Susan E Burton Storey

Hospital Confinement Indemnity Policy

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Keep them in a safe place.

American Family Life Assurance Company of Columbus (Aflac)

Worldwide Headquarters • Columbus, Georgia 31999
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Thank you for choosing Aflac.

1.800.99.AFLAC (1.800.992.3522)
aflac.com

Your Policy Number is: P0G1W1T3

Product: Hospital Confinement Indemnity Policy
Your Type of Coverage: Individual
Your Policy is Effective : 08/12/14
Your Premium is: $14.94 DUPLICATE
Your Premiums are due: Bi-Weekly
Your State of Issue is: Pennsylvania

REL N

N REL INMAIL
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American Family Life Assurance Company of Columbus
Worldwide Headquarters • 1932 Wynnton Road • Columbus, Georgia 31999
For assistance or information about this policy, call 1.800.99.AFLAC (1.800.992.3522).
For claim forms, visit our website at aflac.com.
HOSPITAL CONFINEMENT INDEMNITY POLICY
LIMITED BENEFIT
Non-Participating
P0G1W1T3

NOTICE TO BUYER: This is a hospital confinement indemnity policy providing limited

benefits. Benefits provided are supplemental and are not intended to cover all medical
expenses. Read your policy carefully with the Outline of Coverage.
The Named Insured shown in the Policy Schedule will be referred to as “you,” “your,” or “yours.”
American Family Life Assurance Company of Columbus, a stock company, will be referred to
as “we,” “our,” “us,” or “Aflac.”
HMY73

CONSIDERATION
This policy is issued in consideration of statements made in your application and the payment of
the premium shown in the Policy Schedule. A copy of your application is attached and is a part of
this policy. The following paragraphs set forth the definitions of terms, the limitations and
exclusions, the insurance benefits, and other provisions.
23000G1

NOTICE OF INSURED’S RIGHT TO EXAMINE THIS POLICY FOR 30 DAYS

It is important to us that you are satisfied with this policy. If you are not satisfied, you may return it
within 30 days after you receive it. Send it to Aflac Worldwide Headquarters, 1932 Wynnton Road,
Columbus, Georgia 31999 or to your associate (duly licensed agent). You will receive a full refund
of all premiums paid, and your policy will be void from its Effective Date. If you return this policy,
please note in writing: “This policy is returned for cancellation and refund of premium.”
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IMPORTANT NOTICE
Please read your application attached to this policy. This policy is issued on the basis
that the information shown on the application is correct and complete. Statements made
in the application are deemed representations and not warranties. Carefully check the
application. Write to us within 30 days of the date you receive this policy if any
information on the application is not correct or complete. Material misrepresentation may
result in the denial of claims or voiding of the policy. No associate (duly licensed agent)
may change this policy or waive any of its provisions.
THIS POLICY IS GUARANTEED-RENEWABLE FOR YOUR LIFETIME, SUBJECT TO
*23000G1HMY73P0G1W1T3527*

AFLAC’S RIGHT TO CHANGE PREMIUMS BY CLASS UPON ANY RENEWAL DATE.

We agree that this policy will never be restricted by the addition of any rider without your consent,
nor will renewal be refused because of any change in any Covered Person’s health or physical
condition. You are guaranteed the right to renew this policy for your lifetime by the timely payment
of premiums at the rate in effect at the beginning of each term, except that we may discontinue or
terminate the policy if you have performed an act or practice that constitutes fraud, or have made
an intentional misrepresentation of material fact relating in any way to the policy, including claims
for benefits under the policy.
Aflac may change the established premium rate, but only if the rate is changed for all policies of
this class. While this policy is in force, no change will be made in your class because of the age,
sex, or physical condition of any Covered Person. “Class” means all policies of this form number
and premium classification in your state that are then in force. If the established premium rate
changes, Aflac will notify you in writing at your last known address, as shown in our records, at
least 30 days before the change becomes effective.
PRE-EXISTING CONDITION LIMITATIONS
A “Pre-existing Condition” is an illness, disease, infection, disorder, or injury for which, within the
12-month period before the Effective Date of coverage, prescription medication was taken or
medical testing, medical advice, or treatment was recommended or received from a Physician.
Care or treatment of a Pre-existing Condition will not be covered unless the loss occurs 12 months
or more after the Effective Date of coverage.
This policy does not cover losses caused by or resulting from donating an organ within the first 12
months of the Effective Date of this policy.

Form A49100PA 1 A49100PA.2

© 2012 Aflac All Rights Reserved
 INDEX

Named Insured ......................................................................................................Policy Schedule

Definitions .............................................................................................................................Part 1

Limitations and Exclusions ....................................................................................................Part 2

Right of Conversion ...............................................................................................................Part 3

Uniform Provisions ................................................................................................................Part 4

Benefits .................................................................................................................................Part 5
Policy Schedule
NAMED INSURED: Susan E Burton Storey
TYPE OF COVERAGE: Individual POLICY NUMBER: P0G1W1T3

MODE OF PAYMENT: Bi-Weekly PREMIUM: $14.94

If deductions from your paycheck are made on a frequency other than the mode
of payment shown above, the amount deducted from your paycheck will differ.
COVERAGE: DHIPAE EFFECTIVE DATE: 08/12/14 $14.94

MESSAGES:
BENEFITS PAYABLE UP TO:
DHIPAE HOSPITAL CONFINEMENT INDEMNITY POLICY

In witness whereof, Aflac’s president and secretary signed this policy in Columbus, Georgia, as
of the policy Effective Date shown in the Policy Schedule.

ABC
Daniel P. Amos, President
ABCD
J. Matthew Loudermilk, Secretary

Form A49100PA 2 A49100PA.2

© 2012 Aflac All Rights Reserved
 This policy is a legal contract between you and Aflac.
READ YOUR POLICY CAREFULLY.

