Quality Care at Significant Savings

Access to the right doctors can be the most important part of your health care.

Convenient Doctor Office Copay Benefits

Designed for individuals and families, our copay plans are more like traditional employer plans with a copayment for routine health-care expenses. When you use a network doctor for an office visit, we pay 100% of history and exam fees after a $35 copay with Copay Select^SM. Office visits outside your network are covered subject to the applicable deductible and your chosen coinsurance.

Adult and Child Preventive Care Included

After a 3-month waiting period, you pay $35 for the doctor office visit with Copay Select^SM. X-rays and lab tests are covered after you pay your chosen coinsurance (0%, 20%, or 30%).

Prescription Drug* Card Benefits (Copay Select^SM Only)

• Tier 1 drugs — $15 copay.
  • Tier 2-4 drugs — combined $200 deductible per person, per calendar year, then:
    • $35 copay for Tier 2 drugs.
    • $65 copay for Tier 3 drugs.
    • 25% coinsurance (you pay) for Tier 4 drugs.

Comprehensive Coverage for Inpatient and Outpatient Medical Expenses

(Copay Select^SM Only)

• You choose $3 million or $5 million lifetime maximum benefit per covered person.
• Covered inpatient and outpatient expenses are reimbursed after your chosen coinsurance and the deductible.

Copay Saver^SM

The Copay Saver^SM plan provides the convenience of copays for doctor office visits (limited to 2 visits per person, per calendar year) for a lower monthly premium.

*We have a preferred drug list, which changes periodically. Tier status for a prescription drug may be determined by accessing your prescription drug benefits via our Web site or by calling the telephone number on your identification card. The tier to which a prescription drug is assigned may change as detailed in your policy/certificate.

HSA Plans Offer Quality Coverage, Savings

HSA Plans simply combine a lower-cost, high deductible health insurance plan and a tax-favored savings account.

Lower Premiums, Tax-Advantaged Savings, and an Attractive Interest Rate*

High deductible plans typically cost a lot less than many copay or traditional plans. This means lower premiums for you. You can then take the premium savings and place it into your health savings account.

• You get a tax deduction on the money you put in your HSA.
• Your dollars can grow tax-deferred.
• You spend the savings tax-free to help pay your deductible or for qualified medical care (including prescriptions, vision, or dental care).
• What you don’t use in your account will continue to accumulate year after year. Then, if you ever need it for

health-care expenses, the money will be there.

• With Golden Rule’s HSA custodian, you’ll also earn interest on your savings, beginning with the first dollar deposited.

Adult and Child Preventive Care Included

With our HSA plans, after a 3-month waiting period, you pay a $35 copay (in-network) for the doctor office visit.

Bottom line — HSAs can help make

Traditional Insurance High Deductible Insurance Premium Savings $

health insurance more affordable.

Premium $ Premium $ Put Into HSA
*See HSA insert for important information.

About Your HSA

We have chosen OptumHealth Bank, a leading administrator of health savings accounts (HSA), as our financial institution. Your HSA funds are deposited at OptumHealth Bank in a custodial account. OptumHealth Bank, Member FDIC, will service your account and send information directly to you about your HSA.

You will receive your new Health Savings Account Card^SM and PIN in separate mailings. Once you activate your card, you can use it at:

• Any point-of-service location (such as a doctor’s office or pharmacy) that accepts MasterCard® debit cards.

• Any ATM displaying the MasterCard® brand mark. ($1.50 per transaction OptumHealth Bank fee. In addition, the bank/ATM you use to withdraw funds may charge you its own fee (variable by bank) for the transaction.)

You can also access your HSA funds through:

• Online bill payment at OptumHealthBank.com
• Checks, if you choose to purchase them.

HSA deposits are set up on the same payment plan as premiums for Golden Rule health insurance coverage.

Lump-sum deposits are also accepted by

OptumHealth Bank; however, you must continue to deposit the $25 monthly minimum with your premium payment. OptumHealth Bank will provide online monthly statements detailing your account balance and activity. If you prefer to have statements mailed to your home, simply notify OptumHealth Bank. You can opt out of electronic statements at its Web site (OptumHealthBank.com), call customer service to do so, or send your request to

P.O. Box 271629,

Salt Lake City, UT 84127-1629.

Account Information by Phone or Online

Who is responsible for my HSA?

As custodian, OptumHealth Bank is responsible for your HSA funds. OptumHealth Bank’s deposits are insured by the Federal Deposit Insurance Corporation (FDIC).

