city of schertz 284732 short term disability

CITY OF SCHERTZ

284732

Short Term Disability

Effective 10/01/2008

Per $10 of weekly benefit

Age

00-24 $.620

25-29 $.650

30-34 $.630

35-39 $.590

40-44 $.710

45-49 $.780

50-54 $.900

55-59 $1.220

60-64 $1.650

65-99 $1.790

Please note all rates are subject to change by Unum in the future Generated 10/11/2018

C.AMEND-6 AMEND-1 (5/1/2017)

AMENDMENT NO. 5

This amendment forms a part of Group Policy No. 284732 001 issued to the Policyholder:

City of Schertz

The entire policy is replaced by the policy attached to this amendment.

The effective date of these changes is May 1, 2017. The changes only apply to disabilities which start on or after the effective date.

The policy's terms and provisions will apply other than as stated in this amendment.

Dated at Portland, Maine on April 14, 2017.

Unum Life Insurance Company of America

By

Secretary

If this amendment is unacceptable, please sign below and return this amendment to Unum Life Insurance Company of America at Portland, Maine within 90 days of April 14, 2017.

YOUR FAILURE TO SIGN AND RETURN THIS AMENDMENT BY THAT DATE WILL CONSTITUTE ACCEPTANCE OF THIS AMENDMENT.

City of Schertz

By ____________________________Signature and Title of Officer

C.FP-6 C.FP-6-1 (5/1/2017)

____________________________________________________________________

GROUP INSURANCE POLICYNON-PARTICIPATING

_____________________________________________________________________

POLICYHOLDER: City of Schertz

POLICY NUMBER: 284732 001

POLICY EFFECTIVE DATE: October 1, 2003

POLICY ANNIVERSARY DATE: January 1

GOVERNING JURISDICTION: Texas

Unum Life Insurance Company of America (referred to as Unum) will provide benefits under this policy. Unum makes this promise subject to all of this policy's provisions.

The policyholder should read this policy carefully and contact Unum promptly with any questions. This policy is delivered in and is governed by the laws of the governing jurisdiction and to the extent applicable by the Employee Retirement Income Security Act of 1974 (ERISA) and any amendments. This policy consists of:

- all policy provisions and any amendments and/or attachments issued;- employees' signed applications; and- the certificate of coverage.

This policy may be changed in whole or in part. Only an officer or a registrar of Unum can approve a change. The approval must be in writing and endorsed on or attached to this policy. No other person, including an agent, may change this policy or waive any part of it.

Signed for Unum at Portland, Maine on the Policy Effective Date.

President Secretary

Unum Life Insurance Company of America2211 Congress StreetPortland, Maine 04122

C.FP-6-2 (5/1/2017)

IMPORTANT NOTICE

This is not a policy of Workers' Compensation Insurance. The Employer does not become a subscriber to the Workers' Compensation system by purchasing this policy, and if the Employer is a nonsubscriber, the Employer loses those benefits which would otherwise accrue under the Workers' Compensation laws. The Employer must comply with the Workers' Compensation law as it pertains to nonsubscribers and the required notification that must be filed and posted.

C.FP-6-3 (5/1/2017)

IMPORTANT NOTICE

To obtain information or make a complaint:

You may call Unum's toll-free telephone number for information or to make a complaint at:

1-800-321-3889

You may also write to Unum at:

Deborah J. Jewett, ManagerCustomer RelationsUnum Life Insurance Company of America2211 Congress StreetPortland, Maine 04122

You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at:

1-800-252-3439

You may also write the Texas Department of InsuranceP.O. Box 149104Austin, TX 78714-9104FAX: (512) 490-1007

Web: www.tdi.texas.gov

E-mail: [email protected]

PREMIUM OR CLAIM DISPUTES:

Should you have a dispute concerning your premium or about a claim, you should contact the company first. If the dispute is not resolved, you may contact the Texas Department of Insurance (TDI).

AVISO IMPORTANTE

Para obtener información o para presentar una queja:

Usted puede llamar al número de telefono gratuito de Unum's para obtener información o para presentar una queja al:

1-800-321-3889

Usted también puede escribir a Unum:

Deborah J. JewettGerente de Relaciones alClienteUnum Life Insurance Company of America2211 Congress StreetPortland, Maine 04122

Usted puede comunicarse con el Departamento de Seguros de Texas para obtener información sobre de compañias, coberturas, derechos o quejas al:

1-800-252-3439

Usted puede escribir al Departamento de Seguros de TexasP.O. Box 149104Austin, TX 78714-9104FAX: (512) 490-1007



DISPUTAS POR PRIMAS DE SUGUROS O RECLAMACIONES:

Si tiene una disputa relacionado con su prima de seguro con una reclamación, usted debe comunicarse con la compañia primero. Si la disputa no es resuelta, puede comunicarse con el Departamento de Suguros de Texas(TDI).

ATTACH THIS NOTICE TO YOUR POLICY:

This notice is for information only and does not become a part or condition of the attached document.

ADJUNTE ESTE AVISO A SU POLIZA:

Este aviso es solamente para propósitos informativos y no se convierte en parte o en condición del documento adjunto.

http://www.tdi.texas.gov/


TOC-1 (5/1/2017)

TABLE OF CONTENTS

BENEFITS AT A GLANCE .............................................................................................B@G-STD-1

SHORT TERM DISABILITY PLAN .................................................................................B@G-STD-1

CLAIM INFORMATION ..................................................................................................STD-CLM-1

SHORT TERM DISABILITY ...........................................................................................STD-CLM-1

POLICYHOLDER PROVISIONS....................................................................................EMPLOYER-1

CERTIFICATE SECTION ...............................................................................................CC.FP-6-1

GENERAL PROVISIONS...............................................................................................EMPLOYEE-1

SHORT TERM DISABILITY ...........................................................................................STD-BEN-1

BENEFIT INFORMATION ..............................................................................................STD-BEN-1

OTHER BENEFIT FEATURES.......................................................................................STD-OTR-1

GLOSSARY....................................................................................................................GLOSSARY-1

B@G-STD-1 (5/1/2017)

BENEFITS AT A GLANCESHORT TERM DISABILITY PLAN

This short term disability plan provides financial protection for you by paying a portion of your income while you are disabled. The amount you receive is based on the amount you earned before your disability began.

EMPLOYER'S ORIGINAL PLANEFFECTIVE DATE: October 1, 2003


ELIGIBLE GROUP(S):

All Full-Time Employees in active employment in the United States with the Employer

MINIMUM HOURS REQUIREMENT:

Employees must be working at least 40 hours per week.

WAITING PERIOD:

For employees in an eligible group on or before October 1, 2003: None

For employees entering an eligible group after October 1, 2003: First of the month following 30 days of continuous active employment

REHIRE:

If your employment ends and you are rehired within 12 months, your previous work while in an eligible group will apply toward the waiting period. All other policy provisions apply.

WHO PAYS FOR THE COVERAGE:

You pay the cost of your coverage.

ELIMINATION PERIOD:

7 days for disability due to an injury

7 days for disability due to a sickness

Benefits begin the day after the elimination period is completed.

WEEKLY BENEFIT:

60% of weekly earnings to a maximum benefit of $1,500 per week

Your payment may be reduced by deductible sources of income. Some disabilities may not be covered under this plan.

MAXIMUM PERIOD OF PAYMENT:

25 weeks

Premium payments are required for your coverage while you are receiving payments under this plan.

Your Short Term Disability plan does not cover disabilities due to an occupational sickness or injury.

B@G-STD-2 (5/1/2017)

REHABILITATION AND RETURN TO WORK ASSISTANCE BENEFIT:

10% of your gross disability payment to a maximum benefit of $250 per week.

In addition, we will make weekly payments to you for 3 weeks following the date your disability ends if we determine you are no longer disabled while:

- you are participating in the Rehabilitation and Return to Work Assistance program; and- you are not able to find employment.

OTHER FEATURES:

Minimum Benefit

Pre-Existing: 3/12

The above items are only highlights of this plan. For a full description of your coverage, continue reading your certificate of coverage section.

STD-CLM-1 (5/1/2017)

CLAIM INFORMATION

SHORT TERM DISABILITY

WHEN DO YOU NOTIFY UNUM OF A CLAIM?

We encourage you to notify us of your claim as soon as possible, so that a claim decision can be made in a timely manner. Written notice of a claim should be sent within 30 days after the date your disability begins. However, you must send Unum written proof of your claim no later than 90 days after your elimination period. If it is not possible to give proof within 90 days, it must be given no later than 1 year after the time proof is otherwise required except in the absence of legal capacity.

The claim form is available from your Employer, or you can request a claim form from us. If you do not receive the form from Unum within 15 days of your request, send Unum written proof of claim without waiting for the form.

You must notify us immediately when you return to work in any capacity.

HOW DO YOU FILE A CLAIM?

You and your Employer must fill out your own sections of the claim form and then give it to your attending physician. Your physician should fill out his or her section of the form and send it directly to Unum.

WHAT INFORMATION IS NEEDED AS PROOF OF YOUR CLAIM?

Your proof of claim, provided at your expense, must show:

- that you are under the regular care of a physician;- the appropriate documentation of your weekly earnings;- the date your disability began;- the cause of your disability;- the extent of your disability, including restrictions and limitations preventing you

from performing your regular occupation; and- the name and address of any hospital or institution where you received

treatment, including all attending physicians.

We may request that you send proof of continuing disability indicating that you are under the regular care of a physician. This proof, provided at your expense, must be received within 45 days of a request by us.

In some cases, you will be required to give Unum authorization to obtain additional medical information, and to provide non-medical information as part of your proof of claim, or proof of continuing disability. Unum will deny your claim, or stop sending you payments, if the appropriate information is not submitted.

The initial payment for a payable claim will be made within 60 days from the date proof is received.

TO WHOM WILL UNUM MAKE PAYMENTS?

Unum will make payments to you.

STD-CLM-2 (5/1/2017)

WHAT HAPPENS IF UNUM OVERPAYS YOUR CLAIM?

Unum has the right to recover any overpayments due to:

- fraud;- any error Unum makes in processing a claim; and- your receipt of deductible sources of income.

You must reimburse us in full. We will determine the method by which the repayment is to be made.

Unum will not recover more money than the amount we paid you.

EMPLOYER-1 (5/1/2017)

POLICYHOLDER PROVISIONS

WHAT IS THE COST OF THIS INSURANCE?


The initial premium for each plan is based on the initial rate(s) shown in the Rate Information Amendment(s).

Premium payments are required for an insured while he or she is receiving Short Term Disability payments under this plan.

INITIAL RATE GUARANTEE AND RATE CHANGES

Refer to the Rate Information Amendment(s).

WHEN IS PREMIUM DUE FOR THIS POLICY?

Premium Due Dates: Premium due dates are based on the Premium Due Dates shown in the Rate Information Amendment(s).

The Policyholder must send all premiums to Unum on or before their respective due date. The premium must be paid in United States dollars.

WHEN ARE INCREASES OR DECREASES IN PREMIUM DUE?

Premium increases or decreases which take effect during a policy month are adjusted and due on the next premium due date following the change. Changes will not be pro-rated daily.

If premiums are paid on other than a monthly basis, premiums for increases and decreases will result in a monthly pro-rated adjustment on the next premium due date.

Unum will only adjust premium for the current policy year and the prior policy year. In the case of fraud, premium adjustments will be made for all policy years.

WHAT INFORMATION DOES UNUM REQUIRE FROM THE POLICYHOLDER?

The Policyholder must provide Unum with the following on a regular basis:

- information about employees:who are eligible to become insured;whose amounts of coverage change; and/orwhose coverage ends;

- occupational information and any other information that may be required to manage a claim; and

- any other information that may be reasonably required.

Policyholder records that, in Unum's opinion, have a bearing on this policy will be available for review by Unum at any reasonable time.

Clerical error or omission by Unum will not:

EMPLOYER-2 (5/1/2017)

- prevent an employee from receiving coverage;- affect the amount of an insured's coverage; or- cause an employee's coverage to begin or continue when the coverage would not

otherwise be effective.

WHO CAN CANCEL OR MODIFY THIS POLICY OR A PLAN UNDER THIS POLICY?

This policy or a plan under this policy can be cancelled:

- by Unum; or- by the Policyholder.

Unum may cancel or modify this policy or a plan if:

- there is less than 25% participation of those eligible employees who pay all or part of their premium for a plan; or

- there is less than 100% participation of those eligible employees for a Policyholder paid plan;

- the Policyholder does not promptly provide Unum with information that is reasonably required;

- the Policyholder fails to perform any of its obligations that relate to this policy; - fewer than 15 employees are insured under a plan; - the premium is not paid in accordance with the provisions of this policy that specify

whether the Policyholder, the employee, or both, pay(s) the premiums;- the Policyholder does not promptly report to Unum the names of any employees

who are added or deleted from the eligible group;- Unum determines that there is a significant change, in the size, occupation or age

of the eligible group as a result of a corporate transaction such as a merger, divestiture, acquisition, sale, or reorganization of the Policyholder and/or its employees; or

- the Policyholder fails to pay any portion of the premium within the 31 day grace period.

If Unum cancels or modifies this policy or a plan for reasons other than the Policyholder's failure to pay premium, a written notice will be delivered to the Policyholder at least 31 days prior to the cancellation date or modification date. The Policyholder may cancel this policy or a plan if the modifications are unacceptable.

If any portion of the premium is not paid during the grace period, Unum will either cancel or modify the policy or plan automatically at the end of the grace period. The Policyholder is liable for premium for coverage during the grace period. The Policyholder must pay Unum all premium due for the full period each plan is in force.

The Policyholder may cancel this policy or a plan by written notice delivered to Unum at least 31 days prior to the cancellation date. When both the Policyholder and Unum agree, this policy or a plan can be cancelled on an earlier date. If Unum or the Policyholder cancels this policy or a plan, coverage will end at 12:00 midnight on the last day of coverage.

If this policy or a plan is cancelled, the cancellation will not affect a payable claim.

EMPLOYER-3 (5/1/2017)

WHAT HAPPENS TO AN EMPLOYEE'S COVERAGE UNDER THIS POLICY WHILE HE OR SHE IS ON A FAMILY AND MEDICAL LEAVE OF ABSENCE?

We will continue the employee's coverage in accordance with the policyholder's Human Resource policy on family and medical leaves of absence if premium payments continue and the policyholder approved the employee's leave in writing.

Coverage will be continued until the end of the later of:

1. the leave period required by the federal Family and Medical Leave Act of 1993 and any amendments; or

2. the leave period required by applicable state law.

If the policyholder's Human Resource policy doesn't provide for continuation of an employee's coverage during a family and medical leave of absence, the employee's coverage will be reinstated when he or she returns to active employment.

We will not:

- apply a new waiting period;- apply a new pre-existing conditions exclusion; or- require evidence of insurability.

DIVISIONS, SUBSIDIARIES OR AFFILIATED COMPANIES INCLUDE:

NAME/LOCATION (CITY AND STATE)

None

C.FP-6 CC.FP-6-1 (5/1/2017)

CERTIFICATE SECTION

Unum Life Insurance Company of America (referred to as Unum) welcomes you as a client.

This is your certificate of coverage as long as you are eligible for coverage and you become insured. You will want to read it carefully and keep it in a safe place.

Unum has written your certificate of coverage in plain English. However, a few terms and provisions are written as required by insurance law. If you have any questions about any of the terms and provisions, please consult Unum's claims paying office. Unum will assist you in any way to help you understand your benefits.

If the terms and provisions of the certificate of coverage (issued to you) are different from the policy (issued to the policyholder), the policy will govern. Your coverage may be cancelled or changed in whole or in part under the terms and provisions of the policy.

The policy is delivered in and is governed by the laws of the governing jurisdiction and to the extent applicable by the Employee Retirement Income Security Act of 1974 (ERISA) and any amendments.

For purposes of effective dates and ending dates under the group policy, all days begin at 12:01 a.m. and end at 12:00 midnight at the Policyholder's address.


EMPLOYEE-1 (5/1/2017)

GENERAL PROVISIONS

WHAT IS THE CERTIFICATE OF COVERAGE?

This certificate of coverage is a written statement prepared by Unum and may include attachments. It tells you:

- the coverage for which you may be entitled;- to whom Unum will make a payment; and- the limitations, exclusions and requirements that apply within a plan.

WHEN ARE YOU ELIGIBLE FOR COVERAGE?

If you are working for your Employer in an eligible group, the date you are eligible for coverage is the later of:

- the plan effective date; or- the day after you complete your waiting period.

WHEN DOES YOUR COVERAGE BEGIN?

When your Employer pays 100% of the cost of your coverage under a plan, you will be covered at 12:01 a.m. on the date you are eligible for coverage.

When you and your Employer share the cost of your coverage under a plan or when you pay 100% of the cost yourself, you will be covered at 12:01 a.m. on the latest of:

- the date you are eligible for coverage, if you apply for insurance on or before that date;

- the date you apply for insurance, if you apply within 31 days after your eligibility date; or

- the date Unum approves your application, if evidence of insurability is required.

Evidence of insurability is required if you:

- are a late applicant, which means you apply for coverage more than 31 days after the date you are eligible for coverage; or

- voluntarily cancelled your coverage and are reapplying.

An evidence of insurability form can be obtained from your Employer.

WHAT IF YOU ARE ABSENT FROM WORK ON THE DATE YOUR COVERAGE WOULD NORMALLY BEGIN?

If you are absent from work due to injury, sickness, temporary layoff or leave of absence, your coverage will begin on the date you return to active employment.

ONCE YOUR COVERAGE BEGINS, WHAT HAPPENS IF YOU ARE TEMPORARILY NOT WORKING?

If you are on a temporary layoff, and if premium is paid, you will be covered through the end of the month that immediately follows the month in which your temporary layoff begins.

EMPLOYEE-2 (5/1/2017)

If you are on a leave of absence, and if premium is paid, you will be covered through the end of the month that immediately follows the month in which your leave of absence begins.

WHEN WILL CHANGES TO YOUR COVERAGE TAKE EFFECT?

Once your coverage begins, any increased or additional coverage will take effect immediately if you are in active employment or if you are on a covered layoff or leave of absence. If you are not in active employment due to injury or sickness, any increased or additional coverage will begin on the date you return to active employment.

Any decrease in coverage will take effect immediately but will not affect a payable claim that occurs prior to the decrease.

WHEN DOES YOUR COVERAGE END?

Your coverage under the policy or a plan ends on the earliest of:

- the date the policy or a plan is cancelled;- the date you no longer are in an eligible group;- the date your eligible group is no longer covered;- the last day of the period for which you made any required contributions; or- the last day you are in active employment except as provided under the covered

layoff or leave of absence provision.

Unum will provide coverage for a payable claim which occurs while you are covered under the policy or plan.

WHAT ARE THE TIME LIMITS FOR LEGAL PROCEEDINGS?

You can start legal action regarding your claim 60 days after proof of claim has been given and up to 3 years from the time proof of claim is required, unless otherwise provided under federal law.

HOW CAN STATEMENTS MADE IN YOUR APPLICATION FOR THIS COVERAGE BE USED?

Unum considers any statements you or your Employer make in a signed application for coverage a representation and not a warranty. If any of the material statements you or your Employer make are not complete and/or not true at the time they are made, we can:

- reduce or deny any claim; or- cancel your coverage from the original effective date.

We will use only statements made in a signed application as a basis for doing this. A copy of the statements will be provided to you or your beneficiary. These statements cannot be used to reduce or deny coverage if your coverage has been in force for at least two years.

However, if the Employer gives us information about you that is incorrect, we will:

EMPLOYEE-3 (5/1/2017)

- use the facts to determine if you have coverage under the plan according to the policy provisions and in what amounts; and

- make a fair adjustment of the premium.

HOW WILL UNUM HANDLE INSURANCE FRAUD?

Unum wants to ensure you and your Employer do not incur additional insurance costs as a result of the undermining effects of insurance fraud. Unum promises to focus on all means necessary to support fraud detection, investigation, and prosecution.

It is a crime if you knowingly, and with intent to injure, defraud or deceive Unum, or provide any information, including filing a claim, that contains any false, incomplete or misleading information. These actions, as well as submission of materially false information, will result in denial of your claim, and are subject to prosecution and punishment to the full extent under state and/or federal law. Unum will pursue all appropriate legal remedies in the event of insurance fraud.

DOES THE POLICY REPLACE OR AFFECT ANY WORKERS' COMPENSATION OR STATE DISABILITY INSURANCE?

The policy does not replace or affect the requirements for coverage by any workers' compensation or state disability insurance.

DOES YOUR EMPLOYER ACT AS YOUR AGENT OR UNUM'S AGENT?

For purposes of the policy, your Employer acts on its own behalf or as your agent. Under no circumstances will your Employer be deemed the agent of Unum.

STD-BEN-1 (5/1/2017)


BENEFIT INFORMATION

HOW DOES UNUM DEFINE DISABILITY?

You are disabled when Unum determines that due to your sickness or injury:

- you are unable to perform the material and substantial duties of your regular occupation; and

- you are not working in any occupation.

You must be under the regular care of a physician in order to be considered disabled.

The loss of a professional or occupational license or certification does not, in itself, constitute disability.

We may require you to be examined by a physician, other medical practitioner and/or vocational expert of our choice. Unum will pay for this examination. We can require an examination as often as it is reasonable to do so. We may also require you to be interviewed by an authorized Unum Representative.

HOW LONG MUST YOU BE DISABLED BEFORE YOU ARE ELIGIBLE TO RECEIVE BENEFITS?

You must be continuously disabled through your elimination period.

If your disability is the result of an injury that occurs while you are covered under the plan, your elimination period is 7 days.

If your disability is the result of a sickness, your elimination period is 7 days.

WHEN WILL YOU BEGIN TO RECEIVE PAYMENTS?

You will begin to receive payments when we approve your claim, providing the elimination period has been met and you are disabled. We will send you a payment weekly for any period for which Unum is liable.

After the elimination period, if you are disabled for less than 1 week, we will send you 1/7th of your payment for each day of disability.

HOW MUCH WILL UNUM PAY YOU IF YOU ARE DISABLED?

We will follow this process to figure your payment:

1. Multiply your weekly earnings by 60%.2. The maximum weekly benefit is $1,500.3. Compare the answer from Item 1 with the maximum weekly benefit. The lesser

of these two amounts is your gross disability payment.4. Subtract from your gross disability payment any deductible sources of income.

The amount figured in Item 4 is your weekly payment.

STD-BEN-2 (5/1/2017)

WHAT ARE YOUR WEEKLY EARNINGS?

Paramedics and Fire Fighters"Weekly Earnings" means your average gross weekly income as figured:

a. from the income box on your W-2 form which reflects wages, tips and other compensation received from your Employer for the calendar year just prior to your date of disability; or

b. for the period of your employment with your Employer if you did not receive a W-2 form prior to your date of disability.

Average gross weekly income is your total income before taxes. It is prior to any deductions made for pre-tax contributions to a qualified deferred compensation plan, Section 125 plan, or flexible spending account. It does not include income received from car, housing or moving allowances, Employer contributions to a qualified deferred compensation plan, or income received from sources other than your Employer.

All Employees not eligible in another group"Weekly Earnings" means your gross weekly income from your Employer in effect just prior to your date of disability. It includes your total income before taxes. It is prior to any deductions made for pre-tax contributions to a qualified deferred compensation plan, Section 125 plan, or flexible spending account. It does not include income received from commissions, bonuses, overtime pay, any other extra compensation, or income received from sources other than your Employer.

Changes in earnings to be reported annually each October 1st by the Employer.

WHAT WILL WE USE FOR WEEKLY EARNINGS IF YOU BECOME DISABLED DURING A COVERED LAYOFF OR LEAVE OF ABSENCE?

If you become disabled while you are on a covered layoff or leave of absence, we will use your weekly earnings from your Employer in effect just prior to the date your absence begins.

WHAT ARE DEDUCTIBLE SOURCES OF INCOME?

Unum will subtract from your gross disability payment the following deductible sources of income:

1. The amount that you receive or are entitled to receive as disability income payments under any:

- state compulsory benefit act or law.- automobile liability insurance policy.- other group insurance plan.

2. The amount that you receive:

- under Title 46, United States Code Section 688 (The Jones Act).- from a third party (after subtracting attorney's fees) by judgment, settlement or otherwise.

STD-BEN-3 (5/1/2017)

3. The amount that you:

- receive as disability payments under your Employer's retirement plan.- voluntarily elect to receive as retirement payments under your Employer's retirement plan.- receive as retirement payments when you reach the later of age 62 or normal retirement age, as defined in your Employer's retirement plan.

Disability payments under a retirement plan will be those benefits which are paid due to disability and do not reduce the retirement benefit which would have been paid if the disability had not occurred.

Retirement payments will be those benefits which are based on your Employer's contribution to the retirement plan. Disability benefits which reduce the retirement benefit under the plan will also be considered as a retirement benefit.

Regardless of how the retirement funds from the retirement plan are distributed, Unum will consider your and your Employer's contributions to be distributed simultaneously throughout your lifetime.

Amounts received do not include amounts rolled over or transferred to any eligible retirement plan. Unum will use the definition of eligible retirement plan as defined in Section 402 of the Internal Revenue Code including any future amendments which affect the definition.

Unum will only subtract deductible sources of income which are payable as a result of the same disability.

WHAT ARE NOT DEDUCTIBLE SOURCES OF INCOME?

Unum will not subtract from your gross disability payment income you receive from, but not limited to, the following:

- 401(k) plans- profit sharing plans- thrift plans- tax sheltered annuities- stock ownership plans- non-qualified plans of deferred compensation- pension plans for partners- military pension and disability income plans- credit disability insurance- franchise disability income plans- a retirement plan from another Employer- individual retirement accounts (IRA)- individual disability income plans- salary continuation or accumulated sick leave plans

WHAT IF SUBTRACTING DEDUCTIBLE SOURCES OF INCOME RESULTS IN A ZERO BENEFIT? (Minimum Benefit)

The minimum weekly payment is: $25.

Unum may apply this amount toward an outstanding overpayment.

STD-BEN-4 (5/1/2017)

WHAT IF UNUM DETERMINES YOU MAY QUALIFY FOR DEDUCTIBLE INCOME BENEFITS?

When we determine that you may qualify for benefits under Item(s) 1 in the deductible sources of income section, we will estimate your entitlement to these benefits. We can reduce your payment by the estimated amounts if such benefits:

- have not been awarded; and- have not been denied; or- have been denied and the denial is being appealed.

Your Short Term Disability payment will NOT be reduced by the estimated amount if you:

- apply for the disability payments under Item(s) 1 in the deductible sources of income section and appeal your denial to all administrative levels Unum feels are necessary; and

- sign Unum's payment option form. This form states that you promise to pay us any overpayment caused by an award.

If your payment has been reduced by an estimated amount, your payment will be adjusted when we receive proof:

- of the amount awarded; or- that benefits have been denied and all appeals Unum feels are necessary have

been completed. In this case, a lump sum refund of the estimated amount will be made to you.

If you receive a lump sum payment from any deductible sources of income, the lump sum will be pro-rated on a weekly basis over the time period for which the sum was given. If no time period is stated, the sum will be pro-rated on a weekly basis to the end of the maximum period of payment.

HOW LONG WILL UNUM CONTINUE TO SEND YOU PAYMENTS?

Unum will send you a payment each week up to the maximum period of payment. Your maximum period of payment is 25 weeks during a continuous period of disability.

WHEN WILL PAYMENTS STOP?

We will stop sending you payments and your claim will end on the earliest of the following:

- the end of the maximum period of payment;- the date you are no longer disabled under the terms of the plan, unless you are

eligible to receive benefits under Unum's Rehabilitation and Return to Work Assistance program;

- the date you fail to submit proof of continuing disability;- after 12 months of payments if you are considered to reside outside the United

States or Canada. You will be considered to reside outside these countries when you have been outside the United States or Canada for a total period of 6 months or more during any 12 consecutive months of benefits;

STD-BEN-5 (5/1/2017)

- the date you die.

WHAT DISABILITIES ARE NOT COVERED UNDER YOUR PLAN?

Your plan does not cover any disabilities caused by, contributed to by, or resulting from your:

- occupational sickness or injury, however, Unum will cover disabilities due to occupational sicknesses or injuries for partners or sole proprietors who cannot be covered by a workers' compensation law.

- intentionally self-inflicted injuries.- active participation in a riot.- loss of a professional license, occupational license or certification.- commission of a crime for which you have been convicted.- pre-existing condition.

Your plan will not cover a disability due to war, declared or undeclared, or any act of war.

Unum will not pay a benefit for any period of disability during which you are incarcerated.

WHAT IS A PRE-EXISTING CONDITION?

You have a pre-existing condition if:

- you received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines in the 3 months just prior to your effective date of coverage; and

- the disability begins in the first 12 months after your effective date of coverage.

WHAT HAPPENS IF YOU RETURN TO WORK FULL TIME AND YOUR DISABILITY OCCURS AGAIN?

1. If your current disability is related to or due to the same cause(s) as your prior disability for which Unum made a payment:

Unum will treat your current disability as part of your prior claim and you will not have to complete another elimination period when you are performing any occupation for your Employer on a full time basis for 14 consecutive days or less.

If you return to work on the 15th day, your current disability will be treated as a new claim. The new claim will be subject to all of the provisions of this plan and you will be required to satisfy a new elimination period.

2. If your current disability is unrelated to your prior disability for which Unum made a payment:

Unum will treat your current disability as part of your prior claim and you will not have to complete another elimination period when you are performing any occupation for your Employer on a full time basis for less than 1 full day.

Your disability, as outlined above, will be subject to the same terms of the plan as your prior claim.

STD-BEN-6 (5/1/2017)

If you do not satisfy Item 1 or 2 above, your disability will be treated as a new claim and will be subject to all of the policy provisions.

If you are covered under another group short term disability plan on the date of your recurrent disability and are entitled to payments under that plan, you will not be eligible for further payments from Unum.

STD-OTR-1 (5/1/2017)


OTHER BENEFIT FEATURES

HOW CAN UNUM'S REHABILITATION AND RETURN TO WORK ASSISTANCE PROGRAM HELP YOU RETURN TO WORK?

Unum has a vocational Rehabilitation and Return to Work Assistance program available to assist you in returning to work. We will determine whether you are eligible for this program. In order to be eligible for rehabilitation services and benefits, you must be medically able to engage in a return to work program.

Your claim file will be reviewed by one of Unum's rehabilitation professionals to determine if a rehabilitation program might help you return to gainful employment. As your file is reviewed, medical and vocational information will be analyzed to determine an appropriate return to work program.

We will make the final determination of your eligibility for participation in the program.

We will provide you with a written Rehabilitation and Return to Work Assistance plan developed specifically for you.

The rehabilitation program may include, but is not limited to, the following services and benefits:

- coordination with your Employer to assist you to return to work;- adaptive equipment or job accommodations to allow you to work;- vocational evaluation to determine how your disability may impact your

employment options;- job placement services;- resume preparation;- job seeking skills training; or- education and retraining expenses for a new occupation.

WHAT ADDITIONAL BENEFITS WILL UNUM PAY WHILE YOU PARTICIPATE IN A REHABILITATION AND RETURN TO WORK ASSISTANCE PROGRAM?

We will pay an additional disability benefit of 10% of your gross disability payment to a maximum benefit of $250 per week.

This benefit is not subject to policy provisions which would otherwise increase or reduce the benefit amount such as Deductible Sources of Income.

In addition, we will make weekly payments to you for 3 weeks following the date your disability ends if we determine you are no longer disabled while:

- you are participating in the Rehabilitation and Return to Work Assistance program; and

- you are not able to find employment.

This benefit payment may be paid in a lump sum.

STD-OTR-2 (5/1/2017)

WHEN WILL REHABILITATION AND RETURN TO WORK ASSISTANCE BENEFITS END?

Benefits for the Rehabilitation and Return to Work Assistance program will end on the earliest of the following dates:

- the date Unum determines that you are no longer eligible to participate in Unum's Rehabilitation and Return to Work Assistance program; or

- any other date on which weekly payments would stop in accordance with this plan.

GLOSSARY-1 (5/1/2017)

GLOSSARY

ACTIVE EMPLOYMENT means you are working for your Employer for earnings that are paid regularly and that you are performing the material and substantial duties of your regular occupation. You must be working at least the minimum number of hours as described under Eligible Group(s) in each plan.

Your work site must be:

- your Employer's usual place of business;- an alternative work site at the direction of your Employer, including your home; or- a location to which your job requires you to travel.

Normal vacation is considered active employment.Temporary and seasonal workers are excluded from coverage.

DEDUCTIBLE SOURCES OF INCOME means income from deductible sources listed in the plan which you receive or are entitled to receive while you are disabled. This income will be subtracted from your gross disability payment.

ELIMINATION PERIOD means a period of continuous disability which must be satisfied before you are eligible to receive benefits from Unum.

EMPLOYEE means a person who is in active employment in the United States with the Employer.

EMPLOYER means the Policyholder, and includes any division, subsidiary or affiliated company named in the policy.

EVIDENCE OF INSURABILITY means a statement of your medical history which Unum will use to determine if you are approved for coverage. Evidence of insurability will be at Unum's expense.

GRACE PERIOD means the period of time following the premium due date during which premium payment may be made.

GROSS DISABILITY PAYMENT means the benefit amount before Unum subtracts deductible sources of income.

HOSPITAL OR INSTITUTION means an accredited facility licensed to provide care and treatment for the condition causing your disability.

INJURY means a bodily injury that is the direct result of an accident and not related to any other cause. Injury which occurs before you are covered under the plan will be treated as a sickness. Disability must begin while you are covered under the plan.

INSURED means any person covered under a plan.

LAW, PLAN OR ACT means the original enactments of the law, plan or act and all amendments.

LAYOFF or LEAVE OF ABSENCE means you are temporarily absent from active employment for a period of time that has been agreed to in advance in writing by your Employer.

GLOSSARY-2 (5/1/2017)

Your normal vacation time or any period of disability is not considered a temporary layoff or leave of absence.

MATERIAL AND SUBSTANTIAL DUTIES means duties that:

- are normally required for the performance of your regular occupation; and- cannot be reasonably omitted or modified, except that if you are required to work on

average in excess of 40 hours per week, Unum will consider you able to perform that requirement if you are working or have the capacity to work 40 hours per week.

MAXIMUM PERIOD OF PAYMENT means the longest period of time Unum will make payments to you for any one period of disability.

OCCUPATIONAL SICKNESS OR INJURY means a sickness or injury that was caused by or aggravated by any employment for pay or profit.

PAYABLE CLAIM means a claim for which Unum is liable under the terms of the policy.

PHYSICIAN means:

- a person performing tasks that are within the limits of his or her medical license; and- a person who is licensed to practice medicine and prescribe and administer drugs or

to perform surgery; or- a person with a doctoral degree in Psychology (Ph.D. or Psy.D.) whose primary

practice is treating patients; or- a person who is a legally qualified medical practitioner according to the laws and

regulations of the governing jurisdiction.

Unum will not recognize you, or your spouse, children, parents or siblings as a physician for a claim that you send to us.

PLAN means a line of coverage under the policy.

POLICYHOLDER means the Employer to whom the policy is issued.

PRE-EXISTING CONDITION means a condition for which you received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines for your condition during the given period of time as stated in the plan.

REGULAR CARE means:

- you personally visit a physician as frequently as is medically required, according to generally accepted medical standards, to effectively manage and treat your disabling condition(s); and

- you are receiving the most appropriate treatment and care which conforms with generally accepted medical standards, for your disabling condition(s) by a physician whose specialty or experience is the most appropriate for your disabling condition(s), according to generally accepted medical standards.

REGULAR OCCUPATION means the occupation you are routinely performing when your disability begins. Unum will look at your occupation as it is normally performed in

GLOSSARY-3 (5/1/2017)

the national economy, instead of how the work tasks are performed for a specific employer or at a specific location.

RETIREMENT PLAN means a defined contribution plan or defined benefit plan. These are plans which provide retirement benefits to employees and are not funded entirely by employee contributions. Retirement Plan includes but is not limited to any plan which is part of any federal, state, county, municipal or association retirement system.

SALARY CONTINUATION OR ACCUMULATED SICK LEAVE means continued payments to you by your Employer of all or part of your weekly earnings, after you become disabled as defined by the Policy. This continued payment must be part of an established plan maintained by your Employer for the benefit of all employees covered under the Policy.

SICKNESS means an illness or disease. Disability must begin while you are covered under the plan.

WAITING PERIOD means the continuous period of time (shown in each plan) that you must be in active employment in an eligible group before you are eligible for coverage under a plan.

WE, US and OUR means Unum Life Insurance Company of America.

WEEKLY BENEFIT means the total benefit amount for which an employee is insured under this plan subject to the maximum benefit.

WEEKLY EARNINGS means your gross weekly income from your Employer as defined in the plan.

WEEKLY PAYMENT means your payment after any deductible sources of income have been subtracted from your gross disability payment.

YOU means an employee who is eligible for Unum coverage.

ADDLINFO-1 (5/1/2017)

Additional Claim and Appeal InformationRelative to policy issued by Unum Life Insurance Company of America ("Unum")

APPLICABILITY OF ERISA

If the policy provides benefits under a Plan which is subject to the Employee Retirement Income Security Act of 1974 (ERISA), the following provisions apply. Whether a Plan is governed by ERISA is determined by a court, however, your Employer may have information related to ERISA applicability. If ERISA applies, the following items constitute the Plan: the additional information contained in this document, the policy, including your certificate of coverage, and any additional summary plan description information provided by the Plan Administrator. Benefit determinations are controlled exclusively by the policy, your certificate of coverage, and the information in this document.

HOW TO FILE A CLAIM

If you wish to file a claim for benefits, you should follow the claim procedures described in your insurance certificate. To complete your claim filing, Unum must receive the claim information it requests from you (or your authorized representative), your attending physician and your Employer. If you or your authorized representative has any questions about what to do, you or your authorized representative should contact Unum directly.

CLAIMS PROCEDURES

Unum will give you notice of the decision no later than 45 days after the claim is filed. This time period may be extended twice by 30 days if Unum both determines that such an extension is necessary due to matters beyond the control of the Plan and notifies you of the circumstances requiring the extension of time and the date by which Unum expects to render a decision. If such an extension is necessary due to your failure to submit the information necessary to decide the claim, the notice of extension will specifically describe the required information, and you will be afforded at least 45 days within which to provide the specified information. If you deliver the requested information within the time specified, any 30 day extension period will begin after you have provided that information. If you fail to deliver the requested information within the time specified, Unum may decide your claim without that information.

If your claim for benefits is wholly or partially denied, the notice of adverse benefit determination under the Plan will:

- state the specific reason(s) for the determination;

- reference specific Plan provision(s) on which the determination is based;

- describe additional material or information necessary to complete the claim and why such information is necessary;

- describe Plan procedures and time limits for appealing the determination, and your right to obtain information about those procedures and the right to bring a lawsuit under Section 502(a) of ERISA following an adverse determination from Unum on appeal; and

ADDLINFO-2 (5/1/2017)

- disclose any internal rule, guidelines, protocol or similar criterion relied on in making the adverse determination (or state that such information will be provided free of charge upon request).

Notice of the determination may be provided in written or electronic form. Electronic notices will be provided in a form that complies with any applicable legal requirements.

APPEAL PROCEDURES

You have 180 days from the receipt of notice of an adverse benefit determination to file an appeal. Requests for appeals should be sent to the address specified in the claim denial. A decision on review will be made not later than 45 days following receipt of the written request for review. If Unum determines that special circumstances require an extension of time for a decision on review, the review period may be extended by an additional 45 days (90 days in total). Unum will notify you in writing if an additional 45 day extension is needed.

If an extension is necessary due to your failure to submit the information necessary to decide the appeal, the notice of extension will specifically describe the required information, and you will be afforded at least 45 days to provide the specified information. If you deliver the requested information within the time specified, the 45 day extension of the appeal period will begin after you have provided that information. If you fail to deliver the requested information within the time specified, Unum may decide your appeal without that information.

You will have the opportunity to submit written comments, documents, or other information in support of your appeal. You will have access to all relevant documents as defined by applicable U.S. Department of Labor regulations. The review of the adverse benefit determination will take into account all new information, whether or not presented or available at the initial determination. No deference will be afforded to the initial determination.

The review will be conducted by Unum and will be made by a person different from the person who made the initial determination and such person will not be the original decision maker's subordinate. In the case of a claim denied on the grounds of a medical judgment, Unum will consult with a health professional with appropriate training and experience. The health care professional who is consulted on appeal will not be the individual who was consulted during the initial determination or a subordinate. If the advice of a medical or vocational expert was obtained by the Plan in connection with the denial of your claim, Unum will provide you with the names of each such expert, regardless of whether the advice was relied upon.

A notice that your request on appeal is denied will contain the following information:

- the specific reason(s) for the determination;

- a reference to the specific Plan provision(s) on which the determination is based;

- a statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making the adverse determination (or a statement that such information will be provided free of charge upon request);

ADDLINFO-3 (5/1/2017)

- a statement describing your right to bring a lawsuit under Section 502(a) of ERISA if you disagree with the decision;

- the statement that you are entitled to receive upon request, and without charge, reasonable access to or copies of all documents, records or other information relevant to the determination; and

- the statement that "You or your Plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your State insurance regulatory agency".


Unless there are special circumstances, this administrative appeal process must be completed before you begin any legal action regarding your claim.

OTHER RIGHTS

Unum, for itself and as claims fiduciary for the Plan, is entitled to legal and equitable relief to enforce its right to recover any benefit overpayments caused by your receipt of disability earnings or deductible sources of income from a third party. This right of recovery is enforceable even if the amount you receive from the third party is less than the actual loss suffered by you but will not exceed the benefits paid you under the policy. Unum and the Plan have an equitable lien over such sources of income until any benefit overpayments have been recovered in full.

DISCRETIONARY ACTS

The Plan, acting through the Plan Administrator, delegates to Unum and its affiliate Unum Group discretionary authority to make benefit determinations under the Plan. Unum and Unum Group may act directly or through their employees and agents or further delegate their authority through contracts, letters or other documentation or procedures to other affiliates, persons or entities. Benefit determinations include determining eligibility for benefits and the amount of any benefits, resolving factual disputes, and interpreting and enforcing the provisions of the Plan. All benefit determinations must be reasonable and based on the terms of the Plan and the facts and circumstances of each claim.

Once you are deemed to have exhausted your appeal rights under the Plan, you have the right to seek court review under Section 502(a) of ERISA of any benefit determinations with which you disagree. The court will determine the standard of review it will apply in evaluating those decisions.

GLB-1 (5/1/2017)

Our Commitment to Privacy

We understand your privacy is important. We value our relationship with you and are committed to protecting the confidentiality of nonpublic personal information (NPI). This notice explains why we collect NPI, what we do with NPI and how we protect your privacy.

COLLECTING INFORMATIONWe collect NPI about our customers to provide them with insurance products and services. This may include telephone number, address, date of birth, occupation, income and health history. We may receive NPI from your applications and forms, medical providers, other insurers, employers, insurance support organizations and service providers.

SHARING INFORMATIONWe share the types of NPI described above primarily with people who perform insurance, business and professional services for us, such as helping us pay claims and detect fraud. We may share NPI with medical providers for insurance and treatment purposes. We may share NPI with an insurance support organization. The organization may retain the NPI and disclose it to others for whom it performs services. In certain cases, we may share NPI with group policyholders for reporting and auditing purposes. We may share NPI with parties to a proposed or final sale of insurance business or for study purposes. We may also share NPI when otherwise required or permitted by law, such as sharing with governmental or other legal authorities. When legally necessary, we ask your permission before sharing NPI about you. Our practices apply to our former, current and future customers.

Please be assured we do not share your health NPI to market any product or service. We also do not share any NPI to market non-financial products and services. For example, we do not sell your name to catalog companies.

The law allows us to share NPI as described above (except health information) with affiliates to market financial products and services. The law does not allow you to restrict these disclosures. We may also share with companies that help us market our insurance products and services, such as vendors that provide mailing services to us. We may share with other financial institutions to jointly market financial products and services. When required by law, we ask your permission before we share NPI for marketing purposes.

When other companies help us conduct business, we expect them to follow applicable privacy laws. We do not authorize them to use or share NPI except when necessary to conduct the work they are performing for us or to meet regulatory or other governmental requirements.

Unum companies, including insurers and insurance service providers, may share NPI about you with each other. The NPI might not be directly related to our transaction or experience with you. It may include financial or other personal information such as employment history. Consistent with the Fair Credit Reporting Act, we ask your permission before sharing NPI that is not directly related to our transaction or experience with you.

COVERAGE DECISIONSIf we decide not to issue coverage to you, we will provide you with the specific reason(s) for our decision. We will also tell you how to access and correct certain NPI.

GLB-2 (5/1/2017)

ACCESS TO INFORMATIONYou may request access to certain NPI we collect to provide you with insurance products and services. You must make your request in writing and send it to the address below. The letter should include your full name, address, telephone number and policy number if we have issued a policy. If you request, we will send copies of the NPI to you. If the NPI includes health information, we may provide the health information to you through a health care provider you designate. We will also send you information related to disclosures. We may charge a reasonable fee to cover our copying costs.

This section applies to NPI we collect to provide you with coverage. It does not apply to NPI we collect in anticipation of a claim or civil or criminal proceeding.

CORRECTION OF INFORMATIONIf you believe the NPI we have about you is incorrect, please write to us. Your letter should include your full name, address, telephone number and policy number if we have issued a policy. Your letter should also explain why you believe the NPI is inaccurate. If we agree with you, we will correct the NPI and notify you of the correction. We will also notify any person who may have received the incorrect NPI from us in the past two years if you ask us to contact that person.

If we disagree with you, we will tell you we are not going to make the correction. We will give you the reason(s) for our refusal. We will also tell you that you may submit a statement to us. Your statement should include the NPI you believe is correct. It should also include the reason(s) why you disagree with our decision not to correct the NPI in our files. We will file your statement with the disputed NPI. We will include your statement any time we disclose the disputed NPI. We will also give the statement to any person designated by you if we may have disclosed the disputed NPI to that person in the past two years.

SAFEGUARDING INFORMATIONWe have physical, electronic and procedural safeguards that protect the confidentiality and security of NPI. We give access only to employees who need to know the NPI to provide insurance products or services to you.

CONTACTING USFor additional information about Unum's commitment to privacy and to view a copy of our HIPAA Privacy Notice, please visit unum.com/privacy or coloniallife.com. You may also write to: Privacy Officer, Unum, 2211 Congress Street, C476, Portland, Maine 04122.

We reserve the right to modify this notice. We will provide you with a new notice if we make material changes to our privacy practices.

Unum is providing this notice to you on behalf of the following insuring companies: Unum Life Insurance Company of America, Unum Insurance Company, First Unum Life Insurance Company, Provident Life and Accident Insurance Company, Provident Life and Casualty Insurance Company, Colonial Life & Accident Insurance Company and The Paul Revere Life Insurance Company.

Copyright 2015 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.

MK-1883 (09/15)

GUAR-1 (5/1/2017)

IMPORTANT INFORMATION ABOUT COVERAGE UNDERTHE TEXAS LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION

(For Insurers declared insolvent or impaired on or after September 1, 2011)

Texas law establishes a system to protect Texas policyholders if their life or health insurance company fails. The Texas Life and Health Insurance Guaranty Association ("the Association") administers this protection system. Only the policyholders of insurance companies that are members of the Association are eligible for this protection which is subject to the terms, limitations, and conditions of the Association law. (The law is found in the Texas Insurance Code, Chapter 463.)

It is possible that the Association may not protect all or part of your policy because of statutory limitations.

Eligibility for Protection by the Association

When a member insurance company is found to be insolvent and placed under an order of liquidation by a court or designated as impaired by the Texas Commissioner of Insurance, the Association provides coverage to policyholders who are:- Residents of Texas (regardless of where the policyholder lived when the policy

was issued)- Residents of other states, ONLY if the following conditions are met:

- The policyholder has a policy with a company domiciled in Texas;- The policyholder's state of residence has a similar guaranty association; and- The policyholder is not eligible for coverage by the guaranty association of the policyholder's state of residence.

Limits of Protection by the Association

Accident, Accident and Health, or Health Insurance:- For each individual covered under one or more policies: up to a total of $500,000 for

basic hospital, medical-surgical, and major medical insurance, $300,000 for disability or long term care insurance, or $200,000 for other types of health insurance.

Life Insurance:- Net cash surrender value or net cash withdrawal value up to a total of $100,000 under

one or more policies on a single life; or- Death benefits up to a total of $300,000 under one or more policies on a single life; or- Total benefits up to a total of $5,000,000 to any owner of multiple non-group life

policies.Individual Annuities:- Present value of benefits up to a total of $250,000 under one or more contracts on

any one life.Group Annuities:- Present value of allocated benefits up to a total of $250,000 on any one life; or - Present value of unallocated benefits up to a total of $5,000,000 for one

contractholder regardless of the number of contracts.Aggregate Limit:- $300,000 on any one life with the exception of the $500,000 health insurance limit, the

$5,000,000 multiple owner life insurance limit, and the $5,000,000 unallocated group annuity limit.

These limits are applied for each insolvent insurance company.

GUAR-2 (5/1/2017)

Insurance companies and agents are prohibited by law from using the existence of the Association for the purpose of sales, solicitation, or inducement to purchase any form of insurance. When you are selecting an insurance company, you should not rely on Association coverage. For additional questions on Association protection or general information about an insurance company, please use the following contact information.

Texas Life and Health Texas Department of InsuranceInsurance Guaranty Association P.O. Box 149104515 Congress Avenue, Suite 1875 Austin, TX 78714-9104Austin, TX 78701 800-252-3439 or 800-982-6362 or www.txlifega.org www.tdi.texas.gov

http://www.txlifega.org/


C.AMEND-6 AMEND-1 (5/1/2017)

AMENDMENT NO. 4

This amendment forms a part of Group Policy No. 405524 001 issued to the Policyholder:

City of Schertz

The entire policy is replaced by the policy attached to this amendment.

The effective date of these changes is May 1, 2017. The changes only apply to disabilities which start on or after the effective date.

The policy's terms and provisions will apply other than as stated in this amendment.

Dated at Portland, Maine on May 19, 2017.

Unum Life Insurance Company of America

By

Secretary

If this amendment is unacceptable, please sign below and return this amendment to Unum Life Insurance Company of America at Portland, Maine within 90 days of May 19, 2017.

YOUR FAILURE TO SIGN AND RETURN THIS AMENDMENT BY THAT DATE WILL CONSTITUTE ACCEPTANCE OF THIS AMENDMENT.

City of Schertz

By ____________________________Signature and Title of Officer

C.FP-6 C.FP-6-1 (5/1/2017)

____________________________________________________________________

GROUP INSURANCE POLICYNON-PARTICIPATING

_____________________________________________________________________

POLICYHOLDER: City of Schertz


POLICY EFFECTIVE DATE: January 1, 2015

POLICY ANNIVERSARY DATE: January 1

GOVERNING JURISDICTION: Texas

Unum Life Insurance Company of America (referred to as Unum) will provide benefits under this policy. Unum makes this promise subject to all of this policy's provisions.

The policyholder should read this policy carefully and contact Unum promptly with any questions. This policy is delivered in and is governed by the laws of the governing jurisdiction and to the extent applicable by the Employee Retirement Income Security Act of 1974 (ERISA) and any amendments. This policy consists of:

- all policy provisions and any amendments and/or attachments issued;- employees' signed applications; and- the certificate of coverage.

This policy may be changed in whole or in part. Only an officer or a registrar of Unum can approve a change. The approval must be in writing and endorsed on or attached to this policy. No other person, including an agent, may change this policy or waive any part of it.

Signed for Unum at Portland, Maine on the Policy Effective Date.

President Secretary


C.FP-6-2 (5/1/2017)

IMPORTANT NOTICE

This is not a policy of Workers' Compensation Insurance. The Employer does not become a subscriber to the Workers' Compensation system by purchasing this policy, and if the Employer is a nonsubscriber, the Employer loses those benefits which would otherwise accrue under the Workers' Compensation laws. The Employer must comply with the Workers' Compensation law as it pertains to nonsubscribers and the required notification that must be filed and posted.

C.FP-6-3 (5/1/2017)

IMPORTANT NOTICE

To obtain information or make a complaint:

You may call Unum's toll-free telephone number for information or to make a complaint at:

1-800-321-3889

You may also write to Unum at:

Deborah J. Jewett, ManagerCustomer RelationsUnum Life Insurance Company of America2211 Congress StreetPortland, Maine 04122

You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at:

1-800-252-3439

You may also write the Texas Department of InsuranceP.O. Box 149104Austin, TX 78714-9104FAX: (512) 490-1007



PREMIUM OR CLAIM DISPUTES:

Should you have a dispute concerning your premium or about a claim, you should contact the company first. If the dispute is not resolved, you may contact the Texas Department of Insurance (TDI).

AVISO IMPORTANTE

Para obtener información o para presentar una queja:

Usted puede llamar al número de telefono gratuito de Unum's para obtener información o para presentar una queja al:

1-800-321-3889

Usted también puede escribir a Unum:

Deborah J. JewettGerente de Relaciones alClienteUnum Life Insurance Company of America2211 Congress StreetPortland, Maine 04122

Usted puede comunicarse con el Departamento de Seguros de Texas para obtener información sobre de compañias, coberturas, derechos o quejas al:

1-800-252-3439

Usted puede escribir al Departamento de Seguros de TexasP.O. Box 149104Austin, TX 78714-9104FAX: (512) 490-1007



DISPUTAS POR PRIMAS DE SUGUROS O RECLAMACIONES:

Si tiene una disputa relacionado con su prima de seguro con una reclamación, usted debe comunicarse con la compañia primero. Si la disputa no es resuelta, puede comunicarse con el Departamento de Suguros de Texas(TDI).

ATTACH THIS NOTICE TO YOUR POLICY:


ADJUNTE ESTE AVISO A SU POLIZA:

Este aviso es solamente para propósitos informativos y no se convierte en parte o en condición del documento adjunto.



TOC-1 (5/1/2017)

TABLE OF CONTENTS

BENEFITS AT A GLANCE .............................................................................................B@G-LTD-1

LONG TERM DISABILITY PLAN ...................................................................................B@G-LTD-1

CLAIM INFORMATION ..................................................................................................LTD-CLM-1

LONG TERM DISABILITY..............................................................................................LTD-CLM-1

POLICYHOLDER PROVISIONS....................................................................................EMPLOYER-1

CERTIFICATE SECTION ...............................................................................................CC.FP-6-1

GENERAL PROVISIONS...............................................................................................EMPLOYEE-1

LONG TERM DISABILITY..............................................................................................LTD-BEN-1

BENEFIT INFORMATION ..............................................................................................LTD-BEN-1

OTHER BENEFIT FEATURES.......................................................................................LTD-OTR-1

OTHER SERVICES........................................................................................................SERVICES-1

GLOSSARY....................................................................................................................GLOSSARY-1

B@G-LTD-1 (5/1/2017)

BENEFITS AT A GLANCELONG TERM DISABILITY PLAN

This long term disability plan provides financial protection for you by paying a portion of your income while you are disabled. The amount you receive is based on the amount you earned before your disability began. In some cases, you can receive disability payments even if you work while you are disabled.

EMPLOYER'S ORIGINAL PLANEFFECTIVE DATE: January 1, 2015


ELIGIBLE GROUP(S):

All Full-Time Employees in active employment in the United States with the Employer

MINIMUM HOURS REQUIREMENT:

Employees must be working at least 30 hours per week.

WAITING PERIOD:

For employees in an eligible group on or before January 1, 2015: None

For employees entering an eligible group after January 1, 2015: First of the month coincident with or next following 30 days of continuous active employment

REHIRE:

If your employment ends and you are rehired within 12 months, your previous work while in an eligible group will apply toward the waiting period. All other policy provisions apply.

WHO PAYS FOR THE COVERAGE:

Your Employer pays the cost of your coverage.

ELIMINATION PERIOD:

180 days

Accumulation Period: 360 days

Benefits begin the day after the elimination period is completed.

MONTHLY BENEFIT:

60% of monthly earnings to a maximum benefit of $5,000 per month.

Your payment may be reduced by deductible sources of income and disability earnings. Some disabilities may not be covered or may have limited coverage under this plan.

MAXIMUM PERIOD OF PAYMENT:

Age at Disability Maximum Period of PaymentLess than age 60 To age 65, but not less than 5 yearsAge 60 60 monthsAge 61 48 monthsAge 62 42 monthsAge 63 36 monthsAge 64 30 monthsAge 65 24 monthsAge 66 21 monthsAge 67 18 months

B@G-LTD-2 (5/1/2017)

Age 68 15 monthsAge 69 and over 12 months

No premium payments are required for your coverage while you are receiving payments under this plan.

REHABILITATION AND RETURN TO WORK ASSISTANCE BENEFIT:

10% of your gross disability payment to a maximum benefit of $1,000 per month.

In addition, we will make monthly payments to you for 3 months following the date your disability ends if we determine you are no longer disabled while:

- you are participating in the Rehabilitation and Return to Work Assistance program; and- you are not able to find employment.

DEPENDENT CARE EXPENSE BENEFIT:

While you are participating in Unum's Rehabilitation and Return to Work Assistance program, you may receive payments to cover certain dependent care expenses limited to the following amounts:

Dependent Care Expense Benefit Amount: $350 per month, per dependent

Dependent Care Expense Maximum Benefit Amount: $1,000 per month for all eligible dependent care expenses combined

TOTAL BENEFIT CAP:

The total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 100% of your monthly earnings. However, if you are participating in Unum's Rehabilitation and Return to Work Assistance program, the total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 110% of your monthly earnings.

OTHER FEATURES:

Continuity of Coverage

Minimum Benefit

Pre-Existing: 3/12

Survivor Benefit

Work Life Assistance Program

The above items are only highlights of this plan. For a full description of your coverage, continue reading your certificate of coverage section.

LTD-CLM-1 (5/1/2017)

CLAIM INFORMATION

LONG TERM DISABILITY

WHEN DO YOU NOTIFY UNUM OF A CLAIM?

We encourage you to notify us of your claim as soon as possible so that a claim decision can be made in a timely manner. Notice of claim should be sent within 30 days after the date your disability begins. In addition, you must send Unum proof of your claim no later than one year after the date your disability begins unless your failure to do so is due to your lack of legal capacity. In no event can proof of your claim be submitted after the expiration of the time limit for commencing a legal proceeding as stated in the policy, even if your failure to provide proof of claim is due to a lack of legal capacity or if state law provides an exception to the one year time period.

You must notify us immediately when you return to work in any capacity.

HOW DO YOU FILE PROOF OF CLAIM?

You and your Employer must fill out your own sections of the claim form and then give it to your attending physician. Your physician should fill out his or her section of the form and send it directly to Unum.

The form to use to submit your proof of claim is available from your Employer, or you can request the form from us. If you do not receive the form from Unum or your Employer within 15 days of your request, send Unum proof of claim without waiting for the form.

WHAT INFORMATION IS NEEDED AS PROOF OF YOUR CLAIM?

Proof of your claim, provided at your expense, must show:

- the date your disability began;- the existence and cause of your sickness or injury;- that your sickness or injury causes you to have limitations on your functioning and

restrictions on your activities preventing you from performing the material and substantial duties of your regular occupation or of any other gainful occupation for which you are reasonably fitted by education, training, or experience;

- that you are under the regular care of a physician;- the name and address of any hospital or institution where you received

treatment, including all attending physicians; and- the appropriate documentation of your monthly earnings, any disability earnings,

and any deductible sources of income.

In some cases, you will be required to give Unum authorization to obtain additional medical information and to provide non-medical information as part of your proof of claim, or proof of continuing disability. We may also require that you send us appropriate financial records, which may include income tax returns, which we believe are necessary to substantiate your income. We may request that you send periodic proof of your claim. This proof, provided at your expense, must be received within 45 days of a request by us. Unum will deny your claim, or stop sending you payments, if the appropriate information is not submitted.

LTD-CLM-2 (5/1/2017)

We may require you to be examined by a physician, other medical practitioner and/or vocational expert of our choice. Unum will pay for this examination. We can require an examination as often as it is reasonable to do so. We may also require you to meet with and be interviewed by an authorized Unum Representative. Unum will deny your claim, or stop sending you payments, if you fail to comply with our requests.

The initial payment for a payable claim will be made within 60 days from the date proof is received.

TO WHOM WILL UNUM MAKE PAYMENTS?

Unum will make payments to you.

WHAT HAPPENS IF UNUM OVERPAYS YOUR CLAIM?

Unum has the right to recover any overpayments due to:

- fraud;- any error Unum makes in processing a claim;- disability earnings; or- deductible sources of income.

You must reimburse us in full. We will determine the method by which the repayment is to be made which may include reducing or withholding future payments including the minimum monthly payment.

Unum will not recover more money than the amount we paid you.

Any unpaid premium due for your coverage under this policy may be recovered by us by offsetting against amounts otherwise payable to you under this policy, or by other legally permitted means.

EMPLOYER-1 (5/1/2017)

POLICYHOLDER PROVISIONS

WHAT IS THE COST OF THIS INSURANCE?


The initial premium for each plan is based on the initial rate(s) shown in the Rate Information Amendment(s).

WAIVER OF PREMIUM

Unum does not require premium payments for an insured while he or she is receiving Long Term Disability payments under this plan. INITIAL RATE GUARANTEE AND RATE CHANGES

Refer to the Rate Information Amendment(s).

WHEN IS PREMIUM DUE FOR THIS POLICY?

Premium Due Dates: Premium due dates are based on the Premium Due Dates shown in the Rate Information Amendment(s).

The Policyholder must send all premiums to Unum on or before their respective due date. The premium must be paid in United States dollars.

WHEN ARE INCREASES OR DECREASES IN PREMIUM DUE?

Premium increases or decreases which take effect during a policy month are adjusted and due on the next premium due date following the change. Changes will not be pro-rated daily.

If premiums are paid on other than a monthly basis, premiums for increases and decreases will result in a monthly pro-rated adjustment on the next premium due date.

Unum will only adjust premium for the current policy year and the prior policy year. In the case of fraud, premium adjustments will be made for all policy years.

WHAT INFORMATION DOES UNUM REQUIRE FROM THE POLICYHOLDER?

The Policyholder must provide Unum with the following on a regular basis:

- information about employees:who are eligible to become insured;whose amounts of coverage change; and/orwhose coverage ends;

- occupational information and any other information that may be required to manage a claim; and

- any other information that may be reasonably required.

Policyholder records that, in Unum's opinion, have a bearing on this policy will be available for review by Unum at any reasonable time.

EMPLOYER-2 (5/1/2017)

Clerical error or omission by Unum will not:

- prevent an employee from receiving coverage;- affect the amount of an insured's coverage; or- cause an employee's coverage to begin or continue when the coverage would not

otherwise be effective.

WHO CAN CANCEL OR MODIFY THIS POLICY OR A PLAN UNDER THIS POLICY?

This policy or a plan under this policy can be cancelled:

- by Unum; or- by the Policyholder.

Unum may cancel or modify this policy or a plan if:

- there is less than 75% participation of those eligible employees who pay all or part of their premium for a plan; or

- there is less than 100% participation of those eligible employees for a Policyholder paid plan;

- the Policyholder does not promptly provide Unum with information that is reasonably required;

- the Policyholder fails to perform any of its obligations that relate to this policy; - fewer than 10 employees are insured under a plan; - the premium is not paid in accordance with the provisions of this policy that specify

whether the Policyholder, the employee, or both, pay(s) the premiums;- the Policyholder does not promptly report to Unum the names of any employees

who are added or deleted from the eligible group;- Unum determines that there is a significant change, in the size, occupation or age

of the eligible group as a result of a corporate transaction such as a merger, divestiture, acquisition, sale, or reorganization of the Policyholder and/or its employees; or

- the Policyholder fails to pay any portion of the premium within the 31 day grace period.

If Unum cancels or modifies this policy or a plan for reasons other than the Policyholder's failure to pay premium, a written notice will be delivered to the Policyholder at least 31 days prior to the cancellation date or modification date. The Policyholder may cancel this policy or a plan if the modifications are unacceptable.

If any portion of the premium is not paid during the grace period, Unum will either cancel or modify the policy or plan automatically at the end of the grace period. The Policyholder is liable for premium for coverage during the grace period. The Policyholder must pay Unum all premium due for the full period each plan is in force.

The Policyholder may cancel this policy or a plan by written notice delivered to Unum at least 31 days prior to the cancellation date. When both the Policyholder and Unum agree, this policy or a plan can be cancelled on an earlier date. If Unum or the Policyholder cancels this policy or a plan, coverage will end at 12:00 midnight on the last day of coverage.

If this policy or a plan is cancelled, the cancellation will not affect a payable claim.

EMPLOYER-3 (5/1/2017)

WHAT HAPPENS TO AN EMPLOYEE'S COVERAGE UNDER THIS POLICY WHILE HE OR SHE IS ON A FAMILY AND MEDICAL LEAVE OF ABSENCE?

We will continue the employee's coverage in accordance with the policyholder's Human Resource policy on family and medical leaves of absence if premium payments continue and the policyholder approved the employee's leave in writing.

Coverage will be continued until the end of the later of:

1. the leave period required by the federal Family and Medical Leave Act of 1993 and any amendments; or

2. the leave period required by applicable state law.

If the policyholder's Human Resource policy doesn't provide for continuation of an employee's coverage during a family and medical leave of absence, the employee's coverage will be reinstated when he or she returns to active employment.

We will not:

- apply a new waiting period;- apply a new pre-existing conditions exclusion; or- require evidence of insurability.

DIVISIONS, SUBSIDIARIES OR AFFILIATED COMPANIES INCLUDE:

NAME/LOCATION (CITY AND STATE)

None

C.FP-6 CC.FP-6-1 (5/1/2017)

CERTIFICATE SECTION

Unum Life Insurance Company of America (referred to as Unum) welcomes you as a client.

This is your certificate of coverage as long as you are eligible for coverage and you become insured. You will want to read it carefully and keep it in a safe place.

Unum has written your certificate of coverage in plain English. However, a few terms and provisions are written as required by insurance law. If you have any questions about any of the terms and provisions, please consult Unum's claims paying office. Unum will assist you in any way to help you understand your benefits.

If the terms and provisions of the certificate of coverage (issued to you) are different from the policy (issued to the policyholder), the policy will govern. Your coverage may be cancelled or changed in whole or in part under the terms and provisions of the policy.

The policy is delivered in and is governed by the laws of the governing jurisdiction and to the extent applicable by the Employee Retirement Income Security Act of 1974 (ERISA) and any amendments.

For purposes of effective dates and ending dates under the group policy, all days begin at 12:01 a.m. and end at 12:00 midnight at the Policyholder's address.


EMPLOYEE-1 (5/1/2017)

GENERAL PROVISIONS

WHAT IS THE CERTIFICATE OF COVERAGE?

This certificate of coverage is a written statement prepared by Unum and may include attachments. It tells you:

- the coverage for which you may be entitled;- to whom Unum will make a payment; and- the limitations, exclusions and requirements that apply within a plan.

WHEN ARE YOU ELIGIBLE FOR COVERAGE?

If you are working for your Employer in an eligible group, the date you are eligible for coverage is the later of:

- the plan effective date; or- the day after you complete your waiting period.

WHEN DOES YOUR COVERAGE BEGIN?

When your Employer pays 100% of the cost of your coverage under a plan, you will be covered at 12:01 a.m. on the date you are eligible for coverage.

When you and your Employer share the cost of your coverage under a plan or when you pay 100% of the cost yourself, you will be covered at 12:01 a.m. on the latest of:

- the date you are eligible for coverage, if you apply for insurance on or before that date;

- the date you apply for insurance, if you apply within 31 days after your eligibility date; or

- the date Unum approves your application, if evidence of insurability is required.

Evidence of insurability is required if you:

- are a late applicant, which means you apply for coverage more than 31 days after the date you are eligible for coverage; or

- voluntarily cancelled your coverage and are reapplying.

An evidence of insurability form can be obtained from your Employer.

WHAT IF YOU ARE ABSENT FROM WORK ON THE DATE YOUR COVERAGE WOULD NORMALLY BEGIN?

If you are absent from work due to injury, sickness, temporary layoff or leave of absence, your coverage will begin on the date you return to active employment.

ONCE YOUR COVERAGE BEGINS, WHAT HAPPENS IF YOU ARE TEMPORARILY NOT WORKING?

If you are on a temporary layoff, and if premium is paid, you will be covered through the end of the month that immediately follows the month in which your temporary layoff begins.

EMPLOYEE-2 (5/1/2017)

If you are on a leave of absence, and if premium is paid, you will be covered through the end of the month that immediately follows the month in which your leave of absence begins.

WHEN WILL CHANGES TO YOUR COVERAGE TAKE EFFECT?

Once your coverage begins, any increased or additional coverage will take effect immediately if you are in active employment or if you are on a covered layoff or leave of absence. If you are not in active employment due to injury or sickness, any increased or additional coverage will begin on the date you return to active employment.

Any decrease in coverage will take effect immediately but will not affect a payable claim that occurs prior to the decrease.

WHEN DOES YOUR COVERAGE END?

Your coverage under the policy or a plan ends on the earliest of:

- the date the policy or a plan is cancelled;- the date you no longer are in an eligible group;- the date your eligible group is no longer covered;- the last day of the period for which you made any required contributions; or- the last day you are in active employment except as provided under the covered

layoff or leave of absence provision.

Unum will provide coverage for a payable claim which occurs while you are covered under the policy or plan.

WHAT ARE THE TIME LIMITS FOR LEGAL PROCEEDINGS?

You can start legal action regarding your claim 60 days after proof of claim has been given and up to 3 years from the later of when original proof of your claim was first required to have been given; or your claim was denied; or your benefits were terminated, unless otherwise provided under federal law.

HOW CAN STATEMENTS MADE IN YOUR APPLICATION FOR THIS COVERAGE BE USED?

Unum considers any statements you or your Employer make in a signed application for coverage a representation and not a warranty. If any of the material statements you or your Employer make are not complete and/or not true at the time they are made, we can:

- reduce or deny any claim; or- cancel your coverage from the original effective date.

We will use only statements made in a signed application as a basis for doing this. A copy of the statements will be provided to you or your beneficiary. These statements cannot be used to reduce or deny coverage if your coverage has been in force for at least two years.

However, if the Employer gives us information about you that is incorrect, we will:

EMPLOYEE-3 (5/1/2017)

- use the facts to determine if you have coverage under the plan according to the policy provisions and in what amounts; and

- make a fair adjustment of the premium.

HOW WILL UNUM HANDLE INSURANCE FRAUD?

Unum wants to ensure you and your Employer do not incur additional insurance costs as a result of the undermining effects of insurance fraud. Unum promises to focus on all means necessary to support fraud detection, investigation, and prosecution.

It is a crime if you knowingly, and with intent to injure, defraud or deceive Unum, or provide any information, including filing a claim, that contains any false, incomplete or misleading information. These actions, as well as submission of materially false information, will result in denial of your claim, and are subject to prosecution and punishment to the full extent under state and/or federal law. Unum will pursue all appropriate legal remedies in the event of insurance fraud.

DOES THE POLICY REPLACE OR AFFECT ANY WORKERS' COMPENSATION OR STATE DISABILITY INSURANCE?

The policy does not replace or affect the requirements for coverage by any workers' compensation or state disability insurance.

DOES YOUR EMPLOYER ACT AS YOUR AGENT OR UNUM'S AGENT?

For purposes of the policy, your Employer acts on its own behalf or as your agent. Under no circumstances will your Employer be deemed the agent of Unum.

LTD-BEN-1 (5/1/2017)


BENEFIT INFORMATION

HOW DOES UNUM DEFINE DISABILITY?

You are disabled when Unum determines that:

- you are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury; and

- you have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury.

After 24 months of payments, you are disabled when Unum determines that due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience.

You must be under the regular care of a physician in order to be considered disabled.

The loss of a professional or occupational license or certification does not, in itself, constitute disability.

HOW LONG MUST YOU BE DISABLED BEFORE YOU ARE ELIGIBLE TO RECEIVE BENEFITS?

You must be continuously disabled through your elimination period. The days that you are not disabled will not count toward your elimination period.

Your elimination period is 180 days.

In addition, if you return to work while satisfying your elimination period, and are no longer disabled, you may satisfy your elimination period within the accumulation period. You do not need to be continuously disabled through your elimination period if you are satisfying your elimination period under this provision. If you do not satisfy the elimination period within the accumulation period, a new period of disability will begin.

Your accumulation period is 360 days.

You are not required to have a 20% or more loss in your indexed monthly earnings due to the same injury or sickness to be considered disabled during the elimination period.

CAN YOU SATISFY YOUR ELIMINATION PERIOD IF YOU ARE WORKING?

Yes. If you are working while you are disabled, the days you are disabled will count toward your elimination period.

WHEN WILL YOU BEGIN TO RECEIVE PAYMENTS?

You will begin to receive payments when we approve your claim, providing the elimination period has been met and you are disabled. We will send you a payment monthly for any period for which Unum is liable.

LTD-BEN-2 (5/1/2017)

HOW MUCH WILL UNUM PAY YOU IF YOU ARE DISABLED?

We will follow this process to figure your payment:

1. Multiply your monthly earnings by 60%.2. The maximum monthly benefit is $5,000.3. Compare the answer from Item 1 with the maximum monthly benefit. The lesser

of these two amounts is your gross disability payment.4. Subtract from your gross disability payment any deductible sources of income.

The amount figured in Item 4 is your monthly payment.

Your monthly payment may be reduced based on your disability earnings.

If, at any time after the elimination period, you are disabled for less than 1 month, we will send you 1/30 of your monthly payment for each day of disability and 1/30 of any additional benefits for each day of disability.

WILL UNUM EVER PAY MORE THAN 100% OF MONTHLY EARNINGS?

The total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 100% of your monthly earnings. However, if you are participating in Unum's Rehabilitation and Return to Work Assistance program, the total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 110% of your monthly earnings.

WHAT ARE YOUR MONTHLY EARNINGS?

Paramedics and Fire Fighters"Monthly Earnings" means your average gross monthly income as figured:

a. from the income box on your W-2 form which reflects wages, tips and other compensation received from your Employer for the calendar year just prior to your date of disability; or

b. for the period of your employment with your Employer if you did not receive a W-2 form prior to your date of disability.

Average gross monthly income is your total income before taxes. It is prior to any deductions made for pre-tax contributions to a qualified deferred compensation plan, Section 125 plan, or flexible spending account. It does not include income received from car, housing or moving allowances, Employer contributions to a qualified deferred compensation plan, or income received from sources other than your Employer.

All Full-Time Employees not eligible in another group"Monthly Earnings" means your gross monthly income from your Employer in effect just prior to your date of disability. It includes your total income before taxes. It is prior to any deductions made for pre-tax contributions to a qualified deferred compensation plan, Section 125 plan, or flexible spending account. It does not include income received from commissions, bonuses, overtime pay, any other extra compensation, or income received from sources other than your Employer.

LTD-BEN-3 (5/1/2017)

WHAT WILL WE USE FOR MONTHLY EARNINGS IF YOU BECOME DISABLED DURING A COVERED LAYOFF OR LEAVE OF ABSENCE?

If you become disabled while you are on a covered layoff or leave of absence, we will use your monthly earnings from your Employer in effect just prior to the date your absence begins.

HOW MUCH WILL UNUM PAY YOU IF YOU ARE DISABLED AND WORKING?

We will send you the monthly payment if you are disabled and your monthly disability earnings, if any, are less than 20% of your indexed monthly earnings, due to the same sickness or injury.

If you are disabled and your monthly disability earnings are from 20% through 80% of your indexed monthly earnings, due to the same sickness or injury, Unum will figure your payment as follows:

During the first 12 months of payments, while working, your monthly payment will not be reduced as long as disability earnings plus the gross disability payment does not exceed 100% of indexed monthly earnings.

1. Add your monthly disability earnings to your gross disability payment.2. Compare the answer in Item 1 to your indexed monthly earnings.

If the answer from Item 1 is less than or equal to 100% of your indexed monthly earnings, Unum will not further reduce your monthly payment.

If the answer from Item 1 is more than 100% of your indexed monthly earnings, Unum will subtract the amount over 100% from your monthly payment.

After 12 months of payments, while working, you will receive payments based on the percentage of income you are losing due to your disability.

1. Subtract your disability earnings from your indexed monthly earnings.2. Divide the answer in Item 1 by your indexed monthly earnings. This is your

percentage of lost earnings.3. Multiply your monthly payment by the answer in Item 2.

This is the amount Unum will pay you each month.

As part of your proof of disability earnings, we can require that you send us appropriate financial records, which may include income tax returns, which we believe are necessary to substantiate your income.

After the elimination period, if you are disabled for less than 1 month, we will send you 1/30 of your payment for each day of disability.

HOW DO WE PROTECT YOU IF YOUR DISABILITY EARNINGS FLUCTUATE?

If your disability earnings have fluctuated from month to month, Unum may determine your benefit eligibility based on the average of your disability earnings over the most recent 3 months.

LTD-BEN-4 (5/1/2017)

WHAT ARE DEDUCTIBLE SOURCES OF INCOME?

Unum will subtract from your gross disability payment the following deductible sources of income:

1. The amount that you receive or are entitled to receive under:

- a workers' compensation law.- an occupational disease law.- any other act or law with similar intent.

2. The amount that you receive or are entitled to receive as disability income or disability retirement payments under any:

- state compulsory benefit act or law.- group plan sponsored by your Employer.- other group insurance plan.- governmental retirement system.

3. The amount that you, your spouse and your children receive or are entitled to receive as disability payments because of your disability under:

- the United States Social Security Act.- the Canada Pension Plan.- the Quebec Pension Plan.- any similar plan or act.

4. The amount that you receive as retirement payments or the amount your spouse and children receive as retirement payments because you are receiving retirement payments under:

- the United States Social Security Act.- the Canada Pension Plan.- the Quebec Pension Plan.- any similar plan or act.

5. The amount that you receive as retirement payments under any governmental retirement system. Retirement payments do not include payments made at the later of age 62 or normal retirement age under your Employer's retirement plan which are attributable to contributions you made on a post tax basis to the system.

Regardless of how retirement payments are distributed, Unum will consider payments attributable to your post tax contributions to be distributed throughout your lifetime.


6. The amount that you:

- receive as disability payments under your Employer's retirement plan.

LTD-BEN-5 (5/1/2017)

- voluntarily elect to receive as retirement payments under your Employer's retirement plan.- receive as retirement payments when you reach the later of age 62 or normal retirement age, as defined in your Employer's retirement plan.

Disability payments under a retirement plan will be those benefits which are paid due to disability and do not reduce the retirement benefit which would have been paid if the disability had not occurred.

Retirement payments will be those benefits which are based on your Employer's contribution to the retirement plan. Disability benefits which reduce the retirement benefit under the plan will also be considered as a retirement benefit.

Regardless of how the retirement funds from the retirement plan are distributed, Unum will consider your and your Employer's contributions to be distributed simultaneously throughout your lifetime.


7. The amount that you receive under Title 46, United States Code Section 688 (The Jones Act).

With the exception of retirement payments, Unum will only subtract deductible sources of income which are payable as a result of the same disability.

We will not reduce your payment by your Social Security retirement income if your disability begins after age 65 and you were already receiving Social Security retirement payments.

WHAT ARE NOT DEDUCTIBLE SOURCES OF INCOME?

Unum will not subtract from your gross disability payment income you receive from, but not limited to, the following:

- 401(k) plans- profit sharing plans- thrift plans- tax sheltered annuities- stock ownership plans- non-qualified plans of deferred compensation- pension plans for partners- military pension and disability income plans- credit disability insurance- franchise disability income plans- a retirement plan from another Employer- individual retirement accounts (IRA)- individual disability income plans- no fault motor vehicle plans- salary continuation or accumulated sick leave plans

LTD-BEN-6 (5/1/2017)

WHAT IF SUBTRACTING DEDUCTIBLE SOURCES OF INCOME RESULTS IN A ZERO BENEFIT? (Minimum Benefit)

The minimum monthly payment is the greater of:

- $100; or- 10% of your gross disability payment.