Part 1
DEFINITIONS

A. AMBULATORY SURGICAL CENTER: a facility licensed to provide surgical services in an

operating room environment on an outpatient basis. This does not include a Physician’s or
dentist’s office, a clinic, or other such location.
P0G1W1T3

B. CALENDAR YEAR: January 1 through December 31 of the same year.

C. COMPLICATIONS OF PREGNANCY: a health complication which in the absence of

immediate medical attention, will result in placing the life of the mother in jeopardy including:
(1) conditions requiring medical treatment prior to or subsequent to the termination of a
pregnancy whose diagnoses are distinct from pregnancy but that are adversely affected by
HMY73

pregnancy or caused by pregnancy, such as acute nephritis; nephrosis; cardiac

decompensation; missed abortion; disease of the vascular, hemopoietic, nervous, or
endocrine systems; and similar medical and surgical conditions of comparable severity; (2)
hyperemesis gravidarum and pre-eclampsia requiring Hospital Confinement, ectopic
pregnancy that is terminated, and spontaneous termination of pregnancy that occurs during
23000G1

a period of gestation in which a viable birth is not possible; (3) conditions requiring medical
treatment after the termination of pregnancy whose diagnoses are distinct from pregnancy
but which are adversely affected by pregnancy or caused by pregnancy.

Complications of Pregnancy do not include any of the following: multiple gestation

011529

pregnancy, false labor, occasional spotting, Physician prescribed rest during the
period of pregnancy, morning sickness, and similar conditions associated with the
management of a difficult pregnancy not constituting a classifiably distinct
complication of pregnancy. Cesarean deliveries are not considered Complications of
Pregnancy.

D. COVERED PERSON: persons covered under Individual, Named Insured/Spouse Only,

One-Parent Family, or Two-Parent Family coverage. See Type of Coverage definition.
*23000G1HMY73P0G1W1T3529*

E. DEPENDENT CHILDREN: your natural children, stepchildren, or legally adopted children

who are under age 26. Coverage of a Dependent Child will terminate on the child’s 26th
birthday. Children born to your Dependent Children or children born to Dependent Children
of your Spouse are not covered under this policy. Coverage provided under any One-Parent
or Two-Parent Family policy will include any other Dependent Child, regardless of age, who
is incapable of self-sustaining employment by reason of mental retardation or physical
handicap, and who became so incapacitated prior to age 26 and while covered under this
policy. You must furnish proof of such incapacity and dependency to Aflac within 31 days of
the Dependent Child’s 26th birthday. You must furnish proof of continued incapacity and
dependency at Aflac’s request, but not more often than annually, after the two-year period
following the Dependent Child’s 26th birthday.

F. EFFECTIVE DATE: the date(s) coverage begins as shown in the Policy Schedule or any
attached endorsements or riders. The Effective Date is not the date you signed the
application for coverage.

Form A49100PA 3 A49100PA.2

© 2012 Aflac All Rights Reserved
G. HOSPITAL: an institution operated pursuant to the law and licensed or approved as a
Hospital by the responsible state agency. It must be primarily engaged in providing medical
care and treatment of sick or injured persons on an in-patient basis for which a charge is
made. Nursing services must be provided on a 24-hour basis by or under the supervision of
registered graduate professional nurses (R.N.s). The term “Hospital” does not include a
hospice unit, including any bed designated as a hospice bed or a swing bed; a convalescent
home; a convalescent, rest, or nursing facility; facilities used primarily for the aged, drug or
alcohol rehabilitation and those primarily affording custodial or educational care; or a
Rehabilitation Facility that is not accredited by the Joint Commission on the Accreditation of
Hospitals, American Osteopathic Association, or the Commission on Accreditation of
Rehabilitation Facilities.

H. HOSPITAL CONFINEMENT: a stay of a Covered Person confined to a bed in a Hospital for

23 or more hours for which a room charge is made. The Hospital Confinement must be on
the advice of a Physician, Medically Necessary, and the result of a covered Sickness or
Injury. Treatment or confinement in a U.S. government Hospital does not require a charge for
benefits to be payable. Hospital Confinement does not include confinement in any institution
or part thereof used as an emergency room; a psychiatric unit; an extended-care facility; a
skilled nursing facility; or care or treatment for persons suffering from mental disease or
disorders.

I. HOSPITAL EMERGENCY ROOM: a unit of a Hospital dedicated to providing rapid and

varied treatment 24 hours a day to victims of sudden illness or trauma with an assigned
doctor trained in emergency medicine on duty at all times. The term “Hospital Emergency
Room” does not include urgent care centers.

J. IMMEDIATE FAMILY: anyone related to you in the following manner: spouse; brothers or
sisters (includes stepbrothers and stepsisters); children (includes stepchildren); parents
(includes stepparents); grandchildren (includes step-grandchildren); grandparents (includes
step-grandparents); father- or mother-in-law; brothers- or sisters-in-law; and spouses, as
applicable, of any of these.

K. INJURY: a bodily injury caused directly by an accident, independent of Sickness, bodily

infirmity, or any other cause, occurring on or after the Effective Date of coverage and while
coverage is in force. See the Limitations and Exclusions section for Injuries not covered by
this policy.

L. MEDICALLY NECESSARY: treatment, services, or supplies necessary and appropriate for

the diagnosis or treatment of Sickness or Injury based upon generally accepted medical
practice.

M. PERIOD OF HOSPITAL CONFINEMENT: the number of days a Covered Person is

assigned to and incurs a charge for a bed in a Hospital. Confinements must begin while
coverage under this policy is in force. Covered confinements not separated by 90 days or
more from a same or related previously covered confinement are considered a
continuation of the previous Period of Hospital Confinement. Hospitalization that begins
prior to the end of one Calendar Year and continues into the next Calendar Year will be
considered one confinement.

N. PHYSICIAN: a person legally qualified to practice medicine, other than you or a member of
your Immediate Family, who is licensed as a Physician by the state where treatment is
received to treat the type of condition for which a claim is made.