Please be aware that the money market and mutual

fund investment options are NOT guaranteed by OptumHealth Bank, are NOT FDIC-insured, and may lose value. We encourage you to read the prospectus of each fund carefully before investing and seek the advice of an investment professional you trust.

You will receive a Health Savings Account card from OptumHealth Bank shortly after your qualified medical coverage becomes effective. HSA withdrawals can be made by simply using your Health Savings Account card at any point-of-service location (such as a doctor’s office or pharmacy) that accepts MasterCard® debit cards.

If you prefer, you can purchase the qualified health insurance coverage from Golden Rule and set up your savings account with another qualified custodian.

Lower Premiums

With high deductible plans, you’re keeping more of your money and taking responsibility for covering minor or routine health-care expenses — if they come up. The higher the deductible, the lower your premiums.

Saver 80^SM is our lowest premium plan. This plan provides coverage for hospital confinements, surgical procedures in or out of the hospital (but not in the doctor’s office), and the more costly outpatient expenses, such as CAT scans and MRIs.

Simple to Use

Golden Rule’s top-selling high deductible plan — Plan 100® — pays 100% of covered expenses once you meet your calendar-year deductible. Your benefits are not complicated with multiple copays or coinsurance.

Comprehensive Coverage

• You choose $3 million or $5 million lifetime maximum benefit per covered person.
• Plan 100® and Plan 80^SM include preventive care and child immunizations with no waiting period.
• Add optional benefits to increase coverage (see Optional Benefits on page 12 for details).

This chart summarizes standard network covered expenses, exclusions, Feb 26 2010 10:58:48 and limitations of each plan. See pages 5, 13-18 for more information.

$5 Million Lifetime Maximum

This option is not available in VA. Upgrade your coverage to $5,000,000 of covered expenses per person.

24-Month Initial Rate Guarantee

Extend your rate guarantee to 24 months. Does not apply to benefit and address changes.

No Annual Maximum Prescription Drug

This option is not available with Saver 80^SM or Copay Saver^SM Eliminates the $3,000 calendar-year limit.

$25 Office Visit Copay

This option is available with Copay Select^SM . Reduce the cost of doctor office visit copay from $35 to $25.

2 Additional Dr. Office Visits

This option is available with Copay Saver^SM . Increase the number of Doctor Office Visits from 2 to 4 per person, per calendar year.

Prescription Drug* Copay

This option is available with Plan 100® and Plan 80^SM . Cannot be combined with the No Annual Maximum Prescription Drug Plan Enhancement.

With this benefit, you pay:

• Tier 1 drugs — $15 copay.
• Tier 2-4 drugs — combined $200 deductible per person, per

calendar year, then:

—

Tier 2 drugs — $35 copay.

—

Tier 3 drugs — $65 copay.

— Tier 4 drugs — you pay 25% coinsurance. (Maximum $3,000 in covered expenses, per person, per calendar year.)

Optional Benefits

Preventive Care

This option is available with Plan 100®, Plan 80^SM, Saver 80^SM, and Copay Saver^SM .

• $35 copay on preventive care network office visits (primary care,

OBGYN, etc).

• The following charges for preventive care that are performed in

conjunction with the network office visit are exempt from the deductible and coinsurance whether performed in the doctor’s office or elsewhere:

—

Child (under age 19) and adult immunizations.

—

Mammogram, cervical and Pap smears.

—

Urinalysis and blood tests.

—

Bone density screens.

—

EKG and cardiac stress tests.

—

PSA tests and digital rectal exams.

—

FDA-approved screenings for HPV.

• Copay Saver^SM

—

3-month waiting period eliminated.

—

Not subject to the office visit limit.

Maternity Benefit

This option is available with Plan 100®, Plan 80^SM, Saver 80^SM, Copay Select^SM, and Copay Saver^SM; not available in AR, MD, NC, or VA. This optional benefit helps cover the costs for routine pregnancy and delivery for the primary insured and spouse only. You pay 20%; we pay 80% of covered expenses. After 4 benefit years, the maximum covered expense amount is $7,500.

No covered expenses will be considered for reimbursement for a pregnancy beginning before the maternity benefit’s effective date.

If you purchase name-brand when generic is available, you pay your generic copay plus the additional cost above the generic price.

*We have a preferred drug list, which changes periodically. Tier status for a prescription drug may be determined by accessing your prescription drug benefits via our Web site or Feb 26 2010 10:58:48 by calling the telephone number on your identification card. The tier to which a prescription drug is assigned may change as detailed in your policy/certificate.
You’ve made the decision to help protect your family’s health by seeking insurance; shouldn’t you consider helping protect their financial future too?