Unum may apply this amount toward an outstanding overpayment.

WHAT HAPPENS WHEN YOU RECEIVE A COST OF LIVING INCREASE FROM DEDUCTIBLE SOURCES OF INCOME?

Once Unum has subtracted any deductible source of income from your gross disability payment, Unum will not further reduce your payment due to a cost of living increase from that source.

WHAT IF UNUM DETERMINES YOU MAY QUALIFY FOR DEDUCTIBLE INCOME BENEFITS?

When we determine that you may qualify for benefits under Item(s) 1, 2 and 3 in the deductible sources of income section, we will estimate your entitlement to these benefits. We can reduce your payment by the estimated amounts if such benefits:

- have not been awarded; and- have not been denied; or- have been denied and the denial is being appealed.

Your Long Term Disability payment will NOT be reduced by the estimated amount if you:

- apply for the disability payments under Item(s) 1, 2 and 3 in the deductible sources of income section and appeal your denial to all administrative levels Unum feels are necessary; and

- sign Unum's payment option form. This form states that you promise to pay us any overpayment caused by an award.

If your payment has been reduced by an estimated amount, your payment will be adjusted when we receive proof:

- of the amount awarded; or- that benefits have been denied and all appeals Unum feels are necessary have

been completed. In this case, a lump sum refund of the estimated amount will be made to you.

If you receive a lump sum payment from any deductible sources of income, the lump sum will be pro-rated on a monthly basis over the time period for which the sum was given. If no time period is stated, we will use a reasonable one.

HOW LONG WILL UNUM CONTINUE TO SEND YOU PAYMENTS?

Unum will send you a payment each month up to the maximum period of payment. Your maximum period of payment is based on your age at disability as follows:

LTD-BEN-7 (5/1/2017)

Age at Disability Maximum Period of Payment

Less than age 60 To age 65, but not less than 5 yearsAge 60 60 monthsAge 61 48 monthsAge 62 42 monthsAge 63 36 monthsAge 64 30 monthsAge 65 24 monthsAge 66 21 monthsAge 67 18 monthsAge 68 15 monthsAge 69 and over 12 months

WHEN WILL PAYMENTS STOP?

We will stop sending you payments and your claim will end on the earliest of the following:

- during the first 24 months of payments, when you are able to work in your regular occupation on a part-time basis and you do not;

- after 24 months of payments, when you are able to work in any gainful occupation on a part-time basis and you do not;

- if you are working and your monthly disability earnings exceed 80% of your indexed monthly earnings, the date your earnings exceed 80%;

- the end of the maximum period of payment;- the date you are no longer disabled under the terms of the plan, unless you are

eligible to receive benefits under Unum's Rehabilitation and Return to Work Assistance program;

- the date you fail to submit proof of continuing disability;- after 12 months of payments if you are considered to reside outside the United

States or Canada. You will be considered to reside outside these countries when you have been outside the United States or Canada for a total period of 6 months or more during any 12 consecutive months of benefits;

- the date you die.

WHAT DISABILITIES HAVE A LIMITED PAY PERIOD UNDER YOUR PLAN?

The lifetime cumulative maximum benefit period for all disabilities due to mental illness and disabilities based primarily on self-reported symptoms is 24 months. Only 24 months of benefits will be paid for any combination of such disabilities even if the disabilities:

- are not continuous; and/or- are not related.

However, Unum will send you payments beyond the 24 month period if you meet one of these conditions:

1. If you are confined to a hospital or institution at the end of the 24 month period, Unum will continue to send you payments during your confinement.

If you are still disabled when you are discharged, Unum will send you payments for a recovery period of up to 90 days.

LTD-BEN-8 (5/1/2017)

If you become reconfined at any time during the recovery period and remain confined for at least 14 days in a row, Unum will send payments during that additional confinement and for one additional recovery period up to 90 more days.

2. If you are not confined to a hospital or institution but become confined for a period of at least 14 days within 90 days after the 24 month period for which you have received payments, Unum will send payments during the length of the confinement.

Under no circumstances will Unum pay beyond the maximum period of payment as indicated in the BENEFITS AT A GLANCE section of your policy.

Unum will not apply the mental illness limitation to dementia if it is a result of:

- stroke; - trauma;- viral infection;- Alzheimer's disease; or- other conditions not listed which are not usually treated by a mental health

provider or other qualified provider using psychotherapy, psychotropic drugs, or other similar methods of treatment.

WHAT DISABILITIES ARE NOT COVERED UNDER YOUR PLAN?

Your plan does not cover any disabilities caused by, contributed to by, or resulting from your:

- intentionally self-inflicted injuries.- active participation in a riot.- loss of a professional license, occupational license or certification.- commission of a crime for which you have been convicted.- pre-existing condition.

Your plan will not cover a disability due to war, declared or undeclared, or any act of war.

Unum will not pay a benefit for any period of disability during which you are incarcerated.

WHAT IS A PRE-EXISTING CONDITION?

You have a pre-existing condition if:

- you received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines in the 3 months just prior to your effective date of coverage; and

- the disability begins in the first 12 months after your effective date of coverage.

LTD-BEN-9 (5/1/2017)

WHAT HAPPENS IF YOU RETURN TO WORK FULL TIME WITH THE POLICYHOLDER AND YOUR DISABILITY OCCURS AGAIN?

If you have a recurrent disability, Unum will treat your disability as part of your prior claim and you will not have to complete another elimination period if:

- you were continuously insured under the plan for the period between the end of your prior claim and your recurrent disability; and

- your recurrent disability occurs within 6 months from the end of your prior claim.

Your recurrent disability will be subject to the same terms of the plan as your prior claim and will be treated as a continuation of that disability.

Any disability which occurs after 6 months from the date your prior claim ended will be treated as a new claim. The new claim will be subject to all of the policy provisions, including the elimination period.

If you are covered under another group long term disability plan on the date of your recurrent disability and are entitled to payments under that plan, you will not be eligible for further payments from Unum.

LTD-OTR-1 (5/1/2017)


OTHER BENEFIT FEATURES

WHAT BENEFITS WILL BE PROVIDED TO YOU OR YOUR FAMILY IF YOU DIE OR ARE TERMINALLY ILL? (Survivor Benefit)

When Unum receives proof that you have died, we will pay your eligible survivor a lump sum benefit equal to 3 months of your gross disability payment if, on the date of your death:

- your disability had continued for 180 or more consecutive days; and- you were receiving or were entitled to receive payments under the plan.

If you have no eligible survivors, payment will be made to your estate, unless there is none. In this case, no payment will be made.

However, we will first apply the survivor benefit to any overpayment which may exist on your claim.

You may receive your 3 month survivor benefit prior to your death if you have been diagnosed as terminally ill.

We will pay you a lump sum amount equal to 3 months of your gross disability payment if:

- you have been diagnosed with a terminal illness or condition;- your life expectancy has been reduced to less than 12 months; and- you are receiving monthly payments.

Your right to exercise this option and receive payment is subject to the following:

- you must make this election in writing to Unum; and- your physician must certify in writing that you have a terminal illness or condition

and your life expectancy has been reduced to less than 12 months.

This benefit is available to you on a voluntary basis and will only be payable once.

If you elect to receive this benefit prior to your death, no 3 month survivor benefit will be payable upon your death.

WHAT IF YOU HAVE A DISABILITY DUE TO A PRE-EXISTING CONDITION WHEN YOUR EMPLOYER CHANGES INSURANCE CARRIERS TO UNUM? (Continuity of Coverage)

Unum may send a payment if your disability results from a pre-existing condition if, you were:

- in active employment and insured under the plan on its effective date; and- insured by the prior policy at the time of change.

In order to receive a payment you must satisfy the pre-existing condition provision under:

LTD-OTR-2 (5/1/2017)

1. the Unum plan; or2. the prior carrier's plan, if benefits would have been paid had that policy remained

in force.

If you do not satisfy Item 1 or 2 above, Unum will not make any payments.

If you satisfy Item 1, we will determine your payments according to the Unum plan provisions.

If you only satisfy Item 2, we will administer your claim according to the Unum plan provisions. However, your payment will be the lesser of:

a. the monthly benefit that would have been payable under the terms of the prior plan if it had remained inforce; or

b. the monthly payment under the Unum plan.

Your benefits will end on the earlier of the following dates:

1. the end of the maximum benefit period under the plan; or2. the date benefits would have ended under the prior plan if it had remained in

force.

HOW CAN UNUM'S REHABILITATION AND RETURN TO WORK ASSISTANCE PROGRAM HELP YOU RETURN TO WORK?

Unum has a vocational Rehabilitation and Return to Work Assistance program available to assist you in returning to work. We will determine whether you are eligible for this program. In order to be eligible for rehabilitation services and benefits, you must be medically able to engage in a return to work program.

Your claim file will be reviewed by one of Unum's rehabilitation professionals to determine if a rehabilitation program might help you return to gainful employment. As your file is reviewed, medical and vocational information will be analyzed to determine an appropriate return to work program.

We will make the final determination of your eligibility for participation in the program.

We will provide you with a written Rehabilitation and Return to Work Assistance plan developed specifically for you.

The rehabilitation program may include, but is not limited to, the following services and benefits:

- coordination with your Employer to assist you to return to work;- adaptive equipment or job accommodations to allow you to work;- vocational evaluation to determine how your disability may impact your

employment options;- job placement services;- resume preparation;- job seeking skills training; or- education and retraining expenses for a new occupation.

LTD-OTR-3 (5/1/2017)

WHAT ADDITIONAL BENEFITS WILL UNUM PAY WHILE YOU PARTICIPATE IN A REHABILITATION AND RETURN TO WORK ASSISTANCE PROGRAM?

We will pay an additional disability benefit of 10% of your gross disability payment to a maximum benefit of $1,000 per month.

This benefit is not subject to policy provisions which would otherwise increase or reduce the benefit amount such as Deductible Sources of Income. However, the Total Benefit Cap will apply.

In addition, we will make monthly payments to you for 3 months following the date your disability ends if we determine you are no longer disabled while:

- you are participating in the Rehabilitation and Return to Work Assistance program; and

- you are not able to find employment.

This benefit payment may be paid in a lump sum.

WHEN WILL REHABILITATION AND RETURN TO WORK ASSISTANCE BENEFITS END?

Benefits for the Rehabilitation and Return to Work Assistance program will end on the earliest of the following dates:

- the date Unum determines that you are no longer eligible to participate in Unum's Rehabilitation and Return to Work Assistance program; or

- any other date on which monthly payments would stop in accordance with this plan.

WHAT ADDITIONAL BENEFIT IS AVAILABLE FOR DEPENDENT CARE EXPENSES TO ENABLE YOU TO PARTICIPATE IN UNUM'S REHABILITATION AND RETURN TO WORK ASSISTANCE PROGRAM?

While you are participating in Unum's Rehabilitation and Return to Work Assistance program, we will pay a Dependent Care Expense Benefit when you are disabled and you:

1. are incurring expenses to provide care for a child under the age of 15; and/or2. start incurring expenses to provide care for a child age 15 or older or a family

member who needs personal care assistance.

The payment of the Dependent Care Expense Benefit will begin immediately after you start Unum's Rehabilitation and Return to Work Assistance program.

Our payment of the Dependent Care Expense Benefit will:

1. be $350 per month, per dependent; and2. not exceed $1,000 per month for all dependent care expenses combined.

To receive this benefit, you must provide satisfactory proof that you are incurring expenses that entitle you to the Dependent Care Expense Benefit. Dependent Care Expense Benefits will end on the earlier of the following:

LTD-OTR-4 (5/1/2017)

1. the date you are no longer incurring expenses for your dependent;2. the date you no longer participate in Unum's Rehabilitation and Return to Work

Assistance program; or 3. any other date payments would stop in accordance with this plan.

SERVICES-1 (5/1/2017)

OTHER SERVICES

These services are also available from us as part of your Unum Long Term Disability plan.

IS THERE A WORK LIFE ASSISTANCE PROGRAM AVAILABLE WITH THE PLAN?

We do provide you and your dependents access to a work life assistance program designed to assist you with problems of daily living.

You can call and request assistance for virtually any personal or professional issue, from helping find a day care or transportation for an elderly parent, to researching possible colleges for a child, to helping to deal with the stress of the workplace. This work life program is available for everyday issues as well as crisis support.

This service is also available to your Employer.

This program can be accessed by a 1-800 telephone number available 24 hours a day, 7 days a week or online through a website.

Information about this program can be obtained through your plan administrator.

HOW CAN UNUM HELP YOUR EMPLOYER IDENTIFY AND PROVIDE WORKSITE MODIFICATION?

A worksite modification might be what is needed to allow you to perform the material and substantial duties of your regular occupation with your Employer. One of our designated professionals will assist you and your Employer to identify a modification we agree is likely to help you remain at work or return to work. This agreement will be in writing and must be signed by you, your Employer and Unum.

When this occurs, Unum will reimburse your Employer for the cost of the modification, up to the greater of: - $1,000; or- the equivalent of 2 months of your monthly benefit.

This benefit is available to you on a one time only basis.

HOW CAN UNUM'S SOCIAL SECURITY CLAIMANT ADVOCACY PROGRAM ASSIST YOU WITH OBTAINING SOCIAL SECURITY DISABILITY BENEFITS?

In order to be eligible for assistance from Unum's Social Security claimant advocacy program, you must be receiving monthly payments from us. Unum can provide expert advice regarding your claim and assist you with your application or appeal.

Receiving Social Security benefits may enable:

- you to receive Medicare after 24 months of disability payments;- you to protect your retirement benefits; and- your family to be eligible for Social Security benefits.

We can assist you in obtaining Social Security disability benefits by:

SERVICES-2 (5/1/2017)

- helping you find appropriate legal representation;- obtaining medical and vocational evidence; and- reimbursing pre-approved case management expenses.

GLOSSARY-1 (5/1/2017)

GLOSSARY

ACCUMULATION PERIOD means the period of time from the date disability begins during which you must satisfy the elimination period.

ACTIVE EMPLOYMENT means you are working for your Employer for earnings that are paid regularly and that you are performing the material and substantial duties of your regular occupation. You must be working at least the minimum number of hours as described under Eligible Group(s) in each plan.

Your work site must be:

- your Employer's usual place of business;- an alternative work site at the direction of your Employer, including your home; or- a location to which your job requires you to travel.

Normal vacation is considered active employment.Temporary and seasonal workers are excluded from coverage.

DEDUCTIBLE SOURCES OF INCOME means income from deductible sources listed in the plan which you receive or are entitled to receive while you are disabled. This income will be subtracted from your gross disability payment.

DEPENDENT means:

- your child(ren) under the age of 15; and- your child(ren) age 15 or over or a family member who requires personal care

assistance.

DISABILITY EARNINGS means the earnings which you receive while you are disabled and working, plus the earnings you could receive if you were working to your maximum capacity.

ELIMINATION PERIOD means a period of continuous disability which must be satisfied before you are eligible to receive benefits from Unum.

EMPLOYEE means a person who is in active employment in the United States with the Employer.

EMPLOYER means the Policyholder, and includes any division, subsidiary or affiliated company named in the policy.

EVIDENCE OF INSURABILITY means a statement of your medical history which Unum will use to determine if you are approved for coverage. Evidence of insurability will be at Unum's expense.

GAINFUL OCCUPATION means an occupation that is or can be expected to provide you with an income within 12 months of your return to work, that exceeds:

80% of your indexed monthly earnings, if you are working; or60% of your indexed monthly earnings, if you are not working.

GOVERNMENTAL RETIREMENT SYSTEM means a plan which is part of any federal, state, county, municipal or association retirement system, including but not limited to, a

GLOSSARY-2 (5/1/2017)

state teachers retirement system, public employees retirement system or other similar retirement system for state or local government employees providing for the payment of retirement and/or disability benefits to individuals.

GRACE PERIOD means the period of time following the premium due date during which premium payment may be made.

GROSS DISABILITY PAYMENT means the benefit amount before Unum subtracts deductible sources of income and disability earnings.

HOSPITAL OR INSTITUTION means an accredited facility licensed to provide care and treatment for the condition causing your disability.

INDEXED MONTHLY EARNINGS means your monthly earnings adjusted on each anniversary of benefit payments by the lesser of 10% or the current annual percentage increase in the Consumer Price Index. Your indexed monthly earnings may increase or remain the same, but will never decrease.

The Consumer Price Index (CPI-U) is published by the U.S. Department of Labor. Unum reserves the right to use some other similar measurement if the Department of Labor changes or stops publishing the CPI-U.

Indexing is only used as a factor in the determination of the percentage of lost earnings while you are disabled and working and in the determination of gainful occupation.

INJURY means a bodily injury that is the direct result of an accident and not related to any other cause. Disability must begin while you are covered under the plan.

INSURED means any person covered under a plan.

LAW, PLAN OR ACT means the original enactments of the law, plan or act and all amendments.

LAYOFF or LEAVE OF ABSENCE means you are temporarily absent from active employment for a period of time that has been agreed to in advance in writing by your Employer.

Your normal vacation time or any period of disability is not considered a temporary layoff or leave of absence.

LIMITED means what you cannot or are unable to do.

MATERIAL AND SUBSTANTIAL DUTIES means duties that:

- are normally required for the performance of your regular occupation; and- cannot be reasonably omitted or modified.

MAXIMUM CAPACITY means, based on your restrictions and limitations:

- during the first 24 months of disability, the greatest extent of work you are able to do in your regular occupation, that is reasonably available.

- beyond 24 months of disability, the greatest extent of work you are able to do in any occupation, that is reasonably available, for which you are reasonably fitted by education, training or experience.

GLOSSARY-3 (5/1/2017)

MAXIMUM PERIOD OF PAYMENT means the longest period of time Unum will make payments to you for any one period of disability.

MENTAL ILLNESS means a psychiatric or psychological condition classified in the Diagnostic and Statistical Manual of Mental Health Disorders (DSM), published by the American Psychiatric Association, most current as of the start of a disability. Such disorders include, but are not limited to, psychotic, emotional or behavioral disorders, or disorders relatable to stress. If the DSM is discontinued or replaced, these disorders will be those classified in the diagnostic manual then used by the American Psychiatric Association as of the start of a disability.

MONTHLY BENEFIT means the total benefit amount for which an employee is insured under this plan subject to the maximum benefit.

MONTHLY EARNINGS means your gross monthly income from your Employer as defined in the plan.

MONTHLY PAYMENT means your payment after any deductible sources of income have been subtracted from your gross disability payment.

PART-TIME BASIS means the ability to work and earn between 20% and 80% of your indexed monthly earnings.

PAYABLE CLAIM means a claim for which Unum is liable under the terms of the policy.

PHYSICIAN means:

- a person performing tasks that are within the limits of his or her medical license; and- a person who is licensed to practice medicine and prescribe and administer drugs or

to perform surgery; or- a person with a doctoral degree in Psychology (Ph.D. or Psy.D.) whose primary

practice is treating patients; or- a person who is a legally qualified medical practitioner according to the laws and

regulations of the governing jurisdiction.

Unum will not recognize you, or your spouse, children, parents or siblings as a physician for a claim that you send to us.

PLAN means a line of coverage under the policy.

POLICYHOLDER means the Employer to whom the policy is issued.

PRE-EXISTING CONDITION means a condition for which you received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines for your condition during the given period of time as stated in the plan.

RECURRENT DISABILITY means a disability which is:

- caused by a worsening in your condition; and- due to the same cause(s) as your prior disability for which Unum made a disability

payment.

GLOSSARY-4 (5/1/2017)

REGULAR CARE means:

- you personally visit a physician as frequently as is medically required, according to generally accepted medical standards, to effectively manage and treat your disabling condition(s); and

- you are receiving the most appropriate treatment and care which conforms with generally accepted medical standards, for your disabling condition(s) by a physician whose specialty or experience is the most appropriate for your disabling condition(s), according to generally accepted medical standards.

REGULAR OCCUPATION means the occupation you are routinely performing when your disability begins. Unum will look at your occupation as it is normally performed in the national economy, instead of how the work tasks are performed for a specific employer or at a specific location.

RETIREMENT PLAN means a defined contribution plan or defined benefit plan. These are plans which provide retirement benefits to employees and are not funded entirely by employee contributions. Retirement Plan does not include any plan which is part of any governmental retirement system.

SALARY CONTINUATION OR ACCUMULATED SICK LEAVE means continued payments to you by your Employer of all or part of your monthly earnings, after you become disabled as defined by the Policy. This continued payment must be part of an established plan maintained by your Employer for the benefit of all employees covered under the Policy. Salary continuation or accumulated sick leave does not include compensation paid to you by your Employer for work you actually perform after your disability begins. Such compensation is considered disability earnings, and would be taken into account in calculating your monthly payment.

SELF-REPORTED SYMPTOMS means the manifestations of your condition which you tell your physician, that are not verifiable using tests, procedures or clinical examinations standardly accepted in the practice of medicine. Examples of self-reported symptoms include, but are not limited to headaches, pain, fatigue, stiffness, soreness, ringing in ears, dizziness, numbness and loss of energy.

SICKNESS means an illness or disease. Disability must begin while you are covered under the plan.

SURVIVOR, ELIGIBLE means your spouse, if living; otherwise your children under age 25 equally.

TOTAL COVERED PAYROLL means the total amount of monthly earnings for which employees are insured under this plan.

WAITING PERIOD means the continuous period of time (shown in each plan) that you must be in active employment in an eligible group before you are eligible for coverage under a plan.

WE, US and OUR means Unum Life Insurance Company of America.

YOU means an employee who is eligible for Unum coverage.

ADDLINFO-1 (5/1/2017)

Additional Claim and Appeal InformationRelative to policy issued by Unum Life Insurance Company of America ("Unum")

APPLICABILITY OF ERISA

If the policy provides benefits under a Plan which is subject to the Employee Retirement Income Security Act of 1974 (ERISA), the following provisions apply. Whether a Plan is governed by ERISA is determined by a court, however, your Employer may have information related to ERISA applicability. If ERISA applies, the following items constitute the Plan: the additional information contained in this document, the policy, including your certificate of coverage, and any additional summary plan description information provided by the Plan Administrator. Benefit determinations are controlled exclusively by the policy, your certificate of coverage, and the information in this document.

HOW TO FILE A CLAIM

If you wish to file a claim for benefits, you should follow the claim procedures described in your insurance certificate. To complete your claim filing, Unum must receive the claim information it requests from you (or your authorized representative), your attending physician and your Employer. If you or your authorized representative has any questions about what to do, you or your authorized representative should contact Unum directly.

CLAIMS PROCEDURES

Unum will give you notice of the decision no later than 45 days after the claim is filed. This time period may be extended twice by 30 days if Unum both determines that such an extension is necessary due to matters beyond the control of the Plan and notifies you of the circumstances requiring the extension of time and the date by which Unum expects to render a decision. If such an extension is necessary due to your failure to submit the information necessary to decide the claim, the notice of extension will specifically describe the required information, and you will be afforded at least 45 days within which to provide the specified information. If you deliver the requested information within the time specified, any 30 day extension period will begin after you have provided that information. If you fail to deliver the requested information within the time specified, Unum may decide your claim without that information.

If your claim for benefits is wholly or partially denied, the notice of adverse benefit determination under the Plan will:

- state the specific reason(s) for the determination;

- reference specific Plan provision(s) on which the determination is based;

- describe additional material or information necessary to complete the claim and why such information is necessary;

- describe Plan procedures and time limits for appealing the determination, and your right to obtain information about those procedures and the right to bring a lawsuit under Section 502(a) of ERISA following an adverse determination from Unum on appeal; and

ADDLINFO-2 (5/1/2017)

- disclose any internal rule, guidelines, protocol or similar criterion relied on in making the adverse determination (or state that such information will be provided free of charge upon request).


APPEAL PROCEDURES

You have 180 days from the receipt of notice of an adverse benefit determination to file an appeal. Requests for appeals should be sent to the address specified in the claim denial. A decision on review will be made not later than 45 days following receipt of the written request for review. If Unum determines that special circumstances require an extension of time for a decision on review, the review period may be extended by an additional 45 days (90 days in total). Unum will notify you in writing if an additional 45 day extension is needed.

If an extension is necessary due to your failure to submit the information necessary to decide the appeal, the notice of extension will specifically describe the required information, and you will be afforded at least 45 days to provide the specified information. If you deliver the requested information within the time specified, the 45 day extension of the appeal period will begin after you have provided that information. If you fail to deliver the requested information within the time specified, Unum may decide your appeal without that information.

You will have the opportunity to submit written comments, documents, or other information in support of your appeal. You will have access to all relevant documents as defined by applicable U.S. Department of Labor regulations. The review of the adverse benefit determination will take into account all new information, whether or not presented or available at the initial determination. No deference will be afforded to the initial determination.

The review will be conducted by Unum and will be made by a person different from the person who made the initial determination and such person will not be the original decision maker's subordinate. In the case of a claim denied on the grounds of a medical judgment, Unum will consult with a health professional with appropriate training and experience. The health care professional who is consulted on appeal will not be the individual who was consulted during the initial determination or a subordinate. If the advice of a medical or vocational expert was obtained by the Plan in connection with the denial of your claim, Unum will provide you with the names of each such expert, regardless of whether the advice was relied upon.

A notice that your request on appeal is denied will contain the following information:

- the specific reason(s) for the determination;

- a reference to the specific Plan provision(s) on which the determination is based;

- a statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making the adverse determination (or a statement that such information will be provided free of charge upon request);

ADDLINFO-3 (5/1/2017)

- a statement describing your right to bring a lawsuit under Section 502(a) of ERISA if you disagree with the decision;

- the statement that you are entitled to receive upon request, and without charge, reasonable access to or copies of all documents, records or other information relevant to the determination; and

- the statement that "You or your Plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your State insurance regulatory agency".


Unless there are special circumstances, this administrative appeal process must be completed before you begin any legal action regarding your claim.

OTHER RIGHTS

Unum, for itself and as claims fiduciary for the Plan, is entitled to legal and equitable relief to enforce its right to recover any benefit overpayments caused by your receipt of disability earnings or deductible sources of income from a third party. This right of recovery is enforceable even if the amount you receive from the third party is less than the actual loss suffered by you but will not exceed the benefits paid you under the policy. Unum and the Plan have an equitable lien over such sources of income until any benefit overpayments have been recovered in full.

GLB-1 (5/1/2017)

Our Commitment to Privacy

We understand your privacy is important. We value our relationship with you and are committed to protecting the confidentiality of nonpublic personal information (NPI). This notice explains why we collect NPI, what we do with NPI and how we protect your privacy.

COLLECTING INFORMATIONWe collect NPI about our customers to provide them with insurance products and services. This may include telephone number, address, date of birth, occupation, income and health history. We may receive NPI from your applications and forms, medical providers, other insurers, employers, insurance support organizations and service providers.

SHARING INFORMATIONWe share the types of NPI described above primarily with people who perform insurance, business and professional services for us, such as helping us pay claims and detect fraud. We may share NPI with medical providers for insurance and treatment purposes. We may share NPI with an insurance support organization. The organization may retain the NPI and disclose it to others for whom it performs services. In certain cases, we may share NPI with group policyholders for reporting and auditing purposes. We may share NPI with parties to a proposed or final sale of insurance business or for study purposes. We may also share NPI when otherwise required or permitted by law, such as sharing with governmental or other legal authorities. When legally necessary, we ask your permission before sharing NPI about you. Our practices apply to our former, current and future customers.

Please be assured we do not share your health NPI to market any product or service. We also do not share any NPI to market non-financial products and services. For example, we do not sell your name to catalog companies.

The law allows us to share NPI as described above (except health information) with affiliates to market financial products and services. The law does not allow you to restrict these disclosures. We may also share with companies that help us market our insurance products and services, such as vendors that provide mailing services to us. We may share with other financial institutions to jointly market financial products and services. When required by law, we ask your permission before we share NPI for marketing purposes.

When other companies help us conduct business, we expect them to follow applicable privacy laws. We do not authorize them to use or share NPI except when necessary to conduct the work they are performing for us or to meet regulatory or other governmental requirements.

Unum companies, including insurers and insurance service providers, may share NPI about you with each other. The NPI might not be directly related to our transaction or experience with you. It may include financial or other personal information such as employment history. Consistent with the Fair Credit Reporting Act, we ask your permission before sharing NPI that is not directly related to our transaction or experience with you.

COVERAGE DECISIONSIf we decide not to issue coverage to you, we will provide you with the specific reason(s) for our decision. We will also tell you how to access and correct certain NPI.

GLB-2 (5/1/2017)

ACCESS TO INFORMATIONYou may request access to certain NPI we collect to provide you with insurance products and services. You must make your request in writing and send it to the address below. The letter should include your full name, address, telephone number and policy number if we have issued a policy. If you request, we will send copies of the NPI to you. If the NPI includes health information, we may provide the health information to you through a health care provider you designate. We will also send you information related to disclosures. We may charge a reasonable fee to cover our copying costs.

This section applies to NPI we collect to provide you with coverage. It does not apply to NPI we collect in anticipation of a claim or civil or criminal proceeding.

CORRECTION OF INFORMATIONIf you believe the NPI we have about you is incorrect, please write to us. Your letter should include your full name, address, telephone number and policy number if we have issued a policy. Your letter should also explain why you believe the NPI is inaccurate. If we agree with you, we will correct the NPI and notify you of the correction. We will also notify any person who may have received the incorrect NPI from us in the past two years if you ask us to contact that person.

If we disagree with you, we will tell you we are not going to make the correction. We will give you the reason(s) for our refusal. We will also tell you that you may submit a statement to us. Your statement should include the NPI you believe is correct. It should also include the reason(s) why you disagree with our decision not to correct the NPI in our files. We will file your statement with the disputed NPI. We will include your statement any time we disclose the disputed NPI. We will also give the statement to any person designated by you if we may have disclosed the disputed NPI to that person in the past two years.

SAFEGUARDING INFORMATIONWe have physical, electronic and procedural safeguards that protect the confidentiality and security of NPI. We give access only to employees who need to know the NPI to provide insurance products or services to you.

CONTACTING USFor additional information about Unum's commitment to privacy and to view a copy of our HIPAA Privacy Notice, please visit unum.com/privacy or coloniallife.com. You may also write to: Privacy Officer, Unum, 2211 Congress Street, C476, Portland, Maine 04122.

We reserve the right to modify this notice. We will provide you with a new notice if we make material changes to our privacy practices.

Unum is providing this notice to you on behalf of the following insuring companies: Unum Life Insurance Company of America, Unum Insurance Company, First Unum Life Insurance Company, Provident Life and Accident Insurance Company, Provident Life and Casualty Insurance Company, Colonial Life & Accident Insurance Company and The Paul Revere Life Insurance Company.

Copyright 2015 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.

MK-1883 (09/15)

GUAR-1 (5/1/2017)

IMPORTANT INFORMATION ABOUT COVERAGE UNDERTHE TEXAS LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION

(For Insurers declared insolvent or impaired on or after September 1, 2011)

Texas law establishes a system to protect Texas policyholders if their life or health insurance company fails. The Texas Life and Health Insurance Guaranty Association ("the Association") administers this protection system. Only the policyholders of insurance companies that are members of the Association are eligible for this protection which is subject to the terms, limitations, and conditions of the Association law. (The law is found in the Texas Insurance Code, Chapter 463.)

It is possible that the Association may not protect all or part of your policy because of statutory limitations.

Eligibility for Protection by the Association

When a member insurance company is found to be insolvent and placed under an order of liquidation by a court or designated as impaired by the Texas Commissioner of Insurance, the Association provides coverage to policyholders who are:- Residents of Texas (regardless of where the policyholder lived when the policy

was issued)- Residents of other states, ONLY if the following conditions are met:

- The policyholder has a policy with a company domiciled in Texas;- The policyholder's state of residence has a similar guaranty association; and- The policyholder is not eligible for coverage by the guaranty association of the policyholder's state of residence.

Limits of Protection by the Association

Accident, Accident and Health, or Health Insurance:- For each individual covered under one or more policies: up to a total of $500,000 for

basic hospital, medical-surgical, and major medical insurance, $300,000 for disability or long term care insurance, or $200,000 for other types of health insurance.

Life Insurance:- Net cash surrender value or net cash withdrawal value up to a total of $100,000 under

one or more policies on a single life; or- Death benefits up to a total of $300,000 under one or more policies on a single life; or- Total benefits up to a total of $5,000,000 to any owner of multiple non-group life

policies.Individual Annuities:- Present value of benefits up to a total of $250,000 under one or more contracts on

any one life.Group Annuities:- Present value of allocated benefits up to a total of $250,000 on any one life; or - Present value of unallocated benefits up to a total of $5,000,000 for one

contractholder regardless of the number of contracts.Aggregate Limit:- $300,000 on any one life with the exception of the $500,000 health insurance limit, the

$5,000,000 multiple owner life insurance limit, and the $5,000,000 unallocated group annuity limit.


GUAR-2 (5/1/2017)

Insurance companies and agents are prohibited by law from using the existence of the Association for the purpose of sales, solicitation, or inducement to purchase any form of insurance. When you are selecting an insurance company, you should not rely on Association coverage. For additional questions on Association protection or general information about an insurance company, please use the following contact information.

Texas Life and Health Texas Department of InsuranceInsurance Guaranty Association P.O. Box 149104515 Congress Avenue, Suite 1875 Austin, TX 78714-9104Austin, TX 78701 800-252-3439 or 800-982-6362 or www.txlifega.org www.tdi.texas.gov

http://www.txlifega.org/


Group Accident Insurance Certificate

City of Schertz

Life Insurance Company of North America 1601 Chestnut Street, Philadelphia, Pennsylvania 19192-2235 A Stock Insurance Company

GROUP ACCIDENT CERTIFICATE

THIS CERTIFICATE PROVIDES LIMITED COVERAGE. PLEASE READ YOUR CERTIFICATE CAREFULLY.

We, the Life Insurance Company of North America, have issued a Group Policy, OK 960965 to Trustee of the Group Insurance Trust for Employers in the Public Administration Industry.

We certify that we insure all eligible persons who are enrolled according to the terms of the Group Policy. Your coverage will begin according to the terms set forth in the Eligibility and Effective Date provision.

This Certificate describes the benefits and basic provisions of your coverage. It is not the insurance contract and does not waive or alter any terms of the Policy. If questions arise, the Policy language will govern. You may examine the Policy at the office of the Subscriber.

This Certificate replaces all prior Certificates issued to you under the Group Policy.

Gregory H. Wolf, President

THIS CERTIFICATE IS ISSUED UNDER AN ACCIDENT ONLY POLICY. IT DOES NOT PAY BENEFITS FOR LOSS CAUSED BY SICKNESS. GA-00-CE1000.00 (SIT)

TABLE OF CONTENTS

SECTION PAGE NUMBER SCHEDULE OF BENEFITS 1

GENERAL DEFINITIONS 4

ELIGIBILITY AND EFFECTIVE DATE PROVISIONS 7

COMMON EXCLUSIONS 9

CONVERSION PRIVILEGE 10

CLAIM PROVISIONS 11

ADMINISTRATIVE PROVISIONS 13

GENERAL PROVISIONS 14

ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGE 15

EXPOSURE AND DISAPPEARANCE COVERAGE 16

BULLETPROOF VEST BENEFIT 16

CHILD CARE CENTER BENEFIT 16

FELONIOUS ASSAULT AND VIOLENT CRIME BENEFIT 17

HOME ALTERATION AND VEHICLE MODIFICATION BENEFIT 18

REHABILITATION BENEFIT 18

SEATBELT AND AIRBAG BENEFIT 18

SPECIAL EDUCATION BENEFIT 19

SPOUSE RETRAINING BENEFIT 19

GA-00-CE1000.00 (SIT)

1

SCHEDULE OF BENEFITS This Certificate is intended to be read in its entirety. In order to understand all the conditions, exclusions and limitations applicable to its benefits, please read all the provisions carefully. The Schedule of Benefits provides a brief outline of your coverage and benefits. Please read the Description of Coverages and Benefits Section for full details. Subscriber: City of Schertz Effective Date of Subscriber Participation: October 1, 2005 Covered Class: Class 1 - All active, full-time salaried Employees of the Employer regularly working a minimum of 30

hours per week. SCHEDULE OF BENEFITS This Schedule of Benefits shows maximums, benefit periods and any limitations applicable to benefits provided for each Covered Person unless otherwise indicated. Principal Sum, when referred to in this Schedule, means the Employee’s Principal Sum in effect on the date of the Covered Accident causing the Covered Injury or Covered Loss unless otherwise specified. Eligibility Waiting Period The Eligibility Waiting Period is the period of time the Employee must be in a Covered Class to be eligible for coverage.

For Employees hired on or before the Policy Effective Date: None For Employees hired after the Policy Effective Date: None

Time Period for Loss:

Any Covered Loss must occur within: 365 days of the Covered Accident

Maximum Age for Insurance: None

VOLUNTARY ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS

Employee Principal Sum: $25,000 units Maximum: $500,000; Benefit amounts in excess of $250,000 are limited to

10 times Annual Compensation. Spouse Principal Sum: If no Dependent Children are insured: 50% of the Employee's Principal Sum If one or more Dependent Children are insured: 40% of the Employee's Principal Sum Maximum: $250,000 Dependent Child Principal Sum: If Spouse is insured: 10% of the Employee's Principal Sum If no Spouse is insured: 15% of the Employee's Principal Sum Maximum: $25,000

2

SCHEDULE OF COVERED LOSSES

Covered Loss Benefit Loss of Life 100% of the Principal Sum Loss of Two or More Hands or Feet 100% of the Principal Sum Loss of Sight of Both Eyes 100% of the Principal Sum Loss of One Hand or One Foot and Sight in One Eye 100% of the Principal Sum Loss of Speech and Hearing (in both ears) 100% of the Principal Sum Quadriplegia 100% of the Principal Sum Paraplegia 75% of the Principal Sum Hemiplegia 50% of the Principal Sum Uniplegia 25% of the Principal Sum Coma Monthly Benefit 1% of the Principal Sum Number of Monthly Benefits 11 Lump Sum Benefit 100% of the Principal Sum When Payable Beginning of the 12th month Loss of One Hand or Foot 50% of the Principal Sum Loss of Sight in One Eye 50% of the Principal Sum Loss of Speech 50% of the Principal Sum Loss of Hearing (in both ears) 50% of the Principal Sum Loss of all Four Fingers of the Same Hand 25% of the Principal Sum Loss of all the Toes of the Same Foot 25% of the Principal Sum Loss of Thumb and Index Finger of the Same Hand 25% of the Principal Sum

Age Reductions A Covered Person's Principal Sum will be reduced to the percentage of his Principal Sum in effect on the date preceding the first reduction, as shown below.

Age Percentage of Benefit Amount 70 but less than 75 65% 75 but less than 80 45% 80 but less than 85 30% 85 or over 15%

ADDITIONAL ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGES Accidental Death and Dismemberment benefits are provided under the following coverages. Any benefits payable under them are as shown in the Schedule of Covered Losses and are not paid in addition to any other Accidental Death and Dismemberment benefits. EXPOSURE AND DISAPPEARANCE COVERAGE provides the Principal Sum multiplied by the percentage applicable to the Covered Loss, as shown in the Schedule of Covered Losses. ADDITIONAL ACCIDENT BENEFITS Any benefits payable under these Additional Accident Benefits shown below are paid in addition to any other Accidental Death and Dismemberment benefits payable. BULLETPROOF VEST BENEFIT

50% multiplied by the percentage of the Principal Sum applicable to the Covered Loss, as shown in the Schedule of Covered Losses, subject to a maximum of $25,000

3

CHILD CARE CENTER BENEFIT Benefit Amount 3% of the Employee's Principal Sum subject to a maximum

of $3,000 per year Maximum Benefit Period 5 years but not beyond age 13 for each surviving Dependent

Child FELONIOUS ASSAULT AND VIOLENT CRIME BENEFIT

Accidental Death and Dismemberment Benefit 10% multiplied by the percentage of the Principal Sum

applicable to the Covered Loss, as shown in the Schedule of Covered Losses, subject to a maximum of $10,000

Hospital Stay Benefit $100 per day Maximum Benefit Period 365 days per Hospital Stay per Covered Accident

HOME ALTERATION AND VEHICLE MODIFICATION BENEFIT

Benefit 10% of the Principal Sum subject to a maximum of $25,000 REHABILITATION BENEFIT

Benefit per Covered Accident 5% of the Principal Sum subject to a maximum of $10,000 SEATBELT AND AIRBAG BENEFIT

Seatbelt Benefit 10% of the Principal Sum subject to a Maximum Benefit of $25,000

Airbag Benefit 5% of the Principal Sum subject to a Maximum Benefit of $12,500

Default Benefit $1,000 SPECIAL EDUCATION BENEFIT

Surviving Dependent Child Benefit 3% of the Principal Sum subject to a Maximum Benefit of $5,000

Maximum Number of Annual Payments For Each Surviving Dependent Child 4 Default Benefit $1,000

SPOUSE RETRAINING BENEFIT

3% of the Principal Sum subject to a Maximum Benefit of $3,000 GA-00-1100.00 (SIT)

4

GENERAL DEFINITIONS Please note that certain words used in this Certificate have specific meanings. The words defined below and capitalized within the text of this Certificate have the meanings set forth below. Active Service An Employee will be considered in Active Service with the Employer on any day that is either of the following: 1. one of the Employer’s scheduled work days on which the Employee is performing his regular duties on a full-time

basis, either at one of the Employer’s usual places of business or at some other location to which the Employer’s business requires the Employee to travel;

2. a scheduled holiday, vacation day or period of Employer-approved paid leave of absence, other than sick leave, only if the Employee was in Active Service on the preceding scheduled workday.

A person other than an Employee is considered in Active Service if he is none of the following: 1. an Inpatient in a Hospital or receiving Outpatient care for chemotherapy or radiation therapy; 2. confined at home under the care of a Physician for Sickness or Injury; 3. Totally Disabled. Age A Covered Person’s Age, for purposes of initial premium calculations, is his Age attained on the date coverage becomes effective for him under this Policy. Thereafter, it is his Age attained on his last birthday. Aircraft A vehicle which: 1. has a valid certificate of airworthiness; and 2. is being flown by a pilot with a valid license to operate the Aircraft. Annual Compensation An Employee's annual earnings for normal work established by the Subscriber for his job classification, excluding commissions, bonuses or overtime. Covered Accident A sudden, unforeseeable, external event that results, directly and independently of all other causes, in a Covered Injury or Covered Loss and meets all of the following conditions: 1. occurs while the Covered Person is insured under this Policy; 2. is not contributed to by disease, Sickness, mental or bodily infirmity; 3. is not otherwise excluded under the terms of this Policy. Covered Injury Any bodily harm that results directly and independently of all other causes from a Covered Accident. Covered Loss A loss that is all of the following: 1. the result, directly and independently of all other causes, of a Covered Accident; 2. one of the Covered Losses specified in the Schedule of Covered Losses; 3. suffered by the Covered Person within the applicable time period specified in the Schedule of Benefits. Covered Person An eligible person, as defined in the Schedule of Benefits, for whom an enrollment form has been accepted by Us and required premium has been paid when due and for whom coverage under this Policy remains in force. The term Covered Person shall include, where this Policy provides coverage, an eligible Spouse and eligible Dependent Children.

5

Dependent Child(ren) An Employee’s unmarried child who meets the following requirements: 1. A child from live birth to 19 years old; 2. A child who is 19 or more years old but less than 25 years old, enrolled in a school as a full-time student and primarily

supported by the Employee; 3. A child who is 19 or more years old, primarily supported by the Employee and incapable of self-sustaining

employment by reason of mental or physical handicap. Proof of the child’s condition and dependence must be submitted to Us within 31 days after the date the child ceases to qualify as a Dependent Child for the reasons listed above. During the next two years, We may, from time to time, require proof of the continuation of such condition and dependence. After that, We may require proof no more than once a year.

A child, for purposes of this provision, includes an Employee’s: 1. Natural child; 2. Adopted child, beginning with any waiting period pending finalization of the child’s adoption; 3. Stepchild who resides with the Employee; 4. Child for whom the Employee is legal guardian, as long as the child resides with the Employee and depends on the

Employee for financial support. Financial support means that the Employee is eligible to claim the dependent for purposes of Federal and State income tax returns.

Employee For eligibility purposes, an Employee of the Employer who is in one of the Covered Classes. Employer The Subscriber and any affiliates, subsidiaries or divisions shown in the Schedule of Covered Affiliates and which are covered under this Policy on the date of issue or subsequently agreed to by Us. He, His, Him Refers to any individual, male or female. Hospital An institution that meets all of the following: 1. it is licensed as a Hospital pursuant to applicable law; 2. it is primarily and continuously engaged in providing medical care and treatment to sick and injured persons; 3. it is managed under the supervision of a staff of medical doctors; 4. it provides 24-hour nursing services by or under the supervision of a graduate registered nurse (R.N.); 5. it has medical, diagnostic and treatment facilities, with major surgical facilities on its premises, or available on a

prearranged basis; 6. it charges for its services. The term Hospital does not include a clinic, facility, or unit of a Hospital for: 1. rehabilitation, convalescent, custodial, educational or nursing care; 2. the aged, drug addicts or alcoholics; 3. a Veteran’s Administration Hospital or Federal Government Hospital unless the Covered Person incurs an expense. Inpatient A Covered Person who is confined for at least one full day’s Hospital room and board. The requirement that a person be charged for room and board does not apply to confinement in a Veteran’s Administration Hospital or Federal Government Hospital and in such case, the term 'Inpatient' shall mean a Covered Person who is required to be confined for a period of at least a full day as determined by the Hospital. Nurse A licensed graduate Registered Nurse (R.N.), a licensed practical Nurse (L.P.N.) or a licensed vocational Nurse (L.V.N.) and who is not: 1. employed or retained by the Subscriber; 2. living in the Covered Person’s household; or 3. a parent, sibling, spouse or child of the Covered Person.

6

Outpatient A Covered Person who receives treatment, services and supplies while not an Inpatient in a Hospital. Prior Plan The plan of insurance providing similar benefits, sponsored by the Employer in effect immediately prior to this Policy’s Effective Date. Physician A licensed health care provider practicing within the scope of his license and rendering care and treatment to a Covered Person that is appropriate for the condition and locality and who is not: 1. employed or retained by the Subscriber; 2. living in the Covered Person’s household; 3. a parent, sibling, spouse or child of the Covered Person. Sickness A physical or mental illness. Spouse The Employee’s lawful spouse under age 70. Subscriber Any participating organization that subscribes to the trust to which this Policy is issued. Totally Disabled or Total Disability Totally Disabled or Total Disability means either: 1. inability of the Covered Person who is currently employed to do any type of work for which he is or may become

qualified by reason of education, training or experience; or 2. inability of the Covered Person who is not currently employed to perform all of the activities of daily living including

eating, transferring, dressing, toileting, bathing, and continence, without human supervision or assistance. We, Us, Our Life Insurance Company of North America. You, Your The person to whom the certificate is issued. GA-00-1200.00 (SIT)

7

ELIGIBILITY AND EFFECTIVE DATE PROVISIONS Subscriber Effective Date Accident Insurance Benefits become effective for each Subscriber in consideration of the Subscriber's application, Subscription Agreement and payment of the initial premium when due. Insurance coverage for the Subscriber becomes effective on the Effective Date of Subscriber Participation. Eligibility An Employee becomes eligible for insurance under this Policy on the date he meets all of the requirements of one of the Covered Classes and completes any Eligibility Waiting Period, as shown in the Schedule of Benefits. A Spouse and Dependent Children of an eligible Employee become eligible for any dependent insurance provided by this Policy on the later of the date the Employee becomes eligible and the date the Spouse or Dependent Child meets the applicable definition shown in the Definitions section of this Policy. No person may be eligible for insurance under this Policy as both an Employee and a Spouse or Dependent Child at the same time. Effective Date for Individuals Insurance becomes effective for an eligible Employee who applies and agrees to make required contributions within 31 days of eligibility, and subject to the Deferred Effective Date provision below, on the latest of the following dates: 1. the effective date of this Policy; 2. the date the Employee becomes eligible; 3. the date We receive the Employee’s completed enrollment form and the required first premium, during his lifetime. Insurance becomes effective for an Employee’s eligible dependents if the Employee applies and agrees to make required contributions within 31 days of the date his dependents become eligible on the latest of the following dates: 1. the effective date of this Policy; 2. the date the Employee becomes eligible; 3. the date the Employee’s insurance becomes effective; 4. the date the dependent meets the definition of Spouse or Dependent Child, as applicable; 5. the date We receive a completed enrollment form for Spouse and Dependent Child coverage and the required first

premium, during each dependent’s lifetime. Insurance becomes effective for a newborn Dependent Child automatically from the moment of the child’s live birth. Insurance for that Dependent Child automatically ends 31 days later unless the Employee has a Spouse or other Dependent Children insured under this Policy or makes a request to cover the child and pays the required initial premium, during the child’s lifetime. DEFERRED EFFECTIVE DATE Active Service The effective date of insurance will be deferred for any Employee or any eligible Spouse or Dependent Child who is not in Active Service on the date coverage would otherwise become effective. Coverage will become effective on the later of the date he returns to Active Service and the date coverage would otherwise have become effective. Annual Re-Enrollment An Employee currently insured under this Policy, and a person who is eligible but has not previously enrolled, may increase or become insured for coverage under this Policy during an annual re-enrollment period as agreed to by Us and the Subscriber. An Employee who is insured under this Policy may also elect or increase coverage for his eligible dependents. Coverage elected during an Annual Re-Enrollment Period will become effective, subject to the Active Service section of the Deferred Effective Date provision, on the Policy Anniversary following the date We receive a request and any required premium payment. Life Status Change A Life Status Change is an event that the Employer determines qualifies an Employee to elect or increase accident insurance benefits for himself and his Spouse and Dependent Children. Any change in benefit elections must be made within 31 days of a Life Status Change. Any increases in benefits or added benefits elected under this Life Status Change provision will become effective on the first of the month following the Life Status Change.

8

The Subscriber should seek advice of its tax advisors if Employees may contribute to the cost of any insurance provided by this Policy with earnings not subject to Federal Income Tax. We cannot provide such advice nor offer any opinions on taxation or tax status of any contributions toward the cost of insurance. Effective Date of Changes Any increase or decrease in the amount of insurance for the Covered Person resulting from: 1. a change in benefits provided by this Policy; or 2. a change in the Employee’s Covered Class will take effect on the date of such change. Increases will take effect subject to any Active Service requirement. TERMINATION OF INSURANCE The insurance on a Covered Person will end on the earliest date below: 1. the date this Policy or insurance for a Covered Class is terminated; 2. the next premium due date after the date the Covered Person is no longer in a Covered Class or satisfies eligibility

requirements under this Policy; 3. the last day of the last period for which premium is paid; 4. the next premium due date after the Covered Person attains the maximum Age for insurance under this Policy; 5. with respect to a Spouse or Dependent Child, the date of the death of the covered Employee or the date of divorce from

the covered Employee. Termination will not affect a claim for a Covered Loss or Covered Injury that is the result, directly and independently of all other causes, of a Covered Accident that occurs while coverage was in effect. Continuation for Leave of Absence or Family Medical Leave Insurance for an Employee and Covered Dependents may be continued until the earliest of the following dates if: (a) an Employee is on an Employer-approved leave of absence or an Employer-approved family medical leave; and (b) required premium contributions are paid when due. 1. for an Employer-approved leave of absence: 3 months after the end of the month in which the leave begins; 2. for an Employer-approved family medical leave: 12 weeks in a consecutive 12-month period. GA-00-1300.00 (SIT)

9

COMMON EXCLUSIONS In addition to any benefit-specific exclusions, benefits will not be paid for any Covered Injury or Covered Loss which, directly or indirectly, in whole or in part, is caused by or results from any of the following unless coverage is specifically provided for by name in the Description of Benefits Section: 1. intentionally self-inflicted Injury, suicide or any attempt thereat while sane or insane; 2. commission or attempt to commit a felony or an assault; 3. commission of or active participation in a riot or insurrection; 4. bungee jumping; parachuting; skydiving; parasailing; hang-gliding; 5. declared or undeclared war or act of war; 6. flight in, boarding or alighting from an Aircraft or any craft designed to fly above the Earth’s surface:

a. except as a passenger on a regularly scheduled commercial airline; b. being flown by the Covered Person or in which the Covered Person is a member of the crew; c. being used for:

i. crop dusting, spraying or seeding, giving and receiving flying instruction, fire fighting, sky writing, sky diving or hang-gliding, pipeline or power line inspection, aerial photography or exploration, racing, endurance tests, stunt or acrobatic flying; or

ii. any operation that requires a special permit from the FAA, even if it is granted (this does not apply if the permit is required only because of the territory flown over or landed on);

d. designed for flight above or beyond the earth’s atmosphere; e. an ultra-light or glider; f. being used for the purpose of parachuting or skydiving; g. being used by any military authority, except an Aircraft used by the Air Mobility Command or its foreign

equivalent; 7. Sickness, disease, bodily or mental infirmity, bacterial or viral infection or medical or surgical treatment thereof,

except for any bacterial infection resulting from an accidental external cut or wound or accidental ingestion of contaminated food;

8. travel in any Aircraft owned, leased or controlled by the Subscriber, or any of its subsidiaries or affiliates. An Aircraft will be deemed to be 'controlled' by the Subscriber if the Aircraft may be used as the Subscriber wishes for more than 10 straight days, or more than 15 days in any year;

9. a Covered Accident that occurs while engaged in the activities of active duty service in the military, navy or air force of any country or international organization. Covered Accidents that occur while engaged in Reserve or National Guard training are not excluded until training extends beyond 31 days.

10. operating any type of vehicle while under the influence of alcohol or any drug, narcotic or other intoxicant including any prescribed drug for which the Covered Person has been provided a written warning against operating a vehicle while taking it. Under the influence of alcohol, for purposes of this exclusion, means intoxicated, as defined by the law of the state in which the Covered Accident occurred;

11. voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a Physician and taken in accordance with the prescribed dosage;

12. in addition, benefits will not be paid for services or treatment rendered by a Physician, Nurse or any other person who is: a. employed or retained by the Subscriber; b. providing homeopathic, aroma-therapeutic or herbal therapeutic services; c. living in the Covered Person’s household; d. a parent, sibling, spouse or child of the Covered Person.

GA-00-1401.00 (SIT)

10

CONVERSION PRIVILEGE 1. If the Covered Person’s insurance or any portion of it ends for any of the following reasons:

a. employment or membership ends; b. eligibility ends (except for age); the Covered Person may have Us issue converted accident insurance on an individual policy or an individual certificate under a designated group policy. The Covered Person may apply for an amount of coverage that is: a. in $1,000 increments; b. not less than $25,000, regardless of the amount of insurance under the group policy; and c. not more than the amount of insurance he had under the group policy, except as provided above, up to a maximum

amount of $250,000.

The Covered Person must be under age 70 to get a converted policy. If the Covered Person’s insurance or any portion of it ends for non-payment of premium, he may not convert. If the Covered Person’s insurance ends for a reason described in 2. below, conversion is subject to that section. The converted policy or certificate will cover accidental death and dismemberment. The policy or certificate will not contain disability or other additional benefits. The Covered Person need not show Us that he is insurable. If the Covered Person has converted his group coverage and later becomes insured under the same group plan as before, he may not convert a second time unless he provides, at his own expense, proof of insurability or proof the prior converted policy is no longer in force. The Covered Person must apply for the individual policy within 31 days after his coverage under this Group Policy ends and pay the required premium, based on Our table of rates for such policies, his Age and class of risk. If the Covered Person has assigned ownership of his group coverage, the owner/assignee must apply for the individual policy. If the Covered Person dies during this 31-day period as the result of an accident that would have been covered under this Group Policy, We will pay as a claim under this Group Policy the amount of insurance that the Covered Person was entitled to convert. It does not matter whether the Covered Person applied for the individual policy or certificate. If such policy or certificate is issued, it will be in exchange for any other benefits under this Group Policy. The individual policy or certificate will take effect on the day following the date coverage under the Group Policy ended; or, if later, the date application is made. Exclusions The converted policy may exclude the hazards or conditions that apply to the Covered Person’s group coverage at the time it ends. We will reduce payment under the converted policy by the amount of any benefits paid under the group policy if both cover the same loss.

2. If the Covered Person’s insurance ends because this Group Policy is terminated or is amended to terminate insurance for the Covered Person’s class, and he has been covered under this Group Policy for at least five years, the Covered Person may have Us issue an individual policy or certificate of accident insurance subject to the same terms, conditions and limitations listed above. However, the amount he may apply for will be limited to the lesser of the following: a. coverage under this Group Policy less any amount of group accident insurance for which he is eligible on the date

this Group Policy is terminated or for which he became eligible within 31 days of such termination, or b. $10,000.

GA-01-1500.00 (SIT)

11

CLAIM PROVISIONS Notice of Claim Written or authorized electronic/telephonic notice of claim must be given to Us within 31 days after a Covered Loss occurs or begins or as soon as reasonably possible. If written or authorized electronic/telephonic notice is not given in that time, the claim will not be invalidated or reduced if it is shown that written or authorized electronic/telephonic notice was given as soon as was reasonably possible. Notice can be given to Us at Our Home Office in Philadelphia, Pennsylvania, such other place as We may designate for the purpose, or to Our authorized agent. Notice should include the Subscriber's name and policy number and the Covered Person’s name, address, policy and certificate number. Claim Forms We will send claim forms for filing proof of loss when We receive notice of a claim. If such forms are not sent within 15 days after We receive notice, the proof requirements will be met by submitting, within the time fixed in this Policy for filing proof of loss, written or authorized electronic proof of the nature and extent of the loss for which the claim is made. Claimant Cooperation Provision Failure of a claimant to cooperate with Us in the administration of the claim may result in termination of the claim. Such cooperation includes, but is not limited to, providing any information or documents needed to determine whether benefits are payable or the actual benefit amount due. Proof of Loss Written or authorized electronic proof of loss satisfactory to Us must be given to Us at Our office, within 90 days of the loss for which claim is made. If (a) benefits are payable as periodic payments and (b) each payment is contingent upon continuing loss, then proof of loss must be submitted within 90 days after the termination of each period for which We are liable. If written or authorized electronic notice is not given within that time, no claim will be invalidated or reduced if it is shown that such notice was given as soon as reasonably possible. In any case, written or authorized electronic proof must be given not more than one year after the time it is otherwise required, except if proof is not given solely due to the lack of legal capacity. Time of Payment of Claims We will pay benefits due under this Policy for any loss other than a loss for which this Policy provides any periodic payment immediately upon receipt of due written or authorized electronic proof of such loss. Subject to due written or authorized electronic proof of loss, all accrued benefits for loss for which this Policy provides periodic payment will be paid monthly unless otherwise specified in the benefits descriptions and any balance remaining unpaid at the termination of liability will be paid immediately upon receipt of proof satisfactory to Us. Payment of Claims All benefits will be paid in United States currency. Benefits for loss of life will be payable in accordance with the Beneficiary provision and these Claim Provisions. All other proceeds payable under this Policy, unless otherwise stated, will be payable to the covered Employee or to his estate. If We are to pay benefits to the estate or to a person who is incapable of giving a valid release, We may pay $1,000 to a relative by blood or marriage whom We believe is equitably entitled. Any payment made by Us in good faith pursuant to this provision will fully discharge Us to the extent of such payment and release Us from all liability. Physical Examination and Autopsy We, at Our own expense, have the right and opportunity to examine You, Your Spouse and/or Dependent Child when and as often as We may reasonably require while a claim is pending and to make an autopsy in case of death where it is not forbidden by law. Legal Actions No action at law or in equity may be brought to recover under this Policy less than 60 days after written or authorized electronic proof of loss has been furnished as required by this Policy. No such action will be brought more than three years after the time such written proof of loss must be furnished.

12

Beneficiary The beneficiary is the person or persons You name or change on a form executed by You and satisfactory to Us. This form may be in writing or by any electronic means agreed upon between Us and the Subscriber. Consent of the beneficiary is not required to affect any changes, unless the beneficiary has been designated as an irrevocable beneficiary, or to make any assignment of rights or benefits permitted by this Policy. Any Accidental Death Benefit payable at the death of Your Spouse or Dependent Child will be paid to You or Your estate. A beneficiary designation or change will become effective on the date You execute it. However, We will not be liable for any action taken or payment made before We record notice of the change at our Home Office. If more than one person is named as beneficiary, the interests of each will be equal unless You have specified otherwise. The share of any beneficiary who does not survive You, Your Spouse or Dependent Child will pass equally to any surviving beneficiaries unless otherwise specified. If there is no named beneficiary or surviving beneficiary, or if You die while benefits are payable to You, We may make direct payment to the first surviving class of the following classes of persons: 1. spouse; 2. child or children; 3. mother or father; 4. sisters or brothers; 5. your estate or the estate of your Spouse and/or Dependent Children. Recovery of Overpayment If benefits are overpaid, We have the right to recover the amount overpaid by either of the following methods. 1. A request for lump sum payment of the overpaid amount. 2. A reduction of any amounts payable under this Policy. If there is an overpayment due when You, Your Spouse or Dependent Children die, We may recover the overpayment from Your, Your Spouse's or Dependent Child's estate. GA-00-CE1600.00 (SIT)

13

ADMINISTRATIVE PROVISIONS Premiums All premium rates are expressed in, and all premiums are payable in, United States currency. The premiums for this Policy will be based on the rates set forth in the Policy, the plan and amounts of insurance in effect. If Your, Your Spouse's and/or Dependent Child's insurance amounts are reduced due to age, premium will be based on the amounts of insurance in force on the day before the reduction took place. Grace Period A Grace Period of 31 days will be granted for payment of required premiums under this Policy. Insurance under this Policy for You, Your Spouse and/or Dependent Children will remain in force during the Grace Period. We will reduce any benefits payable for any claims incurred during the grace period by the amount of premium due. If no such claims are incurred and premium is not paid during the grace period, insurance will end on the last day of the period for which premiums were paid. GA-00-CE1700.00 (SIT)

14

GENERAL PROVISIONS Misstatement of Fact If You, Your Spouse or Dependent Children have misstated any fact, all amounts payable under this Policy will be such as the premium paid would have purchased had such fact been correctly stated. Multiple Certificates You may have in force only one certificate or insurance at a time under this Policy. If at any time You have been issued more than one certificate, then only the largest shall be in effect. We will refund premiums paid for the others for any period of time that more than one certificate was issued. Assignment We will be bound by an assignment of a Covered Person's insurance under this Policy only when the original assignment or a certified copy of the assignment, signed by the Covered Person and any irrevocable beneficiary, is filed with Us. The assignee may exercise all rights and receive all benefits assigned only while the assignment remains in effect and insurance under this Policy and the Covered Person’s certificate remains in force. Incontestability of Your, Your Spouse's and/or Dependent Child's Insurance All statements made by You, Your Spouse and/or Dependent Children are considered representations and not warranties. No statement will be used to deny or reduce benefits or be used as a defense to a claim, unless a copy of the instrument containing the statement is, or has been, furnished to the claimant. After two years from Your, Your Spouse's and/or Dependent Child's effective date of insurance, or from the effective date of increased benefits, no such statement will cause insurance or the increased benefits to be contested except for fraud or lack of eligibility for insurance. In the event of death or incapacity, the beneficiary or representative shall be given a copy. Clerical Error Insurance for You, Your Spouse and/or Dependent Children will not be affected by error or delay in keeping records of insurance under this Policy. If such error or delay is found, We will adjust the premium fairly. Policy Changes We may agree with the Subscriber to modify a plan of benefits without Your, Your Spouse's and/or Dependent Child's consent. Workers’ Compensation Insurance This Policy is not in place of and does not affect any requirements for coverage under any Workers’ Compensation law. GA-00-CE1800.00 (SIT)

15

DESCRIPTION OF COVERAGES AND BENEFITS This Description of Coverages and Benefits Section describes the Accident Coverages and Benefits provided to You. Benefit amounts, benefit periods and any applicable aggregate and benefit maximums are shown in the Schedule of Benefits. Certain words capitalized in the text of these descriptions have special meanings within this Certificate and are defined in the General Definitions section. Please read these and the Common Exclusions sections in order to understand all of the terms, conditions and limitations applicable to these coverages and benefits. ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS Covered Loss We will pay the benefit for any one of the Covered Losses listed in the Schedule of Benefits, if the

Covered Person suffers a Covered Loss resulting directly and independently of all other causes from a Covered Accident within the applicable time period specified in the Schedule of Benefits.

If the Covered Person sustains more than one Covered Loss as a result of the same Covered Accident, benefits will be paid for the Covered Loss for which the largest available benefit is payable. If the loss results in death, benefits will only be paid under the Loss of Life benefit provision. Any Loss of Life benefit will be reduced by any paid or payable Accidental Dismemberment benefit. However, if such Accidental Dismemberment benefit equals or exceeds the Loss of Life benefit, no additional benefit will be paid.

Definitions Loss of a Hand or Foot means complete Severance through or above the wrist or ankle joint.

Loss of Sight means the total, permanent loss of all vision in one eye which is irrecoverable by natural, surgical or artificial means. Loss of Speech means total and permanent loss of audible communication which is irrecoverable by natural, surgical or artificial means. Loss of Hearing means total and permanent loss of ability to hear any sound in both ears which is irrecoverable by natural, surgical or artificial means. Loss of a Thumb and Index Finger of the Same Hand or Four Fingers of the Same Hand means complete Severance through or above the metacarpophalangeal joints of the same hand (the joints between the fingers and the hand).

Loss of Toes means complete Severance through the metatarsalphalangeal joint. Paralysis or Paralyzed means total loss of use of a limb. A Physician must determine the loss of use to be complete and irreversible. Quadriplegia means total Paralysis of both upper and both lower limbs. Hemiplegia means total Paralysis of the upper and lower limbs on one side of the body. Paraplegia means total Paralysis of both lower limbs or both upper limbs. Uniplegia means total Paralysis of one upper or one lower limb. Coma means a profound state of unconsciousness which resulted directly and independently from all other causes from a Covered Accident, and from which the Covered Person is not likely to be aroused through powerful stimulation. This condition must be diagnosed and treated regularly by a Physician. Coma does not mean any state of unconsciousness intentionally induced during the course of treatment of a Covered Injury unless the state of unconsciousness results from the administration of anesthesia in preparation for surgical treatment of that Covered Accident.

16

Severance means the complete and permanent separation and dismemberment of the part from the body.

Exclusions The exclusions that apply to this benefit are in the Common Exclusions section. GA-00-2100.00 (SIT) ADDITIONAL ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGES Accidental Death and Dismemberment benefits are provided under the following coverages. Any benefits payable under them are shown in the Schedule of Covered Losses and will not be paid in addition to any other Accidental Death and Dismemberment benefits payable. EXPOSURE AND DISAPPEARANCE COVERAGE Benefits for Accidental Death and Dismemberment, as shown in the Schedule of Covered Losses, will be payable if a Covered Person suffers a Covered Loss which results directly and independently of all other causes from unavoidable exposure to the elements following a Covered Accident. If the Covered Person disappears and is not found within one year from the date of the wrecking, sinking or disappearance of the conveyance in which the Covered Person was riding in the course of a trip which would otherwise be covered under this Policy, it will be presumed that the Covered Person’s death resulted directly and independently of all other causes from a Covered Accident. Exclusions The exclusions that apply to this coverage are in the Common Exclusions Section. GA-00-2202.00 (SIT) ADDITIONAL ACCIDENT BENEFITS Accidental Death and Dismemberment benefits are provided under the following Additional Benefits. Any benefits payable under them will be paid in addition to any other Accidental Death and Dismemberment benefit payable. BULLETPROOF VEST BENEFIT We will pay the benefit shown in the Schedule of Benefits if the covered Employee who is Age 18 or older is on official duty for the Subscriber and is shot during a Covered Accident while wearing a Bulletproof Vest and: 1. the Bulletproof Vest fails to prevent the bullet’s penetration through the vest; and 2. such penetration results, directly and independently of all other causes, in a Covered Loss. Definition For purposes of this benefit:

Bulletproof Vest means a protective vest designated as Threat Level II-A, Threat Level II or Threat Level III-A manufactured by a vendor designated by the Subscriber and purchased not more than five years before the Covered Accident.

Exclusions The exclusions that apply to this benefit are in the Common Exclusions Section. GA-00-2218.00 (SIT) CHILD CARE CENTER BENEFIT We will pay benefits shown in the Schedule of Benefits for the care of each surviving Dependent Child in a Child Care Center if death of the covered Employee results directly and independently of all other causes from a Covered Accident and all of the following conditions are met: 1. coverage for his Dependent Children was in force on the date of the Covered Accident causing his death; and 2. one or more surviving Dependent Children is under Age 13 and:

a. was enrolled in a Child Care Center on the date of the Covered Accident; or b. enrolls in a Child Care Center within 90 days from the date of the Covered Accident.

This benefit will be payable to the Surviving Spouse if the Spouse has custody of the child. If the Surviving Spouse does not have custody of the child, benefits will be paid to the child’s legally appointed guardian. Payments will be made at the end of each 12 month period that begins after the date of the covered Employee’s death. A claim must be submitted to Us at the end of each 12 month period. A 12 month period begins: 1. when the Dependent Child enters a Child Care Center for the first time, within the period specified in (2b) above, after

the covered Employee’s death; or

17

2. on the first of the month following the covered Employee’s death, if the Dependent Child was enrolled in a Child Care Center before the covered Employee’s death.

Each succeeding 12 month period begins on the day immediately following the last day of the preceding period. Pro rata payments will be made for periods of enrollment in a Child Care Center of less than 12 months. Definitions For purposes of this benefit:

Child Care Center is a facility which: 1. is licensed and run according to laws and regulations applicable to child care facilities; and 2. provides care and supervision for children in a group setting on a regular, daily basis. A Child Care Center does not include any of the following: 1. a Hospital; 2. the child’s home; 3. care provided during normal school hours while a child is attending grades one through twelve.

Exclusions The exclusions that apply to this benefit are in the Common Exclusions Section. GA-00-2222.00 (SIT) FELONIOUS ASSAULT AND VIOLENT CRIME BENEFIT We will pay the amount shown in the Schedule of Benefits, subject to the following conditions and exclusions, when the Covered Employee suffers a Covered Loss resulting directly and independently of all other causes from a Covered Accident that occurs during a violent crime or felonious assault as described below. A police report detailing the felonious assault or violent crime must be provided before any benefits will be paid. The Covered Accident must occur while the Covered Person is on the business or premises of the Employer. To qualify for benefit payment, the Covered Accident must occur during any of the following: 1. actual or attempted robbery or holdup; 2. actual or attempted kidnapping; 3. any other type of intentional assault that is a crime classified as a felony by the governing statute or common law in the

state where the felony occurred. We will pay a Hospital Stay Benefit, subject to the following conditions and exclusions, when the Covered Person suffers a Covered Loss resulting directly and independently of all other causes from a Covered Accident that occurs during a violent crime or felonious assault if all of the following conditions are met: 1. the Covered Person is covered for Hospital Stay benefits under this Policy; 2. the Hospital Stay begins within 30 days of the violent crime/felonious assault; 3. the Hospital Stay is at the direction and under the care of a Physician; 4. the Covered Person provides proof satisfactory to Us that his Hospital Stay was necessitated to treat Covered Injuries

sustained in a Covered Accident caused solely by a violent crime or felonious assault; 5. the Hospital Stay begins while the Covered Person’s insurance is in effect. The benefit will be paid for each day of a continuous Hospital Stay. Definitions For purposes of this benefit:

Family Member means the Covered Person’s parent, step-parent, Spouse or former Spouse, son, daughter, brother, sister, mother-in-law, father-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, aunt, uncle, cousins, grandparent, grandchild and stepchild. Fellow Employee means a person employed by the same Employer as the Covered Person or by an Employer that is an affiliated or subsidiary corporation. It shall also include any person who was so employed, but whose employment was terminated not more than 45 days prior to the date on which the defined violent crime/felonious assault was committed. Member of the Same Household means a person who maintains residence at the same address as the Covered Person.

18

Exclusions Benefits will not be paid for treatment of any Covered Injury sustained or Covered Loss incurred during any: 1. violent crime or felonious assault committed by the Covered Person; or 2. felonious assault or violent crime committed upon the Covered Person by a Fellow Employee,

Family Member, or Member of the Same Household.

Other exclusions that apply to this benefit are in the Common Exclusions Section. GA-00-2234.00 (SIT) HOME ALTERATION AND VEHICLE MODIFICATION BENEFIT We will pay the Home Alteration and Vehicle Modification Benefit shown in the Schedule of Benefits, subject to the following conditions and exclusions, when the Covered Person suffers a Covered Loss, other than a Loss of Life, resulting directly and independently of all other causes from a Covered Accident. This benefit will be payable if all of the following conditions are met: 1. prior to the date of the Covered Accident causing such Covered Loss, the Covered Person did not require the use of any

adaptive devices or adaptation of residence and/or vehicle; 2. as a direct result of such Covered Loss, the Covered Person now requires such adaptive devices or adaptation of

residence and/or vehicle to maintain an independent lifestyle; 3. the Covered Person requires home alteration or vehicle modification within one year of the date of the Covered

Accident. Exclusions The exclusions that apply to this benefit are in the Common Exclusions Section. GA-00-2236.00 (SIT) REHABILITATION BENEFIT We will pay the Rehabilitation Benefit shown in the Schedule of Benefits, subject to the following conditions and exclusions, when the Covered Person requires Rehabilitation after sustaining a Covered Loss resulting directly and independently of all other causes from a Covered Accident. The Covered Person must require Rehabilitation within two years after the date of the Covered Loss. Definition For purposes of this benefit:

Rehabilitation means medical services, supplies, or treatment, or Hospital confinement (or part of a Hospital confinement) that satisfies all of the following conditions: 1. are essential for physical rehabilitation required due to the Covered Person’s Covered Loss; 2. meet generally accepted standards of medical practice; 3. are performed under the care, supervision or order of a Physician; 4. prepare the Covered Person to return to his or any other occupation.

Exclusions The exclusions that apply to this benefit are in the Common Exclusions Section. GA-00-2248.00 (SIT) SEATBELT AND AIRBAG BENEFIT We will pay the benefit shown in the Schedule of Benefits, subject to the conditions and exclusions described below, when the Covered Person dies directly and independently of all other causes from a Covered Accident while wearing a seatbelt and operating or riding as a passenger in an Automobile. An additional benefit is provided if the Covered Person was also positioned in a seat protected by a properly-functioning and properly deployed Supplemental Restraint System (Airbag). Verification of proper use of the seatbelt at the time of the Covered Accident and that the Supplemental Restraint System properly inflated upon impact must be a part of an official police report of the Covered Accident or be certified, in writing, by the investigating officer(s) and submitted with the Covered Person’s claim to Us. If such certification or police report is not available or it is unclear whether the Covered Person was wearing a seatbelt or positioned in a seat protected by a properly functioning and properly deployed Supplemental Restraint System, We will pay a default benefit shown in the Schedule of Benefits to the Covered Person’s beneficiary.

19

In the case of a child, seatbelt means a child restraint, as required by state law and approved by the National Highway Traffic Safety Administration, properly secured and being used as recommended by its manufacturer for children of like Age and weight at the time of the Covered Accident. Definitions For purposes of this benefit:

Supplemental Restraint System means an airbag that inflates upon impact for added protection to the head and chest areas. Automobile means a self-propelled, private passenger motor vehicle with four or more wheels which is a type both designed and required to be licensed for use on the highway of any state or country. Automobile includes, but is not limited to, a sedan, station wagon, sport utility vehicle, or a motor vehicle of the pickup, van, camper, or motor-home type. Automobile does not include a mobile home or any motor vehicle which is used in mass or public transit.

Exclusions The exclusions that apply to this benefit are in the Common Exclusions Section. GA-00-2251.00 (SIT) SPECIAL EDUCATION BENEFIT We will pay the benefit, up to the Maximum Benefit shown in the Schedule of Benefits, for each qualifying Dependent Child who is insured under the covered Employee’s certificate on the date he dies. The Covered Person’s death must result, directly and independently of all other causes from a Covered Accident for which an Accidental Death Benefit is payable under this Policy. This benefit is subject to the conditions and exclusions described below. A qualifying Dependent Child must: 1. a. be enrolled as a full-time student in an accredited school of higher learning beyond the 12th grade level on the date

of the covered Employee’s Covered Accident; or b. be at the 12th grade level on the date of the covered Employee’s Covered Accident and then enroll as a full-time

student at an accredited school of higher learning within 365 days from the date of the Covered Accident and continue his education as a full-time student.

2. continue his education as a full-time student in such accredited school of higher learning; and 3. incur expenses for tuition, fees, books, room and board, transportation and any other costs payable directly to, or

approved and certified by, such school. Payments will be made to each qualifying Dependent Child or to the child’s legal guardian, if the child is a minor at the end of each year for the number of years shown in the Schedule of Benefits. We must receive proof satisfactory to Us of the Dependent Child’s enrollment and attendance within 31 days of the end of each year. The first year for which a Special Education Benefit is payable will begin on the first of the month following the date the covered Employee died, if the surviving Dependent Child was enrolled on that date in an accredited school of higher learning beyond the 12th grade; otherwise on the date he enrolls in such school. Each succeeding year for which benefits are payable will begin on the date following the end of the preceding year. If no Dependent Child qualifies for Special Education Benefits within 365 days of the covered Employee’s death, We will pay the default benefit shown in the Schedule of Benefits to the covered Employee’s beneficiary. Exclusions The exclusions that apply to this benefit are in the Common Exclusions Section. GA-00-2252.00 (SIT) SPOUSE RETRAINING BENEFIT We will pay expenses incurred, as described below, up to the Maximum Benefit shown in the Schedule of Benefits, to enable the covered Employee’s Spouse to obtain occupational or educational training needed for employment if the covered Employee dies directly and independently of all other causes from a Covered Accident. A covered Spouse must have been insured under this Policy on the date of the covered Employee’s death to be eligible for this benefit. This benefit is subject to the conditions and exclusions described below.

20

This benefit will be payable if the covered Employee dies within one year of a Covered Accident and is survived by his Spouse who: 1. enrolls, within three years after the covered Employee’s death in any accredited school for the purpose of retraining or

refreshing skills needed for employment; and 2. incurs expenses payable directly to, or approved and certified by, such school. Exclusions The exclusions that apply to this benefit are in the Common Exclusions Section. GA-00-2254.00 (SIT)

UNDERWRITTEN BY: LIFE INSURANCE COMPANY OF NORTH AMERICA a CIGNA company Class 1 09/2005

CIGNA Group Insurance Life • Accident • Disability

IMPORTANT INFORMATION ABOUT COVERAGE UNDER THE TEXAS LIFE, ACCIDENT, HEALTH AND HOSPITAL SERVICE

INSURANCE GUARANTY ASSOCIATION Texas law establishes a system, administered by the Texas Life, Accident, Health and Hospital Service Insurance Guaranty Association (the "Association"), to protect policyholders if their life or health insurance company fails to or cannot meet its contractual obligations. Only the policyholders of insurance companies which are members of the Association are eligible for this protection. However, even if a company is a member of the Association, protection is limited and policyholders must meet certain guidelines to qualify. (The law is found in the Texas Insurance Code, Article 21.28-D.) BECAUSE OF STATUTORY LIMITATIONS ON POLICYHOLDER PROTECTION, IT IS POSSIBLE THAT THE ASSOCIATION MAY NOT COVER YOUR POLICY OR MAY NOT COVER YOUR POLICY IN FULL. ELIGIBILITY FOR PROTECTION BY THE ASSOCIATION When an insurance company which is a member of the Association is designated as impaired by the Texas Commissioner of Insurance, the Association provides coverage to policyholders who are: • residents of Texas at the time that their insurance company is impaired; • residents of other states, ONLY if the following conditions are met:

1) The policyholder has a policy with a company based in Texas; 2) The company has never held a license in the policyholder's state of residence; 3) The policyholder's state of residence has a similar guaranty association; and 4) The policyholder is not eligible for coverage by the guaranty association of the policyholder's

state of residence. LIMITS OF PROTECTION BY THE ASSOCIATION Accident, Accident and Health, or Health Insurance: • up to a total of $200,000 for one or more policies for each individual covered. Life Insurance: • net cash surrender value up to a total of $100,000 under one or more policies on any one life; or • death benefits up to a total of $300,000 under one or more policies on any one life. Individual Annuities: • net cash surrender amount up to a total of $100,000 under one or more policies owned by one contractholder. Group Annuities: • net cash surrender amount up to $100,000 in allocated benefits under one or more policies owned by one

contractholder; or • net cash surrender amount up to $5,000,000 in unallocated benefits under one contractholder regardless of the

number of contracts. THE INSURANCE COMPANY AND ITS AGENTS ARE PROHIBITED BY LAW FROM USING THE EXISTENCE OF THE ASSOCIATION FOR THE PURPOSE OF SALES, SOLICITATION, OR INDUCEMENT TO PURCHASE ANY FORM OF INSURANCE. When you are selecting an insurance company, you should not rely on coverage by the Association.