Form A49100PA 4 A49100PA.2

© 2012 Aflac All Rights Reserved
 O. REHABILITATION FACILITY: a licensed facility or a unit of a Hospital providing coordinated
multidisciplinary physical restorative services to inpatients under the direction of a Physician
knowledgeable and experienced in rehabilitative medicine. If a unit of a Hospital, beds must
be set up and staffed in an area specifically designated for this service. The term
“Rehabilitation Facility” does not include a hospice unit, including any bed designated as a
hospice or a swing bed; a convalescent home; a rest or nursing facility; a psychiatric unit; an
extended-care facility; a skilled nursing facility; or a facility primarily affording custodial or
educational care, care or treatment for persons suffering from mental disease or disorders,
care for the aged, or care for persons addicted to drugs or alcohol.
P. SICKNESS: an illness, disease, infection, or disorder, independent of injury, medically
evaluated, diagnosed or treated by a Physician more than 30 days after the Effective Date of
P0G1W1T3

coverage and while coverage is in force. Illnesses, diseases, infections, or disorders that
are medically evaluated, diagnosed, or treated by a Physician within the 30 day waiting
period will not be covered, unless the loss begins more than 12 months after the
Effective Date of coverage.
Q. TYPE OF COVERAGE: see your Policy Schedule to determine the Type of Coverage
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issued: Individual, Named Insured/Spouse Only, One-Parent Family, or Two-Parent Family.

1. Individual: coverage for only you (the Named Insured listed in the Policy Schedule).

2. Named Insured/Spouse Only: coverage for you (the Named Insured) and your Spouse.
Your “Spouse” is defined as the person to whom you are legally married and who is listed
23000G1

on your application.

3. One-Parent Family: coverage for you (the Named Insured) and all your Dependent
Children.
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4. Two-Parent Family: coverage for you (the Named Insured), your Spouse, and all your
Dependent Children (or those of your Spouse).
Any One-Parent Family or Two-Parent Family member specifically excluded by name from
coverage is not included in the One-Parent Family or Two-Parent Family definition. Any
person who becomes a family member after the Effective Date of this policy, except a
newborn or adopted child as explained below, must be added by endorsement. Persons
added as family members by endorsement will be covered for only that Sickness diagnosed
on or after the 30th day following the Effective Date of their endorsement.
*23000G1HMY73P0G1W1T3531*

Newborn children of any Covered Person are automatically covered under the terms of this
policy from the moment of birth. Adopted children are covered from the date the placement
of adoption is filed. If Individual or Named Insured/Spouse Only coverage is in force and
you desire uninterrupted coverage for a newborn or adopted child, you must notify
Aflac in writing within 31 days of the child’s birth or the date the placement is filed for
adoption of the child. Upon notification, Aflac will convert this policy to One-Parent Family
or Two-Parent Family coverage and advise you of the additional premium due. If One-Parent
Family or Two-Parent Family coverage is in force, it is not necessary for you to notify Aflac of
the birth of your child or the date of placement is filed for adoption of a child, and an
additional premium payment will not be required. Newborn children will not be covered for
routine well-baby care. We will pay policy benefits for their Sickness or Injury, including
medically diagnosed congenital defects, birth abnormalities, prematurity and routine
nursery care, subject to a 30-day waiting period for Sickness for children conceived
prior to the policy Effective Date (See Part 2, Limitations and Exclusions).
If you desire any other person to be covered after the Effective Date of this policy, you must
apply for such coverage, and that person must be added by endorsement. The added
person(s) will be subject to a Pre-existing Conditions provision and a 30-day waiting period
for Sickness that will begin on the Effective Date of the endorsement. If Two-Parent Family
coverage is already in force, an additional premium will not be required. Insurance for
persons added by endorsement becomes effective on the date specified on the
endorsement.

Form A49100PA 5 A49100PA.2

© 2012 Aflac All Rights Reserved
 The insurance on any Dependent Child will terminate on the Dependent Child’s 26th birthday
(for continuation of coverage information, see Part 3, Right of Conversion). Termination will
be without prejudice to any claim originating prior to the date of termination. When coverage
on all Dependent Children terminates, you must notify Aflac, in writing, and elect whether to
continue this policy on an Individual or Named Insured/Spouse Only basis. After such notice,
Aflac will arrange for the payment of the appropriate premium due, including returning any
unearned premium. Coverage provided under any One-Parent Family or Two-Parent Family
policy will continue to include any other Dependent Child, regardless of age, who is
incapable of self-sustaining employment by reason of mental retardation or physical
handicap, and who became so incapacitated prior to age 26 and while covered under this
policy. You must furnish proof of such incapacity and dependency to Aflac within 31 days of
the Dependent Child’s 26th birthday. You must furnish proof of continued incapacity and
dependency at Aflac’s request, but not more often than annually, after the two-year period
following the Dependent Child’s 26th birthday.

Part 2
LIMITATIONS AND EXCLUSIONS

A. Aflac will not pay benefits for care or treatment that is received prior to the Effective Date of
coverage.

B. Aflac will not pay benefits for care or treatment of a Pre-existing Condition, unless the loss
occurs 12 months or more after the Effective Date of coverage.

C. Aflac will not pay benefits for any illness, disease, infection, or disorder that is medically
evaluated, diagnosed, or treated by a Physician before coverage has been in force 30 days,
unless the loss begins more than 12 months after the Effective Date of coverage.

D. Benefits for a covered Sickness for all persons added to this policy (including newborns) are
subject to a 30-day waiting period. Aflac will waive the waiting period for newborns conceived
on or after the Effective Date of this policy.

