Supplemental Insurance Policies Forms

Accident Advantage

A-9520; A-12000

Short-Term Disability

A57600OK

-Value Rider

A57650OK

-Additional Units of Disability Benefit Rider

A57653

Cancer Indemnity – Option 1

B70100OK

Cancer Indemnity – Option 2

B70200OK

Cancer Indemnity – Option 3

B70300OK

-Initial Diagnosis Building Benefit Rider

B70050OK

-Specified-Disease Benefit Rider

B70051OK

-Dependent Child Rider

B70052OK

Hospital Confinement Indemnity – Option 1

B40100OK

-Extended Benefits Rider

B40050

-Hospital Stay and Surgical Care Rider

B40051

Specified Health Event – Option 1

A74100OK

Specified Health Event – Option 2

A74200OK

Specified Health Event – Option 3

A74300OK

Term Life Insurance – 10 Year

ICC1368200

Term Life Insurance – 20 Year

ICC1368300

Term Life Insurance – 30 Year

ICC1368400

Renewable & Convertible Term Life Insurance Policy

ICC14 RCTL14

Whole Life To Age 121 Insurance Policy

ICC14 WL14

Accelerated Benefit for Critical Illness Rider

ICC14 LR203

Accelerated Benefit for Long Term Illness Rider

ICC16 LR204.R416

Waiver of Premium Rider

ICC14 LR205

Level Term Insurance for Children Rider

ICC14 LR206

Renewable & Convertible Term Rider with Accelerated Benefit for Terminal Condition Provision

ICC14 LR207

Accidental Death & Dismemberment Rider

ICC14 LR208

Limited Benefit Specified Disease Cancer Policy

C1106(0K)

Critical Illness Rider

AMDl-239(0K)

Hospital Intensive Care Unit Rider

AMDl-240(0K)

Accident Only Policy

A0-03(0K)

Accident Only Benefit Enhancement Rider

AMD1258

Accident Disability Income Rider - 24-Hour Covewrage

AMDl-224(0K)

Group Critical Illness Limited Benefit

G9250K, G925

Spouse Limited Benefit Rider

AMD2117

Group Supplemental Limited Benefit Medical Expense

G9230K, G923

Group Hospital Indemnity

G14020K, G1402

Accident Expense, Death and Dismemberment

A-2 (3/80)

Cancer and Specified Disease

S-CSD-1 (6/83)

Cancer and Specified Disease

BDCPA (7/83)

Cancer and Specified Disease

APL-1 (6/86)

Cancer and Specified Disease

GCPW (6/86)

Cancer and Specified Disease

APLIC-1 (10/90)

Cancer and Specified Disease

APLIC-2 (10/90)

Cancer and Specified Disease

APLIC-3 (10/90)

Convertible Term Life/Decr. Term

S-900 (1/89)

Hospital Intensive Care/Coronary Care

IC-CC-1 (Rev. 8/82)

Hospital Intensive Care/Coronary Care

IC-CC-2 (6/86)

Heart Attack/Stroke

HA/S-1 (6/86)

Intensive Care/Coronary Care

IC/CC-3 (2/90)

Whole Life

WL-1 (11/86)

Return of Premium Rider

CIR018

Disability Waiver

CIR016

Automatic Benefit Increase

A-DR205

Return of Premium Rider

A-DR208

Residual Benefit Rider

R-D220

Guaranteed Insurability Rider

RD221

Hospital Benefit Rider

A-DR202

Home Modification Rider

A-DR210

Retroactive Injury Benefit

RD222

Critical Illness

CI005 (OK)

Accidental Death Benefit

A-R126 (OK)

Spouse Rider

CIR-010 (OK)

Dependent Child Rider

CIR014 (OK)

Critical Illness

CI007 (OK)

Spouse Rider

CIR012 (OK)

Children's Rider

CIR020 (OK)

Personal Disability

A-D100 (OK)

Supplemental DI Rider

A-DR200 (9/95)

Simplified Life

A-LN00 (OK)

Accident Expense Policy

AAW-A117OK

Family Rider

AAW-AR260OK

Outpatient Sickness

AAW-DR225OK

Intensive Care Benefit

AAW-DR226OK

Private Duty Nurse

AAW-DR227OK

Surgical and Anesthesia and Additional Benefits

AAW-DR228OK

Surgical Anesthesia and Additional Benefits

AAW-DR230OK

Disability Income Policy

AAW-D113OK

Sickness Benefits

AAW-DR220N0

Emergency Accident

AAW-DR221

Accidental Death and Dismemberment

AAW-DR222

Cancer Expense

AAW-C120 OK

Cancer Expense Rider

AAW-CR261 OK

Cancer Expense Rider

AAW-CR262 OK

Cancer Expense Rider

AAW-CR263 OK

Cancer Expense Rider

AAW-CR264 OK

Accident Expense

W A200 OK

Accident Expense (Off the Job)

W A205 OK

Short Term Disability Income Rider

R WA201 OK

Short Term Disability Income Rider (Off the Job)

R WA251 OK

Universal Life

9900

Accidental Death Rider

0027

Level Term Insurance Rider (20-Year)

0150

Additional Insured Rider Level Term (20-Year)

0151

Rider to Apply Monthly Payments and Waive Monthly Deductions in Case of Total Disability