Term life insurance may be an ideal benefit to make sure you provide for your loved ones’ future.

Consider your current financial picture and ask, “Without a term life insurance benefit paid to my loved ones upon my death, would they be able to:

• Pay for funeral expenses?
• Pay the mortgage or other debts?
• Save for college or retire comfortably?”

Remember to select this option as you apply for health coverage.

Enhanced Term Life Benefit

You may choose an optional term life insurance benefit for you and/or a spouse who is also a covered person under the health plan. You and/or your spouse must be age 18 or older. The term life benefit expires when a covered person reaches age 65.

You select one of three benefit amounts. You may select different amounts for you and your spouse.

Benefit Amounts: $50,000 $100,000 $150,000

Accidental Death Benefit

This benefit provides $50,000 in coverage in the event of an accidental death for you and/or your spouse if your spouse is also a covered person under the health plan. You and/or your spouse must be age 18 or older. The accidental death benefit expires when a covered person reaches age 65. It may be purchased with or without the term life benefit.

Motorcyclists are not eligible for this benefit.

Golden Rule Insurance Company, a UnitedHealthcare company, is the underwriter and administrator of these plans marketed under the UnitedHealthOne brand.

Additional premium is required. Availability varies by state. Exclusions for suicide, military service, and certain hazardous activities apply. Please see the corresponding health product brochure. Enhanced Term Life Benefit replaces any term life benefit in the corresponding health product brochure.

Something to Smile About.

Keeping your smile beautiful doesn’t have to be expensive. You can now upgrade your health plan with an optional dental benefit that can help keep you smiling brightly. UnitedHealthcare’s extensive network of dental care providers can offer you significant savings.

UnitedHealthcare Dental Benefit Rider — Two Options to Choose From

With Dental Coverage From UnitedHealthcare — You Have the Advantage.

With a UnitedHealthcare dental rider, your family has access to over 73,000 network dentists. The result can be significant discounts on quality care, and you never file a claim form. A healthy smile can be easier than you thought.

Preventive services have no waiting period and include routine dental exams, routine X-rays, cleaning, fluoride treatment, sealants, and space maintainers.

Basic services have a 6-month waiting period and include dental exams, X-rays, routine extractions, treatment to ease dental pain, and simple fillings.

Major services have a 12-month waiting period and include treatment for diseases of the pulp (including root canals), bone and other tissues supporting the teeth, crowns, inlays, onlays, veneers, bridges, dentures, and oral surgery for impactions.

You may choose an optional Enhanced Supplemental Accident benefit to reduce your out-of-pocket expenses for unexpected injuries.

• Up-front coverage can pay your deductible.
• Select a benefit amount: $500, $1,000, $2,500, $5,000, or $10,000, per accident, per covered person.

• Helps cover your deductible or other out-of pocket expenses (before the health insurance starts paying covered expenses).

• Expenses must be eligible for payment under the health insurance and incurred within 90 days of an injury.

• Any benefit amount paid by the Enhanced Supplemental Accident benefit will be credited to the network deductible and coinsurance of the health insurance.

• Additional premium is required for the optional Enhanced Supplemental Accident benefit rider.

Consult a tax advisor regarding whether our HSA plan with the optional Enhanced Supplemental Accident qualifies for favorable HSA (account) tax treatment.Golden Rule Insurance Company, a UnitedHealthcare company, is the underwriter and administrator of these plans marketed under the UnitedHealthOne brand.

Copay Select^SM, HSA 100®, HSA 70^SM, Plan 100®, and Plan 80^SM

To be considered for reimbursement, expenses must qualify as covered expenses. Expenses are also subject to reasonable and customary limits unless you use a network provider. We recommend review of the more detailed plan information on pages 15-18 and the state variations on pages 19-21.

Medical Expense Benefits

• Daily hospital* room and board and nursing services at the most common semiprivate rate.

• Charges for intensive care unit.
• Hospital emergency room treatment of an injury or illness

• Services and supplies, including drugs and medicines, which are routinely provided by the hospital to persons for use while they are inpatients.

• Professional fees of doctors and surgeons (but not for standby availability).

• Dressings, sutures, casts, or other necessary medical supplies.
• Professional fees for outpatient services of licensed physical therapists.

• Diagnostic testing using radiologic, ultrasonographic, or laboratory services in or out of the hospital.

• Local ground ambulance service to the nearest hospital for necessary emergency care. Air ambulance, within U.S., if requested by police or medical authorities at the site of emergency.