E. This policy does not cover losses caused by or resulting from:

1. Being pregnant or giving birth within the first ten months of the Effective Date of
coverage, if the pregnancy is in existence on the Effective Date of coverage
(Complications of Pregnancy will be covered to the same extent as a Sickness);

2. Receiving routine well-baby care for a newborn child;

3. Using any narcotic (unless administered by a Physician and taken according to the
Physician’s instructions);

4. Committing, or attempting to commit, an illegal activity that is defined as a felony (“felony”

is as defined by the law of the jurisdiction in which the activity takes place); engaging in
any illegal occupation;

5. Being intoxicated or under the influence of any narcotic, unless administered on the
advice of a Physician (the term “intoxicated” refers to that condition as defined by the law
of the jurisdiction in which the cause of the loss occurred);

6. Intentionally self-inflicting a bodily injury, or committing suicide;

7. Having dental treatment except as a result of Injury, or having cosmetic surgery except
when necessitated by a covered Sickness or Injury;

Form A49100PA 6 A49100PA.2

© 2012 Aflac All Rights Reserved
 8. Having elective surgery, except when necessitated by a covered Sickness or Injury,
within the first 12 months of the Effective Date of coverage;

9. Enemy action or act of war, whether declared or undeclared, or actively serving as a

member in any of the armed forces of any nation, or units auxiliary thereto, including the
National Guard or Reserve; or

10. Having mental or emotional disorders, including but not limited to the following: bipolar
affective disorder (manic-depressive syndrome), delusional (paranoid) disorders,
psychotic disorders, somatoform disorders (psychosomatic illness), eating disorders,
schizophrenia, anxiety disorders, depression, stress, or post-partum depression. This
P0G1W1T3

policy will pay, however, for covered losses resulting from Alzheimer’s disease, or similar
forms of senility or senile dementia, which made itself known while coverage is in force.

Part 3
RIGHT OF CONVERSION

A. DISSOLUTION OF MARRIAGE: If you and your Spouse dissolve your marriage by a valid
HMY73

decree of dissolution and your ex-Spouse was covered under a Named Insured/Spouse Only
or a Two-Parent Family policy, your ex-Spouse’s coverage will terminate. Your ex-Spouse
may then apply for and receive, without evidence of insurability, a policy providing coverage
not greater than the terminated coverage. To obtain the policy, your ex-Spouse must make
application to Aflac within 60 days following the entry of the decree of dissolution and pay
23000G1

the appropriate premium for the policy. No waiting period is required except to the extent that
such period has not been satisfied under this policy. If such dissolution occurs, the Named
Insured under this policy at the time of the dissolution will retain that status. Any Dependent
Children may be covered under either policy, but not both.

B. DEATH: In the event of your death, your Spouse, if alive and covered under this policy, will
011533

become the Named Insured. All benefits accrued prior to your death will be paid to your
estate. No waiting period is required except to the extent that such period has not been
satisfied by that person under this policy.

C. TERMINATION OF DEPENDENCY: A Dependent Child whose dependency has terminated

and who desires to continue coverage as a Named Insured under a separate policy may do
so by notifying Aflac of the request in writing. Such person will have the right to apply for an
equivalent policy without evidence of insurability and without interruption in coverage,
provided Aflac receives written notification of the request prior to 31 days after the date he or
*23000G1HMY73P0G1W1T3533*

she is no longer considered a Dependent Child. No waiting period is required for such
person unless the waiting period under this policy has not been satisfied.

Part 4
UNIFORM PROVISIONS

A. ENTIRE CONTRACT; CHANGES: This policy, together with the application, endorsements,
benefit agreements, riders, and attached papers, if any, constitutes the entire contract of
insurance. No change in this policy is valid until approved in writing by the president and the
secretary of Aflac at our worldwide headquarters. Any such change must be noted hereon or
attached hereto. No associate (duly licensed agent) has the authority to change this policy or
to waive any of its provisions.

B. TIME LIMIT ON CERTAIN DEFENSES: After two years from the Effective Date of coverage,
no misstatements, except fraudulent misstatements, made by you in the application shall be
used to void this policy or to deny a claim for loss incurred after the expiration of such
two-year period. No claim for loss commencing after 12 months from the Effective Date of
coverage will be reduced or denied on the grounds that a disease or physical condition, not
excluded from coverage by name or specific description, had existed prior to such Effective
Date.

Form A49100PA 7 A49100PA.2

© 2012 Aflac All Rights Reserved
C. TERM: The term of this policy begins at midnight, standard time, at the place where you
reside on the Effective Date shown in the Policy Schedule. It ends at midnight, at the same
standard time, on the first renewal date. Each renewal term ends at midnight, at the same
standard time, on the next following renewal date. Renewal dates are determined by the
mode of payment. The mode of payment for the original term of this policy is shown in the
Policy Schedule. An annual premium will maintain this policy in force for 12 months,
semiannual for six months, quarterly for three months, and monthly for one month. Premium
for a term is due on the first day of that term. If you fail to pay your premium by the end of
the grace period, coverage under this policy will terminate.

D. GRACE PERIOD: A grace period of 31 days will be granted for the payment of each
premium falling due after the first premium. During the grace period, this policy will continue
in force.

E. REINSTATEMENT: You may request reinstatement of your policy from Aflac or from your
associate (duly licensed agent). If your policy has lapsed for nonpayment of premium and we
accept a later payment without requiring an application, your policy will be reinstated. If we
require a written application and provide you with a conditional receipt, your policy will be
reinstated upon our approval of the application. If we do not notify you of our disapproval in
writing within 45 days of the date your application is received at our worldwide headquarters,
your policy will be deemed reinstated. The reinstated policy will cover loss resulting from
accidental Injury sustained on or after the date of reinstatement and loss resulting from
Sickness that begins more than ten days after the date of reinstatement. In all other respects
you and Aflac will have the same rights as provided under the policy immediately before the
due date of the defaulted premium, subject to any provisions added in connection with the
reinstatement. Any premium accepted in connection with a reinstatement will be applied to a
period for which premium has not been previously paid, but not to any period more than 60
days prior to the date of reinstatement.

F. NOTICE OF CLAIM: Written notice of claim must be given within 60 days after a covered
loss starts or as soon as reasonably possible. The notice can be given to Aflac at our
worldwide headquarters, 1932 Wynnton Road, Columbus, Georgia 31999, or to your
associate (duly licensed agent). The notice of claim should include the name of the Covered
Person and the policy number.

G. CLAIM FORMS: When we receive a notice of claim, we will send you forms for filing proof of
loss. If the forms are not sent to you within 15 working days after such notice is given, you
will meet the proof-of-loss requirements by giving us a written statement of the nature and
extent of the loss within the time limit stated in the Proof of Loss provision.

