximumof $5,000 for each Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 3 Education Expense 5% of the Principal Sum up to a maximumof $5,000 for each eligible Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 3 Home Alteration or Vehicle Modification Benefit Amount for Home Alteration 10%of Principal SumBenefit Amount for Vehicle Modification 10% of Principal SumMaximum Benefit Amount 20% of the Principal Sum to a maximum of $50,000 3 Medical Evacuation And Repatriation Maximum Benefit Amount UnlimitedMedical Expense Amount $100,000 Benefit Amount for Hospital Admission Guaranty $5,000 Family Travel Expense Maximum 2 0.060 per Day $100 Maximum Number of Days 5 3 Psychological Therapy 5% of Principal SumMaximum Benefit Amount $25,000 3 Rehabilitation Expense 5% of Principal SumMaximum Benefit Amount $25,000 3 Seatbelt Occupant Protection Device 10% of Principal SumAlternate Benefit Amount $1,000 Occupant Protection Device Benefit Amount 10% of Principal Sum Maximum Benefit Amount 20% of Principal Sum up to $50,000 4 Home Alteration or Vehicle Modification Benefit Amount for Home Alteration 10%of Principal SumBenefit Amount for Vehicle Modification 10% of Principal SumMaximum Benefit Amount 20% of the Principal Sum to a maximum of $50,000 4 Medical Evacuation And Repatriation Maximum Benefit Amount UnlimitedMedical Expense Amount $100,000 Benefit Amount for Hospital Admission Guaranty $5,000 Family Travel Expense Maximum per Day $100 Maximum Number of Days 5 4 Psychological Therapy 5% of Principal SumMaximum Benefit Amount $25,000 4 Rehabilitation Expense 5% of Principal SumMaximum Benefit Amount $25,000 4 Seatbelt Occupant Protection Device 10% of Principal SumAlternate Benefit Amount $1,000 Occupant Protection Device Benefit Amount 10% of Principal Sum Maximum Benefit Amount 20% of Principal Sum up to $50,000 Aggregate Limit of Insurance The Aggregate Limit of Insurance applies: $1,000,000 Premium Amount Due Due Date per Accident $5,808 06/01/2022 Employee Retirement Income Security Act Is this plan subject to Employee Retirement Income Security Act (ERISA) regulations? (Y/N) Policy Acceptance The undersigned declares that all information provided in this application and any attachments hereto is true and correct. The undersigned understands that all information provided in this application and any attachments hereto is material to the insurer's decision to provide this insurance, and that insurance will be provided, at the insurer's sole discretion, in reliance upon the truth of such information. It is hereby agreed and understood this insurance is provided by the Company in consideration of payment of the required premium. The insurance under the policy begins on the Effective Date shown in the Insuring Agreement of the policy. The acceptance of the policy terminates any prior policy of the same policy number, effective with the inception of the policy. Fraud Warning Any person who who, knowingly and with intent to defraud any insurance company or other person person, files an application for insurance or statement of claim containing any materially false information information, or conceals for the purpose of misleading, information concerning any material fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Name of Policyholder: Date GC3001 APP Signature Title

Loss of Life. Loss of Speech and Loss of Hearing Loss of Speech and one of Loss of Hand, Loss of Foot or Loss of Sight of One Eye Loss of Hearing and one of Loss of Hand, Loss of Foot or Loss of Sight of One Eye Benefit Amounts (Percentage of Principal Sum) 100% 100% 100% 100% Loss of Hands(Both), Loss of Feet(Both), Loss of Sight or a combination of any two of Loss100% of Hand, Loss of Foot or Loss of Sight of One Eye Quadriplegia 100% Paraplegia 75% Hemiplegia 50% Loss of Hand, Loss of Foot or Loss of Sight of one Eye (Any one of each) 50% Loss of Speech or Loss of Hearing 50% Uniplegia 25% Loss of Thumb and Index Finger of the same Hand 25% E) ADDITIONAL BENEFITS CLASS BENEFIT BENEFIT AMOUNT 1 Child Care Expense 5% of the Principal Sum up to a maximumof $5,000 for each Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 1 Education Expense 5% of the Principal Sum up to a maximumof $5,000 for each eligible Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 1 Home Alteration or Vehicle Modification Benefit Amount for Home Alteration 10%of Principal SumBenefit Amount for Vehicle Modification 10% of Principal SumMaximum Benefit Amount 20% of the Principal Sum to a maximum of $50,000 1 Medical Evacuation And Repatriation Maximum Benefit Amount UnlimitedMedical Expense Amount $100,000 Benefit UnlimitedBenefit Amount for Hospital Admission Guaranty $5,000 Family