0153

Group Accident Medical Insurance

Group Master Policy B 21301- MP-E

Group Accident Medical Expense

B 21301 CRT-E Certificate of Insurance

Accident Indemnity Policy

B 21302 OK- Policy

Accident Indemnity Policy

B 21302 R1 Rider

Accident Indemnity Policy

B 21302 R2 Rider

Accident Indemnity Policy

B 21302 R3 Rider

Accident Indemnity Policy

B 21302 R4 Rider

Critical Illness

B 21303 OK – Policy

Group Hospital Indemnity

B 21304 MP-E Master Policy

Group Hospital Indemnity

B 21304 CRT-E Certification of Insurance

Cancer Expense Policy

B 9401 OK (01-01)- Policy

Cancer Expense Policy

B 9401 R1-1 OK (01-01) Rider

Cancer Expense Policy

B 9401 R1-2 OK (01-01) Rider

Cancer Expense Policy

B 9401 R1-3 OK (01-01) Rider

Short Term Care Policy

B 9305 OK – Policy

Disability Income Policy

B 8722 OK – Policy

Disability Income Policy

B 8722 R1- Rider

Disability Income Policy

B 20702 OK – Policy

Term Life Insurance Policy

B 20601 OK – Policy

Term Life Insurance Policy

B 0211-2 CIBR – Rider

Whole Term Insurance Policy

B 20803 OK – Policy

Cancer Assist

CanAssist-OK

Critical Illness 1.0

CI-1.0-OK

Individual Medical Bridge

IMB7000-OK

Individual Accident 4000

IAC4000-OK

Term Life 5000

ICC18-ITL5000

Whole Life 5000

ICC19-IWL5000

Individual Short Term Disability 3000

ISTD3000-OK

Individual Dental PPO

IDN8000-OK

Group Supplemental Benefit Certificate

NGSBCRT-OK 3/17

Accident Medical Expense - Certificate

KB-MAE-CER-1301-0K

Accident Medical Expense - Spouse Rider

KB-MA-SR-1301

Accident Medical Expense -Child(ren) Rider

KB-MA-CR-1301-0K

Accident Medical Expense - Accidental Death Benefit Rider

KB-MAE-AR-1301

Accident Medical Expense - Group Policy

KB-MAE-POL-1301-0K

Critical Illness - Certificate

KB-MCI-CER-1301-0K

Critical Illness - Spouse Rider

KB-MCI-SR-1301

Critical Illness - Child(ren) Rider

KB-MCI-CR-1301-0K

Critical Illness - Group Policy

KB-MCI-POL-1301-0K

Whole Life - Certificate

KB-MWL-CER-1301-0K

Whole Life - Accidental Death Benefit Rider

KB-MWL-ADR-1301-0K

Whole Life - Chlld(ren) Term Life Benefit Rider

KB-MWL-CTR-1301-0K

Whole Life - Accelerated Death Benefit Terminal Illness Disclosure

KB-WL-ABTIR-D-1301

Whole Life - Accelerated Death Benefit Payment Notice

KB-WL-AB-NOT-1301

Whole Life -Group Policy

KB-MWL-POL-1301-0K

Group Term Paid Up at 65

GE65

Group Term

GE2

Accident Protector Max

HAJ, HAK, HAL

Cancer Endurance

5KM, KKN, 5KO

Cash Center

LCANLS-2

Career Life Plus

8039/5148

Cancer Care Plus

CP4000OK04104

Intensive Care Rider

1CUR 4000

Critical Care Rider

CCBR4000OK

Accident Expense

C-ACEXP-OK

Wellness Rider

C-ACEEXWL19

Accident Policy

GRA-3001 (1/95)

Cancer Policy

GRC-2004-OK (1/03)

Heart Disease, Heart Attack and Stroke Policy

GRH-1003-OK (10/96)

Disability Income Policy

GRD-6003-OK (10/99)

Spouse Rider - Accident

GRA-SR-OK (1/95)

Child Rider - Accident

GRA-CR-OK (1/95)

ICU Rider - Accident

GRA-ICU-OK (1/95)

All Purpose Impatient Rider

GR-1026-OK (2/03)

ICU - All Purpose Rider

GR-2015-OK (1/03)

Specified Disease Rider

GR-1045-OK (10/96)

Hospital Enhancement Rider

GR-1013-OK (8/98)

Benefit Booster Rider

GR-1056-OK (10/04)

Return of Premium Rider

GR-1082-OK (10/04)

ICU - Heart Only Rider

GR-1025-OK (10/96)

Heart Attack & Stroke First Occurrence Benefit Rider

GR-1035-OK (10/96)

Heart Wellness Rider

GR-1011-OK (6/98)

Cancer Benefit Enhancement Rider

GR-1014-OK (1/03)

Whole Life Insurance Policy

L-1115 (1/94)

Renewable & Convertible Term Life Insurance Policy

L-2225 (1/94)

Convertible Decreasing Term Life Insurance Policy

L-2224 (1/94)

Accidental Death and Dismemberment Rider

L-ADDR.70 (1/94)

Children's Term Insurance Rider

LCR-111 (1/94)

Accident Policy -- Series II

GRA-3002-OK (5/06)

Accident Home Recovery Benefit Rider

GR-AHRBR-OK (3/07)

Heart Disease, Heart Attack & Stroke Policy -- Series III

GRH-1004-OK (9/06)

Heart Benefit Enhancement Rider

GR-HBER-OK (10/07)

Cancer

CC-174

Intensive Care

IC-101

Universal Life

0430 OK

Accident Secure (AD&D and Accident Insurance)

BM000/PS1OK-A

LifeChoices Series

CH000/PS1OK-A

Benefit Rider

CH0B1/IS1ST-A

Benefit Rider

IS003/EA1OK-AA

Benefit Rider

SD090/EA1ST-A

Pulse Protection (Heart & Stroke Insurance)

KH000/PS1OK-BZ

Worksite Universal Life

CIC-3001-OK