H. PROOF OF LOSS: Written proof of loss (claim forms, medical bills, medical authorizations,
or other reasonable evidence of the claim that is ordinarily required) must be furnished to
Aflac at our worldwide headquarters within 90 days after the date of such loss. Failure to
furnish such proof within the time required will not invalidate or reduce any claim if it was not
reasonably possible to give proof within such time. However, such proof must be furnished
as soon as reasonably possible and in no event (except in the absence of legal capacity)
later than 15 months from the time proof is otherwise required.

I. TIME OF PAYMENT OF CLAIMS: All benefits payable under this policy will be paid
immediately upon receipt of due written proof of loss.

J. PAYMENT OF CLAIMS: All benefits will be payable to you unless assigned by you or by
operation of law. Any accrued benefits unpaid at your death will be paid to your estate.

K. LEGAL ACTIONS: No legal action may be brought to recover on this policy within 60 days
after written proof of loss has been furnished in accordance with the requirements of this
policy. No such action may be brought after three years from the time written proof of loss is
required to be furnished.

Form A49100PA 8 A49100PA.2

© 2012 Aflac All Rights Reserved
 L. CONFORMITY WITH STATE AND FEDERAL STATUTES: Any provision of this policy that,
on its Effective Date, is in conflict with the statutes of the state in which it was issued or with
any federal statute is hereby amended to conform to the minimum requirements of such
statutes.

M. OTHER INSURANCE WITH AFLAC: If any person is covered under more than one hospital
confinement indemnity policy or rider, only the one chosen by you, your beneficiary, or your
estate, as the case may be, will be effective. Aflac will pay benefits under the policies for
claims that may have been incurred since their respective Effective Dates. Aflac will also
return all premiums paid for the canceled policies from the date of duplication, less any
benefits paid under these policies from such date.
P0G1W1T3

N. PHYSICAL EXAMINATIONS AND AUTOPSY: Aflac, at its own expense, will have the right
and opportunity to examine a covered person when and as often as it may be reasonably
required while a claim is pending hereunder, and to make an autopsy in the case of death
where autopsy is not forbidden by law.
HMY73

O. INTOXICANTS AND NARCOTICS: Aflac shall not be liable for any loss sustained or
contracted in consequence of the Covered Person’s being intoxicated or under the influence
of any narcotic, unless administered on the advice of a Physician.

Part 5
BENEFITS
23000G1

Aflac will pay the following benefits, as applicable, for a covered Sickness or Injury that occurs
while coverage is in force, subject to the Pre-existing Condition Limitations, Limitations and
Exclusions, and all other policy provisions, unless indicated otherwise. The term “Hospital
Confinement” does not include emergency rooms. Treatment or confinement in a U.S.
011535

government Hospital does not require a charge for benefits to be payable.

A. HOSPITAL CONFINEMENT BENEFIT: Aflac will pay $1,000 when a Covered Person
requires Hospital Confinement for 23 or more hours for a covered Sickness or Injury and a
charge is incurred. This benefit is payable once per Period of Hospital Confinement, per
Covered Person. Confinements must be separated by a minimum of 90 days from the
previous covered Hospital Confinement for this benefit to be payable. No lifetime maximum.

B. REHABILITATION FACILITY BENEFIT: Aflac will pay $100 per day when a Covered
Person is confined in a Hospital and is transferred to a bed in a Rehabilitation Facility for a
*23000G1HMY73P0G1W1T3535*

covered Sickness or Injury, and a charge is incurred. This benefit is limited to 31 days per
Period of Hospital Confinement and is limited to a Calendar Year maximum of 31 days, per
Covered Person. No lifetime maximum.

C. HOSPITAL EMERGENCY ROOM BENEFIT: Aflac will pay $100 when a Covered Person
receives treatment for a covered Sickness or Injury in a Hospital Emergency Room, including
triage, and a charge is incurred. This benefit is payable twice per Calendar Year, per policy.
No lifetime maximum.

D. HOSPITAL SHORT-STAY BENEFIT: Aflac will pay $100 when a Covered Person receives
treatment for a covered Sickness or Injury in a Hospital, including an observation room, or an
Ambulatory Surgical Center, for a period of less than 23 hours and a charge is incurred. This
benefit is not payable for treatment received in a Hospital Emergency Room. This benefit is
payable twice per Calendar Year, per policy. No lifetime maximum.

Form A49100PA 9 A49100PA.2

© 2012 Aflac All Rights Reserved
E. WAIVER OF PREMIUM BENEFIT: Upon written notice, Aflac will waive from month to month
any premium(s) falling due during a continued Period of Hospital Confinement for the Named
Insured only. This benefit will begin after the Period of Hospital Confinement for the Named
Insured has exceeded 30 consecutive days. When such continued Period of Hospital
Confinement has ended, premium payments must be resumed. Once premium payments are
resumed, any new Period of Hospital Confinement must again satisfy the 30-day continued
confinement for premiums to be waived.

If you die and your Spouse becomes the new Named Insured, premiums will start again at
the appropriate rate and will be due on the first premium due date after the change. The new
Named Insured will then be eligible for this benefit if the need arises.

Form A49100PA 10 A49100PA.2

© 2012 Aflac All Rights Reserved
 AMERICAN FAMILY LIFE ASSURANCE COMPANY OF COLUMBUS
(herein referred to as Aflac)
Worldwide Headquarters • 1932 Wynnton Road • Columbus, Georgia 31999
A Stock Company

ENDORSEMENT
POLICY FORMS A49100PA, A49200PA, A49300PA, A49400PA and A4910HPA

CERTIFICATE OR
POLICY NUMBER: P0G1W1T3 DATE OF ISSUE: See Policy Schedule
P0G1W1T3

INSURED: Susan E Burton Storey ENDORSEMENT DATE: August 12, 2014

This endorsement is subject to all of the provisions of the policy to which it is attached.
HMY73

A change has been made to the above policy and indicated as follows:

DEPENDENT CHILDREN definition has been amended by deleting “Children born to your
Dependent Children or children born to Dependent Children of your Spouse are not covered
under this policy.”
23000G1

This endorsement will automatically terminate with the policy.