Travel Expense Maximum per Day $100 Maximum Number of Days 5 1 Psychological Therapy 5% of Principal SumMaximum Benefit Amount $25,000 1 Rehabilitation Expense 5% of Principal SumMaximum Benefit Amount $25,000 1 Seatbelt Occupant Protection Device 10% of Principal SumAlternate Benefit Amount $1,000 Occupant Protection Device Benefit Amount 10% of Principal Sum Maximum Benefit Amount 20% of Principal Sum up to $50,000 2 Child Care Expense 5% of the Principal Sum up to a maximumof $5,000 for each Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 2 Education Expense 5% of the Principal Sum up to a maximumof $5,000 for each eligible Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 2 Home Alteration or Vehicle Modification Benefit Amount for Home Alteration 10%of Principal SumBenefit Amount for Vehicle Modification 10% of Principal SumMaximum Benefit Amount 20% of the Principal Sum to a maximum of $50,000 2 Medical Evacuation And Repatriation Maximum Benefit Amount UnlimitedMedical Expense Amount $100,000 Benefit UnlimitedBenefit Amount for Hospital Admission Guaranty $5,000 Family Travel Expense Maximum per Day $100 Maximum Number of Days 5 2 Psychological Therapy 5% of Principal SumMaximum Benefit Amount $25,000 2 Rehabilitation Expense 5% of Principal SumMaximum Benefit Amount $25,000 2 Seatbelt Occupant Protection Device 10% of Principal SumAlternate Benefit Amount $1,000 Occupant Protection Device Benefit Amount 10% of Principal Sum Maximum Benefit Amount 20% of Principal Sum up to $50,000 3 Child Care Expense 5% of the Principal Sum up to a maximumof $5,000 for each Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 3 Education Expense 5% of the Principal Sum up to a maximumof $5,000 for each eligible Dependent Child Alternate Benefit Amount $2,000 Maximum Benefit Amount $25,000 3 Home Alteration or Vehicle Modification Benefit Amount for Home Alteration 10%of Principal SumBenefit Amount for Vehicle Modification 10% of Principal SumMaximum Benefit Amount 20% of the Principal Sum to a maximum of $50,000 3 Medical Evacuation And Repatriation Maximum Benefit Amount UnlimitedMedical Expense Amount $100,000 Benefit UnlimitedBenefit Amount for Hospital Admission Guaranty $5,000 Family Travel Expense Maximum per Day $100 Maximum Number of Days 5 3 Psychological Therapy 5% of Principal SumMaximum Benefit Amount $25,000 3 Rehabilitation Expense 5% of Principal SumMaximum Benefit Amount $25,000 3 Seatbelt Occupant Protection Device 10% of Principal SumAlternate Benefit Amount $1,000 Occupant Protection Device Benefit Amount 10% of Principal Sum Maximum Benefit Amount 20% of Principal Sum up to $50,000 4 Home Alteration or Vehicle Modification Benefit Amount for Home Alteration 10%of Principal SumBenefit Amount for Vehicle Modification 10% of Principal SumMaximum Benefit Amount 20% of the Principal Sum to a maximum of $50,000 4 Medical Evacuation And Repatriation Maximum Benefit Amount UnlimitedMedical Expense Amount $100,000 Benefit UnlimitedBenefit Amount for Hospital Admission Guaranty $5,000 Family Travel Expense Maximum per Day $100 Maximum Number of Days 5 4 Psychological Therapy 5% of Principal SumMaximum Benefit Amount $25,000 4 Rehabilitation Expense 5% of Principal SumMaximum Benefit Amount $25,000 4 Seatbelt Occupant Protection Device 10% of Principal SumAlternate Benefit Amount $1,000 Occupant Protection Device Benefit Amount 10% of Principal Sum Maximum Benefit Amount 20% of Principal Sum up to $50,000 Aggregate Limit of Insurance The Aggregate Limit of Insurance applies: $1,000,000 Premium Amount Due Due Date per Accident $5,808 06/01/2022 3,849, payable in three annual installments of $1,283 06/01/2019 Employee Retirement Income Security Act Is this plan subject to Employee Retirement Income Security Act (ERISA) regulations? (Y/N) Policy Acceptance The undersigned declares that all information provided in this application and any attachments hereto is true and correct. The undersigned understands that all information provided in this application and any attachments hereto is material to the insurer's decision to provide this insurance, and that insurance will be provided, at the insurer's sole discretion, in reliance upon the truth of such information. It is hereby agreed and understood this insurance is provided by the Company in consideration of payment of the required premium. The insurance under the policy begins on the Effective Date shown in the Insuring Agreement of the policy. The acceptance of the policy terminates any prior policy of the same policy number, effective with the inception of the policy. Fraud Warning Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Name of Policyholder: Date Signature Title