Guaranteed Acceptance Accident Only Disability Plan for members of the

Guaranteed Acceptance Accident Only Disability Plan for members of the Rhode Island Bar Association Eligibility & Effective Date You are eligible for Guaranteed Acceptance Accident Only Disability coverage so long as you are an Association member, member spouse (not legally separated or divorced from the eligible member), or member employee, who is between the ages of 18 and 65 and currently residing in the United States. Your coverage will become effective on the first day of the month following your acceptance to the Plan, provided that you are actively at work at least 24 hours a week and that the premium has been paid. If an Eligible Member, Spouse or Employee is to become covered under the Policy; or covered for increased benefits under the Policy; and is not Actively-at-Work on that date, he or she will not be so covered until the date he or she has been Actively-at-Work for a period of three consecutive months. Benefits of up to $5,000 a Month You can receive up to $5,000 per month in benefit payments (not to exceed 70% of your Basic Monthly Pay), for up to two full years should you suffer a disabling injury due to an accident. Under the Guaranteed Acceptance Accident Only Disability Plan, full benefits are paid regardless of any other benefits you receive except for Workers’ Compensation. Basic Monthly Pay means your regular monthly rate of pay, not counting commissions, bonuses, overtime pay or any other fringe benefit or extra compensation, in effect on the last day of Active Employment prior to becoming Disabled. Injury means bodily injury which results independently and directly of all other causes from an accident Your Money Back Guarantee of Satisfaction Unrestricted Coverage as to Time & Place Guaranteed Acceptance Accident Only Disability coverage applies 24 hours a day, 7 days a week. It is specific only to you and protects you at work, home, or leisure, anywhere in the U.S. or around the world. This is a no risk offer. Once you enroll in the Guaranteed Acceptance Accident Only Disability Plan, your Certificate of Insurance will be sent to you in the mail. You will then have 30 days to review your Certificate and make sure this coverage is right for you. If you are not completely satisfied, simply return your Certificate for a full refund of your initial premium (less any claims paid). No questions asked Affordable Group Rates Select the benefit amount you desire, not to exceed 70% of your Basic Monthly Pay. Then select the waiting period option you would like: 30, 60, or 90 days corresponding to the rates below. Monthly Benefit Amount $5,000 $4,000 $3,000 $2,000 Quarterly Premium Amount by Waiting Period 30 Day $67.50 $54.00 $40.50 $25.50 60 Day $51.00 $40.50 $30.00 $19.50 90 Day $36.00 $28.50 $21.00 $13.50 Coverage Cannot Be Individually Cancelled This coverage cannot be individually cancelled as long as you remain an Association member under the age of 70 living in the U.S. who is actively at work (except by reason of disability covered under the Plan) with your premium paid to date. With respect to Member Spouse or Member Employee coverage: termination will be when the Member is no longer covered under the Policy, or when they no longer qualify as a dependent under the terms of the Policy. See reverse side for more plan details. Rates and/or coverage may be changed on a class basis. To Enroll in the Guaranteed Acceptance Accident Only Disability Plan 1. Confirm enrollee(s) eligibility. Member spouses and member employees may enroll whether or not the member is taking coverage. 2. Select your desired benefit amount and waiting period. 3. Complete the following and be sure to sign and date the form on the reverse side. Each enrollee must sign individually. 4. Detach and mail to: ISI Administrative Center • P.O. Box 2327 • Beaufort, SC 29901 I am applying as a: (Check One) Member Name (First, Middle, Last) Applicant Name (First, Middle, Last) Address (Street, City, State, Zip Code) Member Member Spouse Name of Organization Rhode Island Bar Association Applicant Occupation Phone Number Me Member Employee Policyholder Name ISI Insur ance Trust Sex Date of Birth Basic Monthly Pay Underwritten by: Hartford Life and Accident Insurance Company Policy Form # SRP-1311 A (HLA) (5350) Policy #: AGP-5350 See reverse side to complete and sign application. Total Disability Total Disability means disability which wholly and continuously prevents a Covered Person from performing the substantial and material duties of his or her usual occupation. Exclusions This Policy does not cover: 1) intentionally self inflicted Injury, suicide or attempted suicide, while sane or insane; 2) war or act of war, whether declared or not; 3) any Injury sustained while riding on, boarding or alighting from, any aircraft: a) as a pilot, crew member or student pilot; b) operated by any military authority (land, sea or air), unless it is a Military Transport Aircraft used for transport and operated by the United States Military Air Mobility Command (AMC) or an AMC type service of a national government recognized by the United States; or c) being used for tests, experimental purposes, stunt flying, racing or endurance tests; 4) the commission or attempted commission of a felony by the Covered Person; 5) sickness or disease; 6) Injury sustained while on full-time active duty as a member of the Armed Forces (land, water, air) of any country international authority. We will refund the pro rata portion of any premium paid for the Covered Person while he or she is in the Armed Forces on full-time active duty for a period of two months or more. Written notice must be given to us within 12 months of the date he or she enters the Armed Forces. Successive Periods of Disability Limitation: Periods of Disability due to the same or related medical causes; and separated by less than 6 months during which you are Actively-at-Work; will be considered one Period of Disability. Periods of Disability separated by at least 6 months during which you are Actively-at-Work will be considered separate Periods of Disability. Concurrent Disabilities: Benefits during any Period of Disability as the result of more than one accident will be considered the same as if the disability resulted from only one cause. This brochure explains the general purpose of the insurance described, but in no way changes or affects the Master Policy AGP-5350 as actually issued. In the event of a discrepancy between this brochure and the policy, the terms of the policy apply. All benefits are subject to the terms and conditions of the policy. Policies underwritten by the Hartford Life and Accident Insurance Company detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in full or discontinued. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy issued to the policyholder. This program may vary and may not be available to residents of all states. Policy Form # SRP-1311 A (HLA) (5350) Underwritten By: Hartford Life and Accident Insurance Company Hartford, CT • 06104-2999 The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including the issuing company of Hartford Life and Accident Insurance Company. 1 Plan Administrator: ISI Direct: 1-888-ISI-1959 Fax: 843-525-9992 Monthly Benefit Amount Waiting Period Premium Enclosed Checks payable to Insurance Specialists, Inc. Specialists $5,000 $4,000 $3,000 $2,000 30 Day 60 Day 90 Day $ I hereby request coverage under the Guaranteed Acceptance Accident Only Disability Plan. I represent that I am an Association member, member spouse, or member employee working at least 24 hours per week, living in the U.S., and am under age 65. I further certify that the statements above are true and complete to the best of my knowledge and are binding on any person. By selecting coverage under this Plan, I recognize that the benefit amount cannot exceed 70% of my monthly base income (minus any benefits payable under Workers Compensation) or my maximum benefit selected in enrollment. Enrollee Signature - Submit one Enrollment Form per Enrollee. Copies of this form with original signatures are acceptable. Date Signature and date required to process your application. WS0606