Texas Life, Accident, Health and Hospital Texas Department of Insurance Service Insurance Guaranty Association P.O. Box 149104 6504 Bridge Point Parkway, Suite 450 Austin, Texas 78714-9104 Austin, Texas 78730 800-252-3439 800-982-6362 www.txlifega.org

Life Insurance Company of North America 1601 Chestnut Street, Philadelphia, Pennsylvania 19192-2235 A Stock Insurance Company

GROUP ACCIDENT POLICY

POLICYHOLDER: Trustee of the Group Insurance Trust for Employers in the Public Administration Industry

POLICY NUMBER: OK 960965

POLICY EFFECTIVE DATE:

October 1, 2005

POLICY ANNIVERSARY DATE: October 1

STATE OF ISSUE: Delaware

This Policy describes the terms and conditions of insurance. This Policy goes into effect subject to its applicable terms and conditions at 12:01 AM on the Policy Effective Date shown above at the Policyholder’s address. The laws of the State of Issue shown above govern this Policy. We and the Policyholder agree to all of the terms of this Policy.

THIS IS A GROUP ACCIDENT ONLY INSURANCE POLICY. IT DOES NOT PAY BENEFITS FOR LOSS CAUSED BY SICKNESS.

THIS IS A LIMITED POLICY.

PLEASE READ IT CAREFULLY.

Susan L. Cooper, Secretary Gregory H. Wolf, President

Countersigned________________________________________ Where Required By Law

GA-00-1000.00 (SIT)

TABLE OF CONTENTS

SECTION PAGE NUMBER SCHEDULE OF AFFILIATES 1

SCHEDULE OF BENEFITS 2

GENERAL DEFINITIONS 6

ELIGIBILITY AND EFFECTIVE DATE PROVISIONS 9

COMMON EXCLUSIONS 11

CONVERSION PRIVILEGE 12

CLAIM PROVISIONS 13

ADMINISTRATIVE PROVISIONS 15

GENERAL PROVISIONS 16

ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGE 18

EXPOSURE AND DISAPPEARANCE COVERAGE 19

BULLETPROOF VEST BENEFIT 19

CHILD CARE CENTER BENEFIT 20

FELONIOUS ASSAULT AND VIOLENT CRIME BENEFIT 20

HOME ALTERATION AND VEHICLE MODIFICATION BENEFIT 21

REHABILITATION BENEFIT 21

SEATBELT AND AIRBAG BENEFIT 22

SPECIAL EDUCATION BENEFIT 22

SPOUSE RETRAINING BENEFIT 23

GA-00-1000.00 (SIT)

1

SCHEDULE OF AFFILIATES The following affiliates are covered under this Policy on the effective dates listed below. AFFILIATE NAME LOCATION EFFECTIVE DATE None GA-00-1000.00 (SIT)

2

SCHEDULE OF BENEFITS This Policy is intended to be read in its entirety. In order to understand all the conditions, exclusions and limitations applicable to its benefits, please read all the policy provisions carefully. The Schedule of Benefits provides a brief outline of the coverage and benefits provided by this Policy. Please read the Description of Coverages and Benefits Section for full details. Subscriber: City of Schertz Effective Date of Subscriber Participation: October 1, 2005 Covered Classes: Class 1 All active, full-time salaried Employees of the Employer regularly working a minimum of 30 hours per

week.

3

SCHEDULE OF BENEFITS FOR CLASS 1 This Schedule of Benefits shows maximums, benefit periods and any limitations applicable to benefits provided in this Policy for each Covered Person unless otherwise indicated. Principal Sum, when referred to in this Schedule, means the Employee’s Principal Sum in effect on the date of the Covered Accident causing the Covered Injury or Covered Loss unless otherwise specified. Eligibility Waiting Period The Eligibility Waiting Period is the period of time the Employee must be in a Covered Class to be eligible for coverage.

For Employees hired on or before the Policy Effective Date: None For Employees hired after the Policy Effective Date: None

Time Period for Loss:

Any Covered Loss must occur within: 365 days of the Covered Accident Maximum Age for Insurance: None

VOLUNTARY ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS

Employee Principal Sum: $25,000 units Maximum: $500,000; Benefit amounts in excess of $250,000 are limited to

10 times Annual Compensation. Spouse Principal Sum: If no Dependent Children are insured: 50% of the Employee's Principal Sum If one or more Dependent Children are insured: 40% of the Employee's Principal Sum Maximum: $250,000 Dependent Child Principal Sum: If Spouse is insured: 10% of the Employee's Principal Sum If no Spouse is insured: 15% of the Employee's Principal Sum Maximum: $25,000

SCHEDULE OF COVERED LOSSES

Covered Loss Benefit Loss of Life 100% of the Principal Sum Loss of Two or More Hands or Feet 100% of the Principal Sum Loss of Sight of Both Eyes 100% of the Principal Sum Loss of One Hand or One Foot and Sight in One Eye 100% of the Principal Sum Loss of Speech and Hearing (in both ears) 100% of the Principal Sum Quadriplegia 100% of the Principal Sum Paraplegia 75% of the Principal Sum Hemiplegia 50% of the Principal Sum Uniplegia 25% of the Principal Sum Coma Monthly Benefit 1% of the Principal Sum Number of Monthly Benefits 11 Lump Sum Benefit 100% of the Principal Sum When Payable Beginning of the 12th month Loss of One Hand or Foot 50% of the Principal Sum Loss of Sight in One Eye 50% of the Principal Sum Loss of Speech 50% of the Principal Sum Loss of Hearing (in both ears) 50% of the Principal Sum Loss of all Four Fingers of the Same Hand 25% of the Principal Sum Loss of all the Toes of the Same Foot 25% of the Principal Sum Loss of Thumb and Index Finger of the Same Hand 25% of the Principal Sum

4

Age Reductions A Covered Person's Principal Sum will be reduced to the percentage of his Principal Sum in effect on the date preceding the first reduction, as shown below.

Age Percentage of Benefit Amount 70 but less than 75 65% 75 but less than 80 45% 80 but less than 85 30% 85 or over 15%

ADDITIONAL ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGES Accidental Death and Dismemberment benefits are provided under the following coverages. Any benefits payable under them are as shown in the Schedule of Covered Losses and are not paid in addition to any other Accidental Death and Dismemberment benefits. EXPOSURE AND DISAPPEARANCE COVERAGE Principal Sum multiplied by the percentage applicable to the

Covered Loss, as shown in the Schedule of Covered Losses. ADDITIONAL ACCIDENT BENEFITS Any benefits payable under these Additional Accident Benefits shown below are paid in addition to any other Accidental Death and Dismemberment benefits payable. BULLETPROOF VEST BENEFIT 50% multiplied by the percentage of the Principal Sum

applicable to the Covered Loss, as shown in the Schedule of Covered Losses, subject to a maximum of $25,000

CHILD CARE CENTER BENEFIT

Benefit Amount 3% of the Employee's Principal Sum subject to a maximum of $3,000 per year

Maximum Benefit Period 5 years but not beyond age 13 for each surviving Dependent Child

FELONIOUS ASSAULT AND VIOLENT CRIME BENEFIT

Accidental Death and Dismemberment Benefit 10% multiplied by the percentage of the Principal Sum applicable to the Covered Loss, as shown in the Schedule of Covered Losses, subject to a maximum of $10,000

Hospital Stay Benefit $100 per day Maximum Benefit Period 365 days per Hospital Stay per Covered Accident

HOME ALTERATION AND VEHICLE MODIFICATION BENEFIT

Benefit 10% of the Principal Sum subject to a maximum of $25,000 REHABILITATION BENEFIT

Benefit per Covered Accident 5% of the Principal Sum subject to a maximum of $10,000 SEATBELT AND AIRBAG BENEFIT

Seatbelt Benefit 10% of the Principal Sum subject to a Maximum Benefit of $25,000

Airbag Benefit 5% of the Principal Sum subject to a Maximum Benefit of $12,500

Default Benefit $1,000

5

SPECIAL EDUCATION BENEFIT Surviving Dependent Child Benefit 3% of the Principal Sum subject to a Maximum Benefit of

$5,000 Maximum Number of Annual Payments For Each Surviving Dependent Child 4 Default Benefit $1,000

SPOUSE RETRAINING BENEFIT 3% of the Principal Sum subject to a Maximum Benefit of

$3,000 INITIAL PREMIUM RATES

Premium Rate: Voluntary Insurance Employee Rate: $0.04 per $1,000 Family Rate: $0.06 per $1,000

Mode of Premium Payment: Monthly Contributions: The cost of the coverage is paid by the Employee Premium Due Dates: The Policy Effective Date and the first day of each succeeding modal

period

Premium rates are subject to change in accordance with the Changes in Premium Rates section contained in the Administrative Provisions section of this Policy. GA-00-1100.00 (SIT)

6

GENERAL DEFINITIONS Please note that certain words used in this Policy have specific meanings. The words defined below and capitalized within the text of this Policy have the meanings set forth below. Active Service An Employee will be considered in Active Service with his employer on any day

that is either of the following: 1. one of the Employer’s scheduled work days on which the Employee is

performing his regular duties on a full-time basis, either at one of the Employer’s usual places of business or at some other location to which the Employer’s business requires the Employee to travel;

2. a scheduled holiday, vacation day or period of Employer-approved paid leave of absence, other than sick leave, only if the Employee was in Active Service on the preceding scheduled workday.

A person other than an Employee is considered in Active Service if he is none of the following: 1. an Inpatient in a Hospital or receiving Outpatient care for chemotherapy or

radiation therapy; 2. confined at home under the care of Physician for Sickness or Injury; 3. Totally Disabled.

Age A Covered Person’s Age, for purposes of initial premium calculations, is his Age attained on the date coverage becomes effective for him under this Policy. Thereafter, it is his Age attained on his last birthday.

Aircraft A vehicle which:

1. has a valid certificate of airworthiness; and 2. is being flown by a pilot with a valid license to operate the Aircraft.

Annual Compensation An Employee's annual earnings for normal work established by the Subscriber for

his job classification, excluding commissions, bonuses or overtime. Covered Accident A sudden, unforeseeable, external event that results, directly and independently of

all other causes, in a Covered Injury or Covered Loss and meets all of the following conditions: 1. occurs while the Covered Person is insured under this Policy; 2. is not contributed to by disease, Sickness, mental or bodily infirmity; 3. is not otherwise excluded under the terms of this Policy.

Covered Injury Any bodily harm that results directly and independently of all other causes from a

Covered Accident. Covered Loss A loss that is all of the following:

1. the result, directly and independently of all other causes, of a Covered Accident;

2. one of the Covered Losses specified in the Schedule of Covered Losses; 3. suffered by the Covered Person within the applicable time period specified in

the Schedule of Benefits. Covered Person An eligible person, as defined in the Schedule of Benefits, for whom an enrollment

form has been accepted by Us and required premium has been paid when due and for whom coverage under this Policy remains in force. The term Covered Person shall include, where this Policy provides coverage, an eligible Spouse and eligible Dependent Children.

7

Dependent Child(ren) An Employee’s unmarried child who meets the following requirements: 1. A child from live birth to 19 years old; 2. A child who is 19 or more years old but less than 25 years old, enrolled in a

school as a full-time student and primarily supported by the Employee; 3. A child who is 19 or more years old, primarily supported by the Employee and

incapable of self-sustaining employment by reason of mental or physical handicap. Proof of the child’s condition and dependence must be submitted to Us within 31 days after the date the child ceases to qualify as a Dependent Child for the reasons listed above. During the next two years, We may, from time to time, require proof of the continuation of such condition and dependence. After that, We may require proof no more than once a year.

A child, for purposes of this provision, includes an Employee’s: 1. Natural child; 2. Adopted child, beginning with any waiting period pending finalization of the

child’s adoption; 3. Stepchild who resides with the Employee; 4. Child for whom the Employee is legal guardian, as long as the child resides

with the Employee and depends on the Employee for financial support. Financial support means that the Employee is eligible to claim the dependent for purposes of Federal and State income tax returns.

Employee For eligibility purposes, an Employee of the Employer who is in one of the

Covered Classes. Employer The Subscriber and any affiliates, subsidiaries or divisions shown in the Schedule

of Covered Affiliates and which are covered under this Policy on the date of issue or subsequently agreed to by Us.

He, His, Him Refers to any individual, male or female. Hospital An institution that meets all of the following:

1. it is licensed as a Hospital pursuant to applicable law; 2. it is primarily and continuously engaged in providing medical care and

treatment to sick and injured persons; 3. it is managed under the supervision of a staff of medical doctors; 4. it provides 24-hour nursing services by or under the supervision of a graduate

registered nurse (R.N.); 5. it has medical, diagnostic and treatment facilities, with major surgical facilities

on its premises, or available on a prearranged basis; 6. it charges for its services. The term Hospital does not include a clinic, facility, or unit of a Hospital for: 1. rehabilitation, convalescent, custodial, educational or nursing care; 2. the aged, drug addicts or alcoholics; 3. a Veteran’s Administration Hospital or Federal Government Hospital unless

the Covered Person incurs an expense. Inpatient A Covered Person who is confined for at least one full day’s Hospital room and

board. The requirement that a person be charged for room and board does not apply to confinement in a Veteran’s Administration Hospital or Federal Government Hospital and in such case, the term 'Inpatient' shall mean a Covered Person who is required to be confined for a period of at least a full day as determined by the Hospital.

8

Nurse A licensed graduate Registered Nurse (R.N.), a licensed practical Nurse (L.P.N.) or a licensed vocational Nurse (L.V.N.) and who is not: 1. employed or retained by the Subscriber; 2. living in the Covered Person’s household; or 3. a parent, sibling, spouse or child of the Covered Person.

Outpatient A Covered Person who receives treatment, services and supplies while not an

Inpatient in a Hospital. Prior Plan The plan of insurance providing similar benefits, sponsored by the Employer in

effect immediately prior to this Policy’s Effective Date. Physician A licensed health care provider practicing within the scope of his license and

rendering care and treatment to a Covered Person that is appropriate for the condition and locality and who is not: 1. employed or retained by the Subscriber; 2. living in the Covered Person’s household; 3. a parent, sibling, spouse or child of the Covered Person.

Sickness A physical or mental illness. Spouse The Employee’s lawful spouse under age 70. Subscriber Any participating organization that subscribes to the trust to which this Policy is

issued. Totally Disabled or Totally Disabled or Total Disability means either: Total Disability 1. inability of the Covered Person who is currently employed to do any type of

work for which he is or may become qualified by reason of education, training or experience; or

2. inability of the Covered Person who is not currently employed to perform all of the activities of daily living including eating, transferring, dressing, toileting, bathing, and continence, without human supervision or assistance.

We, Us, Our Life Insurance Company of North America. GA-00-1200.00 (SIT)

9

ELIGIBILITY AND EFFECTIVE DATE PROVISIONS Subscriber Effective Date Accident Insurance Benefits become effective for each Subscriber in consideration of the Subscriber’s application, Subscription Agreement and payment of the initial premium when due. Insurance coverage for the Subscriber becomes effective on the Effective Date of Subscriber Participation as long as the Minimum Participation Requirement shown in the Schedule of Benefits has been satisfied. Eligibility An Employee becomes eligible for insurance under this Policy on the date he meets all of the requirements of one of the Covered Classes and completes any Eligibility Waiting Period, as shown in the Schedule of Benefits. A Spouse and Dependent Children of an eligible Employee become eligible for any dependent insurance provided by this Policy on the later of the date the Employee becomes eligible and the date the Spouse or Dependent Child meets the applicable definition shown in the Definitions section of this Policy. No person may be eligible for insurance under this Policy as both an Employee and a Spouse or Dependent Child at the same time. Effective Date for Individuals Insurance becomes effective for an eligible Employee who applies and agrees to make required contributions within 31 days of eligibility, and subject to the Deferred Effective Date provision below, on the latest of the following dates: 1. the effective date of this Policy; 2. the date the Employee becomes eligible; 3. the date We receive the Employee’s completed enrollment form and the required first premium, during his

lifetime. Insurance becomes effective for an Employee’s eligible dependents if the Employee applies and agrees to make required contributions within 31 days of the date his dependents become eligible on the latest of the following dates: 1. the effective date of this Policy; 2. the date the Employee becomes eligible; 3. the date the Employee’s insurance becomes effective; 4. the date the dependent meets the definition of Spouse or Dependent Child, as applicable; 5. the date We receive a completed enrollment form for Spouse and Dependent Child coverage and the required first

premium, during each dependent’s lifetime. Insurance becomes effective for a newborn Dependent Child automatically from the moment of the child’s live birth. Insurance for that Dependent Child automatically ends 31 days later unless the Employee has a Spouse or other Dependent Children insured under this Policy or makes a request to cover the child and pays the required initial premium, during the child’s lifetime. DEFERRED EFFECTIVE DATE Active Service The effective date of insurance will be deferred for any Employee or any eligible Spouse or Dependent Child who is not in Active Service on the date coverage would otherwise become effective. Coverage will become effective on the later of the date he returns to Active Service and the date coverage would otherwise have become effective. Annual Re-Enrollment An Employee currently insured under this Policy, and a person who is eligible but has not previously enrolled, may increase or become insured for coverage under this Policy during an annual re-enrollment period as agreed to by Us and the Subscriber. An Employee who is insured under this Policy may also elect or increase coverage for his eligible dependents. Coverage elected during an Annual Re-Enrollment Period will become effective, subject to the Active Service section of the Deferred Effective Date provision, on the Policy Anniversary following the date We receive a request and any required premium payment.

10

Life Status Change A Life Status Change is an event that the Employer determines qualifies an Employee to elect or increase accident insurance benefits for himself and his Spouse and Dependent Children. Any change in benefit elections must be made within 31 days of a Life Status Change. Any increases in benefits or added benefits elected under this Life Status Change provision will become effective on the first of the month following the Life Status Change. The Subscriber should seek advice of its tax advisors if Employees may contribute to the cost of any insurance provided by this Policy with earnings not subject to Federal Income Tax. We cannot provide such advice nor offer any opinions on taxation or tax status of any contributions toward the cost of insurance. Effective Date of Changes Any increase or decrease in the amount of insurance for the Covered Person resulting from: 1. a change in benefits provided by this Policy; or 2. a change in the Employee’s Covered Class will take effect on the date of such change. Increases will take effect subject to any Active Service requirement. TERMINATION OF INSURANCE The insurance on a Covered Person will end on the earliest date below: 1. the date this Policy or insurance for a Covered Class is terminated; 2. the next premium due date after the date the Covered Person is no longer in a Covered Class or satisfies eligibility

requirements under this Policy; 3. the last day of the last period for which premium is paid; 4. the next premium due date after the Covered Person attains the maximum Age for insurance under this Policy; 5. with respect to a Spouse or Dependent Child, the date of the death of the covered Employee or the date of divorce

from the covered Employee. Termination will not affect a claim for a Covered Loss or Covered Injury that is the result, directly and independently of all other causes, of a Covered Accident that occurs while coverage was in effect. Continuation for Leave of Absence or Family Medical Leave Insurance for an Employee and Covered Dependents may be continued until the earliest of the following dates if: (a) an Employee is on an Employer-approved leave of absence or an Employer-approved family medical leave; and (b) required premium contributions are paid when due. 1. for an Employer-approved leave of absence: 3 months after the end of the month in which the leave begins; 2. for an Employer-approved family medical leave: 12 weeks in a consecutive 12-month period. GA-00-1300.00 (SIT)

11

COMMON EXCLUSIONS In addition to any benefit-specific exclusions, benefits will not be paid for any Covered Injury or Covered Loss which, directly or indirectly, in whole or in part, is caused by or results from any of the following unless coverage is specifically provided for by name in the Description of Benefits Section: 1. intentionally self-inflicted Injury, suicide or any attempt thereat while sane or insane; 2. commission or attempt to commit a felony or an assault; 3. commission of or active participation in a riot or insurrection; 4. bungee jumping; parachuting; skydiving; parasailing; hang-gliding; 5. declared or undeclared war or act of war; 6. flight in, boarding or alighting from an Aircraft or any craft designed to fly above the Earth’s surface:

a. except as a passenger on a regularly scheduled commercial airline; b. being flown by the Covered Person or in which the Covered Person is a member of the crew; c. being used for:

i. crop dusting, spraying or seeding, giving and receiving flying instruction, fire fighting, sky writing, sky diving or hang-gliding, pipeline or power line inspection, aerial photography or exploration, racing, endurance tests, stunt or acrobatic flying; or

ii. any operation that requires a special permit from the FAA, even if it is granted (this does not apply if the permit is required only because of the territory flown over or landed on);

d. designed for flight above or beyond the earth’s atmosphere; e. an ultra-light or glider; f. being used for the purpose of parachuting or skydiving; g. being used by any military authority, except an Aircraft used by the Air Mobility Command or its foreign

equivalent; 7. Sickness, disease, bodily or mental infirmity, bacterial or viral infection or medical or surgical treatment thereof,

except for any bacterial infection resulting from an accidental external cut or wound or accidental ingestion of contaminated food;

8. travel in any Aircraft owned, leased or controlled by the Subscriber, or any of its subsidiaries or affiliates. An Aircraft will be deemed to be ''controlled'' by the Subscriber if the Aircraft may be used as the Subscriber wishes for more than 10 straight days, or more than 15 days in any year;

9. a Covered Accident that occurs while engaged in the activities of active duty service in the military, navy or air force of any country or international organization. Covered Accidents that occur while engaged in Reserve or National Guard training are not excluded until training extends beyond 31 days;

10. operating any type of vehicle while under the influence of alcohol or any drug, narcotic or other intoxicant including any prescribed drug for which the Covered Person has been provided a written warning against operating a vehicle while taking it. Under the influence of alcohol, for purposes of this exclusion, means intoxicated, as defined by the law of the state in which the Covered Accident occurred;

11. voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a Physician and taken in accordance with the prescribed dosage;

12. in addition, benefits will not be paid for services or treatment rendered by a Physician, Nurse or any other person who is: a. employed or retained by the Subscriber; b. providing homeopathic, aroma-therapeutic or herbal therapeutic services; c. living in the Covered Person’s household; d. a parent, sibling, spouse or child of the Covered Person.

GA-00-1401.00 (SIT)

12

CONVERSION PRIVILEGE 1. If the Covered Person’s insurance or any portion of it ends for any of the following reasons:

a. employment or membership ends; b. eligibility ends (except for age); the Covered Person may have Us issue converted accident insurance on an individual policy or an individual certificate under a designated group policy. The Covered Person may apply for an amount of coverage that is: a. in $1,000 increments; b. not less than $25,000, regardless of the amount of insurance under the group policy; and c. not more than the amount of insurance he had under the group policy, except as provided above, up to a maximum

amount of $250,000.

The Covered Person must be under age 70 to get a converted policy. If the Covered Person’s insurance or any portion of it ends for non-payment of premium, he may not convert. If the Covered Person’s insurance ends for a reason described in 2. below, conversion is subject to that section. The converted policy or certificate will cover accidental death and dismemberment. The policy or certificate will not contain disability or other additional benefits. The Covered Person need not show Us that he is insurable. If the Covered Person has converted his group coverage and later becomes insured under the same group plan as before, he may not convert a second time unless he provides, at his own expense, proof of insurability or proof the prior converted policy is no longer in force. The Covered Person must apply for the individual policy within 31 days after his coverage under this Group Policy ends and pay the required premium, based on Our table of rates for such policies, his Age and class of risk. If the Covered Person has assigned ownership of his group coverage, the owner/assignee must apply for the individual policy. If the Covered Person dies during this 31-day period as the result of an accident that would have been covered under this Group Policy, We will pay as a claim under this Group Policy the amount of insurance that the Covered Person was entitled to convert. It does not matter whether the Covered Person applied for the individual policy or certificate. If such policy or certificate is issued, it will be in exchange for any other benefits under this Group Policy. The individual policy or certificate will take effect on the day following the date coverage under the Group Policy ended; or, if later, the date application is made. Exclusions The converted policy may exclude the hazards or conditions that apply to the Covered Person’s group coverage at the time it ends. We will reduce payment under the converted policy by the amount of any benefits paid under the group policy if both cover the same loss.

2. If the Covered Person’s insurance ends because this Group Policy is terminated or is amended to terminate insurance for the Covered Person’s class, and he has been covered under this Group Policy for at least five years, the Covered Person may have Us issue an individual policy or certificate of accident insurance subject to the same terms, conditions and limitations listed above. However, the amount he may apply for will be limited to the lesser of the following: a. coverage under this Group Policy less any amount of group accident insurance for which he is eligible on the date

this Group Policy is terminated or for which he became eligible within 31 days of such termination, or b. $10,000.

GA-01-1500.00 (SIT)

13

CLAIM PROVISIONS Notice of Claim Written or authorized electronic/telephonic notice of claim must be given to Us within 31 days after a Covered Loss occurs or begins or as soon as reasonably possible. If written or authorized electronic/telephonic notice is not given in that time, the claim will not be invalidated or reduced if it is shown that written or authorized electronic/telephonic notice was given as soon as was reasonably possible. Notice can be given to Us at Our Home Office in Philadelphia, Pennsylvania, such other place as We may designate for the purpose, or to Our authorized agent. Notice should include the Subscriber's name and policy number and the Covered Person’s name, address, policy and certificate number. Claim Forms We will send claim forms for filing proof of loss when We receive notice of a claim. If such forms are not sent within 15 days after We receive notice, the proof requirements will be met by submitting, within the time fixed in this Policy for filing proof of loss, written or authorized electronic proof of the nature and extent of the loss for which the claim is made. Claimant Cooperation Provision Failure of a claimant to cooperate with Us in the administration of the claim may result in termination of the claim. Such cooperation includes, but is not limited to, providing any information or documents needed to determine whether benefits are payable or the actual benefit amount due. Proof of Loss Written or authorized electronic proof of loss satisfactory to Us must be given to Us at Our office, within 90 days of the loss for which claim is made. If (a) benefits are payable as periodic payments and (b) each payment is contingent upon continuing loss, then proof of loss must be submitted within 90 days after the termination of each period for which We are liable. If written or authorized electronic notice is not given within that time, no claim will be invalidated or reduced if it is shown that such notice was given as soon as reasonably possible. In any case, written or authorized electronic proof must be given not more than one year after the time it is otherwise required, except if proof is not given solely due to the lack of legal capacity. Time of Payment of Claims We will pay benefits due under this Policy for any loss other than a loss for which this Policy provides any periodic payment immediately upon receipt of due written or authorized electronic proof of such loss. Subject to due written or authorized electronic proof of loss, all accrued benefits for loss for which this Policy provides periodic payment will be paid monthly unless otherwise specified in the benefits descriptions and any balance remaining unpaid at the termination of liability will be paid immediately upon receipt of proof satisfactory to Us. Payment of Claims All benefits will be paid in United States currency. Benefits for loss of life will be payable in accordance with the Beneficiary provision and these Claim Provisions. All other proceeds payable under this Policy, unless otherwise stated, will be payable to the covered Employee or to his estate. If We are to pay benefits to the estate or to a person who is incapable of giving a valid release, We may pay $1,000 to a relative by blood or marriage whom We believe is equitably entitled. Any payment made by Us in good faith pursuant to this provision will fully discharge Us to the extent of such payment and release Us from all liability. Payment of Claims to Foreign Employees The Subscriber may, in a fiduciary capacity, receive and hold any benefits payable to covered Employees whose place of employment is other than the United States of America. We will not be responsible for the application or disposition by the Subscriber of any such benefits paid. Our payments to the Subscriber will constitute a full discharge of Our liability for those payments under this Policy. Physical Examination and Autopsy We, at Our own expense, have the right and opportunity to examine the Covered Person when and as often as We may reasonably require while a claim is pending and to make an autopsy in case of death where it is not forbidden by law.

14

Legal Actions No action at law or in equity may be brought to recover under this Policy less than 60 days after written or authorized electronic proof of loss has been furnished as required by this Policy. No such action will be brought more than three years after the time such written proof of loss must be furnished. Beneficiary The beneficiary is the person or persons the Employee names or changes on a form executed by him and satisfactory to Us. This form may be in writing or by any electronic means agreed upon between Us and the Subscriber. Consent of the beneficiary is not required to affect any changes, unless the beneficiary has been designated as an irrevocable beneficiary, or to make any assignment of rights or benefits permitted by this Policy. Any Accidental Death Benefit payable at the death of the Employee’s Spouse or Dependent Child will be paid to the Employee or to his estate. A beneficiary designation or change will become effective on the date the Employee executes it. However, We will not be liable for any action taken or payment made before We record notice of the change at our Home Office. If more than one person is named as beneficiary, the interests of each will be equal unless the Employee has specified otherwise. The share of any beneficiary who does not survive the Covered Person will pass equally to any surviving beneficiaries unless otherwise specified. If there is no named beneficiary or surviving beneficiary, or if the Employee dies while benefits are payable to him, We may make direct payment to the first surviving class of the following classes of persons: 1. spouse; 2. child or children; 3. mother or father; 4. sisters or brothers; 5. estate of the Covered Person. Recovery of Overpayment If benefits are overpaid, We have the right to recover the amount overpaid by either of the following methods. 1. A request for lump sum payment of the overpaid amount. 2. A reduction of any amounts payable under this Policy. If there is an overpayment due when the Covered Person dies, We may recover the overpayment from the Covered Person’s estate. GA-00-1600.00 (SIT)

15

ADMINISTRATIVE PROVISIONS Premiums All premium rates are expressed in, and all premiums are payable in, United States currency. The premiums for this Policy will be based on the rates set forth in the Schedule of Benefits, the plan and amounts of insurance in effect. If a Covered Person’s insurance amounts are reduced due to age, premium will be based on the amounts of insurance in force on the day before the reduction took place. Changes in Premium Rates We may change the premium rates from time to time with at least 31 days advance written notice to the Subscriber. No change in rates will be made until 24 months after the Policy Effective Date. An increase in rates will not be made more often than once in a 12-month period. However, We reserve the right to change rates at any time if any of the following events take place: 1. the terms of this Policy change; 2. the terms of the Subscriber's participation change; 3. a division, subsidiary, affiliated company or eligible class is added or deleted from this Policy; 4. there is a change in the factors bearing on the risk assumed; 5. any federal or state law or regulation is amended to the extent it affects Our benefit obligation. Payment of Premium The first premium is due on the Subscriber's effective date of participation under this Policy. Thereafter, premiums are due on the Premium Due Dates agreed upon between Us and the Subscriber. If any premium is not paid when due, the Subscriber's participation under this Policy will be terminated as of the Premium Due Date on which premium was not paid. Grace Period A Grace Period of 31 days will be granted to each Subscriber for payment of required premiums under this Policy. A Subscriber's participation under this Policy will remain in effect during the Grace Period. The Subscriber is liable to Us for any unpaid premium for the time its participation under this Policy was in force. A Grace Period of 31 days will be granted for payment of required premiums under this Policy. A Covered Person’s insurance under this Policy will remain in force during the Grace Period. We will reduce any benefits payable for any claims incurred during the grace period by the amount of premium due. If no such claims are incurred and premium is not paid during the grace period, insurance will end on the last day of the period for which premiums were paid. GA-00-1700.00 (SIT)

16

GENERAL PROVISIONS Entire Contract; Changes This Policy, including the endorsements, amendments and any attached papers constitutes the entire contract of insurance. No change in this Policy will be valid until approved by one of Our executive officers and endorsed on or attached to this Policy. No agent has authority to change this Policy or to waive any of its provisions. Subscriber Participation Under This Policy An organization may elect to participate under this Policy by submitting a signed Subscriber participation agreement to the Policyholder. No participation by an organization is in effect until approved by Us. Misstatement of Fact If the Covered Person has misstated any fact, all amounts payable under this Policy will be such as the premium paid would have purchased had such fact been correctly stated. Certificates Where required by law, We will provide a certificate of insurance for delivery to the Covered Person. Each certificate will list the benefits, conditions and limits of this Policy. It will state to whom benefits will be paid. 30 Day Right To Examine Certificate If a Covered Person does not like the Certificate for any reason, it may be returned to Us within 30 days after receipt. We will return any premium that has been paid and the Certificate will be void as if it had never been issued. Multiple Certificates The Covered Person may have in force only one certificate at a time under this Policy. If at any time the Covered Person has been issued more than one certificate, then only the largest shall be in effect. We will refund premiums paid for the others for any period of time that more than one certificate was issued. Assignment We will be bound by an assignment of a Covered Person's insurance under this Policy only when the original assignment or a certified copy of the assignment, signed by the Covered Person and any irrevocable beneficiary, is filed with Us. The assignee may exercise all rights and receive all benefits assigned only while the assignment remains in effect and insurance under this Policy and the Covered Person’s certificate remains in force. Incontestability 1. Of This Policy or Participation Under This Policy All statements made by the Subscriber to obtain this Policy or to participate under this Policy are considered representations and not warranties. No statement will be used to deny or reduce benefits or be used as a defense to a claim, or to deny the validity of this Policy or of participation under this Policy unless a copy of the instrument containing the statement is, or has been, furnished to the Subscriber. After two years from the Policy Effective Date, no such statement will cause this Policy to be contested except for fraud. 2. Of A Covered Person's Insurance All statements made by a Covered Person are considered representations and not warranties. No statement will be used to deny or reduce benefits or be used as a defense to a claim, unless a copy of the instrument containing the statement is, or has been, furnished to the claimant. After two years from the Covered Person’s effective date of insurance, or from the effective date of increased benefits, no such statement will cause insurance or the increased benefits to be contested except for fraud or lack of eligibility for insurance. In the event of death or incapacity, the beneficiary or representative shall be given a copy.

17

Policy Termination We may terminate coverage on or after the first anniversary of the policy effective date. The Subscriber may terminate coverage on any premium due date. Written or authorized electronic notice must be given at least 31 days prior to such premium due date. Termination will not affect a claim for a Covered Loss that is the result, directly and independently of all other causes, of a Covered Accident that occurs while coverage was in effect. Reinstatement This Policy may be reinstated if it lapsed for nonpayment of premium. Requirements for reinstatement are written application of the Subscriber satisfactory to Us and payment of all overdue premiums. Any premium accepted in connection with a reinstatement will be applied to a period for which premium was not previously paid. Clerical Error A Covered Person's insurance will not be affected by error or delay in keeping records of insurance under this Policy. If such error or delay is found, We will adjust the premium fairly. Conformity with Statutes Any provisions in conflict with the requirements of any state or federal law that apply to this Policy are automatically changed to satisfy the minimum requirements of such laws. Policy Changes We may agree with the Subscriber to modify a plan of benefits without the Covered Person’s consent. Workers’ Compensation Insurance This Policy is not in place of and does not affect any requirements for coverage under any Workers’ Compensation law. Examination of the Policy This Group Policy will be available for inspection at the Subscriber's office during regular business hours. Examination of Records We will be permitted to examine all of the Subscriber's records relating to this Group Policy. Examination may occur at any reasonable time while the Group Policy is in force; or it may occur: 1. at any time for two years after the expiration of this Group Policy; or, if later, 2. upon the final adjustment and settlement of all Group Policy claims. The Subscriber is acting as an agent of the Covered Person for transactions relating to this insurance. The actions of the Subscriber will not be considered Our actions. GA-00-1800.00 (SIT)

18

DESCRIPTION OF COVERAGES AND BENEFITS This Description of Coverages and Benefits Section describes the Accident Coverages and Benefits provided by this Policy. Benefit amounts, benefit periods and any applicable aggregate and benefit maximums are shown in the Schedule of Benefits. Certain words capitalized in the text of these descriptions have special meanings within this Policy and are defined in the General Definitions section. Please read these and the Common Exclusions sections in order to understand all of the terms, conditions and limitations applicable to these coverages and benefits. ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS Covered Loss We will pay the benefit for any one of the Covered Losses listed in the Schedule of Benefits, if

the Covered Person suffers a Covered Loss resulting directly and independently of all other causes from a Covered Accident within the applicable time period specified in the Schedule of Benefits.

If the Covered Person sustains more than one Covered Loss as a result of the same Covered Accident, benefits will be paid for the Covered Loss for which the largest available benefit is payable. If the loss results in death, benefits will only be paid under the Loss of Life benefit provision. Any Loss of Life benefit will be reduced by any paid or payable Accidental Dismemberment benefit. However, if such Accidental Dismemberment benefit equals or exceeds the Loss of Life benefit, no additional benefit will be paid.

Definitions Loss of a Hand or Foot means complete Severance through or above the wrist or ankle

joint. Loss of Sight means the total, permanent loss of all vision in one eye which is irrecoverable by natural, surgical or artificial means. Loss of Speech means total and permanent loss of audible communication which is irrecoverable by natural, surgical or artificial means. Loss of Hearing means total and permanent loss of ability to hear any sound in both ears which is irrecoverable by natural, surgical or artificial means. Loss of a Thumb and Index Finger of the Same Hand or Four Fingers of the Same Hand means complete Severance through or above the metacarpophalangeal joints of the same hand (the joints between the fingers and the hand). Loss of Toes means complete Severance through the metatarsalphalangeal joint. Paralysis or Paralyzed means total loss of use of a limb. A Physician must determine the loss of use to be complete and irreversible. Quadriplegia means total Paralysis of both upper and both lower limbs. Hemiplegia means total Paralysis of the upper and lower limbs on one side of the body. Paraplegia means total Paralysis of both lower limbs or both upper limbs. Uniplegia means total Paralysis of one upper or one lower limb.

19

Coma means a profound state of unconsciousness which resulted directly and independently from all other causes from a Covered Accident, and from which the Covered Person is not likely to be aroused through powerful stimulation. This condition must be diagnosed and treated regularly by a Physician. Coma does not mean any state of unconsciousness intentionally induced during the course of treatment of a Covered Injury unless the state of unconsciousness results from the administration of anesthesia in preparation for surgical treatment of that Covered Accident. Severance means the complete and permanent separation and dismemberment of the part from the body.

Exclusions The exclusions that apply to this benefit are in the Common Exclusions section. GA-00-2100.00 (SIT) ADDITIONAL ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGES Accidental Death and Dismemberment benefits are provided under the following coverages. Any benefits payable under them are shown in the Schedule of Covered Losses and will not be paid in addition to any other Accidental Death and Dismemberment benefits payable. EXPOSURE AND DISAPPEARANCE COVERAGE Benefits for Accidental Death and Dismemberment, as shown in the Schedule of Covered Losses, will be payable if a Covered Person suffers a Covered Loss which results directly and independently of all other causes from unavoidable exposure to the elements following a Covered Accident. If the Covered Person disappears and is not found within one year from the date of the wrecking, sinking or disappearance of the conveyance in which the Covered Person was riding in the course of a trip which would otherwise be covered under this Policy, it will be presumed that the Covered Person’s death resulted directly and independently of all other causes from a Covered Accident. Exclusions The exclusions that apply to this coverage are in the Common Exclusions Section. GA-00-2202.00 (SIT) ADDITIONAL ACCIDENT BENEFITS Accidental Death and Dismemberment benefits are provided under the following Additional Benefits. Any benefits payable under them will be paid in addition to any other Accidental Death and Dismemberment benefit payable. BULLETPROOF VEST BENEFIT We will pay the benefit shown in the Schedule of Benefits if the covered Employee who is Age 18 or older is on official duty for the Subscriber and is shot during a Covered Accident while wearing a Bulletproof Vest and: 1. the Bulletproof Vest fails to prevent the bullet’s penetration through the vest; and 2. such penetration results, directly and independently of all other causes, in a Covered Loss. Definition For purposes of this benefit:

Bulletproof Vest means a protective vest designated as Threat Level II-A, Threat Level II or Threat Level III-A manufactured by a vendor designated by the Subscriber and purchased not more than five years before the Covered Accident.

Exclusions The exclusions that apply to this benefit are in the Common Exclusions Section. GA-00-2218.00 (SIT)

20

CHILD CARE CENTER BENEFIT We will pay benefits shown in the Schedule of Benefits for the care of each surviving Dependent Child in a Child Care Center if death of the covered Employee results directly and independently of all other causes from a Covered Accident and all of the following conditions are met: 1. coverage for his Dependent Children was in force on the date of the Covered Accident causing his death; and 2. one or more surviving Dependent Children is under Age 13 and:

a. was enrolled in a Child Care Center on the date of the Covered Accident; or b. enrolls in a Child Care Center within 90 days from the date of the Covered Accident.

This benefit will be payable to the Surviving Spouse if the Spouse has custody of the child. If the Surviving Spouse does not have custody of the child, benefits will be paid to the child’s legally appointed guardian. Payments will be made at the end of each 12 month period that begins after the date of the covered Employee’s death. A claim must be submitted to Us at the end of each 12 month period. A 12 month period begins: 1. when the Dependent Child enters a Child Care Center for the first time, within the period specified in (2b) above,

after the covered Employee’s death; or 2. on the first of the month following the covered Employee’s death, if the Dependent Child was enrolled in a Child

Care Center before the covered Employee’s death. Each succeeding 12 month period begins on the day immediately following the last day of the preceding period. Pro rata payments will be made for periods of enrollment in a Child Care Center of less than 12 months. Definitions For purposes of this benefit:

Child Care Center is a facility which: 1. is licensed and run according to laws and regulations applicable to child care facilities; and 2. provides care and supervision for children in a group setting on a regular, daily basis. A Child Care Center does not include any of the following: 1. a Hospital; 2. the child’s home; 3. care provided during normal school hours while a child is attending grades one through twelve.

Exclusions The exclusions that apply to this benefit are in the Common Exclusions Section. GA-00-2222.00 (SIT) FELONIOUS ASSAULT AND VIOLENT CRIME BENEFIT We will pay the amount shown in the Schedule of Benefits, subject to the following conditions and exclusions, when the Covered Employee suffers a Covered Loss resulting directly and independently of all other causes from a Covered Accident that occurs during a violent crime or felonious assault as described below. A police report detailing the felonious assault or violent crime must be provided before any benefits will be paid. The Covered Accident must occur while the Covered Person is on the business or premises of the Employer. To qualify for benefit payment, the Covered Accident must occur during any of the following: 1. actual or attempted robbery or holdup; 2. actual or attempted kidnapping; 3. any other type of intentional assault that is a crime classified as a felony by the governing statute or common law

in the state where the felony occurred. We will pay a Hospital Stay Benefit, subject to the following conditions and exclusions, when the Covered Person suffers a Covered Loss resulting directly and independently of all other causes from a Covered Accident that occurs during a violent crime or felonious assault if all of the following conditions are met: 1. the Covered Person is covered for Hospital Stay benefits under this Policy; 2. the Hospital Stay begins within 30 days of the violent crime/felonious assault; 3. the Hospital Stay is at the direction and under the care of a Physician; 4. the Covered Person provides proof satisfactory to Us that his Hospital Stay was necessitated to treat Covered

Injuries sustained in a Covered Accident caused solely by a violent crime or felonious assault; 5. the Hospital Stay begins while the Covered Person’s insurance is in effect.

21

The benefit will be paid for each day of a continuous Hospital Stay. Definitions For purposes of this benefit:

Family Member means the Covered Person’s parent, step-parent, Spouse or former Spouse, son, daughter, brother, sister, mother-in-law, father-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, aunt, uncle, cousins, grandparent, grandchild and stepchild. Fellow Employee means a person employed by the same Employer as the Covered Person or by an Employer that is an affiliated or subsidiary corporation. It shall also include any person who was so employed, but whose employment was terminated not more than 45 days prior to the date on which the defined violent crime/felonious assault was committed.

Member of the Same Household means a person who maintains residence at the same address as the Covered Person.

Exclusions Benefits will not be paid for treatment of any Covered Injury sustained or Covered Loss incurred during

any: 1. violent crime or felonious assault committed by the Covered Person; or 2. felonious assault or violent crime committed upon the Covered Person by a Fellow

Employee, Family Member, or Member of the Same Household.

Other exclusions that apply to this benefit are in the Common Exclusions Section. GA-00-2234.00 (SIT) HOME ALTERATION AND VEHICLE MODIFICATION BENEFIT We will pay the Home Alteration and Vehicle Modification Benefit shown in the Schedule of Benefits, subject to the following conditions and exclusions, when the Covered Person suffers a Covered Loss, other than a Loss of Life, resulting directly and independently of all other causes from a Covered Accident. This benefit will be payable if all of the following conditions are met: 1. prior to the date of the Covered Accident causing such Covered Loss, the Covered Person did not require the use

of any adaptive devices or adaptation of residence and/or vehicle; 2. as a direct result of such Covered Loss, the Covered Person now requires such adaptive devices or adaptation of

residence and/or vehicle to maintain an independent lifestyle; 3. the Covered Person requires home alteration or vehicle modification within one year of the date of the Covered

Accident. Exclusions The exclusions that apply to this benefit are in the Common Exclusions Section. GA-00-2236.00 (SIT) REHABILITATION BENEFIT We will pay the Rehabilitation Benefit shown in the Schedule of Benefits, subject to the following conditions and exclusions, when the Covered Person requires Rehabilitation after sustaining a Covered Loss resulting directly and independently of all other causes from a Covered Accident. The Covered Person must require Rehabilitation within two years after the date of the Covered Loss. Definition For purposes of this benefit:

Rehabilitation means medical services, supplies, or treatment, or Hospital confinement (or part of a Hospital confinement) that satisfies all of the following conditions: 1. are essential for physical rehabilitation required due to the Covered Person’s Covered

Loss; 2. meet generally accepted standards of medical practice; 3. are performed under the care, supervision or order of a Physician; 4. prepare the Covered Person to return to his or any other occupation.

22

Exclusions The exclusions that apply to this benefit are in the Common Exclusions Section. GA-00-2248.00 (SIT) SEATBELT AND AIRBAG BENEFIT We will pay the benefit shown in the Schedule of Benefits, subject to the conditions and exclusions described below, when the Covered Person dies directly and independently of all other causes from a Covered Accident while wearing a seatbelt and operating or riding as a passenger in an Automobile. An additional benefit is provided if the Covered Person was also positioned in a seat protected by a properly-functioning and properly deployed Supplemental Restraint System (Airbag). Verification of proper use of the seatbelt at the time of the Covered Accident and that the Supplemental Restraint System properly inflated upon impact must be a part of an official police report of the Covered Accident or be certified, in writing, by the investigating officer(s) and submitted with the Covered Person’s claim to Us. If such certification or police report is not available or it is unclear whether the Covered Person was wearing a seatbelt or positioned in a seat protected by a properly functioning and properly deployed Supplemental Restraint System, We will pay a default benefit shown in the Schedule of Benefits to the Covered Person’s beneficiary. In the case of a child, seatbelt means a child restraint, as required by state law and approved by the National Highway Traffic Safety Administration, properly secured and being used as recommended by its manufacturer for children of like Age and weight at the time of the Covered Accident. Definitions For purposes of this benefit:

Supplemental Restraint System means an airbag that inflates upon impact for added protection to the head and chest areas. Automobile means a self-propelled, private passenger motor vehicle with four or more wheels which is a type both designed and required to be licensed for use on the highway of any state or country. Automobile includes, but is not limited to, a sedan, station wagon, sport utility vehicle, or a motor vehicle of the pickup, van, camper, or motor-home type. Automobile does not include a mobile home or any motor vehicle which is used in mass or public transit.

Exclusions The exclusions that apply to this benefit are in the Common Exclusions Section. GA-00-2251.00 (SIT) SPECIAL EDUCATION BENEFIT We will pay the benefit, up to the Maximum Benefit shown in the Schedule of Benefits, for each qualifying Dependent Child who is insured under the covered Employee’s certificate on the date he dies. The Covered Person’s death must result, directly and independently of all other causes from a Covered Accident for which an Accidental Death Benefit is payable under this Policy. This benefit is subject to the conditions and exclusions described below. A qualifying Dependent Child must: 1. a. be enrolled as a full-time student in an accredited school of higher learning beyond the 12th grade level on the date

of the covered Employee’s Covered Accident; or b. be at the 12th grade level on the date of the covered Employee’s Covered Accident and then enroll as a full-time

student at an accredited school of higher learning within 365 days from the date of the Covered Accident and continue his education as a full-time student.

2. continue his education as a full-time student in such accredited school of higher learning; and 3. incur expenses for tuition, fees, books, room and board, transportation and any other costs payable directly to, or

approved and certified by, such school. Payments will be made to each qualifying Dependent Child or to the child’s legal guardian, if the child is a minor at the end of each year for the number of years shown in the Schedule of Benefits. We must receive proof satisfactory to Us of the Dependent Child’s enrollment and attendance within 31 days of the end of each year. The first year for which a Special Education Benefit is payable will begin on the first of the month following the date the covered Employee died, if the surviving Dependent Child was enrolled on that date in an accredited school of higher learning beyond the 12th grade; otherwise on the date he enrolls in such school. Each succeeding year for which benefits are payable will begin on the date following the end of the preceding year.

23

If no Dependent Child qualifies for Special Education Benefits within 365 days of the covered Employee’s death, We will pay the default benefit shown in the Schedule of Benefits to the covered Employee’s beneficiary. Exclusions The exclusions that apply to this benefit are in the Common Exclusions Section. GA-00-2252.00 (SIT) SPOUSE RETRAINING BENEFIT We will pay expenses incurred, as described below, up to the Maximum Benefit shown in the Schedule of Benefits, to enable the covered Employee’s Spouse to obtain occupational or educational training needed for employment if the covered Employee dies directly and independently of all other causes from a Covered Accident. A covered Spouse must have been insured under this Policy on the date of the covered Employee’s death to be eligible for this benefit. This benefit is subject to the conditions and exclusions described below. This benefit will be payable if the covered Employee dies within one year of a Covered Accident and is survived by his Spouse who: 1. enrolls, within three years after the covered Employee’s death in any accredited school for the purpose of

retraining or refreshing skills needed for employment; and 2. incurs expenses payable directly to, or approved and certified by, such school. Exclusions The exclusions that apply to this benefit are in the Common Exclusions Section. GA-00-2254.00 (SIT)

LIFE INSURANCE COMPANY OF NORTH AMERICA Philadelphia, PA 19192-2235

We, City of Schertz, whose main office address is Schertz, TX, hereby approve and accept the terms of Group Policy Number OK 960965 issued by the LIFE INSURANCE COMPANY OF NORTH AMERICA to the TRUSTEE OF THE GROUP INSURANCE TRUST FOR EMPLOYERS IN THE PUBLIC ADMINISTRATION INDUSTRY. This form is to be signed in duplicate. One part is to be retained by City of Schertz; the other part is to be returned to the LIFE INSURANCE COMPANY OF NORTH AMERICA.

City of Schertz

Signature and Title:____________________________________________ Date: __________________________

(This Copy Is To Be Returned To Life Insurance Company of North America) -------------------------------------------------------------------------------------------------------------------------------------------

LIFE INSURANCE COMPANY OF NORTH AMERICA Philadelphia, PA 19192-2235

We, City of Schertz, whose main office address is Schertz, TX, hereby approve and accept the terms of Group Policy Number OK 960965 issued by the LIFE INSURANCE COMPANY OF NORTH AMERICA to the TRUSTEE OF THE GROUP INSURANCE TRUST FOR EMPLOYERS IN THE PUBLIC ADMINISTRATION INDUSTRY. This form is to be signed in duplicate. One part is to be retained by City of Schertz; the other part is to be returned to the LIFE INSURANCE COMPANY OF NORTH AMERICA.

City of Schertz

Signature and Title:____________________________________________ Date: __________________________

(This Copy Is To Be Retained By City of Schertz)

zip birthdate Plan Selection

78154 12/7/1949 Dental Plan ‐ Ameritas Dental ‐ 100/80/50 with Ortho EE Only




































































78109 9/22/1978 Dental Plan ‐ Ameritas Dental ‐ 100/80/50 with Ortho EE + Children
















78154 10/27/1950 Dental Plan ‐ Ameritas Dental ‐ 100/80/50 with Ortho EE + Spouse














78233 11/20/1981 Dental Plan ‐ Ameritas Dental ‐ 100/80/50 with Ortho EE + Family






















78064 3/29/1985 Dental Plan ‐ Ameritas Dental ‐ Preventative Plus EE Only











































78666 10/16/1983 Dental Plan ‐ Ameritas Dental ‐ Preventative Plus EE + Spouse














78154 6/8/1977 Dental Plan ‐ Ameritas Dental ‐ Preventative Plus EE + Children















78154 8/29/1983 Dental Plan ‐ Ameritas Dental ‐ Preventative Plus EE + Family
























78233 11/20/1981 Vision Plan ‐ Ameritas Vision EE Only

































78155 12/11/1961 Vision Plan ‐ Ameritas Vision EE + 1







































78109 9/22/1978 Vision Plan ‐ Ameritas Vision EE + Family








































gender zip birthdate Plan Selection

M 78108 9/18/1968 Humana PPO ‐ $1500 Deductible (Base Plan) EE Only


F 78260 5/11/1993 Humana PPO ‐ $1500 Deductible (Base Plan) EE Only


























































































M 78064 3/29/1985 Humana PPO ‐ $3000 Deductible (HDHP) EE Only




F 78148 8/31/1980 Humana PPO ‐ $3000 Deductible (HDHP) EE Only


































M 78233 11/20/1981 Humana PPO ‐ $1000 Deductible (High Option) EE Only


F 78154 8/12/1982 Humana PPO ‐ $1000 Deductible (High Option) EE Only



















































F 78108 11/1/1980 Humana PPO ‐ $3000 Deductible (HDHP) EE + Children

M 78154 10/16/1973 Humana PPO ‐ $3000 Deductible (HDHP) EE + Children

M 78130 9/29/1956 Humana PPO ‐ $3000 Deductible (HDHP) EE + Spouse

M 78258 7/5/1981 Humana PPO ‐ $3000 Deductible (HDHP) EE + Spouse

F 78218 6/3/1994 Humana PPO ‐ $3000 Deductible (HDHP) EE + Spouse

M 78233 1/14/1975 Humana PPO ‐ $1500 Deductible (Base Plan) EE + Children




F 78108 1/3/1960 Humana PPO ‐ $1500 Deductible (Base Plan) EE + Children






















M 78233 5/7/1968 Humana PPO ‐ $1500 Deductible (Base Plan) EE + Spouse

M 78215 7/13/1983 Humana PPO ‐ $1500 Deductible (Base Plan) EE + Spouse

M 78108 4/30/1971 Humana PPO ‐ $1000 Deductible (High Option) EE + Children

F 78154 5/16/1979 Humana PPO ‐ $1000 Deductible (High Option) EE + Children





F 78216 12/1/1980 Humana PPO ‐ $1000 Deductible (High Option) EE + Children

M 78154 2/8/1957 Humana PPO ‐ $1000 Deductible (High Option) EE + Spouse







M 78666 10/16/1983 Humana PPO ‐ $3000 Deductible EE+ Family






F 78133 9/24/1981 Humana PPO ‐ $3000 Deductible EE+ Family

F 78154 3/4/1975 Humana PPO ‐ $1500 Deductible (Base Plan) EE+ Family

F 78154 8/16/1961 Humana PPO ‐ $1500 Deductible (Base Plan) EE+ Family

M 78109 12/28/1988 Humana PPO ‐ $1500 Deductible (Base Plan) EE+ Family



F 78108 3/27/1960 Humana PPO ‐ $1000 Deductible (High Option) EE+ Family

M 78124 2/23/1973 Humana PPO ‐ $1000 Deductible (High Option) EE+ Family





F 78108 12/18/1989 Humana PPO ‐ $1000 Deductible (High Option) EE+ Family



F 78154 3/14/1956 Health Insurance ‐ Decline Health Benefit

M 78154 5/23/1986 Health Insurance ‐ Decline Health Benefit



















Platform Group # Provider ID HOSP PHY CD PROV NPI ID Tax ID Organization Par/Non Par Specialty #Claims #Claimants Net Paid Bill Address Bill Address2 Bill City Bill ST

EM 704728 107843033716 1841688579 202505226 SHARMA, GEETANJALI CP P COUNSELOR PROFESSIONAL 2 1 $425 2161 NW MILITARY HWY STE 207 SAN ANTONIO TX

EM 704728 112788114402 1467538439 487769275 CLIFFORD, SUSAN D LPC P COUNSELOR PROFESSIONAL 7 1 $286 1122 W BLANCO RD SAN ANTONIO TX

EM 704728 115021085008 1467758003 257960812 STEWART, ALLISON M CP P COUNSELOR PROFESSIONAL 8 1 $442 921 LAKEVIEW BLVD NEW BRAUNFELS TX

EM 704728 145381162871 1043229339 272389923 ALANIZ, MARTHA LPC P COUNSELOR PROFESSIONAL 1 1 $65 17503 LA CANTERA PKWY STE 104 BOX 509 SAN ANTONIO TX

EM 704728 145794405248 1861749574 472351558 FRYAR, NECOLE W LPC P COUNSELOR PROFESSIONAL 7 1 $490 9830 APPELLATE WAY CONVERSE TX

EM 704728 150785374765 1700017928 272389923 TRIBETT, TERESA I PC P COUNSELOR PROFESSIONAL 2 1 $110 4201 MEDICAL DR STE 330 SAN ANTONIO TX

EM 704728 153638540664 1245406222 467170339 KAPPUS, LINDA E LPC P COUNSELOR PROFESSIONAL 5 1 $247 11107 WURZBACH RD STE 604 SAN ANTONIO TX

EM 704728 180014180186 1801081849 450977029 GURNO, ANGELA B LPC P COUNSELOR PROFESSIONAL 1 1 $76 20634 WILD SPRINGS DR SAN ANTONIO TX

EM 704728 10659950883 1992734479 010624198 CASTILLO, MICHAEL G PHD P PSYCHOLOGIST 2 1 $141 4242 MEDICAL DR BLDG 6 SAN ANTONIO TX

EM 704728 121025444999 1912356197 742815026 GAULTNEY, NICHOLAS APN P PSYCHOLOGIST 2 1 $251 1380 PANTHEON WAY STE 310 SAN ANTONIO TX

EM 704728 133878414230 1760467963 272756909 GUTIERREZ, CHARLES E PHD P PSYCHOLOGIST 2 1 $234 343 W HOUSTON ST SUITE 1010 SAN ANTONIO TX

EM 704728 147203352442 1053865816 741586031 LOPEZ, ELIOT PHD P PSYCHOLOGIST 5 1 $423 7703 FLOYD CURL DR SAN ANTONIO TX

EM 704728 165970450505 1356789234 461487562 INGRAM, HEATHER A PSYD P PSYCHOLOGIST 1 1 $121 4715 VIEWRIDGE AVE STE 230 SAN DIEGO CA

EM 704728 174897532050 1740206135 047522911 CHATILLON, LISA PH D N PSYCHOLOGIST 8 1 $456 1868 NACOGDOCHES RD SAN ANTONIO TX

EM 704728 195892570912 1619248416 202505226 ZUMWALT, KARRI A PHD P PSYCHOLOGIST 1 1 $252 8610 N NEW BRAUNFELS AVE STE 700 SAN ANTONIO TX

EM 704728 124677420330 1538270400 462909966 MORRIS, TIMOTHY C LCSW P SOCIAL WORKER 1 1 $67 715 SLUMBER PASS SAN ANTONIO TX

EM 704728 138565202705 1952734980 272389923 BLACKMAN, JIRZIA LCSW N SOCIAL WORKER 1 1 $0 17503 LA CANTERA PKWY STE 104 BOX 509

SAN ANTONIO TX

EM 704728 160187525387 1124082029 467196956 WARREN, LESLIE A LCSW P SOCIAL WORKER 9 1 $325 3030 NACOGDOCHES RD STE 101 SAN ANTONIO TX

EM 704728 10659952142 1831109776 457766641 KOEHLER, KATHLEEN G LMFT P MARRIAGE & FAMILY THERAPIST 1 1 $52 3030 NACOGDOCHES RD STE 101 SAN ANTONIO TX

EM 704728 108268455599 1497791560 464541549 PUHL III, HAROLD F DC P CHIROPRACTOR 6 2 $0 147 W SUNSET RD STE 101 SAN ANTONIO TX

EM 704728 120075453927 1518030501 451153429 KENNELL, JAMES F DC P CHIROPRACTOR 3 2 $107 215 W BANDERA RD STE 114 BOERNE TX

EM 704728 127134370394 1033523139 465566175 ROSE, KOREY A DC P CHIROPRACTOR 2 1 $9 395 LANDA ST NEW BRAUNFELS TX

EM 704728 128562023682 1457512733 467968341 VAJDOS, VANESSA E DC P CHIROPRACTOR 2 1 $118 6781 FM 1102 NEW BRAUNFELS TX

EM 704728 130025204305 1912236175 261455666 YOUNG, SHELDON DC P CHIROPRACTOR 5 2 $570 PO BOX 223950 PITTSBURGH PA

CLAIM SUMMARY BY PROVIDER

CITY OF SCHERTZ(704728)

Service Address information may be incomplete

Humana Confidential and Proprietary 1 of 66




EM 704728 131990592600 1386886422 742974923 OLIVER, CHARLES A DC P CHIROPRACTOR 8 1 $0 930 PROTON RD STE 104 SAN ANTONIO TX

EM 704728 152958382860 1932232410 741978834 RYAN, BILLY L DC P CHIROPRACTOR 1 1 $18 458 PAMELA DR SAN ANTONIO TX

EM 704728 167028585486 1275674681 742927914 OTTERMAN, GREGORY T DC P CHIROPRACTOR 2 1 $125 13133 NW MILITARY HWY STE 300 SAN ANTONIO TX

EM 704728 171119231145 1427188051 742855391 CZERMINSKI, DREW S DC P CHIROPRACTOR 6 1 $0 12107 TOEPPERWEIN RD STE 8 LIVE OAK TX

EM 704728 171728384259 1467528083 742627149 SCHULZE, RANDALL M DC P CHIROPRACTOR 3 1 $108 11924 VANCE JACKSON RD STE 104 SAN ANTONIO TX

EM 704728 177949520643 1396967998 452376311 LAMBERT, JEREMY A DC P CHIROPRACTOR 1 1 $133 908 AVENUE F MARBLE FALLS TX

EM 704728 180034591979 1346354628 205026080 MAIRE, DANIEL J DC P CHIROPRACTOR 13 4 $63 750 SCHNEIDER STE 170 CIBOLO TX

EM 704728 184638365736 1083725444 742893354 MOORE, ANDREW W DC P CHIROPRACTOR 7 1 $0 8507 MCCULLOUGH AVE STE A1 SAN ANTONIO TX

EM 704728 188157071284 1134514862 465566175 ROSE, KELSEY E DC P CHIROPRACTOR 1 1 $0 395 LANDA ST NEW BRAUNFELS TX

EM 704728 192529170413 1427099514 742907091 WERSELL, CHAD E DC P CHIROPRACTOR 2 1 $40 15150 NACOGDOCHES RD STE 185 SAN ANTONIO TX

EM 704728 105755520690 1184970782 453673502 DAWAR, NEHA DDS N DENTIST 1 1 $0 PO BOX 511474 LOS ANGELES CA

EM 704728 125450425060 1760620173 742676907 PINA, DIANA C S DDS N DENTIST 1 1 $0 8606 VILLAGE DR STE B SAN ANTONIO TX

EM 704728 169548074878 1104987478 742559563 DRAKE, RICHARD B DDS P DENTIST 1 1 $2,243 14603 HUEBNER RD BLDG 4 SAN ANTONIO TX

EM 704728 192979040565 1811040363 270065849 HAERENS, OLAF J DDS N DENTIST 1 1 $0 652 NORTH HOUSTON AVENUE SUITE 1 NEW BRAUNFELS TX

EM 704728 151358444343 1053739367 743010657 HEB GROCERY COMPANY P DIETITIAN, REGISTERED 1 1 $0 646 S MAIN AVE SAN ANTONIO TX

EM 704728 10659950941 1568467298 742143569 OROZCO, MICHAEL A OD P OPTOMETRIST 1 1 $25 PO BOX 1358 SAN ANTONIO TX

EM 704728 104891591649 1588744288 202144835 KLUFAS, ROMAN Y OD P OPTOMETRIST 15 11 $811 1420 SCHERTZ PKWY STE 130 SCHERTZ TX

EM 704728 109003313576 1134416241 452641469 NIELSEN, LEIGHA M OD P OPTOMETRIST 4 3 $147 1928 STATE HWY 46 W STE 110 NEW BRAUNFELS TX

EM 704728 109232531064 1386687432 742977936 BARNES, DEBRA M OD P OPTOMETRIST 1 1 $0 17323 IH 35 N STE 110 SCHERTZ TX

EM 704728 126486431391 1225104888 742006921 BLASE, JOHN SCOTT OD P OPTOMETRIST 1 1 $74 9250 F M 78 CONVERSE TX

EM 704728 146241121275 742977936 BUTTLAR, MICHELLE L OD P OPTOMETRIST 2 1 $22 17323 IH 35 N STE 110 SCHERTZ TX

EM 704728 151800463318 1841360633 205542441 JENSEN, KENT C OD P OPTOMETRIST 1 1 $86 11703 HUEBNER RD STE 109 SAN ANTONIO TX

EM 704728 199776072160 1578571683 474005162 KIKUCHI, KENTARO OD P OPTOMETRIST 1 1 $86 PO BOX 6957 CORPUS CHRISTI TX

EM 704728 115081510641 1538251764 331007777 BAMC MCHE COU T DEPT 201 P MULTI-SPECIALTY 7 3 $33 3551 ROGER BROOKE DR FT SAM HOUSTON TX

EM 704728 128762244306 743005464 359TH MEDICAL GROUP RANDOLPH AFB CLINIC P MULTI-SPECIALTY 2 2 $46 221 3RD STREET WEST BLDG 1040 RANDOLPH AFB TX

EM 704728 171870055572 1265423693 200376970 M AND S RADIOLOGY ASSOCIATES PA P MULTI-SPECIALTY 15 13 $879 PO BOX 2947 SAN ANTONIO TX





EM 704728 115065410407 1255386140 731009960 GISSELL, MICHAEL B DDS P ORAL & MAXILLOFACIAL SURGERY 2 1 $761 6501 BLANCO RD SAN ANTONIO TX

EM 704728 125005290091 1659331650 412086979 CLARK, CHARLES L DDS N ORAL & MAXILLOFACIAL SURGERY 2 2 $0 4470 E HIGHWAY 287 STE 1200 MIDLOTHIAN TX

EM 704728 150243320426 1881623304 412086979 CROSS, STEVEN E DDS N ORAL & MAXILLOFACIAL SURGERY 2 2 $0 109 FALLS CT STE 700 BOERNE TX

EM 704728 116901031695 1053397265 741936369 WOOD, DALE A MD P ALLERGY & IMMUNOLOGY ALLERGY 18 2 $840 341 E HILDEBRAND AVE SAN ANTONIO TX

EM 704728 122547555741 1487844775 208694108 BUSSEY SMITH, KRISTIN L MD P ALLERGY & IMMUNOLOGY ALLERGY 2 1 $0 PO BOX 1198 HELOTES TX

EM 704728 134865241481 1649527334 460928477 CROWELL, FAYE M PA P ALLERGY & IMMUNOLOGY ALLERGY 5 1 $69 21 SPURS LN STE 100 SAN ANTONIO TX

EM 704728 148295343590 1346281839 742047021 GUPTA, PRIYANKA MD P ALLERGY & IMMUNOLOGY ALLERGY 14 3 $1,076 212 HUNTERS VILLAGE STE 105 NEW BRAUNFELS TX

EM 704728 150654001940 1568653756 460928477 TROTT-GREGORIO, AMANDA A MD P ALLERGY & IMMUNOLOGY ALLERGY 3 1 $34 5656 BEE CAVE RD G201 AUSTIN TX

EM 704728 174364254461 1770709370 271952252 GOMEZ DINGER, PATRICIA L DO P ALLERGY & IMMUNOLOGY ALLERGY 35 7 $2,877 540 MADISON OAK DR STE 210 SAN ANTONIO TX

EM 704728 102402260269 1699742312 275559874 FOMITCHEV, IVAN MD P ANESTHESIOLOGY 13 1 $1,034 1642 LOCKHILL SELMA RD SAN ANTONIO TX

EM 704728 107545080775 1851434831 742779329 HAEDGE, PHILIP MD P ANESTHESIOLOGY 1 1 $1,299 PO BOX 659 SAN ANTONIO TX

EM 704728 114673290215 1417243338 020721955 STEVENS, SAMUEL H MD P ANESTHESIOLOGY 1 1 $326 PO BOX 733947 DALLAS TX

EM 704728 116705345725 1336117381 742779329 CLIFTON, JOHN B MD N ANESTHESIOLOGY 1 1 $208 PO BOX 659 SAN ANTONIO TX

EM 704728 119608253108 1144257833 743003947 DOBSON, MICKEY B MD P ANESTHESIOLOGY 1 1 $438 PO BOX 9585 BELFAST ME

EM 704728 120399401190 1760662191 742779329 CHANG, KUANG YU M MD P ANESTHESIOLOGY 2 2 $2,495 PO BOX 659 SAN ANTONIO TX

EM 704728 123232515011 1992971063 742779329 HARVILLE, AARON L MD P ANESTHESIOLOGY 1 1 $1,966 PO BOX 659 SAN ANTONIO TX

EM 704728 126895144426 1780662098 742779329 BOATMAN, ERIK A MD P ANESTHESIOLOGY 1 1 $672 PO BOX 659 SAN ANTONIO TX

EM 704728 133375510025 1619974789 020721955 MILLER, ERIC J MD P ANESTHESIOLOGY 3 1 $1,633 PO BOX 733947 DALLAS TX

EM 704728 134790153616 1275516056 742779329 HARRINGTON, BRIAN B MD N ANESTHESIOLOGY 1 1 $0 PO BOX 659 SAN ANTONIO TX

EM 704728 135292370479 1982655866 300857847 SJULSON, NEIL B MD N ANESTHESIOLOGY 2 2 $220 1550 BOYSON RD HIAWATHA IA

EM 704728 141875195793 1083653513 275559874 BORSHCH, YURII D MD P ANESTHESIOLOGY 1 1 $57 PO BOX 26 SAN ANTONIO TX

EM 704728 142908150458 1457721243 020721955 KENNEDY, KAYCEE W FNP P ANESTHESIOLOGY 1 1 $144 PO BOX 733947 DALLAS TX

EM 704728 143650180205 1215156542 743003947 GREWAL, PRABHDEEP K MD P ANESTHESIOLOGY 11 2 $830 PO BOX 9585 BELFAST ME

EM 704728 146089381681 1699758201 742779329 RIOS, RUBEN MD P ANESTHESIOLOGY 1 1 $58 PO BOX 659 SAN ANTONIO TX

EM 704728 148730341549 1649435090 742779329 PAYNE, MILES MD P ANESTHESIOLOGY 1 1 $1,107 PO BOX 659 SAN ANTONIO TX

EM 704728 150619303019 1255314068 742779329 JOHNSON JR, OLIVER H MD P ANESTHESIOLOGY 1 1 $305 PO BOX 659 SAN ANTONIO TX





EM 704728 154905422377 1154391944 300857847 GOLDSTEIN, DAVID MD N ANESTHESIOLOGY 1 1 $0 PO BOX 2778 SAN ANTONIO TX

EM 704728 159559534489 1710961255 742779329 CROCKETT, RICHARD W MD P ANESTHESIOLOGY 1 1 $1,072 PO BOX 659 SAN ANTONIO TX

EM 704728 162569223072 1275517450 742779329 PERCHES, DAVID MD P ANESTHESIOLOGY 2 2 $1,374 PO BOX 659 SAN ANTONIO TX

EM 704728 165369292972 1396728101 742779329 HOFFMAN, MICHAEL R MD N ANESTHESIOLOGY 1 1 $0 PO BOX 659 SAN ANTONIO TX

EM 704728 165369292972 1396728101 742779329 HOFFMAN, MICHAEL R MD P ANESTHESIOLOGY 2 2 $1,697 PO BOX 659 SAN ANTONIO TX

EM 704728 166297531443 1548208564 760482007 USAP TEXAS N ANESTHESIOLOGY 2 1 $158 PO BOX 840853 DALLAS TX

EM 704728 173100473001 1154400810 300857847 NORWOOD, PATRICIA A MD N ANESTHESIOLOGY 2 2 $1,649 PO BOX 845347 DALLAS TX

EM 704728 173790400600 1851374037 742779329 GRABOW, MARIA MD P ANESTHESIOLOGY 1 1 $454 PO BOX 659 SAN ANTONIO TX

EM 704728 176808581707 1114989985 300857847 HARPER, DONALD R MD N ANESTHESIOLOGY 1 1 $62 PO BOX 845347 DALLAS TX

EM 704728 179949214684 1184618472 272177557 MINA, MAGED M MD P ANESTHESIOLOGY 1 1 $43 PO BOX 659 SAN ANTONIO TX

EM 704728 188546525598 1619915907 208324675 VALLE, JOSE J MD P ANESTHESIOLOGY 1 1 $99 PO BOX 254 SAN ANTONIO TX

EM 704728 189879365753 1508840588 742779329 PERRETTA, PETER T MD P ANESTHESIOLOGY 1 1 $1,264 PO BOX 659 SAN ANTONIO TX

EM 704728 190067515945 1659383305 742712486 TEJAS ANESTHESIA PA N ANESTHESIOLOGY 8 8 $1,986 PO BOX 34717 SAN ANTONIO TX

EM 704728 190067515945 1659383305 742712486 TEJAS ANESTHESIA PA P ANESTHESIOLOGY 4 2 $3,860 PO BOX 34717 SAN ANTONIO TX

EM 704728 199504553290 1427435387 473856415 SOUTH TEXAS ANESTHESIA GROUP N ANESTHESIOLOGY 1 1 $1,071 PO BOX 29211 PHOENIX AZ

EM 704728 10654345813 1114978624 320043653 QUINTERO, VICENTE MD P DERMATOLOGY 2 2 $50 493 S SEGUIN AVE NEW BRAUNFELS TX

EM 704728 10654345820 1114089844 462971399 TIEMAN, JOHN M MD P DERMATOLOGY 1 1 $0 1584 COMMON ST NEW BRAUNFELS TX

EM 704728 10659961836 1104834456 742592013 JOHNSON, RINNA CONOL MD P DERMATOLOGY 10 7 $497 7832 PAT BOOKER RD SAN ANTONIO TX

EM 704728 10659961963 1184600165 383744511 ROSS GARCIA, KIM M MD P DERMATOLOGY 2 2 $315 1303 MCCULLOUGH AVE STE 560 SAN ANTONIO TX

EM 704728 103778432019 1154339455 742592013 ATKINSON GARZA, ELOISE L MD P DERMATOLOGY 1 1 $39 7832 PAT BOOKER RD LIVE OAK TX

EM 704728 104521121835 1154567212 320043653 MARTIN, ALLISON PA P DERMATOLOGY 1 1 $113 493 S SEGUIN AVE NEW BRAUNFELS TX

EM 704728 105914432876 1447278262 204727613 GARCIA, MARK D DO P DERMATOLOGY 7 5 $157 2660 COMMON ST STE 104 NEW BRAUNFELS TX

EM 704728 113221530820 1144458373 742592013 STAHR, STEPHEN G MD P DERMATOLOGY 6 6 $119 PO BOX 9 CONVERSE TX

EM 704728 116160212425 1013993096 742162581 MAGNON, ROBERT J MD P DERMATOLOGY 2 1 $63 1342 E WALNUT ST SEGUIN TX

EM 704728 116539064311 1235147810 742592013 HOCKLEY III, ALFRED J MD P DERMATOLOGY 17 9 $441 PO BOX 9 CONVERSE TX

EM 704728 122246125529 1144493024 742592013 ALTMEYER, MARY D MD P DERMATOLOGY 5 5 $313 7832 PAT BOOKER RD SAN ANTONIO TX





EM 704728 124970562988 1477556256 200761158 LADD II, DANIEL J DO P DERMATOLOGY 3 1 $0 3500 JEFFERSON ST STE 200 AUSTIN TX

EM 704728 125199563830 1760454060 742935457 MILLER, STEPHEN MD P DERMATOLOGY 1 1 $76 PO BOX 116 SAN ANTONIO TX

EM 704728 136269231494 1831215763 208819467 SAYED, AMARA Z DO P DERMATOLOGY 2 1 $59 PO BOX 639355 CINCINNATI OH

EM 704728 136357330661 1588670780 742592013 GUERRERO, KAREN T MD P DERMATOLOGY 2 2 $68 7832 PAT BOOKER RD LIVE OAK TX

EM 704728 137493434510 1861460644 814895898 SAAP, LILIANA J MD P DERMATOLOGY 8 1 $6,907 PO BOX 593437 SAN ANTONIO TX

EM 704728 156806443802 1003158544 460938434 SANDHU, AMANDEEP S MD P DERMATOLOGY 1 1 $42 7832 PAT BOOKER RD SAN ANTONIO TX

EM 704728 160479462319 1205827532 474637409 BOUCHER, JEAN DENIS MD N DERMATOLOGY 5 3 $0 PO BOX 5166 BELFAST ME

EM 704728 171249582734 1194876193 943455563 KELSO, REBECCA L MD P DERMATOLOGY 1 1 $18 PO BOX 2537 SAN ANTONIO TX

EM 704728 172847461378 1124181615 460938434 BROWNING, JOHN C MD P DERMATOLOGY 2 2 $84 PO BOX 14507 BELFAST ME

EM 704728 178335013957 1013181916 451627697 GARCIA, ANNABELLE L MD P DERMATOLOGY 4 2 $126 1314 E SONTERRA STE 2201 SAN ANTONIO TX

EM 704728 182666334044 1528294055 300829929 FINKLEA, LINDSEY MD P DERMATOLOGY 1 1 $70 PO BOX 17348 SAN ANTONIO TX

EM 704728 197606263397 1760612410 460832820 ANDERSON, JOHN H MD P DERMATOLOGY 2 2 $290 901A LOOP 337 NEW BRAUNFELS TX

EM 704728 175055443651 1831417211 813002925 OBASI, ADAOBI N MD N DERMATOLOGY DERMATOPATHOLOGY 3 2 $0 6801 MCPHERSON RD STE 332 LAREDO TX

EM 704728 10654328324 1962440933 742501542 TRAVIS COUNTY EMERGENCY PHYSICIANS P EMERGENCY MEDICINE EMERGENCY MED SVCS 9 8 $3,367 PO BOX 21906 BELFAST ME

EM 704728 10654328904 1023101649 464235251 SCRIBBICK, ARIE T MD N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $1,850 PO BOX 674085 DALLAS TX

EM 704728 10659948339 1972563476 822018522 FROLICHSTEIN, ROBERT A MD N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $56 PO BOX 64568 PHOENIX AZ

EM 704728 111982505678 1215946439 455637445 BADEN, ERIC YANG MD N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $149 PO BOX 64568 PHOENIX AZ

EM 704728 112089081485 450929075 MIDWEST EMER CENTRALIA CAMPUS N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $85 PO BOX 24061 FORT WORTH TX