011537

In witness whereof, this endorsement has been executed by Aflac’s Worldwide Headquarters
in Columbus, Georgia, on the above stated endorsement date.

ABC ABCD
Daniel P. Amos, President J. Matthew Loudermilk, Secretary
*23000G1HMY73P0G1W1T3537*

Form A49090PA A49090PA.1

© 2012 Aflac All Rights Reserved
The following privacy practice pages are not part of your policy contract but
are provided to you as required by Federal law. Please review these
documents carefully.
 AFLAC CUSTOMER PRIVACY POLICY

Protecting the privacy and confidentiality of information about our customers is very important to American
Family Life Assurance Company of Columbus, American Family Life Assurance Company of New York, and
Continental American Insurance Company (collectively, "Aflac"). Accordingly, Aflac has developed and
adopted this “Customer Privacy Policy” which is designed to ensure that our collection and use of customer
information complies with the following commitments:

• Aflac does not sell, rent, lease, or otherwise disclose nonpublic personal information (NPI) of
its customers for purposes unrelated to Aflac products and services. Our customers’ NPI is of
paramount importance to us. Therefore, we provide your NPI only to our affiliates, employees,
agents, and third parties as necessary to facilitate the development and delivery of our insurance
P0G1W1T3

and employee benefit products and services. Aflac may also provide your NPI to its affiliates for
marketing purposes consistent with the terms disclosed herein (see Sharing Information, below).

• Aflac works to ensure information integrity and security. We use technology tools and design
our business practices to help ensure that our customers’ NPI is properly gathered, stored, and
processed. We also work to maintain the security of our customers’ NPI through the use of
technology and our business practices.
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• Aflac expects its agents and employees to respect customer NPI. Aflac has adopted internal
policies and procedures designed to ensure that employees and agents adhere to Aflac’s privacy
policies and otherwise protect our customers’ NPI. Both employees and agents are subject to
censure, dismissal, or termination for violation of these policies.
10010G1

This Customer Privacy Policy applies to those individuals who receive our products and services, as well as
to individuals who provide us with NPI in the course of submitting an application to us for our products and
services.

PRIVACY NOTICE

Aflac provides this notice to let you know about our current privacy practices with respect to the collection,
011539

sharing, and protection of your NPI. You do not need to do anything in response to this notice, unless
you would like to prohibit the use of your NPI by our affiliates to market products and services to
you, as described below.

Collecting Information

As part of Aflac’s normal underwriting and operating procedures, Aflac (and our agents acting on our behalf)
needs to obtain information to determine an individual’s eligibility for our products and services, and to
perform our insurance functions. Aflac and our agents may collect NPI about Aflac’s customers, including:

• Information from our customers (including names, addresses, and financial and health information).
*10010G1HMY73P0G1W1T3539*

• Information about our customers’ transactions with Aflac or our agents (including claims and
payment information).
• Information from or about your transactions with nonaffiliated third parties (including, but not limited
to, accident reports, claims, health and insurance application histories, health history, and salary
data).

Sharing Information

• Aflac shares the NPI it collects about you, as described above, among Aflac and its affiliates so that
Aflac and its affiliates may perform their everyday business functions, such as processing your
transactions and claims, or otherwise maintaining your policies. Aflac also reserves the right to
share your NPI with its affiliates to enable Aflac affiliates to market their products and services
directly to you. You can prevent the use of your NPI for this purpose by following the “opt-out”
procedure described below, “Opting Out of Information Sharing.”

• Aflac does not share, and does not reserve the right to share, customer NPI with nonaffiliated third
parties except as permitted or required by applicable law.

• Aflac agents will share your NPI only while acting on Aflac’s behalf and, furthermore, will share your
NPI only to the extent Aflac itself is permitted to do so.

• Neither Aflac nor its agents will disclose the NPI of former customers unless the disclosure is
authorized by or at the request of the former customer, or is otherwise permitted or required by law.

Form A-90070 1 A90070.4

 Opting Out of Information Sharing

As described above, Aflac shares your NPI when permitted or required by law. You are not able to limit
Aflac’s ability to share your NPI for these purposes.

Affiliate Marketing Opt-Out

If you would prefer not to receive marketing materials from Aflac’s affiliates about their products or services,
you can opt out of such affiliate marketing by either (1) calling 800-992-3522; or (2) visiting www.aflac.com
and downloading, completing, and returning the Affiliate Marketing Opt-Out Form to Aflac at the referenced
address. If you opt out and later change your mind, please let Aflac know and we will change your choice.
Your opt-out does not prevent Aflac from sending you information about products or services offered by
Aflac or its affiliates. Similarly, your opt-out will not prevent an Aflac affiliate from using NPI received from
Aflac to market affiliate products and services to you if (a) you have a pre-existing relationship with such
affiliate, or (b) you contact such affiliate directly and request information about such affiliate’s products or
services.

Confidentiality and Security

Aflac and its agents safeguard customer (and former customer) NPI by maintaining administrative, technical,
and physical safeguards to ensure the security and confidentiality of such NPI. This includes having security
practices in place to protect against anticipated threats or hazards, and to protect against unauthorized
access to or use of customer and former customer NPI.

Aflac limits access to NPI to only those employees who need access to such information to perform their job
functions. Employees who misuse NPI are subject to disciplinary actions. Aflac provides privacy training
and awareness to all of its employees.

NOTICE OF INFORMATION PRACTICES

California, Connecticut, Georgia, Illinois, Kansas, Maine, Massachusetts, Minnesota, Montana, Nevada, New
Jersey, North Carolina, Ohio, Oregon, and Virginia require insurers and agents to describe their information
practices in addition to providing a Privacy Notice. There is significant overlap between the two notices, but
in general our Information Practices include the following: Aflac may obtain information about you and any
other persons proposed for insurance. Some of this information will come from you and some may come
from other sources. That information and any other subsequent information collected by Aflac may in some
circumstances be disclosed to third parties without your specific consent. Residents of these states have the
right to access and correct the information collected about them except information that relates to a claim or
to a civil or criminal proceeding. They also have the right to receive the specific reason for an adverse
underwriting decision in writing. If you wish to have a more detailed explanation of our information practices
required by your state, please submit a written request to: Aflac Worldwide Headquarters, ATTN: Policy
Service, 1932 Wynnton Road, Columbus, Georgia 31999.