• Charges for operating, treatment, or recovery room for surgery.
• Dental expenses due to an injury which damages natural teeth if expenses are incurred within six months.
• Surgical treatment of TMJ disorders (see limitations on page 17).
• Cost and administration of anesthetic, oxygen, and other gases.
• Radiation therapy or chemotherapy.
• Prescription drugs.
• Hemodialysis, processing, and administration of blood and components.
• Mammography, Pap smear, and PSA test fees.
• Artificial eyes, larynx, breast prosthesis, or basic artificial limbs (but not replacements).

• Surgery in a doctor’s office or at an outpatient surgical facility, including services and supplies.

• Occupational therapy following a covered treatment for traumatic hand injuries.

Preventive Care Expense Benefits

Three-month waiting period for wellness benefits (not applicable to Plan 100® and Plan 80^SM). (Plan 100® and Plan 80^SM subject to the applicable deductible amount and coinsurance percentage. Copay Select^SM, HSA 100®, and HSA 70^SM exempt from any applicable deductible amount.)

Covered expenses are expanded to include charges for the following when incurred for preventive care:

The following are not subject to the 3-month waiting period:

Preventive Care Expense Benefits will not include and no benefits will be paid for computerized axial tomography (CAT or CT scan), magnetic resonance imaging (MRI) or positron emission tomography (PET scan) performed on a routine or preventive basis.

See pages 7, 9, and 11 for coverage details. For information on additional plan provisions, including Transplant Expense Benefit, Limited Exclusion for AIDS or HIV-related Disease, Notification Requirements, Preexisting Conditions, General Exclusions, General Limitations, and Other Plan Provisions, read pages 15-18.

*Hospital does not include a nursing home or convalescent home or an extended care facility.

Saver Plans — Copay Saver^SM and Saver 80^SM

To be considered for reimbursement, expenses must qualify as covered expenses. Expenses are also subject to reasonable and customary limits unless you use a network provider. We recommend review of the more detailed plan information on pages 15-18 and the state variations on pages 19-21.

Inpatient Expense Benefits

• Daily hospital* room and board and nursing services at the most common semiprivate rate.

• Charges for intensive care unit.
• Drugs, medicines, dressings, sutures, casts, or other necessary medical supplies.

• Artificial limbs, eyes, larynx, or breast prosthesis (but not replacements).

• Professional fees of doctors and surgeons (but not for standby availability).

• Hemodialysis, processing, and administration of blood or components.

• Charges for an operating, treatment, or recovery room for surgery.

• Cost and administration of an anesthetic, oxygen, or other gases.
• Radiation therapy or chemotherapy and diagnostic tests using radiologic, ultrasonographic, or laboratory services.

• Local ground ambulance service to the nearest hospital for necessary emergency care. Air ambulance, within U.S., if requested by police or medical authorities at the site of the emergency.

Outpatient Expense Benefits

• Charges for outpatient surgery in an outpatient surgical facility, including the fee from the primary surgeon, the assistant surgeon, and/or administration of anesthetic (surgery performed in the doctor’s office is not covered).

• Hemodialysis, radiation, and chemotherapy.
• Prescription drugs to protect against organ rejection in transplant cases.
• Mammography, Pap smear, and PSA test fees.
• Hospital emergency room treatment of an injury or illness (subject to limitations shown on pages 7 and 11).
• CAT scan and MRI testing.
• Diagnostic testing related to, and performed within 14 days prior to, surgery or inpatient confinement.
• Copay Saver^SM plan includes two doctor office copay visits per person, per year (see page 7).
• Copay Saver^SM plan includes coverage for generic prescription drugs (see page 7).

**For family HSA plans, when combined per family deductible is not met. Feb 26 2010 10:58:48

Limited Exclusion for AIDS or HIV-Related Disease

AIDS or HIV-related disease are treated the same as any other illness unless the onset of AIDS or HIV-related disease is: (a) diagnosed before the coverage has been in force for one year; or (b) first manifested before the coverage has been in force for one year. If diagnosed or first manifested before coverage has been in force for one year, AIDS or HIV-related disease claims will never be covered. Details of this limited exclusion are set forth in the policy and certificates.

General Exclusions

No benefits are payable for expenses which:

• Are due to pregnancy (except for complications of pregnancy) or routine newborn care (unless optional coverage is selected, if available).

• Are for routine or preventive care unless provided for in the policy.

• Are incurred while confined primarily for custodial, rehabilitative, or educational care or nursing services.