EM 704728 113606133040 1043471469 464235251 ROMO, VICTOR M MD N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $104 PO BOX 98756 LAS VEGAS NV

EM 704728 117149300600 1649669672 472785231 LONGHORN EMERGENCY MEDICAL ASSOC PA N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $729 PO BOX 638761 CINCINNATI OH

EM 704728 120361543559 1053667279 463330652 LESNICK, JOSEPH S MD N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $158 PO BOX 528 SAN ANTONIO TX

EM 704728 120753253455 1003165259 453308093 LEADING EDGE EMERGENCY PHYSICIANS N EMERGENCY MEDICINE EMERGENCY MED SVCS 9 7 $3,761 PO BOX 733850 DALLAS TX

EM 704728 121971535476 1013955533 464804904 NURNBERG, JASON DO N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $112 PO BOX 95330 GRAPEVINE TX

EM 704728 122136561547 1487697074 812961997 WILLIAMS, GRANT D MD N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $1,849 PO BOX 98756 LAS VEGAS NV

EM 704728 125169001965 1033376710 742938811 ZINK, CHRISTINE L MD P EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $306 PO BOX 64568 PHOENIX AZ

EM 704728 126196184499 1699037572 383906905 RYAN, CHRISTOPHER P FNPC N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $95 PO BOX 98756 LAS VEGAS NV





EM 704728 127006204969 1942408463 464235251 CHRISTENSEN, HILARY DO N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $149 PO BOX 64568 PHOENIX AZ

EM 704728 131674262300 1629324678 383906905 DAVILA, NICHOLAS FNP N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $834 PO BOX 98794 LAS VEGAS NV

EM 704728 133278585519 1538125901 475454741 THOMAS, DAVID MD N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $61 PO BOX 64568 PHOENIX AZ

EM 704728 136188284890 1285078220 462579194 EMP OF CHAMPAIGN COUNTY LTD N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $378 PO BOX 849332 BOSTON MA

EM 704728 136418114224 1427096023 421679415 SEGUIN TEXAS EMERGENCY PHYSICIANS P EMERGENCY MEDICINE EMERGENCY MED SVCS 2 2 $731 PO BOX 2283 MANSFIELD TX

EM 704728 142553571115 1245214998 823361169 VILLARREAL, LUIS F MD N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $158 4619 SAN DARIO AVE STE 310 LAREDO TX

EM 704728 143844350587 464235251 MATTI, STEVEN J MD N EMERGENCY MEDICINE EMERGENCY MED SVCS 2 2 $3,399 PO BOX 60259 FORT MYERS FL

EM 704728 148022322146 1174560437 030427714 SOUTHWEST GENERAL EMERGENCY PHYSICIANS PLLC

N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $149 PO BOX 731175 DALLAS TX

EM 704728 153029070025 1295720209 455637445 MCDANIEL, JOSEPH L MD N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $1,458 PO BOX 203949 DALLAS TX

EM 704728 154458322675 1326334871 743000576 WILLIAMS, JORDAN C MD N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $0 PO BOX 638392 CINCINNATI OH

EM 704728 154720065309 1487866471 464235251 ALDRICH, JOSEPH DO N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $1,945 PO BOX 98756 LAS VEGAS NV

EM 704728 155593135903 1427053503 383906905 DE LOS SANTOS, MARIA FNP N EMERGENCY MEDICINE EMERGENCY MED SVCS 2 2 $211 PO BOX 98822 LAS VEGAS NV

EM 704728 156867215307 1548519168 463330652 CARLSON, PETER J MD N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $1,904 PO BOX 301173 DALLAS TX

EM 704728 158446493655 1629291844 742877743 BCEP PA P EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $555 PO BOX 21904 BELFAST ME

EM 704728 159249260782 1750327995 464235251 DONNELLY, JOSEPH L MD N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $1,120 PO BOX 96118 OKLAHOMA CITY OK

EM 704728 160792411851 1154741155 464235251 LEONARD, JOHN H MD N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $95 PO BOX 98756 LAS VEGAS NV

EM 704728 170106535440 1366541336 813872272 LECKY, ROBERT A MD P EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $386 PO BOX 722755 NORMAN OK

EM 704728 172598224172 1770730392 463330652 FURR, CORALYN NP N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $149 PO BOX 98822 LAS VEGAS NV

EM 704728 172620462383 1407278286 742501542 VAUGHN, JAMES C PA P EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $147 PO BOX 21906 BELFAST ME

EM 704728 174084412609 1639608482 383906905 CABRERA, ANALUISA NP N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $61 PO BOX 98822 LAS VEGAS NV

EM 704728 175465552617 1831563410 742501542 WILGUS, SUSAN E NP P EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $100 PO BOX 21906 BELFAST ME

EM 704728 179849200716 1811008410 822018522 CHOPRA, LIZA P MD N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $158 PO BOX 64568 PHOENIX AZ

EM 704728 183822051372 1417205675 463330652 DE LOS SANTOS, DANIEL MD N EMERGENCY MEDICINE EMERGENCY MED SVCS 3 3 $403 PO BOX 96451 OKLAHOMA CITY OK

EM 704728 184790252514 1386683423 455637445 WILLIS, ROGER S MD N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $0 PO BOX 98608 LAS VEGAS NV

EM 704728 190855164991 1619347895 475082681 SCHERTZ CIBOLO EMERGENCY PHYSICIANS N EMERGENCY MEDICINE EMERGENCY MED SVCS 11 11 $1,368 PO BOX 2597 SAN ANTONIO TX





EM 704728 192117101665 1518114115 823361169 LIEBHARDT, DAMIAN J DO N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $61 PO BOX 528 SAN ANTONIO TX

EM 704728 192468503199 1114367612 464235251 POSTEL, MARK MD N EMERGENCY MEDICINE EMERGENCY MED SVCS 2 1 $3,515 PO BOX 98756 LAS VEGAS NV

EM 704728 199727490598 1740573260 455637445 DUENES, ARISTEO MD N EMERGENCY MEDICINE EMERGENCY MED SVCS 1 1 $988 PO BOX 203949 DALLAS TX

EM 704728 10654324894 1881610152 742740337 ALBRECHT, WARREN A MD P FAMILY PRACTICE 15 3 $1,344 PO BOX 311627 NEW BRAUNFELS TX

EM 704728 10654326401 1871542936 203059260 SCHNEIDER, DAVID L MD P FAMILY PRACTICE 2 1 $282 PO BOX 5730 BELFAST ME

EM 704728 10654327339 1336164425 742922275 LEE, ALAN L MD P FAMILY PRACTICE 2 2 $31 PO BOX 17887 BELFAST ME

EM 704728 10654336800 1205820990 453808279 KELLUM JR, DANIEL H MD P FAMILY PRACTICE 7 6 $713 PO BOX 678779 DALLAS TX

EM 704728 10654341260 1669467031 742990878 VELA, VICTOR D MD P FAMILY PRACTICE 1 1 $39 PO BOX 18542 BELFAST ME

EM 704728 10659949042 1568480887 742740337 HINDMAN, MICHAEL G MD P FAMILY PRACTICE 1 1 $0 PO BOX 311627 NEW BRAUNFELS TX

EM 704728 10659949112 1750460317 741996652 WALTHALL IV, WALTER MD P FAMILY PRACTICE 2 2 $101 PO BOX 19263 BELFAST ME

EM 704728 10659953310 1245276732 300185398 NAIK, SUNEETA MD P FAMILY PRACTICE 3 2 $244 2009 PAT BOOKER RD UNIVERSAL CITY TX

EM 704728 10659966267 1598831281 471161014 VINYARD, PATRICK G MD P FAMILY PRACTICE 1 1 $29 711 NAVARRO ST STE 600 SAN ANTONIO TX

EM 704728 100120522936 1407883259 200719874 JIANG, NAN MD P FAMILY PRACTICE 1 1 $284 PO BOX 579 BELLAIRE TX

EM 704728 100216302589 1376525618 272814620 WRIGHT, FRANK D MD P FAMILY PRACTICE 3 1 $747 1215 EAST COURT ST SEGUIN TX

EM 704728 100881552170 1194919639 261264937 BENAVIDES, EDGARDO DO P FAMILY PRACTICE 4 1 $311 12650 NACOGDOCHES RD SAN ANTONIO TX

EM 704728 102289323327 1437156130 760422435 HICKS, STEPHEN B PA P FAMILY PRACTICE 1 1 $70 PO BOX 18542 BELFAST ME

EM 704728 102406120038 1700010964 264748275 GUADALUPE FAMILY HEALTH PA P FAMILY PRACTICE 3 1 $499 PO BOX 1206 SEGUIN TX

EM 704728 104015520501 1932618121 203059260 TOBIAS, EMILY NP P FAMILY PRACTICE 1 1 $87 PO BOX 5730 BELFAST ME

EM 704728 104592470217 1780671313 742803685 ROSS, ROBERT D MD P FAMILY PRACTICE 2 1 $72 PO BOX 830605 SAN ANTONIO TX

EM 704728 105186025216 1134195993 200383974 CLARK, ELIZABETH P DO P FAMILY PRACTICE 2 1 $0 1015 W 39TH 1 2 ST AUSTIN TX

EM 704728 107486143841 1629117031 743003947 WINTER, CORNELIA P MD P FAMILY PRACTICE 3 1 $105 PO BOX 9585 BELFAST ME

EM 704728 110649575240 1679515746 010669008 WILLIAMS, MACHELLE E DO N FAMILY PRACTICE 1 1 $0 7594 US HIGHWAY 181 N FLORESVILLE TX

EM 704728 110831262579 1508978487 260513290 BERNSTEIN, ERIC D MD P FAMILY PRACTICE 1 1 $72 PO BOX 14043 BELFAST ME

EM 704728 111986060614 1568864031 742553856 LESCH, NATHAN J NP P FAMILY PRACTICE 3 1 $369 189 E AUSTIN ST STE 102 NEW BRAUNFELS TX

EM 704728 112108260297 1346488905 471161014 ROSALES, VICTOR G DO P FAMILY PRACTICE 1 1 $29 711 NAVARRO ST STE 600 SAN ANTONIO TX

EM 704728 112703475195 1215167119 742740337 FEHLIS, KYLE H MD P FAMILY PRACTICE 5 2 $637 PO BOX 311627 NEW BRAUNFELS TX





EM 704728 113625350789 1982777488 261699544 BRANSON, RICHARD P PA P FAMILY PRACTICE 6 2 $449 11403 OCONNOR RD STE 108 SAN ANTONIO TX

EM 704728 115151224966 1174638902 742517354 CANNON, JEFFREY A MD P FAMILY PRACTICE 6 3 $242 11901 TOEPPERWEIN RD STE 1201 SAN ANTONIO TX

EM 704728 115589375962 1831117076 742740337 REEVES, WILLIAM E MD P FAMILY PRACTICE 1 1 $140 PO BOX 311627 NEW BRAUNFELS TX

EM 704728 115634442867 1083746119 760422435 MCGINNIS, RACHEL C DO P FAMILY PRACTICE 2 1 $142 PO BOX 844658 DALLAS TX

EM 704728 119649531503 1790776276 741586031 SUTTON, JENNEFER C MD P FAMILY PRACTICE 1 1 $40 PO BOX 528 SAN ANTONIO TX

EM 704728 119649531503 1790776276 760422435 SUTTON, JENNEFER C MD P FAMILY PRACTICE 1 1 $40 PO BOX 528 SAN ANTONIO TX

EM 704728 123400203395 1508808700 742900029 CURRIER, DARYL C MD P FAMILY PRACTICE 3 1 $88 PO BOX 98 STOCKDALE TX

EM 704728 129020203145 1356314124 742740337 JACKS, RANDAL KEITH MD P FAMILY PRACTICE 1 1 $134 PO BOX 311627 NEW BRAUNFELS TX

EM 704728 131349393791 1538255781 760422435 DAPP WADDELL, KRISTIE S FNP P FAMILY PRACTICE 4 1 $178 PO BOX 18542 BELFAST ME

EM 704728 131370542911 1528066362 201972784 NARON, MANUEL S MD P FAMILY PRACTICE 1 1 $66 150 E SONTERRA BLVD STE 220 SAN ANTONIO TX

EM 704728 131838310797 1154353548 742922275 LAUE, RICHARD R MD P FAMILY PRACTICE 2 2 $127 PO BOX 17887 BELFAST ME

EM 704728 131916124865 1265559421 201291976 THOMAS, BOBBI G FNP P FAMILY PRACTICE 8 2 $1,252 214 N CAMP SEGUIN TX

EM 704728 131955123683 1033344999 273452401 YANES, JESUS A MD P FAMILY PRACTICE 4 1 $193 PO BOX 4136 BELFAST ME

EM 704728 132046313167 1598050676 208814408 RIOJAS, NICOLE A DO P FAMILY PRACTICE 1 1 $189 PO BOX 17807 BELFAST ME

EM 704728 133053450282 1487006417 742019736 HERNANDEZ, ANGELA FNP P FAMILY PRACTICE 1 1 $0 5224 75TH ST STE D LUBBOCK TX

EM 704728 133180481817 1932425089 271580687 SULLIVAN, LINDA J DO P FAMILY PRACTICE 3 1 $575 PO BOX 20506 BELFAST ME

EM 704728 134646102477 1538368535 471161014 BLOCK, JANELLE M DNP P FAMILY PRACTICE 7 2 $170 711 NAVARRO ST STE 600 SAN ANTONIO TX

EM 704728 135813502258 1528226396 203059260 GARZA, TRINI J MD P FAMILY PRACTICE 1 1 $85 PO BOX 5730 BELFAST ME

EM 704728 135889303287 1922514603 742946068 LATA, KUSAM FNP P FAMILY PRACTICE 2 2 $47 11355 TOEPPERWEIN RD LIVE OAK TX

EM 704728 135985370410 1700331436 760422435 FLUITT, MARKAY W PAC P FAMILY PRACTICE 2 1 $96 PO BOX 18542 BELFAST ME

EM 704728 136368464298 1922014133 742323822 DROST, JAMES E MD P FAMILY PRACTICE 3 1 $311 1200 CARL RAMERT DRIVE SUITE D YOAKUM TX

EM 704728 136385351492 1154327047 204017002 GRUHLKEY, JAY L MD P FAMILY PRACTICE 21 4 $1,429 301 MAIN PLZ STE 342 NEW BRAUNFELS TX

EM 704728 136778302637 1801988928 464781735 SANCHEZ III, TEOFILIO R MD P FAMILY PRACTICE 1 1 $78 PO BOX 15319 BELFAST ME

EM 704728 138764520432 1609197003 203059260 CATAGUE, BELMUND RAY Y MD P FAMILY PRACTICE 5 3 $252 PO BOX 5730 BELFAST ME

EM 704728 138885532203 1669420204 201972784 EARP, DEAN A MD P FAMILY PRACTICE 1 1 $0 150 E SONTERRA BLVD STE 220 SAN ANTONIO TX

EM 704728 138898460018 1043208184 742721601 ZINCONE, DEAN L MD P FAMILY PRACTICE 9 3 $1,002 1355 E COURT ST SEGUIN TX





EM 704728 139235115230 1417945726 203059260 BELL, JAMES P PA P FAMILY PRACTICE 4 2 $268 PO BOX 5730 BELFAST ME

EM 704728 140126434291 1568801470 741586031 ALVARADO, MAUREEN DO P FAMILY PRACTICE 2 1 $197 PO BOX 528 SAN ANTONIO TX

EM 704728 140437095673 1902887953 742719352 WHITE, EMILY A NP P FAMILY PRACTICE 1 1 $42 PO BOX 2952 SAN ANTONIO TX

EM 704728 140619533989 1104834340 742740337 STIGALL, BRIAN W MD P FAMILY PRACTICE 28 9 $3,043 PO BOX 311627 NEW BRAUNFELS TX

EM 704728 141639060069 1093706293 264673078 SANJANA, HORMAZD B MD P FAMILY PRACTICE 24 1 $506 PO BOX 15311 BELFAST ME

EM 704728 142125582576 1073509220 742951434 HOEFLE, STEPHANIE F MD P FAMILY PRACTICE 2 1 $0 PO BOX 11908 BELFAST ME

EM 704728 142387073726 1922528645 453808279 COURCHESNE, ASHLEY N FNP P FAMILY PRACTICE 9 5 $386 PO BOX 678779 DALLAS TX

EM 704728 143856045911 1639628589 223940595 SALDIVA, ANDREW FNP P FAMILY PRACTICE 1 1 $254 5016 E FM 1518 N SELMA TX

EM 704728 144082101760 1801894944 201972784 GERALDE, RENATO A DO P FAMILY PRACTICE 15 5 $1,007 150 E SONTERRA BLVD STE 220 SAN ANTONIO TX

EM 704728 144248461408 1073523866 271448946 JUAREZ, MARIO R MD P FAMILY PRACTICE 1 1 $29 4151 CALLAGHAN RD STE 102 SAN ANTONIO TX

EM 704728 144253371977 1740331016 472191758 STANHOPE, JOHN E DO P FAMILY PRACTICE 3 1 $0 955 LOOP 337 NEW BRAUNFELS TX

EM 704728 146238581381 1871672436 741996652 SANDERCOCK, DAVID J DO P FAMILY PRACTICE 3 2 $283 PO BOX 19263 BELFAST ME

EM 704728 146670535669 1417996570 742935944 SPENCER, KEVIN P MD P FAMILY PRACTICE 2 1 $147 5625 EIGER RD STE 200 AUSTIN TX

EM 704728 147978431708 1326112715 201291976 BILIR, SULE P MD P FAMILY PRACTICE 12 3 $2,091 214 N CAMP SEGUIN TX

EM 704728 151380195555 1215022421 742946068 TAJKHANJI, MOIZ A MD P FAMILY PRACTICE 14 8 $1,143 11355 TOEPPERWEIN RD SAN ANTONIO TX

EM 704728 151503091227 1235313016 272092060 MINA, EMAN G F MD P FAMILY PRACTICE 1 1 $0 PO BOX 461467 SAN ANTONIO TX

EM 704728 156694092531 1790193340 201972784 BENTON, STEPHANIE A FNP P FAMILY PRACTICE 1 1 $55 150 E SONTERRA BLVD STE 220 SAN ANTONIO TX

EM 704728 158517022602 1093989352 471161014 RODRIGUEZ, ROXANNE PAC P FAMILY PRACTICE 5 3 $128 711 NAVARRO ST STE 600 SAN ANTONIO TX

EM 704728 160414573916 1205096906 742517354 ROSEDALE, MICHAEL J DO P FAMILY PRACTICE 22 4 $1,069 11901 TOEPPERWEIN RD STE 1201 SAN ANTONIO TX

EM 704728 162392195918 1104894468 203575618 VREEKE, STEPHEN J MD P FAMILY PRACTICE 1 1 $96 6098 FM 311 SPRING BRANCH TX

EM 704728 163480403220 1144403486 742951434 USHER, ELENITA L MD P FAMILY PRACTICE 2 1 $85 PO BOX 11908 BELFAST ME

EM 704728 163748434751 742606349 EDEN, MARK D MD P FAMILY PRACTICE 3 1 $240 820 RUEBEN STE B FREDERICKSBURG TX

EM 704728 164290411552 1376730747 742553856 CAMPOS, CARLOS MD P FAMILY PRACTICE 5 1 $415 189 E AUSTIN ST STE 102 NEW BRAUNFELS TX

EM 704728 165191444756 1669719365 264489576 TANYA R GRUN MD PA N FAMILY PRACTICE 1 1 $0 301 MAIN PLAZA STE 330 NEW BRAUNFELS TX

EM 704728 165191444756 1669719365 264489576 TANYA R GRUN MD PA P FAMILY PRACTICE 8 2 $935 301 MAIN PLAZA STE 330 NEW BRAUNFELS TX

EM 704728 169957025988 1114911161 204962475 TALBOT, NICOLE J DO P FAMILY PRACTICE 5 2 $860 515 KING ST STE 103 SEGUIN TX





EM 704728 171340091447 1316985583 742773647 MANN, MICHAEL W MD P FAMILY PRACTICE 5 1 $468 32665 US HIGHWAY 281 N STE 208 BULVERDE TX

EM 704728 172359465917 1144670944 261755891 MEYER, ROBERT P FNPC P FAMILY PRACTICE 1 1 $31 9135 SCHAEFER RD STE 4 CONVERSE TX

EM 704728 172605365191 1851478424 472363732 FRIEDMAN, MYRON S PAC P FAMILY PRACTICE 2 1 $64 MSC #550 PO BOX 659831 SAN ANTONIO TX

EM 704728 173667472766 1275551400 742740337 NELSON, JASON A MD P FAMILY PRACTICE 4 3 $492 PO BOX 311627 NEW BRAUNFELS TX

EM 704728 173697244153 1134440688 815041727 MACKIN, PATRICIA A MD P FAMILY PRACTICE 1 1 $114 PO BOX 22954 BELFAST ME

EM 704728 175170084382 1154640993 264748275 RIDER, JAMES A DO P FAMILY PRACTICE 2 1 $320 PO BOX 1206 SEGUIN TX

EM 704728 175373550385 1831190578 741586031 STARKWEATHER, HELEN M NP P FAMILY PRACTICE 1 1 $224 PO BOX 528 SAN ANTONIO TX

EM 704728 177239025343 1508848276 911491167 LINEHAN, BARRY E PAC P FAMILY PRACTICE 1 1 $111 PO BOX 421 LIBERTY LAKE WA

EM 704728 180799401460 1518055581 454633262 BARTAY, JAMES R MD P FAMILY PRACTICE 6 2 $1,150

EM 704728 181655400428 1508853938 201291976 FLORES, ANTONIO A MD N FAMILY PRACTICE 1 1 $0 214 N CAMP SEGUIN TX

EM 704728 181655400428 1508853938 201291976 FLORES, ANTONIO A MD P FAMILY PRACTICE 5 4 $1,063 214 N CAMP SEGUIN TX

EM 704728 182960430762 1982602264 742889254 ROKA, ALEXANDER S MD P FAMILY PRACTICE 2 1 $59 20658 STONE OAK PKWY UNIT 108 SAN ANTONIO TX

EM 704728 185126382618 1689848137 742803685 DURAN JR, CRESENCIO DO P FAMILY PRACTICE 1 1 $58 PO BOX 830605 SAN ANTONIO TX

EM 704728 185876113626 1699953257 300785442 ESMAILI, ARASH I DO P FAMILY PRACTICE 62 4 $1,900 PO BOX 306276 NASHVILLE TN

EM 704728 187999472590 1154397842 223940595 WRIGHT, GLORIA S DO P FAMILY PRACTICE 146 24 $9,082 PO BOX 11553 BELFAST ME

EM 704728 188308372969 1144254061 742740337 OVERMAN, DOROTHY N MD P FAMILY PRACTICE 4 2 $653 PO BOX 311627 NEW BRAUNFELS TX

EM 704728 188310245698 1629074737 203059260 LOPEZ, JOSEPH A MD P FAMILY PRACTICE 1 1 $50 1045 CENTRAL PKWY N STE 200 SAN ANTONIO TX

EM 704728 190061484729 1124424734 453808279 CAMPSEY III, ARTHUR L PA P FAMILY PRACTICE 34 10 $2,209 PO BOX 678779 DALLAS TX

EM 704728 190990512062 1225292386 471161014 CLARK, SHARLA R PAC P FAMILY PRACTICE 2 1 $92 711 NAVARRO ST STE 600 SAN ANTONIO TX

EM 704728 191604151112 1194996314 742844785 MOCK, STEFFANY PA P FAMILY PRACTICE 1 1 $46 PO BOX 565 BANDERA TX

EM 704728 191869465272 1255367108 742740337 LEE, JOHN Y MD P FAMILY PRACTICE 4 3 $274 1200 N VIRGINIA ST PORT LAVACA TX

EM 704728 192046532415 1194142406 471161014 CHEATHAM, MAEGAN M FNP P FAMILY PRACTICE 1 1 $66 711 NAVARRO ST STE 600 SAN ANTONIO TX

EM 704728 192283531770 1134560667 742946068 BRUNO, STEPHANIE A APRN P FAMILY PRACTICE 2 1 $89 11355 TOEPPERWEIN RD SAN ANTONIO TX

EM 704728 192766514971 1972877785 203059260 ALIOTTA, MICHELLE L MD P FAMILY PRACTICE 2 1 $104 PO BOX 5730 BELFAST ME

EM 704728 193001394140 1225264369 274267742 ZGOURIDES, GEORGE D MD N FAMILY PRACTICE 111 12 $0 PO BOX 306276 NASHVILLE TN

EM 704728 193001394140 1225264369 320520720 ZGOURIDES, GEORGE D MD N FAMILY PRACTICE 119 10 $0 PO BOX 306276 NASHVILLE TN





EM 704728 193001394140 1225264369 742089103 ZGOURIDES, GEORGE D MD P FAMILY PRACTICE 7 7 $297 PO BOX 306276 NASHVILLE TN

EM 704728 193786171670 1851816011 453808279 ALBRIGHT, ERIKA D FNP P FAMILY PRACTICE 3 3 $167 PO BOX 678779 DALLAS TX

EM 704728 195056034238 1952548133 472363732 STOGRYN, RONALD S MD P FAMILY PRACTICE 1 1 $3 9135 SCHAEFER RD STE 4 CONVERSE TX

EM 704728 195610214167 1043326788 760422435 THOMPSON, LYNN E MD P FAMILY PRACTICE 1 1 $88 PO BOX 18542 BELFAST ME

EM 704728 197873553809 1568504835 741996652 ALPRIN, CLIFFORD N MD P FAMILY PRACTICE 3 3 $123 PO BOX 19263 BELFAST ME

EM 704728 198568403918 1619294592 455637445 KAY, THOMAS M MD N FAMILY PRACTICE 1 1 $149 13402 WEST AVE STE 103 SAN ANTONIO TX

EM 704728 199500242414 1245236231 743015655 FINNIE, MITCHELL F MD P FAMILY PRACTICE 2 1 $188 PO BOX 13636 BELFAST ME

EM 704728 199730432982 1881887545 800553568 KELLY, CECILY MD P FAMILY PRACTICE 13 4 $2,796 794 GENERATIONS DR STE 100 NEW BRAUNFELS TX

EM 704728 102570050719 1437132966 742855569 ALVES, PATRICE MD P INTERNAL MEDICINE 2 1 $133 2711 FOSTER AVE NASHVILLE TN

EM 704728 111864230895 1588625735 741386053 TAMTAM, SANKARARAO MD N INTERNAL MEDICINE 1 1 $0 944 S HIGHWAY 123 BYP SEGUIN TX

EM 704728 117421562248 1265767768 742574229 LIM, JOHN BRIAN C MD P INTERNAL MEDICINE 2 1 $125 8637 FREDERICKSBURG RD STE 360 SAN ANTONIO TX

EM 704728 123192451896 1801846068 262400924 PICO, JUAN S DO P INTERNAL MEDICINE 3 1 $223 PO BOX 841941 DALLAS TX

EM 704728 123428585078 1679564587 742844785 JAAFAR, SALEH N MD P INTERNAL MEDICINE 1 1 $0 1051 US HIGHWAY 90 E CASTROVILLE TX

EM 704728 125363220364 1609854090 742844785 CRESPO, RODRIGO MD P INTERNAL MEDICINE 4 2 $222 PO BOX 565 BANDERA TX

EM 704728 128930220439 1164820643 262400924 GAMIO, MICHELLE MSN P INTERNAL MEDICINE 2 1 $168 PO BOX 841941 DALLAS TX

EM 704728 131490161036 1033165634 742855814 LIU, NADINE DO P INTERNAL MEDICINE 9 1 $554 11901 TOEPPERWEIN RD STE 1402 SAN ANTONIO TX

EM 704728 132607270264 1780083360 726073441 BLANCHARD, SARA S FNP P INTERNAL MEDICINE 3 1 $289 1115 WEBER ST FRANKLIN LA

EM 704728 150687235340 1386633121 203059260 CARMICHAEL, BLAINE P PA P INTERNAL MEDICINE 16 7 $1,130 PO BOX 5730 BELFAST ME

EM 704728 151279272354 1235293457 743019577 QUIROZ, REBECCA A MD P INTERNAL MEDICINE 5 1 $321 PO BOX 17567 BELFAST ME

EM 704728 165504545267 1306165014 822654592 PATEL, DERINBHAI J MD P INTERNAL MEDICINE 2 2 $469 2009 PAT BOOKER RD UNIVERSAL CITY TX

EM 704728 168292290351 1598107963 461846260 GAONA, JUANA M NP P INTERNAL MEDICINE 2 1 $44 6101 BLUE LAGOON DR STE 400 MIAMI FL

EM 704728 170307492363 1437256179 453201756 JOUKOVSKI, OLGA MD P INTERNAL MEDICINE 2 1 $149 PO BOX 17039 BELFAST ME

EM 704728 171489085715 1114077161 262400924 FORSETH, BARBARA J MD P INTERNAL MEDICINE 1 1 $99 PO BOX 841941 DALLAS TX

EM 704728 174734210418 1972942738 202148889 RAMOS, STEVEN D MD P INTERNAL MEDICINE 1 1 $113 PO BOX 100026 SAN ANTONIO TX

EM 704728 176146093671 1538262407 471161014 MILLER, SUSAN L MD P INTERNAL MEDICINE 2 1 $59 1045 CENTRAL PKWY N STE 200 SAN ANTONIO TX

EM 704728 179790333703 1467525808 208369279 GENCO, FRANK R MD P INTERNAL MEDICINE 1 1 $125 8245 PRECINCT LINE RD STE 100 N RICHLND HLS TX





EM 704728 182903015354 1659547354 262400924 PERRY, KAREN L FNP P INTERNAL MEDICINE 1 1 $62 PO BOX 841941 DALLAS TX

EM 704728 183109472532 1841266517 223940595 WRIGHT JR, ANTHONY R DO P INTERNAL MEDICINE 155 20 $9,094 PO BOX 11553 BELFAST ME

EM 704728 187535475798 1811417629 471161014 PARTNERS IN PRIMARY CARE PA P INTERNAL MEDICINE 2 2 $131 711 NAVARRO ST STE 600 SAN ANTONIO TX

EM 704728 199769113515 1194722660 742938437 SENGER, BRIAN P MD P INTERNAL MEDICINE 1 1 $0 PO BOX 2448 SAN ANTONIO TX

EM 704728 100875041463 1265403562 470923533 GRONA, ANGELIA PA P INTERNAL MEDICINE CARDIOVASCULAR DISEASE

6 3 $201 18615 TUSCANY STONE STE 170 SAN ANTONIO TX

EM 704728 107480490809 1881853778 203059260 NIKAM, NAVIN S MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE

2 1 $305 PO BOX 5730 BELFAST ME

EM 704728 112159024056 1710924675 470923533 KIESZ, R STEFAN MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE

13 5 $2,018 343 W HOUSTON STE 1005 SAN ANTONIO TX

EM 704728 113367590271 1588774061 742861174 BENCA, MICHAEL J MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE

1 1 $109 PO BOX 949 LA GRANGE TX

EM 704728 115214395428 1285897272 272713767 MADAN, PANKAJ MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE

1 1 $9 PO BOX 741248 ATLANTA GA

EM 704728 117581254875 1568553733 203059260 WELLFORD IV, ARMISTEAD L MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE


EM 704728 125355171364 1568642361 742861174 WYATT, JAMISON N MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE

3 2 $3,528 PO BOX 949 LA GRANGE TX

EM 704728 130200310716 1669995320 470923533 DEL RIO, MANUEL NP P INTERNAL MEDICINE CARDIOVASCULAR DISEASE

3 3 $101 11212 HWY 151 BLDG 2 STE 200 SAN ANTONIO TX

EM 704728 131486503676 1528054749 742861174 FARRA, YASSER M DO P INTERNAL MEDICINE CARDIOVASCULAR DISEASE

7 2 $1,788 PO BOX 949 LA GRANGE TX

EM 704728 131882242956 1386153138 752646025 RAMIREZ, AMANDA V NP P INTERNAL MEDICINE CARDIOVASCULAR DISEASE

2 1 $118 1003 NE LOOP 410 SAN ANTONIO TX

EM 704728 133688532647 1235159195 262400924 CAREY, STEPHEN C MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE

3 1 $264 PO BOX 841941 DALLAS TX

EM 704728 136343382403 1447288022 262400924 KUNAVARAPU, CHANDRASEKHAR R MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE

1 1 $0 PO BOX 841941 DALLAS TX

EM 704728 138232343393 1669470332 470923533 SUAREZ, JOSE A MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE

6 4 $385 4316 23 RD STREET LUBBOCK TX

EM 704728 140713135374 1205044633 742861174 BOSE, RAHUL MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE

3 1 $1,106 16620 N US HIGHWAY 281 STE 300 SAN ANTONIO TX

EM 704728 145485571151 1619170347 454549833 GRESHAM, JOHN K MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE

11 1 $47 1303 MCCULLOUGH AVE STE 333 SAN ANTONIO TX

EM 704728 146546422469 1548447196 272713767 PRICE, ADAM D MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE


EM 704728 146838434989 1891715769 203059260 GARZA, JUAN L MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE


EM 704728 153538320632 1902998347 203059260 COLLIGAN, MARK F MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE


EM 704728 154253263725 1760575278 203059260 CHERUKU, KIRAN K MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE


EM 704728 156600094115 1427058643 262400924 ROMAN-GONZALEZ, JAVIER MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE

2 1 $235 PO BOX 2600 SAN ANTONIO TX

EM 704728 159555492586 1548211477 272713767 PALOMINO, GEORGE MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE


EM 704728 159696545921 1134459514 203059260 YOHO, JASON A MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE

6 1 $2,275 16620 N US HIGHWAY 281 STE 300 SAN ANTONIO TX





EM 704728 159835392652 1043755739 203059260 RODRIGUEZ, JENNA FNP P INTERNAL MEDICINE CARDIOVASCULAR DISEASE


EM 704728 166788380813 1710986302 262400924 REDDY, BAL T MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE


EM 704728 173240252064 1104825785 203059260 TAN, CHUN W Y MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE


EM 704728 173294305495 1164558540 272713767 QUIROZ, RENE MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE


EM 704728 176904532120 1174753198 813395457 ITURBE, JOSE M MD N INTERNAL MEDICINE CARDIOVASCULAR DISEASE

6 1 $2,663 PO BOX 87 SAN ANTONIO TX

EM 704728 184869434343 1023109295 203059260 WILKS, RICHARD F MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE


EM 704728 185744363808 1548377088 272713767 CANALES, JOHN F MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE


EM 704728 186264021745 1427320399 330604557 CARDIONET LLC P INTERNAL MEDICINE CARDIOVASCULAR DISEASE

1 1 $1,000 PO BOX 417559 BOSTON MA

EM 704728 186638500707 1851387070 742861174 RUBALCAVA, FRANK J MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE

1 1 $145 1730 SW MILITARY DR STE 204 SAN ANTONIO TX

EM 704728 187102385773 1669443115 742861174 BOYD, SHERI Y N MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE


EM 704728 187156375997 1881669604 742861174 GARCIA, RONNIE MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE


EM 704728 188727203620 1275648529 205231836 ARORA, UMESH K MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE

3 1 $1,044 1314 E SONTERRA BLVD STE 102 SAN ANTONIO TX

EM 704728 189933575190 1912158387 455289404 MUSHTAQ, ALIYA N MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE

2 1 $187 1110 N SARAH DEWITT DR GONZALES TX

EM 704728 190498430588 1235135344 752646025 GAROUTTE, MAX G MD P INTERNAL MEDICINE CARDIOVASCULAR DISEASE

6 3 $235 1003 NE LOOP 410 SAN ANTONIO TX

EM 704728 121699464680 1245230507 262400924 MACHELL, CHARLES H MD P INTERNAL MEDICINE CLINICAL CARDIAC ELECT 1 1 $0 PO BOX 2600 SAN ANTONIO TX

EM 704728 10659957055 1891764957 331128828 WELCH, MICHELLE D MD P INTERNAL MEDICINE ENDOCRINOLOGY/ DIABETE 6 1 $348 PO BOX 2241 SAN ANTONIO TX

EM 704728 121419023856 1396746442 462845944 CRUZ, JAIME O MD P INTERNAL MEDICINE ENDOCRINOLOGY/ DIABETE 1 1 $105 PO BOX 855 SAN ANTONIO TX

EM 704728 150093472740 1235313321 742145952 BECKER, JOSEPH R MD P INTERNAL MEDICINE ENDOCRINOLOGY/ DIABETE 2 1 $268 PO BOX 528 SAN ANTONIO TX

EM 704728 151127212812 1932368768 272814620 OKORODUDU, DANIEL MD P INTERNAL MEDICINE ENDOCRINOLOGY/ DIABETE 5 2 $793 PO BOX 117838 CARROLLTON TX

EM 704728 152348301381 1568548204 742484538 AKRIGHT, LAURA S MD P INTERNAL MEDICINE ENDOCRINOLOGY/ DIABETE 5 3 $563 5000 SCHERTZ PKWY STE 200 SCHERTZ TX

EM 704728 161069433450 1487636205 742146518 AKHRASS, FIRAS MD P INTERNAL MEDICINE ENDOCRINOLOGY/ DIABETE 4 1 $402 PO BOX 1537 SAN ANTONIO TX

EM 704728 167848443450 1346211604 742484538 GUERRERO, ARTHUR F MD P INTERNAL MEDICINE ENDOCRINOLOGY/ DIABETE 26 7 $2,900 1355 CENTRAL PKWY S STE 200 SAN ANTONIO TX

EM 704728 196106115079 1417968306 742844785 OCAMPO, GLORIA L MD P INTERNAL MEDICINE ENDOCRINOLOGY/ DIABETE 2 1 $78 PO BOX 565 BANDERA TX

EM 704728 10654326285 1023003563 752005254 DESCHNER, WILLIAM K MD P INTERNAL MEDICINE GASTROENTEROLOGY 3 2 $809 PO BOX 206239 DALLAS TX

EM 704728 10654326286 1962497420 741967809 RAMIREZ, OSCAR G MD P INTERNAL MEDICINE GASTROENTEROLOGY 8 4 $671 PO BOX 2778 SAN ANTONIO TX

EM 704728 10654348864 1366436032 741967809 SWAN, JOHN T MD P INTERNAL MEDICINE GASTROENTEROLOGY 1 1 $0 PO BOX 2778 SAN ANTONIO TX





EM 704728 133290215165 1881699734 742246239 OTERO, RICHARD L MD P INTERNAL MEDICINE GASTROENTEROLOGY 2 1 $0 520 E EUCLID AVE SAN ANTONIO TX

EM 704728 135248303730 1730173832 742727952 HEARNE, STEVEN E MD P INTERNAL MEDICINE GASTROENTEROLOGY 6 3 $371 PO BOX 2778 SAN ANTONIO TX

EM 704728 143836072825 741967809 ARNOLD, HAYS L MD P INTERNAL MEDICINE GASTROENTEROLOGY 7 4 $787 PO BOX 2778 SAN ANTONIO TX

EM 704728 151538300781 1346244936 742246239 RAMOS, STEVEN R MD P INTERNAL MEDICINE GASTROENTEROLOGY 4 1 $43 520 E EUCLID AVE SAN ANTONIO TX

EM 704728 154043245694 1528282050 752005254 MAREK, SHANNON J MD P INTERNAL MEDICINE GASTROENTEROLOGY 7 3 $1,508 PO BOX 206239 DALLAS TX

EM 704728 169126072091 1265410914 741967809 JONES, DAVID P DO P INTERNAL MEDICINE GASTROENTEROLOGY 2 1 $317 PO BOX 2778 SAN ANTONIO TX

EM 704728 169686052036 1851323034 741967809 SPEARMAN, DARREN C MD P INTERNAL MEDICINE GASTROENTEROLOGY 1 1 $271 PO BOX 2778 SAN ANTONIO TX

EM 704728 178858582466 1205803442 760647257 TSEN, TONY N R MD P INTERNAL MEDICINE GASTROENTEROLOGY 8 4 $2,197 911 S HIGHWAY 123 BYP SEGUIN TX

EM 704728 188867321339 1750402046 741967809 PIESMAN, MICHAEL MD P INTERNAL MEDICINE GASTROENTEROLOGY 1 1 $271 PO BOX 2778 SAN ANTONIO TX

EM 704728 195461261797 1497749790 742727952 POLHAMUS, CLINTON D MD P INTERNAL MEDICINE GASTROENTEROLOGY 1 1 $14 PO BOX 2778 SAN ANTONIO TX

EM 704728 109574372663 1124284757 742083988 HERNANDEZ, JUDITH MD P INTERNAL MEDICINE NEPHROLOGY 2 1 $99 PO BOX 700148 SAN ANTONIO TX

EM 704728 136507585616 742743906 BANKS, HEATHER E MD P INTERNAL MEDICINE NEPHROLOGY 1 1 $21 7142 SAN PEDRO AVE STE 120 SAN ANTONIO TX

EM 704728 113229382681 1821016023 204790934 MARKS, DAVID A MD P INTERNAL MEDICINE PULMONARY DISEASE 3 2 $128 PO BOX 268977 OKLAHOMA CITY OK

EM 704728 177161490603 1578505665 462751836 HERNANDEZ, DAVID S MD P INTERNAL MEDICINE PULMONARY DISEASE 4 1 $69 PO BOX 2483 DALLAS TX

EM 704728 179783462358 1700855640 452276376 TALIB, MUHAMMAD MD P INTERNAL MEDICINE PULMONARY DISEASE 1 1 $14 PO BOX 1300 LONDON KY

EM 704728 188230370239 1861637597 020752585 SIQUEIROS, ALAN MD P INTERNAL MEDICINE PULMONARY DISEASE 1 1 $14 8715 VILLAGE DR STE 514 SAN ANTONIO TX

EM 704728 105931520570 1285644427 562613565 ROLDAN, JOSE F MD P INTERNAL MEDICINE RHEUMATOLOGY 12 1 $1,307 4511 HORIZON HILL BLVD STE 150 SAN ANTONIO TX

EM 704728 125568031289 1770522633 461051939 ALISSA, HASSAN M MD P INTERNAL MEDICINE RHEUMATOLOGY 11 1 $1,906 DEPT 231 POBOX 4346 HOUSTON TX

EM 704728 130177041656 1003895020 161751617 KEMPF, KEVIN J MD P INTERNAL MEDICINE RHEUMATOLOGY 4 1 $626 19272 STONE OAK PKWY STE 101 SAN ANTONIO TX

EM 704728 160582515873 1104008952 264007666 CLINTON, CHELSEA I MD P INTERNAL MEDICINE RHEUMATOLOGY 4 1 $380 17503 LA CANTERA PKWY STE 434 SAN ANTONIO TX

EM 704728 195249294141 1588622922 742746171 HORAN, TERRI T MD P INTERNAL MEDICINE RHEUMATOLOGY 2 1 $451 901 LOOP 337 NEW BRAUNFELS TX

EM 704728 122814413590 1346323888 752131429 TREVINO, ABRAM MD P INTERNAL MEDICINE MEDICAL ONCOLOGY 6 1 $221 PO BOX 911234 DALLAS TX

EM 704728 144838441958 1750392908 742980813 KAPOOR, ROHIT MD P INTERNAL MEDICINE MEDICAL ONCOLOGY 5 2 $300 PO BOX 2336 SAN ANTONIO TX

EM 704728 105118402600 1275707689 270610680 ZAVALA II, GERARDO MD P NEUROLOGICAL SURGERY 4 1 $13,930 PO BOX 205124 DALLAS TX

EM 704728 143242244326 1255512539 474994681 GALVAN, GEORGE M MD P NEUROLOGICAL SURGERY 1 1 $49 PO BOX 17072 BELFAST ME

EM 704728 149603323162 1093771297 262400924 GENNUSO, ROSEMARIA MD P NEUROLOGICAL SURGERY 2 1 $173 PO BOX 2078 SAN ANTONIO TX





EM 704728 165205190780 1598006876 270610680 PACHOLSKI, RACHEL M PAC P NEUROLOGICAL SURGERY 3 1 $92 PO BOX 700930 TULSA OK

EM 704728 166761470875 1144670316 270610680 LEBENS, KAYLEN C PAC P NEUROLOGICAL SURGERY 1 1 $249 PO BOX 205124 DALLAS TX

EM 704728 185410244264 1841625951 752131429 WANNAMAKER, MOLLYROSE M PA P NEUROLOGICAL SURGERY 1 1 $124 PO BOX 911230 DALLAS TX

EM 704728 10654341263 1104987510 742748826 GELDERNICK, MARY E MD P OBSTETRICS & GYNECOLOGY 2 2 $456 505 N UNION AVE NEW BRAUNFELS TX

EM 704728 10654348197 1982603593 611744250 KUNDA, KOTESWARA R MD P OBSTETRICS & GYNECOLOGY 2 1 $360 PO BOX 14588 BELFAST ME

EM 704728 10659947589 1255326989 453808279 KELLUM, JOHN H MD P OBSTETRICS & GYNECOLOGY 1 1 $3 PO BOX 6284 GREENVILLE SC

EM 704728 10659953375 1841218633 742312850 JACOBS, JENNIFER D MD P OBSTETRICS & GYNECOLOGY 1 1 $135 7950 FLOYD CURL DR STE 300 SAN ANTONIO TX

EM 704728 101907414110 1457532830 264333033 GUERRERO, JESSICA D MD P OBSTETRICS & GYNECOLOGY 4 1 $224 1355 CENTRAL PKWY S STE 400 SAN ANTONIO TX

EM 704728 104081492962 1295918266 272814620 KIRCHNER, ALYSON J MD P OBSTETRICS & GYNECOLOGY 5 3 $927 PO BOX 117838 CARROLLTON TX

EM 704728 106248363561 1164681987 203059260 TRESZEZAMSKY, ALEJANDRO D MD P OBSTETRICS & GYNECOLOGY 4 2 $58 PO BOX 5730 BELFAST ME

EM 704728 109938123167 1437115698 742806531 QUEZADA, CARLOS E MD P OBSTETRICS & GYNECOLOGY 1 1 $92 PO BOX 9067 BELFAST ME

EM 704728 112168500708 1821169228 464536372 CROCKETT, SUSAN A MD P OBSTETRICS & GYNECOLOGY 1 1 $95 PO BOX 14000 BELFAST ME

EM 704728 113690590569 1568470714 371602059 PILKINGTON, STEVEN G MD P OBSTETRICS & GYNECOLOGY 6 1 $1,174 4499 MEDICAL DR STE 151 SAN ANTONIO TX

EM 704728 120010231376 1801885959 264333033 REYES, CESAR MD P OBSTETRICS & GYNECOLOGY 1 1 $137 1355 CENTRAL PKWY S STE 400 SAN ANTONIO TX

EM 704728 121419020506 1932102266 742591869 VILLA OLVERA, MICHELLE M MD P OBSTETRICS & GYNECOLOGY 1 1 $145 502 MADISON OAK DRIVE STE 440 SAN ANTONIO TX

EM 704728 122664415120 1750370821 264333033 WOMACK, ROBIN L MD P OBSTETRICS & GYNECOLOGY 8 6 $875 1355 CENTRAL PKWY S STE 400 SAN ANTONIO TX

EM 704728 128573024214 1396971255 264333033 SHIELDS, MOLLY D MD P OBSTETRICS & GYNECOLOGY 3 2 $1,454 1355 CENTRAL PKWY S STE 400 SAN ANTONIO TX

EM 704728 130710255371 1134365869 611744250 BLAUE, BARRETT R MD P OBSTETRICS & GYNECOLOGY 1 1 $85 PO BOX 14588 BELFAST ME

EM 704728 139860200795 1952333213 264333033 THEIS JR, VERNON D MD P OBSTETRICS & GYNECOLOGY 3 1 $2,675 1355 CENTRAL PKWY S STE 400 SAN ANTONIO TX

EM 704728 140948415940 1134230931 742764739 HARLE, BRIAN W MD P OBSTETRICS & GYNECOLOGY 5 1 $1,261 PO BOX 1506 SAN ANTONIO TX

EM 704728 141039060888 1740283886 760448912 SERRANO, CHRISTOPHER W MD P OBSTETRICS & GYNECOLOGY 1 1 $92 PO BOX 6284 GREENVILLE SC

EM 704728 141123394528 1972522555 264333033 GARZA, JOSEPH A MD P OBSTETRICS & GYNECOLOGY 2 1 $179 1355 CENTRAL PKWY S STE 400 SAN ANTONIO TX

EM 704728 141976513123 1962454694 264333033 DO, JEAN ANTHONY P MD P OBSTETRICS & GYNECOLOGY 4 3 $293 1355 CENTRAL PKWY S STE 400 SAN ANTONIO TX

EM 704728 142649100762 1821017484 264333033 THOMPSON, MARK E MD P OBSTETRICS & GYNECOLOGY 1 1 $2,270 1355 CENTRAL PKWY S STE 400 SAN ANTONIO TX

EM 704728 146110200688 1467470021 264333033 FARHART, SCOTT A MD P OBSTETRICS & GYNECOLOGY 5 3 $225 1355 CENTRAL PKWY S STE 400 SAN ANTONIO TX

EM 704728 146200231415 1841280849 264333033 VALDEZ, RONALD A MD P OBSTETRICS & GYNECOLOGY 2 1 $156 1355 CENTRAL PKWY S STE 400 SAN ANTONIO TX





EM 704728 150288565682 1013055813 752131429 SANTILLAN GOMEZ, ANTONIO MD P OBSTETRICS & GYNECOLOGY 21 1 $649 PO BOX 911234 DALLAS TX

EM 704728 151049020079 1952400814 261827978 HARDEN, MICHELLE A MD P OBSTETRICS & GYNECOLOGY 17 3 $1,222 PO BOX 1976 SAN ANTONIO TX

EM 704728 152768304740 1720017601 264333033 SADLER, RANDALL K MD P OBSTETRICS & GYNECOLOGY 5 4 $691 1355 CENTRAL PKWY S STE 400 SAN ANTONIO TX

EM 704728 157409221703 1568579852 743022188 BLAIR, KEVIN D MD P OBSTETRICS & GYNECOLOGY 1 1 $195 571 N UNION NEW BRAUNFELS TX

EM 704728 157756403500 1457644106 264333033 ROSEN, MARCY L MD P OBSTETRICS & GYNECOLOGY 1 1 $85 1355 CENTRAL PKWY S STE 400 SAN ANTONIO TX

EM 704728 157788311446 1184613242 264333033 TROY, MICHAEL J MD P OBSTETRICS & GYNECOLOGY 6 2 $3,076 1355 CENTRAL PKWY S STE 400 SAN ANTONIO TX

EM 704728 160125134178 1194027607 264333033 MULDROW, MICHELLE J DO P OBSTETRICS & GYNECOLOGY 1 1 $151 1355 CENTRAL PKWY S STE 400 SAN ANTONIO TX

EM 704728 160970200795 1679515373 264333033 AKRIGHT, BRUCE D MD P OBSTETRICS & GYNECOLOGY 3 2 $474 1355 CENTRAL PKWY S STE 400 SAN ANTONIO TX

EM 704728 161216040666 1538505698 741586031 MURRAY, AMANDA M DO P OBSTETRICS & GYNECOLOGY 1 1 $3 PO BOX 528 SAN ANTONIO TX

EM 704728 167356431720 1871615229 752131429 DE LA GARZA, JOSEPH A MD P OBSTETRICS & GYNECOLOGY 2 1 $177 PO BOX 911230 DALLAS TX

EM 704728 167900103330 1699737437 741586031 BERKUS, MICHAEL D MD P OBSTETRICS & GYNECOLOGY 2 1 $320 PO BOX 528 SAN ANTONIO TX

EM 704728 169310233351 1609870930 742591869 WILLIAMS, DEBRA J MD P OBSTETRICS & GYNECOLOGY 5 2 $1,444 502 MADISON OAK DRIVE STE 440 SAN ANTONIO TX

EM 704728 173863400812 1265465827 205448551 ARREDONDO, FRANCISCO MD P OBSTETRICS & GYNECOLOGY 1 1 $0 PO BOX 19470 BELFAST ME

EM 704728 176734280603 1720075021 742591869 NOVAK, SUSAN P MD P OBSTETRICS & GYNECOLOGY 10 7 $1,717 502 MADISON OAK DRIVE STE 440 SAN ANTONIO TX

EM 704728 177514014803 1649289927 461104136 HUDSON, SUSAN B A MD P OBSTETRICS & GYNECOLOGY 3 1 $168 705 GENERATIONS DR SUITE 102 NEW BRAUNFELS TX

EM 704728 179581083936 1356630784 264333033 FORBES, JOANNA MD P OBSTETRICS & GYNECOLOGY 7 1 $681 PO BOX 845347 DALLAS TX

EM 704728 182444372144 1154319283 910900432 SCHEMMEL, MARK T MD P OBSTETRICS & GYNECOLOGY 1 1 $24 105 W 8TH AVE STE 6060 SPOKANE WA

EM 704728 186281132993 1003034091 742922251 HART, CHRIS C MD P OBSTETRICS & GYNECOLOGY 1 1 $138 PO BOX 269092 OKLAHOMA CITY OK

EM 704728 187275444575 1114936408 264333033 ADEN, JOY T MD P OBSTETRICS & GYNECOLOGY 4 4 $674 1355 CENTRAL PKWY S STE 400 SAN ANTONIO TX

EM 704728 188951342475 1023098100 742591869 SHOWS ATKERSON, JANE A MD P OBSTETRICS & GYNECOLOGY 6 4 $594 502 MADISON OAK DRIVE STE 440 SAN ANTONIO TX

EM 704728 190810442872 1811992589 742958075 MISKELL, MELISSA H DO P OBSTETRICS & GYNECOLOGY 4 3 $339 PO BOX 674240 DALLAS TX

EM 704728 191168514937 1275542698 264333033 SKOP, INGRID P MD P OBSTETRICS & GYNECOLOGY 11 6 $1,492 1355 CENTRAL PKWY S STE 400 SAN ANTONIO TX

EM 704728 191714384166 1265466833 261827978 BIGLER, CHARLES R MD P OBSTETRICS & GYNECOLOGY 3 2 $176 1139 E SONTERRA BLVD STE 205 SAN ANTONIO TX

EM 704728 194110405232 1417966854 800306408 VILLANUEVA, GIL R MD P OBSTETRICS & GYNECOLOGY 4 2 $279 1162 E SONTERRA BLVD STE 110 SAN ANTONIO TX

EM 704728 194876092503 1396188157 203059260 SCHECHTMAN, JESSICA DO P OBSTETRICS & GYNECOLOGY 2 1 $142 PO BOX 5730 BELFAST ME

EM 704728 195547024815 1184643769 264333033 KING, ELIZABETH A MD P OBSTETRICS & GYNECOLOGY 4 1 $295 1355 CENTRAL PKWY S STE 400 SAN ANTONIO TX





EM 704728 195735564963 1649289455 741586031 PLASTINO, KRISTEN A MD P OBSTETRICS & GYNECOLOGY 1 1 $61 PO BOX 528 SAN ANTONIO TX

EM 704728 10654347942 1972641751 752990526 STARCK, TOMY MD P OPHTHALMOLOGY 3 1 $110 6818 HEUERMANN RD SAN ANTONIO TX

EM 704728 10659956803 1659369601 770618862 ISKANDER, NADER G MD P OPHTHALMOLOGY 3 1 $269 PO BOX 174 SAN ANTONIO TX

EM 704728 103974200762 1215996525 741916103 ROBERTS II, SANFORD E MD P OPHTHALMOLOGY 1 1 $10 800 MCCULLOUGH AVE SAN ANTONIO TX

EM 704728 112088592937 1629006051 364496120 MCCASH, CHARLES S MD P OPHTHALMOLOGY 3 2 $200 1314 E SONTERRA BLVD STE 5201 SAN ANTONIO TX

EM 704728 119586074778 1720379316 760386391 CROCKETT, CHARLENE H MD P OPHTHALMOLOGY 1 1 $279 PO BOX 840786 DALLAS TX

EM 704728 130583402897 1861432114 741742582 LEHMANN, JAMES D P OPHTHALMOLOGY 2 2 $217 4775 HAMILTON WOLFE BLDG 2 SAN ANTONIO TX

EM 704728 141468505881 1952383101 742555297 TSCHOEPE, MICHAEL D MD P OPHTHALMOLOGY 1 1 $39 PO BOX 844164 DALLAS TX

EM 704728 149098381195 1669464822 571049412 SPEICHER, PETER J MD P OPHTHALMOLOGY 1 1 $80 730 N MAIN AVE STE 418 SAN ANTONIO TX

EM 704728 152786142554 1326482902 741742582 YANG, LINDA C MD P OPHTHALMOLOGY 4 2 $223 4775 HAMILTON WOLFE BLDG 2 SAN ANTONIO TX

EM 704728 165895153373 1992718373 742979530 KAVANAGH, JOSEPH T MD P OPHTHALMOLOGY 3 3 $696 PO BOX 202293 DALLAS TX

EM 704728 169860093697 1508082132 202397444 BAUMAN II, WENDALL C MD P OPHTHALMOLOGY 4 1 $1,436 137 PRIMROSE PL SAN ANTONIO TX

EM 704728 102355003154 1073752879 471438900 JACKSON, RUSSELL B DO P ORTHOPAEDIC SURGERY 3 2 $57 PO BOX 593377 SAN ANTONIO TX

EM 704728 102398051019 1114084365 743025288 CHANCE, JOHN R MD P ORTHOPAEDIC SURGERY 1 1 $69 12709 TOEPPERWEIN RD STE 101 LIVE OAK TX

EM 704728 107350391103 1366654667 743003947 BALLDIN, BJORN C MD P ORTHOPAEDIC SURGERY 31 4 $1,143 PO BOX 660706 DALLAS TX

EM 704728 109019205269 1992779292 262865869 TUDER, DMITRY MD P ORTHOPAEDIC SURGERY 3 2 $133 1801 W OLYMPIC BLVD FILE 2090 PASADENA CA

EM 704728 116234215961 1710078969 743025288 SIMON, PATRICK M MD P ORTHOPAEDIC SURGERY 2 2 $62 12709 TOEPPERWEIN RD STE 101 LIVE OAK TX

EM 704728 121078404989 1104930361 742637785 SLEDGE, SCOTT L MD P ORTHOPAEDIC SURGERY 1 1 $62 155 E SONTERRA BLVD STE 211 SAN ANTONIO TX

EM 704728 144455325183 1306070479 743003947 ADENIRAN, ADEWALE O MD P ORTHOPAEDIC SURGERY 2 1 $176 PO BOX 9585 BELFAST ME

EM 704728 145983192334 1497848055 760422435 DEAN, JEFFREY A MD P ORTHOPAEDIC SURGERY 6 1 $318 PO BOX 23106 BELFAST ME

EM 704728 146535584672 1700075637 270466353 PHELPS, CHRISTOPHER I MD P ORTHOPAEDIC SURGERY 1 1 $203 PO BOX 301173 DALLAS TX

Platform Group # Provider ID HOSP PHY CD PROV NPI ID Tax ID Organization Par/Non Par Specialty #Claims #Claimants Net Paid Bill Address Bill Address2 Bill City Bill ST





EM 704728 163518460319 1164602868 205613593 VRANA, MICHAEL MD P ORTHOPAEDIC SURGERY 7 2 $2,245 960 GRUENE RD STE 101 NEW BRAUNFELS TX

EM 704728 169996351998 1487633384 261972800 NILSSON, JOEL B MD P ORTHOPAEDIC SURGERY 1 1 $142 PO BOX 848827 BOSTON MA

EM 704728 182489135464 1407960685 743025288 SCHULZE, BRIAN E MD P ORTHOPAEDIC SURGERY 13 2 $732 12709 TOEPPERWEIN RD STE 101 LIVE OAK TX

EM 704728 185247093994 1376771063 742019736 KRAUSE, FREDERICK R W MD P ORTHOPAEDIC SURGERY 1 1 $0 499 10TH ST FLORESVILLE TX

EM 704728 193540020440 1699723320 742634231 DEETJEN, JACK L MD P ORTHOPAEDIC SURGERY 1 1 $135 515 N KING ST STE 106 SEGUIN TX

EM 704728 196314370367 1811125859 743003947 NUELLE, CLAYTON W MD P ORTHOPAEDIC SURGERY 35 4 $2,544 PO BOX 9585 BELFAST ME

EM 704728 173267264913 743003947 WOODBURY, CHRISTIAN A MD P ORTHOPAEDIC SURGERY HAND SURGERY 1 1 $890 PO BOX 9585 BELFAST ME

EM 704728 10654324852 1124092671 760596676 LANO JR, CHARLES F MD P OTOLARYNGOLOGY 8 4 $7,393 42 GRUENE PARK DR NEW BRAUNFELS TX

EM 704728 10654326995 1396730776 760698947 ATKINS JR, JAMES H MD P OTOLARYNGOLOGY 1 1 $184 PO BOX 661 SAN ANTONIO TX

EM 704728 115775315500 1033127022 742625722 BIEDIGER, CHARLES P MD P OTOLARYNGOLOGY 1 1 $112 PO BOX 2679 SAN ANTONIO TX

EM 704728 117095054849 1336158294 742625722 EDWARDS, JOHN D MD P OTOLARYNGOLOGY 6 2 $215 PO BOX 2679 SAN ANTONIO TX

EM 704728 135362470306 1942218938 742625722 NAU, THOMAS W MD P OTOLARYNGOLOGY 1 1 $14 PO BOX 2679 SAN ANTONIO TX

EM 704728 143838370191 1851399463 742654495 MOSS JR, JESSE MD FASC PA P OTOLARYNGOLOGY 2 1 $109 12602 TOEPPERWEIN RD STE 211 LIVE OAK TX

EM 704728 182058041548 1972545549 741895428 SAN ANTONIO HEAD AND NECK SURGICAL ASSOCIATES PA

P OTOLARYNGOLOGY 10 5 $1,239 4775 HAMILTON WOLFE RD STE 1 SAN ANTONIO TX

EM 704728 187689243424 1780618843 030594553 FRANKLIN, GERALD M MD P OTOLARYNGOLOGY 4 2 $1,015 948 GRUENE RD STE 120 NEW BRAUNFELS TX

EM 704728 10659949795 1548260078 752740653 BONILLA, JUAN A MD P OTOLARYNGOLOGY PEDIATRIC OTOLARYNGOLOGY

2 1 $616 16723 HUEBNER RD SAN ANTONIO TX

EM 704728 149895135927 1619966686 453835571 BARRERA, JOSE E MD P OTOLARYNGOLOGY FACIAL PLASTIC SURGERY 1 1 $128 555 E BASSE RD STE 201 SAN ANTONIO TX

EM 704728 165326544886 1710977145 203017624 HENNESSEE, JENNIFER G MD P OTOLARYNGOLOGY FACIAL PLASTIC SURGERY 2 1 $343 PO BOX 1266 SEGUIN TX

EM 704728 10654326203 1538172028 741703601 AUSTIN PATHOLOGY ASSOCIATES PA P PATHOLOGY ANATOMIC PATHOLOGY 11 4 $1,965 PO BOX 203294 DALLAS TX

EM 704728 10659947172 1104817022 742998494 HENSLEY, RICHARD G MD P PATHOLOGY ANATOMIC PATHOLOGY 1 1 $49 PO BOX 98146 RALEIGH NC

EM 704728 105847421178 1588655401 742998494 BERARDO, MELORA D MD P PATHOLOGY ANATOMIC PATHOLOGY 5 4 $268 MSC 580 PO BOX 2458 SAN ANTONIO TX

EM 704728 108387130440 1659574127 621771540 KINSEY, RICHARD S MD P PATHOLOGY ANATOMIC PATHOLOGY 1 1 $484 DEPT 461 PO BOX 1000 MEMPHIS TN

EM 704728 121025092927 1912954025 742922218 SOUTH TEXAS PATHOLOGY ASSOCIATES P PATHOLOGY ANATOMIC PATHOLOGY 23 10 $1,055 PO BOX 681149 SAN ANTONIO TX

EM 704728 124460221359 1992935845 741586031 KLAZYNSKI, BRIAN C MD P PATHOLOGY ANATOMIC PATHOLOGY 1 1 $102 PO BOX 900046 RALEIGH NC

EM 704728 131898311114 1205885878 742406834 JOYCE, ROBY P MD P PATHOLOGY ANATOMIC PATHOLOGY 13 10 $194 PO BOX 29447 SAN ANTONIO TX

EM 704728 139361540689 1316054315 741586031 FURMAGA, WIESLAW MD P PATHOLOGY ANATOMIC PATHOLOGY 1 1 $14 PO BOX 528 SAN ANTONIO TX





EM 704728 140918182975 272341992 SKINPATH SOLUTIONS INC P PATHOLOGY ANATOMIC PATHOLOGY 1 1 $70 PO BOX 3429 AUGUSTA GA

EM 704728 143896251277 742406834 HUMPHREYS, JAMES L MD P PATHOLOGY ANATOMIC PATHOLOGY 3 2 $574 PO BOX 29447 SAN ANTONIO TX

EM 704728 149991100359 1083831689 621771540 PURDY, JULIANNE K MD P PATHOLOGY ANATOMIC PATHOLOGY 1 1 $66 PO BOX 360734 PITTSBURGH PA

EM 704728 153895575089 1669450441 752005254 LEWIN, MATTHEW MD P PATHOLOGY ANATOMIC PATHOLOGY 1 1 $0 PO BOX 206239 DALLAS TX

EM 704728 173727130053 1184788747 621771540 RAI, HAR P MD P PATHOLOGY ANATOMIC PATHOLOGY 1 1 $197 611 GRAMMONT ST MONROE LA

EM 704728 177467571979 1255395810 741619182 CLINICAL PATHOLOGY ASSOCIATES PA P PATHOLOGY ANATOMIC PATHOLOGY 26 15 $591 PO BOX 28770 AUSTIN TX

EM 704728 193570222824 1881729309 742463565 GRIEDER, KEVIN T DO P PATHOLOGY ANATOMIC PATHOLOGY 3 2 $845 1255 ASHBY ST STE B SEGUIN TX

EM 704728 195612311961 1750540613 452815598 LEE, KEAGAN H MD P PATHOLOGY ANATOMIC PATHOLOGY 1 1 $214 4131 DIRECTORS ROW HOUSTON TX

EM 704728 180764005999 1265412928 742728787 ADDINGTON, SHARI L MD P PATHOLOGY ANATOMIC PATHOLOGY & CLINICAL 1 1 $0 PO BOX 743 SAN ANTONIO TX

EM 704728 193490232110 1407844848 746106575 PATHOLOGY ASSOCIATES OF SAN ANTONIO LLP P PATHOLOGY CHEMICAL PATHOLOGY 1 1 $10 PO BOX 2216 SAN ANTONIO TX

EM 704728 10654327652 1932104353 753050146 PRUITT, ROGER D DO P PEDIATRICS 4 3 $484 180 JOE WIMBERLEY BLVD STE 102 WIMBERLEY TX

EM 704728 10654345810 1164475604 742619659 STATLER, MARK D MD P PEDIATRICS 7 3 $1,521 1535 E COMMON ST NEW BRAUNFELS TX

EM 704728 10659946462 1578651972 742531032 GARCIA, MELISSA A MD P PEDIATRICS 3 2 $36 948 GRUENE RD STE 140 NEW BRAUNFELS TX

EM 704728 10659962135 1194801381 264333033 RHAME, FREDERICK T MD P PEDIATRICS 1 1 $0 1355 CENTRAL PKWY S STE 400 SAN ANTONIO TX

EM 704728 10659963890 1346336625 760386391 HIGGINS, ANGELICA Y MD P PEDIATRICS 2 1 $639 PO BOX 840786 DALLAS TX

EM 704728 105966060536 1699937078 208736944 ALMENDAREZ, YVETTE M MD P PEDIATRICS 1 1 $562 11515 TOEPPERWEIN RD STE 203 LIVE OAK TX

EM 704728 107015381306 1346447000 742531032 GARCIA, AMY D MD P PEDIATRICS 4 1 $123 PO BOX 34415 SAN ANTONIO TX

EM 704728 108612031539 1942221015 742531032 HYSLOP, JAMES A MD P PEDIATRICS 3 1 $267 PO BOX 34415 SAN ANTONIO TX

EM 704728 110408462999 1750381810 742531032 ARNOLD, J LAURA MD P PEDIATRICS 2 2 $175 PO BOX 34415 SAN ANTONIO TX

EM 704728 111745370879 1588812283 742531032 DIAZ DE LEON, DAVID MD P PEDIATRICS 18 9 $2,370 PO BOX 34415 SAN ANTONIO TX

EM 704728 113716440501 510554507 JACOBSON, LEAH H MD P PEDIATRICS 3 2 $383 15316 HUEBNER RD STE 102 SAN ANTONIO TX

EM 704728 117472312681 1558430884 208736944 RODRIGUEZ, JESUS L MD P PEDIATRICS 3 2 $100 12602 TOEPPERWEIN RD STE 104 SAN ANTONIO TX

EM 704728 117519235633 1194778456 742619659 RIEGER, SARAH E MD P PEDIATRICS 3 2 $167 1535 E COMMON ST NEW BRAUNFELS TX

EM 704728 121615324529 1144512633 264333033 TRIMBLE, ROBERT B MD P PEDIATRICS 3 3 $243 1355 CENTRAL PKWY S STE 400 SAN ANTONIO TX

EM 704728 123628043310 1285864066 742531032 GUERRA, NICOLAS N MD P PEDIATRICS 32 13 $3,181 PO BOX 34415 SAN ANTONIO TX

EM 704728 128019460010 1215270277 742531032 KURI, ANN M MD P PEDIATRICS 2 1 $204 PO BOX 34415 SAN ANTONIO TX





EM 704728 130338115146 1104996156 742531032 TRESSLER, SAMUEL D MD P PEDIATRICS 5 3 $2,257 PO BOX 34415 SAN ANTONIO TX

EM 704728 130499431551 1659321602 742619659 WEINBERG, JAY S MD P PEDIATRICS 10 4 $689 1535 E COMMON ST NEW BRAUNFELS TX

EM 704728 130848093639 1942293600 742531032 SIMONE, SUSANNAH L MD P PEDIATRICS 14 7 $1,699 PO BOX 34415 SAN ANTONIO TX

EM 704728 131599504790 1407856941 742531032 BASEY, M SUZANNE MD P PEDIATRICS 1 1 $89 PO BOX 34415 SAN ANTONIO TX

EM 704728 136367303728 1245246420 741724391 COLLINS, KARYN W MD P PEDIATRICS 5 2 $1,073 3066 E COMMERCE ST SAN ANTONIO TX

EM 704728 142417582156 1558597088 742531032 HOOD, SUSANNE DO P PEDIATRICS 2 1 $152 PO BOX 34415 SAN ANTONIO TX

EM 704728 143434060267 1104246594 264333033 THOMAS, ANU DO P PEDIATRICS 2 2 $102 1355 CENTRAL PKWY S STE 400 SAN ANTONIO TX

EM 704728 146066480262 1346395217 742759858 MILLER, MICHELLE E MD P PEDIATRICS 2 1 $178 601 LEAH AVE STE B SAN MARCOS TX

EM 704728 147646185846 1154400489 260764726 LOPEZ GLYNN, MICHELE MD P PEDIATRICS 7 1 $1,760 PO BOX 735 SEGUIN TX

EM 704728 151987585807 1598902207 264023067 CEVEY, RENEE L MD P PEDIATRICS 1 1 $105 414 W SUNSET RD STE 105 SAN ANTONIO TX

EM 704728 161059361871 1831168483 742619659 OWENS, TIMOTHY W MD P PEDIATRICS 4 2 $335 1535 E COMMON ST NEW BRAUNFELS TX

EM 704728 163673505139 1912970187 202750529 BOECKER, ANNA M MD P PEDIATRICS 11 2 $2,453 301 MAIN PLZ STE 322 NEW BRAUNFELS TX

EM 704728 176686504734 1447679857 742531032 HERNANDEZ, ALISSA MD P PEDIATRICS 3 2 $77 PO BOX 34415 SAN ANTONIO TX

EM 704728 178084504756 1801890157 742199591 CUELLAR, RICARDO L MD P PEDIATRICS 2 2 $246 7430 BARLITE BLVD STE 104 SAN ANTONIO TX

EM 704728 180617174576 1801116496 264333033 STAFFORD, SARAH A MD P PEDIATRICS 39 11 $6,333 1355 CENTRAL PKWY S STE 400 SAN ANTONIO TX

EM 704728 188989260132 1750381380 742531032 WILKE, KRISTIN M MD P PEDIATRICS 2 2 $77 PO BOX 34415 SAN ANTONIO TX

EM 704728 190106040865 1215223144 742932237 MOONEY, CAITLYN C MD P PEDIATRICS 2 1 $114 PO BOX 87 SAN ANTONIO TX

EM 704728 191464323074 1154615201 742531032 GUERRA, MEGAN C MD P PEDIATRICS 1 1 $0 PO BOX 34415 SAN ANTONIO TX

EM 704728 193919280861 1790874402 742759858 HUMPHREY, JILL S MD P PEDIATRICS 2 1 $736 601 LEAH AVE STE B SAN MARCOS TX

EM 704728 199397015519 1568621159 264333033 REYBURN, AMANDA C DO P PEDIATRICS 1 1 $0 1355 CENTRAL PKWY S STE 400 SAN ANTONIO TX

EM 704728 110467104532 1699714998 752740653 HENDERSON, CODY MD P PEDIATRICS NEONATAL-PERINATAL MEDICINE 1 1 $205 PO BOX 840384 DALLAS TX

EM 704728 114533303229 1255516910 752740653 EGALKA, MATTHEW C MD P PEDIATRICS NEONATAL-PERINATAL MEDICINE 1 1 $0 PO BOX 840384 DALLAS TX

EM 704728 128918404549 1922056274 752740653 ORTIZ, AMIL MD P PEDIATRICS NEONATAL-PERINATAL MEDICINE 1 1 $272 PO BOX 840384 DALLAS TX

EM 704728 143139141744 1881689081 752740653 HIGBY, KENNETH MD P PEDIATRICS NEONATAL-PERINATAL MEDICINE 1 1 $40 PO BOX 840384 DALLAS TX

EM 704728 161949364320 1942590955 752740653 VIJAYAMADHAVAN, VIVEK K MD P PEDIATRICS NEONATAL-PERINATAL MEDICINE 2 1 $0 PO BOX 840384 DALLAS TX

EM 704728 182289062495 1679521371 752740653 WEARDEN, MARY E MD P PEDIATRICS NEONATAL-PERINATAL MEDICINE 7 4 $1,183 PO BOX 840384 DALLAS TX





EM 704728 198463261019 1215227475 752740653 ONAGHISE, BLOSSOM DO P PEDIATRICS NEONATAL-PERINATAL MEDICINE 1 1 $4,074 PO BOX 840384 DALLAS TX

EM 704728 115694453829 1104828995 742958277 TRAN, NHUNG T MD P PEDIATRICS DEVELOPMENTAL-BEHAVIORAL PED


EM 704728 146138303210 1457399081 263749619 TOMASOVIC, JERRY J MD P PEDIATRICS NEURODEVELOPMENTAL DISABILITY


EM 704728 127707233210 1154633212 752740653 LONDONO-OBREGON, CAMILA MD P PEDIATRICS PEDIATRIC CARDIOLOGY 1 1 $1,750 PO BOX 840384 DALLAS TX

EM 704728 196561354076 1588845705 752740653 GOLDSTEIN, BRIAN S MD P PEDIATRICS PEDIATRIC CARDIOLOGY 2 2 $4,427 1110 E 32ND ST AUSTIN TX

EM 704728 10654325023 1174596670 822018522 ARMSTRONG, LEE M MD N PEDIATRICS PEDIATRIC EMERGENCY MEDICINE 1 1 $1,850 7 SABLE CLF SAN ANTONIO TX

EM 704728 120202504996 1114944048 742938811 PORRATA, EDWARD A MD P PEDIATRICS PEDIATRIC EMERGENCY MEDICINE 1 1 $306 PO BOX 14507 BELFAST ME

EM 704728 135103071238 1598724395 742877743 WILKINSON, MATTHEW H MD N PEDIATRICS PEDIATRIC EMERGENCY MEDICINE 1 1 $70 PO BOX 2283 MANSFIELD TX

EM 704728 174034571020 1891774154 462714379 BATES, BRIAN A MD P PEDIATRICS PEDIATRIC EMERGENCY MEDICINE 1 1 $187 PO BOX 64568 PHOENIX AZ

EM 704728 152769102304 1568675726 742146518 PANKRATZ, LAUREN A MD P PEDIATRICS PEDIATRIC ENDOCRINOLOGY 3 1 $254 PO BOX 1537 SAN ANTONIO TX

EM 704728 169532352530 1972784239 262400924 FALCON-CANTRILL, MARIA G MD P PEDIATRICS PEDIATRIC HEMATOLOGY-ONCOLOGY

1 1 $163 PO BOX 98610 LAS VEGAS NV

EM 704728 135045583256 1528198405 263749619 SMITH, KELLY J MD P PEDIATRICS PEDIATRIC PULMONOLOGY 1 1 $47 PO BOX 781383 SAN ANTONIO TX

EM 704728 121599245368 1467750554 275122769 PHYSICAL THERAPY OF WIMBERLY P PHYSICAL MEDICINE & REHABILITATION 15 1 $54 14100 RANCH ROAD 12 STE 100 WIMBERLEY TX

EM 704728 126300271446 1871990275 472388509 MOMENTUM PHYSICAL THERAPY AND SPORTS REHABILITATIO

P PHYSICAL MEDICINE & REHABILITATION 14 1 $530 8627 CINNAMON CREEK DR STE 402 SAN ANTONIO TX

EM 704728 135303174633 1104911551 822018522 JOHNSON, CHRISTINE L MD N PHYSICAL MEDICINE & REHABILITATION 1 1 $149 PO BOX 14507 BELFAST ME

EM 704728 142290024089 1538573746 471126252 ATI PHYSICAL THERAPY P PHYSICAL MEDICINE & REHABILITATION 78 1 $3,878 PO BOX 74008345 CHICAGO IL

EM 704728 153639095317 1154411262 742951754 CAMINO REAL COOMUNITY MHMR CENTER P PHYSICAL MEDICINE & REHABILITATION 2 2 $0 PO BOX 725 LYTLE TX

EM 704728 180649571562 1497989479 261455666 AIRROSTI REHAB CENTERS LLC P PHYSICAL MEDICINE & REHABILITATION 75 19 $13,940 PO BOX 223950 PITTSBURGH PA

EM 704728 183083252878 201238109 TEXAS PHYSICAL THERAPY SPECIALISTS P PHYSICAL MEDICINE & REHABILITATION 29 1 $1,303 STE 110 12508 JONES MALTSBERGER RD

SAN ANTONIO TX

EM 704728 192722193193 1487976478 271778064 CIBOLO CREEK PHYSICAL THERAPY P PHYSICAL MEDICINE & REHABILITATION 21 2 $1,185 6032 FM 3009 STE 130 SCHERTZ TX

EM 704728 195336392776 1396031761 452607567 SCHERTZ PARKWAY PHYSICAL THERAPY PLLC P PHYSICAL MEDICINE & REHABILITATION 9 2 $23 392 SCHERTZ PKWY SCHERTZ TX

EM 704728 107325090489 1356302871 752990642 NEIMAN, RICHARD B MD P PSYCHIATRY & NEUROLOGY 3 2 $278 PO BOX 293879 KERRVILLE TX

EM 704728 107870495875 1073615704 320448409 KATUNA, BRUCE A MD N PSYCHIATRY & NEUROLOGY 1 1 $1,384 1511 ONYX CIR LONGMONT CO

EM 704728 121050015452 1154352557 742711998 DAVIS JR, BILL D MD P PSYCHIATRY & NEUROLOGY 3 1 $857 224 HUNTERS VILLAGE NEW BRAUNFELS TX

