Page 33 - Complete Hi-Res 7-product Kit

[Monthly [Biweekly [Weekly
[Sickness Hospital Confinement Benefit Option] Premium] Premium] Premium]

Employee only [$0.00] [$0.00] [$0.00]
Employee & spouse[/domestic partner] [$0.00] [$0.00] [$0.00]
Employee & child/children [$0.00] [$0.00] [$0.00]

Employee & family [(spouse/domestic partner and [$0.00] [$0.00] [$0.00]
child/children)]

[Sickness Hospital Confinement Benefit Option]
• You receive a [$0 daily] cash benefit (for up to 30 days) if you are hospitalized for a sickness.
• [You receive an additional [$0] cash benefit if you are admitted to the hospital for a sickness.]

• [You receive an additional [$0 daily] cash benefit (for up to 30 days) if you are admitted to the ICU
for a sickness.]

• [This benefit option is also available to family members/domestic partners.]

[Monthly [Biweekly [Weekly
[Motor Vehicle Accident (MVA) Benefit Option] Premium] Premium] Premium]
Employee only [$0.00] [$0.00] [$0.00]
Employee & spouse[/domestic partner] [$0.00] [$0.00] [$0.00]

Employee & child/children [$0.00] [$0.00] [$0.00]
Employee & family [(spouse/domestic partner and [$0.00] [$0.00] [$0.00]
child/children)]

[Motor Vehicle Accident (MVA) Benefit Option]
• You receive a [$0] cash benefit if you have a covered injury in a motor vehicle accident.
• [This benefit option is also available to family members/domestic partners.]

Note: You receive one cash benefit per motor vehicle accident, regardless of the number of covered
occupants injured in the motor vehicle.

Additional Plan Benefit
Portability Included

• You may be able to continue your coverage if you leave your job.
• To take advantage of this benefit, send your written application and first premium payment
to Lincoln Financial Group within 31 days of the date your coverage would otherwise end.

[Form Filing Number] Accident Insurance | [Choice Plan] Summary of Benefits