• Result from or in the course of employment for wage or profit, if the covered person is insured, or is required to be insured, by workers’ compensation insurance pursuant to applicable state or federal law. If you enter into a settlement that waives a covered person’s right to recover future medical benefits under a workers’ compensation law or insurance plan, this exclusion will still apply.

• Are in relation to, or incurred in conjunction with, investigational treatment.

• Are for dental expenses or oral surgery, eyeglasses, contacts, eye refraction, hearing aids, or any examination or fitting related to these.

• Are for modification of the physical body, including breast reduction or augmentation.

• Are incurred for cosmetic or aesthetic reasons, such as weight modification or surgical treatment of obesity.

• Would not have been charged in the absence of insurance.
• Are for eye surgery to correct nearsightedness, farsightedness, or astigmatism.

• Result from war, intentionally self-inflicted bodily harm (whether sane or insane), or participation in a felony (whether or not charged).

• Are for treatment of temporomandibular joint disorders, except as may be provided for under covered expenses.

• Are incurred for animal-to-human organ transplants, artificial or mechanical organs, procurement or transportation of the organ or tissue, or the cost of keeping a donor alive.

• Are incurred for marriage, family, or child counseling.
• Are for recreational or vocational therapy or rehabilitation.
• Are incurred for services performed by an immediate family member.

• Are not specifically provided for in the policy or incurred while your certificate is not in force.

• Are for any drug treatment or procedure that promotes conception.

• Are for any procedure that prevents conception or childbirth.
• Result from intoxication, as defined by applicable state law in the state where the illness or injury occurred, or under the influence of illegal narcotics or controlled substances unless administered or prescribed by a doctor.
• Are for or related to surrogate parenting.
• Are for or related to treatment of hyperhidrosis (excessive sweating).
• Are for fetal reduction surgery.
• Are for alternative treatments, except as specifically identified as covered expenses under the policy/certificate, including: acupressure, acupuncture, aromatherapy, hypnotism, massage therapy, rolfing, and other forms of alternative treatment as defined by the Office of Alternative Medicine of the National Institutes of Health.

Benefits will not be paid for services or supplies that are not medically necessary to the diagnosis or treatment of an illness or injury, as defined in the policy.

General Limitations

• Expenses incurred by a covered person for treatment of tonsils, adenoids, middle ear disorders, hemorrhoids, hernia, or any disorders of the reproductive organs are not covered during the covered person’s first six months of coverage under the policy. This provision will not apply if treatment is provided on an “emergency” basis. “Emergency” means a medical condition manifesting itself by acute signs or symptoms that could reasonably result in placing a person’s life or limb in danger if medical attention is not provided within 24 hours.

• Covered expenses will not include more than what was determined to be the reasonable and customary charge for a service or supply.

• Transplants eligible for coverage under the Transplant Expense

• Charges for an assistant surgeon are limited to 20% of the primary surgeon’s covered fee.

• Covered expenses for surgical treatment of TMJ, excluding tooth

extractions, are limited to $10,000 per covered person.

• All diagnoses or treatments of mental disorders, as defined in the

policy, including substance abuse, are limited to a lifetime maximum benefit of $3,000 (not covered in Saver Plans, subject to state variations). Covered expenses for outpatient diagnosis or treatment of mental disorders are further limited to $50 per visit. As with any other illness or injury, inpatient care that is primarily for educational or rehabilitative care is not covered.

• Covered outpatient expenses relating to diagnosis or treatment of

any spine or back disorders are limited to a maximum of $2,000 per calendar year. CAT scan and MRI tests are not subject to this limitation.

• Covered expenses are limited to no more than a 34-day supply for

any one outpatient prescription drug order or refill.

Effective Date

For injuries, the effective date for a mailed application will be the later of: (a) the requested effective date, if any, shown on the application; or

(b) the date upon which the original application is actually received by

Golden Rule. For an application sent by any electronic method including fax, the effective date for injuries will be the later of: (a) the requested effective date, if any, shown on the application; or (b) the day after the date upon which the application is actually received by Golden Rule.

The effective date for illnesses will be the same as for injuries if you are replacing prior coverage within 62 days of application for this coverage and disclose replacement information on the initial application for insurance. If replacement information is not disclosed on the initial application for insurance, the effective date for illnesses will be the 15th day after the effective date for injuries. Illnesses that begin prior to that 15th day will be treated as preexisting conditions and will not be covered until the individual has been a covered person for 12 months.