EM 704728 125963383395 1619150588 742609006 VAN DELDEN, ELLEN S MD P PSYCHIATRY & NEUROLOGY 1 1 $43 PO BOX 293879 KERRVILLE TX

EM 704728 126651451054 1801815147 742885893 GROGAN, PATRICK M MD P PSYCHIATRY & NEUROLOGY 1 1 $348 255 E SONTERRA BLVD STE 211 SAN ANTONIO TX





EM 704728 156693142398 1255533592 203059260 REDDY, ARON KUMAR T MD P PSYCHIATRY & NEUROLOGY 1 1 $19 PO BOX 5730 BELFAST ME

EM 704728 157176544375 1093033698 264733435 SHARRON, JENNIFER A MD P PSYCHIATRY & NEUROLOGY 2 1 $145 11212 STATE HWY 151 STE 200 SAN ANTONIO TX

EM 704728 178750251086 1952307241 742905174 GOLDMAN, JOSHUA W MD P PSYCHIATRY & NEUROLOGY 1 1 $22 PO BOX 5560 SAN ANTONIO TX

EM 704728 182478592911 1104925171 742842145 BASS, ANN D MD P PSYCHIATRY & NEUROLOGY 1 1 $62 1314 E SONTERRA BLVD STE 601 SAN ANTONIO TX

EM 704728 109714374788 1710167333 272181563 CANTU, MICHELLE L MD P PSYCHIATRY & NEUROLOGY PSYCHIATRY 9 3 $1,537 14603 HUEBNER RD STE 3505 SAN ANTONIO TX

EM 704728 154588445908 1790946986 010624198 CHAISSON MCRAE, CLARISSA M MD P PSYCHIATRY & NEUROLOGY PSYCHIATRY 5 1 $455 PO BOX 848710 BOSTON MA

EM 704728 158381185119 1275526188 203059260 MILLAR, BENJAMIN R MD P PSYCHIATRY & NEUROLOGY PSYCHIATRY 1 1 $78 PO BOX 5730 BELFAST ME

EM 704728 185449090025 1093710758 010624198 BROTHERS, TERESITA M MD P PSYCHIATRY & NEUROLOGY PSYCHIATRY 3 1 $511 4242 MEDICAL DR STE 6300 SAN ANTONIO TX

EM 704728 190151021762 1952666331 010624198 CAVAZOS, JAVEN MD P PSYCHIATRY & NEUROLOGY PSYCHIATRY 4 1 $249 4242 MEDICAL DR STE 6300 SAN ANTONIO TX

EM 704728 10654345371 1851368039 741671142 SOUTH TEXAS RADIOLOGY GROUP PA P RADIOLOGY DIAGNOSTIC RADIOLOGY 28 14 $1,935 PO BOX 29407 SAN ANTONIO TX

EM 704728 10654345472 1992704803 742900160 IGLESIA, GREGORY C MD P RADIOLOGY DIAGNOSTIC RADIOLOGY 5 5 $101 PO BOX 1005 SAN MARCOS TX

EM 704728 10659950764 1366495798 450480099 SEGGERMAN, RICHARD D MD P RADIOLOGY DIAGNOSTIC RADIOLOGY 1 1 $0 PO BOX 678253 DALLAS TX

EM 704728 100360513607 1871500520 275404338 WASH, KAREN R MD P RADIOLOGY DIAGNOSTIC RADIOLOGY 1 1 $44 7418 JOHN SMITH STE 218 SAN ANTONIO TX

EM 704728 105567553456 1780894147 450480099 FELTER, DANIEL F MD P RADIOLOGY DIAGNOSTIC RADIOLOGY 1 1 $0 PO BOX 678253 DALLAS TX

EM 704728 108061521609 1720366339 463886288 RATAKONDA, PREETHI MD N RADIOLOGY DIAGNOSTIC RADIOLOGY 1 1 $0 PO BOX 102287 ATLANTA GA

EM 704728 109630452062 1730190521 741586031 MUMBOWER, AMY L MD P RADIOLOGY DIAGNOSTIC RADIOLOGY 1 1 $23 PO BOX 528 SAN ANTONIO TX

EM 704728 110303121992 1679871081 275404338 RIVER CITY IMAGING ASSOCIATES N RADIOLOGY DIAGNOSTIC RADIOLOGY 7 4 $370 PO BOX 10270 LONGVIEW TX

EM 704728 113504053958 1477549830 050589923 UZQUIANO, NELSON G MD P RADIOLOGY DIAGNOSTIC RADIOLOGY 1 1 $36 PO BOX 29447 SAN ANTONIO TX

EM 704728 126052091530 1164498226 275404338 THOMPSON, ROBERT L MD P RADIOLOGY DIAGNOSTIC RADIOLOGY 1 1 $44 220 WILSON ST STE 207 CARLISLE PA

EM 704728 135874265418 1205036316 275404338 WALKER, JEFFREY A MD P RADIOLOGY DIAGNOSTIC RADIOLOGY 2 2 $44 PO BOX 5460 LONGVIEW TX

EM 704728 135951490968 1447367420 741586031 CHINTAPALLI, KEDAR N MD P RADIOLOGY DIAGNOSTIC RADIOLOGY 1 1 $119 PO BOX 528 SAN ANTONIO TX

EM 704728 150105302063 1538363114 275404338 REDDY, VENKATRAMANA P MD P RADIOLOGY DIAGNOSTIC RADIOLOGY 2 2 $0 777 N LOOP 337 NEW BRAUNFELS TX

EM 704728 152141051439 1205093200 275404338 CHENG, JASON A MD P RADIOLOGY DIAGNOSTIC RADIOLOGY 1 1 $16 PO BOX 5460 LONGVIEW TX

EM 704728 155200543375 1669408159 310745303 COLUMBUS RADIOLOGY CORPORATION P RADIOLOGY DIAGNOSTIC RADIOLOGY 1 1 $21 PO BOX 714150 CINCINNATI OH

EM 704728 156596464501 1285862235 742900160 GATES JR, CAMERON H MD P RADIOLOGY DIAGNOSTIC RADIOLOGY 2 2 $83 PO BOX 1005 SAN MARCOS TX

EM 704728 157466181106 1346449980 275404338 JACO, JOHN W MD P RADIOLOGY DIAGNOSTIC RADIOLOGY 1 1 $27 PO BOX 10270 LONGVIEW TX





EM 704728 169912100761 1740258615 741586031 FOSTER, JEFFREY L MD P RADIOLOGY DIAGNOSTIC RADIOLOGY 1 1 $22 PO BOX 528 SAN ANTONIO TX

EM 704728 172578251774 1841463056 275404338 LINDSEY, SARA MD P RADIOLOGY DIAGNOSTIC RADIOLOGY 1 1 $0 PO BOX 10270 LONGVIEW TX

EM 704728 172587380836 1871814616 741597116 SHADEMAN, ASHKAN MD P RADIOLOGY DIAGNOSTIC RADIOLOGY 1 1 $12 PO BOX 4099 AUSTIN TX

EM 704728 177035413708 1437311321 821447133 MEDINA, JOSUE A MD N RADIOLOGY DIAGNOSTIC RADIOLOGY 2 1 $0 PO BOX 1019 SAN ANTONIO TX

EM 704728 187761310794 1598732158 050589923 DABBOUS, SUZANNE M MD P RADIOLOGY DIAGNOSTIC RADIOLOGY 1 1 $270 PO BOX 29447 SAN ANTONIO TX

EM 704728 188636154271 1033257753 742900160 SMITH, DOUGLAS S MD P RADIOLOGY DIAGNOSTIC RADIOLOGY 6 5 $123 PO BOX 1005 SAN MARCOS TX

EM 704728 194047451882 1841585726 450480099 SMITH, CHRISTOPHER R MD P RADIOLOGY DIAGNOSTIC RADIOLOGY 1 1 $374 PO BOX 60352 SAINT LOUIS MO

EM 704728 195773453774 1609966522 741597116 MURRAY, MATTHEW F MD P RADIOLOGY DIAGNOSTIC RADIOLOGY 1 1 $15 PO BOX 4099 AUSTIN TX

EM 704728 10659948903 1669466975 742749181 SAN ANTONIO DIGESTIVE DISEASE ENDOSCOPY CENTER

P SURGERY 2 2 $336 1804 NE LOOP 410 STE 101 SAN ANTONIO TX

EM 704728 10659949097 1235241688 742863505 SPECIALTY SURGERY AND PAIN CENTER P SURGERY 1 1 $0 5255 PRUE RD STE 100 SAN ANTONIO TX

EM 704728 10659950407 1144406927 200075829 SAN ANTONIO GASTROENTEROLOGY ENDOSCOPY CENTER

P SURGERY 2 2 $336 20650 STONE OAK PKWY STE 105 SAN ANTONIO TX

EM 704728 10659951135 1912965963 631275972 PASTEUR PLAZA SURGERY CENTER LLP P SURGERY 2 2 $2,797 7909 FREDERICKSBURG RD STE 222 SAN ANTONIO TX

EM 704728 10659951161 1922075167 742998447 METHODIST AMBULATORY SURGERY CENTER P SURGERY 4 3 $7,396 19010 STONE OAK PKWY SAN ANTONIO TX

EM 704728 101158531516 1558379891 741586031 SIRINEK, KENNETH R MD P SURGERY 1 1 $180 PO BOX 528 SAN ANTONIO TX

EM 704728 103258513094 1053359315 201511073 THOMPSON, JUDITH L MD P SURGERY 1 1 $371 876 LOOP 337 BLDG STE 101 NEW BRAUNFELS TX

EM 704728 111430155576 1497738272 742791224 KNEUPER, MARK F MD P SURGERY 1 1 $209 1929 W HWY 46 STE 105 NEW BRAUNFELS TX

EM 704728 129846404607 1124213400 752131429 SANTILLAN GOMEZ, ALFREDO A MD P SURGERY 9 2 $2,898 PO BOX 528 SAN ANTONIO TX

EM 704728 136264441632 1023064524 203059260 DILWORTH, DONALD D MD P SURGERY 2 1 $143 PO BOX 5980 LUBBOCK TX

EM 704728 141837234498 1568645281 203059260 VELA, SELENA M PA P SURGERY 1 1 $120 PO BOX 5730 BELFAST ME

EM 704728 168110415868 1164448486 412092141 CHRISTUS SANTA ROSA ASC SAN ANTONIO-STONE OAK

P SURGERY 5 4 $13,564 100 NE LOOP 410 STE 475 SAN ANTONIO TX

EM 704728 181540301620 1225375587 611699459 GCSA AMBULATORY SURGERY CENTER LLC P SURGERY 8 8 $5,112 PO BOX 844516 DALLAS TX

EM 704728 182243433881 1285171538 814995275 EYE 35 ASC N SURGERY 2 1 $0 17005 INTERSTATE 35 N SCHERTZ TX

EM 704728 186209063680 1447212121 810571409 CHRISTUS NEW BRAUNFELS OP SURGERY P SURGERY 9 6 $45,024 1738 E COMMON ST NEW BRAUNFELS TX

EM 704728 191630545149 1083659866 742976746 ORTHOPAEDIC SURGERY CENTER OF SAN ANTONIO

P SURGERY 3 2 $4,443 PO BOX 5106 BELFAST ME

EM 704728 134522172383 1104820554 205384198 BALDWIN, CHARLES E MD P SURGERY PEDIATRIC SURGERY 2 1 $70 PO BOX 9190 BELFAST ME

EM 704728 138548530066 1578595690 742653603 SARGENT, MARY C MD P SURGERY PEDIATRIC SURGERY 3 1 $929 PO BOX 1377 SAN ANTONIO TX





EM 704728 190968470798 1992711279 203640509 WARMAN, JEFFREY R MD P SURGERY PEDIATRIC SURGERY 1 1 $175 PO BOX 82 SAN ANTONIO TX

EM 704728 10659947348 1386607596 741833341 FIALA, LOIS A MD FACS P SURGERY VASCULAR SURGERY 2 1 $193 PO BOX 276 SAN ANTONIO TX

EM 704728 163850200126 1295731164 741833341 MARTINEZ, JEFFREY M MD P SURGERY VASCULAR SURGERY 2 1 $0 PO BOX 276 SAN ANTONIO TX

EM 704728 199399542386 1386683704 742861174 ROSSBACH, MARIO M MD P SURGERY VASCULAR SURGERY 1 1 $165 PO BOX 949 LA GRANGE TX

EM 704728 121838291151 1760596415 742719352 RUSSELL II, LEWIS F MD P UROLOGY 3 2 $167 PO BOX 2952 SAN ANTONIO TX

EM 704728 121995082627 1578524955 742151159 SEDLAK, MICHAEL F MD N UROLOGY 2 1 $0 PO BOX 20405 BELFAST ME

EM 704728 129100214608 1922088947 742719352 SALTZSTEIN, DANIEL R MD P UROLOGY 4 1 $418 PO BOX 2952 SAN ANTONIO TX

EM 704728 133800045622 1568642296 742719352 CANTRILL, CHRISTOPHER H MD P UROLOGY 2 1 $0 PO BOX 2952 SAN ANTONIO TX

EM 704728 135688294232 1053383620 742915297 BEST, GEORGE S MD P UROLOGY 3 2 $263 3338 OAKWELL CT STE 216 SAN ANTONIO TX

EM 704728 137505272190 1780764258 272814620 RYAN II, ROBERT T MD N UROLOGY 2 1 $0 PO BOX 117838 CARROLLTON TX

EM 704728 137505272190 1780764258 272814620 RYAN II, ROBERT T MD P UROLOGY 3 1 $722 PO BOX 117838 CARROLLTON TX

EM 704728 139029413381 1770563173 742719352 TALLEY, DAVID R MD P UROLOGY 6 3 $543 PO BOX 2952 SAN ANTONIO TX

EM 704728 143023123887 1811395320 742719352 BROOKS WHITE, KRISTEN FNPC P UROLOGY 1 1 $0 7909 FREDERICKSBURG ROAD STE 110 SAN ANTONIO TX

EM 704728 150907084833 1881847960 742837301 MOBLEY, ELIZABETH M MD P UROLOGY 1 1 $63 PO BOX 19119 BELFAST ME

EM 704728 156099210659 1124313184 742719352 COCKERILL, PATRICK A MD P UROLOGY 2 2 $396 7909 FREDERICKSBURG RD STE 110 SAN ANTONIO TX

EM 704728 180963533327 1386624740 742719352 CENTENO, ARTHUR S MD P UROLOGY 5 2 $153 PO BOX 2952 SAN ANTONIO TX

EM 704728 180992395439 1033513890 742719352 COCHRUM, JASON N FNP P UROLOGY 1 1 $3 PO BOX 2952 SAN ANTONIO TX

EM 704728 181734313812 1154309573 742719352 WELD, KYLE J MD P UROLOGY 2 1 $97 PO BOX 2952 SAN ANTONIO TX

EM 704728 191980222268 1174528459 742429894 VICK, SAMMY C MD P UROLOGY 2 1 $91 8038 WURZBACH RD STE 430 SAN ANTONIO TX

EM 704728 112991115205 1154580769 203059260 PRIETO, JAMES H MD P COLON & RECTAL SURGERY 1 1 $50 PO BOX 5730 BELFAST ME

EM 704728 144178453989 1164432357 741880422 JACKSON II, RICHARD B MD P COLON & RECTAL SURGERY 2 1 $94 PO BOX 911230 DALLAS TX

EM 704728 175246114911 1982930335 203059260 IZFAR, SEEMA MD P COLON & RECTAL SURGERY 1 1 $101 PO BOX 5730 BELFAST ME

EM 704728 104773022091 1265536254 900357698 SPARKS, VICKI J MD P GENERAL PRACTICE 2 1 $202 114 SOUTHBRIDGE ST STE D SAN ANTONIO TX

EM 704728 119780105065 1851709133 464291310 DOCTOR ON DEMAND INC P GENERAL PRACTICE 20 17 $326 DODTX 163 DEPT 3613 PO BOX 123613 DALLAS TX

EM 704728 153270105300 1346658614 464708943 DOCTOR ON DEMAND, INC. P GENERAL PRACTICE 2 1 $0 DODCA 157 DEPT LA 24468 PASADENA CA

EM 704728 172359465917 1144670944 261755891 MEYER, ROBERT P FNPC N GENERAL PRACTICE 1 1 $0 9135 SCHAEFER RD STE 4 CONVERSE TX





EM 704728 194383111114 1265613483 453808279 GONZALES, ARTHUR MD P GENERAL PRACTICE 25 8 $1,564 PO BOX 678779 DALLAS TX

EM 704728 10654328229 1902863731 203059260 BARTRA, HOMAR J MD P HOSPITALIST 1 1 $0 PO BOX 203517 DALLAS TX

EM 704728 104364073509 1467443986 020752585 DEAL, LEONARD MD P HOSPITALIST 1 1 $290 PO BOX 5730 SAN ANTONIO TX

EM 704728 127691143865 1841591229 364871690 GOEL, SHIV K MD N HOSPITALIST 2 1 $138 PO BOX 92729 LOS ANGELES CA

EM 704728 129005291254 1477746121 203059260 WRIGHT, ERIN L MD P HOSPITALIST 2 2 $336 PO BOX 5730 BELFAST ME

EM 704728 141162531990 1497816417 203059260 HAGHIRI CANELES, MITRA MD P HOSPITALIST 1 1 $109 PO BOX 5730 BELFAST ME

EM 704728 143770124725 1114092111 742866987 CARVAJAL, HUGO F MD P HOSPITALIST 1 1 $0 19223 STONEHUE STE 117 SAN ANTONIO TX

EM 704728 145831521329 1932337896 320536120 PARK, WON H DO N HOSPITALIST 1 1 $0 7585 KITTY HAWK STE 201 CONVERSE TX

EM 704728 150775304981 1881822179 203059260 AHMED, ANINDITA MD P HOSPITALIST 2 1 $146 PO BOX 742227 LOS ANGELES CA

EM 704728 169147140779 200376970 ANWAR, NABEEL MD P HOSPITALIST 2 2 $27 PO BOX 2947 SAN ANTONIO TX

EM 704728 170579135439 1073833299 742844785 PATEL, JIGAR R MD P HOSPITALIST 2 1 $160 PO BOX 29385 PHOENIX AZ

EM 704728 188016424898 1770861742 742844785 MYERS, AUSTON J MD P HOSPITALIST 2 2 $190 PO BOX 565 BANDERA TX

EM 704728 197805423009 1174797955 742866987 ORTIZ, OZIEL MD P HOSPITALIST 1 1 $0 19223 STONEHUE STE 117 SAN ANTONIO TX

EM 704728 197860100245 1790077212 320536120 AHMAD, MINAL DO N HOSPITALIST 1 1 $0 PO BOX 844063 LOS ANGELES CA

EM 704728 106795455522 1134162381 462433646 GARTON, SUSAN M MD P PAIN MEDICINE PAIN MANAGEMENT 5 1 $391 PO BOX 47875 SAN ANTONIO TX

EM 704728 109407433861 1396744660 742734272 JONES, STEPHANIE S MD P PAIN MEDICINE PAIN MANAGEMENT 8 1 $292 PO BOX 2208 SAN ANTONIO TX

EM 704728 152580082337 1568428589 462433646 HERNANDEZ, ARTHUR S MD P PAIN MEDICINE PAIN MANAGEMENT 3 1 $930 PO BOX 47875 SAN ANTONIO TX

EM 704728 193155551370 1114947462 811771573 ORIHEL, TIMOTHY S MD P PAIN MEDICINE PAIN MANAGEMENT 3 1 $68 9150 HUEBNER RD STE 155 SAN ANTONIO TX

EM 704728 10654329558 1336253392 261943394 BEITO, STEVEN B DPM P PODIATRIST 1 1 $162 1524 N WALNUT AVE NEW BRAUNFELS TX

EM 704728 127118404473 1467772863 742717646 MECHELL, RUBEN J DPM P PODIATRIST 2 1 $7 7424 BROADWAY SAN ANTONIO TX

EM 704728 158359562148 1649224791 453043087 QUEBEDEAUX, TERRI L DPM P PODIATRIST 1 1 $174 1055 E HUMPHREYS SEGUIN TX

EM 704728 183155135835 1154505089 743003368 MCCARTY, KATHREN D DPM P PODIATRIST 3 3 $137 PO BOX 847877 DALLAS TX

EM 704728 190050165695 1073792883 743011723 SILVESTER, DARREN J DPM P PODIATRIST 3 1 $0 409 N BRYANT PLEASANTON TX

EM 704728 126015384918 1871673848 741653179 EASTER SEAL REHABILITATION CENTER N PHYSICAL THERAPIST 4 1 $0 2203 BABCOCK RD SAN ANTONIO TX

EM 704728 165406173246 1568802072 743003947 MARTINEZ, ANDREA M PT P PHYSICAL THERAPIST 5 2 $198 PO BOX 9585 BELFAST ME

EM 704728 179546195797 1275966343 743025288 FAZIO, KATHRYN N PT N PHYSICAL THERAPIST 2 1 $0 12709 TOEPPERWEIN RD STE 101 LIVE OAK TX





EM 704728 197862335918 1063456804 743003947 ZAPATA, GLORIA I PT P PHYSICAL THERAPIST 9 2 $294 7206 MASSACHUSETTS AVE NEW PRT RCHY FL

EM 704728 198057462255 1821288523 742965998 GENOVESE, KAREN MCDILL PT P PHYSICAL THERAPIST 5 1 $405 20475 HWY 46 WEST STE 150 SPRING BRANCH TX

EM 704728 169782553273 1477838928 743003947 RICHARDSON, RACHEL L OT P OCCUPATIONAL THERAPIST 1 1 $53 PO BOX 9585 BELFAST ME

EM 704728 141254570035 1053652206 800886561 DOSS AUDIOLOGY & HEARING CENTER P AUDIOLOGIST 1 1 $92 5000 SCHERTZ PKWY STE 300 SCHERTZ TX

EM 704728 141734160706 1942441886 611316926 HUMANA SPECIALTY PHARMACY P HOME INFUSION 3 3 $4,317 PO BOX 747 CINCINNATI OH

EM 704728 114802093737 1255370813 200894669 CONCORD IMAGING P CLINIC/CENTER RADIOLOGY 1 1 $171 PO BOX 1888 GREENVILLE TX

EM 704728 124585101207 1982852992 208954472 HEALTH AND WELLNESS PROFESSIONALS INC P CLINIC/CENTER RADIOLOGY 1 1 $32 1700 N MCMULLEN BOOTH RD STE C4 CLEARWATER FL

EM 704728 133317445839 1033227616 742726932 SAN ANTONIO DIAGNOSTIC IMAGING INC P CLINIC/CENTER RADIOLOGY 1 1 $119 PO BOX 2569 STAFFORD TX

EM 704728 141599124867 1457350993 331082073 VHS SAN ANTONIO IMAGING PARTNERS LP P CLINIC/CENTER RADIOLOGY 22 14 $1,653 PO BOX 849553 DALLAS TX

EM 704728 157659573210 1659478303 742776427 CENTRAL TEXAS OPEN MRI P CLINIC/CENTER RADIOLOGY 2 2 $199 66 GRUENE PARK DR STE 205 NEW BRAUNFELS TX

EM 704728 168847412127 1396718334 742896068 SOUTH TEXAS RADIOLOGY IMAGING CENTERS P CLINIC/CENTER RADIOLOGY 88 59 $18,353 PO BOX 29490 SAN ANTONIO TX

EM 704728 169488233812 1154526945 205940576 ALAMO CITY MRI N CLINIC/CENTER RADIOLOGY 1 1 $0 STE 103 8706 FREDERICKSBURG RD

SAN ANTONIO TX

EM 704728 178711475398 1194117853 462908086 SENDERO IMAGING AND TREATMENT CENTER NORTH CENTRAL

P CLINIC/CENTER RADIOLOGY 1 1 $1,386 PO BOX 117004 ATLANTA GA

EM 704728 179449324828 1992786883 770597972 ADVANCED IMAGING SAN MARCOS P CLINIC/CENTER RADIOLOGY 4 2 $1,906 1330 WONDER WORLD DR STE 202 SAN MARCOS TX

EM 704728 191431003928 1033196464 741597116 AUSTIN RADIOLOGICAL ASSOCIATION P CLINIC/CENTER RADIOLOGY 3 2 $491 PO BOX 4099 AUSTIN TX

EM 704728 141929210006 1467528471 742691598 SAN ANTONIO SLEEP CENTERS P CLINIC/CENTER SLEEP DISORDER DIAGNOSTIC 1 1 $180 PO BOX 29833 SAN ANTONIO TX

EM 704728 159768072153 1861655961 262531558 SNAP DIAGNOSTICS P CLINIC/CENTER SLEEP DISORDER DIAGNOSTIC 1 1 $126 5210 CAPITOL DR WHEELING IL

EM 704728 162950232179 1649261579 800286290 HOANG, JOSEPH T MD P CLINIC/CENTER SLEEP DISORDER DIAGNOSTIC 11 1 $1,874 117 MEDICAL DR STE 1 VICTORIA TX

EM 704728 199845502112 800816309 ADVANCED SLEEP CENTERS P CLINIC/CENTER SLEEP DISORDER DIAGNOSTIC 1 1 $618 3600 W PARMER LN STE 108 AUSTIN TX

EM 704728 100510475526 1598087207 271893780 QUALITY URGENT CARE OF AMERICA N CLINIC/CENTER URGENT CARE 6 6 $0 6032 FM 3009 STE 120 SCHERTZ TX

EM 704728 100510475526 1598087207 271893780 QUALITY URGENT CARE OF AMERICA P CLINIC/CENTER URGENT CARE 28 23 $3,059 6032 FM 3009 STE 120 SCHERTZ TX

EM 704728 128784413884 1053784660 475349604 TEXAS MEDCLINIC P CLINIC/CENTER URGENT CARE 45 32 $6,311 13722 EMBASSY ROW SAN ANTONIO TX

EM 704728 132700371611 1871933259 900993578 DAVAM URGENT CARE P CLINIC/CENTER URGENT CARE 1 1 $202 PO BOX 4562 HOUSTON TX

EM 704728 142038300327 1871985861 472897722 AMBULATORY STRATEGIES PHYSICIAN GROUP P CLINIC/CENTER URGENT CARE 71 53 $7,492 PO BOX 842652 DALLAS TX

EM 704728 142460354148 1811355639 811313034 FASTPASS UCC PLLC N CLINIC/CENTER URGENT CARE 1 1 $0 PO BOX 840787 DALLAS TX





EM 704728 143272154998 1902270770 461894468 MEDPOST URGENT CARE-CIBOLO P CLINIC/CENTER URGENT CARE 1 1 $175 PO BOX 844691 DALLAS TX

EM 704728 144812242883 1033511332 208621296 RCMH LLC P CLINIC/CENTER URGENT CARE 1 1 $83 PO BOX 18852 BELFAST ME

EM 704728 148975013128 1275905341 810697290 FAST TEX URGENT CARE P CLINIC/CENTER URGENT CARE 3 3 $230 PO BOX 37 CIBOLO TX

EM 704728 151481135065 1609076330 204768243 MINUTECLINIC DIAGNOSTIC OF TEXAS LLC P CLINIC/CENTER URGENT CARE 13 11 $964 PO BOX 8447 BELFAST ME

EM 704728 175760013431 1013194455 205805198 AMERICAN CURRENT CARE PA P CLINIC/CENTER URGENT CARE 1 1 $190 PO BOX 9011 BROOMFIELD CO

EM 704728 181947065033 1780673319 202313462 LITTLE SPURS PEDIATRIC URGENT CARE P CLINIC/CENTER URGENT CARE 3 3 $265 PO BOX 701950 SAN ANTONIO TX

EM 704728 185078465332 1922289412 260845489 NEXTCARE URGENT CARE P CLINIC/CENTER URGENT CARE 8 6 $902 PO BOX 952245 DALLAS TX

EM 704728 187705313217 1568622272 261378424 LEGACY URGENT CARE PA N CLINIC/CENTER URGENT CARE 1 1 $0 PO BOX 58239 OKLAHOMA CITY OK

EM 704728 197493063533 1386983609 461830325 QUALITY URGENT CARE P CLINIC/CENTER URGENT CARE 1 1 $0 318 W LOOP 1604 N SAN ANTONIO TX

EM 704728 197966321675 1346545209 274412271 FASTMED URGENT CARE P CLINIC/CENTER URGENT CARE 6 5 $818 935 SHOTWELL RD STE 108 CLAYTON NC

EM 704728 10654324504 1518904689 742781812 ROUND ROCK MEDICAL CENTER P GENERAL ACUTE CARE HOSPITAL 1 1 $727 PO BOX 406164 ATLANTA GA

EM 704728 10654325532 1821009242 742575462 CENTRAL TEXAS MEDICAL CENTER P GENERAL ACUTE CARE HOSPITAL 1 1 $5,644 PO BOX 951558 DALLAS TX

EM 704728 10654346138 1598744856 760714523 NORTH EAST BAPTIST HOSPITAL P GENERAL ACUTE CARE HOSPITAL 3 3 $9,515 PO BOX 848333 DALLAS TX

EM 704728 10654346371 1396767778 741386053 GUADALUPE REGIONAL MEDICAL CENTER P GENERAL ACUTE CARE HOSPITAL 27 13 $21,936 1215 E COURT ST SEGUIN TX

EM 704728 10659947115 1104818723 756004585 FAITH RURAL CLINIC OF BOWIE P GENERAL ACUTE CARE HOSPITAL 7 6 $16,937 PO BOX 15689 BELFAST ME

EM 704728 10659948965 1598744856 760714523 NORTH CENTRAL BAPTIST HOSPITAL P GENERAL ACUTE CARE HOSPITAL 22 12 $37,742 PO BOX 848333 DALLAS TX

EM 704728 10659948972 1912906298 621795572 SOUTHWEST GENERAL HOSPITAL P GENERAL ACUTE CARE HOSPITAL 2 2 $760 PO BOX 27396 SALT LAKE CITY UT

EM 704728 10659948977 1881697878 742323822 YOAKUM COMMUNITY HOSPITAL P GENERAL ACUTE CARE HOSPITAL 1 1 $0 PO BOX 731033 DALLAS TX

EM 704728 10659949614 1598744856 760714523 BAPTIST HEALTH SYSTEM P GENERAL ACUTE CARE HOSPITAL 1 1 $124 PO BOX 848333 DALLAS TX

EM 704728 10659951138 1821011248 746002164 UNIVERSITY HEALTH SYSTEM P GENERAL ACUTE CARE HOSPITAL 1 1 $81 PO BOX 2376 SAN ANTONIO TX

EM 704728 100297470969 1376786996 742112082 NEW BRAUNFELS VA CBOC P GENERAL ACUTE CARE HOSPITAL 1 1 $42 PO BOX 2469 SMYRNA TN

EM 704728 102338475159 1972586238 954896822 DEWITT HOSPITAL AND NURSING HOME P GENERAL ACUTE CARE HOSPITAL 1 1 $1,568 PO BOX 32 DE WITT AR

EM 704728 105724012814 1659525236 742730328 METHODIST STONE OAK HOSPITAL P GENERAL ACUTE CARE HOSPITAL 4 4 $6,026 PO BOX 405653 ATLANTA GA

EM 704728 107637544266 1114473329 452497248 EMERUS BHS SA THOUSAND OAKS NW MILITARY LLC

P GENERAL ACUTE CARE HOSPITAL 1 1 $2,972 PO BOX 49109 HOUSTON TX

EM 704728 111828321253 1871560003 742730328 METHODIST AMBULATORY SURGICAL HOSPITAL P GENERAL ACUTE CARE HOSPITAL 1 1 $4,013 PO BOX 405648 ATLANTA GA

EM 704728 113514225667 1003224049 742112082 SAN ANTONIO VAMC P GENERAL ACUTE CARE HOSPITAL 11 5 $561 PO BOX 2469 SMYRNA TN





EM 704728 117919573778 1538117452 621501856 US PAIN & SPINE HOSPITAL N GENERAL ACUTE CARE HOSPITAL 1 1 $0 5445 LA BRANCH ST HOUSTON TX

EM 704728 118217490266 1144698689 472255328 SCHERTZ CIBOLO EMERGENCY CLINIC N GENERAL ACUTE CARE HOSPITAL 11 11 $10,196 PO BOX 2406 SAN ANTONIO TX

EM 704728 119280493649 1265568638 203749695 BAYLOR SCOTT AND WHITE MEDICAL CENTER ROUND ROCK

P GENERAL ACUTE CARE HOSPITAL 2 1 $0 PO BOX 844658 DALLAS TX

EM 704728 124983063226 1376662296 203904667 CEDAR PARK REGIONAL MED CTR P GENERAL ACUTE CARE HOSPITAL 1 1 $141 PO BOX 841091 DALLAS TX

EM 704728 125133135388 1083617245 370662580 ST MARYS HOSPITAL N GENERAL ACUTE CARE HOSPITAL 1 1 $266 7398 SOLUTION CTR CHICAGO IL

EM 704728 125151045249 1225381197 452497248 EMERUS BHS SA THOUSAND OAKS LLC P GENERAL ACUTE CARE HOSPITAL 1 1 $957 PO BOX 49110 HOUSTON TX

EM 704728 130209404491 742723334 COMMUNITY HEALTH PLANS N GENERAL ACUTE CARE HOSPITAL 3 2 $0 PO BOX 2639 SAN ANTONIO TX

EM 704728 132712025303 1427472463 462942963 RESOLUTE HOSPITAL COMPANY LLC P GENERAL ACUTE CARE HOSPITAL 14 8 $93,983 PO BOX 847382 DALLAS TX

EM 704728 133562163302 1144286352 310785684 MERCY MEMORIAL HOSPITAL P GENERAL ACUTE CARE HOSPITAL 1 1 $1,140 PO BOX 636500 CINCINNATI OH

EM 704728 138978003275 1568835569 474964977 EMERGENCY CLINIC LA VERNIA N GENERAL ACUTE CARE HOSPITAL 1 1 $939 PO BOX 92275 SOUTHLAKE TX

EM 704728 141747073293 1447355771 741109643 DELL CHILDRENS MEDICAL CENTER P GENERAL ACUTE CARE HOSPITAL 2 2 $19,597 PO BOX 204301 DALLAS TX

EM 704728 144387502558 1053312090 741109665 CHRISTUS SANTA ROSA HOSPITAL NEW BRAUNFELS

P GENERAL ACUTE CARE HOSPITAL 14 10 $27,704 PO BOX 846131 DALLAS TX

EM 704728 145652292942 1568848059 474612520 CUMBERLAND SURGICAL HOSPITAL N GENERAL ACUTE CARE HOSPITAL 2 1 $44,839 PO BOX 205947 DALLAS TX

EM 704728 146704380219 1124074273 742730328 METHODIST SPECIALTY TRANSPLANT HOSPITAL P GENERAL ACUTE CARE HOSPITAL 2 2 $4,706 PO BOX 406178 ATLANTA GA

EM 704728 151783275628 1639422504 452497248 EMERUS BHS SA THOUSAND OAKS LLC P GENERAL ACUTE CARE HOSPITAL 7 7 $14,356 DEPT 475 PO BOX 4869 HOUSTON TX

EM 704728 152090125826 1124074273 742730328 METHODIST HOSPITAL P GENERAL ACUTE CARE HOSPITAL 11 6 $52,220 PO BOX 406180 ATLANTA GA

EM 704728 154512253718 1275553539 720763512 THIBODAUX REGIONAL MEDICAL CENTER P GENERAL ACUTE CARE HOSPITAL 1 1 $956 PO BOX 54829 NEW ORLEANS LA

EM 704728 160038153356 1447325543 750808798 KNOX COUNTY HOSPITAL P GENERAL ACUTE CARE HOSPITAL 3 3 $10,238 PO BOX 608 KNOX CITY TX

EM 704728 164001542945 1316911597 743000576 359TH MEDICAL GROUP - RANDOLPH AFB CLINIC P GENERAL ACUTE CARE HOSPITAL 9 4 $0 221 3RD ST W RANDOLPH AFB TX

EM 704728 168164264880 1891770368 208057151 EVERGREEN MEDICAL CENTER LLC N GENERAL ACUTE CARE HOSPITAL 2 1 $0 DEPT 133 PO BOX 4458 HOUSTON TX

EM 704728 173380154506 1700826575 463085950 GLENN ROSE MEDICAL CENTER P GENERAL ACUTE CARE HOSPITAL 5 5 $11,338 PO BOX 2099 GLEN ROSE TX

EM 704728 174973261738 1669752234 452497248 EMERUS BHS SA THOUSAND OAKS LLC P GENERAL ACUTE CARE HOSPITAL 1 1 $368 DEPT 403 PO BOX 4869 HOUSTON TX

EM 704728 176910531574 1538251764 331007777 BAMC MCHE COU T DEPT 201 P GENERAL ACUTE CARE HOSPITAL 13 4 $603 3551 ROGER BROOKE DR FT SAM HOUSTON TX

EM 704728 180912550823 1124074273 742730328 NORTHEAST METHODIST HOSPITAL P GENERAL ACUTE CARE HOSPITAL 18 13 $80,368 PO BOX 406174 ATLANTA GA

EM 704728 185734595737 1306933692 205220791 LITTLE RIVER HEALTHCARE P GENERAL ACUTE CARE HOSPITAL 1 1 $696 PO BOX 674240 DALLAS TX

EM 704728 186048235262 1619115383 741109643 SETON MEDICAL CENTER HAYS P GENERAL ACUTE CARE HOSPITAL 1 1 $0 PO BOX 204301 DALLAS TX





EM 704728 186255542960 1700214863 463049741 STC OPERATIONS LLC N GENERAL ACUTE CARE HOSPITAL 1 1 $655 2810 SOUTH INTERSATE 35 SAN MARCOS TX

EM 704728 187006110113 1003224049 742112082 SAN ANTONIO VAMC P GENERAL ACUTE CARE HOSPITAL 2 1 $0 PO BOX 2469 SMYRNA TN

EM 704728 187198320259 1992172019 474866295 CLEVELAND EMERGENCY HOSPITAL N GENERAL ACUTE CARE HOSPITAL 2 2 $0 1017 S TRAVIS AVE CLEVELAND TX

EM 704728 187328282294 1821004151 741109665 CHILDRENS HOSPITAL OF SAN ANTONIO P GENERAL ACUTE CARE HOSPITAL 1 1 $816 PO BOX 846131 DALLAS TX

EM 704728 190471245659 1497726343 746083124 HILL COUNTRY MEMORIAL HOSPITAL P GENERAL ACUTE CARE HOSPITAL 1 1 $10,668 PO BOX 835 FREDERICKSBURG TX

EM 704728 193963195126 1477805406 452497248 BAPTIST EMERGENCY HOSPITAL WESTOVER HILLS

P GENERAL ACUTE CARE HOSPITAL 1 1 $1,690 DEPT 439 PO BOX 4869 HOUSTON TX

EM 704728 194368483347 1194787218 741109665 CHRISTUS SANTA ROSA MEDICAL CENTER P GENERAL ACUTE CARE HOSPITAL 1 1 $0 PO BOX 846131 DALLAS TX

EM 704728 197153231279 1295890093 364412922 SOUTH TEXAS SPINE AND SURGICAL HOSPITAL LP

P GENERAL ACUTE CARE HOSPITAL 2 1 $1,876 18600 N HARDY OAK BLVD SAN ANTONIO TX

EM 704728 10654322608 1073642641 330685754 PROMETHEUS LABORATORIES INC N CLINICAL MEDICAL LABORATORY 1 1 $0 PO BOX 894115 LOS ANGELES CA

EM 704728 10659957100 1063435808 751093698 PROPATH SERVICES LLP P CLINICAL MEDICAL LABORATORY 5 4 $1,033 DEPT 41074 PO BOX 660811 DALLAS TX

EM 704728 10659973220 1699849786 205819700 LITHOLINK CORPORATION P CLINICAL MEDICAL LABORATORY 2 2 $278 PO BOX 8109 BURLINGTON NC

EM 704728 101197123978 1003078403 262679473 REPROSOURCE FERTILITY DIAGNOSTICS N CLINICAL MEDICAL LABORATORY 1 1 $0 300 TRADE CTR STE 6540 WOBURN MA

EM 704728 101648202218 1659655124 453194060 CAP DIAGNOSTICS N CLINICAL MEDICAL LABORATORY 1 1 $0 PO BOX 101844 PASADENA CA

EM 704728 104765240282 1053650135 454236873 QT TOXICOLOGY N CLINICAL MEDICAL LABORATORY 1 1 $0 DEPT 8017 PO BOX 650002 DALLAS TX

EM 704728 106309264120 1023054863 382084239 QUEST DIAGNOSTICS N CLINICAL MEDICAL LABORATORY 6 5 $0 PO BOX 41691 PHILADELPHIA PA

EM 704728 106309264120 1023054863 382084239 QUEST DIAGNOSTICS P CLINICAL MEDICAL LABORATORY 156 83 $8,879 PO BOX 41691 PHILADELPHIA PA

EM 704728 131979181607 1215272406 900863464 GENOTOX LABORATORIES LTD N CLINICAL MEDICAL LABORATORY 1 1 $0 PO BOX 246 SAN ANTONIO TX

EM 704728 133575055609 1134438427 205455398 VERACYTE INC N CLINICAL MEDICAL LABORATORY 1 1 $0 DEPT 35173 PO BOX 39000 SAN FRANCISCO CA

EM 704728 134237555071 1366808388 475201395 PRISMHEALTHDX INC N CLINICAL MEDICAL LABORATORY 2 2 $0 4115 FREIDRICH LN STE 300 AUSTIN TX

EM 704728 135583432636 455345806 UNIFIED LABORATORY SERVICES N CLINICAL MEDICAL LABORATORY 3 2 $0 6116 OAKBEND TRL STE 106 FORT WORTH TX

EM 704728 143904405535 1346479169 743238060 COUNSYL INC CT P CLINICAL MEDICAL LABORATORY 1 1 $0 180 KIMBALL WAY SOUTH SAN FRANCISCO

CA

EM 704728 146608435673 1639541295 473492884 HIGHLINE LABS LLC N CLINICAL MEDICAL LABORATORY 2 2 $0 5900 NORTHWOODS BUSINESS PKWY STE K

CHARLOTTE NC

EM 704728 147259295559 1619376316 465219452 TRUE HEALTH DIAGNOSTICS LLC N CLINICAL MEDICAL LABORATORY 7 6 $0 737 N 8TH ST STE 103 RICHMOND VA

EM 704728 147348494213 1225110497 201236503 ACCU REFERENCE LAB N CLINICAL MEDICAL LABORATORY 9 6 $0 1901 E LINDEN AVE UNIT 4 LINDEN NJ

EM 704728 147604595970 1316326838 471355107 RELIABLE LABS LLC N CLINICAL MEDICAL LABORATORY 1 1 $0 1735 KELLER SPRINGS RD STE 210 B CARROLLTON TX

EM 704728 148464043253 1770984239 471479810 GENESIS DIAGNOSTICS N CLINICAL MEDICAL LABORATORY 1 1 $0 900 TOWN CENTER DRIVER SUITE H50 LANGHORNE PA





EM 704728 148601210996 1902131857 270943279 PATHOLOGY ASSOCIATES MED LABS P CLINICAL MEDICAL LABORATORY 2 1 $72 PO BOX 2670 SPOKANE WA

EM 704728 149348282803 261594502 PREMIER MEDICAL N CLINICAL MEDICAL LABORATORY 1 1 $0 10 JACK CASEY CT FOUNTAIN INN SC

EM 704728 151492305657 1114222817 273950390 PROGENITY INC N CLINICAL MEDICAL LABORATORY 1 1 $0 PO BOX 674425 DETROIT MI

EM 704728 157448265833 1194769497 742554159 CLINICAL PATHOLOGY LABORATORIES INC P CLINICAL MEDICAL LABORATORY 159 74 $7,985 PO BOX 141669 AUSTIN TX

EM 704728 158291170553 1760760805 452808991 TEXAS STATE CLINICAL LABORATORIES N CLINICAL MEDICAL LABORATORY 8 1 $0 11149 RESEARCH BLVD STE 360 AUSTIN TX

EM 704728 160076500474 382084239 QUEST DIAGNOSTICS N CLINICAL MEDICAL LABORATORY 5 4 $0 ONE MALCOLM AVE TETERBORO NJ

EM 704728 163019545944 010894487 NATERA INC N CLINICAL MEDICAL LABORATORY 1 1 $0 PO BOX 8427 PASADENA CA

EM 704728 165160091495 1538157086 742959346 PATHOLOGY REFERENCE LABORATORY LLC P CLINICAL MEDICAL LABORATORY 73 61 $5,792 PO BOX 2037 SAN ANTONIO TX

EM 704728 168195043626 1699782722 880241758 AEGIS SCIENCES CORPORATION P CLINICAL MEDICAL LABORATORY 3 2 $240 PO BOX 645463 CINCINNATI OH

EM 704728 168835391345 1750373908 223510467 MEDICAL DIAGNOSTICS LABS LLC P CLINICAL MEDICAL LABORATORY 1 1 $61 2439 KUSER RD HAMILTON NJ

EM 704728 176092092215 1902141500 911491167 PMG PHC P CLINICAL MEDICAL LABORATORY 2 1 $87 PO BOX 421 LIBERTY LAKE WA

EM 704728 180706033263 1063497451 133757370 LABCORP OF AMERICA HOLDINGS P CLINICAL MEDICAL LABORATORY 5 5 $328 PO BOX 2270 BURLINGTON NC

EM 704728 180706033263 1063497451 840611484 LABCORP OF AMERICA HOLDINGS P CLINICAL MEDICAL LABORATORY 84 54 $4,354 PO BOX 2270 BURLINGTON NC

EM 704728 196191352190 1013382431 474187111 CLIO LABORATORIES LLC N CLINICAL MEDICAL LABORATORY 1 1 $0 1180 BEAVER RUIN RD STE B NORCROSS GA

EM 704728 196583581559 1992779664 112659192 NTD LABORATORIES INC P CLINICAL MEDICAL LABORATORY 2 2 $240 80 RULAND RD STE 1 MELVILLE NY

EM 704728 196649401406 1497173348 465063805 DIAGNOSTICES LAB LLC SPECTRUM N CLINICAL MEDICAL LABORATORY 4 3 $0 209 BILLINGS ST STE 420 ARLINGTON TX

EM 704728 198561134011 1982142345 813675987 AVANTI LABORATORIES N CLINICAL MEDICAL LABORATORY 5 4 $0 1650 HIGHWAY 9 E UNIT 1 LONGS SC

EM 704728 10654328842 1194025338 742579862 PREMIER SPECIALTIES INC DBA MEDICAL EXPRESS PSI

N DME AND MEDICAL SUPPLIES 2 2 $0 8800B SHOAL CREEK BLVD AUSTIN TX

EM 704728 104118163747 1336234194 330057155 APRIA HEALTHCARE LLC P DME AND MEDICAL SUPPLIES 28 5 $1,175 73 ENTERPRISE DR STE A PENDERGRASS GA

EM 704728 114566105247 621298835 AMERICAN HOMEPATIENT N DME AND MEDICAL SUPPLIES 4 1 $0 PO BOX 676482 DALLAS TX

EM 704728 124562045260 1396901047 800213302 STRIVE MEDICAL LLC P DME AND MEDICAL SUPPLIES 2 1 $253 8428 STERLING ST STE B IRVING TX

EM 704728 131932472347 1154499077 743003947 SAN ANTONIO ORTHOPEDIC GRP DME N DME AND MEDICAL SUPPLIES 1 1 $0 PO BOX 9585 BELFAST ME

EM 704728 132016321522 621298835 AMERICAN HOMEPATIENT INC N DME AND MEDICAL SUPPLIES 4 1 $0 PO BOX 744271 ATLANTA GA

EM 704728 132642104391 1306025903 203546931 AEROFLOW BREASTPUMPS P DME AND MEDICAL SUPPLIES 3 3 $468 3165 SWEETEN CREEK RD ASHEVILLE NC

EM 704728 133923024556 1609858729 341650951 EDGEPARK MEDICAL SUPPLIES P DME AND MEDICAL SUPPLIES 1 1 $156 1810 SUMMIT COMMERCE PARK TWINSBURG OH

EM 704728 137607233785 1346590973 263876331 A PLUS BREAST PUMPS BY YUMMY MUMMY P DME AND MEDICAL SUPPLIES 1 1 $169 600 HICKSVILLE RD BETHPAGE NY





EM 704728 143255265663 1033199641 591450889 ROTECH P DME AND MEDICAL SUPPLIES 10 1 $272 PO BOX 27968 SALT LAKE CITY UT

EM 704728 143259370584 1003896747 591450889 ROTECH P DME AND MEDICAL SUPPLIES 1 1 $283 PO BOX 4829 PLANT CITY FL

EM 704728 150557234701 1164535274 201121194 ZOLL SERVICES LLC N DME AND MEDICAL SUPPLIES 3 1 $3,643 PO BOX 644321 PITTSBURGH PA

EM 704728 156182585590 1770511552 841451963 ZYNEX MEDICAL INC N DME AND MEDICAL SUPPLIES 2 1 $0 PO BOX 840932 DALLAS TX

EM 704728 163129355500 1023347721 341774213 EDWARDS HEALTH CARE SRVC INC P DME AND MEDICAL SUPPLIES 7 1 $1,296 PO BOX 309 HUDSON OH

EM 704728 163797192254 1043317761 810660995 A & P QUALITY CARE MEDICAL N DME AND MEDICAL SUPPLIES 1 1 $0 8220 CROSS PARK DR STE 100 AUSTIN TX

EM 704728 176469171374 1982753299 202391271 SSI DME SOLUTIONS LP N DME AND MEDICAL SUPPLIES 1 1 $0 1540 SOUTHTOWN RD STE 101 GRANBURY TX

EM 704728 180512170250 1629167028 593323767 ELECTROSTIM MEDICAL SERVICES INC P DME AND MEDICAL SUPPLIES 12 1 $197 3504 CRAGMONT DR SUITE 100 TAMPA FL

EM 704728 181073442366 1376542837 412062056 GOOD NIGHT MEDICAL P DME AND MEDICAL SUPPLIES 9 1 $0 975 EASTWIND DR STE 165 WESTERVILLE OH

EM 704728 186480305705 1235312695 330857544 DEXCOM INC P DME AND MEDICAL SUPPLIES 3 1 $2,079 DEPT LA 24120 PASADENA CA

EM 704728 191082392767 208715566 ADVANCED ORTHOPEDIC DESIGNS P DME AND MEDICAL SUPPLIES 1 1 $0 12315 JUDSON RD STE 206 LIVE OAK TX

EM 704728 199730204560 591450889 ROTECH P DME AND MEDICAL SUPPLIES 2 1 $151 PO BOX 27968 SALT LAKE CITY UT

EM 704728 107286075854 1134279425 742276859 SAN MARCOS HAYS COUNTY EMS INC P AMBULANCE 1 1 $1,312 PO BOX 612224 DALLAS TX

EM 704728 149921250258 1043213606 741469344 CITY OF SCHERTZ EMS N AMBULANCE 8 7 $1,043 1400 SCHERTZ PKWY BLDG 7 SCHERTZ TX

EM 704728 199510313019 1750676870 300688582 ACADIAN AMBULANCE SERVICE OF TEXAS INC P AMBULANCE 1 1 $876 PO BOX 92970 LAFAYETTE LA

EM 704728 156175334122 1912037201 742951434 GORHAM, BECKY L PA P PHYSICIAN ASSISTANT 1 1 $0 PO BOX 11908 BELFAST ME

EM 704728 166779251012 1942205430 200761158 GIACONTIERE, KEVIN J PA P PHYSICIAN ASSISTANT 1 1 $0 1303 MCCULLOUGH AVE STE 560 SAN ANTONIO TX

EM 704728 171615380333 1669529129 752005254 HALE, LORI L PAC P PHYSICIAN ASSISTANT 2 2 $223 PO BOX 206239 DALLAS TX

EM 704728 183593060171 1356732028 743025288 TUBB, ASHLEY D PA P PHYSICIAN ASSISTANT 1 1 $76 12709 TOEPPERWEIN RD STE 101 SAN ANTONIO TX

EM 704728 157444324741 1932445863 454937699 CASTILLO, HOMERO LSA N PHYSICIAN ASSISTANT SURGICAL 1 1 $0 1822 W BRAKER LN 81603 AUSTIN TX

EM 704728 171475162991 1275819385 270604044 WHITE, STEVEN C CSFA P PHYSICIAN ASSISTANT SURGICAL 1 1 $113 PO BOX 33607 SAN ANTONIO TX

EM 704728 172590065672 1992174502 474775527 ALAMO CITY FIRST ASSIST N PHYSICIAN ASSISTANT SURGICAL 1 1 $0 3806 MIRA MESA SAN ANTONIO TX

EM 704728 117764375539 1346523719 742719352 GARCIA, ADRIENNE R NP P NURSE PRACTITIONER 3 2 $135 7909 FREDERICKSBURG RD STE 110 SAN ANTONIO TX

EM 704728 168320433924 1215043690 742734272 LONGORIA, CHRISTIAN R FNP RN P NURSE PRACTITIONER 1 1 $29 PO BOX 2208 SAN ANTONIO TX

EM 704728 173130515293 1154560092 203059260 BERRIOS, LUIS A MSN ANP P NURSE PRACTITIONER 5 1 $163 PO BOX 5730 BELFAST ME

EM 704728 10659948048 1518921808 742727952 SHOBER JR, ROBERT C CRNA P NURSE ANESTHETIST, CERTIFIED REGISTERED 1 1 $270 PO BOX 2778 SAN ANTONIO TX





EM 704728 100092155324 1881671550 300857847 EWERS, KATHLEEN CRNA N NURSE ANESTHETIST, CERTIFIED REGISTERED 1 1 $248 PO BOX 849892 DALLAS TX

EM 704728 103116090396 1740256742 742886514 JOHNSON, MARISSA L CRNA P NURSE ANESTHETIST, CERTIFIED REGISTERED 2 2 $1,170 1215 E COURT ST SEGUIN TX

EM 704728 109377470113 1902855612 461990477 WALLACE, ANNMARIE CRNA N NURSE ANESTHETIST, CERTIFIED REGISTERED 1 1 $356 PO BOX 659 SAN ANTONIO TX

EM 704728 115004394383 1942248125 300857847 FITZPATRICK, LEO J CRNA N NURSE ANESTHETIST, CERTIFIED REGISTERED 1 1 $351 PO BOX 1712 LONGVIEW PA

EM 704728 126101564794 1215918370 742246239 TABLIZO, KATHRYN R CRNA P NURSE ANESTHETIST, CERTIFIED REGISTERED 1 1 $0 PO BOX 528 SAN ANTONIO TX

EM 704728 147972131562 1124090667 463562649 HELMINIAK, JOSEPH J CRNA N NURSE ANESTHETIST, CERTIFIED REGISTERED 1 1 $0 14603 HUEBNER RD BLDG 2 SAN ANTONIO TX

EM 704728 150076324851 1083927057 300857847 GOOCH, JERRY A CRNA N NURSE ANESTHETIST, CERTIFIED REGISTERED 3 3 $131 PO BOX 2778 SAN ANTONIO TX

EM 704728 155093233701 1801848742 300857847 PAPIZAN, CYNTHIA CRNA N NURSE ANESTHETIST, CERTIFIED REGISTERED 1 1 $151 PO BOX 849892 DALLAS TX

EM 704728 156018052408 1205194537 742886514 MATTHEWS, MICHAEL CRNA P NURSE ANESTHETIST, CERTIFIED REGISTERED 2 2 $486 1215 E COURT ST SEGUIN TX

EM 704728 182838233223 1194878983 300706634 HOLLADAY, WENDELL CRNA N NURSE ANESTHETIST, CERTIFIED REGISTERED 1 1 $163 PO BOX 206239 DALLAS TX

EM 704728 190871125927 1942265921 742246239 BERNATEK, THOMAS J CRNA P NURSE ANESTHETIST, CERTIFIED REGISTERED 1 1 $0 520 E EUCLID AVE SAN ANTONIO TX

EM 704728 191995131503 1790060101 300857847 SCOTT, TERESITA RN N NURSE ANESTHETIST, CERTIFIED REGISTERED 1 1 $910 PO BOX 849892 DALLAS TX

EM 704728 196545491179 1013994656 300706634 BOCK, JUDITH A CRNA N NURSE ANESTHETIST, CERTIFIED REGISTERED 1 1 $315 MSC STE 500 PO BOX 659830 SAN ANTONIO TX

EM 704728 114824124117 1720274228 742312850 GUEHL, LAUREN S CNM P MIDWIFE, CERTIFIED NURSE 3 1 $195 7950 FLOYD CURL DR STE 300 SAN ANTONIO TX

EM 704728 141985204562 1407207921 742312850 BRISTER, MEGAN CNM P MIDWIFE, CERTIFIED NURSE 1 1 $67 PO BOX 5730 BELFAST ME

EM 704728 151496450146 1558591289 742312850 MORPHET, KIMBERLY A CNM P MIDWIFE, CERTIFIED NURSE 3 1 $101 7950 FLOYD CURL DR STE 300 SAN ANTONIO TX

EM 704728 172607405845 1255569588 742312850 SCHLEICHER, ERIN L CNM P MIDWIFE, CERTIFIED NURSE 1 1 $101 7950 FLOYD CURL DR STE 300 SAN ANTONIO TX

EM 704728 195249154166 1508976200 742312850 BIBLE, AMY A CNM P MIDWIFE, CERTIFIED NURSE 1 1 $139 PO BOX 730 AUGUSTA GA

EM 704728 128762244306 743000576 359TH MEDICAL GROUP RANDOLPH AFB CLINIC N UNKNOWN 2 2 $0 221 3RD STREET WEST BLDG 1040 RANDOLPH AFB TX

EM 704728 130295454539 1578762563 814676328 OPEOLA, MOBOLAJI M MD P UNKNOWN 3 1 $85 MEDICAL PLAZA 1 SUITE 320 11212 STATE HIGHWAY 151

SAN ANTONIO TX

EM 704728 133386400151 1801802640 010784663 TAMAYO, LAURA R MD P UNKNOWN 1 1 $631 11085 BANDERA RD STE 102 SAN ANTONIO TX

EM 704728 135492472876 1003935107 810651320 NORTH CENTRAL URGENT CARE P UNKNOWN 1 1 $0 19223 STONEHUE SAN ANTONIO TX

EM 704728 144145114077 1174801971 452773091 ALL SCHERTZ CIBOLO PHYSICAL THERAPY P UNKNOWN 10 1 $20 790 ROY RICHARD DR STE EF SCHERTZ TX

EM 704728 148951470828 1225137342 800370174 WILFORD HALL MED CENTER P UNKNOWN 7 3 $0 2200 BERGQUIST DR STE 1 LACKLAND AFB TX

EM 704728 159933051853 1225137342 800370174 WILFORD HALL MED CENTER N UNKNOWN 8 3 $0 2200 BERGQUIST DR STE 1 LACKLAND AFB TX