STATE-SPECIFIC DISCLOSURES

Customer NPI shall be collected, used, and stored in accordance with applicable federal privacy laws. To
the extent that the privacy laws of a Customer’s state of residence are more protective of the Customer’s NPI
than federal privacy laws, Aflac will protect the Customer’s NPI in accordance with such state law.

Attention Washington Residents: You have the right to limit disclosures of your nonpublic personal
information under the circumstances described in WAC 284-04-510. For instance, you may request in writing
that Aflac limit the disclosure of nonpublic personal information to specified individuals if the disclosure of the
information to those individuals could jeopardize your safety. In addition, you may also request, in writing,
that Aflac limit certain disclosures of information regarding reproductive health, sexually transmitted
diseases, chemical dependency, and mental health. For more information or if you wish to submit a request,
please write to: Aflac Worldwide Headquarters, ATTN: Privacy Office, 1932 Wynnton Road, Columbus,
Georgia 31999.

NOTICE OF PRIVACY PRACTICES - PROTECTED HEALTH INFORMATION

If you would like a copy of Aflac’s Notice of Privacy Practices - Protected Health Information, issued pursuant
to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), copies are available by visiting
Aflac’s website, www.aflac.com, or sending a written request to: Aflac Worldwide Headquarters, ATTN:
Privacy Office, 1932 Wynnton Road, Columbus, Georgia 31999.

Form A-90070 2 A90070.4

 NOTICE OF PRIVACY PRACTICES – PROTECTED HEALTH INFORMATION

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY. The terms of this Notice of Privacy Practices – Protected Health Information (“Notice”)
apply to Protected Health Information (defined below) associated with Health Plans (defined below) issued
by American Family Life Assurance Company of Columbus, American Family Life Assurance Company of
New York, and Continental American Insurance Company (collectively, “we,” “our,” or “Aflac”) 1. This
Notice describes how Aflac may use and disclose Protected Health Information to carry out payment and
health care operations, and for other purposes that are permitted or required by law.
P0G1W1T3

We are required by the privacy regulations issued under the Health Insurance Portability and
Accountability Act of 1996 (“HIPAA”) to maintain the privacy of Protected Health Information and to
provide our policyholders with notice of our legal duties and privacy practices concerning Protected Health
Information. In the event applicable law, other than HIPAA, prohibits or materially limits our uses and
disclosures of Protected Health Information, as set forth below, we will restrict our uses or disclosure of
your Protected Health Information in accordance with the more stringent standard. We are required to
abide by the terms of this Notice so long as it remains in effect. We reserve the right to change the terms
of this Notice of Privacy Practices as necessary and to make the new Notice effective for all Protected
Health Information maintained by us. If we make material changes to our privacy practices, we will mail
HMY73

copies of revised notices to all policyholders then covered by a Health Plan. Copies of our current Notice
may be obtained by contacting Aflac at the telephone number or address below, or on our Web site at
www.aflac.com.
10010G1

DEFINITIONS

Health Plan means, for purposes of this Notice, the following policies issued by Aflac: long-term care,
Medicare supplement, dental, specified disease (e.g., cancer), hospital indemnity, intensive care, and other
coverages that meet the definition of Health Plan contained in HIPAA. The following products are not
considered Health Plans: coverage only for accident, or disability income insurance, or any combination
thereof, life insurance, and other coverages that do not meet the definition of Health Plan contained in
011541

HIPAA.

Protected Health Information (“PHI”) means individually identifiable health information, as defined by
HIPAA, that is created or received by Aflac and that relates to the past, present, or future physical or
mental health or condition of an individual; the provision of health care to an individual; or the past,
present, or future payment for the provision of health care to an individual; and that identifies the individual
or for which there is a reasonable basis to believe the information can be used to identify the individual.
PHI includes information of persons living or deceased, unless the person has been deceased more than
50 years.

USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION

*10010G1HMY73P0G1W1T3541*

The following categories describe different ways that we use and disclose PHI. For each category of uses
and disclosures we will explain what we mean and, where appropriate, provide examples for illustrative
purposes. Not every use or disclosure in a category will be listed. However, all of the ways we are
permitted or required to use and disclose PHI will fall within one of the categories.

Uses and Disclosures for Payment – We may make requests, uses, and disclosures of your PHI as
necessary for payment purposes. For example, we may use information regarding your medical
procedures and treatment to process and pay claims. We may also disclose your PHI for the payment
purposes of a health care provider or another Health Plan.

Uses and Disclosures for Health Care Operations – We may use and disclose your PHI as necessary
for our health care operations. Examples of health care operations include underwriting, premium rating,
or other activities relating to the creation, renewal, or replacement of a Health Plan, reinsurance,
compliance, auditing, rating, business management, quality improvement and assurance, and other
functions related to your Health Plan. Unless permitted by HIPAA, we are prohibited from using or
disclosing your PHI that is genetic information for underwriting purposes.

1 With respect to its Health Plans, American Family Life Assurance Company of Columbus, American
Family Life Assurance Company of New York and Continental American Insurance Company are affiliated
covered entities (see 45 CFR 164.105).

Form A-90069 1 A90069.5

Family and Friends Involved in Your Care – If you are available and do not object, we may disclose
your PHI to your family, friends, and others who are involved in your care or payment of a claim. If you are
unavailable or incapacitated and we determine that a limited disclosure is in your best interest, we may
share limited PHI with such individuals. For example, we may use our professional judgment to disclose
PHI to your spouse concerning the processing of a claim. If you do not wish Aflac to share PHI with your
spouse or others, you may exercise your right to request a restriction on Aflac’s disclosures of your PHI
(see below).

Business Associates – Certain aspects and components of our services are performed through contracts
with outside persons or organizations. Examples of these outside persons and organizations include our
duly-appointed insurance agents and vendors that help us process your claims. At times it may be
necessary for us to provide certain of your PHI to one or more of these outside persons or organizations.