Premium

We may adjust the premium rates from time to time. Premium rates are set by class, and you will not be singled out for a premium change regardless of your health. The policy plan, age and sex of covered persons, type and level of benefits, time the certificate has been in force, and your place of residence are factors that may be used in setting rate classes. Premiums will increase the longer you are insured.

Home Health Care

To qualify for benefits, home health care must be provided through a

licensed home health-care agency. Covered expenses for home health aide services are limited to seven visits per week and a lifetime maximum of 365 visits. Registered nurse services are limited to a lifetime maximum of 1,000 hours.

Hospice Care

To qualify for benefits, a Hospice Care program for a terminally ill covered person must be licensed by the state in which it operates. Benefits for inpatient care in a hospice are limited to 180 days in a covered person’s lifetime. Covered expenses for room and board are limited to the most common semiprivate room rate of the hospital or nursing home with which the hospice is associated.

Dependents

For purposes of this coverage, eligible dependents are your lawful spouse and eligible children. Eligible children must be unmarried and under 25 years of age at time of application.

Termination of a Covered Person

A covered person’s coverage will terminate on the date that person no longer meets the eligibility requirements or if the covered person commits fraud or intentional misrepresentation.

Continued Eligibility Requirements

A covered person’s eligibility will cease on the earlier of the date a covered person:

Renewability

You may renew coverage by paying the premium as it comes due. We may decline renewal only:

Feb 26 2010 10:58:48

Underwriting

Coverage will not be issued as a supplement to other health plans that you may have at the time of application. Plans are subject to health underwriting. If you provide incorrect or incomplete information on your insurance application your coverage may be voided or claims denied.

Conditions Prior to Legal Action

To help resolve disputes before litigation, the policy requires that you provide us with written notice of intent to sue as a condition prior to legal action. This notice must identify the source of the disagreement, including all relevant facts and information supporting your position. Unless prohibited by law, any action for extra-contractual or punitive damages is waived if the contract claims at issue are paid or the disagreement is resolved or corrected within 30 days of the written notice.

Group — COB

If, after coverage is issued, a covered person becomes insured under a group plan, benefits will be determined under the Coordination of Benefits (COB) clause. COB allows two or more plans to work together so that the total amount of all benefits will never be more than 100% of covered expenses. COB also takes into account medical coverage under auto insurance contracts.

Medicare — Carve-Out

Covered persons who reach the age of Medicare eligibility and obtain Medicare coverage may continue coverage under these plans. Benefits will be provided according to the Medicare Carve-Out Benefit Reduction provision. Basically, “carve-out” pays the difference between what Golden Rule benefits normally would pay and what is paid by Medicare.

Feb 26 2010 10:58:48

State Variations

• The references to 24 and 12 months in the definition of a preexisting condition are changed to 6 months. Feb 26 2010 10:58:48

• The preexisting conditions reference to treatment within 24 months prior to the applicable effective date is changed to 12 months. This 12-month waiting period may be reduced for persons covered by qualifying prior coverage.

• The limited exclusion for AIDS does not apply.

• Nonemergency care provided out-of-network will be: reduced by 25% of the in-network benefit paid rather than 25% of the covered expense. (Still subject to reasonable and customary charges; and an additional deductible amount equal to the per person, calendar-year deductible.)

• Send medical claims to: Golden Rule Insurance Company 7440 Woodland Dr. Indianapolis, IN 46278-1720

Feb 26 2010 10:58:48

West Virginia

• The lifetime maximum benefit for all diagnosis or treatment of mental disorders, including substance abuse, is $10,000.

• The exclusion of TMJ disorders does not apply.
• Covered child immunizations are not subject

to the deductible or waiting period.

• Portability plans (guarantee issue without preexisting conditions exclusions) are available to eligible applicants. Review the application for insurance for details.

Wisconsin

• The limited exclusion for AIDS does not apply.
• The spine and back limitation does not apply.

• Covered expenses for all diagnoses or treatments of mental or nervous disorders and substance abuse are subject to the deductible and coinsurance, and are limited to a policy year maximum benefit of $7,000. Outpatient treatment is further limited to a maximum benefit of $2,000.

• Limited coverage for nonsurgical treatment of TMJ disorders is provided.
• Covered child immunizations are not subject

to the deductible or waiting period.

27 years of age at time of application.

personal representative);

if necessary, to make sure your privacy is protected; and

Exercising Your rights

• Contacting your Health Plan. If you have any questions about this notice or want to exercise any of your rights, please

• Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us at the following address: Golden Rule Insurance Company, Privacy Officer, 7440

Woodland Drive, Indianapolis, IN 46278-1719 You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any action against you for filing a complaint.