EM 704728 167648133837 1154649465 742531032 WHEELER, MICHELLE CPNP P UNKNOWN 6 6 $421 PO BOX 34415 SAN ANTONIO TX





EM 704728 191711581237 1336163054 800245679 IM, STEPHEN S MD P UNKNOWN 1 1 $14 12709 TOEPPERWEIN RD STE 201 LIVE OAK TX

EM 704728 192900200006 1437155405 741833341 THOMPSON III, ROBERT K MD P UNKNOWN 1 1 $3 PO BOX 276 SAN ANTONIO TX


Bill Zip Serv Address Serv Address2 Serv City Serv ST Serv Zip

78213 2161 NW MILITARY HWY STE 207 SAN ANTONIO TX 78213-1844

78232-1012 1122 W BLANCO RD SAN ANTONIO TX 78232-1012

78130 2034 SUNDANCE PKWY NEW BRAUNFELS TX 78130-2750

78257 4201 MEDICAL DR STE 330 SAN ANTONIO TX 78229-5805

78109-1985 9830 APPELLATE WAY CONVERSE TX 78109-1985

78229-5805 4201 MEDICAL DR STE 330 SAN ANTONIO TX 78229-5805

78230-2570 11107 WURZBACH RD STE 604 SAN ANTONIO TX 78230-2570

78258-7410 17890 BLANCO RD STE 306 SAN ANTONIO TX 78232-1098


78232 1380 PANTHEON WAY STE 310 SAN ANTONIO TX 78232-2288

78205 343 W HOUSTON ST STE 1010 SAN ANTONIO TX 78205-2271

78229 3939 MEDICAL DR SAN ANTONIO TX 78229-2291

92123 641 N WALNUT AVE NEW BRAUNFELS TX 78130-7925

78209

78217 8610 N NEW BRAUNFELS AVE

STE 700 SAN ANTONIO TX 78217-6357

78260-5318 200 N SEGUIN AVE NEW BRAUNFELS TX 78130-5031


78217 3030 NACOGDOCHES RD STE 101 SAN ANTONIO TX 78217-4502

78217 114 S BRYANT ST PLEASANTON TX 78064-4006

78209-2681 147 W SUNSET RD STE 101 SAN ANTONIO TX 78209-2681

78006-2842 115 HWY 46 W BOERNE TX 78006-8115

78130-5407 395 LANDA ST NEW BRAUNFELS TX 78130-5407

78132-3411 6781 FM 1102 NEW BRAUNFELS TX 78132-3411

15251-2950 11355 TOEPPERWEIN RD LIVE OAK TX 78233-3000


78258-4232 930 PROTON RD STE 104 SAN ANTONIO TX 78258-4232

78223 116 JAMES ST BOERNE TX 78006-2302

78231 13133 NW MILITARY HWY STE 300 SAN ANTONIO TX 78231-1848

78233 12107 TOEPPERWEIN RD STE 8 LIVE OAK TX 78233-3157

78230 11924 VANCE JACKSON RD STE 104 SAN ANTONIO TX 78230-1459

78654-5233 908 AVENUE F MARBLE FALLS TX 78654-5233

78108-3360 750 SCHNEIDER STE 170 CIBOLO TX 78108-3360

78216 8507 MCCULLOUGH AVE STE A1 SAN ANTONIO TX 78216-6457


78247 15150 NACOGDOCHES RD STE 185 SAN ANTONIO TX 78247-1201

90051 8455 CRESTWAY DR STE 101 CONVERSE TX 78109-3528

78217-5506 4358 THOUSAND OAKS DR SAN ANTONIO TX 78217-2102

78230-5473 14603 HUEBNER RD BLDG 4 SAN ANTONIO TX 78230-5473

78130 652 N HOUSTON AVE STE 1 NEW BRAUNFELS TX 78130-4123

78204-1210 646 S MAIN AVE SAN ANTONIO TX 78204-1210

78295-1358 11900 CROWN PT STE 140 SAN ANTONIO TX 78233-5356

78154-1667 1420 SCHERTZ PKWY STE 130 SCHERTZ TX 78154-1667

78132 17460 IH 35 N STE 412 SCHERTZ TX 78154-1222

78154-1278 17323 IH 35 N STE 110 SCHERTZ TX 78154-1278

78109 9250 FM 78 CONVERSE TX 78109-2903


78230-1211 11703 HUEBNER RD STE 109 SAN ANTONIO TX 78230-1211

78466 15069 IH 35 N STE 108 SELMA TX 78154-3567

78234

78150

78299-2947 9901 IH 10 W STE 400 SAN ANTONIO TX 78230-2255


78216-6627 403 N MILAM ST SEGUIN TX 78016-4946

76065-7556 5000 BAPTIST HEALTH DR STE 114 SCHERTZ TX 78154-1194

78006-2984 5000 BAPTIST HEALTH DR STE 114 SCHERTZ TX 78154-1194

78212 341 E HILDEBRAND AVE SAN ANTONIO TX 78212-2412

78023-1198 19260 STONE OAK PKWY STE 101 SAN ANTONIO TX 78258-3370

78240-1670 155 E SONTERRA BLVD STE 101 SAN ANTONIO TX 78258-3988

78132-5250 212 HUNTERS VLG STE 105 NEW BRAUNFELS TX 78132-5250

78746-5236 525 OAK CENTRE DR SAN ANTONIO TX 78258-3944

78258-3920 540 MADISON OAK DR STE 210 SAN ANTONIO TX 78258-3920

78213 1642 LOCKHILL SELMA RD SAN ANTONIO TX 78213-1929

78216 3510 N LOOP 1604 E SAN ANTONIO TX 78247-2303

75373-3947 495 10TH ST STE 103 FLORESVILLE TX 78114-3163

78293-0659 3510 N LOOP 1604 E SAN ANTONIO TX 78247-2303

04915-9585 400 CONCORD PLAZA DR STE 300 SAN ANTONIO TX 78216-6991




75373-3947 411 S KING ST SEGUIN TX 78155-5838


52233-2362 722 5TH AVE SE CEDAR RAPIDS IA 52401-1916

78291-0026 1642 LOCKHILL SELMA RD SAN ANTONIO TX 78213-1929

75373-3947 213 HUNTERS VLG NEW BRAUNFELS TX 78132-4764

04915-9585 11212 STATE HIGHWAY 151 STE 150

PLAZA 1 SAN ANTONIO TX 78251-4505





78299-2778 8415 DATAPOINT DR STE 1000 SAN ANTONIO TX 78229





75284-0853 100 MEDICAL DR LAKE JACKSON TX 77566-5674

75284-5347 1500 CITYWEST BLVD STE 300

HOUSTON TX 77042-2549


75284-5347 5323 HARRY HINES BLVD DALLAS TX 75390-7208


78291-0254 7940 FLOYD CURL STE 1030 SAN ANTONIO TX 78229-3906




85038

78130 2550 N ESPLANADE ST CUERO TX 77954-4736

78130 1584 COMMON ST NEW BRAUNFELS TX 78130-3113

78233 7832 PAT BOOKER RD SAN ANTONIO TX 78233-2601

78201 519 N KING ST STE 103 SEGUIN TX 78155-4859

78233-2601 18540 SIGMA RD SAN ANTONIO TX 78258-4274

78130 20475 HIGHWAY 46 W STE 270 SPRING BRANCH TX 78070-6182

78130 2660 COMMON ST STE 104 NEW BRAUNFELS TX 78130-3168

78109 2154 GABRIELS PL STE 103 NEW BRAUNFELS TX 78130-5475

78155-5126 1342 E WALNUT ST SEGUIN TX 78155-5126

78109 2154 GABRIELS PL STE 103 NEW BRAUNFELS TX 78130-5475


78731-6200 3500 JEFFERSON ST STE 200 AUSTIN TX 78731-6200

78291 12415 BANDERA RD STE 114 HELOTES TX 78023-4265

45263-9355 4513 WILLIAMS DR GEORGETOWN TX 78633-1302

78233-2601 7832 PAT BOOKER RD SAN ANTONIO TX 78233-2601

78259-0221 2115 STEPHENS PL STE 800 NEW BRAUNFELS TX 78130-2163

78233-2601 7832 PAT BOOKER RD SAN ANTONIO TX 78233-2601

04915 1920 DON WICKHAM DR STE 330 CLERMONT FL 34711-1978


04915-4038 3320 OAKWELL CT SAN ANTONIO TX 78218-3019

78258 1314 E SONTERRA STE 2201 SAN ANTONIO TX 78258

78217-0348 414 NAVARRO ST STE 520 SAN ANTONIO TX 78205-2532

78130-3556 901A LOOP 337 NEW BRAUNFELS TX 78130-3556

78041 6801 MCPHERSON RD STE 332 LAREDO TX 78041-6417

04915-4116 1201 W 38TH ST AUSTIN TX 78705-1006

75267-4085 8401 DATAPOINT DR STE 500 SAN ANTONIO TX 78229-5907


85082-4568 4204 GARDENDALE ST STE 312 SAN ANTONIO TX 78229-3141

76124

89193 1018 6TH AVE WORTHINGTON MN 56187-2202

45263-8761

78292-0528 555 CREEKSIDE XING NEW BRAUNFELS TX 78130-2594

75373

76099 1505 BELLAIRE DR AUSTIN TX 78741-2505

89193 1301 WONDER WORLD DR SAN MARCOS TX 78666-7533

85082-4568 1500 RED RIVER ST AUSTIN TX 78701-1918

89193 111 DALLAS ST SAN ANTONIO TX 78205-1201


85082-4568 4204 GARDENDALE ST STE 312 SAN ANTONIO TX 78229-3141

89193 1310 MCCULLOUGH AVE SAN ANTONIO TX 78212-5601


02284-9332

76063-0047 1215 E COURT ST SEGUIN TX 78155-5129

78041-5773 1222 W OAKLAWN RD STE B PLEASANTON TX 78064-4302

33906-6259 1201 W 38TH ST AUSTIN TX 78705-1006

75373

75320-3949 16414 SAN PEDRO STE 710 SAN ANTONIO TX 78232-2277

45263 952 GRUENE RD STE 150 NEW BRAUNFELS TX 78130

89193 7950 MARTIN LOOP MACH DEPARTMENT OF EMERGENCY MEDICINE

FORT BENNING GA 31905-5648

89193 12141 RICHMOND AVE HOUSTON TX 77082-2408

75303-1173 6431 FANNIN ST HOUSTON TX 77030

04915-4116 601 E 15TH ST AUSTIN TX 78701-1930

73143-6118 1615 GRAND AVENUE PKWY STE 110 PFLUGERVILLE TX 78660-2060

89193 1501 KINGS HWY SHREVEPORT LA 71103-4228

73070-9088 701 CYPRESS ST SULPHUR LA 70663-5053

89193 5038 BECKWITH BLVD STE 107 SAN ANTONIO TX 78249-2292

04915-4116 6800 W IH 10 STE 250 SAN ANTONIO TX 78201-2038

89193 1310 MCCULLOUGH AVE SAN ANTONIO TX 78212-5601

04915-4116 1201 W 38TH ST AUSTIN TX 78705-1006


73143 555 CREEKSIDE XING EMERGENCY DEPT NEW BRAUNFELS TX 78130-2594

89193-8608 PO BOX 203949 DALLAS TX 75320-3949

78299-2597


78292-0528 1201 W 38TH ST AUSTIN TX 78705-1006

89193 7435 W TALCOTT AVE RESURRECTION EM RESIDENCY

CHICAGO IL 60631-3707

75320-3949 305 MALLARD LN TAYLOR TX 76574-1208

78131 774 LANDA ST NEW BRAUNFELS TX 78130-6114

04915-5700 1601 REDWOOD RD STE B SAN MARCOS TX 78666-1423

04915-4073 2406 HUNTER RD STE 106 SAN MARCOS TX 78666-5256

75267-8779 3401 FM 3009 SCHERTZ TX 78154-2711

04915-4080 1201 S MAIN ST STE 114 BOERNE TX 78006-2838


04915-4087 1228 HWY 123 SAN MARCOS TX 78666-7730

78148 2009 PAT BOOKER RD UNIVERSAL CITY TX 78148-3201

78205-1892 4360 GRECO DR SAN ANTONIO TX 78222-2725

77402-0579 235 W 20TH ST HOUSTON TX 77008-2511


78217-2118 12650 NACOGDOCHES RD SAN ANTONIO TX 78217-2118


78156 1414 E WALNUT SEGUIN TX 78155


78283-0605 7355 BARLITE BLVD STE 301 SAN ANTONIO TX 78224-1340

78756-4005 9727 POTEET JOURDANTON FWY



78114-6293 7594 US HIGHWAY 181 N SUITE 1 FLORESVILLE TX 78114-6293

04915-4031 11212 STATE HIGHWAY 151 PLAZA 1


78130-4170 189 E AUSTIN ST STE 102 NEW BRAUNFELS TX 78130-4170

78205-1892 12602 TOEPPERWEIN RD STE 100 LIVE OAK TX 78233-3204



78233-5391 6170 I W EAST SAN ANTONIO TX 78219

78233-3160 11901 TOEPPERWEIN RD STE 1201 SAN ANTONIO TX 78233-3159


75284-4658 1340 WONDER WORLD DR STE 2300 SAN MARCOS TX 78666-7598

78292-0528 4118 POND HILL RD STE 202 SAN ANTONIO TX 78231-1282


78160-0098 601 PEARSON ST STOCKDALE TX 78160


04915-4080 2020 SUNDANCE PKWY STE A1 NEW BRAUNFELS TX 78130-2770

78258-4098 11212 STATE HIGHWAY 151 BLDG 2 STE 201 SAN ANTONIO TX 78251-4498

04915-4073 2406 HUNTER RD STE 106 SAN MARCOS TX 78666-5256

78156-5631 214 N CAMP ST SEGUIN TX 78155-5631

04915 9179 GRISSOM RD STE 101 SAN ANTONIO TX 78251-2810

04915-4073 1320 WONDER WORLD DR SAN MARCOS TX 78666-7557

79424 1533 5TH ST CORPUS CHRISTI TX 78404-1901

04915-4102 1417 E WALNUT ST STE 600 SEGUIN TX 78155-5184

78205-1892 1860 S SEGUIN AVE BLDG E NEW BRAUNFELS TX 78130-3914

04915-5700 16088 SAN PEDRO AVE STE 115 SAN ANTONIO TX 78232-2249

78233-3000 910 LA GARGANTA SAN ANTONIO TX 78258-2931


77995-2718 1200 CARL RAMERT DR STE D

YOAKUM TX 77995-4868

78130 952 GRUENE RD STE 150 NEW BRAUNFELS TX 78130-3920

04915-4048 11345 ALAMO RANCH PKWY STE 103 SAN ANTONIO TX 78253-6440


78258-4098 18818 MEISNER DR STE 102 SAN ANTONIO TX 78258-3569

78155 1355 E COURT ST SEGUIN TX 78155-5130


04915-5700 16088 SAN PEDRO AVE STE 115 SAN ANTONIO TX 78232-2249


78299-2952 18915 MEISNER DR SAN ANTONIO TX 78258-4223


04915-4048 2277 NW MILITARY HWY STE 100 SAN ANTONIO TX 78213-1853


75267-8779 3401 FM 3009 SCHERTZ TX 78154-2711

78154 5016 FM 1518 SELMA TX 78154-1360

78258-4098 11212 STATE HIGHWAY 151 BLDG 2 STE 201 SAN ANTONIO TX 78251-4498

78228-3419 4151 CALLAGHAN RD STE 102 SAN ANTONIO TX 78228-3419

78130-3556 955 LOOP 337 NEW BRAUNFELS TX 78130-3556

04915-4087 3338 OAKWELL CT STE 107 SAN ANTONIO TX 78218-3087

78735-8982 5625 EIGER RD STE 200 AUSTIN TX 78735-8976



78246-1467 18626 HARDY OAK BLVD STE 230 SAN ANTONIO TX 78258-4219


78205-1892 12602 TOEPPERWEIN RD ST 100

SAN ANTONIO TX 78233


78070-7253 6098 FM 311 SPRING BRANCH TX 78070-7253


78624 820 RUEBEN STE B FREDERICKSBURG TX 78624

78130-4170 189 E AUSTIN ST STE 102 NEW BRAUNFELS TX 78130-4170

78130 921 LAKEVIEW BLVD NEW BRAUNFELS TX 78130-4135

78130 921 LAKEVIEW BLVD NEW BRAUNFELS TX 78130-4135

78155 515 N KING ST STE 103 SEGUIN TX 78155-4815


78163-3256 32665 US HIGHWAY 281 N STE 208 BULVERDE TX 78163-3256

78109-1980 9135 SCHAEFER RD STE 4 CONVERSE TX 78109-1980



04915-4480 4334 N LOOP 1604 W STE 102 SAN ANTONIO TX 78249-3485

78156-1206 1201 W COURT ST SEGUIN TX 78155-5943


99019-0421 624 E FRONT AVE SPOKANE WA 99202

1260 RIVER ACRES DR STE 1 NEW BRAUNFELS TX 78130-3689



78258-7361 20658 STONE OAK PKWY UNIT 108 SAN ANTONIO TX 78258-7361

78283-0605 7355 BARLITE BLVD STE 301 SAN ANTONIO TX 78224-1340

37230-6276 4450 FRONTIER TRL AUSTIN TX 78745-1514

04915-4006 5016 FM 1518 SELMA TX 78154-1360


78232-5087 2130 NE LOOP 410 STE 325 SAN ANTONIO TX 78217-4659

75267-8779 3401 FM 3009 SCHERTZ TX 78154-2711

78205-1892 1860 S SEGUIN AVE BLDG E NEW BRAUNFELS TX 78130-3914





04915-5700 6402 N NEW BRAUNFELS AVE

SAN ANTONIO TX 78209-3827





75267-8779 3401 FM 3009 SCHERTZ TX 78154-2711


04915-4080 2020 SUNDANCE PKWY STE A1

NEW BRAUNFELS TX 78130-2771


78216-2029 240 CENTRAL AVE EAST ORANGE NJ 07018-3313

04915-4027 530 W 20TH ST HOUSTON TX 77008-3615

78130 794 GENERATIONS STE 100 NEW BRAUNFELS TX 78130


78155 944 S HIGHWAY 123 BYP SEGUIN TX 78155-9756

78240 1739 SCHERTZ PKWY SCHERTZ TX 78154

75284 12702 IH35 N SAN ANTONIO TX 78233-2609

78009-5210 1051 US HIGHWAY 90 E CASTROVILLE TX 78009-5210


75284-1941 12702 NORTH IH 35 NORTH LIVE OAK TX 78233-2609

78233 11901 TOEPPERWEIN RD STE 1402 SAN ANTONIO TX 78233-3160

70538 1124 7TH ST MORGAN CITY LA 70380-1951


04915 20306 ENCINO LEDGE STE 103 SAN ANTONIO TX 78259-1832

78148-3201 2009 PAT BOOKER RD UNIVERSAL CITY TX 78148-3201

33126-2051 9727 POTEET JOURDANTON FWY


04915-4065 3303 ROGERS ROAD STE 120 SAN ANTONIO TX 78251

75284 12702 IH35 N SAN ANTONIO TX 78233-2609

78201-1326 1200 BROOKLYN AVE STE 240 SAN ANTONIO TX 78212-4830

78232-5087 1860 S SEGUIN AVE BLDG E. NEW BRAUNFELS TX 78130-3914

76182-8674 1650 W COLLEGE ST GRAPEVINE TX 76051-3565


75284 12702 IH 35N SAN ANTONIO TX 78233

04915-4006 5016 FM 1518 SELMA TX 78154-1360

78205-1892 260 US HIGHWAY 181 N FLORESVILLE TX 78114-3136

78298 9969 FREDERICKSBURG RD SAN ANTONIO TX 78240-4106

78258-3498 18615 TUSCANY STONE STE 170 SAN ANTONIO TX 78258-3498

04915-5700 1933 NE LOOP 410 SAN ANTONIO TX 78217-5320

78205 18615 TUSCANY STONE STE 170 SAN ANTONIO TX 78258-3498

78945-0949 1626 E COMMON ST NEW BRAUNFELS TX 78130-3156




78251 2827 BABCOCK RD SAN ANTONIO TX 78229-4813


78209-1205 12410 TOEPPERWEIN RD LIVE OAK TX 78233

75284-1941 1583 COMMON ST STE 105 NEW BRAUNFELS TX 78130-3321


79410 18615 TUSCANY STONE STE 170






04915-5700 502 MADISON OAK STE 310 SAN ANTONIO TX 78258




78232-2679 545 CREEKSIDE XING STE 218 NEW BRAUNFELS TX 78130-4274


04915-5700 545 CREEKSIDE XING STE 218 NEW BRAUNFELS TX 78130-4274

30374-1148 94 BRIGGS ST STE 600 SAN ANTONIO TX 78224-1272

04915-5700 1808 HIGHWAY 97 E JOURDANTON TX 78026-1535


78291-0087 4502 MEDICAL DR STE R2-R07 SAN ANTONIO TX 78229-4402



02241-7559 1000 CEDAR HOLLOW ROAD SUITE 120 MALVERN PA 19355


78945-0949 19B GRUENE PARK DR NEW BRAUNFELS TX 78130-2459


78258 1314 E SONTERRA BLVD STE 102 SAN ANTONIO TX 78258-9999

78629-3311 1340 E WALNUT ST STE 1348 SEGUIN TX 78155

78209-1205 90 PARK RD NOCONA TX 76255-3600


78298 4118 POND HILL RD BLDG 3 SAN ANTONIO TX 78231-1281


78292-0528 1303 MCCULLOUGH AVE STE 374 SAN ANTONIO TX 78212-5615

75011-7838 411 S KING ST SEGUIN TX 78155-5838

78154 5000 SCHERTZ PKWY STE 200

SCHERTZ TX 78154-1403

78295-1537 5107 MEDICAL DR SAN ANTONIO TX 78229-4801

78232-5055 5000 SCHERTZ PKWY STE 200



75320-6239 3600 GASTON AVE STE 809 DALLAS TX 75246-1808

78299-2778 5223 HAMILTON WOLFE RD SAN ANTONIO TX 78229-4463



78212-4414 520 E EUCLID AVE SAN ANTONIO TX 78212-4414

78299-2778 1804 NE LOOP 410 STE 101 SAN ANTONIO TX 78217-5211






78155-9754 911 S HWY 123 BYP SEGUIN TX 78155-9754


78299-2778 1802 BRAEBURN DR SALEM VA 24153-7357


78216-6254 2660 COMMON ST STE 201 NEW BRAUNFELS TX 78130-3585

73126-8977 115 GALLERY CIR STE 102 SAN ANTONIO TX 78258-3389


40743-1300 310 E 9TH ST LONDON KY 40741-1204

78217-5407 8715 VILLAGE DR STE 514 SAN ANTONIO TX 78217-5407

78229-2449 6126 WURZBACH RD SAN ANTONIO TX 78238-1743

77210 1340 WONDER WORLD DR STE 2203 SAN MARCOS TX 78666-7791


78257 18585 SIGMA RD STE 102 SAN ANTONIO TX 78258-4204

78130 901 LOOP 337 NEW BRAUNFELS TX 78130-3556

75391 1448 COMMON ST NEW BRAUNFELS TX 78130-3162


75320-5124 4611 CENTERVIEW SAN ANTONIO TX 78228-1202




74170-0930 4423 NW LOOP 410 STE 103 SAN ANTONIO TX 78229-5167

75320-5124 4611 CENTERVIEW SAN ANTONIO TX 78228-1202

75391-1230 5206 RESEARCH DR SAN ANTONIO TX 78240-5251

78130 505 N UNION AVE NEW BRAUNFELS TX 78130-4157

04915-4038 2003 MEDICAL PKWY STE B SAN MARCOS TX 78666-7554

29606-6284 1310 MCCULLOUGH AVE SAN ANTONIO TX 78212-5601

78229-3916 7950 FLOYD CURL DR STE 300 SAN ANTONIO TX 78229-3916

78232-5057 3903 WISEMAN BLVD STE 200 SAN ANTONIO TX 78251

75011-7838 1339 E COURT ST STE 210 SEGUIN TX 78155-5141


04915-9067 11130 CHRISTUS HLS FL 3 MEDICAL PLAZA 3 SAN ANTONIO TX 78251-3585




78258 5000 BAPTIST HEALTH DR STE 100 SCHERTZ TX 78154

78232-5057 502 MADISON OAK STE 240 SAN ANTONIO TX 78258-4086


04915-4038 705 GENERATIONS STE 101 NEW BRAUNFELS TX 78130-0007


78295-1506 7711 LOUIS PASTEUR DR STE 200 SAN ANTONIO TX 78229-3412

29606-6284 919 E 32ND ST AUSTIN TX 78705-2703

78232-5057 5000 SCHERTZ PKWY STE 100

SCHERTZ TX 78154

78232-5057 1355 CENTRAL PKWY S STE 400 SAN ANTONIO TX 78232-5055







78232-5057 5000 SCHERTZ PKWY STE 100

SCHERTZ TX 78154

78130-4157 571 N UNION AVE NEW BRAUNFELS TX 78130-4157


78232-5057 1303 MCCULLOUGH AVE STE GL70 SAN ANTONIO TX 78212-5631

78232-5055 1 CLARA MAASS DR STE 1A BELLEVILLE NJ 07109-3550


78292-0528 8300 FLOYD CURL DR FL 5-5A SAN ANTONIO TX 78229-3931


78292-0528 903 W MARTIN ST SAN ANTONIO TX 78207-0903

78258 502 MADISON OAK DR STE 440 SAN ANTONIO TX 78258-4084

04915-4089 5300 N MCCOLL RD STE 200 MCALLEN TX 78504-3968

78258 1400 FOREST GLEN RD STE 500 SILVER SPRING MD 20910-1467


75284-5347 6201 HARRY HINES BLVD DALLAS TX 75235-5202

99204-2312 105 W 8TH AVE STE 6060 SPOKANE WA 99204-2312

73126-9092 9805 BRODIE LN AUSTIN TX 78748-5610


78258 5000 BAPTIST HEALTH DR STE 100 SCHERTZ TX 78154

75267-4240 598 N UNION AVE STE 300 NEW BRAUNFELS TX 78130-4179





78232-5057 5000 SCHERTZ PKWY STE 100

SCHERTZ TX 78154


78292-0528 8300 FLOYD CURL DR FL 5-5A SAN ANTONIO TX 78229-3931

78256-9603 6818 HEUERMANN RD SAN ANTONIO TX 78256-9603

78291 2810 N LOOP 1604 W STE 200 SAN ANTONIO TX 78248-2222

78215-1625 14807 SAN PEDRO AVE SAN ANTONIO TX 78232-3708


75284-0786 2727 W HOLCOMBE BLVD HOUSTON TX 77025-1669

78229 4775 HAMILTON WOLFE RD STE 2 SAN ANTONIO TX 78229-3456

75284-4164 218 E AUSTIN ST NEW BRAUNFELS TX 78130-4106

78205-1116 730 N MAIN AVE STE 418 SAN ANTONIO TX 78205-1116

78229-3463 4775 HAMILTON WOLFE RD STE 2 SAN ANTONIO TX 78229-3456





75266-0706 2829 BABCOCK RD STE 700 SAN ANTONIO TX 78229-6015

91199 5307 BROADWAY STE 130 SAN ANTONIO TX 78209



04915-9585 400 CONCORD PLAZA DR STE 30


04915-4482 11212 STATE HIGHWAY 151 STE 250 SAN ANTONIO TX 78251


75284 9150 HUEBNER RD STE 200 SAN ANTONIO TX 78240-1545



04915-9585 150 E SONTERRA BLVD STE 300


04915-9585 2829 BABCOCK RD STE 700 SAN ANTONIO TX 78229-6015


78130-3919 960 GRUENE RD STE 101 NEW BRAUNFELS TX 78130-3919

02284-8827 18518 HARDY OAK BLVD STE 205



78114-3175 495 10TH ST STE 104 FLORESVILLE TX 78114-3163

78155-4815 515 N KING ST STE 106 SEGUIN TX 78155-4815

04915-9585 400 CONCORD PLAZA DR STE 300 SAN ANTONIO TX 78216-6991

04915-9585 3327 RESEARCH PLZ STE 404 SAN ANTONIO TX 78235-5159

78130-2460 42 GRUENE PARK DR NEW BRAUNFELS TX 78130-2460

78293-0661 15900 LA CANTERA PKWY STE 20210 SAN ANTONIO TX 78256-2464

78299 19026 STONE OAK PKWY STE 110 SAN ANTONIO TX 78258-3226

78299 8715 VILLAGE DR STE 618 SAN ANTONIO TX 78217-5407

78299 7940 FLOYD CURL DR STE 400 SAN ANTONIO TX 78229-3907


78229-3456 4775 HAMILTON WOLFE RD STE 1 SAN ANTONIO TX 78229-3456


78248 16723 HUEBNER RD SAN ANTONIO TX 78248-2342

78209-8329 14603 HUEBNER RD BLDG 1 SAN ANTONIO TX 78230-5470

78156 1414 E WALNUT ST SEGUIN TX 78155-5175

75320-3294 601 E 15TH ST AUSTIN TX 78701-1930

27624 1020 S STATE HWY 16 FREDERICKSBURG TX 78624

78298 1020 S STATE HIGHWAY 16 FREDERICKSBURG TX 78624-4471

38148 28080 GRAND RIVER AVE STE 306 FARMINGTON HILLS MI 48336-5966

78268-1149 11122 WURZBACH RD STE 302 SAN ANTONIO TX 78230-2574


78229 12412 JUDSON RD SAN ANTONIO TX 78233-3255



30914 2000 LAKE PARK DR SE SMYRNA GA 30080-7611

78229 7418 JOHN SMITH STE 218 SAN ANTONIO TX 78229-6019

15251 1500 E MEDICAL CENTER DR FL 2 ANN ARBOR MI 48109-5000

75320-6239 9103 JEFFERSON HWY BATON ROUGE LA 70809-2440

71201-7516 611 GRAMMONT ST MONROE LA 71201-7516

78755-8770 9200 WALL ST AUSTIN TX 78754-4534

78155-5100 1255 ASHBY ST STE B SEGUIN TX 78155-5100

77092-8703 4131 DIRECTORS ROW HOUSTON TX 77092-8703

78293-0743 551 HILL COUNTRY DR KERRVILLE TX 78028-6085

78298-2216 9600 DATAPOINT DR SAN ANTONIO TX 78229-2028

78676-6083 180 JOE WIMBERLEY BLVD STE 102 WIMBERLEY TX 78676-6083


78130-3919 2115 STEPHENS PL STE 900 NEW BRAUNFELS TX 78130-2164

78232-5057 8606 VILLAGE DR STE A SAN ANTONIO TX 78217-5506

75284-0786 5001 E SAM HOUSTON PKWY S

PASADENA TX 77505

78233-3166 11515 TOEPPERWEIN RD STE 203

LIVE OAK TX 78233-3166

78265 19238 STONEHUE SAN ANTONIO TX 78258-3447

78265 2200 ROY RICHARDS DRIVE SCHERTZ TX 78154


78265 7711 LOUIS PASTEUR DR STE 707 SAN ANTONIO TX 78229-3422

78248-0988 6126 WURZBACH RD SAN ANTONIO TX 78238-1743

78233 12602 TOEPPERWEIN RD STE 104





78265 5120 YALE RD MEMPHIS TN 38134-8219






78220-1013 201 STILLWATER STE 6 WIMBERLEY TX 78676-5374

78265 2200 ROY RICHARD DR SCHERTZ TX 78154


78666-7849 601 LEAH AVE STE B SAN MARCOS TX 78666-7849






78224 7430 BARLITE BLVD STE 104 SAN ANTONIO TX 78224-1366



78291-0087 903 W MARTIN ST SAN ANTONIO TX 78207-0903

78265 121 BULVERDE CROSSING RD STE 100

BULVERDE TX 78163-6200

78666-7849 601 LEAH AVE STE B SAN MARCOS TX 78666-7849


75284-0384 919 E 32ND ST AUSTIN TX 78705-2703

75284-0384 333 N SANTA ROSA ST SAN ANTONIO TX 78207-3108

75284-0384 111 DALLAS ST SAN ANTONIO TX 78205-1201

75284-0384 1139 E SONTERRA BLVD SAN ANTONIO TX 78258-3999


75284-0384 101 MEDICAL DR VICTORIA TX 77904-3102


75284 5430 FREDERICKSBURG RD STE 508


78292-0528 1901 SW H K DODGEN LOOP TEMPLE TX 76508-0001


75284 1021 GARNER FIELD RD UVALDE TX 78801-4809

78722-2211 1110 E 32ND ST AUSTIN TX 78722-2211



76063 1201 W 38TH ST AUSTIN TX 78705-1006

85082-4568 77 W FOREST AVE STE 207 FLAGSTAFF AZ 86001-1483


89193 1220 N MALINCHE AVE LAREDO TX 78043-3354


78676-5354 14100 RANCH ROAD 12 STE 100 WIMBERLEY TX 78676-5354

78240-1482


60674-0001 1267 W EXCHANGE PKWY STE 400 ALLEN TX 75013-7097

78052-0725 19965 FM 3175 LYTLE TX 78052-3481

15251-0001 9090 GAYLORD DR STE 201 HOUSTON TX 77024-2948

78247-4215

78154-3443 6032 FM 3009 STE 130 SCHERTZ TX 78154-3258

78154 392 SCHERTZ PKWY SCHERTZ TX 78154-2073

78029-3879 3603 PAESANOS PKWY STE 300 SAN ANTONIO TX 78231-1227

80504-7805 1511 ONYX CIR LONGMONT CO 80504-7805

78132 224 HUNTERS VLG NEW BRAUNFELS TX 78132-4742

78029-3879 3603 PAESANOS PKWY STE 300 SAN ANTONIO TX 78231-1227



04915-5700 525 OAK CENTRE DR STE 350 SAN ANTONIO TX 78258-3945

78251-4501 11212 STATE HIGHWAY 151 STE 200 SAN ANTONIO TX 78251-4501

78201-0560 5805 CALLAGHAN RD STE 104 SAN ANTONIO TX 78228-1127







78229 414 NAVARRO ST STE 1502 SAN ANTONIO TX 78205-2550


75267 3500 GASTON AVE 4 ROBERTS DALLAS TX 75246


75267 3500 GASTON AVE 4 ROBERTS DALLAS TX 75246

30368-2287 59 EXECUTIVE PARK SOUTH NE

ATLANTA GA 30329-2208

78292-0528 25723 OLD FREDERICKSBURG RD

BOERNE TX 78006

75608

78229-0447 115 GALLERY CIR STE 101 SAN ANTONIO TX 78258-3389

17013 333 N SANTA ROSA ST SAN ANTONIO TX 78207-3108





45271-4150 471 E BROAD ST STE 1500 COLUMBUS OH 43215-3875


75608-0270 7600 W TIDWELL RD STE 103 HOUSTON TX 77040-5719




78765 12554 RIATA VISTA CIR AUSTIN TX 78727-6431

78294-1019 622 ISOM RD SAN ANTONIO TX 78216-4464

78229-0447 1580 S MAIN ST BOERNE TX 78006-3311


63160 510 S KINGSHIGHWAY BLVD SAINT LOUIS MO 63110-1016

78765 12554 RIATA VISTA CIR AUSTIN TX 78727-6431

78217 1804 NE LOOP 410 STE 101 SAN ANTONIO TX 78217-5211

78240 5255 PRUE RD SUITE 100 SAN ANTONIO TX 78240-1331

78258

78229 7909 FREDERICKSBURG RD STE 222 SAN ANTONIO TX 78229-3400

78258-3225 19010 STONE OAK PKWY SAN ANTONIO TX 78258-3225

78292-0528 8300 FLOYD CURL DR 4TH FL 4A SAN ANTONIO TX 78229-3931

78130-3518 876 LOOP 337 BLDG STE 101 NEW BRAUNFELS TX 78130-3553

78132 1929 HIGHWAY 46 W STE 105 NEW BRAUNFELS TX 78132-5245


79408-5980 525 OAK CENTRE DR STE 350 SAN ANTONIO TX 78258-3945



75281

78154

78130

04915-5100 400 CONCORD PLZ STE 200 SAN ANTONIO TX 78216-6990

04915 502 MADISON OAK STE 330 SAN ANTONIO TX 78258-4298

78295-1377 1301 BARBARA JORDAN BLVD

STE 300 AUSTIN TX 78723-3078







04915 876 LOOP 337 STE 302 NEW BRAUNFELS TX 78130-3553


78299-2952 7909 FREDERICKSBURG RD STE 120 SAN ANTONIO TX 78229-3400




78299-2952 12709 TOEPPERWEIN RD STE 206 SAN ANTONIO TX 78233

78229 7909 FREDERICKSBURG RD STE 120 SAN ANTONIO TX 78229-3400

04915-4086 11410 JOLLYVILLE RD STE 1101 AUSTIN TX 78759-4093





78229 8029 FLOYD CURL DR STE 430 SAN ANTONIO TX 78229

04915 311 CAMDEN ST STE 501 SAN ANTONIO TX 78215-2015



78216-6200 114 SOUTHBRIDGE ST STE D SAN ANTONIO TX 78216-6200

75312-3613

91185-4468



75267-8779 3401 FM 3009 SCHERTZ TX 78154-2711

75320 555 CREEKSIDE CROSSING NEW BRAUNFELS TX 78130


90009-2729 301 N N ST MIDLAND TX 79701-6404


04915 555 CREEKSIDE XING NEW BRAUNFELS TX 78130-2594

78258-3457 19223 STONEHUE SAN ANTONIO TX 78258-3456

78109 7585 KITTY HAWK STE 201 CONVERSE TX 78109-1632



85038-9385 1111 E MCDOWELL RD INTERNAL MEDICINE LL2 PHOENIX AZ 85006-2612


78258-3457 19223 STONEHUE SAN ANTONIO TX 78258-3456

90084 11234 ANDERSON ST MC-1507 LOMA LINDA CA 92354-2804

78265-8875 88 BRIGGS ST STE 250 SAN ANTONIO TX 78224-1269

78298-2208 423 TREELINE PARK STE 325 SAN ANTONIO TX 78209-2060

78265 88 BRIGGS ST STE 250 SAN ANTONIO TX 78224-1269


78130 1524 N WALNUT AVE NEW BRAUNFELS TX 78130-6074

78209-3254 604 N MAIN ST STE 200 BOERNE TX 78006-1695

78155-4652 1345 E COLLEGE ST SEGUIN TX 78155-3962

75284 6051 FM 3009 STE 260 SCHERTZ TX 78154-3236

78064 409 N BRYANT ST PLEASANTON TX 78064-3432

78229-4412

04915-9585 5000 SCHERTZ PKWY STE 600




34653-2934 601 CREEKSIDE XING STE 106

NEW BRAUNFELS TX 78130-4093

78070 21200 HWY 46 WEST SPRING BRANCH TX 78070-6180


78154-1403 5000 SCHERTZ PKWY STE 300


45201 4302 W BUCKEYE RD PHOENIX AZ 85043-4904


33759-2129 1700 N MCMULLEN BOOTH RD

STE C4 CLEARWATER FL 33759-2129

77497

75284-9553 215 E QUINCY STREET SUITE 100 SAN ANTONIO TX 78215-2032

78130-2219 19A GRUENE PARK DR NEW BRAUNFELS TX 78130-2484

78229 4410 MEDICAL DR SUITE 200 SAN ANTONIO TX 78229-6306

78240


78666 1330 WONDER WORLD DR STE 202 SAN MARCOS TX 78666-7590

78765-4099

78229

60090

77904-3114 117 MEDICAL DR STE 1 VICTORIA TX 77904-3114

78727 3600 W PARMER LN STE 108 AUSTIN TX 78727-4111

78154-3443 6032 FM 3009 STE 120 SCHERTZ TX 78154-3258

78154-3443 6032 FM 3009 STE 120 SCHERTZ TX 78154-3258

78216-2000 6530 WESTLOOP 1604 NORTH


77210-4562 6022 FM 1488 RD MAGNOLIA TX 77354-2542


75284


75201 513 CIBOLO DR CIBOLO TX 78108

04915-4083

78108-0037 791 FM 1103 STE 125 CIBOLO TX 78108-3673

04915-8447

80021-9011

78270-1950 11398 BANDERA RD STE 201 SAN ANTONIO TX 78250-6840

75395-2245 6001 W WILLIAM CANNON DR

STE 302 AUSTIN TX 78749-1973

73157-8239

78245-3194 2106 W OAKLAWN RD PLEASANTON TX 78064-4609

27520-5598

30384 2400 ROUND ROCK AVE ROUND ROCK TX 78681-4004

75395 1301 WONDER WORLD DR SAN MARCOS TX 78666-7533

75284 8811 VILLAGE DR SAN ANTONIO TX 78217-5415


04915-4051 717 MAGNOLIA ST JACKSBORO TX 76458-1111


84127-0396 7400 BARLITE BLVD SAN ANTONIO TX 78224-1308

75373-1033 1200 CARL RAMERT DR STE D YOAKUM TX 77995-4868



37167-1720

72042 1641 S WHITEHEAD DR DE WITT AR 72042-2994

30384-5653 1139 E SONTERRA BLVD SAN ANTONIO TX 78258-3999

77210


37167-1720 3600 MEMORIAL BLVD KERRVILLE TX 78028-5768


77004 5445 LA BRANCH HOUSTON TX 77004

78298

75284-4658 300 UNIVERSITY BLVD ROUND ROCK TX 78665-1032

75284-1091 1401 MEDICAL PKWY STE 410 CEDAR PARK TX 78613-7464

60677-0001

77210 8230 N 1604 W SAN ANTONIO TX 78249

78299-2639


45263-0001

76092

75320-4301 4900 MUELLER BLVD AUSTIN TX 78723-3079

75284

75320

30384

77210 16977 INTERSTATE 35 N SCHERTZ TX 78154-1466

30384 7700 FLOYD CURL DR SAN ANTONIO TX 78229-3902

70154-4829 602 N ACADIA RD THIBODAUX LA 70301-4847

79529 701 SE 5TH ST KNOX CITY TX 79529-2107

78150

77210 101 CRESTVIEW AVE EVERGREEN AL 36401-3333

76043-2099 1021 HOLDEN ST GLEN ROSE TX 76043-4937

77210 16088 SAN PEDRO AVE SAN ANTONIO TX 78232-2251

78234

30384 12412 JUDSON RD LIVE OAK TX 78233-3255

75267-4240 1700 BRAZOS AVE STE A ROCKDALE TX 76567-2517

75320-4301 6001 KYLE PKWY KYLE TX 78640-6112


78666

37167

77327

74284 333 N SANTA ROSA AVE SAN ANTONIO TX 78207-3108

78624 1020 S STATE HIGHWAY 16 FREDERICKSBURG TX 78624-4471

77210-4869 10811 TOWN CENTER DR SAN ANTONIO TX 78251-4585

75284 11212 STATE HIGHWAY 151 SAN ANTONIO TX 78251

78258 18600 HARDY OAK BLVD SAN ANTONIO TX 78258-4206

90189

75266-0811 1355 RIVER BEND DR DALLAS TX 75247-4915

27216-8109

01801

91189-1844

75265

19101 1781 TATE BLVD SE TATE MEDICAL COMMONS STE 206

HICKORY NC 28602-4218

19101 1781 TATE BLVD SE TATE MEDICAL COMMONS STE 206

HICKORY NC 28602-4218

78291

94139

78744

76132

94080-6218 180 KIMBALL WAY SOUTH SAN FRANCISCO

CA 94080-6218

28269

23219

07036-1195 901 E LINDEN AVENUE LINDEN NJ 07036

75006

19047-3208


99220-2695

29644

48267

78714

78759

07608 1 MALCOLM AVE TETERBORO NJ 07608-1011

91109

78297-2037 9600 DATAPOINT DR SAN ANTONIO TX 78229-2028

45264-0001 515 GREAT CIRCLE RD NASHVILLE TN 37228-1310

08690 2439 KUSER RD TRENTON NJ 08690-3303

99019-0421 212 E CENTRAL AVE STE 440 SPOKANE WA 99208-6291

27216

27216

30093

11747-4211 80 RULAND RD STE 1 MELVILLE NY 11747-4211

76010

29568

78757-6818

30567-4712 26220 ENTERPRISE CT LAKE FOREST CA 92630-8405

75267

75063 8428 STERLING ST STE B IRVING TX 75063-1903

04915

30384

28803-2115 3165 SWEETEN CREEK RD ASHEVILLE NC 28803-2115

44087 1810 SUMMIT COMMERCE PARK

TWINSBURG OH 44087-2300

11714-3453 1201 LEXINGTON AVE NEW YORK NY 10028-1437


84127-0968

33563-0032

15264 121 GAMMA DR PITTSBURGH PA 15238-2919

75284

44236-0309 5640 HUDSON INDUSTRIAL PKWY

HUDSON OH 44236-5011

78754 8220 CROSS PARK DR SUITE 100 AUSTIN TX 78754-5228

76048

33619 3504 CRAGMONT DR SUITE # 100 TAMPA FL 33619-8336

43081-3398 10920 SWITZER AVE STE 106 DALLAS TX 75238-5303

91185-4120 6340 SEQUENCE DR SAN DIEGO CA 92121

78233-3264 12315 JUDSON RD STE 206 SAN ANTONIO TX 78233-3264

84127-0968

75261-2224 1305 IH 35 N SAN MARCOS TX 78666-7102

78154

70509 3720 CORLEY ST BEAUMONT TX 77701-6431


78201 160 CREEKSIDE PARK RD STE 300 SPRING BRANCH TX 78070-6150

75320-6239 505 S NOLEN DR STE A SOUTHLAKE TX 76092-9167


78758-3606 8000 WEST AVE # I-10 SAN ANTONIO TX 78213-1837

78265-3607 540 MADISON OAK DR STE 610


78259


78298-2208 423 TREELINE PARK STE 325 SAN ANTONIO TX 78209-2060


78299-2778 350 PARK ST STE 203B BOWLING GREEN KY 42101-1784


75284 CMR 442 BOX678 APO AE 09042


78293-0659 7700 FLOYD CURL DR SAN ANTONIO TX 78229-3902

19178 545 VALLEY VIEW DR MOLINE IL 61265-6138


78230 6999 MCPHERSON RD STE 108 LAREDO TX 78041-6450

78299-2778 855 PROTON RD SAN ANTONIO TX 78258-4203

75284 5151 N 9TH AVE PENSACOLA FL 32504-5705




75284 3551 ROGER BROOKE DR FORT SAM HOUSTON TX 78234-4504

78265-9130 19226 STONEHUE STE 101 SAN ANTONIO TX 78258-3480






78150

78251-4498 11212 STATE HIGHWAY 151 MEDICAL PLZ 1 STE 320 SAN ANTONIO TX 78251

78250-6814 11085 BANDERA RD STE 102 SAN ANTONIO TX 78250

78258


78236

78236




78291-0276 111 DALLAS ST STE 200 A SAN ANTONIO TX 78205


Group # 704728Date Paid Claims Line of Business Subscribers Premium

8/1/2015 0 ADD 294 146.038/1/2015 0 CVL 39 37.058/1/2015 0 DPA 18/1/2015 0 DPL 108 112.358/1/2015 0 EVA 114 307.968/1/2015 0 EVL 114 1820.838/1/2015 0 LIFE 294 876.38/1/2015 0 SVA 36 30.098/1/2015 0 SVL 36 187.59/1/2015 0 ADD 292 145.039/1/2015 0 CVL 39 37.059/1/2015 0 DPA 19/1/2015 0 DPL 106 110.259/1/2015 0 EVA 113 305.869/1/2015 0 EVL 113 1801.239/1/2015 0 LIFE 292 870.39/1/2015 0 SVA 36 30.099/1/2015 0 SVL 36 187.5

10/1/2015 0 ADD 294 146.5310/1/2015 0 CVL 39 37.0510/1/2015 0 DPA 110/1/2015 0 DPL 106 110.2510/1/2015 0 EVA 114 307.3610/1/2015 0 EVL 114 1808.7310/1/2015 0 LIFE 294 879.310/1/2015 0 SVA 36 29.8210/1/2015 0 SVL 36 176.3611/1/2015 0 ADD 288 142.8511/1/2015 0 CVL 37 35.1511/1/2015 0 DPA 111/1/2015 0 DPL 103 107.111/1/2015 0 EVA 112 303.6111/1/2015 0 EVL 112 1781.9811/1/2015 0 LIFE 288 857.2511/1/2015 0 SVA 34 28.7111/1/2015 0 SVL 34 163.6112/1/2015 0 ADD 292 144.8512/1/2015 0 CVL 36 34.212/1/2015 0 DPA 112/1/2015 0 DPL 102 106.0512/1/2015 0 EVA 112 302.1112/1/2015 0 EVL 112 1770.9812/1/2015 0 LIFE 292 869.2512/1/2015 0 SVA 33 27.9612/1/2015 0 SVL 33 161.611/1/2016 0 ADD 299 148.351/1/2016 0 CVL 38 36.1

City of Schertz

Group # 704728

City of Schertz

1/1/2016 0 DPA 11/1/2016 0 DPL 107 111.31/1/2016 0 EVA 114 318.311/1/2016 0 EVL 114 1947.71/1/2016 0 LIFE 299 890.251/1/2016 0 SVA 31 27.661/1/2016 0 SVL 31 216.282/1/2016 0 ADD 292 145.032/1/2016 0 CVL 38 36.12/1/2016 0 DPA 12/1/2016 0 DPL 105 109.22/1/2016 0 EVA 114 317.562/1/2016 0 EVL 114 1946.22/1/2016 0 LIFE 292 870.32/1/2016 0 SVA 32 27.662/1/2016 0 SVL 32 216.283/1/2016 0 ADD 291 144.353/1/2016 0 CVL 38 36.13/1/2016 0 DPA 13/1/2016 0 DPL 105 109.23/1/2016 0 EVA 114 319.063/1/2016 0 EVL 114 1950.23/1/2016 0 LIFE 291 866.253/1/2016 0 SVA 32 28.023/1/2016 0 SVL 32 218.084/1/2016 0 ADD 291 144.354/1/2016 0 CVL 37 35.154/1/2016 0 DPA 14/1/2016 0 DPL 104 108.154/1/2016 0 EVA 114 319.064/1/2016 0 EVL 114 1950.24/1/2016 0 LIFE 291 866.254/1/2016 0 SVA 33 28.774/1/2016 0 SVL 33 219.585/1/2016 0 ADD 291 144.355/1/2016 0 CVL 35 33.255/1/2016 0 DPA 15/1/2016 0 DPL 102 106.055/1/2016 0 EVA 111 311.565/1/2016 0 EVL 111 1903.25/1/2016 0 LIFE 291 866.255/1/2016 0 SVA 33 29.525/1/2016 0 SVL 33 221.086/1/2016 0 ADD 294 145.856/1/2016 0 CVL 35 33.256/1/2016 0 DPA 16/1/2016 0 DPL 100 103.956/1/2016 0 EVA 110 308.56

Group # 704728

City of Schertz

6/1/2016 0 EVL 110 1888.26/1/2016 0 LIFE 294 875.256/1/2016 0 SVA 33 29.526/1/2016 0 SVL 33 221.087/1/2016 0 ADD 300 149.17/1/2016 0 CVL 35 33.257/1/2016 0 DPA 17/1/2016 0 DPL 100 103.957/1/2016 0 EVA 112 314.567/1/2016 0 EVL 112 1902.27/1/2016 0 LIFE 300 894.757/1/2016 0 SVA 33 29.527/1/2016 0 SVL 33 221.088/1/2016 0 ADD 298 148.18/1/2016 0 CVL 35 33.258/1/2016 0 DPA 18/1/2016 0 DPL 100 103.958/1/2016 0 EVA 113 317.568/1/2016 0 EVL 113 1977.28/1/2016 0 LIFE 298 888.758/1/2016 0 SVA 33 29.528/1/2016 0 SVL 33 221.089/1/2016 0 ADD 297 147.69/1/2016 0 CVL 35 33.259/1/2016 0 DPA 19/1/2016 0 DPL 99 102.99/1/2016 0 EVA 113 317.569/1/2016 0 EVL 113 1977.29/1/2016 0 LIFE 297 885.759/1/2016 0 SVA 33 29.529/1/2016 0 SVL 33 221.08

10/1/2016 0 ADD 300 149.110/1/2016 0 CVL 36 34.210/1/2016 0 DPA 110/1/2016 0 DPL 99 102.910/1/2016 0 EVA 114 317.8610/1/2016 0 EVL 114 1977.810/1/2016 0 LIFE 300 894.7510/1/2016 0 SVA 33 29.5210/1/2016 0 SVL 33 221.0811/1/2016 0 ADD 305 151.611/1/2016 0 CVL 35 33.2511/1/2016 0 DPA 111/1/2016 0 DPL 97 100.811/1/2016 0 EVA 115 320.8611/1/2016 0 EVL 115 2006.811/1/2016 0 LIFE 305 909.7511/1/2016 0 SVA 33 29.52

Group # 704728

City of Schertz

11/1/2016 0 SVL 33 221.0812/1/2016 0 ADD 305 151.612/1/2016 0 CVL 35 33.2512/1/2016 0 DPA 112/1/2016 0 DPL 97 100.812/1/2016 0 EVA 114 320.1112/1/2016 0 EVL 114 2005.312/1/2016 0 LIFE 305 909.7512/1/2016 0 SVA 33 29.5212/1/2016 0 SVL 33 221.081/1/2017 0 ADD 308 152.921/1/2017 0 CVL 36 34.21/1/2017 0 DPA 11/1/2017 0 DPL 98 101.851/1/2017 0 EVA 114 321.611/1/2017 0 EVL 114 2306.641/1/2017 0 LIFE 308 917.71/1/2017 0 SVA 32 28.021/1/2017 0 SVL 32 233.742/1/2017 0 ADD 301 149.62/1/2017 0 CVL 36 34.22/1/2017 0 DPA 12/1/2017 0 DPL 96 99.752/1/2017 0 EVA 113 323.412/1/2017 0 EVL 113 2308.142/1/2017 0 LIFE 301 897.752/1/2017 0 SVA 32 28.022/1/2017 0 SVL 32 233.743/1/2017 0 ADD 304 151.283/1/2017 0 CVL 35 33.253/1/2017 0 DPA 13/1/2017 0 DPL 95 98.73/1/2017 0 EVA 113 324.463/1/2017 0 EVL 113 2167.243/1/2017 0 LIFE 304 907.83/1/2017 0 SVA 31 27.543/1/2017 0 SVL 31 196.914/1/2017 0 ADD 307 152.64/1/2017 0 CVL 35 33.254/1/2017 0 DPA 14/1/2017 0 DPL 94 97.654/1/2017 0 EVA 113 324.464/1/2017 0 EVL 113 2167.244/1/2017 0 LIFE 307 915.754/1/2017 0 SVA 31 27.544/1/2017 0 SVL 31 196.915/1/2017 0 ADD 304 151.285/1/2017 0 CVL 35 33.25

Group # 704728

City of Schertz

5/1/2017 0 DPA 15/1/2017 0 DPL 94 97.655/1/2017 0 EVA 113 329.715/1/2017 0 EVL 113 2177.745/1/2017 0 LIFE 304 907.85/1/2017 0 SVA 31 27.545/1/2017 0 SVL 31 196.916/1/2017 0 ADD 301 150.286/1/2017 0 CVL 34 32.36/1/2017 0 DPA 16/1/2017 0 DPL 92 95.556/1/2017 0 EVA 112 326.716/1/2017 0 EVL 112 2102.746/1/2017 0 LIFE 301 901.86/1/2017 0 SVA 30 26.796/1/2017 0 SVL 30 185.917/1/2017 0 ADD 302 150.287/1/2017 0 CVL 32 30.47/1/2017 0 DPA 17/1/2017 0 DPL 92 95.557/1/2017 0 EVA 111 328.067/1/2017 0 EVL 111 2173.597/1/2017 0 LIFE 302 901.87/1/2017 0 SVA 32 27.847/1/2017 0 SVL 32 217.468/1/2017 0 ADD 297 147.68/1/2017 0 CVL 32 30.48/1/2017 0 DPA 18/1/2017 0 DPL 90 93.458/1/2017 0 EVA 109 320.568/1/2017 0 EVL 109 2153.998/1/2017 0 LIFE 297 885.758/1/2017 0 SVA 32 27.848/1/2017 0 SVL 32 217.469/1/2017 0 ADD 297 147.969/1/2017 0 CVL 33 31.359/1/2017 0 DPA 19/1/2017 0 DPL 89 92.49/1/2017 0 EVA 110 324.319/1/2017 0 EVL 110 2161.499/1/2017 0 LIFE 297 887.859/1/2017 0 SVA 32 27.849/1/2017 0 SVL 32 217.46

10/1/2017 0 ADD 299 148.9610/1/2017 0 CVL 33 31.3510/1/2017 0 DPA 110/1/2017 0 DPL 88 91.3510/1/2017 0 EVA 109 323.56

Group # 704728

City of Schertz

10/1/2017 0 EVL 109 2142.7410/1/2017 0 LIFE 299 893.8510/1/2017 0 SVA 32 27.8410/1/2017 0 SVL 32 217.4611/1/2017 0 ADD 304 151.4611/1/2017 0 CVL 33 31.3511/1/2017 0 DPA 111/1/2017 0 DPL 88 91.3511/1/2017 0 EVA 111 326.8611/1/2017 0 EVL 111 2156.2411/1/2017 0 LIFE 304 908.8511/1/2017 0 SVA 32 27.8411/1/2017 0 SVL 32 217.4612/1/2017 0 ADD 305 151.9612/1/2017 0 CVL 33 31.3512/1/2017 0 DPA 112/1/2017 0 DPL 88 91.3512/1/2017 0 EVA 111 326.8612/1/2017 0 EVL 111 2156.2412/1/2017 0 LIFE 305 911.8512/1/2017 0 SVA 32 27.8412/1/2017 0 SVL 32 217.461/1/2018 0 ADD 307 152.961/1/2018 0 CVL 34 32.31/1/2018 0 DPL 89 93.451/1/2018 0 EVA 112 325.361/1/2018 0 EVL 112 2333.741/1/2018 0 LIFE 307 917.851/1/2018 0 SVA 34 28.741/1/2018 0 SVL 34 241.112/1/2018 0 ADD 305 152.142/1/2018 0 CVL 33 31.352/1/2018 0 DPL 88 92.42/1/2018 0 EVA 111 322.362/1/2018 0 EVL 111 2325.742/1/2018 0 LIFE 305 912.92/1/2018 0 SVA 33 27.992/1/2018 0 SVL 33 239.613/1/2018 0 ADD 304 151.643/1/2018 0 CVL 33 31.353/1/2018 0 DPL 88 92.43/1/2018 0 EVA 110 319.363/1/2018 0 EVL 110 2281.743/1/2018 0 LIFE 304 909.93/1/2018 0 SVA 33 27.993/1/2018 0 SVL 33 239.614/1/2018 0 ADD 302 150.644/1/2018 0 CVL 33 31.35

Group # 704728

City of Schertz

4/1/2018 0 DPL 87 91.354/1/2018 0 EVA 107 322.814/1/2018 0 EVL 107 2319.744/1/2018 0 LIFE 302 903.94/1/2018 0 SVA 32 29.194/1/2018 0 SVL 32 242.015/1/2018 0 ADD 305 152.145/1/2018 0 CVL 32 30.45/1/2018 0 DPL 86 90.35/1/2018 0 EVA 106 319.065/1/2018 0 EVL 106 2283.495/1/2018 0 LIFE 305 912.95/1/2018 0 SVA 31 28.445/1/2018 0 SVL 31 234.766/1/2018 0 ADD 309 154.146/1/2018 0 CVL 31 29.456/1/2018 0 DPL 85 89.256/1/2018 0 EVA 104 313.816/1/2018 0 EVL 104 2246.746/1/2018 0 LIFE 309 924.96/1/2018 0 SVA 30 26.946/1/2018 0 SVL 30 220.267/1/2018 0 ADD 316 157.647/1/2018 0 CVL 32 30.47/1/2018 0 DPL 86 90.37/1/2018 0 EVA 106 319.817/1/2018 0 EVL 106 2283.747/1/2018 0 LIFE 316 945.97/1/2018 0 SVA 32 28.447/1/2018 0 SVL 32 238.518/1/2018 0 ADD 314 156.468/1/2018 0 CVL 32 30.48/1/2018 0 DPL 87 91.358/1/2018 0 EVA 106 322.068/1/2018 0 EVL 106 2297.248/1/2018 0 LIFE 314 938.858/1/2018 0 SVA 33 29.198/1/2018 0 SVL 33 242.269/1/2018 0 ADD 317 157.969/1/2018 0 CVL 31 29.459/1/2018 0 DPL 88 92.49/1/2018 0 EVA 105 323.449/1/2018 0 EVL 105 2302.929/1/2018 0 LIFE 317 947.859/1/2018 0 SVA 33 29.949/1/2018 0 SVL 33 253.26

Earned Premium Paid Claims Loss Ratio Earned Premium Paid Claims Loss Ratio Earned Premium Paid Claims Loss Ratio2014 -$ -$ 0% -$ -$ 0% -$ -$ 0%2015 4,352.40$ -$ 0% 725.29$ -$ 0% -$ -$ 0%2016 10,618.05$ -$ 0% 1,769.38$ -$ 0% -$ -$ 0%2017 10,838.55$ -$ 0% 1,806.18$ -$ 0% -$ -$ 0%2018 3,644.55$ -$ 0% 759.52$ -$ 0% -$ -$ 0%

Total 25,809.00$ -$ 0% 4,300.85$ -$ 0% -$ -$ 0%

Earned Premium Paid Claims Loss Ratio Earned Premium Paid Claims Loss Ratio Earned Premium Paid Claims Loss Ratio2014 -$ -$ 0% -$ -$ 0% -$ -$ 0%2015 8,983.75$ -$ 0% 1,526.90$ -$ 0% -$ -$ 0%2016 23,432.20$ -$ 0% 3,802.62$ -$ 0% -$ -$ 0%2017 26,174.03$ -$ 0% 3,900.57$ -$ 0% -$ -$ 0%2018 9,260.96$ -$ 0% 1,289.89$ -$ 0% -$ -$ 0%

Total 58,589.98$ -$ 0% 9,230.09$ -$ 0% -$ -$ 0%

Earned Premium Paid Claims Loss Ratio2014 -$ -$ 0%2015 15,588.34$ -$ 0%2016 39,622.25$ -$ 0%2017 42,719.33$ -$ 0%2018 14,954.92$ -$ 0%Total 97,929.92$ -$ 0%

City of Schertz

Combined All Lines

EE Basic Life EE Basic AD&D STD

EE Voluntary Life EE Voluntary AD&D LTD

TX-70051-07 EM COVER

L C EMPLOYER: CITY OF SCHERTZ

GROUP NUMBER: 704728

CERTIFICATE OF INSURANCE

Humana Insurance Company

This Certificate is not an insurance policy. It is an outline of the insurance provided by the group policy and it does not extend or change the coverage afforded by such group policy. The insurance described by this Certificate is subject to all the provisions, terms, exclusions and conditions of the group policy. This Certificate supersedes and replaces any Certificate previously issued under the provisions of the group policy. THE DEATH BENEFIT IN FORCE UNDER THE POLICY WILL BE REDUCED IF ACCELERATED BENEFIT ARE PAID. The Accelerated Benefits offered in this Certificate may or may not qualify for favorable tax treatment under the Internal Revenue Code of 1986. Whether such benefits qualify depends on factors such as your life expectancy at the time benefits are accelerated or whether you use the benefits to pay for necessary long-term care expenses, such as nursing home care. If the Accelerated Benefit qualifies for such favorable tax treatment, the benefits will be excludable from your income and not subject to federal taxation. Tax laws relating to Accelerated Benefits are complex. You are advised to consult with a qualified tax advisor about circumstances under which you could receive Accelerated Benefits excludable from income under federal law. Receipt of Accelerated Benefits may affect you, your spouse or your family’s eligibility for public assistance programs such as medical assistance (Medicaid), Aid to Families with Dependent Children (AFDC), supplemental Social Security Income (SSI) and drug assistance programs. You are advised to consult with a qualified tax advisor and with social service agencies concerning how receipt of such payment will affect you, your spouse and your family’s eligibility for public assistance.

Michael B. McCallister President

TX-70051-07 EM Notice 3/07

POLICYHOLDER (EMPLOYER): CITY OF SCHERTZ GROUP NUMBER: 704728 BENEFITS EFFECTIVE DATE Employee Voluntary Life for Employee 01/01/2018 Employee Voluntary AD&D for Employee 01/01/2018 Dependent Voluntary Life for Employee & Covered Dependent 01/01/2018 Dependent Voluntary Life for Employee & Covered Spouse 01/01/2018 Spouse Voluntary AD&D for Employee & Covered Spouse 01/01/2018

IMPORTANT NOTICE To obtain information or make a complaint: You may call Humana Insurance Company's toll free telephone number for information or to make a complaint at 1-800-558-4444 You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at 1-800-252-3439 You may write the Texas Department of Insurance P.O. BOX 149104 Austin, TX 78714-9104 FAX: (512) 475-1771 WEB: http://www.tdi.state.tx.us E-mail: [email protected] PREMIUM OR CLAIM DISPUTES: Should you have a dispute concerning your premium or about a claim you should contact the company first. If the dispute is not resolved, you may contact the Texas

AVISO IMPORTANTE Para obtener informacion o para someter una queja: Usted puede llamar al numero de telefono gratis de Humana Insurance Company para informacion o para someter una queja al 1-800-558-4444 Puede communicarse con el Departamento de Seguros de Texas para obtener informacion acerca de companias, coberturas, derechos o quejas al 1-800-252-3439 Puede escribir al Departamento de Seguros de Texas P.O.BOX 149104 Austin, TX 78714-9104 FAX: (512) 475-1771 WEB: http://www.tdi.state.tx.us E-mail: [email protected] DISPUTAS SOBRE PRIMAS O RECLAMOS: Si tiene una disputa concerniente a su prima o a un reclamo, debe communicarse con el la compania primero. Si no se resuelve la disputa, puede entonces communicarse con el departamento (TDI).

http://www.tdi.state.tx.us/


Department of Insurance. ATTACH THIS NOTICE TO YOUR POLICY: This notice is for information only and does not become a part or condition of the attached document.

UNA ESTE AVISO A SU POLIZA: Este aviso es solo para proposito de informacion y no se convierte en parte o condicion del documento adjunto.

TABLE OF CONTENTS

GN-70051-07 EM TAB

SCHEDULE OF BENEFITS DEFINITIONS ELIGIBILITY AND EFFECTIVE DATE OF INSURANCE TERMINATION OF COVERAGE EMPLOYEE TERM LIFE INSURANCE BENEFITS WAIVER OF PREMIUM ACCIDENTAL DEATH OR BODILY INJURY BENEFIT FOR COVERED EMPLOYEES ACCELERATED BENEFITS GENERAL PROVISIONS DEPENDENT TERM LIFE INSURANCE BENEFITS ACCIDENTAL DEATH OR BODILY INJURY BENEFIT FOR COVERED DEPENDENT SPOUSE PORTABILITY PRIVILEGE SPLIT BILL AMENDMENT

SCHEDULE OF BENEFITS

GN-70051-07 EM ERSCBV 4

EMPLOYEE VOLUNTARY TERM LIFE INSURANCE VOLUNTARY TERM LIFE INSURANCE BENEFIT - As shown on your Employee's Schedule of Benefits. THE TERM LIFE INSURANCE BENEFIT IS REDUCED TO THE FOLLOWING FOR YOUR EMPLOYEES: Reduced by 35% AT AGE 65 based on the amount of Term Life Insurance in force at age 64 Reduced by 55% AT AGE 70 based on the amount of Term Life Insurance in force at age 64 Reduced by 70% AT AGE 75 based on the amount of Term Life Insurance in force at age 64 Reduced by 80% AT AGE 80 based on the amount of Term Life Insurance in force at age 64 Reduced by 85% AT AGE 85 based on the amount of Term Life Insurance in force at age 64

SCHEDULE OF BENEFITS (continued)

GN-70051-07 EM ERSCBVA 5

EMPLOYEE VOLUNTARY ACCIDENTAL DEATH OR BODILY INJURY BENEFIT ACCIDENTAL DEATH OR BODILY INJURY BENEFIT - As shown on Your Employee's Schedule Of Benefits. ACCIDENTAL DEATH BODILY INJURY BENEFIT IS REDUCED TO THE FOLLOWING FOR YOUR EMPLOYEES: Reduced by 35% AT AGE 65 based on the amount of Term Life Insurance in force at age 64 Reduced by 55% AT AGE 70 based on the amount of Term Life Insurance in force at age 64 Reduced by 70% AT AGE 75 based on the amount of Term Life Insurance in force at age 64 Reduced by 80% AT AGE 80 based on the amount of Term Life Insurance in force at age 64 Reduced by 85% AT AGE 85 based on the amount of Term Life Insurance in force at age 64


GN-70051-07 EM SCBCV 6

DEPENDENT CHILD VOLUNTARY TERM LIFE INSURANCE BENEFIT DEPENDENT CHILD VOLUNTARY - BIRTH THROUGH 14 DAYS ............................................... $0 DEPENDENT CHILD VOLUNTARY - 15 DAYS UP TO 6 MONTHS ...........................................$500 DEPENDENT CHILD VOLUNTARY - FROM AGE 6 MONTHS TO ATTAINMENT OF LIMITING AGE................................................................................................................................................$5,000


GN-70051-07 EM ERSCBSV 7

DEPENDENT SPOUSE VOLUNTARY TERM LIFE INSURANCE BENEFIT DEPENDENT SPOUSE VOLUNTARY TERM LIFE INSURANCE BENEFIT - As shown on the Schedule Of Benefits in Your Employee's Certificate. THE DEPENDENT SPOUSE TERM LIFE INSURANCE BENEFIT IS REDUCED TO THE FOLLOWING: Reduced by 35% AT AGE 65 based on the amount of Term Life Insurance in force at age 64 Reduced by 55% AT AGE 70 based on the amount of Term Life Insurance in force at age 64 Reduced by 70% AT AGE 75 based on the amount of Term Life Insurance in force at age 64 Reduced by 80% AT AGE 80 based on the amount of Term Life Insurance in force at age 64 Reduced by 85% AT AGE 85 based on the amount of Term Life Insurance in force at age 64


GN-70051-07 EM ERSCBSVA 8

DEPENDENT SPOUSE VOLUNTARY ACCIDENTAL DEATH OR BODILY INJURY BENEFIT ACCIDENTAL DEATH OR BODILY INJURY BENEFIT - As shown on the Schedule Of Benefits in Your Employee's Certificate. THE ACCIDENTAL DEATH OR BODILY INJURY BENEFIT IS REDUCED TO THE FOLLOWING: Reduced by 35% AT AGE 65 based on the amount of Term Life Insurance in force at age 64 Reduced by 55% AT AGE 70 based on the amount of Term Life Insurance in force at age 64 Reduced by 70% AT AGE 75 based on the amount of Term Life Insurance in force at age 64 Reduced by 80% AT AGE 80 based on the amount of Term Life Insurance in force at age 64 Reduced by 85% AT AGE 85 based on the amount of Term Life Insurance in force at age 64

DEFINITIONS

TX-70051-07 EM DEF 10/11 9

The following are definitions of terms as they are used in this Certificate. Defined terms are printed in bold face type wherever found in this Certificate.

A

Active Status means the Employee is performing all of the material duties of his/her occupation whether performed at the Employer's business establishment or another location of business when required to travel on behalf of the Employer: • On a regular, full-time basis; • For the number of hours per week shown on the Employer Group Application; and • For 48 weeks a year. An Employee will be considered in Active Status with the Employer on a day which is one of the Employer's scheduled work days if the Employee is performing, in the usual way, all of the material duties of his/her occupation on a full-time basis. The Employee will also be considered actively at work on each day of a regular scheduled paid vacation, or any regular non-working holiday, only if the Employee was at work on the preceding scheduled work day and was not Totally Disabled including a hospital confinement on that day.

B Bodily Injury means injury due directly to a specific accident, independent of all other causes. Muscle strain due to athletic or physical activity, or bodily damage resulting from infection, is considered a Sickness.

C Confinement means being a resident patient in a Hospital or Qualified Treatment Facility for at least 15 consecutive hours. Confinement does not mean detainment in Observation Status. Successive Confinements are considered to be one Confinement if: • Due to the same Bodily Injury or Sickness; and • Separated by fewer than 30 consecutive days when You are not confined. Covered Person means the Employee and/or the Employee's covered Dependents.

DEFINITIONS (continued)

TX-70051-07 EM DEF 10/11 10

D DEPENDENT Dependent means a covered Employee's:

1. Legally recognized spouse; or 2. Natural blood related child, step-child, or legally adopted child, child or grandchild placed

with the Employee for the purpose of adoption whose age is less than the limiting age. Dependent DOES NOT mean a great grandchild, or foster child.

The limiting age for each Dependent child is 26 years of age. You must furnish satisfactory proof to Us upon Our request that the above conditions continuously exist. If satisfactory proof is not submitted to Us, the child's coverage will not continue beyond the last date of eligibility. A covered Dependent child who becomes an employee eligible for other group coverage through employment is no longer eligible as a Dependent for coverage under the Policy. A covered Dependent child who attains the limiting age WHILE INSURED under the Policy remains eligible for Benefits if mentally or physically disabled and under the Employee’s supervision. You must furnish satisfactory proof to Us upon Our request that the above conditions continuously exist on and after the date the limiting age is reached. After two years from the date the first proof was furnished, We may not request such proof more often than annually. If satisfactory proof is not submitted to Us, the child's coverage will not continue beyond the last date of eligibility.

E Employee means a person who is in Active Status for the Employer on a permanent full-time basis. The Employee must be paid a salary or wage by the Employer that meets the minimum wage requirements of Your state or federal minimum wage law for work done at the Employer's usual place of business or some other location which is usual for the Employee's particular duties. Employer means the Policyholder of this Group Insurance Plan, or any subsidiary described in the Employer Group Application.

H Hospital means an institution which: • Maintains permanent full-time facilities for bed care of resident patients; • Has a physician or surgeon in regular attendance; • Provides continuous 24-hour-a-day nursing services; • Is primarily engaged in providing diagnostic and therapeutic facilities for medical or surgical care of

sick or injured persons;


TX-70051-07 EM DEF 10/11 11

• Is legally operated in the jurisdiction where located; and • Has surgical facilities on its premises or has a contractual agreement for surgical services with an

institution having a valid license to provide such surgical services; or • Is a lawfully operated Qualified Treatment Facility certified by the First Church of Scientist,

Boston, Massachusetts. Hospital does NOT include an institution which is principally a rest home, nursing home, convalescent home or home for the aged. Hospital does NOT include a place principally for the treatment of alcohol or chemical dependency or Mental Disorders.

M Material And Substantial Duties are the duties that: Are normally required for the performance of the occupation; and Cannot be reasonably omitted or changed. You will no longer be considered Totally Disabled or Partially Disabled under this Plan when You are able to increase Your current earnings by increasing the number of hours You work or the number of duties You perform in Your regular occupation but You do not do so.

P Policyholder means the Employer who is the Legal Entity named as the Policyholder on the face page of the Policy.

Q Qualified Practitioner means a practitioner, professionally licensed by the appropriate state agency to diagnose or treat a Bodily Injury or Sickness, and who provides services within the scope of that license. A Qualified Practitioner does not include a practitioner who resides in Your home or is Your Family Member. Qualified Treatment Facility means only a facility, institution, or clinic duly licensed by the appropriate state agency, and is primarily established and operating within the scope of its license.

S Sickness means a disturbance in function or structure of Your body which causes physical signs or symptoms which, if left untreated, will result in a deterioration of the health state of the structure or system(s) of Your body.


TX-70051-07 EM DEF 10/11 12

Surgery means excision or incision of the skin or mucosal tissues or insertion for exploratory purposes into a natural body opening. This includes insertion of instruments into any body opening, natural or otherwise, done for diagnostic or other therapeutic purposes.

T Total Disability or Totally Disabled means, for the Employee that during the disability he or she is at all times prevented by Bodily Injury or Sickness from performing each and every Material And Substantial Duty of his or her occupation as it is generally performed in the economy. A Totally Disabled person may not engage in ANY job or occupation for wage or profit.

W We, Us, and Our means the Insurance Company as shown on the cover page of this Certificate.

Y You and Your means any Covered Person.

ELIGIBILITY AND EFFECTIVE DATE OF INSURANCE

TX-70051-07 EM EE 13

EMPLOYEE COVERAGE EMPLOYEE ELIGIBILITY DATE The Employee is eligible for coverage on the date: • Eligibility requirements stated in the Employer Group Application are satisfied; and • The Employee is in an Active Status. EMPLOYEE ENROLLMENT The Employee must enroll on forms furnished and accepted by Us. Depending on the total number of Employees covered by the Employer's plan, We may require any Employee to provide evidence of insurability and any applicable evidence of health status whenever an enrollment form is submitted. If You enroll more than 31 days after Your eligibility date, You are a late applicant and must provide Us with evidence of insurability and any applicable evidence of health status. This form is available from the Employer or Us. We have the right to accept or decline coverage. If accepted, You will be covered on the date We specify. EMPLOYEE EFFECTIVE DATE The Employee's Effective Date Provision is stated in the Employer Group Application. It may be the date immediately following, or the first of the month following, completion of the probationary period (waiting period), or the date approved by Us. EMPLOYEE DELAYED EFFECTIVE DATE If the Employee is not in Active Status on the effective date shown on the Schedule of Benefits, coverage will be effective the day after the Employee returns to Active Status. The Employer must notify Us in writing of the Employee's return to Active Status. EMPLOYEE BENEFIT CHANGES Additional or increased insurance will become effective on the approved date of change if the Employee is in Active Status on that date. Otherwise, the approved change will be effective on the day after the Employee returns to Active Status. We may require any Employee to provide evidence of insurability and any applicable evidence of health status whenever a benefit change is requested. A decrease in insurance will be effective immediately on the approved date of change.

ELIGIBILITY AND EFFECTIVE DATE OF INSURANCE (continued)

TX-70051-07 EM EE 14

DEPENDENT COVERAGE DEPENDENT ELIGIBILITY DATE Each Dependent is eligible for coverage on: • The date the Employee is eligible for coverage, if he or she has Dependents who may be covered on

that date; • The date of the Employee's marriage for any Dependents (spouse or child) acquired on that date; • The date of birth of the Employee's natural-born child; or • The date the child is legally adopted or placed in the Employee's home for the purpose of adoption

by the Employee. The Employee may cover his or her Dependents ONLY if the Employee is also covered. A Dependent child who becomes eligible for other group coverage through any employment is no longer eligible for group coverage under the Policy. If a Dependent child becomes an Employee of the participating Employer, he or she is no longer eligible as a Dependent and must make application as an eligible Employee. DEPENDENT ENROLLMENT Check with the Employer immediately on how to enroll for Dependent Coverage. Late enrollment may result in denial of Dependent Coverage by Us. The Employee must enroll for Dependent Coverage and enroll additional Dependents on forms furnished and accepted by Us. No Dependent will become a Covered Person until We approve the Dependent for coverage. Depending on the total number of Employees covered by the Employer's plan, We may require any Dependent to provide evidence of insurability and any applicable evidence of health status whenever an enrollment form is submitted. If You enroll more than 31 days after Your eligibility date, You are a late applicant and must provide Us evidence of insurability and any applicable evidence of health status. This form is available from the Employer or Us. We have the right to accept or decline coverage. If accepted, You will be covered on the date We specify.


TX-70051-07 EM EE 15

NEWBORN DEPENDENT ENROLLMENT Employees who already have full Dependent (spouse and children) coverage in force PRIOR to the newborn's date of birth are not required to complete an enrollment form for the newborn child. All other Employees who are changing their current coverage must complete an enrollment form for the newborn Dependent. This form is available from Your Employer or from Us. DEPENDENT EFFECTIVE DATE Each Dependent's effective date of coverage is determined as follows, subject to the Dependent Delayed Effective Date provision: • If We receive the enrollment form ON, PRIOR TO or WITHIN 31 days of the Dependent's

eligibility date, that Dependent is covered on the date he or she is eligible; • If We receive the enrollment form MORE THAN 31 days after the Dependent's eligibility date, We

require evidence of insurability and any applicable evidence of health status. We have the right to accept or decline coverage for the Dependent based upon the evidence of insurability and any applicable evidence of health status. If accepted, the effective date of coverage will be the date We specify.

However, NO Dependent's effective date will be prior to the Employee's effective date of coverage. Refer to Your Schedule of Benefits for benefits available. NEWBORN DEPENDENT EFFECTIVE DATE A newborn Dependent's effective date is determined as follows: • If We receive the enrollment form ON, PRIOR TO or WITHIN 31 days of the newborn's date of

birth, Dependent Coverage is effective on the newborn's date of birth. • If We receive the enrollment form MORE THAN 31 days after the newborn's date of birth, We

require evidence of insurability and any applicable evidence of health status. We have the right to accept or decline coverage for the newborn based upon the evidence of insurability and any applicable evidence of health status. If accepted, the newborn will be covered on the date We specify.


TX-70051-07 EM EE 16

DEPENDENT DELAYED EFFECTIVE DATE If the Dependent: • Is confined in a Hospital or Qualified Treatment Facility; or • Is receiving Home Health Care or Hospice benefits, the Dependent's effective date of coverage will be delayed. The Dependent's coverage will be effective on the day after: • Discharge from Confinement, if the discharge from Confinement is certified by a Qualified

Practitioner; or • A Qualified Practitioner certifies that Home Health Care is no longer required. If Dependent coverage is in force or applied for within 31 days of the newborn child's date of birth, the Dependent Delayed Effective Date provision will not apply to the newborn child on its date of birth. DEPENDENT BENEFIT CHANGES Additional or increased insurance will become effective on the approved date of change, subject to the Dependent Delayed Effective Date provision. We may require any Dependent to provide evidence of insurability and any applicable evidence of health status whenever a benefit change is requested. A decrease in insurance will be effective immediately on the approved date of change.

TERMINATION OF COVERAGE

GN-70051-07 EM TER 17

Termination of Coverage may be immediate or at the end of the period which was selected by Your Employer on the Employer Group Application. Insurance terminates on the earliest of the following: • The date the Group Policy terminates; • The end of the period for which required premium was due Us and not received by Us; • For an Employee, the date he or she terminates employment with the Employer; • For an Employee, the date he or she no longer qualifies as an Employee; • The date You fail to be in an eligible class of persons as provided in the Insurance Classifications as

stated in the Employer Group Application; • The date You enter full-time military, naval or air service except that termination will not occur if

You are in temporary active duty as a reservist for military training that lasts 30 days or less; • The date the Employee retires, except if the Employer Group Application provides coverage for a

retiree class of Employees and the retiree is in an eligible class of retirees, selected by the Employer, and We are notified by the Employer;

• The date the Employee requests termination of insurance to be effective for the Employee or

Dependents; • For a Dependent, the date the Employee's insurance terminates; • For a Dependent, the date he or she no longer qualifies as a Dependent; or • For any benefit, the date the benefit is deleted from the Policy. YOU AND THE EMPLOYER ARE RESPONSIBLE TO ADVISE US OF ANY CHANGES IN ELIGIBILITY INCLUDING THE LACK OF ELIGIBILITY OF ANY COVERED PERSON. COVERAGE WILL NOT CONTINUE BEYOND THE LAST DATE OF ELIGIBILITY REGARDLESS OF THE LACK OF NOTICE TO US. SPECIAL PROVISIONS FOR NOT BEING IN ACTIVE STATUS If the Employer continues to pay required premiums and continues coverage under the Policy, Your coverage, other than Short Term Disability benefits,if any, will remain in force for: • No longer than three consecutive months if the Employee is:

- Temporarily laid-off; - In part-time status; or - On an Employer approved leave of absence.

TERMINATION OF COVERAGE (continued)

GN-70051-07 EM TER 18

• No longer than twelve consecutive months if the Employee is Totally Disabled. If the Employee becomes Totally Disabled and wishes to apply for Waiver of Premium, We must receive premium for Employee Term Life Insurance Coverage for the six consecutive month period while the Employee is covered under the Special Provisions for Not Being in Active Status. All premium must be submitted to Us through the Employer. YOUR OPTIONS Employee Voluntary Term Life Coverage: If this coverage terminates, the Employee may exercise the rights under the Portability of Voluntary Term Life Benefit described in this Certificate, if applicable, or the Life Conversion Privilege described in this Certificate. If the Employee utilizes the Conversion Privilege, he or she thereby waives the right to Port Voluntary Term Life Coverage. If the Employee utilizes any applicable Port Privilege, he or she will have an option to Convert all or part of the coverage if the Port coverage terminates. If the Employee returns to an Active Status, he or she will be considered a new Employee and must re-enroll for Employee Coverage.

EMPLOYEE TERM LIFE INSURANCE BENEFITS

TX-70051-07 EM TL 3/2004 19

BENEFIT The amount of the Employee Term Life Insurance benefit is shown on the Schedule of Benefits. Subject to the terms below, a payment in this amount will be made to the beneficiary named by the Employee. Payment is made no later than two months after the date We receive proof the Employee’s death, and the death occurred while insured for this benefit. The Employee Group Term Life Insurance has no cash surrender or loan values. REDUCTION FOR AGE Reduction percentage(s) and reduction age(s), if any, are shown on the Schedule of Benefits. If the Employee's death occurs on or after a reduction age, the amount of payment will be reduced by the corresponding reduction percentage shown. A reduction in benefits due to age is effective on the first day of the calendar month following the date the Employee attains that age. BENEFICIARY The Employee may name any beneficiary he or she chooses. The Employee may also change a named beneficiary at any time by notifying Us in writing. The change will be effective on the date the Employee signs the form. If We make a payment before receiving the change form, We are released from further liability to the extent of the payment. If a payment is to be made to two or more beneficiaries, but the Employee has not specified the portions payable to each, the payment will be shared equally. If the Employee has not named a beneficiary, or if the beneficiary he or she named is not alive at the Employee's death, the payment will be made, at Our option, to any one or more of the following: • Your spouse; • Your children; • Your parents; • Your brothers and sisters; or • Your estate. We will rely upon an affidavit to determine benefit payment, unless We receive written notice of a valid claim before payment is made. Payment pursuant to the affidavit will release Us from further liability. Any payment made by Us in good faith will fully discharge Us to the extent of such payment. Any amount payable to a minor will be paid to the minor's legal guardian. NOTICE OF DEATH No payment will be made unless We receive written proof of Your death. If a death claim is filed while the Waiver of Premium is in effect, proof of continuous Total Disability must accompany the death claim.

EMPLOYEE TERM LIFE INSURANCE BENEFITS (continued)

TX-70051-07 EM TL 3/2004 20

LIMITED BENEFITS FOR SELF-INDUCED SICKNESS, SUICIDE OR SELF-INFLICTED BODILY INJURY In the event of death caused by self-induced Sickness, suicide, or intentional self-inflicted Bodily Injury, whether sane or insane, within the first year of Your effective date under this Certificate, benefits for Employee Voluntary Term Life Insurance will be limited to the premium paid for the Employee Voluntary Term Life Insurance. EMPLOYEE LIFE INSURANCE CONVERSION PRIVILEGE The Employee is entitled to apply for a Conversion Policy of Life Insurance if any portion of his or her Term Life Insurance Benefit terminates due to: • Termination of employment or membership in a class eligible for Term Life Insurance. The amount

the Employee is entitled to apply for is the amount of Term Life Insurance that is terminating, LESS the amount of Term Life Insurance for which he or she becomes eligible under any group coverage within 31 days after such termination; or

• Reduction for Age. The amount the Employee is entitled to apply for is the amount of insurance lost

due to the reduction, but not more than $10,000. If the Employee's Term Life Insurance benefit terminates because this coverage terminates, or is amended so as to terminate the eligible class to which the Employee belongs, and his or her Employee Term Life Insurance has been in effect under the Policy for at least three years, the amount the Employee is entitled to apply for is the lesser of: • The amount of Employee Term Life Insurance that is terminating, LESS the amount of any Life

Insurance for which he or she becomes eligible under any group coverage within 31 days after such termination; or

• $10,000. CONVERSION POLICY The Conversion Policy is issued without evidence of insurability. The Employee must apply for and pay the first premium within 31 days of the termination of the Employee's coverage under the Group Plan. The Conversion Policy will be effective on the 32nd day following such termination. The Conversion Policy will not include any Short Term Disability or Accidental Death or Bodily Injury benefits. It will be issued on any one of the Policy forms, except term insurance, then being issued by Us to individuals of the same age. Premiums for the Conversion Policy will be based on Our current rate for the form, amount of insurance and the Employee's age on the date of issue of the Conversion Policy.


TX-70051-07 EM TL 3/2004 21

DEATH DURING CONVERSION PERIOD If the Employee dies during the 31 day period that he or she could have applied for a Conversion Policy, the amount of Life Insurance the Employee could have converted will be paid as the death benefit, even if the Employee had not applied for the Conversion Policy. THE FOLLOWING EXCLUSIONS ARE APPLICABLE TO VOLUNTARY TERM LIFE BENEFITS IF SHOWN ON YOUR SCHEDULE OF BENEFITS. LIMITATIONS Voluntary Term Life Benefits do not cover loss resulting from: • Self-induced Sickness, attempted suicide or intentionally self-inflicted Bodily Injury, whether sane

or insane within the first year of Your effective date. Benefits will be limited to the premium paid for this Employee Voluntary Term Life Insurance;

• The voluntary taking of any sedative, drug, alcohol, poison or inhalation of any gas unless taken or

inhaled as prescribed or administered by a Qualified Practitioner within the first year of Your effective date. Benefits will be limited to the premium paid for this Employee Voluntary Term Life Insurance;

• Travel or flight in a device of any type for aerial navigation, except as a fare-paying passenger of a

licensed passenger airline; • Service in any armed forces, except if You are in temporary active duty as a reservist for military

training that lasts 30 days or less; • Bodily Injury or Sickness contributed to or caused by;

- War or any act of war, whether declared or not; or - Any act of armed conflict, or any conflict involving armed forces of any authority; or

• Participation in a riot, rebellion or insurrection. Participation means taking an active part in common with others. Riot means any use or threat to use force or violence by three or more persons without the authority of law.

WAIVER OF PREMIUM

GN-70051-07 EM WOP 3/2004 22

If the Employee becomes Totally Disabled while insured for this Employee Term Life Insurance Benefit, We will continue the Employee's Term Life Insurance Benefit during his or her Total Disability without the requirement of premium payment subject to the Waiver of Premium provision. In order for Us to approve Waiver of Premium, the Employee must: • Become Totally Disabled before age 60; • Remain Totally Disabled throughout the 180 consecutive day Elimination Period;

Elimination Period means a period of continuous disability which must be satisfied before You are eligible to have Your life premium waived by Us.

• Request an application for Waiver of Premium and submit such application with proof of Total Disability, acceptable to Us, no later than 12 consecutive months after the Employee first became Totally Disabled.

Premium payment must continue until We approve the application for Waiver of Premium. Failure to do so will result in forfeiture of Your rights to Wavier of Premium. The Wavier of Premium benefit begins at the end of the Elimination Period. If the Employee dies prior to submitting the initial proof of Total Disability as required, proof that the Total Disability continued until the date of the Employee's death must be given to Us no later than 12 months after the Employee's death. We will not approve an application for Waiver of Premium if the Employee becomes Totally Disabled after the Employer terminates coverage under the Policy. EFFECT OF WAIVER OF PREMIUM When We approve Waiver of Premium, no premium payment will be required for the Employee's Term Life Insurance benefit during his or her Total Disability. Proof of the Total Disability must be received by Us within one year from the date the Total Disability began. The Employee is required to submit proof of continued Total Disability to Us three months before each anniversary date of the disability. We have the right to have the Employee examined for the Total Disability at any reasonable time during the first two years he or she is Totally Disabled. After that, We may have the Employee examined only once a year. AMOUNT CONTINUED The amount of the Employee Term Life Insurance benefit which will be continued under this Waiver of Premium is the amount that was in effect for the Employee on the date the Total Disability began. This amount will be reduced by the same amount, on the same dates, and for the same reasons that it would have been reduced if the Employee had not become Totally Disabled.

WAIVER OF PREMIUM (continued)

GN-70051-07 EM WOP 3/2004 23

TERMINATION OF WAIVER OF PREMIUM The Waiver of Premium terminates on the earliest of: • The date the Employee fails or refuses to furnish proof of Total Disability as required; • The date the Employee fails or refuses to be examined as required; • The date the Employee is no longer Totally Disabled; or • The Employee's 65th birthday. If the Waiver of Premium benefit terminates and the Employee returns to an Active Status, he or she will be insured for the Employee Term Life Insurance benefit for which he or she is then eligible. Premium payment will be required for the Employee Term Life Insurance benefit. If this Waiver of Premium terminates because the Employee is no longer Totally Disabled or attains age 65, and does not return to an Active Status, he or she may apply for a Conversion Policy of Life Insurance according to the Conversion Privilege provision in this Certificate. Termination of the Employer's participation under the Policy WILL NOT terminate the Employee's Waiver of Premium. If the Waiver of Premium terminates after the Employer's participation under the Policy terminates, and if the Employee Term Life Insurance Benefit has been in force for at least three years, the Employee may apply for a Conversion Policy. The amount of any Conversion Policy is limited to the lesser of: • The amount of Employee Term Life Insurance that is terminating LESS the amount of any Life

Insurance for which the Employee becomes eligible under any group coverage within 31 days after such termination; or

• $10,000.

ACCIDENTAL DEATH OR BODILY INJURY BENEFIT FOR COVERED EMPLOYEES

GN-70051-07 EM ADD 5/2005 24

Subject to the terms below, a benefit is payable for loss due to the Employee's Accidental Death or Accidental Bodily Injury if shown on the Schedule of Benefits. The loss must: (a) occur within 180 days after the accident which caused the loss; and (b) be due to an accident which occurs while the Employee is insured under the Benefit. If the Employee suffers multiple losses in the same accident, Our liability will be limited to payment for the one type of loss which provides the greatest benefit. The amount of benefit payable for each type of loss is: LOSS OF LIFE OR BENEFIT OTHER THAN BENEFIT FOR DISMEMBERMENT BENEFIT A COMMON CARRIER COMMON CARRIER ACCIDENT ACCIDENT Loss of Life Full Amount 2 Times Full Amount Loss of both hands Full Amount 2 Times Full Amount Loss of both feet Full Amount 2 Times Full Amount Loss of sight of both eyes Full Amount 2 Times Full Amount Loss of one hand and one foot Full Amount 2 Times Full Amount Loss of one hand or one foot and sight of one eye Full Amount 2 Times Full Amount Loss of one hand One-Half of the Full Amount Full Amount Loss of one foot One-Half of the Full Amount Full Amount Loss of sight of one eye One-Half of the Full Amount Full Amount Loss of thumb and index finger One-Fourth of the One-Half of the of the same hand Full Amount Full Amount

ACCIDENTAL DEATH OR BODILY INJURY BENEFIT FOR COVERED EMPLOYEES (continued)

GN-70051-07 EM ADD 5/2005 25

PARALYSIS BENEFIT The paralysis must be determined by a Qualified Practitioner to be permanent, complete and irreversible. BENEFIT OTHER THAN BENEFIT FOR A COMMON CARRIER COMMON CARRIER ACCIDENT ACCIDENT Quadriplegia Full Amount 2 Times Full Amount Paraplegia One-Half of the Full Amount Full Amount Hemiplegia One-Half of the Full Amount Full Amount REDUCTION FOR AGE Reduction percentage(s) and reduction age(s), if applicable, are also shown on the Schedule of Benefits. If the Employee's loss occurs on or after a reduction age is effective, the full amount shown on the Schedule of Benefits will be reduced by the corresponding reduction percentage shown. This means that if the accident occurs before the effective date of the reduction age, but the Employee's loss occurs on or after the effective date of the reduction age, We will pay the benefit based on the reduced amount. A reduction age is effective on the first day of a calendar month following the date the Employee attains that age. TO WHOM PAYABLE Benefits for Accidental Dismemberment, or Paralysis are payable to the Employee. Benefits for Accidental Death are payable in accordance with the Employee Term Life Insurance Benefits provision - Beneficiary section. DEFINITIONS • ACCIDENTAL DEATH Accidental Death means loss of life which results directly from:

- Bodily Injury; - Infection caused by Bodily Injury, or infection resulting from accidental ingestion of

contaminated substances; or - Accidental drowning.


GN-70051-07 EM ADD 5/2005 26

• ACCIDENTAL DISMEMBERMENT Accidental Dismemberment means complete, permanent and irretrievable loss, resulting directly from Bodily Injury of:

- A hand or foot by severance at or above the wrist or ankle joint; or - The sight of an eye.

• COMMON CARRIER ACCIDENT Common Carrier Accident means a covered accidental Bodily Injury that is sustained while riding as a fare-paying passenger (not a pilot, operator or crew member) in or on, boarding or getting off from a common carrier. • COMMON CARRIER Common Carrier means any land, air or water vehicle operated under a valid license to transport passengers for hire. • QUADRIPLEGIA Quadriplegia means total paralysis of all four limbs. • PARAPLEGIA Paraplegia means total paralysis of both lower limbs. • HEMIPLEGIA Hemiplegia means total paralysis of one arm and one leg on the same side of the body. REPATRIATION BENEFIT We will pay a Repatriation Benefit if: 1. The Employee dies as a result of a accidental death at least 150 miles from his or her principal place

of residence; and 2. Expense is incurred for preparing the Employee's body and transporting the Employee's body to a

mortuary. This benefit will be in addition to all other benefits payable under this Certificate. This benefit will equal the expenses incurred for preparing and transporting the Employee's body to a mortuary, subject to the maximum of $5,000. This benefit will be paid the date both proof of accidental loss of life and proof of expense incurred for preparing and transporting the body is received.


GN-70051-07 EM ADD 5/2005 27

PROOF FOR REPATRIATION BENEFIT For this benefit to be payable, proof of payment for any expense incurred for repatriation must be provided to Us. TO WHOM PAYABLE FOR REPATRIATION BENEFIT Benefits for repatriation will be paid in accordance with the Beneficiary Section of this Certificate. Benefits will not be payable for any loss excluded under the Accidental Death or Bodily Injury for covered Employees Limitations section. EDUCATION BENEFIT We will pay an Education Benefit for each of the Employee's eligible Dependent children if the Employee: • Is injured in a covered accident while insured under this Certificate; • Dies as a direct result of these injuries within 365 days after the accident; and • Is survived by one or more Dependent children who are eligible for the benefit. To be eligible for the Education Benefit, a Dependent Child: • Must be Dependent on the Employee for principal support; • Must be enrolled as a full-time student on the date of the Employee's death or within 365 days after

the date of death; and • Must incur expenses after the date of the Employee's death for tuition, fees, books, room and board,

approved or certified by that school, paid by the student or payable directly to that school. This benefit will be paid in addition to all other benefits payable under this Certificate. The benefit will equal the actual expense incurred after the date of the Employee's death up to 5% of the Employee's death benefit, subject to a maximum of $5,000 for each eligible Dependent child per year, for up to four (4) consecutive years or until age 25 if all eligibility requirements are met for each payment. This benefit will be paid to the Dependent child if the child has reached the age of majority. Otherwise, benefits will be paid to the child's legal guardian. The first payment will be paid, the date both proof of accidental loss of life and proof of Educational expenses and that the Dependent child meets the above requirements is received. Subsequent payments will be made when We receive: • Verification that the eligible Dependent child continues to be a full-time student and meets the

requirements of this benefit during each additional semester/year; and • Proof of payment for the expenses incurred.


GN-70051-07 EM ADD 5/2005 28

"Full-time student" means a Dependent child who: • Is attending a licensed or accredited college, university or vocational school beyond the 12th grade; • Is considered a full-time student based upon that school's standards; and • Incurs expenses for tuition, fees, books, room and board, or other costs approved or certified by that

school, paid by the student or payable directly to that school. SPOUSE TRAINING BENEFIT A Spouse Training Benefit will be paid to the Employee's lawful recognize spouse, if the Employee: • Dies as a direct result of an Accidental Death; and • Is survived by a spouse who is eligible for the benefit. To be eligible for the Spouse Training Benefit, the Employee's spouse: • Must be the lawfully recognized spouse of the Employee on the date of the accident; • Must be enrolled as a student on the date of the Employee's death or within 365 days after that date

of the Employee's death in an accredited school; and • Must incur expenses after the date of the Employee's death for tuition, fees, books, room and board

or other costs approved or certified by the school, paid by the student or payable directly to that school.

