Additional Benefits

Life and Dismemberment Losses

Accidental Death

$50,000

Accidental Death Common Carrier

$100,000

Catastrophic Loss: Both arms or both
hands, both legs or both feet, one hand
and one foot or one arm and one leg, or
irrecoverable loss of sight of both eyes

$15,000

One hand, one foot, one leg, one arm

$7,500

Loss of sight of one eye or loss of one eye

$7,500

Two or more fingers or toes

$1,500

One finger or one toe

$750

Loss of hearing of one ear or loss of one ear

$2,500

Dislocations

Open

Closed

Hip

$4,000

$2,000

Knee, ankle, or bones of the foot

$2,000

$1,000

Elbow, wrist or Lower jaw

$800

$400

Shoulder

$1,000

$500

Collarbone or bones of the hand

$1,600

$800

Finger(s) or toe(s)

$200

$100

Fractures

Open

Closed

Hip or thigh

$4,000

$2,000

Skull-depressed

$6,000

$3,000

Skull-simple

$3,000

$1,500

Vertebral processes, Bones of the face,
Nose, Lower jaw, Collarbone, Shoulder,
Forearm, Hand, Wrist, Foot, Ankle,
Kneecap, Elbow or Heel

$700

$350

Leg

$2,000

$1,000

Vertebrae, Sternum or Pelvis

$1,600

$800

Upper jaw or upper arm

$800

$400

Rib, Finger, Toe or Coccyx

$400

$200

Multiple ribs

$1,000

$500

Additional Injuries

Eye Injury - surgical repair

$200

Eye Injury - object remove

$200

Brain injury

$500

Paralysis—paraplegia

$5,000

Paralysis—quadriplegia

$10,000

Coma

$10,000

Concussion

$100

Lacerations

No sutures and treated by doctor

$20

Single laceration under 5 cm with sutures

$35

5-15 cm with sutures (total of all lacerations)

$125

Greater than 15 cm with sutures (total of all lacerations)

$500

Burns

2nd Degree

3rd Degree

21-40 square centimeters

$200

$500

41-65 square centimeters

$400

$1,000

66-160 square centimeters

$600

$3,000

161-225 square centimeters

$800

$7,000

More than 225 square centimeters

$1,000

$10,000

Skin graft

50% of the
applicable Benefit

50% of the
applicable Benefit

Medical Services

Diagnostic Exam
Arteriogram, Angiogram, CT, CAT, EKG, EEG, or MRI
(1 time per benefit year)

$200

Diagnostic Exam
X-ray (1 time per covered accident)

$50

Accident Emergency Treatment, non-emergency
room (once per covered accident)

$100

Physician's Follow-up Treatment office visit
(per visit, up to 6 times per covered accident)

$50

Physical Therapy
(per visit up to 10 visits per covered accident)

$25

Medical Devices

$200

Epidural Pain Management
(up to 2 times per covered accident)

$50

Prescription drug

$15

Prosthesis (one)

$500

Prosthesis (two)

$1,000

Blood, Plasma, or Platelet Transfusion

$100

Hospital

Hospital Admission (once per benefit year)

$1,500

Hospital Confinement
(per day up to 365 days per covered accident)

$200

Intensive Care Unit Admission (once per Benefit Year;
payable instead of Hospital Admission benefit if
Confined immediately to ICU)

$1,500

Intensive Care Unit Confinement (per day up
to 15 days, payable in addition to any Hospital
Confinement benefit)

$200

Ambulance (Ground)

$400

Ambulance (Air)

$2,000

Emergency Room Admission

$200

Family Lodging (per day up to 30 days per benefit year)

$50

Transportation (100 or more miles up to 3 times per
covered accident)

$250

Rehabilitation Unit (per day up to 30 days per covered
accident)

$50

Surgery

Miscellaneous Surgery requiring general
anesthesia (not covered by any other
benefit)

$300

Open Surgery

$1,000

Exploratory Surgery or Debridement

$250

Tendon/Ligament/Rotator Cuff Tear

$500

Torn Knee Cartilage

$500

Ruptured/Herniated Disc

$500

Wellness

Emergency Dental extraction

$30

Emergency Dental crown

$100

Wellness Screening Benefit (once per benefit year)

$50

Employee Only

$12.21

Employee + Spouse

$19.46

Employee + Children

$22.57

Employee + Family

$29.82

Employee Benefit

Increments with a minimum of $10,000 up to a maximum of $40,000

Spouse Benefit

Increments with a minimum of $10,000 up to a maximum of $40,000,
not to exceed 100% of the employee’s benefit.

Child Benefit

50% of Employee's elected amount of coverage.

Policy maximum

Unlimited

Pre-existing condition limitation

None

Age

Rate

< 25

$0.44

25-29

$0.53

30-34

$0.68

35-39

$0.88

40-44

$1.20

45-49

$1.64

50-54

$2.28

55-59

$3.11

60-64

$3.83

65-69

$5.08

70-74

$6.78

75+

$9.31

Age

Rate

< 25

$0.44

25-29

$0.53

30-34

$0.68

35-39

$0.88

40-44

$1.20

45-49

$1.64

50-54

$2.28

55-59

$3.11

60-64

$3.83

65-69

$5.08

70-74

$6.78

75+

$9.31

Age

Rate

All ages

Child cost is included in the Employee Premium

Eligibility Waiting Period

First of the month following 30 days of employment

First Day Benefits Payable per benefit year

First Day Hospital

$1,500 per day 1 day

First Day ICU

$1,000 per day 1 day

Confinement Benefits Payable per benefit year

Hospital Confinement

$100 per day 30 days

ICU Confinement

$100 per day 30 days

Newborn Nursery Confinement

$100 per day 3 days Not payable with any other confinement

Rehabilitation Unit

$100 per day 60 days Stay must begin within 30 days of Hospital Confinement

Additional & Enhanced Benefits Payable per benefit year

Observation Unit Stay
Not payable with any confinement
benefits

$100 per day

1 day

Covered Conditions

Newborn Care

Routine care covered under newborn nursery confinement

Complications of Pregnancy

Included

Normal Pregnancy

Included

Mental/Nervous

Included

Substance Abuse

Included

Normal Pregnancy Waiting Period

No Waiting Period

Sickness and Accidents

Sickness: 24-hour coverage

Accident: 24 Hour coverage

Pre-existing Condition Limitation

Not included

Employee Only

$28.88

Employee + Spouse

$54.89

Employee + Children

$44.27

Employee + Family

$70.28