Fair Credit reporting act Notice

In some cases, we may ask a consumer-reporting agency to compile a consumer report, including potentially an investigative consumer report, about you. If we request an investigative consumer report, we will notify you promptly with the name and address of the agency that will furnish the report. You may request in writing to be interviewed as part of the investigation. The agency may retain a copy of the report. The agency may disclose it to other persons as allowed by the federal Fair Credit Reporting Act.

We may disclose information solely about our transactions or experiences with you to our affiliates.

medical Information Bureau

In conjunction with our membership in MIB, Inc., formerly known as Medical Information Bureau (MIB), we or our reinsurers may make a report of your personal information to MIB. MIB is a nonprofit organization of life and health insurance companies that operates an information exchange on behalf of its members.

If you submit an application or claim for benefits to another MIB member company for life or health insurance coverage, the MIB, upon request, will supply such company with information regarding you that it has in its file.

If you question the accuracy of information in the MIB’s file, you may seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. Contact MIB at:

MIB, Inc., 50 Braintree Hill Ste. 400, Braintree, MA 02184-8734,

(866) 692-6901, www.mib.com or (TTY) (866) 346-3642.

FINaNCIaL INFOrmaTION PrIVaCY NOTICE

We (including our affiliates listed at the end of this notice) are committed to maintaining the confidentiality of your personal financial information. For the purposes of this notice, “personal financial information” means information, other than health information, about an insured or an applicant for health care coverage that identifies the individual, is not generally publicly available and is collected from the individual or is obtained in connection with providing health care coverage to the individual.

We collect personal financial information about you from the following sources:

• Information we receive from you on applications or other forms

• Information about your transactions with us, our affiliates or

others, such as premium payment history. We do not disclose personal financial information about our

insureds or former insureds to any third party, except as required or permitted by law. We restrict access to personal financial information about you to

employees, affiliates, and service providers who are involved in administering your health care coverage or providing services to you. We maintain physical, electronic, and procedural safeguards that comply with federal standards to guard your personal financial information.

We may disclose personal financial information to financial institutions which perform services for us. These services may include marketing our products or services or joint marketing of financial products or services.

The Notice of Information Practices, effective July 2009, is provided on behalf of American Medical Security Life Insurance Company; Golden Rule Insurance Company; PacifiCare Life and Health Insurance Company; PacifiCare Life Assurance Company, UnitedHealthcare Insurance Company; All Savers Insurance Company; and United HealthCare Services, Inc.

To obtain an authorization to release your personal information to another party, please go to the appropriate Web site listed at the bottom of the page.

33638-X-0709 Products are either underwritten or administered by: American Medical Security Life Insurance Company, PacifiCare Life and Health Insurance Company, PacifiCare Life Assurance Company, UnitedHealthcare Insurance Company, www.eAMS.com; or All Savers Insurance Company, United HealthCare Services, Inc., and/or Golden Rule Insurance Company, www.goldenrule.com Feb 26 2010 10:58:48

TO BE COMPLETED BY BROKER ONLY IF PERSONALLY COLLECTING INITIAL PREMIUM PAYMENT.

CONDITIONAl RECEIPT FOR _________________________________________________ THIS FORM lIMITS OuR lIABIlITY.

Proposed Insured: _____________________________________________________________________________________________________ Amount Received: ________________________________________________ Date of Receipt: ____________________________________

NO INSuRANCE WIll BECOME EFFECTIvE uNlESS All SIx CONDITIONS PRIOR TO COvERAGE ARE MET. NO PERSON IS AuTHORIzED TO AlTER OR WAIvE ANY OF THE FOllOWING CONDITIONS. YOuR CANCEllED CHECk WIll BE YOuR RECEIPT.

THIS CONDITIONAL RECEIPT DOES NOT CREATE ANY TEMPORARY OR INTERIM INSURANCE AND DOES NOT PROVIDE ANY COVERAGE EXCEPT AS EXPRESSLY PROVIDED IN THE CONDITIONS PRIOR TO COVERAGE.