This benefit will be paid in addition to all other benefits payable under this Certificate. The benefit will equal the actual expense incurred after the date of the Employee's death up to 5% of the Employee's benefit, subject to a maximum of $5,000. This benefit will be paid for one year after the Employee's death. Payment will be made the date both proof of accidental loss of life and proof of expense incurred for Spousal Training and the spouse meets the above requirement is received. EXCLUSIONS FOR SPOUSE TRAINING BENEFIT Benefits will not be payable for any loss excluded under the Accidental Death or Bodily Injury Benefit for Covered Employees Limitation section. CHILD CARE BENEFIT A Child Care Benefit will be paid for each of the Employee's eligible Dependent children if the Employee: • Is injured in a covered accident while insured under this Certificate; • Dies as a direct result of these injuries within 365 days after the accident; and • Is survived by one or more Dependent children who are eligible for the benefit.


GN-70051-07 EM ADD 5/2005 29

To be eligible for the Child Care Benefit, a Dependent child must: • Meet all the qualifications of a Dependent as determined by the Internal Revenue Service; • Be declared on and legally qualify as a Dependent on the Employee's Federal personal income tax

return filed for each year the benefits are request under the Child Care Benefit; • Be under age 13 on the date of the accident; and • Attends a licensed Child Care Center, once a week or on a more frequent basis, on the date of the

Employee's death or within 365 days after that date. The Child Care Benefit is paid in addition to all other Certificate benefits. The benefit will equal the actual expense incurred after the date of the Employee's death, up to 5% of the Employee's benefit, subject to a maximum of $5,000 for each eligible Dependent child per year. The benefit will be paid to the legal guardian of the eligible Dependent child the earliest of the following: • For up to four (4) consecutive years; or • Until the Dependent child's 13th birthday. The first payment will be made the date proof of accidental loss of life and proof of expenses incurred for Child Care and that the eligible Dependent child meets the above requirements is received. Subsequent payment will be made on a reimbursement basis when We receive: • Verification that the eligible Dependent child continues to attend a licensed Child Care Center on a

regular basis; and • Satisfactory proof of payment for the childcare expense incurred. DEFINITIONS • CHILD CARE CENTER Child Care Center means any facility, other than a family day care home that:

- Is licensed as a Child Care Center by the state in which it is physically located, and where the Dependent child physically attends; and

- Provides non-medical care and supervision for children in a group setting: and - Cares for children at least six (6) but less than 24 hours per day.

• EXPENSE INCURRED Expense incurred means the cost for the supervision and care of a Dependent child, excluding any fees for extra activities that are directly payable to a Child Care Center.


GN-70051-07 EM ADD 5/2005 30

EXCLUSIONS FOR CHILD CARE BENEFIT Benefits will not be paid: • When the Dependent Child's care is provided by, or at a facility operated by the child's grandparent,

parent, aunt, uncle or sibling; or • For any loss excluded under the Accidental Death or Bodily Injury for Covered Employees

Limitation section of this Certificate. COMA BENEFIT Coma means being in a state of complete mental and physical unresponsiveness in which neither arousal nor awareness is present and there is no evidence of appropriate responses to stimulation. We will pay a Coma Benefit when the Employee remains in a Coma if: • The Coma is caused by a Bodily Injury sustained while insured under this Certificate; • The Coma begins within 365 days after the date of the accident; and • The person remains in a Coma for more than 31 consecutive days. The Coma must result directly from the Bodily Injury and from no other causes. The benefit will be paid in addition to all other benefits payable under this Certificate. The Coma Benefit will equal a one time payment of 5% of the Employee's benefit, subject to a maximum of $5,000. PROOF FOR COMA BENEFIT Proof of the Coma must be provided to Us. We retain the right to investigate and to determine whether the coma exists. TO WHOM PAYABLE FOR COMA BENEFIT Upon receipt of satisfactory proof, the Coma Benefit will be paid to the Employee. EXCLUSIONS FOR COMA BENEFIT Benefits will not be paid: • When the Employee remains in a coma for less than 31 consecutive days; or • For any loss excluded under the Accidental Death or Bodily Injury for Covered Employees

Limitation section of this Certificate.


GN-70051-07 EM ADD 5/2005 31

SEAT BELT - AIRBAG - HELMET BENEFIT The Seat Belt, Airbag, Helmet Benefit is payable if You die as a direct result of Bodily Injury sustained in an automobile or motorcycle accident as a passenger or driver. In the event of an automobile accident the benefit is payable if: • A copy of the police report is submitted with the claim; • You were seated in a seat equipped with a properly functioning air bag; • You were wearing a properly fastened seat belt in the correct position; and • The correct position of the seat belt was certified by the investigating officer or indicated in the police

report. We will increase Your Accidental Death benefit by 10%, up to $10,000, but not less than $1,000 for using Your seat belt. Additionally, We will increase Your Accidental Death benefit by 5%, up to $5,000, but no less than $500 for the properly functioning airbag. In the event of a motorcycle accident the benefit is payable if: • A copy of the police report is submitted with the claim: • You were wearing a properly fitting and fastened motorcycle helmet; and • The use of properly fitted and fastened motorcycle helmet was certified by the investigating officer or

indicated in the police report. We will increase Your Accidental Death benefit by 10%, up to $10,000, but not less than $1,000 for wearing a properly fitted and fastened motorcycle helmet. If We are unable to determine whether You had been wearing a properly fastened seat belt, seated in a seat equipped with a functioning airbag, or wearing a properly fitted and fastened motorcycle helmet. We will pay a benefit of $1,000 to Your beneficiary. DEFINITIONS • AUTO Auto means a four-wheel passenger car, station wagon, sport utility vehicle, truck or van-type car. It must be licensed for use on public highways. It includes a car owned or leased by a group certificate holder. • MOTOR CYCLE Motor Cycle means a two wheel passenger motorcycle. It must be licensed for use on public highways. it includes a motorcycle owned or leased by a group certificate holder.


GN-70051-07 EM ADD 5/2005 32

LIMITATIONS Accidental Death or Bodily Injury benefits DO NOT cover loss resulting from: • Self-induced Sickness, attempted suicide or intentionally self-inflicted Bodily Injury, whether sane

or insane; • The voluntary taking of any sedative, drug, alcohol, poison or inhalation of any gas unless taken or

inhaled as prescribed or administered by a Qualified Practitioner; • Being intoxicated or under the influence of any unlawful substance, narcotic or hallucinogenic, unless

administered on the advice of a Qualified Practitioner; • Travel or flight in a device of any type for aerial navigation, except as a fare-paying passenger of a

licensed passenger airline; • Commission or attempt to commit a civil or criminal battery or felony; • Driving or operating a motorized vehicle while legally intoxicated or under the influence of illegal

substance. Intoxication means that blood alcohol content or the results of other means of testing blood alcohol level meet or exceeds the legal presumption of intoxication under the law of the state where the accident took place;

• Driving or operating a motorized vehicle without a valid drivers' license; • Driving or operating a motorized vehicle in excess of the legal speed limit; • Service in any armed forces, except if You are in temporary active duty as a reservist for military

training that lasts 30 days or less; • Bodily Injury or Sickness contributed to or caused by:

− War or any act of war, whether declared or not; or − Any act of armed conflict, or any conflict involving armed forces of any authority;

• Bodily or mental infirmity, or its related surgical or medical treatment or any infection unless the

direct result of Bodily Injury, or unless resulting from the accidental ingestion of a contaminated substance;

• Participation in a riot, rebellion or insurrection. Participation means taking an active part in common

with others. Riot means any use or threat to use force or violence by three or more persons without the authority of law; or

• Participation in hazardous sports, including but not limited to: bungee jumping, motorized vehicle

racing, rock climbing, rodeo events, scuba diving, skydiving, parachuting, hang gliding, or ballooning.

ACCELERATED BENEFITS

TX-70051-07 EM ADB 33

If a covered Employee is diagnosed with a Qualifying Condition, the Employee may request that an accelerated benefit be paid immediately. The amount payable is 50% to a maximum benefit of $250,000. DEATH BENEFITS WILL BE REDUCED IF AN ACCELERATED BENEFIT IS PAID. DEFINITIONS Activities of Daily Living mean Bathing, Maintaining Continence, Dressing, Eating, Toileting and Transferring. Adult Day Care means a social and health-related services program provided during the day in a community group setting, for the purpose of supporting frail, impaired elderly, or other disabled adults who can benefit from care in a group setting outside the home. Adult Day Care Facility means a provider of Adult Day Care services operated pursuant to the provisions of the Human Resources Code, Chapter 103 (concerning licensing and quality of care requirements in the provision of adult day care). Bathing means washing yourself by sponge bath or in either a tub or shower, including the task of getting into or out of the tub or shower. Dressing means putting on and taking off all items of clothing and any necessary braces, fasteners or artificial limbs. Eating means feeding yourself by getting food into the body from a receptacle (such as a plate, cup or table) or by a feeding tube or intravenously. Home Health Agency means a business which provides home health service and is licensed by the Texas Department of Health under Texas Civil Statutes, Article 4447u. Home Health Care Services mean medical or nonmedical services provided to ill, disabled or infirm persons in their residences. Such services may include homemaker services, assistance with activities of daily living, respite care services, case management services, and maintenance or personal care services. Long Term Care Illness means the Employee: • Is unable to perform at least two Activities of Daily Living; or • Has an impairment of cognitive ability. Impairment of cognitive ability means the deterioration or

loss in intellectual capacity requiring substantial supervision for protection of self and others, as established by the clinical diagnosis of any Qualified Practitioner in the state of Texas authorized to make such a diagnosis. Such diagnosis shall include the patient's history and physical, neurological, psychological and/or psychiatric evaluations and laboratory findings.

ACCELERATED BENEFITS (continued)

TX-70051-07 EM ADB 34

Maintaining Continence means the ability to maintain control of bowel and bladder function or when unable to maintain control of bowel or bladder function, the ability to perform associated personal hygiene (including care for catheter or colostomy bag). Qualifying Condition means: • Long-Term Care Illness; • Specified Disease; or • Terminal Illness. Specified Disease means a Sickness or Bodily Injury that is likely to cause permanent disability or premature death including, but not limited to: • Acquired Immune Deficiency Syndrome (AIDS); • Malignant tumor; • A condition that requires an organ transplant; • Coronary artery disease resulting in acute infarction or requiring surgery; or • Permanent neurological deficit resulting from cerebral vascular accident. Terminal Illness means a Sickness or Bodily Injury which is diagnosed by a Qualified Practitioner as life-threatening with a life expectancy of 24 months or less. Toileting means getting to and from the toilet, getting on and off the toilet and performing associated personal hygiene. Transferring means sufficient mobility to move into or out of a bed, chair or wheelchair or to move from place to place, either by way of walking, a wheelchair or other means. QUALIFICATIONS FOR ACCELERATED BENEFITS Payment of this benefit does not guarantee that the Employee's full death benefit will eventually be paid. The Employee must still be insured under the Policy at the time of death for the remainder of the Term Life Insurance benefit to be paid. To qualify for the Accelerated Death Benefit the covered Employee must: • Be covered under the Policy a minimum of 6 months; • Provide proof of Qualifying Condition acceptable to Us; and • Request this benefit in writing on a form acceptable by Us.


TX-70051-07 EM ADB 35

PROOF OF QUALIFYING CONDITIONS A Qualified Practitioner's written certification is required as proof that a Qualifying Condition exists. We reserve the right to request any additional medical information We believe necessary to confirm the Employee's Qualifying Condition. We also reserve the right to request a second opinion from a Qualified Practitioner appointed by Us. The second opinion would be paid by Us. If You fail to submit proof satisfactory to Us that You have a Qualifying Condition, or refuse to be examined as may be required by Us, no Accelerated Benefit will be payable. In the event that Your Qualified Practitioner and a Qualified Practitioner appointed by Us are unable to agree that a Qualifying Condition has occurred, the opinion of the Qualified Practitioner appointed by Us will prevail. QUALIFIED TREATMENT FACILITY OF LONG TERM CARE ILLNESS Qualified Treatment Facility of Long Term Care Illness includes, but is not limited to, a convalescent nursing home, residential care or intermediate nursing facility, which is operated pursuant to state and federal law. Qualified Treatment Facility of Long Term Care Illness does not include: • Any home, facility or part thereof used primarily for rest; • A home or facility for:

- The aged; - Drug addicts or Alcoholics; - The care and treatment of mental diseases or disorder; - Custodial care; or - Educational care.

EXCLUSIONS • Accelerated Benefits are not available for a Qualifying Condition which resulted from a self-induced

Sickness, attempted suicide or intentionally self-inflicted Bodily Injury, whether sane or insane; or • Accelerated Benefits are not payable to an Employee who is:

- Required by law to use this benefit to satisfy claims of creditors; or - Required by a government agency to use this benefit to apply for, obtain or keep a government

benefit or entitlement.


TX-70051-07 EM ADB 36

BENEFITS PAYABLE Payment will be made in one lump sum to You and is payable once during Your lifetime. The amount requested must be at least $5,000. Notice: At the time of payment of this benefit, We will send You or the owner, whichever is applicable, a statement specifying the amount of benefits paid and the effect of the benefit payment on Your Term Life Insurance amount. If the amount of Your Term Life Insurance is scheduled to reduce within 6 months following the date You apply for the Accelerated Benefit, Your benefit payable will be based on the reduced amount. Payment from this benefit may be taxable. Assistance should be sought from Your personal tax advisor. We are not responsible for any tax or other effects of an accelerated benefit payment or loss of eligibility for any State or Federal program. EFFECT ON EMPLOYEE TERM LIFE INSURANCE BENEFIT The amount of Term Life Insurance payable to the beneficiary at the time of death will be reduced by any accelerated benefit amount paid. The remaining Term Life Insurance amount will be paid according to the terms and provisions of the Policy. Any amount You could otherwise convert will also be reduced by the accelerated benefit.

GENERAL PROVISIONS

TX-70051-07 EM GP 3/2004 37

NOTICE OF CLAIM Written notice of claim, other than claim for loss of life, must be given within 30 days after the date of loss covered by this Policy, or as soon thereafter as is reasonably possible. Notice may be given at Our address and should include Your name and the name(s) of Your Dependent(s) and Your Group Number. CLAIM FORMS Upon receipt of notice of claim, We will send You the forms for filing proof of loss. If the forms are not sent to You within 15 days, You will have met the proof of loss requirement by sending Us a written statement of the nature and extent of the loss within the time limit stated in the Proof of Loss provision. PROOF OF LOSS You must give written proof of loss within 91 days after the date of loss, except for loss of life. Your claim will not be reduced or denied if it was not reasonably possible to give such proof. In any event, written notice must be given within one year after the date proof of loss is otherwise required, except if You were legally incapacitated. TIME OF PAYMENT OF CLAIMS Payments due under the Policy will be paid upon receipt of written proof of loss. CLAIM APPEAL PROCEDURE If We partially or fully deny a claim for benefits submitted by You, and You disagree or do not understand the reasons for this denial, You may appeal this decision. You have the right to: • Request a review of the denial; • Review pertinent plan documents; and • Submit in writing, any data, documents or comments which are relevant to Our review of this denial. Your appeal must be submitted in writing within 60 days of receiving written notice of denial. We will review all information and send written notification within 60 days of Your request.

GENERAL PROVISIONS (continued)

TX-70051-07 EM GP 3/2004 38

INCONTESTABILITY After You are insured without interruption for two years, We cannot contest the validity of Your coverage except for nonpayment of premium. The incontestability period begins with Your effective date as stated on the cover page of this Certificate. An independent incontestability period begins for each type of increase in coverage. The new incontestability period will only apply to the increased coverage. No statement made by You can be contested unless it is in a written form signed by You. A copy of the form must be given to You or Your beneficiary. FRAUD If You intentionally commit fraud against Us or Your Employer commits fraud pertaining to You against Us or You or Your Employer misrepresent material information to Us as determined by a court of competent jurisdiction, Your coverage ends automatically, subject to the Incontestability clause under this Policy. TIME LIMIT ON CERTAIN DEFENSES A claim will not be reduced or denied after two years from the effective date of the benefit because a disease or physical condition not excluded and causing the loss existed before the benefit effective date. CLERICAL ERROR, MISSTATEMENT OF AGE OR GENDER If it is determined that information about the age or gender of You or Your Dependents was omitted or misstated in error, the amount of insurance for which You are properly eligible will be in effect. An equitable premium adjustment will be made. This provision applies equally to You and to Us. DUPLICATING PROVISIONS If any charge is described as covered under two or more benefit provisions, We will pay only under the provision allowing the greater benefits. This may require Us to make a recalculation based upon both the amounts already paid and the amounts due to be paid. We have NO liability for benefits other than those the Policy provides.


TX-70051-07 EM GP 3/2004 39

WORKERS' COMPENSATION NOT AFFECTED This Plan is not issued in lieu of, nor does it affect any requirement for coverage by any Workers' Compensation or Occupational Disease Act or Law. RIGHT TO REQUEST OVERPAYMENTS We reserve the right to recover any payments made by Us that were made in error. RIGHT TO COLLECT NEEDED INFORMATION You must cooperate with Us and when asked, assist Us by: • Authorizing the release of medical information including the names of all providers from whom You

received medical attention; • Obtaining medical information and/or records from any provider as requested by Us; • Providing information regarding the circumstances of Your injury or accident; • Providing information about other insurance coverage and benefits; and • Providing information We request to administer the Policy. PHYSICAL EXAMINATION AND AUTOPSY We, at Our expense, have the right to have You examined as often as We deem reasonably necessary, but no more frequently than every three months. We may also have an autopsy performed unless prohibited by law. LEGAL ACTIONS You cannot bring an action at law or equity to recover a claim until 60 days after the date written proof of loss is made. You cannot bring such action more than two years after such proof of loss is made. ASSIGNMENT OF BENEFITS FOR LIFE COVERAGE Except for the dismemberment benefits under the Accidental Death and Bodily Injury Benefit for Covered Employees. You have the right to absolutely assign all of Your rights and interest under the Policy including, but not limited to, the following: • The right to make any contributions required to keep the insurance in force; • The privilege of converting; and • The right to name and change a beneficiary.


TX-70051-07 EM GP 3/2004 40

If an Irrevocable beneficiary has been designated, Assignment of Benefit will not be allowed. No absolute assignment of rights and interest shall be binding on Us until and unless the original or certified copy of the form documenting the absolute assignment is received and acknowledge by Us at our office. WORKER'S COMPENSATION If benefits are paid by Us and We determine You received Workers' Compensation for the same incident, We have the right to recover as described under the "Recovery Rights" provision. We will exercise Our right to recover against You. The Recovery Rights will be applied even though: • The Workers' Compensation benefits are in dispute or are made by means of settlement or

compromise; • NO final determination is made that Bodily Injury or Sickness was sustained in the course of or

resulted from Your employment; • The amount of Workers' Compensation due to medical or health care is not agreed upon or defined by

You or the Workers' Compensation carrier; or • The medical or health care benefits are specifically excluded from the Workers' Compensation

settlement or compromise. You hereby agree that, in consideration for the coverage provided by the Policy, You will notify Us of any Workers' Compensation claim You make, and that You agree to reimburse Us as described above. MODIFICATION OF POLICY The Policy may be modified at any time by agreement between Us and the Policyholder without the consent of any Covered Person or any beneficiary. No modification will be valid unless approved by Our President or Secretary. The approval must be endorsed on or attached to the Policy. No agent has authority to modify the Policy, or waive any of the Policy provisions, to extend the time of premium payment, or bind Us by making any promise or representation.


TX-70051-07 EM GP 3/2004 41

PREMIUM CONTRIBUTIONS Your Employer must pay the required premium to Us as they become due. Your Employer may require You to contribute toward the cost of Your insurance. Failure of Your Employer to pay any required premium to Us on time will result in the termination of Your insurance. GRACE PERIOD A grace period of 31 days will be allowed for payment of each premium due. If premium due is not paid within the grace period, We will cancel the insurance at the end of the grace period. All due and unpaid premium, including premium for the grace period, must be paid to Us by Your Employer.

SUPPLEMENTAL BENEFIT DEPENDENT TERM LIFE INSURANCE BENEFITS

TX-70051-07 EM DL 3/2004 42

This benefit is attached to and made a part of Your Certificate. The effective date of this change is the latter of the effective date of this Certificate or the date this benefit is added to the Policy. Except as modified below, all Policy terms, conditions, and limitations apply. The amount of the Dependent Term Life Insurance Benefit is shown on the Schedule of Benefits. In no event will the Dependent Term Life Insurance Benefit exceed 50% of the Employee Term Life Insurance amount. BENEFITS The applicable Dependent Term Life Insurance Benefit will be paid to the beneficiary subject to the terms below: • The covered Dependent dies while coverage is in force; and • Proof of death is received that the Dependent's death occurred while insured for this benefit. Dependent Term Life Insurance has no cash surrender or loan values. REDUCTION FOR AGE Reduction percentage(s) and reduction age(s), if any, are shown on the Schedule of Benefits. If the Dependent's death occurs on or after a reduction age, the amount of payment will be reduced by the corresponding reduction percentage shown. A reduction in benefits due to age is effective on the first day of the calendar month following the date the Dependent attains that age. BENEFICIARY The Employee will be paid the applicable amount of Dependent Term Life Insurance shown on the Schedule of Benefits in the event of death of one of his or her covered Dependents. If the Employee does not survive the Dependent, the applicable Dependent Term Life Insurance amount will be payable, at Our option, to one or more of the following; • Your parents; • Your children; • Your brothers and sisters; or • Your estate. We will rely upon an affidavit to determine benefit payment, unless We receive written notice of valid claim before payment is made. Payment pursuant to the affidavit will release Us from further liability.

SUPPLEMENTAL BENEFIT DEPENDENT TERM LIFE INSURANCE BENEFITS (continued)

TX-70051-07 EM DL 3/2004 43

Any payment made by Us in good faith will fully discharge Us to the extent of such payment. Any amount payable to a minor will be paid to the minor’s legal guardian. NOTICE OF DEATH No payment will be made unless We receive written proof of Your death. LIMITED BENEFITS FOR SELF-INDUCED SICKNESS, SUICIDE OR SELF-INFLICTED BODILY INJURY In the event of death caused by self-induced Sickness, suicide, or intentional self-inflicted Bodily Injury, whether sane or insane, within the first year of Your effective date under this Certificate, benefits for Voluntary Dependent Term Life Insurance will be limited to the premium paid for the Voluntary Dependent Term Life Insurance. DEPENDENT LIFE INSURANCE CONVERSION PRIVILEGE A covered Dependent may apply for a Conversion Policy of Life Insurance if the Dependent's Term Life Insurance benefit terminates because: • The Employee's employment terminates; • The Employee dies or transfers to a class of Employees not eligible for coverage under the Policy; or • The Dependent ceases to qualify as a Dependent. The amount the Dependent is entitled to apply for is the amount of Term Life Insurance in force for the Dependent under this Plan at the time coverage terminates. A covered Dependent may also apply for a Conversion Policy of Life Insurance if the Dependent Term Life Insurance benefit terminates due to a Policy amendment removing the Dependent Life Insurance Benefit or termination of the Policy, and the Dependent's Term Life Insurance has been in effect under this Plan for at least three years. The amount the covered Dependent is entitled to apply for is the lesser of: • The amount of Dependent Term Life Insurance that is terminating LESS the amount of any Life

Insurance for which that Dependent becomes eligible within 31 days after such termination; or • $10,000.


TX-70051-07 EM DL 3/2004 44

CONVERSION POLICY The Life Conversion Policy is issued without evidence of insurability. The Employee, on behalf of the covered Dependent, must apply for and pay the first premium within 31 days of the termination of the Dependent's coverage under the group Plan. The Conversion Policy will be effective on the 32nd day following such termination. The Conversion Policy will not include any Disability or Accidental Death or Bodily Injury benefits. It will be issued on any one of the policy forms, except term insurance, then being issued by Us to individuals of the same age. Premiums for the Conversion Policy will be based on Our current rate for the Policy form, amount of insurance and the covered Dependent's age on the date of issue of the Conversion Policy. DEATH DURING CONVERSION PERIOD If the covered Dependent dies during the 31 day period that he or she could have applied for a Conversion Policy, the amount of Life Insurance he or she could have converted will be paid as the death benefit, even if the Dependent had not applied for the Conversion Policy. THE FOLLOWING EXCLUSIONS ARE APPLICABLE TO VOLUNTARY TERM LIFE BENEFITS IF SHOWN ON YOUR SCHEDULE OF BENEFITS. LIMITATIONS Voluntary Term Life Benefits do not cover loss resulting from: • Self-induced Sickness, attempted suicide or intentionally self-inflicted Bodily Injury, whether sane

or insane within the first year of Your effective date. Benefits will be limited to the premium paid for this Voluntary Dependent Term Life Insurance;


inhaled as prescribed or administered by a Qualified Practitioner within the first year of Your effective date. Benefits will be limited to the premium paid for this Voluntary Dependent Term Life Insurance;



training that lasts 30 days or less;


TX-70051-07 EM DL 3/2004 45

• Bodily Injury or Sickness contributed to or caused by;

- War or any act of war, whether declared or not; or - Any act of armed conflict, or any conflict involving armed forces of any authority; or

• Participation in a riot, rebellion or insurrection. Participation means taking an active part in common with others. Riot means any use or threat to use force or violence by three or more persons without the authority of law.

Michael B. McCallister

President

SUPPLEMENTAL BENEFIT ACCIDENTAL DEATH OR BODILY INJURY BENEFIT FOR

COVERED DEPENDENT SPOUSE

GN-70051-07 EM ADDS 5/2005 46

This benefit is attached to and made a part of Your Certificate. The effective date of this change is the latter of the effective date of this Certificate or the date this benefit is added to the Policy. Except as modified below, all Policy terms, conditions, and limitations apply. Subject to the terms below, a benefit is payable for loss due to the covered Dependent Spouse's Accidental Death or Accidental Bodily Injury if shown on the Schedule of Benefits. The loss must: (a) occur within 180 days after the accident which caused the loss; and (b) be due to an accident which occurs while the covered Dependent Spouse is insured under the Benefit. If the covered Dependent Spouse suffers multiple losses in the same accident, Our liability will be limited to payment for the one type of loss which provides the greatest benefit. The amount of benefit payable for each type of loss is: LOSS BENEFIT OTHER THAN BENEFIT FOR A COMMON CARRIER COMMON ACCIDENT ACCIDENT Loss of Life Full Amount 2 Times Full Amount Loss of both hands Full Amount 2 Times Full Amount Loss of both feet Full Amount 2 Times Full Amount Loss of sight of both eyes Full Amount 2 Times Full Amount Loss of one hand and one foot Full Amount 2 Times Full Amount Loss of one hand or one foot Full Amount 2 Times Full Amount and sight of one eye Loss of one hand One-Half of the Full Amount Full Amount Loss of one foot One-Half of the Full Amount Full Amount Loss of sight of one eye One-Half of the Full Amount Full Amount Loss of thumb and index finger One-Fourth of the One-Half of the of the same hand Full Amount Full Amount


COVERED DEPENDENT SPOUSE (continued)

GN-70051-07 EM ADDS 5/2005 47

PARALYSIS BENEFIT The paralysis must be determined by a Qualified Practitioner to be permanent, complete and irreversible. LOSS BENEFIT OTHER THAN BENEFIT FOR A COMMON CARRIER COMMON ACCIDENT ACCIDENT Quadriplegia Full Amount 2 Times Full Amount Paraplegia One-half of the Full Full Amount Amount Hemiplegia One-half of the Full Full Amount Amount REDUCTION FOR AGE Reduction percentage(s) and reduction age(s), if applicable, are also shown on the Schedule of Benefits. If the covered Dependent Spouse's loss occurs on or after a reduction age is effective, the full amount shown on the Schedule of Benefits will be reduced by the corresponding reduction percentage shown. This means that if the accident occurs before the effective date of the reduction age, but the covered Dependent Spouse's loss occurs on or after the effective date of the reduction age, We will pay the benefit based on the reduced amount. A reduction age is effective on the first day of a calendar month following the date the covered Dependent Spouse attains that age. TO WHOM PAYABLE Benefits for Accidental Dismemberment, or Paralysis are payable to the Employee. Benefits for Accidental Death are payable in accordance with the Dependent Term Life Insurance Benefits provision - Beneficiary section. DEFINITIONS • ACCIDENTAL DEATH

Accidental Death means loss of life which results directly from: − Bodily Injury; − Infection caused by Bodily Injury, or infection resulting from accidental ingestion of

contaminated substances; or − Accidental drowning.



GN-70051-07 EM ADDS 5/2005 48

• ACCIDENTAL DISMEMBERMENT

Accidental Dismemberment means complete, permanent and irretrievable loss, resulting directly from Bodily Injury of: − A hand or foot by severance at or above the wrist or ankle joint; or − The sight of an eye.

• COMMON CARRIER ACCIDENT

Common Carrier Accident means a covered accident Bodily Injury that is sustained while riding as a fare-paying passenger (not a pilot, operator or crew member) in or on, boarding or getting of from a common carrier.

• COMMON CARRIER

Common Carrier means any land, air, water vehicle operated under a valid licensed to transport passengers for hire.

• QUADRIPLEGIA

Quadriplegia means total paralysis of all four limbs. • PARAPLEGIA

Paraplegia means total paralysis of both lower limbs. • HEMIPLEGIA

Hemiplegia means total paralysis of one arm and one leg on the same side of the body. SEAT BELT, AIRBAG - HELMET BENEFIT The Seat Belt, Airbag, Helmet Benefit is payable if You die as a direct result of Bodily Injury sustained in an automobile or motorcycle accident as a passenger or driver. In the event of a automobile accident the benefit is payable if: • A copy of the police report is submitted with the claim; • You were seated in a seat equipped with a properly functioning airbag; • You were wearing a properly fastened seat belt in the correct position; and • The correct position of the seat belt was certified by the investigating officer or indicated in the police

report



GN-70051-07 EM ADDS 5/2005 49

We will increase Your Accidental Death benefit by 10%, up to $10,000 but not less than $1,000 for using Your seat belt. Additionally, We will increase Your Accidental Death benefit by 5%, up to $5,000, but not less than $500 for the properly functioning airbag. In the event of a motorcycle accident the benefit is payable if: • A copy of the policy report is submitted with the claim; • You were wearing a properly fitted and fastened motorcycle helmet; and • The use of properly fitted and fastened motorcycle helmet was certified by the investigating officer or

indicated in the police report. We will increase Your Accidental Death benefit by 10%, up to $10,000, but not less than $1,000 for wearing a properly fitted and fastened motorcycle helmet. If We are unable to determine whether You had been wearing a properly fastened seat belt, seated in a seat equipped with a functioning airbag, or wearing a properly fitted and fastened motorcycle helmet. We will pay a benefit of $1,000 to Your beneficiary. We will increase Your Accidental Death benefit by 10%, up to $10,000 but not less than $1,000 for using Your seat belt. Additionally, We will increase Your Accidental Death benefit by 5%, up to $5,000, but not less than $500 for the properly functioning airbag. DEFINITIONS • AUTO Auto means a four-wheel passenger car, station wagon, sport utility vehicle, truck or van-type car. It must be licensed for use on public highways. It includes a care owned or leased by a group certificate holder. • MOTOR CYLCE Motor cycle means a two wheel passenger motorcycle. It must be licensed for use on public highways. It includes a motorcycle owed or leased by a group certificate holder. LIMITATIONS Accidental Death or Bodily Injury benefits DO NOT cover loss resulting from: • Self-induced Sickness, attempted suicide or intentionally self-inflicted Bodily Injury, whether sane


inhaled as prescribed or administered by a Qualified Practitioner;



GN-70051-07 EM ADDS 5/2005 50

• Being intoxicated or under the influence of any unlawful substance, narcotic or hallucinogenic unless


licensed passenger airline; • Commission or attempt to commit a civil or criminal battery or felony; • Driving or operating while legally intoxicated or under the influence of illegal substance.

Intoxication means that blood alcohol content or the results of other means of testing blood alcohol level meet or exceeds the legal presumption of intoxication under the law of the state where the accident took place;

• Driving or operating a motorized vehicle without a valid drivers’ license; • Driving or operating a motorized vehicle in excess of the legal speed limit; • Service in any armed forces, except if You are in temporary active duty as a reservist for military


− War or any act of war, whether declared or not; or

− Any act of armed conflict, or any conflict involving armed forces of any authority; • Bodily or mental infirmity, or its related surgical or medical treatment or any infection unless the


• Participation in a riot, rebellion or insurrection. Participation means taking an active part in common with others. Riot means any use or threat to use force or violence by three or more persons without the authority of law; or

• Participation in hazardous sports, including but not limited to: Bungee jumping, motorized vehicle racing, rock climbing, rodeo events, scuba diving, skydiving, parachuting, hang gliding, or ballooning.

Bruce Broussard President

SUPPLEMENTAL BENEFIT PORTABILITY PRIVILEGE

GN-70057-07 EM PORTE 51

This benefit is attached to and made a part of Your Certificate. The effective date of this change is the latter of the effective date of this Certificate or the date this benefit is added to the Policy. Except as modified below, all Policy terms, conditions, and limitations apply. APPLICABILITY This provision applies only to contributory Voluntary Term Life Insurance. It DOES NOT apply to any other coverages. DEFINITION As used in this provision, the term Port means to elect a continuation of Your contributory Voluntary Term Life Insurance. ELIGIBILITY TO "PORT" An Employee may elect to continue all or part of the Employee's Voluntary Term Life Insurance and Dependent Voluntary Term Life Insurance, if applicable, by electing a continuation of coverage, subject to the following terms and restrictions: • No Employee may elect to continue coverage unless the Employee has been covered by this group

Plan, or the one it replaced, for Voluntary Term Life Insurance for at least 31 consecutive days prior to the date the Employee's coverage under this Plan ends.

• The Employee is not allowed to convert coverage and elect to Port at the same time. If a situation

arises in which the Employee would be eligible to both convert and Port, he or she may only exercise one of these privileges. You may never be insured under both a converted policy and a portable certificate of coverage at the same time.

• The Employee may not Port his or her coverage, or coverage for any Dependents if the Employee

has reached his or her 70th birthday on the day his or her coverage ends under this Plan. • An Employee may not Port a Dependent spouse's coverage if the Dependent spouse has reached his

or her 70th birthday on the day his or her coverage ends under this Plan. • An Employee may not Port coverage if he or she has received a benefit under the Accelerated Death

Benefit provision. • An Employee may Port his or her coverage if coverage under this Plan ends for any reason other

than:

− Termination of employment due to Total Disability; − Failure to pay any required premium; or − The Employer terminates the Policy.

SUPPLEMENTAL BENEFIT PORTABILITY PRIVILEGE

GN-70057-07 EM PORTE 52

AMOUNT OF PORTABLE COVERAGE An Employee may Port the full amount of his or her Voluntary Term Life Insurance amount as of the day his or her coverage under this Plan ends, or any lesser amount in increments of $20,000 equal to a multiple of the Employee's basic annual compensation in force on the date employment ends. An Employee may Port the full amount of his or her Dependent Voluntary Term Life Insurance amount(s) as of the day the Employee's coverage under this Plan ends. The Employee may Port any lesser amount of Dependent Voluntary Term Life Insurance in increments of $10,000. In no event will a Dependent's amount be more than 50% of the Employee's amount. The amount of the coverage You may Port will be reduced or terminated according to the Reduction for Age Schedule, if applicable, shown on Your Schedule of Benefits. An Employee may Port: • The Employee's insurance amount only; • The Employee's insurance amount and the Dependent spouse insurance amount; • The Employee's insurance amount and insurance amount of all of the covered Dependents; or • The Employee's insurance amount and the insurance amount of the covered Dependent children. No other combinations of Ported insurance amounts will be allowed. To be eligible for portability, a Dependent must be covered as of the day the Employee's coverage under this Plan ends. THE PORTABILITY CERTIFICATE OF COVERAGE The Portability Certificate of Coverage provides group Term Life Insurance. It does not provide any other benefits. The benefits provided by the Portability Certificate of Coverage may not be identical to the benefits provided by this Plan. HOW TO PORT The Employee must apply to Us in writing, and pay the required premium to receive a Portability Certificate of Coverage. The Employee has 31 days from the date coverage under this Plan ends to apply. No proof of insurability is required.

Bruce Broussard President

Toll Free: 800-558-4444 1100 Employers Blvd. Green Bay,WI 54344 HumanaLife.com

HUMANA INSURANCE COMPANY

IMPORTANT INFORMATION ABOUT COVERAGE UNDER THE TEXAS LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION

(For insurers declared insolvent or impaired on or after September 1, 2011)

Texas law establishes a system to protect Texas policyholders if their life or health insurance company fails. The Texas Life and Health Insurance Guaranty Association (“the Association"), administers this protection system. Only the policyholders of insurance companies which are members of the Association are eligible for this protection which is subject to the terms, limitations and conditions of the Association law. (The law is found in the Texas Insurance Code, Chapter 463) IT IS POSSIBLE THAT THE ASSOCIATION MAY NOT COVER ALL OR PART OF YOUR POLICY BECAUSE OF STATUTORY LIMITATIONS.

Eligibility for Protection by the Association When a member insurance company is found to be insolvent and placed under an order of liquidation by a court or designated as impaired by the Texas Commissioner of Insurance, the Association provides coverage to policyholders who are:

• Residents of Texas (regardless of where the policyholder lived when the policy was issued); • Residents of other states, ONLY if the following conditions are met:

1. The policyholder has a policy with a company domiciled in Texas; 2. The policyholder's state of residence has a similar guaranty association; and 3. The policyholder is not eligible for coverage by the guaranty association of the

policyholder's state of residence.

Limits of Protection by the Association Accident, Accident and Health, or Health Insurance:

• For each individual covered under one or more policies: up to a total of $500,000 for basic hospital, medical-surgical, and major medical insurance, $300,000 for disability or long term care insurance, or $200,000 for other types of health insurance.

Life Insurance:

• Net cash surrender value or net cash withdrawal value up to a total of $100,000 under one or more policies on a single life; or

• Death benefits up to a total of $300,000 under one or more policies on any one life; or • Total benefits up to a total of $5,000,000 to any owner of multiple non-group life policies.

Individual Annunities:

• Present value of benefits up to a total of $250,000 under one or more contracts on any one life. Group Annunities:

• Present value of allocated benefits up to $250,000 on any one life; or • Present value of unallocated benefits up to $5,000,000 for one contractholder regardless of the

number of contracts.

Aggregate Limit:

• $300,000 on any one life with the exception of the $500,000 health insurance limit, the $5,000,000 multiple owner life insurance limit, and the $5,000,000 unallocated group annuity limit.


Insurance companies and agents are prohibited by law from using the existence of the association for the purpose of sales, solicitation, or inducement to purchase any form of insurance. When you are selecting an insurance company, you should not rely on Association coverage. For additional questions on Association protection or general information about an insurance company, please use the following contact information. Texas Life and Health Texas Department of Insurance Insurance Guaranty Association P.O. Box 149104 515 Congress Avenue, Suite 1875 Austin, Texas 78714-9104 800-982-6362 or 800-252-3439 or www.txlifega.org www.tdi.texas.gov

Notices

The following pages contain important information about Humana's claims procedures and certain federal laws. There may be differences between the Certificate of Insurance and this Notice packet. There may also be differences between this notice packet and state law. The Plan participant is eligible for the rights more beneficial to the participant. This section includes notices about: Claims and Appeal Procedures Federal Legislation Claims Procedures Appeals of Adverse Determinations

Your Rights Under ERISA Privacy and Confidentiality Statement Discrimination Notice

LIFE INSURANCE WAVIER OF PREMIUM AND SHORT TERM DISABILITY CLAIMS PROCEDURES

CLAIMS PROCEDURES Definitions Humana: Humana Insurance Company Claimant: A covered person (or authorized representative) who files a claim. Submitting a Claim This section describes how a Claimant files a claim for plan benefits. A request for a waiver of Life Insurance premium due to a total disability will be treated as a claim. A claim must be filed in writing and delivered by mail, postage prepaid, by FAX or e-mail. Claims will be not be deemed submitted for purposes of these procedures unless and until received at the correct address. Claims submissions must be in a format acceptable to Humana and compliant with any legal requirements. Claims not submitted in accordance with the requirements of applicable federal law respecting privacy of protected health information and/or electronic claims standards will not be accepted by Humana. Claims submissions must be timely. Claims must be filed as soon as reasonably possible, and in no event later than the period of time described in the benefit plan document. Claims submissions must be submitted on the claims form provided by Humana and available from your employer. The claim form must be complete. Authorized Representatives A covered person may designate an authorized representative to act on his or her behalf in pursuing a benefit claim or appeal. The authorization must be in writing and authorize disclosure of health information. If a document is not sufficient to constitute designation of an authorized representative, as determined by Humana, the plan will not consider a designation to have been made. An assignment of benefits does not constitute designation of an authorized representative. Covered persons should carefully consider whether to designate an authorized representative. Circumstances may arise under which an authorized representative may make decisions independent of the covered person, such as whether and how to appeal a claim denial. Claims Decisions Humana will provide notice of a favorable or adverse determination within a reasonable time but no later than 45 days after the plan receives the claim.

This period may be extended an additional 30 days, if Humana determines the extension is necessary due to matters beyond the plan’s control. Before the end of the initial 45-day period, Humana will notify the affected Claimant of the extension, the circumstances requiring the extension and the date by which the plan expects to make a decision. The review period may be extended for another 30 days, if before the end of the first 30-day extension, the plan determines a second extension is necessary due to matters beyond the plan’s control. Before the end of the first 30-day extension, Humana will notify the affected Claimant of the additional extension, the circumstances requiring the extension and the date by which the plan expects to make a decision. If the reason for the extension is because Humana does not have enough information to decide the claim, the notice of extension will describe the required information, and the Claimant will have at least 45 days from the date the notice is received to provide the specified information. Humana will make a decision on the earlier of the date on which the Claimant responds or the expiration of the time allowed for submission of the requested information. Initial Denial Notices Notice of a claim denial (including a partial denial) will be provided to Claimants by mail, postage prepaid, by FAX or by e-mail, as appropriate, within the time frames noted above. A claims denial notice will convey the specific reason for the adverse determination and the specific plan provisions upon which the determination is based. The notice will also include a description of any additional information necessary to perfect the claim and an explanation of why such information is necessary. The notice will disclose if any internal plan rule, protocol or similar criterion was relied upon to deny the claim. A copy of the rule, protocol or similar criterion will be provided to Claimants, free of charge, upon request. APPEALS OF ADVERSE DETERMINATIONS A Claimant must appeal an adverse determination within 180 days after receiving written notice of the denial (or partial denial). An appeal may be made by a Claimant by means of written application to Humana, in person, or by mail, postage prepaid. Determination of appeals of denied claims will be conducted promptly, will not defer to the initial determination and will not be made by the person who made the initial adverse claim determination or a subordinate of that person. On appeal, a Claimant may review pertinent documents and may submit issues and comments in writing. A Claimant on appeal may, upon request, discover the identity of medical or vocational experts whose advice was obtained on behalf of the plan in connection with the adverse determination being appealed, as permitted under applicable law. If the claims denial is based in whole, or in part, upon a medical judgment, the person deciding the appeal will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. The consulting health care professional will not be the same person who decided the initial appeal or a subordinate of that person.

Time Periods for Decisions on Appeal Appeals of claims denials will be decided and notice provided within 45 days after Humana receives the appeal request. This period may be extended an additional 45 days, if Humana determines the extension is necessary due to matters beyond the plan's control. Before the end of the initial 45-day period, Humana will notify the affected Claimant of the extension, the circumstances requiring the extension and the date by which the plan expects to make a decision. Appeals Denial Notices Notice of a claim denial (including a partial denial) will be provided to Claimants by mail, postage prepaid, by FAX or by e-mail, as appropriate, within the time periods noted above. A notice that a claim appeal has been denied will include: • The specific reason or reasons for the adverse determination. • Reference to the specific plan provision upon which the determination is based. • If any internal plan rule, protocol or similar criterion was relied upon to deny the claim. A copy of

the rule, protocol or similar criterion will be provided to the Claimant, free of charge, upon request. • A statement describing any voluntary appeal procedures offered by the plan and the claimant's right

to obtain the information about such procedures, and a statement about the Claimant's right to bring an action under ERISA.

In the event an appealed claim is denied, the Claimant will be entitled to receive without charge reasonable access to and copies of any documents, records or other information that: • Was relied upon in making the determination. • Was submitted, considered or generated in the course of making the benefit determination, without

regard to whether such document, record or other information was relied upon in making the benefit determination.

• Demonstrates compliance with the administrative processes and safeguards required in making the

determination. • Constitutes a statement of plan policy or guidance with respect to the plan concerning the denied

benefit, without regard to whether the statement was relied on in making the benefit determination. EXHAUSTION OF REMEDIES Upon completion of the appeals process under this section, a Claimant will have exhausted his or her administrative remedies under the plan. If Humana fails to complete a claim determination or appeal within the time limits set forth above, the claim shall be deemed to have been denied and the Claimant may proceed to the next level in the review process.

After exhaustion of remedies, a Claimant may pursue any other legal remedies available, which may include bringing civil action under ERISA section 502(a) for judicial review of the plan's determination. Additional information may be available from the local U.S. Department of Labor Office. LEGAL ACTIONS AND LIMITATIONS No lawsuit may be brought with respect to plan benefits until all remedies under the plan have been exhausted. No lawsuit with respect to plan benefits may be brought after the expiration of the applicable limitations period stated in the benefit plan document. If no limitation is stated in the benefit plan document, then no such suit may be brought after the expiration of the applicable limitations under applicable law. YOUR RIGHTS UNDER ERISA Under the Employee Retirement Income Security Act of 1974 (ERISA), all plan participants covered by ERISA are entitled to certain rights and protections, as described below. Notwithstanding anything in the group health plan or group insurance policy, following are a covered person’s minimum rights under ERISA. ERISA requirements do not apply to plans maintained by governmental agencies or churches. Information about the Plan and Benefits Plan participants may: 1. Examine, free of charge, all documents governing the plan. These documents are available in the

plan administrator's office. 2. Obtain, at a reasonable charge, copies of documents governing the plan, including a copy of any

updated summary plan description and a copy of the latest annual report for the plan (Form 5500), if any, by writing to the plan administrator.

3. Obtain, at a reasonable charge, a copy of the latest annual report (Form 5500) for the plan, if any, by writing to the plan administrator.

As a plan participant, you will receive a summary of any material changes made in the plan within 210 days after the end of the plan year in which the changes are made unless the change is a material reduction in covered services or benefits, in which case you will receive a summary of the material reduction within 60 days after the date of its adoption. If the plan is required to file a summary annual financial report, you will receive a copy from the plan administrator. Responsibilities of Plan Fiduciaries In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for the operation of the plan. These people, called 'fiduciaries" of the plan, have a duty to act prudently and in the interest of plan participants and beneficiaries. No one, including an employer, may discharge or otherwise discriminate against a plan participant in any way to prevent the participant from obtaining a benefit to which the participant is otherwise entitled under the plan or from exercising ERISA rights.

Claims Determinations If a claim for a plan benefit is denied or disregarded, in whole or in part, participants have the right to know why this was done, to obtain copies of documents relating to the decision without charge and to appeal any denial within certain time schedules. Enforce Your Rights Under ERISA, there are steps participants may take to enforce the above rights. For instance, if a participant requests a copy of plan documents does not receive them within 30 days, the participant may file suit in a Federal court. In such a case, the court may require the plan administrator to provide the materials and pay you up to $ 110 a day until the participant receives the materials, unless the materials were not sent because of reasons beyond the control of the plan administrator. If a claim for benefits is denied or disregarded, in whole or in part, the participant may file suit in a state or Federal court. In addition, if the participant disagrees with the plan's decision, or lack thereof, concerning the qualified status of a domestic relations order or a medical child support order, the participant may file suit in Federal court. If plan fiduciaries misuse the plan's money, or if participants are discriminated against for asserting their rights, they may seek assistance from the U.S. Department of Labor, or may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If the participant is successful, the court may order the person sued to pay costs and fees. If the participant loses, the court may order the participant to pay the costs and fees. Assistance with Questions Contact the group health plan human resources department or the plan administrator with questions about the plan. Contact the nearest area office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210 with questions about ERISA rights. Call the publications hotline of the Employee Benefits Security Administration to obtain publications about ERISA rights. PRIVACY AND CONFIDENTIALITY STATEMENT We understand the importance of keeping your personal and health information private (PHI). PHI includes both medical information and individually identifiable information, such as your name, address, telephone number or social security number. We are required by applicable federal and state law to maintain the privacy of your PHI. Under both law and our policies, we have a responsibility to protect the privacy of your PHI. We: • Protect your privacy by limiting who may see your PHI; • Limit how we may use or disclose your PHI; • Inform you of our legal duties with respect to your PHI; • Explain our privacy policies; and • Strictly adhere to the policies currently in effect. We reserve the right to change our privacy practices at any time, as allowed by applicable law, rules and regulations. We reserve the right to make changes in our privacy practices for all PHI that we maintain, including information we created or received before we made the changes. When we make a significant change in our privacy practices, we will send notice to our health plan subscribers. For more information about our privacy practices, please contact us.

As a covered person, we may use and disclose you PHI, without your consent/authorization, in the following ways: Treatment: we may disclose your PHI to a health care practitioner, a hospital or other entity which asks for it in order for you to receive medical treatment. Payment: we may use and disclose your PHI to pay claims for covered services provided to you by health care practitioners, hospitals or other entities. We may use and disclose your PHI to conduct other health care operations activities. It has always been our goal to ensure the protection and integrity of your personal and health information. Therefore, we will notify you of any potential situations where your identification would be used for reasons other than treatment, payment and health plan operations.

Discrimination is Against the Law

Humana Inc. and its subsidiaries comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. Humana Inc. and its subsidiaries do not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Humana Inc. and its subsidiaries provide: • Free auxiliary aids and services, such as qualified sign language interpreters, video remote

interpretation, and written information in other formats to people with disabilities when such auxiliary aids and services are necessary to ensure an equal opportunity to participate.

• Free language services to people whose primary language is not English when those services are

necessary to provide meaningful access, such as translated documents or oral interpretation. If you need these services, call 1-855-448-6982 or, if you use a TTY, call 711. If you believe that Humana Inc. and its subsidiaries have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Discrimination Grievances P.O. Box 14618 Lexington, KY 40512-4618 If you need help filing a grievance, call 1-855-448-6982 or if you use a TTY, call 711. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

http://www.hhs.gov/ocr/office/file/index.html

Multi-Language Interpreter Services

GN-70054-07 EM



PORTABILITY CERTIFICATE OF INSURANCE


This Certificate is not an insurance policy. It is an outline of the insurance provided by the group policy and it does not extend or change the coverage afforded by such group policy. The insurance described by this Certificate is subject to all the provisions, terms, exclusions and conditions of the group policy. This Certificate supersedes and replaces any Certificate previously issued under the provisions of the group policy.


President

GROUP INSURANCE CERTIFICATE

GN-70054-07 EM CP

POLICYHOLDER (EMPLOYER): CITY OF SCHERTZ GROUP NUMBER: 704728 BENEFITS EFFECTIVE DATE Employee Voluntary Life for Employee 01/01/2018 Dependent Voluntary Life for Employee and Covered Dependents 01/01/2018

TX-70051-07 EM Notice 3/07

IMPORTANT NOTICE To obtain information or make a complaint: You may call Humana Insurance Company's toll free telephone number for information or to make a complaint at 1-800-558-4444 You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at 1-800-252-3439 You may write the Texas Department of Insurance P.O. BOX 149104 Austin, TX 78714-9104 FAX: (512) 475-1771 WEB: http://www.tdi.state.tx.us E-mail: [email protected] PREMIUM OR CLAIM DISPUTES: Should you have a dispute concerning your premium or about a claim you should contact the company first. If the dispute is not resolved, you may contact the Texas Department of Insurance. ATTACH THIS NOTICE TO YOUR POLICY: This notice is for information only and does not become a part or condition of the attached document.

AVISO IMPORTANTE Para obtener informacion o para someter una queja: Usted puede llamar al numero de telefono gratis de Humana Insurance Company para informacion o para someter una queja al 1-800-558-4444 Puede communicarse con el Departamento de Seguros de Texas para obtener informacion acerca de companias, coberturas, derechos o quejas al 1-800-252-3439 Puede escribir al Departamento de Seguros de Texas P.O.BOX 149104 Austin, TX 78714-9104 FAX: (512) 475-1771 WEB: http://www.tdi.state.tx.us E-mail: [email protected] DISPUTAS SOBRE PRIMAS O RECLAMOS: Si tiene una disputa concerniente a su prima o a un reclamo, debe communicarse con el la compania primero. Si no se resuelve la disputa, puede entonces communicarse con el departamento (TDI). UNA ESTE AVISO A SU POLIZA: Este aviso es solo para proposito de informacion y no se convierte en parte o condicion del documento adjunto.



TABLE OF CONTENTS

GN-70054-07 EM TAB

SCHEDULE OF BENEFITS DEFINITIONS WHO IS COVERED GENERAL PROVISIONS EMPLOYEE VOLUNTARY TERM LIFE INSURANCE BENEFITS DEPENDENT VOLUNTARY TERM LIFE INSURANCE BENEFITS


GN-70054-07 EM ERSCBPORT 4

VOLUNTARY TERM LIFE INSURANCE

VOLUNTARY TERM LIFE INSURANCE BENEFIT - As shown on each Covered Person's Schedule of Benefits THE TERM LIFE INSURANCE BENEFIT IS REDUCED TO THE FOLLOWING: Reduced by 35% AT AGE 65 based on the amount of Term Life Insurance in force at age 64 Reduced by 55% AT AGE 70 based on the amount of Term Life Insurance in force at age 64 Reduced by 70% AT AGE 75 based on the amount of Term Life Insurance in force at age 64 Reduced by 80% AT AGE 80 based on the amount of Term Life Insurance in force at age 64 Reduced by 85% AT AGE 85 based on the amount of Term Life Insurance in force at age 64


GN-70054-07 EM ERSCBPORTS 5

VOLUNTARY DEPENDENT SPOUSE TERM LIFE INSURANCE

BENEFIT VOLUNTARY DEPENDENT SPOUSE TERM LIFE INSURANCE BENEFIT - As shown on each Covered Person's Schedule of Benefits THE DEPENDENT SPOUSE TERM LIFE INSURANCE BENEFIT IS REDUCED TO THE FOLLOWING: Reduced by 35% AT AGE 65 based on the amount of Term Life Insurance in force at age 64 Reduced by 55% AT AGE 70 based on the amount of Term Life Insurance in force at age 64 Reduced by 70% AT AGE 75 based on the amount of Term Life Insurance in force at age 64 Reduced by 80% AT AGE 80 based on the amount of Term Life Insurance in force at age 64 Reduced by 85% AT AGE 85 based on the amount of Term Life Insurance in force at age 64


GN-70054-07 EM ESCBPORTC 6

DEPENDENT CHILD VOLUNTARY TERM LIFE INSURANCE BENEFIT DEPENDENT CHILD VOLUNTARY - BIRTH THROUGH 14 DAYS .......................................$ 0 DEPENDENT CHILD VOLUNTARY - 15 DAYS UP TO 6 MONTHS .......................................$500 DEPENDENT CHILD VOLUNTARY - FROM AGE 6 MONTHS TO ATTAINMENT OF LIMITING AGE..............................................................................................................................................$5,000

DEFINITIONS

TX-70054-07 EM PORT 8

The following are definitions of terms as they are used in this Certificate. Defined terms are printed in bold face type wherever found in this Certificate. BODILY INJURY Bodily Injury means injury due directly to a specific accident, independent of all other causes. Muscle strain due to athletic or physical activity or bodily damage resulting from infection, is considered a Sickness. COVERED PERSON Covered Person means the Employee and/or the Employee's covered Dependents. DEPENDENT Dependent means a covered Employee's: • Legally recognized spouse; or • Unmarried natural blood related child, step-child, legally adopted child or child placed with

the Employee for the purpose of adoption whose age is less than the limiting age. Dependent DOES NOT mean a grandchild, great grandchild, or foster child. Each child must:

− Meet all of the qualifications of a Dependent as determined by the Internal Revenue

Service; and

− Be declared on and legally qualify as a Dependent on the Employee's federal personal income tax return filed for each year of coverage.

The limiting age for each Dependent child is: • The child's 26th birthday; or • The child's 26th birthday if such child is in regular full-time attendance at an accredited

secondary school, college or university. The Dependent child must be enrolled for sufficient course credits to maintain full-time status as defined by that school. A Dependent child continues to be eligible for coverage for up to four months following the close of a school term only if enrolled as a full-time student for the following school term.

You must furnish satisfactory proof to Us upon Our request that the above conditions continuously exist. If satisfactory proof is not submitted to Us, the child's coverage will not continue beyond the last date of eligibility. A covered Dependent child who becomes an employee eligible for other group coverage through employment is no longer eligible as a Dependent for coverage under this Policy.


TX-70054-07 EM PORT 9

A covered Dependent child who attains the limiting age WHILE INSURED under this Policy remains eligible for Benefits if: • Mentally retarded or permanently physically handicapped; • Incapable of self-sustaining employment; • The child meets all of the qualifications of a Dependent as determined by the Internal

Revenue Service; • Declared on and legally qualified as a Dependent on the Employee's federal personal

income tax return filed for each year of coverage; and • Unmarried. You must furnish satisfactory proof to Us upon Our request that the above conditions continuously exist on and after the date the limiting age is reached. After two years from the date the first proof was furnished, We may not request such proof more often than annually. If satisfactory proof is not submitted to Us, the child's coverage will not continue beyond the last date of eligibility. EMPLOYEE Employee means a person who chose to Port his or her Employee Voluntary Term Life Insurance coverage. EMPLOYER Employer means the Policyholder of this Group Insurance Plan, or any subsidiary described in the Employer Group Application. POLICYHOLDER The Legal Entity named as the Policyholder on the face page of the Policy. PORT Port means to elect a continuation of Your contributory Voluntary Term Life Insurance. PRIOR PLAN Prior Plan means the group life insurance Policy, issued by Us, from which You Ported coverage to this Plan.


TX-70054-07 EM PORT 10

QUALIFIED PRACTITIONER Qualified Practitioner means a practitioner, professionally licensed by the appropriate state agency to diagnose or treat a Bodily Injury or Sickness, and who provides services within the scope of that license. A Qualified Practitioner does not include a practitioner who resides in Your home or is Your Family Member. SICKNESS Sickness means a disturbance in function or structure of Your body which causes physical signs or symptoms which, if left untreated, will result in a deterioration of the health state of the structure or system(s) of Your body. WE, US, and OUR We, Us, and Our means the Insurance Company as shown on the cover page of this Certificate. YOU and YOUR You and Your means any Covered Person.

WHO IS COVERED WHO IS ELIGIBLE FOR COVERAGE The Employee is eligible for coverage if covered under the Employer's plan, and the Employee is under the age of 70 years. The Employee's Dependents are covered if they were covered under the Employer's plan and the Employee applied and paid premium to Port the Dependent coverage. No other persons may become covered under this Plan after the Effective Date, except for the following: • The Employee's newborn child; or • A child legally adopted by the Employee or a child placed in the Employee's home for the

purpose of adoption by the Employee. If You wish to enroll the newborn child, the adopted child or the child placed for adoption, You must enroll the child within 31 days from the date of birth, date of adoption or date of placement for adoption, as applicable, and pay any required premium. Refer to Your Schedule of Benefits for benefits available.

WHO IS COVERED (continued)

TX-70054-07 EM PORT 11

EFFECTIVE DATE The Employee must complete and sign an enrollment form. This must be done within the time period allowed to Port under the Employer's plan. The enrollment form and the premium must be received by Us for coverage to be in effect. In no event will coverage be in effect before the enrollment form and premium are received by Us and the enrollment form is accepted by Us. If We accept the enrollment form, Your coverage is in effect on the day immediately following the date Your coverage terminated under the Employer's plan. PREMIUM You must pay premium for this insurance. Premium must be paid on or before the first day of each premium period. Premium period means a annual basis. Premium must be received by Us to be considered paid. Coverage is in effect until the next premium due date. If We accept premium from You immediately prior to or after a date Your coverage would otherwise terminate, You are covered until the end of the period for which premium is paid. You have the right to cancel this coverage before that date. You will be refunded any unused premium up to the cancellation date. GRACE PERIOD If You do not pay Your premium on or before the premium due date, You have a Grace Period to pay it. The Grace Period is 31 days immediately following the premium due date. You are insured during the Grace Period. If You do not pay the premium before the end of the 31 days, Your coverage terminates at the end of the Grace Period. If You die during the Grace Period and You do not pay the premium, the amount of premium will be deducted from the benefits payable. The Grace Period does not apply if You write Us at least 15 days before a premium due date that You are canceling coverage. WHEN COVERAGE TERMINATES Your coverage automatically terminates on the earliest of the following: • The last day of the period of time for which You paid premium, subject to the Grace Period; • For a Dependent, the date that person no longer satisfies the definition of Dependent in this

certificate; • For a Dependent Spouse, the date they attain the age of 70 years; • The date the Employee attains the age of 70 years; • The date the Employee becomes re-employed with the Employer; • For a Dependent, the date that the Employee's coverage ends;

WHO IS COVERED (continued)

TX-70054-07 EM PORT 12

• The date You enter full-time military, naval or air service except that termination will not occur if You are in temporary active duty as a reservist for military training that lasts 30 days or less;


Dependents; • The date the Employer's Policy terminates; or • The date the Employer terminates the Portability Provision. YOU ARE RESPONSIBLE TO ADVISE US OF ANY CHANGES IN ELIGIBILITY INCLUDING THE LACK OF ELIGIBILITY OF ANY COVERED PERSON. COVERAGE WILL NOT CONTINUE BEYOND THE LAST DATE OF ELIGIBILITY REGARDLESS OF THE LACK OF NOTICE TO US.

GENERAL PROVISIONS Written notice of claim must be given within 30 days after the date of loss covered by this Policy, or as soon thereafter as is reasonably possible. Notice may be given at Our address shown on the back cover of the Certificate. Notice should include Your name and the name(s) of Your Dependent(s) and Your Policy number. CLAIM FORMS Upon receipt of notice of claim, We will send You the forms for filing proof of loss. If the forms are not sent to You within 15 days, You will have met the proof of loss requirement by sending Us a written statement of the nature and extent of the loss within the time limit stated in the Proof of Loss provision. PROOF OF LOSS You must give written proof of loss within 91 days after the date of loss. Your claim will not be reduced or denied if it was not reasonably possible to give such proof. In any event, written notice must be given within one year after the date proof of loss is otherwise required, except if You were legally incapacitated. TIME OF PAYMENT OF CLAIMS Payments due under the Policy will be paid immediately upon receipt of written proof of loss.


TX-70054-07 EM PORT 13

INCONTESTABILITY After You are insured without interruption for two years, We cannot contest the validity of Your coverage except for nonpayment of premium. The incontestability period begins with Your effective date as stated on the cover page of this Certificate. An independent incontestability period begins for each type of increase in coverage. The new incontestability period will only apply to the increased coverage. No statement made by You can be contested unless it is in a written form signed by You. A copy of the form must be given to You or Your beneficiary. TIME LIMIT ON CERTAIN DEFENSES A claim will not be reduced or denied after two years from the effective date of the benefit because a disease or physical condition not excluded and causing the loss existed before the benefit effective date. CLERICAL ERROR, MISSTATEMENT OF AGE OR SEX If it is determined that information about You or Your Dependents was omitted or misstated in error, the amount of insurance for which You are properly eligible will be in effect. An equitable premium adjustment will be made. This provision applies equally to You and to Us. RIGHT TO COLLECT NEEDED INFORMATION You must cooperate with Us and when asked, assist Us by: • Authorizing the release of medical information including the names of all providers from

whom You received medical attention; • Providing information regarding the circumstances of Your injury or accident; and • Providing information about other insurance coverage and benefits. PHYSICAL EXAMINATION AND AUTOPSY We, at Our expense, have the right to have You examined as often as We deem reasonably necessary, but no more frequently than every three months. We may also have an autopsy performed unless prohibited by law.


TX-70054-07 EM PORT 14

LEGAL ACTIONS You cannot bring an action at law or equity to recover a claim until 60 days after the date written proof of loss is made. You cannot bring such action more than two years after such proof of loss is made. CONFORMITY WITH STATE STATUTES Any provisions which, on the Policy effective date, are in conflict with the laws of the state in which the Policy is issued are amended to conform to the minimum requirements of those laws. ASSIGNMENT OF BENEFITS FOR LIFE COVERAGE You have the right to absolutely assign all of Your rights and interest under the Policy including, but not limited to, the following: • The right to make any contributions required to keep the insurance in force; • The privilege of converting; and • The right to name and change beneficiary. If an Irrevocable beneficiary has been designated, Assignment of Benefit will not be allowed. No absolute assignment of rights and interest shall be binding on Us until and unless the original or certified copy of the form documenting the absolute assignment is received and acknowledge by Us at our office. We have no responsibility: • For the validity or effect of any assignment; or • To provide any assignee with notice which We may be obligated to provide You. ENTIRE CONTRACT CHANGES The Policy, including any endorsements and attached papers, constitutes the entire contract of insurance. No change in the Policy is valid until approved by an executive officer of Our company and unless such approval is endorsed or attached to the Policy. No agent has the authority to change the Policy or to remove any of its provisions. UNPAID PREMIUMS Upon the payment of a claim under the Policy, any premium then due and unpaid or covered by any note or written order, may be deducted from the claim payment.


TX-70054-07 EM PORT 15

UNEARNED PREMIUM Upon Your death, the proceeds payable to You or Your estate, shall include premiums paid for any period beyond the end of the Policy-month in which the death occurred.

EMPLOYEE VOLUNTARY TERM LIFE INSURANCE BENEFITS

TX-70054-07 EM EPORT 16

BENEFIT The amount of Your Voluntary Term Life Insurance benefit is shown on the Schedule of Benefits. Subject to the terms below, a payment in this amount will be made to the beneficiary named by You. Payment is made when We receive proof that Your death occurred while insured for this benefit. The Voluntary Term Life Insurance has no cash surrender or loan values. REDUCTION FOR AGE Reduction percentage(s) and reduction age(s), if any, are shown on the Schedule of Benefits. If Your death occurs on or after a reduction age, the amount of payment will be reduced by the corresponding reduction percentage shown. A reduction in benefits due to age is effective on the first day of the calendar month following the date You attain that age. BENEFICIARY You may name any beneficiary You choose. You may also change a named beneficiary at any time by notifying Us in writing. The change will be effective on the date You sign the form. If We make a payment before receiving the change form, We are released from further liability to the extent of the payment. If a payment is to be made to two or more beneficiaries, but You have not specified the portions payable to each, the payment will be shared equally. If You have not named a beneficiary, or if the beneficiary You named is not alive at Your death, the payment will be made, at Our option, to any one or more of the following: • Your spouse; • Your children; • Your parents; • Your brothers and sisters; or • Your estate. We will rely upon an affidavit to determine benefit payment, unless We receive written notice of valid claim before payment is made. Payment pursuant to the affidavit will release Us from further liability. Any payment made by Us in good faith will fully discharge Us to the extent of such payment. Any amount payable to a minor will be paid to the minor's legal guardian.

EMPLOYEE VOLUNTARY TERM LIFE INSURANCE BENEFITS (continued)

TX-70054-07 EM EPORT 17

NOTICE OF DEATH No payment will be made unless We receive written proof of Your death. If a death claim is filed while the Waiver of Premium is in effect, proof of continuous Total Disability must accompany the death claim. LIMITED BENEFITS FOR SELF-INDUCED SICKNESS, SUICIDE, OR SELF-INFLICTED BODILY INJURY In the event of death caused by self-induced Sickness, suicide or intentional self-inflicted Bodily Injury, whether sane or insane, within the first year of Your effective date of Voluntary Term Life coverage under Your Employer's plan, benefits will be limited to the premium paid for this Employee Voluntary Term Life Insurance. LIMITATIONS Benefits do not cover loss resulting from: • Self-induced Sickness, attempted suicide or intentionally self-inflicted Bodily Injury, whether sane

or insane, within the first year of Your effective date of Voluntary Term Life coverage under Your Employer's plan. Benefits will be limited to the premium paid for this Employee Voluntary Term Life Insurance;

• The voluntary taking of any sedative or drug or alcohol or inhalation of any gas unless taken or

inhaled as prescribed or administered by a Qualified Practitioner within the first year of Your effective date of Voluntary Term Life coverage under Your Employer's plan. Benefits will be limited toe the premium paid for this Employee Voluntary Term Life Insurance;





− Any act of armed conflict, or any conflict involving armed forces of any authority; or • Participation in a riot, rebellion or insurrection. Participation means taking an active part in common with others. Riot means any use or threat to use force or violence by three or more persons without the authority of law.

EMPLOYEE VOLUNTARY TERM LIFE INSURANCE BENEFITS (continued)

TX-70054-07 EM EPORT 18

EMPLOYEE LIFE INSURANCE CONVERSION PRIVILEGE The Employee is entitled to apply for a Conversion Policy of Life Insurance if insurance which has been continued under this section of the Employer's policy terminates or the Employer terminates the Portability Provision. The amount the Employee is entitled to apply for is the lesser of: • The amount of Employee Term Life Insurance that is terminating, LESS the amount of any Life


• $10,000. CONVERSION POLICY The Conversion Policy is issued without evidence of insurability. The Employee must apply for and pay the first premium within 31 days of the termination of the Employee's coverage under the Group Plan. The Conversion Policy will be effective on the 32nd day following such termination. It will be issued on any one of the policy forms, except term insurance, then being issued by Us to individuals of the same age. Premiums for the Conversion Policy will be based on Our current rate for the form, amount of insurance and the Employee's age on the date of issue of the Conversion Policy. DEATH DURING CONVERSION PERIOD If the Employee dies during the 31 day period that he or she could have applied for a Conversion Policy, the amount of Life Insurance the Employee could have converted will be paid as the death benefit, even if the Employee had not applied for the Conversion Policy.

DEPENDENT VOLUNTARY TERM LIFE INSURANCE BENEFITS

TX-70054-07 EM DL.PORT 19

The amount of the Dependent Voluntary Term Life Insurance Benefit is shown on the Schedule of Benefits. In no event will the Dependent Term Life Insurance Benefit exceed 50% of the Employee Term Life Insurance amount. BENEFITS The applicable Dependent Voluntary Term Life Insurance Benefit will be paid to the beneficiary subject to the terms below: • The covered Dependent dies while coverage is in force; and • Proof of death is received that the Dependent's death occurred while insured for this benefit. Dependent Voluntary Term Life Insurance has no cash surrender or loan values. REDUCTION FOR AGE Reduction percentage(s) and reduction age(s), if any, are shown on the Schedule of Benefits. If Your death occurs on or after a reduction age, the amount of payment will be reduced by the corresponding reduction percentage shown. A reduction in benefits due to age is effective on the first day of the calendar month following the date You attain that age. BENEFICIARY The Employee will be paid the applicable amount of Dependent Voluntary Term Life Insurance shown on the Schedule of Benefits in the event of death of one of his or her covered Dependents. If the Employee does not survive the Dependent, the applicable Dependent Voluntary Term Life Insurance amount will be payable, at our option, to one or more of the following; • Your parents; • Your children; • Your brothers and sisters; or • Your estate. We will rely upon an affidavit to determine benefit payment, unless We receive written notice of valid claim before payment is made pursuant to the affidavit will release Us from further liability. Any payment made by Us in good faith will fully discharge Us to the extent of such payment. Any amount payable to a minor will be paid to the minor's legal guardian.

DEPENDENT VOLUNTARY TERM LIFE INSURANCE BENEFITS (continued)


NOTICE OF DEATH No payment will be made unless We receive written proof of death. LIMITED BENEFITS FOR SELF-INDUCED SICKNESS, SUICIDE OR SELF-INFLICTED BODILY INJURY In the event of death caused by self-induced Sickness, suicide or self-inflicted Bodily Injury, whether sane or insane, within the first year of Your effective date of Dependent Voluntary Life coverage under the Employer's plan, benefits will be limited to the premium paid for this Dependent Voluntary Life insurance. LIMITATIONS Voluntary Life Benefits do not cover loss resulting from: • Self-induced Sickness, attempted suicide or intentionally self-inflicted Bodily Injury, whether sane

or insane within the first year of Your effective date of Dependent Voluntary Term Life coverage under the Employer's plan. Benefits will be limited to the premium paid for this Dependent Voluntary Term Life Insurance;


inhaled as prescribed or administered by a Qualified Practitioner within the first year of Your effective date of Dependent Voluntary Term Life coverage under the Employer's plan. Benefits will be limited to the premium paid for this Dependent Voluntary Term Life Insurance;


licensed passenger airline; • Service in any armed forces except if You are in temporary active duty as a reservist for military



− Any act of armed conflict, or any conflict involving armed forces of any authority; or • Participation in a riot, rebellion or insurrection. Participation means taking an active part in common with others. Riot means any use or threat to use force or violence by three or more persons without the authority of law.

DEPENDENT VOLUNTARY TERM LIFE INSURANCE BENEFITS (continued)


DEPENDENT LIFE INSURANCE CONVERSION PRIVILEGE The Dependent is entitled to apply for a Conversion Policy of Life Insurance if: • Insurance which has been continued under this section of the Employer's Policy terminates; • The Employer terminates the Portability Provision; • The Employee dies; or • The Dependent ceases to qualify as a Dependent or reaches the limiting age. The amount the Dependent is entitled to apply for is the lesser of: • The amount of Dependent Voluntary Term Life Insurance that is terminating, LESS the amount of

any Life Insurance for which he or she becomes eligible under any group coverage within 31 days after such termination; or

• $10,000. CONVERSION POLICY The Conversion Policy is issued without evidence of insurability. The Employee, on behalf of the covered Dependent, must apply for and pay the first premium within 31 days of the termination of the Dependent's coverage under the Group Plan. The Conversion Policy will be effective on the 32nd day following such termination. It will be issued on any one of the policy forms, except term insurance, then being issued by Us to individuals of the same age. Premiums for the Conversion Policy will be based on Our current rate for the form, amount of insurance and the Dependent's age on the date of issue of the Conversion Policy. DEATH DURING CONVERSION PERIOD If the Dependent dies during the 31 day period that he or she could have applied for a Conversion Policy, the amount of Life Insurance the Dependent could have converted will be paid as the death benefit, even if the Dependent had not applied for the Conversion Policy.










Life Insurance:







Aggregate Limit:




Notices



on CITY OF SCHERTZ Presented by

ZAN TERRY10999 IH-10 WSTE 700SAN ANTONIO TX 78230-1349210-638-7964

10/16/2018

CITY OF SCHERTZ Monthly Experience Summary

Policy #: 46433 01/01/2018 through 09/30/2018

LOB Month Premium $ Paid Claims $ Paid L/R EE Lives Dep Units

VIS Sep 2018 -$3,092 $2,936 -95% 330 105VIS Aug 2018 $3,219 $2,478 77% 328 107VIS Jul 2018 $3,213 $2,514 78% 1 1VIS Jun 2018 $3,184 $3,827 120% 323 107VIS May 2018 $1,804 $3,757 208% 319 107VIS Apr 2018 $5,730 $2,704 47% 314 107VIS Mar 2018 $4,395 $1,493 34% 124 46VIS Feb 2018 $3,855 $1,685 44% 316 109VIS Jan 2018 $0 $0 0% 193 64

TOTAL$22,308 $21,393 2,248 753

Paid Claims : $21,393 Change in Reserves: $0 = Incurred Claims: $21,393 ** Incurred Claims = Paid Claims + Change in Reserves

on CITY OF SCHERTZ Presented by

ZAN TERRY10999 IH-10 WSTE 700SAN ANTONIO TX 78230-1349210-638-7964

10/16/2018

CITY OF SCHERTZ Monthly Experience Summary

Policy #: 46433 01/01/2018 through 09/30/2018

LOB Month Premium $ Paid Claims $ Paid L/R EE Lives Dep Units

DEN Sep 2018 -$10,466 $7,858 -75% 320 113DEN Aug 2018 $11,089 $9,412 85% 318 114DEN Jul 2018 $11,269 $6,968 62% 1 1DEN Jun 2018 $11,408 $8,152 71% 313 113DEN May 2018 $6,491 $10,528 162% 309 114DEN Apr 2018 $20,491 $13,352 65% 1 0DEN Mar 2018 $15,947 $12,532 79% 123 51DEN Feb 2018 $13,933 $6,749 48% 307 115DEN Jan 2018 $0 $3,071 0% 185 65

TOTAL$80,162 $78,622 1,877 686

Paid Claims : $78,622 Change in Reserves: $0 = Incurred Claims: $78,622 ** Incurred Claims = Paid Claims + Change in Reserves

AMERITAS LIFE INSURANCE CORP.