Other Products and Services – We may contact you to provide information about other health-related
products and services that may be of interest to you. For example, we may use and disclose your PHI for
the purpose of communicating to you about our health insurance products that could enhance or substitute
for existing Health Plan coverage, and about health-related products and services that may add value to
your Health Plan.

Other Uses and Disclosures – We may make certain other uses and disclosures of your PHI without your
authorization:

o We may use or disclose your PHI for any purpose required by law. For example, Aflac
may be required by law to use or disclose your PHI to respond to a court order.
o We may disclose your PHI for public health activities, such as reporting of disease, injury,
birth and death, and for public health investigations.
o We may disclose your PHI to the proper authorities if we suspect child abuse or neglect;
we may also disclose your PHI if we believe you to be a victim of abuse, neglect, or
domestic violence.
o We may disclose your PHI if authorized by law to a government oversight agency (e.g., a
state insurance department) conducting audits, investigations, or civil or criminal
proceedings.
o We may disclose your PHI in the course of a judicial or administrative proceeding (e.g., to
respond to a subpoena or discovery request).
o We may disclose your PHI to the proper authorities for law enforcement purposes.
o We may disclose your PHI to coroners, medical examiners, and/or funeral directors
consistent with law.
o We may use or disclose your PHI for cadaveric organ, eye or tissue donation.
o We may use or disclose your PHI for research purposes, but only as permitted by law.
o We may use or disclose PHI to avert a serious threat to health or safety.
o We may use or disclose your PHI if you are a member of the military as required by armed
forces services, and we may also disclose your PHI for other specialized government
functions such as national security or intelligence activities.
o We may disclose your PHI to workers’ compensation agencies for your workers’
compensation benefit determination.
o We will, if required by law, release your PHI to the Secretary of the Department of Health
and Human Services for enforcement of HIPAA.

Your Authorization – Except as outlined above, we will not use or disclose your PHI unless you have
signed a form authorizing the use or disclosure. You have the right to revoke that authorization in writing
except to the extent that we have taken action in reliance upon the authorization or that the authorization
was obtained as a condition of obtaining insurance, and we have the right, under other law, to contest a
claim under the policy or the policy itself.

• The following are examples of when your authorization would be required prior to use and
disclosure:

o Most uses and disclosures of your psychotherapy notes.

o Uses and disclosures of your PHI for marketing purposes.
o Uses and disclosures that constitute a sale of PHI.

Breach of Unsecured PHI – If Aflac or a Business Associate of Aflac causes a breach to occur that
involved your unsecured PHI, we are required by law to notify you of the incident.

Form A-90069 2 A90069.5

 RIGHTS THAT YOU HAVE

Access to Your PHI – You have the right to copy and/or inspect certain PHI that we maintain about you.
Certain requests for access to your PHI must be in writing, must state that you want access to your PHI,
and must be signed by you or your representative (e.g., requests for medical records provided to us
directly from your health care provider). We must provide you with access to your PHI in the form or
format requested by you, if it is readily producible in such form or format, or, if not, in a form or format
agreed upon by you and Aflac. Access request forms are available from Aflac at the address below. We
may charge you a fee for copying and postage.

Amendments to Your PHI – You have the right to request that PHI that we maintain about you be
P0G1W1T3

amended or corrected. We are not obligated to make all requested amendments but will give each request
careful consideration. To be considered, your amendment request must be in writing, must be signed by
you or your representative, and must state the reasons for the amendment/correction request.
Amendment request forms are available from Aflac at the address below.

Accounting for Disclosures of Your PHI – You have the right to receive an accounting of certain
disclosures made by us of your PHI. Examples of disclosures that we are required to account for include
those to state insurance departments, pursuant to valid legal process, or for law enforcement purposes. To
be considered, your accounting requests must be in writing and signed by you or your representative.
HMY73

Accounting request forms are available from Aflac at the address below. The first accounting in any
12-month period is free; however, we may charge you a fee for each subsequent accounting you request
within the same 12-month period.
10010G1

Restrictions on Use and Disclosure of Your PHI – You have the right to request restrictions on certain
of our uses and disclosures of your PHI for insurance payment or health care operations, disclosures made
to persons involved in your care, and disclosures for disaster relief purposes. For example, you may
request that we not disclose your PHI to your spouse. Your request must describe in detail the restriction
you are requesting. HIPAA does not require us to agree to your request but we will accommodate
reasonable requests when appropriate. We retain the right to terminate an agreed-to restriction if we
believe such termination is appropriate. In the event of a termination by us, we will notify you of such
011543

termination. You also have the right to terminate, in writing or orally, any agreed-to restriction. Requests
for a restriction (or termination of an existing restriction) may be made by contacting Aflac at the telephone
number or address below.

Request for Confidential Communications – You have the right to request that communications
regarding your PHI be made by alternative means or at alternative locations. For example, you may
request that messages not be left on voice mail or sent to a particular address. We are required to
accommodate reasonable requests if you inform us that disclosure of all or part of your information could
place you in danger. Requests for confidential communications must be in writing, signed by you or your
representative, and sent to Aflac at the address below.
*10010G1HMY73P0G1W1T3543*

Right to a Copy of the Notice – You have the right to a paper copy of this Notice upon request by
contacting Aflac at the telephone number or address below.

Complaints – If you believe your privacy rights have been violated, you can file a complaint with Aflac in
writing at the address below. You may also file a complaint in writing with the Secretary of the U.S.
Department of Health and Human Services in Washington, D.C., within 180 days of a violation of your
rights. There will be no retaliation for filing a complaint.

FOR FURTHER INFORMATION

If you have questions or need further assistance regarding this Notice, you may contact Aflac’s Privacy
Office by writing to: Aflac, Attn: Privacy Office, 1932 Wynnton Road, Columbus, Georgia 31999, or by
calling 1-800-99-AFLAC.

EFFECTIVE DATE

This Notice is effective January 6, 2017.

Form A-90069 3 A90069.5