Signature of Secretary Signature of Agent/Broker

CONDITIONS PRIOR TO COvERAGE (APPlICABlE WITH OR WITHOuT THE CONDITIONAl RECEIPT)

Subject to the limitations shown below, insurance will become effective if the following conditions are met:

1. The application is completed in full and is unconditionally accepted and approved by Golden Rule Insurance Company (Golden Rule).
2. The person is a member of the Federation of American Consumers and Travelers.
3. All medical examinations, if required, have been satisfactorily completed.
4. The persons proposed for insurance must be, on the effective date for injuries, not less than a standard risk acceptable to Golden Rule according to its regular underwriting rules and standards for the exact plan and amount of insurance applied for.
5. The first full premium, according to the mode of premium payment chosen, has been paid on or prior to the effective date for injuries, and any check is honored on first presentation for payment.
6. The certificate is: (a) issued by Golden Rule exactly as applied for within 45 days from date of application; (b) delivered to the proposed insured; and (c) accepted by the proposed insured.

Definitions:

1. “Satisfactorily completed” means that no adverse medical conditions or abnormal findings have been detected which would lead Golden Rule to decline issuing the certificate or to issue a specially ridered certificate.
2. “Effective date for injuries” for a mailed application means the later of: (a) the requested effective date, if any, shown on the application; or (b) the date upon which the original application is actually received by Golden Rule.
3. “Effective date for injuries” for an application sent by any electronic method including fax means the later of:

limitation:

If, for any reason, Golden Rule declines to issue a certificate or issues a certificate other than a standard certificate as applied for, Golden Rule shall incur no liability under this receipt except to return any premium amount received. Interest will not be paid on premium refunds.

NOTICE TO APPlICANT REGARDING REPlACEMENT OF ACCIDENT AND SICkNESS INSuRANCE

If you intend to lapse or otherwise terminate existing insurance and replace it with a new plan from Golden Rule, you should be aware of and seriously consider certain factors that may affect your coverage under the new plan.

1. Full coverage will be provided under the new plan for preexisting health conditions: (a) that are fully disclosed in your application; and (b) for which coverage is not excluded or limited by name or specific description. Other health conditions that you now have may not be immediately or fully covered under the new plan. This could result in a claim for benefits being denied, reduced, or delayed under the new plan, whereas a similar claim might have been payable under your present plan.
2. If after due consideration, you still wish to terminate your present insurance and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical and health history.
3. You may wish to secure the advice of your present insurer or its agent regarding the proposed replacement of or addition to your present plan. You should be certain that you understand all the relevant factors involved in replacing or adding to your present coverage.
4. Finally, we recommend that you not terminate your present plan until you are certain that your application for the new plan has been accepted by Golden Rule.

A COPY OF YOuR AuTHORIzATION FOR ElECTRONIC FuNDS TRANSFER (EFT)

I (we) hereby authorize FACT or Golden Rule to initiate debit entries to the account indicated below. I also authorize the named depository to debit the same to such account.

I agree this authorization will remain in effect until you actually receive written notification of its termination from me.

In Tennessee and Texas, drafts may only be scheduled on 1) the premium due date; or 2) up to 10 days after the due date.

A COPY OF Your Authorization to Release and Receive Information

I authorize Golden Rule Insurance Company’s Insurance Administration and Claims Departments to obtain health information that they need to underwrite or verify my application for insurance. Any health-care provider, consumer-reporting agency, the Medical Information Bureau (MIB), or insurance company having any information as to a diagnosis, the treatment, or prognosis of any physical or mental conditions about my family or me is authorized to give it to Golden Rule’s Insurance Administration and Claims Departments. This includes information related to substance use or abuse.

I understand any existing or future requests I have made or may make to restrict my protected health information do not and will not apply to this authorization, unless I revoke this authorization.

Golden Rule may release this information about my family or me to the MIB or any member company for the purposes described in Golden Rule’s Notice of Information Practices.

I (we) have received Golden Rule’s Notice of Information Practices. This authorization shall remain valid for 30 months from the date below.

I (we) understand the following:

• A photocopy of this authorization is as valid as the original.

• I (we) or my (our) authorized representative may obtain a copy of this authorization by writing to Golden Rule.

• I (we) may request revocation of this authorization as described in Golden Rule’s Notice of Information Practices.

• Golden Rule may condition enrollment in its health plan or eligibility for benefits on my (our) refusal to sign this authorization.

• The information that is used or disclosed in accordance with this authorization may be redisclosed by the  receiving entity and may no longer be protected by federal or state privacy laws regulating health insurers. I have retained a copy of this authorization.

Failure to include all material medical information, correct information regarding the tobacco use of any applicant, or information concerning other health plans may cause the Company to deny a future claim and to void your coverage as though it has never been in force. After you have completed the application and before you sign it, reread it carefully. Be certain that all information has been properly recorded.

What is FACT?

Is there a cost for joining FACT?

FACT privacy notice