Large Claimant Report - CITY OF SCHERTZ (704728) Claims Incurred 7/1/2016 - 6/30/2017 Claims Processed through 9/30/2018

Report Selection Criteria

Report Create Date: 10/22/2018

Report Type: Incurred

Line Of Business: PPO

Customer Groups: All Selected

Funding Type: Fully-Insured

Divisions: All Selected

Benefits: All Selected

Claim Spend Threshold: $15,000

1 of 6Prepared by BISS - Enterprise Performance Analytics on 10/22/2018Humana Confidential and Proprietary

Member #Relation to Subscriber Status Primary MCC Primary Diagnosis Medical Paid Rx Paid Total Paid

Clinical PGM

Member # 0001 SELF Active Musculoskeletal and Connective Tissue OTHER SPONDYLOSIS WITH RADICULOPATHY, LUMBOSACRAL REGION $102,523 $1,162 $103,685

Member # 0002 SELF Active Other/Unclassified $849 $84,641 $85,490 PN

Member # 0003 SELF Active Musculoskeletal and Connective Tissue OTHER SPONDYLOSIS WITH RADICULOPATHY, CERVICAL REGION $82,922 $0 $82,922

Member # 0004 SELF Active Other Heart Disease NONRHEUMATIC AORTIC (VALVE) STENOSIS $77,111 $4,276 $81,387 CC

Member # 0005 SELF Active Other Heart Disease SUPRAVENTRICULAR TACHYCARDIA $73,957 $6,191 $80,148 CC,PN

Member # 0006 SELF Active Digestive $22,029 $39,257 $61,286 PN

Member # 0007 SPOUSE Active Digestive DIVERTICULITIS OF LARGE INTESTINE WITH PERFORATION AND ABSCESS WITH BLEEDING $56,308 $1,906 $58,214

Member # 0008 SELF Active Rare Diseases $21,863 $35,523 $57,385

Member # 0009 CHILD Active Digestive ACUTE APPENDICITIS WITH LOCALIZED PERITONITIS $37,919 $963 $38,882

Member # 0010 SELF Active Diseases of Skin and Subcutaneous Tissue $212 $36,436 $36,648

Member # 0011 SELF Active Malignant Neoplasms CARCINOMA IN SITU OF ENDOCERVIX $33,998 $23 $34,021

Member # 0012 SELF Active Genitourinary System $21,174 $11,592 $32,766

Member # 0013 SELF Active Digestive NONINFECTIVE GASTROENTERITIS AND COLITIS, UNSPECIFIED $24,707 $6,841 $31,548

Member # 0014 SELF Active Other Circulatory ABNORMAL RESULT OF OTHER CARDIOVASCULAR FUNCTION STUDY $27,473 $0 $27,473

Member # 0015 SPOUSE Active Genitourinary System HYDRONEPHROSIS WITH RENAL AND URETERAL CALCULOUS OBSTRUCTION $26,692 $0 $26,692

Member # 0016 SELF Active Malignant Neoplasms MALIGNANT NEOPLASM OF CERVIX UTERI, UNSPECIFIED $25,302 $570 $25,872

Member # 0017 SELF Termed Diabetes TYPE 2 DIABETES MELLITUS WITH DIABETIC POLYNEUROPATHY $16,499 $8,308 $24,807

Member # 0018 SELF Active Neoplasms (Benign) BENIGN NEOPLASM OF DESCENDING COLON $20,513 $4,164 $24,677

Member # 0019 SPOUSE Active Chronic Kidney Disease END STAGE RENAL DISEASE $13,304 $9,784 $23,088

Member # 0020 SELF Termed Digestive ACUTE PANCREATITIS, UNSPECIFIED $19,522 $2,613 $22,135

Members with Total Paid of $15,000 and Greater

CITY OF SCHERTZ (704728)

LARGE CLAIMANT REPORT by Incurred DateClaims Incurred 7/1/2016 through 6/30/2017

Claims Processed through 9/30/2018

ASO_IND = NO Line Of Business = PPO



Clinical PGM

Member # 0021 CHILD Active Endocrine $6,747 $12,862 $19,608

Member # 0022 SELF Active Musculoskeletal and Connective Tissue SPINAL STENOSIS, LUMBAR REGION $17,192 $1,532 $18,724

Member # 0023 SELF Active Injury and Poisoning SPRAIN OF ANTERIOR CRUCIATE LIGAMENT OF RIGHT KNEE, INITIAL ENCOUNTER $17,334 $1,235 $18,569

Member # 0024 SELF Active Musculoskeletal and Connective Tissue CERVICAL DISC DISORDER AT C5-C6 LEVEL WITH MYELOPATHY $17,162 $0 $17,162

Member # 0025 SELF Active Digestive ESOPHAGEAL OBSTRUCTION $13,517 $3,619 $17,136

Member # 0026 SPOUSE Active Endocrine HYPOTHYROIDISM, UNSPECIFIED $15,012 $1,595 $16,607

Member # 0027 CHILD Active Digestive OTHER SPECIFIED DISEASES OF GALLBLADDER $14,571 $1,732 $16,303

Member # 0028 SELF Active Digestive CALCULUS OF GALLBLADDER WITH CHRONIC CHOLECYSTITIS WITHOUT OBSTRUCTION $16,243 $0 $16,243

Member # 0029 SPOUSE Active Genitourinary System OTHER SPECIFIED CONDITIONS ASSOCIATED WITH FEMALE GENITAL ORGANS AND MENSTRUAL CYCLE $14,888 $152 $15,040



Clinical PGM

Member # 0001 SPOUSE Active Diseases of Skin and Subcutaneous Tissue $14,774 $67,481 $82,255 PN

Member # 0002 SELF Active Musculoskeletal and Connective Tissue CERVICAL DISC DISORDER AT C4-C5 LEVEL WITH MYELOPATHY $63,546 $409 $63,955

Member # 0003 SELF Active Coronary Artery Disease ST ELEVATION (STEMI) MYOCARDIAL INFARCTION INVOLVING OTHER CORONARY ARTERY OF ANTERIOR WALL $57,976 $3,556 $61,532

Member # 0004 SELF Termed Other/Unclassified $359 $52,912 $53,270

Member # 0005 CHILD Active Endocrine $21,002 $31,657 $52,658 PN

Member # 0006 SELF Active Diseases of Skin and Subcutaneous Tissue $724 $46,713 $47,436

Member # 0007 SELF Active Coronary Artery Disease ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITH UNSTABLE ANGINA PECTORIS $44,586 $1,752 $46,338

Member # 0008 SELF Active Coronary Artery Disease ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS $45,263 $1,004 $46,267

Member # 0009 SELF Active Digestive $4,993 $33,308 $38,301

Member # 0010 SELF Active Respiratory OTHER SPECIFIED DISORDERS OF NOSE AND NASAL SINUSES $27,144 $53 $27,197

Member # 0011 CHILD Active Digestive VOMITING, UNSPECIFIED $20,671 $2,752 $23,423

Member # 0012 CHILD Active Injury and Poisoning DISPLACED COMMINUTED SUPRACONDYLAR FRACTURE WITHOUT INTERCONDYLAR FRACTURE OF LEFT HUMERUS, INITIAL ENCOUNTER FOR CLOSED FRACTURE

$21,700 $0 $21,700

Member # 0013 SPOUSE Termed Neoplasms (Benign) LEIOMYOMA OF UTERUS, UNSPECIFIED $20,341 $384 $20,725

Member # 0014 SELF Active Rare Diseases $145 $18,846 $18,991

Member # 0015 SPOUSE Active Exams and Preventive Services ENCOUNTER FOR SCREENING FOR MALIGNANT NEOPLASM OF COLON $17,554 $1,126 $18,680

Member # 0016 SELF Active Diseases of Skin and Subcutaneous Tissue $8,191 $9,800 $17,990

Member # 0017 SELF Active Coronary Artery Disease ST ELEVATION (STEMI) MYOCARDIAL INFARCTION INVOLVING OTHER SITES $17,734 $0 $17,734

Member # 0018 SELF Active Nervous System OTHER ACUTE POSTPROCEDURAL PAIN $16,945 $0 $16,945










Clinical PGM

Member # 0021 SELF Active Other Circulatory ESSENTIAL (PRIMARY) HYPERTENSION $9,175 $6,064 $15,239



Clinical PGM

Member # 0001 SELF Active Musculoskeletal and Connective Tissue UNILATERAL PRIMARY OSTEOARTHRITIS, LEFT KNEE $41,183 $129 $41,311







TX-70051-07 EM COVER



CERTIFICATE OF INSURANCE


This Certificate is not an insurance policy. It is an outline of the insurance provided by the group policy and it does not extend or change the coverage afforded by such group policy. The insurance described by this Certificate is subject to all the provisions, terms, exclusions and conditions of the group policy. This Certificate supersedes and replaces any Certificate previously issued under the provisions of the group policy. THE DEATH BENEFIT IN FORCE UNDER THE POLICY WILL BE REDUCED IF ACCELERATED BENEFIT ARE PAID. The Accelerated Benefits offered in this Certificate may or may not qualify for favorable tax treatment under the Internal Revenue Code of 1986. Whether such benefits qualify depends on factors such as your life expectancy at the time benefits are accelerated or whether you use the benefits to pay for necessary long-term care expenses, such as nursing home care. If the Accelerated Benefit qualifies for such favorable tax treatment, the benefits will be excludable from your income and not subject to federal taxation. Tax laws relating to Accelerated Benefits are complex. You are advised to consult with a qualified tax advisor about circumstances under which you could receive Accelerated Benefits excludable from income under federal law. Receipt of Accelerated Benefits may affect you, your spouse or your family’s eligibility for public assistance programs such as medical assistance (Medicaid), Aid to Families with Dependent Children (AFDC), supplemental Social Security Income (SSI) and drug assistance programs. You are advised to consult with a qualified tax advisor and with social service agencies concerning how receipt of such payment will affect you, your spouse and your family’s eligibility for public assistance.

Michael B. McCallister President

TX-70051-07 EM Notice 3/07

POLICYHOLDER (EMPLOYER): CITY OF SCHERTZ GROUP NUMBER: 704728 BENEFITS EFFECTIVE DATE BASIC TERM LIFE COVERAGE for Employee 01/01/2018 ACCIDENTAL DEATH AND BODILY INJURY COVERAGE for Employee 01/01/2018 DEPENDENT LIFE COVERAGE for covered dependents 01/01/2018

IMPORTANT NOTICE To obtain information or make a complaint: You may call Humana Insurance Company's toll free telephone number for information or to make a complaint at 1-800-558-4444 You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at 1-800-252-3439 You may write the Texas Department of Insurance P.O. BOX 149104 Austin, TX 78714-9104 FAX: (512) 475-1771 WEB: http://www.tdi.state.tx.us E-mail: [email protected] PREMIUM OR CLAIM DISPUTES: Should you have a dispute concerning your premium or about a claim you should contact the company first. If the dispute is not resolved, you may contact the Texas Department of Insurance. ATTACH THIS NOTICE TO YOUR POLICY:

AVISO IMPORTANTE Para obtener informacion o para someter una queja: Usted puede llamar al numero de telefono gratis de Humana Insurance Company para informacion o para someter una queja al 1-800-558-4444 Puede communicarse con el Departamento de Seguros de Texas para obtener informacion acerca de companias, coberturas, derechos o quejas al 1-800-252-3439 Puede escribir al Departamento de Seguros de Texas P.O.BOX 149104 Austin, TX 78714-9104 FAX: (512) 475-1771 WEB: http://www.tdi.state.tx.us E-mail: [email protected] DISPUTAS SOBRE PRIMAS O RECLAMOS: Si tiene una disputa concerniente a su prima o a un reclamo, debe communicarse con el la compania primero. Si no se resuelve la disputa, puede entonces communicarse con el departamento (TDI). UNA ESTE AVISO A SU POLIZA: Este aviso es solo para proposito de informacion y no se convierte en parte o condicion del documento




adjunto.

TABLE OF CONTENTS

GN-70051-07 EM TAB

PAGE NUMBER

SCHEDULE OF BENEFITS...................................................................................................... 3 DEFINITIONS........................................................................................................................... 6 ELIGIBILITY AND EFFECTIVE DATE OF INSURANCE.................................................... 10 TERMINATION OF COVERAGE .......................................................................................... 14 EMPLOYEE TERM LIFE INSURANCE BENEFITS.............................................................. 16 WAIVER OF PREMIUM......................................................................................................... 19 ACCIDENTAL DEATH OR BODILY INJURY BENEFIT FOR COVERED EMPLOYEES.. 21 ACCELERATED BENEFITS .................................................................................................. 30 GENERAL PROVISIONS ....................................................................................................... 34 DEPENDENT TERM LIFE INSURANCE BENEFITS............................................................ 39


GN-70051-07 EM ERSCB 3

EMPLOYEE BASIC TERM LIFE INSURANCE BASIC TERM LIFE INSURANCE BENEFIT: $25,000 Amount of coverage x Salary (rounded to the next highest $1,000) Class % Salary Benefit Amount THE BASIC TERM LIFE INSURANCE BENEFIT IS REDUCED TO THE FOLLOWING FOR YOUR EMPLOYEES: Reduced by 35% AT AGE 65 based on the amount of Basic Term Life Insurance in force at age 64 Reduced by 55% AT AGE 70 based on the amount of Basic Term Life Insurance in force at age 64 Reduced by 70% AT AGE 75 based on the amount of Basic Term Life Insurance in force at age 64 Reduced by 80% AT AGE 80 based on the amount of Basic Term Life Insurance in force at age 64 Reduced by 85% AT AGE 85 based on the amount of Basic Term Life Insurance in force at age 64


GN-70051-07 EM ERSCBA 4

EMPLOYEE ACCIDENTAL DEATH OR BODILY INJURY BENEFIT ACCIDENTAL DEATH OR BODILY INJURY BENEFIT: $25,000 Amount of coverage x Salary (rounded to the next highest $1,000) Class % Salary Benefit Amount ACCIDENTAL DEATH OR BODILY INJURY BENEFIT IS REDUCED TO THE FOLLOWING FOR YOUR EMPLOYEES: Reduced by 35% AT AGE 65 based on the amount of Basic Term Life Insurance in force at age 64 Reduced by 55% AT AGE 70 based on the amount of Basic Term Life Insurance in force at age 64 Reduced by 70% AT AGE 75 based on the amount of Basic Term Life Insurance in force at age 64 Reduced by 80% AT AGE 80 based on the amount of Basic Term Life Insurance in force at age 64 Reduced by 85% AT AGE 85 based on the amount of Basic Term Life Insurance in force at age 64


GN-70051-07 EM SCBDL 5

DEPENDENT CHILD TERM LIFE INSURANCE BENEFIT DEPENDENT CHILD - BIRTH THROUGH 14 DAYS................................................................$ 0 DEPENDENT CHILD - 15 DAYS UP TO 6 MONTHS ................................................................$ 500 DEPENDENT CHILD - FROM AGE 6 MONTHS TO ATTAINMENT OF LIMITING AGE.......$2,500 DEPENDENT SPOUSE TERM LIFE INSURANCE BENEFIT SPOUSE LIFE BENEFIT THROUGH AGE 64 $5,000 DEPENDENT SPOUSE TERM LIFE INSURANCE BENEFITS TERMINATE AT ATTAINMENT OF AGE 65.

DEFINITIONS

TX-70051-07 EM DEF 10/11 6

The following are definitions of terms as they are used in this Certificate. Defined terms are printed in bold face type wherever found in this Certificate.

A

Active Status means the Employee is performing all of the material duties of his/her occupation whether performed at the Employer's business establishment or another location of business when required to travel on behalf of the Employer: • On a regular, full-time basis; • For the number of hours per week shown on the Employer Group Application; and • For 48 weeks a year. An Employee will be considered in Active Status with the Employer on a day which is one of the Employer's scheduled work days if the Employee is performing, in the usual way, all of the material duties of his/her occupation on a full-time basis. The Employee will also be considered actively at work on each day of a regular scheduled paid vacation, or any regular non-working holiday, only if the Employee was at work on the preceding scheduled work day and was not Totally Disabled including a hospital confinement on that day.

B Bodily Injury means injury due directly to a specific accident, independent of all other causes. Muscle strain due to athletic or physical activity, or bodily damage resulting from infection, is considered a Sickness.

C Confinement means being a resident patient in a Hospital or Qualified Treatment Facility for at least 15 consecutive hours. Confinement does not mean detainment in Observation Status. Successive Confinements are considered to be one Confinement if: • Due to the same Bodily Injury or Sickness; and • Separated by fewer than 30 consecutive days when You are not confined. Covered Person means the Employee and/or the Employee's covered Dependents.


TX-70051-07 EM DEF 10/11 7

D DEPENDENT Dependent means a covered Employee's:

1. Legally recognized spouse; or 2. Natural blood related child, step-child, or legally adopted child, child or grandchild placed

with the Employee for the purpose of adoption whose age is less than the limiting age. Dependent DOES NOT mean a great grandchild, or foster child.

The limiting age for each Dependent child is 26 years of age. You must furnish satisfactory proof to Us upon Our request that the above conditions continuously exist. If satisfactory proof is not submitted to Us, the child's coverage will not continue beyond the last date of eligibility. A covered Dependent child who becomes an employee eligible for other group coverage through employment is no longer eligible as a Dependent for coverage under the Policy. A covered Dependent child who attains the limiting age WHILE INSURED under the Policy remains eligible for Benefits if mentally or physically disabled and under the Employee’s supervision. You must furnish satisfactory proof to Us upon Our request that the above conditions continuously exist on and after the date the limiting age is reached. After two years from the date the first proof was furnished, We may not request such proof more often than annually. If satisfactory proof is not submitted to Us, the child's coverage will not continue beyond the last date of eligibility.

E Employee means a person who is in Active Status for the Employer on a permanent full-time basis. The Employee must be paid a salary or wage by the Employer that meets the minimum wage requirements of Your state or federal minimum wage law for work done at the Employer's usual place of business or some other location which is usual for the Employee's particular duties. Employer means the Policyholder of this Group Insurance Plan, or any subsidiary described in the Employer Group Application.

H Hospital means an institution which: • Maintains permanent full-time facilities for bed care of resident patients; • Has a physician or surgeon in regular attendance; • Provides continuous 24-hour-a-day nursing services; • Is primarily engaged in providing diagnostic and therapeutic facilities for medical or surgical care of

sick or injured persons;


TX-70051-07 EM DEF 10/11 8

• Is legally operated in the jurisdiction where located; and • Has surgical facilities on its premises or has a contractual agreement for surgical services with an

institution having a valid license to provide such surgical services; or • Is a lawfully operated Qualified Treatment Facility certified by the First Church of Scientist,

Boston, Massachusetts. Hospital does NOT include an institution which is principally a rest home, nursing home, convalescent home or home for the aged. Hospital does NOT include a place principally for the treatment of alcohol or chemical dependency or Mental Disorders.

M Material And Substantial Duties are the duties that: Are normally required for the performance of the occupation; and Cannot be reasonably omitted or changed. You will no longer be considered Totally Disabled or Partially Disabled under this Plan when You are able to increase Your current earnings by increasing the number of hours You work or the number of duties You perform in Your regular occupation but You do not do so.

P Policyholder means the Employer who is the Legal Entity named as the Policyholder on the face page of the Policy.

Q Qualified Practitioner means a practitioner, professionally licensed by the appropriate state agency to diagnose or treat a Bodily Injury or Sickness, and who provides services within the scope of that license. A Qualified Practitioner does not include a practitioner who resides in Your home or is Your Family Member. Qualified Treatment Facility means only a facility, institution, or clinic duly licensed by the appropriate state agency, and is primarily established and operating within the scope of its license.

S Sickness means a disturbance in function or structure of Your body which causes physical signs or symptoms which, if left untreated, will result in a deterioration of the health state of the structure or system(s) of Your body.


TX-70051-07 EM DEF 10/11 9

Surgery means excision or incision of the skin or mucosal tissues or insertion for exploratory purposes into a natural body opening. This includes insertion of instruments into any body opening, natural or otherwise, done for diagnostic or other therapeutic purposes.

T Total Disability or Totally Disabled means, for the Employee that during the disability he or she is at all times prevented by Bodily Injury or Sickness from performing each and every Material And Substantial Duty of his or her occupation as it is generally performed in the economy. A Totally Disabled person may not engage in ANY job or occupation for wage or profit.

W We, Us, and Our means the Insurance Company as shown on the cover page of this Certificate.

Y You and Your means any Covered Person.

ELIGIBILITY AND EFFECTIVE DATE OF INSURANCE

TX-70051-07 EM EE 10

EMPLOYEE COVERAGE EMPLOYEE ELIGIBILITY DATE The Employee is eligible for coverage on the date: • Eligibility requirements stated in the Employer Group Application are satisfied; and • The Employee is in an Active Status. EMPLOYEE ENROLLMENT The Employee must enroll on forms furnished and accepted by Us. Depending on the total number of Employees covered by the Employer's plan, We may require any Employee to provide evidence of insurability and any applicable evidence of health status whenever an enrollment form is submitted. If You enroll more than 31 days after Your eligibility date, You are a late applicant and must provide Us with evidence of insurability and any applicable evidence of health status. This form is available from the Employer or Us. We have the right to accept or decline coverage. If accepted, You will be covered on the date We specify. EMPLOYEE EFFECTIVE DATE The Employee's Effective Date Provision is stated in the Employer Group Application. It may be the date immediately following, or the first of the month following, completion of the probationary period (waiting period), or the date approved by Us. EMPLOYEE DELAYED EFFECTIVE DATE If the Employee is not in Active Status on the effective date shown on the Schedule of Benefits, coverage will be effective the day after the Employee returns to Active Status. The Employer must notify Us in writing of the Employee's return to Active Status. EMPLOYEE BENEFIT CHANGES Additional or increased insurance will become effective on the approved date of change if the Employee is in Active Status on that date. Otherwise, the approved change will be effective on the day after the Employee returns to Active Status. We may require any Employee to provide evidence of insurability and any applicable evidence of health status whenever a benefit change is requested. A decrease in insurance will be effective immediately on the approved date of change.


TX-70051-07 EM EE 11

DEPENDENT COVERAGE DEPENDENT ELIGIBILITY DATE Each Dependent is eligible for coverage on: • The date the Employee is eligible for coverage, if he or she has Dependents who may be covered on

that date; • The date of the Employee's marriage for any Dependents (spouse or child) acquired on that date; • The date of birth of the Employee's natural-born child; or • The date the child is legally adopted or placed in the Employee's home for the purpose of adoption

by the Employee. The Employee may cover his or her Dependents ONLY if the Employee is also covered. A Dependent child who becomes eligible for other group coverage through any employment is no longer eligible for group coverage under the Policy. If a Dependent child becomes an Employee of the participating Employer, he or she is no longer eligible as a Dependent and must make application as an eligible Employee. DEPENDENT ENROLLMENT Check with the Employer immediately on how to enroll for Dependent Coverage. Late enrollment may result in denial of Dependent Coverage by Us. The Employee must enroll for Dependent Coverage and enroll additional Dependents on forms furnished and accepted by Us. No Dependent will become a Covered Person until We approve the Dependent for coverage. Depending on the total number of Employees covered by the Employer's plan, We may require any Dependent to provide evidence of insurability and any applicable evidence of health status whenever an enrollment form is submitted. If You enroll more than 31 days after Your eligibility date, You are a late applicant and must provide Us evidence of insurability and any applicable evidence of health status. This form is available from the Employer or Us. We have the right to accept or decline coverage. If accepted, You will be covered on the date We specify.


TX-70051-07 EM EE 12

NEWBORN DEPENDENT ENROLLMENT Employees who already have full Dependent (spouse and children) coverage in force PRIOR to the newborn's date of birth are not required to complete an enrollment form for the newborn child. All other Employees who are changing their current coverage must complete an enrollment form for the newborn Dependent. This form is available from Your Employer or from Us. DEPENDENT EFFECTIVE DATE Each Dependent's effective date of coverage is determined as follows, subject to the Dependent Delayed Effective Date provision: • If We receive the enrollment form ON, PRIOR TO or WITHIN 31 days of the Dependent's

eligibility date, that Dependent is covered on the date he or she is eligible; • If We receive the enrollment form MORE THAN 31 days after the Dependent's eligibility date, We

require evidence of insurability and any applicable evidence of health status. We have the right to accept or decline coverage for the Dependent based upon the evidence of insurability and any applicable evidence of health status. If accepted, the effective date of coverage will be the date We specify.

However, NO Dependent's effective date will be prior to the Employee's effective date of coverage. Refer to Your Schedule of Benefits for benefits available. NEWBORN DEPENDENT EFFECTIVE DATE A newborn Dependent's effective date is determined as follows: • If We receive the enrollment form ON, PRIOR TO or WITHIN 31 days of the newborn's date of

birth, Dependent Coverage is effective on the newborn's date of birth. • If We receive the enrollment form MORE THAN 31 days after the newborn's date of birth, We

require evidence of insurability and any applicable evidence of health status. We have the right to accept or decline coverage for the newborn based upon the evidence of insurability and any applicable evidence of health status. If accepted, the newborn will be covered on the date We specify.


TX-70051-07 EM EE 13

DEPENDENT DELAYED EFFECTIVE DATE If the Dependent: • Is confined in a Hospital or Qualified Treatment Facility; or • Is receiving Home Health Care or Hospice benefits, the Dependent's effective date of coverage will be delayed. The Dependent's coverage will be effective on the day after: • Discharge from Confinement, if the discharge from Confinement is certified by a Qualified

Practitioner; or • A Qualified Practitioner certifies that Home Health Care is no longer required. If Dependent coverage is in force or applied for within 31 days of the newborn child's date of birth, the Dependent Delayed Effective Date provision will not apply to the newborn child on its date of birth. DEPENDENT BENEFIT CHANGES Additional or increased insurance will become effective on the approved date of change, subject to the Dependent Delayed Effective Date provision. We may require any Dependent to provide evidence of insurability and any applicable evidence of health status whenever a benefit change is requested. A decrease in insurance will be effective immediately on the approved date of change.

TERMINATION OF COVERAGE

GN-70051-07 EM TER 14

Termination of Coverage may be immediate or at the end of the period which was selected by Your Employer on the Employer Group Application. Insurance terminates on the earliest of the following: • The date the Group Policy terminates; • The end of the period for which required premium was due Us and not received by Us; • For an Employee, the date he or she terminates employment with the Employer; • For an Employee, the date he or she no longer qualifies as an Employee; • The date You fail to be in an eligible class of persons as provided in the Insurance Classifications as

stated in the Employer Group Application; • The date You enter full-time military, naval or air service except that termination will not occur if

You are in temporary active duty as a reservist for military training that lasts 30 days or less; • The date the Employee retires, except if the Employer Group Application provides coverage for a

retiree class of Employees and the retiree is in an eligible class of retirees, selected by the Employer, and We are notified by the Employer;


Dependents; • For a Dependent, the date the Employee's insurance terminates; • For a Dependent, the date he or she no longer qualifies as a Dependent; or • For any benefit, the date the benefit is deleted from the Policy. YOU AND THE EMPLOYER ARE RESPONSIBLE TO ADVISE US OF ANY CHANGES IN ELIGIBILITY INCLUDING THE LACK OF ELIGIBILITY OF ANY COVERED PERSON. COVERAGE WILL NOT CONTINUE BEYOND THE LAST DATE OF ELIGIBILITY REGARDLESS OF THE LACK OF NOTICE TO US. SPECIAL PROVISIONS FOR NOT BEING IN ACTIVE STATUS If the Employer continues to pay required premiums and continues coverage under the Policy, Your coverage, other than Short Term Disability benefits,if any, will remain in force for: • No longer than three consecutive months if the Employee is:

- Temporarily laid-off; - In part-time status; or - On an Employer approved leave of absence.

TERMINATION OF COVERAGE (continued)

GN-70051-07 EM TER 15

• No longer than twelve consecutive months if the Employee is Totally Disabled. If the Employee becomes Totally Disabled and wishes to apply for Waiver of Premium, We must receive premium for Employee Term Life Insurance Coverage for the six consecutive month period while the Employee is covered under the Special Provisions for Not Being in Active Status. All premium must be submitted to Us through the Employer. YOUR OPTIONS Basic Term Life Coverage: If this coverage terminates, the Employee may exercise the rights under the Life Conversion Privilege described in this Certificate. If the Employee returns to an Active Status, he or she will be considered a new Employee and must re-enroll for Employee Coverage.

EMPLOYEE TERM LIFE INSURANCE BENEFITS

TX-70051-07 EM TL 3/2004 16

BENEFIT The amount of the Employee Term Life Insurance benefit is shown on the Schedule of Benefits. Subject to the terms below, a payment in this amount will be made to the beneficiary named by the Employee. Payment is made no later than two months after the date We receive proof the Employee’s death, and the death occurred while insured for this benefit. The Employee Group Term Life Insurance has no cash surrender or loan values. REDUCTION FOR AGE Reduction percentage(s) and reduction age(s), if any, are shown on the Schedule of Benefits. If the Employee's death occurs on or after a reduction age, the amount of payment will be reduced by the corresponding reduction percentage shown. A reduction in benefits due to age is effective on the first day of the calendar month following the date the Employee attains that age. BENEFICIARY The Employee may name any beneficiary he or she chooses. The Employee may also change a named beneficiary at any time by notifying Us in writing. The change will be effective on the date the Employee signs the form. If We make a payment before receiving the change form, We are released from further liability to the extent of the payment. If a payment is to be made to two or more beneficiaries, but the Employee has not specified the portions payable to each, the payment will be shared equally. If the Employee has not named a beneficiary, or if the beneficiary he or she named is not alive at the Employee's death, the payment will be made, at Our option, to any one or more of the following: • Your spouse; • Your children; • Your parents; • Your brothers and sisters; or • Your estate. We will rely upon an affidavit to determine benefit payment, unless We receive written notice of a valid claim before payment is made. Payment pursuant to the affidavit will release Us from further liability. Any payment made by Us in good faith will fully discharge Us to the extent of such payment. Any amount payable to a minor will be paid to the minor's legal guardian. NOTICE OF DEATH No payment will be made unless We receive written proof of Your death. If a death claim is filed while the Waiver of Premium is in effect, proof of continuous Total Disability must accompany the death claim.


TX-70051-07 EM TL 3/2004 17

LIMITED BENEFITS FOR SELF-INDUCED SICKNESS, SUICIDE OR SELF-INFLICTED BODILY INJURY In the event of death caused by self-induced Sickness, suicide, or intentional self-inflicted Bodily Injury, whether sane or insane, within the first year of Your effective date under this Certificate, benefits for Employee Voluntary Term Life Insurance will be limited to the premium paid for the Employee Voluntary Term Life Insurance. EMPLOYEE LIFE INSURANCE CONVERSION PRIVILEGE The Employee is entitled to apply for a Conversion Policy of Life Insurance if any portion of his or her Term Life Insurance Benefit terminates due to: • Termination of employment or membership in a class eligible for Term Life Insurance. The amount

the Employee is entitled to apply for is the amount of Term Life Insurance that is terminating, LESS the amount of Term Life Insurance for which he or she becomes eligible under any group coverage within 31 days after such termination; or

• Reduction for Age. The amount the Employee is entitled to apply for is the amount of insurance lost

due to the reduction, but not more than $10,000. If the Employee's Term Life Insurance benefit terminates because this coverage terminates, or is amended so as to terminate the eligible class to which the Employee belongs, and his or her Employee Term Life Insurance has been in effect under the Policy for at least three years, the amount the Employee is entitled to apply for is the lesser of: • The amount of Employee Term Life Insurance that is terminating, LESS the amount of any Life


• $10,000. CONVERSION POLICY The Conversion Policy is issued without evidence of insurability. The Employee must apply for and pay the first premium within 31 days of the termination of the Employee's coverage under the Group Plan. The Conversion Policy will be effective on the 32nd day following such termination. The Conversion Policy will not include any Short Term Disability or Accidental Death or Bodily Injury benefits. It will be issued on any one of the Policy forms, except term insurance, then being issued by Us to individuals of the same age. Premiums for the Conversion Policy will be based on Our current rate for the form, amount of insurance and the Employee's age on the date of issue of the Conversion Policy.


TX-70051-07 EM TL 3/2004 18

DEATH DURING CONVERSION PERIOD If the Employee dies during the 31 day period that he or she could have applied for a Conversion Policy, the amount of Life Insurance the Employee could have converted will be paid as the death benefit, even if the Employee had not applied for the Conversion Policy.

WAIVER OF PREMIUM

GN-70051-07 EM WOP 3/2004 19

If the Employee becomes Totally Disabled while insured for this Employee Term Life Insurance Benefit, We will continue the Employee's Term Life Insurance Benefit during his or her Total Disability without the requirement of premium payment subject to the Waiver of Premium provision. In order for Us to approve Waiver of Premium, the Employee must: • Become Totally Disabled before age 60; • Remain Totally Disabled throughout the 180 consecutive day Elimination Period;

Elimination Period means a period of continuous disability which must be satisfied before You are eligible to have Your life premium waived by Us.

• Request an application for Waiver of Premium and submit such application with proof of Total Disability, acceptable to Us, no later than 12 consecutive months after the Employee first became Totally Disabled.

Premium payment must continue until We approve the application for Waiver of Premium. Failure to do so will result in forfeiture of Your rights to Wavier of Premium. The Wavier of Premium benefit begins at the end of the Elimination Period. If the Employee dies prior to submitting the initial proof of Total Disability as required, proof that the Total Disability continued until the date of the Employee's death must be given to Us no later than 12 months after the Employee's death. We will not approve an application for Waiver of Premium if the Employee becomes Totally Disabled after the Employer terminates coverage under the Policy. EFFECT OF WAIVER OF PREMIUM When We approve Waiver of Premium, no premium payment will be required for the Employee's Term Life Insurance benefit during his or her Total Disability. Proof of the Total Disability must be received by Us within one year from the date the Total Disability began. The Employee is required to submit proof of continued Total Disability to Us three months before each anniversary date of the disability. We have the right to have the Employee examined for the Total Disability at any reasonable time during the first two years he or she is Totally Disabled. After that, We may have the Employee examined only once a year. AMOUNT CONTINUED The amount of the Employee Term Life Insurance benefit which will be continued under this Waiver of Premium is the amount that was in effect for the Employee on the date the Total Disability began. This amount will be reduced by the same amount, on the same dates, and for the same reasons that it would have been reduced if the Employee had not become Totally Disabled.

WAIVER OF PREMIUM (continued)

GN-70051-07 EM WOP 3/2004 20

TERMINATION OF WAIVER OF PREMIUM The Waiver of Premium terminates on the earliest of: • The date the Employee fails or refuses to furnish proof of Total Disability as required; • The date the Employee fails or refuses to be examined as required; • The date the Employee is no longer Totally Disabled; or • The Employee's 65th birthday. If the Waiver of Premium benefit terminates and the Employee returns to an Active Status, he or she will be insured for the Employee Term Life Insurance benefit for which he or she is then eligible. Premium payment will be required for the Employee Term Life Insurance benefit. If this Waiver of Premium terminates because the Employee is no longer Totally Disabled or attains age 65, and does not return to an Active Status, he or she may apply for a Conversion Policy of Life Insurance according to the Conversion Privilege provision in this Certificate. Termination of the Employer's participation under the Policy WILL NOT terminate the Employee's Waiver of Premium. If the Waiver of Premium terminates after the Employer's participation under the Policy terminates, and if the Employee Term Life Insurance Benefit has been in force for at least three years, the Employee may apply for a Conversion Policy. The amount of any Conversion Policy is limited to the lesser of: • The amount of Employee Term Life Insurance that is terminating LESS the amount of any Life

Insurance for which the Employee becomes eligible under any group coverage within 31 days after such termination; or

• $10,000.

ACCIDENTAL DEATH OR BODILY INJURY BENEFIT FOR COVERED EMPLOYEES

GN-70051-07 EM ADD 5/2005 21

Subject to the terms below, a benefit is payable for loss due to the Employee's Accidental Death or Accidental Bodily Injury if shown on the Schedule of Benefits. The loss must: (a) occur within 180 days after the accident which caused the loss; and (b) be due to an accident which occurs while the Employee is insured under the Benefit. If the Employee suffers multiple losses in the same accident, Our liability will be limited to payment for the one type of loss which provides the greatest benefit. The amount of benefit payable for each type of loss is: LOSS OF LIFE OR BENEFIT OTHER THAN BENEFIT FOR DISMEMBERMENT BENEFIT A COMMON CARRIER COMMON CARRIER ACCIDENT ACCIDENT Loss of Life Full Amount 2 Times Full Amount Loss of both hands Full Amount 2 Times Full Amount Loss of both feet Full Amount 2 Times Full Amount Loss of sight of both eyes Full Amount 2 Times Full Amount Loss of one hand and one foot Full Amount 2 Times Full Amount Loss of one hand or one foot and sight of one eye Full Amount 2 Times Full Amount Loss of one hand One-Half of the Full Amount Full Amount Loss of one foot One-Half of the Full Amount Full Amount Loss of sight of one eye One-Half of the Full Amount Full Amount Loss of thumb and index finger One-Fourth of the One-Half of the of the same hand Full Amount Full Amount


GN-70051-07 EM ADD 5/2005 22

PARALYSIS BENEFIT The paralysis must be determined by a Qualified Practitioner to be permanent, complete and irreversible. BENEFIT OTHER THAN BENEFIT FOR A COMMON CARRIER COMMON CARRIER ACCIDENT ACCIDENT Quadriplegia Full Amount 2 Times Full Amount Paraplegia One-Half of the Full Amount Full Amount Hemiplegia One-Half of the Full Amount Full Amount REDUCTION FOR AGE Reduction percentage(s) and reduction age(s), if applicable, are also shown on the Schedule of Benefits. If the Employee's loss occurs on or after a reduction age is effective, the full amount shown on the Schedule of Benefits will be reduced by the corresponding reduction percentage shown. This means that if the accident occurs before the effective date of the reduction age, but the Employee's loss occurs on or after the effective date of the reduction age, We will pay the benefit based on the reduced amount. A reduction age is effective on the first day of a calendar month following the date the Employee attains that age. TO WHOM PAYABLE Benefits for Accidental Dismemberment, or Paralysis are payable to the Employee. Benefits for Accidental Death are payable in accordance with the Employee Term Life Insurance Benefits provision - Beneficiary section. DEFINITIONS • ACCIDENTAL DEATH Accidental Death means loss of life which results directly from:

- Bodily Injury; - Infection caused by Bodily Injury, or infection resulting from accidental ingestion of

contaminated substances; or - Accidental drowning.


GN-70051-07 EM ADD 5/2005 23

• ACCIDENTAL DISMEMBERMENT Accidental Dismemberment means complete, permanent and irretrievable loss, resulting directly from Bodily Injury of:

- A hand or foot by severance at or above the wrist or ankle joint; or - The sight of an eye.

• COMMON CARRIER ACCIDENT Common Carrier Accident means a covered accidental Bodily Injury that is sustained while riding as a fare-paying passenger (not a pilot, operator or crew member) in or on, boarding or getting off from a common carrier. • COMMON CARRIER Common Carrier means any land, air or water vehicle operated under a valid license to transport passengers for hire. • QUADRIPLEGIA Quadriplegia means total paralysis of all four limbs. • PARAPLEGIA Paraplegia means total paralysis of both lower limbs. • HEMIPLEGIA Hemiplegia means total paralysis of one arm and one leg on the same side of the body. REPATRIATION BENEFIT We will pay a Repatriation Benefit if: 1. The Employee dies as a result of a accidental death at least 150 miles from his or her principal place

of residence; and 2. Expense is incurred for preparing the Employee's body and transporting the Employee's body to a

mortuary. This benefit will be in addition to all other benefits payable under this Certificate. This benefit will equal the expenses incurred for preparing and transporting the Employee's body to a mortuary, subject to the maximum of $5,000. This benefit will be paid the date both proof of accidental loss of life and proof of expense incurred for preparing and transporting the body is received.


GN-70051-07 EM ADD 5/2005 24

PROOF FOR REPATRIATION BENEFIT For this benefit to be payable, proof of payment for any expense incurred for repatriation must be provided to Us. TO WHOM PAYABLE FOR REPATRIATION BENEFIT Benefits for repatriation will be paid in accordance with the Beneficiary Section of this Certificate. Benefits will not be payable for any loss excluded under the Accidental Death or Bodily Injury for covered Employees Limitations section. EDUCATION BENEFIT We will pay an Education Benefit for each of the Employee's eligible Dependent children if the Employee: • Is injured in a covered accident while insured under this Certificate; • Dies as a direct result of these injuries within 365 days after the accident; and • Is survived by one or more Dependent children who are eligible for the benefit. To be eligible for the Education Benefit, a Dependent Child: • Must be Dependent on the Employee for principal support; • Must be enrolled as a full-time student on the date of the Employee's death or within 365 days after

the date of death; and • Must incur expenses after the date of the Employee's death for tuition, fees, books, room and board,

approved or certified by that school, paid by the student or payable directly to that school. This benefit will be paid in addition to all other benefits payable under this Certificate. The benefit will equal the actual expense incurred after the date of the Employee's death up to 5% of the Employee's death benefit, subject to a maximum of $5,000 for each eligible Dependent child per year, for up to four (4) consecutive years or until age 25 if all eligibility requirements are met for each payment. This benefit will be paid to the Dependent child if the child has reached the age of majority. Otherwise, benefits will be paid to the child's legal guardian. The first payment will be paid, the date both proof of accidental loss of life and proof of Educational expenses and that the Dependent child meets the above requirements is received. Subsequent payments will be made when We receive: • Verification that the eligible Dependent child continues to be a full-time student and meets the

requirements of this benefit during each additional semester/year; and • Proof of payment for the expenses incurred.


GN-70051-07 EM ADD 5/2005 25

"Full-time student" means a Dependent child who: • Is attending a licensed or accredited college, university or vocational school beyond the 12th grade; • Is considered a full-time student based upon that school's standards; and • Incurs expenses for tuition, fees, books, room and board, or other costs approved or certified by that

school, paid by the student or payable directly to that school. SPOUSE TRAINING BENEFIT A Spouse Training Benefit will be paid to the Employee's lawful recognize spouse, if the Employee: • Dies as a direct result of an Accidental Death; and • Is survived by a spouse who is eligible for the benefit. To be eligible for the Spouse Training Benefit, the Employee's spouse: • Must be the lawfully recognized spouse of the Employee on the date of the accident; • Must be enrolled as a student on the date of the Employee's death or within 365 days after that date

of the Employee's death in an accredited school; and • Must incur expenses after the date of the Employee's death for tuition, fees, books, room and board

or other costs approved or certified by the school, paid by the student or payable directly to that school.

This benefit will be paid in addition to all other benefits payable under this Certificate. The benefit will equal the actual expense incurred after the date of the Employee's death up to 5% of the Employee's benefit, subject to a maximum of $5,000. This benefit will be paid for one year after the Employee's death. Payment will be made the date both proof of accidental loss of life and proof of expense incurred for Spousal Training and the spouse meets the above requirement is received. EXCLUSIONS FOR SPOUSE TRAINING BENEFIT Benefits will not be payable for any loss excluded under the Accidental Death or Bodily Injury Benefit for Covered Employees Limitation section. CHILD CARE BENEFIT A Child Care Benefit will be paid for each of the Employee's eligible Dependent children if the Employee: • Is injured in a covered accident while insured under this Certificate; • Dies as a direct result of these injuries within 365 days after the accident; and • Is survived by one or more Dependent children who are eligible for the benefit.


GN-70051-07 EM ADD 5/2005 26

To be eligible for the Child Care Benefit, a Dependent child must: • Meet all the qualifications of a Dependent as determined by the Internal Revenue Service; • Be declared on and legally qualify as a Dependent on the Employee's Federal personal income tax

return filed for each year the benefits are request under the Child Care Benefit; • Be under age 13 on the date of the accident; and • Attends a licensed Child Care Center, once a week or on a more frequent basis, on the date of the

Employee's death or within 365 days after that date. The Child Care Benefit is paid in addition to all other Certificate benefits. The benefit will equal the actual expense incurred after the date of the Employee's death, up to 5% of the Employee's benefit, subject to a maximum of $5,000 for each eligible Dependent child per year. The benefit will be paid to the legal guardian of the eligible Dependent child the earliest of the following: • For up to four (4) consecutive years; or • Until the Dependent child's 13th birthday. The first payment will be made the date proof of accidental loss of life and proof of expenses incurred for Child Care and that the eligible Dependent child meets the above requirements is received. Subsequent payment will be made on a reimbursement basis when We receive: • Verification that the eligible Dependent child continues to attend a licensed Child Care Center on a

regular basis; and • Satisfactory proof of payment for the childcare expense incurred. DEFINITIONS • CHILD CARE CENTER Child Care Center means any facility, other than a family day care home that:

- Is licensed as a Child Care Center by the state in which it is physically located, and where the Dependent child physically attends; and

- Provides non-medical care and supervision for children in a group setting: and - Cares for children at least six (6) but less than 24 hours per day.

• EXPENSE INCURRED Expense incurred means the cost for the supervision and care of a Dependent child, excluding any fees for extra activities that are directly payable to a Child Care Center.


GN-70051-07 EM ADD 5/2005 27

EXCLUSIONS FOR CHILD CARE BENEFIT Benefits will not be paid: • When the Dependent Child's care is provided by, or at a facility operated by the child's grandparent,

parent, aunt, uncle or sibling; or • For any loss excluded under the Accidental Death or Bodily Injury for Covered Employees

Limitation section of this Certificate. COMA BENEFIT Coma means being in a state of complete mental and physical unresponsiveness in which neither arousal nor awareness is present and there is no evidence of appropriate responses to stimulation. We will pay a Coma Benefit when the Employee remains in a Coma if: • The Coma is caused by a Bodily Injury sustained while insured under this Certificate; • The Coma begins within 365 days after the date of the accident; and • The person remains in a Coma for more than 31 consecutive days. The Coma must result directly from the Bodily Injury and from no other causes. The benefit will be paid in addition to all other benefits payable under this Certificate. The Coma Benefit will equal a one time payment of 5% of the Employee's benefit, subject to a maximum of $5,000. PROOF FOR COMA BENEFIT Proof of the Coma must be provided to Us. We retain the right to investigate and to determine whether the coma exists. TO WHOM PAYABLE FOR COMA BENEFIT Upon receipt of satisfactory proof, the Coma Benefit will be paid to the Employee. EXCLUSIONS FOR COMA BENEFIT Benefits will not be paid: • When the Employee remains in a coma for less than 31 consecutive days; or • For any loss excluded under the Accidental Death or Bodily Injury for Covered Employees

Limitation section of this Certificate.


GN-70051-07 EM ADD 5/2005 28

SEAT BELT - AIRBAG - HELMET BENEFIT The Seat Belt, Airbag, Helmet Benefit is payable if You die as a direct result of Bodily Injury sustained in an automobile or motorcycle accident as a passenger or driver. In the event of an automobile accident the benefit is payable if: • A copy of the police report is submitted with the claim; • You were seated in a seat equipped with a properly functioning air bag; • You were wearing a properly fastened seat belt in the correct position; and • The correct position of the seat belt was certified by the investigating officer or indicated in the police

report. We will increase Your Accidental Death benefit by 10%, up to $10,000, but not less than $1,000 for using Your seat belt. Additionally, We will increase Your Accidental Death benefit by 5%, up to $5,000, but no less than $500 for the properly functioning airbag. In the event of a motorcycle accident the benefit is payable if: • A copy of the police report is submitted with the claim: • You were wearing a properly fitting and fastened motorcycle helmet; and • The use of properly fitted and fastened motorcycle helmet was certified by the investigating officer or

indicated in the police report. We will increase Your Accidental Death benefit by 10%, up to $10,000, but not less than $1,000 for wearing a properly fitted and fastened motorcycle helmet. If We are unable to determine whether You had been wearing a properly fastened seat belt, seated in a seat equipped with a functioning airbag, or wearing a properly fitted and fastened motorcycle helmet. We will pay a benefit of $1,000 to Your beneficiary. DEFINITIONS • AUTO Auto means a four-wheel passenger car, station wagon, sport utility vehicle, truck or van-type car. It must be licensed for use on public highways. It includes a car owned or leased by a group certificate holder. • MOTOR CYCLE Motor Cycle means a two wheel passenger motorcycle. It must be licensed for use on public highways. it includes a motorcycle owned or leased by a group certificate holder.


GN-70051-07 EM ADD 5/2005 29

LIMITATIONS Accidental Death or Bodily Injury benefits DO NOT cover loss resulting from: • Self-induced Sickness, attempted suicide or intentionally self-inflicted Bodily Injury, whether sane


inhaled as prescribed or administered by a Qualified Practitioner; • Being intoxicated or under the influence of any unlawful substance, narcotic or hallucinogenic, unless


licensed passenger airline; • Commission or attempt to commit a civil or criminal battery or felony; • Driving or operating a motorized vehicle while legally intoxicated or under the influence of illegal

substance. Intoxication means that blood alcohol content or the results of other means of testing blood alcohol level meet or exceeds the legal presumption of intoxication under the law of the state where the accident took place;

• Driving or operating a motorized vehicle without a valid drivers' license; • Driving or operating a motorized vehicle in excess of the legal speed limit; • Service in any armed forces, except if You are in temporary active duty as a reservist for military


− War or any act of war, whether declared or not; or − Any act of armed conflict, or any conflict involving armed forces of any authority;

• Bodily or mental infirmity, or its related surgical or medical treatment or any infection unless the


• Participation in a riot, rebellion or insurrection. Participation means taking an active part in common

with others. Riot means any use or threat to use force or violence by three or more persons without the authority of law; or

• Participation in hazardous sports, including but not limited to: bungee jumping, motorized vehicle

racing, rock climbing, rodeo events, scuba diving, skydiving, parachuting, hang gliding, or ballooning.

ACCELERATED BENEFITS

TX-70051-07 EM ADB 30

If a covered Employee is diagnosed with a Qualifying Condition, the Employee may request that an accelerated benefit be paid immediately. The amount payable is 50% to a maximum benefit of $250,000. DEATH BENEFITS WILL BE REDUCED IF AN ACCELERATED BENEFIT IS PAID. DEFINITIONS Activities of Daily Living mean Bathing, Maintaining Continence, Dressing, Eating, Toileting and Transferring. Adult Day Care means a social and health-related services program provided during the day in a community group setting, for the purpose of supporting frail, impaired elderly, or other disabled adults who can benefit from care in a group setting outside the home. Adult Day Care Facility means a provider of Adult Day Care services operated pursuant to the provisions of the Human Resources Code, Chapter 103 (concerning licensing and quality of care requirements in the provision of adult day care). Bathing means washing yourself by sponge bath or in either a tub or shower, including the task of getting into or out of the tub or shower. Dressing means putting on and taking off all items of clothing and any necessary braces, fasteners or artificial limbs. Eating means feeding yourself by getting food into the body from a receptacle (such as a plate, cup or table) or by a feeding tube or intravenously. Home Health Agency means a business which provides home health service and is licensed by the Texas Department of Health under Texas Civil Statutes, Article 4447u. Home Health Care Services mean medical or nonmedical services provided to ill, disabled or infirm persons in their residences. Such services may include homemaker services, assistance with activities of daily living, respite care services, case management services, and maintenance or personal care services. Long Term Care Illness means the Employee: • Is unable to perform at least two Activities of Daily Living; or • Has an impairment of cognitive ability. Impairment of cognitive ability means the deterioration or

loss in intellectual capacity requiring substantial supervision for protection of self and others, as established by the clinical diagnosis of any Qualified Practitioner in the state of Texas authorized to make such a diagnosis. Such diagnosis shall include the patient's history and physical, neurological, psychological and/or psychiatric evaluations and laboratory findings.


TX-70051-07 EM ADB 31

Maintaining Continence means the ability to maintain control of bowel and bladder function or when unable to maintain control of bowel or bladder function, the ability to perform associated personal hygiene (including care for catheter or colostomy bag). Qualifying Condition means: • Long-Term Care Illness; • Specified Disease; or • Terminal Illness. Specified Disease means a Sickness or Bodily Injury that is likely to cause permanent disability or premature death including, but not limited to: • Acquired Immune Deficiency Syndrome (AIDS); • Malignant tumor; • A condition that requires an organ transplant; • Coronary artery disease resulting in acute infarction or requiring surgery; or • Permanent neurological deficit resulting from cerebral vascular accident. Terminal Illness means a Sickness or Bodily Injury which is diagnosed by a Qualified Practitioner as life-threatening with a life expectancy of 24 months or less. Toileting means getting to and from the toilet, getting on and off the toilet and performing associated personal hygiene. Transferring means sufficient mobility to move into or out of a bed, chair or wheelchair or to move from place to place, either by way of walking, a wheelchair or other means. QUALIFICATIONS FOR ACCELERATED BENEFITS Payment of this benefit does not guarantee that the Employee's full death benefit will eventually be paid. The Employee must still be insured under the Policy at the time of death for the remainder of the Term Life Insurance benefit to be paid. To qualify for the Accelerated Death Benefit the covered Employee must: • Be covered under the Policy a minimum of 6 months; • Provide proof of Qualifying Condition acceptable to Us; and • Request this benefit in writing on a form acceptable by Us.


TX-70051-07 EM ADB 32

PROOF OF QUALIFYING CONDITIONS A Qualified Practitioner's written certification is required as proof that a Qualifying Condition exists. We reserve the right to request any additional medical information We believe necessary to confirm the Employee's Qualifying Condition. We also reserve the right to request a second opinion from a Qualified Practitioner appointed by Us. The second opinion would be paid by Us. If You fail to submit proof satisfactory to Us that You have a Qualifying Condition, or refuse to be examined as may be required by Us, no Accelerated Benefit will be payable. In the event that Your Qualified Practitioner and a Qualified Practitioner appointed by Us are unable to agree that a Qualifying Condition has occurred, the opinion of the Qualified Practitioner appointed by Us will prevail. QUALIFIED TREATMENT FACILITY OF LONG TERM CARE ILLNESS Qualified Treatment Facility of Long Term Care Illness includes, but is not limited to, a convalescent nursing home, residential care or intermediate nursing facility, which is operated pursuant to state and federal law. Qualified Treatment Facility of Long Term Care Illness does not include: • Any home, facility or part thereof used primarily for rest; • A home or facility for:

- The aged; - Drug addicts or Alcoholics; - The care and treatment of mental diseases or disorder; - Custodial care; or - Educational care.

EXCLUSIONS • Accelerated Benefits are not available for a Qualifying Condition which resulted from a self-induced

Sickness, attempted suicide or intentionally self-inflicted Bodily Injury, whether sane or insane; or • Accelerated Benefits are not payable to an Employee who is:

- Required by law to use this benefit to satisfy claims of creditors; or - Required by a government agency to use this benefit to apply for, obtain or keep a government

benefit or entitlement.


TX-70051-07 EM ADB 33

BENEFITS PAYABLE Payment will be made in one lump sum to You and is payable once during Your lifetime. The amount requested must be at least $5,000. Notice: At the time of payment of this benefit, We will send You or the owner, whichever is applicable, a statement specifying the amount of benefits paid and the effect of the benefit payment on Your Term Life Insurance amount. If the amount of Your Term Life Insurance is scheduled to reduce within 6 months following the date You apply for the Accelerated Benefit, Your benefit payable will be based on the reduced amount. Payment from this benefit may be taxable. Assistance should be sought from Your personal tax advisor. We are not responsible for any tax or other effects of an accelerated benefit payment or loss of eligibility for any State or Federal program. EFFECT ON EMPLOYEE TERM LIFE INSURANCE BENEFIT The amount of Term Life Insurance payable to the beneficiary at the time of death will be reduced by any accelerated benefit amount paid. The remaining Term Life Insurance amount will be paid according to the terms and provisions of the Policy. Any amount You could otherwise convert will also be reduced by the accelerated benefit.

GENERAL PROVISIONS

TX-70051-07 EM GP 3/2004 34

NOTICE OF CLAIM Written notice of claim, other than claim for loss of life, must be given within 30 days after the date of loss covered by this Policy, or as soon thereafter as is reasonably possible. Notice may be given at Our address and should include Your name and the name(s) of Your Dependent(s) and Your Group Number. CLAIM FORMS Upon receipt of notice of claim, We will send You the forms for filing proof of loss. If the forms are not sent to You within 15 days, You will have met the proof of loss requirement by sending Us a written statement of the nature and extent of the loss within the time limit stated in the Proof of Loss provision. PROOF OF LOSS You must give written proof of loss within 91 days after the date of loss, except for loss of life. Your claim will not be reduced or denied if it was not reasonably possible to give such proof. In any event, written notice must be given within one year after the date proof of loss is otherwise required, except if You were legally incapacitated. TIME OF PAYMENT OF CLAIMS Payments due under the Policy will be paid upon receipt of written proof of loss. CLAIM APPEAL PROCEDURE If We partially or fully deny a claim for benefits submitted by You, and You disagree or do not understand the reasons for this denial, You may appeal this decision. You have the right to: • Request a review of the denial; • Review pertinent plan documents; and • Submit in writing, any data, documents or comments which are relevant to Our review of this denial. Your appeal must be submitted in writing within 60 days of receiving written notice of denial. We will review all information and send written notification within 60 days of Your request.


TX-70051-07 EM GP 3/2004 35

INCONTESTABILITY After You are insured without interruption for two years, We cannot contest the validity of Your coverage except for nonpayment of premium. The incontestability period begins with Your effective date as stated on the cover page of this Certificate. An independent incontestability period begins for each type of increase in coverage. The new incontestability period will only apply to the increased coverage. No statement made by You can be contested unless it is in a written form signed by You. A copy of the form must be given to You or Your beneficiary. FRAUD If You intentionally commit fraud against Us or Your Employer commits fraud pertaining to You against Us or You or Your Employer misrepresent material information to Us as determined by a court of competent jurisdiction, Your coverage ends automatically, subject to the Incontestability clause under this Policy. TIME LIMIT ON CERTAIN DEFENSES A claim will not be reduced or denied after two years from the effective date of the benefit because a disease or physical condition not excluded and causing the loss existed before the benefit effective date. CLERICAL ERROR, MISSTATEMENT OF AGE OR GENDER If it is determined that information about the age or gender of You or Your Dependents was omitted or misstated in error, the amount of insurance for which You are properly eligible will be in effect. An equitable premium adjustment will be made. This provision applies equally to You and to Us. DUPLICATING PROVISIONS If any charge is described as covered under two or more benefit provisions, We will pay only under the provision allowing the greater benefits. This may require Us to make a recalculation based upon both the amounts already paid and the amounts due to be paid. We have NO liability for benefits other than those the Policy provides.


TX-70051-07 EM GP 3/2004 36

WORKERS' COMPENSATION NOT AFFECTED This Plan is not issued in lieu of, nor does it affect any requirement for coverage by any Workers' Compensation or Occupational Disease Act or Law. RIGHT TO REQUEST OVERPAYMENTS We reserve the right to recover any payments made by Us that were made in error. RIGHT TO COLLECT NEEDED INFORMATION You must cooperate with Us and when asked, assist Us by: • Authorizing the release of medical information including the names of all providers from whom You

received medical attention; • Obtaining medical information and/or records from any provider as requested by Us; • Providing information regarding the circumstances of Your injury or accident; • Providing information about other insurance coverage and benefits; and • Providing information We request to administer the Policy. PHYSICAL EXAMINATION AND AUTOPSY We, at Our expense, have the right to have You examined as often as We deem reasonably necessary, but no more frequently than every three months. We may also have an autopsy performed unless prohibited by law. LEGAL ACTIONS You cannot bring an action at law or equity to recover a claim until 60 days after the date written proof of loss is made. You cannot bring such action more than two years after such proof of loss is made. ASSIGNMENT OF BENEFITS FOR LIFE COVERAGE Except for the dismemberment benefits under the Accidental Death and Bodily Injury Benefit for Covered Employees. You have the right to absolutely assign all of Your rights and interest under the Policy including, but not limited to, the following: • The right to make any contributions required to keep the insurance in force; • The privilege of converting; and • The right to name and change a beneficiary.


TX-70051-07 EM GP 3/2004 37

If an Irrevocable beneficiary has been designated, Assignment of Benefit will not be allowed. No absolute assignment of rights and interest shall be binding on Us until and unless the original or certified copy of the form documenting the absolute assignment is received and acknowledge by Us at our office. WORKER'S COMPENSATION If benefits are paid by Us and We determine You received Workers' Compensation for the same incident, We have the right to recover as described under the "Recovery Rights" provision. We will exercise Our right to recover against You. The Recovery Rights will be applied even though: • The Workers' Compensation benefits are in dispute or are made by means of settlement or

compromise; • NO final determination is made that Bodily Injury or Sickness was sustained in the course of or

resulted from Your employment; • The amount of Workers' Compensation due to medical or health care is not agreed upon or defined by

You or the Workers' Compensation carrier; or • The medical or health care benefits are specifically excluded from the Workers' Compensation

settlement or compromise. You hereby agree that, in consideration for the coverage provided by the Policy, You will notify Us of any Workers' Compensation claim You make, and that You agree to reimburse Us as described above. MODIFICATION OF POLICY The Policy may be modified at any time by agreement between Us and the Policyholder without the consent of any Covered Person or any beneficiary. No modification will be valid unless approved by Our President or Secretary. The approval must be endorsed on or attached to the Policy. No agent has authority to modify the Policy, or waive any of the Policy provisions, to extend the time of premium payment, or bind Us by making any promise or representation.


TX-70051-07 EM GP 3/2004 38

PREMIUM CONTRIBUTIONS Your Employer must pay the required premium to Us as they become due. Your Employer may require You to contribute toward the cost of Your insurance. Failure of Your Employer to pay any required premium to Us on time will result in the termination of Your insurance. GRACE PERIOD A grace period of 31 days will be allowed for payment of each premium due. If premium due is not paid within the grace period, We will cancel the insurance at the end of the grace period. All due and unpaid premium, including premium for the grace period, must be paid to Us by Your Employer.

SUPPLEMENTAL BENEFIT DEPENDENT TERM LIFE INSURANCE BENEFITS

TX-70051-07 EM DL 3/2004 39

This benefit is attached to and made a part of Your Certificate. The effective date of this change is the latter of the effective date of this Certificate or the date this benefit is added to the Policy. Except as modified below, all Policy terms, conditions, and limitations apply. The amount of the Dependent Term Life Insurance Benefit is shown on the Schedule of Benefits. In no event will the Dependent Term Life Insurance Benefit exceed 50% of the Employee Term Life Insurance amount. BENEFITS The applicable Dependent Term Life Insurance Benefit will be paid to the beneficiary subject to the terms below: • The covered Dependent dies while coverage is in force; and • Proof of death is received that the Dependent's death occurred while insured for this benefit. Dependent Term Life Insurance has no cash surrender or loan values. REDUCTION FOR AGE Reduction percentage(s) and reduction age(s), if any, are shown on the Schedule of Benefits. If the Dependent's death occurs on or after a reduction age, the amount of payment will be reduced by the corresponding reduction percentage shown. A reduction in benefits due to age is effective on the first day of the calendar month following the date the Dependent attains that age. BENEFICIARY The Employee will be paid the applicable amount of Dependent Term Life Insurance shown on the Schedule of Benefits in the event of death of one of his or her covered Dependents. If the Employee does not survive the Dependent, the applicable Dependent Term Life Insurance amount will be payable, at Our option, to one or more of the following; • Your parents; • Your children; • Your brothers and sisters; or • Your estate. We will rely upon an affidavit to determine benefit payment, unless We receive written notice of valid claim before payment is made. Payment pursuant to the affidavit will release Us from further liability.


TX-70051-07 EM DL 3/2004 40

Any payment made by Us in good faith will fully discharge Us to the extent of such payment. Any amount payable to a minor will be paid to the minor’s legal guardian. NOTICE OF DEATH No payment will be made unless We receive written proof of Your death. LIMITED BENEFITS FOR SELF-INDUCED SICKNESS, SUICIDE OR SELF-INFLICTED BODILY INJURY In the event of death caused by self-induced Sickness, suicide, or intentional self-inflicted Bodily Injury, whether sane or insane, within the first year of Your effective date under this Certificate, benefits for Voluntary Dependent Term Life Insurance will be limited to the premium paid for the Voluntary Dependent Term Life Insurance. DEPENDENT LIFE INSURANCE CONVERSION PRIVILEGE A covered Dependent may apply for a Conversion Policy of Life Insurance if the Dependent's Term Life Insurance benefit terminates because: • The Employee's employment terminates; • The Employee dies or transfers to a class of Employees not eligible for coverage under the Policy; or • The Dependent ceases to qualify as a Dependent. The amount the Dependent is entitled to apply for is the amount of Term Life Insurance in force for the Dependent under this Plan at the time coverage terminates. A covered Dependent may also apply for a Conversion Policy of Life Insurance if the Dependent Term Life Insurance benefit terminates due to a Policy amendment removing the Dependent Life Insurance Benefit or termination of the Policy, and the Dependent's Term Life Insurance has been in effect under this Plan for at least three years. The amount the covered Dependent is entitled to apply for is the lesser of: • The amount of Dependent Term Life Insurance that is terminating LESS the amount of any Life

Insurance for which that Dependent becomes eligible within 31 days after such termination; or • $10,000.


TX-70051-07 EM DL 3/2004 41

CONVERSION POLICY The Life Conversion Policy is issued without evidence of insurability. The Employee, on behalf of the covered Dependent, must apply for and pay the first premium within 31 days of the termination of the Dependent's coverage under the group Plan. The Conversion Policy will be effective on the 32nd day following such termination. The Conversion Policy will not include any Disability or Accidental Death or Bodily Injury benefits. It will be issued on any one of the policy forms, except term insurance, then being issued by Us to individuals of the same age. Premiums for the Conversion Policy will be based on Our current rate for the Policy form, amount of insurance and the covered Dependent's age on the date of issue of the Conversion Policy. DEATH DURING CONVERSION PERIOD If the covered Dependent dies during the 31 day period that he or she could have applied for a Conversion Policy, the amount of Life Insurance he or she could have converted will be paid as the death benefit, even if the Dependent had not applied for the Conversion Policy.


President










Life Insurance:







Aggregate Limit:




Notices



nicebenname curpayrolldedamount

Employer Paid Life Insurance ‐ Humana ER Basic Life Insurance ‐ $25,000 0.48

Employer Paid Life Insurance ‐ Humana ER Basic Life Insurance ‐ $25,000 0


















































































Group Term Life Insurance ‐ Humana Voluntary Term Life 9.63












Group Term Life Insurance ‐ Humana Voluntary Term Life 27













































curamountem

3.5

3.5

3.5

3.5

3.5

2.28

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

2.28

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

3.5

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

City of SchertzLTD Claim Detail

Policy #405524

3/16 - 3/17 3/17 - 3/18 3/18 - 10/18 TotalP1P2 0P3 0 0P4 3,009 0 3,009P5 2,107 0 0 2,107P6 0 0 0 0

Total 5,116 0 0 5,116

Reserves 22,427 0 0 22,427IBNR 0 0 26,592 26,592

Incurred Claims 27,543 0 26,592 54,135

Constant Premium 43,945 47,221 31,285 122,451Loss Ratio 62.7% 0.0% 85.0% 44.2%

Open Claims 1 0 0 1Monthly Indemnity 301 0 0 301

gender birthdate hiredate incomeannual

M 9/22/1978 10/25/2010 57803.2

M 11/20/1981 5/11/2009 44678.4

M 3/29/1985 6/7/2010 44678.4

M 6/8/1977 8/20/1996 44678.4

M 10/16/1983 3/26/2012 44678.4

M 2/15/1988 4/22/2013 52353.6

M 4/30/1971 4/9/2001 73299.2

F 12/7/1949 10/10/2000 37377.6

F 12/11/1961 5/25/2006 32552

M 9/15/1965 7/1/2015 58947.2

M 3/10/1973 10/15/1996 94827.2

M 9/9/1969 5/9/2001 62566.4

F 8/12/1982 10/1/2010 55556.8

M 8/29/1983 1/3/2005 66393.6

F 8/16/1961 4/25/2003 33196.8

F 11/22/1981 6/23/2004 82555.2

M 6/9/1977 2/28/2011 42952

F 10/27/1950 2/1/1992 47424

M 4/14/1973 1/3/2011 67724.8

M 2/8/1957 10/1/1990 73299.2

M 6/8/1987 10/1/2011 56659.2

F 4/12/1989 1/30/2012 36649.6

F 3/14/1973 8/21/2000 46488

M 1/30/1981 9/26/2011 30076.8

F 4/29/1987 11/19/2012 53393.6

M 6/1/1975 11/13/2000 77792

M 11/14/1974 8/8/2006 33196.8

M 4/17/1972 10/31/2005 60132.8

M 9/29/1956 1/7/2009 100630.4

M 7/24/1971 10/13/2009 43804.8

M 6/27/1968 5/28/2002 55556.8

M 8/29/1984 12/10/2007 62566.4

M 7/18/1967 1/12/1998 50315.2

M 5/27/1978 6/11/2002 36649.6

F 3/4/1975 5/21/2012 45572.8

F 7/29/1961 3/30/2009 31907.2

F 2/24/1965 2/26/2001 52353.6

M 5/18/1977 12/4/2002 66393.6

F 12/15/1957 1/1/2008 83360.78

M 3/31/1960 7/10/2006 42099.2

M 8/12/1967 7/24/1996 71864

M 9/19/1978 2/6/2008 44678.4

M 12/23/1986 10/12/2009 56659.2

F 8/1/1976 11/26/2007 36649.6

F 4/6/1964 1/14/2008 31283.2

M 10/16/1962 4/17/2006 55556.8

F 10/2/1961 6/24/2013 50315.2

M 12/5/1968 6/9/2008 50315.2

F 5/2/1987 4/26/2010 42099.2

M 6/16/1979 3/17/2003 54454.4

M 2/1/1964 1/3/2011 51313.6

M 7/14/1980 8/13/2011 31283.2

F 4/1/1983 8/18/2008 70449.6

F 10/18/1971 11/14/2002 76273.6

F 3/9/1975 11/3/2003 42099.2

F 2/1/1967 10/1/1999 35235.2

F 5/16/1979 1/4/2010 55556.8

M 5/22/1982 8/23/2006 49337.6

M 10/12/1985 7/1/2011 51313.6

M 5/22/1958 3/18/2013 130166.4

M 6/24/1969 6/20/2011 66393.6

M 7/18/1983 9/8/2007 60132.8

M 10/11/1971 3/6/2007 51313.6

M 8/11/1969 12/1/1989 84198.4

M 7/27/1980 6/4/2011 60132.8

M 9/27/1982 12/19/2011 53393.6

M 11/4/1966 12/11/1989 76273.6

M 3/27/1988 10/22/2012 52353.6

F 4/17/1965 9/27/2010 48360

M 11/17/1980 7/6/2010 52353.6

F 8/25/1968 5/24/2010 35942.4

M 9/30/1968 3/12/2012 125112

M 6/11/1966 10/20/2000 55556.8

F 8/14/1971 12/10/2007 48360

M 8/22/1971 6/16/2002 71864

M 6/16/1964 10/15/1996 55556.8

F 3/18/1982 9/8/2007 62566.4

M 6/30/1984 4/20/2015 108929.6

M 8/17/1983 2/15/2004 60132.8

F 8/5/1987 4/11/2011 65083.2

M 7/16/1985 2/7/2008 56659.2

F 9/22/1956 6/8/2009 31907.2

F 2/17/1964 10/2/2000 35235.2

M 1/18/1980 9/25/2006 58947.2

F 8/31/1980 10/4/2004 45572.8

M 8/3/1974 7/10/2002 65083.2

M 4/3/1968 3/12/1995 76273.6

F 10/2/1975 5/24/2010 37377.6

M 3/26/1963 1/22/2008 76273.6

M 4/17/1987 8/29/2011 42099.2

M 12/15/1971 10/3/2006 104686.4

F 10/14/1978 6/18/2007 35942.4

M 8/29/1971 12/16/2006 62566.4

M 6/30/1978 1/22/2008 33862.4

M 11/1/1962 5/9/2011 56659.2

F 6/7/1958 5/5/2003 53393.6

M 3/19/1984 3/15/2010 66393.6

M 12/26/1990 4/9/2012 51313.6

M 9/25/1966 7/9/2007 62566.4

M 12/4/1956 10/29/2007 38126.4

M 9/9/1969 7/24/2003 65083.2

M 10/16/1973 5/1/1999 80932.8

M 7/29/1978 12/5/2000 63814.4

F 10/25/1961 11/1/1999 45572.8

F 3/27/1960 9/26/2011 35942.4

M 4/3/1977 10/20/2000 71864

M 5/14/1982 11/6/2006 45572.8

M 7/6/1983 12/8/2008 52353.6

M 5/26/1967 6/13/2006 35235.2

M 5/27/1958 7/17/1995 47424

M 8/29/1974 12/1/2008 31907.2

M 2/12/1986 11/7/2011 55556.8

M 10/18/1956 12/13/2003 54454.4

F 4/14/1973 8/16/2004 35942.4

M 5/23/1973 11/2/2015 50315.2

M 4/4/1978 5/11/1998 38126.4

M 9/15/1974 1/27/1997 85883.2

M 9/18/1968 3/31/2003 80932.8

M 9/14/1961 1/22/2003 42952

M 11/15/1983 5/22/2006 53393.6

M 2/23/1973 11/5/2007 56659.2

M 9/21/1963 8/29/2011 28912

M 2/1/1970 1/8/2007 61339.2

M 10/26/1972 4/2/2007 55556.8

M 9/20/1969 6/18/2007 48360

M 1/4/1982 1/3/2005 49337.6

M 10/8/1985 1/2/2012 44678.4

M 4/18/1986 1/8/2007 33196.8

M 9/24/1968 8/8/2006 33196.8

M 12/4/1969 6/25/2005 56659.2

F 1/15/1954 1/3/2011 49337.6

M 11/11/1980 10/22/2003 67724.8

M 7/5/1981 6/7/2010 43804.8

F 5/5/1983 7/9/2007 45572.8

F 10/12/1976 12/11/2000 46488

M 6/14/1972 1/5/1998 42952

M 2/23/1970 3/11/2013 79352

M 9/12/1973 4/8/2002 71864

F 1/22/1963 10/14/2008 50315.2

M 7/13/1968 1/12/1998 63814.4

M 12/11/1974 5/8/2006 60132.8

M 10/16/1971 12/11/2000 65083.2

M 4/20/1973 1/30/2011 44678.4

M 1/14/1975 4/17/2004 61339.2

M 1/16/1965 10/1/1988 84198.4

M 12/8/1964 8/14/2000 42099.2

F 5/4/1982 1/4/2010 54454.4

M 1/13/1978 3/5/2007 55556.8

M 11/30/1976 4/14/2004 69076.8

M 8/30/1961 7/2/1990 71864

M 8/21/1983 1/13/2007 52353.6

F 4/1/1961 1/15/2002 77792

F 5/29/1965 1/31/2011 38896

F 12/15/1971 5/23/2002 63814.4

M 12/8/1980 10/23/2001 57803.2

M 6/27/1967 6/11/2001 117894.4

M 12/2/1986 7/6/2010 82555.2

M 4/9/1993 8/13/2012 28912

M 2/7/1982 8/10/2009 56659.2

M 2/21/1982 2/27/2012 55556.8

M 8/7/1986 8/29/2011 28329.6

F 3/14/1956 9/2/2003 42952

M 2/2/1979 9/21/2004 67724.8

M 2/24/1981 8/27/2012 43804.8

F 9/4/1967 2/20/2007 89356.8

M 1/11/1961 3/6/2007 62566.4

M 7/27/1987 8/26/2013 52353.6

F 5/16/1969 9/4/2013 42952

F 11/3/1991 10/8/2013 31283.2

M 8/28/1965 9/16/2013 76273.6

F 8/3/1968 11/4/2013 94827.2

F 9/5/1979 11/18/2013 53393.6

F 11/14/1961 11/18/2013 50315.2

M 2/25/1971 12/2/2013 33862.4

M 9/1/1975 1/21/2014 52353.6

F 11/29/1974 1/13/2014 41267.2

M 8/5/1968 12/16/2013 29473.6

M 10/1/1975 2/11/2014 28912

F 6/16/1981 8/6/2016 27768

M 12/18/1985 6/2/2014 42952

M 7/4/1971 5/12/2014 50315.2

M 5/23/1986 7/28/2014 48360

M 3/26/1979 7/28/2014 27227.2

M 8/11/1988 8/25/2014 51313.6

F 6/12/1976 10/6/2014 55556.8

M 7/6/1989 10/6/2014 49337.6

M 8/25/1989 10/6/2014 49337.6

M 6/10/1958 10/20/2014 67724.8

M 7/6/1990 12/15/2014 42099.2

M 7/13/1989 12/15/2014 42952

F 8/4/1979 12/3/2014 34528

M 8/14/1976 12/29/2014 41267.2

M 11/5/1978 12/29/2014 28329.6

F 2/17/1983 2/23/2015 87609.6

M 3/4/1993 3/22/2015 27227.2

M 5/19/1981 5/4/2015 42099.2

M 10/15/1987 5/4/2015 42099.2

F 10/21/1981 6/29/2015 49337.6

F 12/18/1989 6/15/2015 49337.6

M 11/15/1973 8/24/2015 102648

F 11/1/1980 8/24/2015 41267.2

M 5/13/1984 10/3/2015 40476.8

F 8/5/1992 10/5/2015 47424

F 3/28/1978 10/5/2015 50315.2

F 5/7/1987 10/5/2015 51313.6

M 6/22/1978 10/20/2015 27768

M 9/8/1988 11/30/2015 41267.2

M 6/12/1983 11/30/2015 28912

M 10/7/1959 11/30/2015 26707.2

F 9/24/1992 12/28/2015 48360

F 5/24/1964 1/22/2016 28912

M 7/14/1990 2/22/2016 41267.2

M 7/5/1989 3/21/2016 41267.2

F 7/20/1994 4/4/2016 42099.2

M 5/3/1987 4/4/2016 41267.2

M 4/28/1983 4/4/2016 41267.2

F 7/16/1975 4/2/2016 28912

M 6/30/1980 4/18/2016 31283.2

M 3/22/1956 5/2/2016 25667.2

M 8/19/1996 5/2/2016 33862.4

F 7/5/1989 5/16/2016 50315.2

F 9/24/1981 6/13/2016 57803.2

F 1/3/1960 6/13/2016 28912

M 11/2/1988 6/11/2016 41267.2

F 12/1/1980 7/23/2016 28329.6

M 5/10/1994 8/8/2016 40476.8

M 3/10/1986 8/8/2016 40476.8

M 12/31/1991 8/8/2016 40476.8

M 7/10/1971 8/22/2016 54454.4

M 10/3/1966 9/6/2016 42952

M 10/3/1986 9/3/2016 40476.8

M 6/28/1982 9/19/2016 30680

F 4/24/1991 10/3/2016 28329.6

F 7/29/1968 10/3/2016 55556.8

F 8/3/1979 10/17/2016 28329.6

F 8/31/1961 10/17/2016 28329.6

M 2/11/1987 11/7/2016 40476.8

M 5/25/1990 11/28/2016 27227.2

M 7/29/1965 11/28/2016 42099.2

M 9/13/1985 1/23/2017 47424

F 11/4/1990 1/23/2017 28329.6

M 9/22/1994 2/6/2017 47424

F 10/13/1965 2/6/2017 25168

M 8/22/1989 2/21/2017 40476.8

F 5/11/1993 3/21/2017 38896

M 2/15/1996 3/21/2017 27227.2

M 5/7/1968 5/15/2017 84198.4

M 8/20/1990 5/15/2017 51313.6

M 3/5/1959 5/15/2017 29473.6

M 12/28/1988 6/12/2017 48360

F 7/21/1983 6/12/2017 38986

M 12/5/1986 5/29/2017 40476.8

F 6/28/1991 7/10/2017 28329.6

F 5/18/1988 7/10/2017 25168

F 2/2/1994 7/24/2017 47424

F 1/12/1994 7/24/2017 35000

F 10/8/1987 8/7/2017 30000

F 12/18/1990 8/21/2017 60132.8

M 2/7/1977 8/21/2017 34528

F 8/26/1981 9/5/2017 37377.6

F 5/24/1989 9/5/2017 42099.2

F 6/3/1994 9/5/2017 24190.4

F 1/1/1972 9/5/2017 34528

F 8/16/1981 9/5/2017 47424

M 4/30/1997 10/16/2017 42099.2

M 5/14/1996 10/30/2017 42099.2

F 2/25/1993 11/13/2017 34500

M 12/16/1967 11/13/2017 100630.4

M 9/3/1967 11/9/2017 24200

F 11/21/1982 11/27/2017 51313.6

M 7/13/1983 11/27/2017 42099.2

M 11/19/1978 12/11/2017 38896

M 5/16/1983 12/11/2017 25168

M 8/30/1996 1/8/2018 26187.2

M 5/1/1991 2/5/2018 30680

M 2/21/1963 2/20/2018 84198.4

M 2/26/1991 3/19/2018 28000

M 1/27/1993 3/19/2018 42000

M 8/17/1963 3/19/2018 33217

M 7/20/1987 3/19/2018 28329.6

M 3/8/1990 3/19/2018 31907.2

M 8/18/1964 3/19/2018 38896

M 3/17/2000 9/17/2018 31907.2

M 5/14/1968 4/2/2018 28329

F 11/30/1992 4/2/2018 37777.6

M 11/29/1992 4/2/2018 31907.2

F 12/16/1985 4/30/2018 53393

M 12/27/1991 4/30/2018 42099.2

F 9/26/1984 4/30/2018 42099.2

F 9/26/1998 4/30/2018 34528

M 12/28/1973 5/14/2018 49337.6

F 3/31/1994 4/30/2018 34528

F 11/12/1980 5/29/2018 49337.6

F 10/26/1999 5/14/2018 34528

F 11/8/1977 5/14/2018 60132

M 4/26/1996 5/14/2018 26787

F 10/26/1992 5/14/2018 34528

M 7/14/1983 5/14/2018 26182.27

M 11/13/1969 5/14/2018 31907.7

F 3/7/1999 5/29/2018 34528

M 10/4/1973 6/11/2018 42099.2

F 6/6/1988 6/11/2018 33196.8

F 4/14/1990 6/2/2018 29473.6

M 8/26/1981 7/9/2018 74776

M 7/9/1983 7/23/2018 42099.2

M 6/10/1968 7/23/2018 34528

M 8/16/1997 7/23/2018 26187.2

M 3/29/1990 7/23/2018 26187.2

M 2/1/1979 7/23/2018 38896

F 11/16/1996 7/23/2018 42099.2

M 12/30/1971 7/28/2018 28329.6

M 4/14/1995 8/6/2018 28329.6

F 12/12/1986 9/1/2018 85883

M 8/5/1996 9/4/2018 41600

F 11/13/1972 9/17/2018 55000

F 4/10/1971 10/1/2018 35000

F 7/6/1978 10/1/2018 29000

F 7/10/1972 10/15/2018 24190.4

M 8/12/1997 10/15/2018 24000

nicebenname incomeannual curamounttotal

Short Term Disability Insurance ‐ UNUM STD 61339.2 50.25







Short Term Disability Insurance ‐ UNUM STD 28912 23.69








Short Term Disability Insurance ‐ UNUM STD 130166.4 183






























Short Term Disability Insurance ‐ UNUM STD 28000 21

city of schertz 284732 short term disability

Documents