Additional Benefits

Accidental Death

Employee

$50,000

Spouse

$25,000

Child

$12,500

Dismemberment

ONE Hand, Foot, or Eye

$25,000

BOTH Hands, Feet, or Eyes

$50,000

Speech or Hearing (both Ears)

$50,000

Thumb or Index Finger - Same Hand

$5,000

Multiple Fingers or Toes - Same Hand/Foot

25%

Paralysis

Quadriplegia

$50,000

Paraplegia

$25,000

Initial Care

Emergency Room

$150

Urgent care

$100

Hospitalization

Admission

$1,000

Confinement

$200

ICU Admission

$1,000

ICU Confinement

$400

Rehabilitation

$150

Surgery

Cranial, Open Abdominal, Thoracic

$2,000

Repair of Tendon, Ligament, Rotator Cuff

$750

Exploratory/Arthroscopic

$250

Other Benefits

Appliances (Wheelchairs, Crutches, etc.)

$100

Burns

Schedule up to
$10,000

Childcare

$25

Coma

$10,000

Concussions

$150

Dislocations

Less or equal 200% of
Highest Benefit

Emergency Dental Work

Crowns

$300

Extractions

$100

Eye Injury

$500

Fractures

Less or equal 200% of
Highest Benefit

Lacerations

Schedule up to
$500

Lodging

$125

Major Diagnostic Exams

$200

Physical Therapy

$50

Prosthetics

Schedule up to
$2,000

Transportation

Ambulance

$500

Air Ambulance

$1,500

Employee Only

$1.62

Employee + Spouse

$2.55

Employee + Child(ren)

$2.69

Employee + Family

$4.24

Hospital/ICU Admission

$500;
Once per Year

Hospital/ICU Confinement

$200 / $400

Pre-Existing Condition Limitation

3/6

Treatments Covered

Sickness and Injury

Portability

Included

Employee Only

$3.08

Employee + Spouse

$6.35

Employee + Child(ren)

$5.84

Employee + Family

$9.57

Vascular

First / Second Occurrence

Heart Attack

STEMI: 100%
NSTEMI: 25%
100% (2nd)

Stroke

Mild: 10%
Moderate: 25%
Severe: 100%
100% (2nd)

Coronary Bypass Surgery

Minor: 10%
Major: 100%
100% (2nd)

Cancer

Invasive Cancer

100% / 100%

Cancer in Situ

25% / 100%

Benign Brain Tumor

Early
Diagnosis: 10%
Advanced: 50%
N/A (2nd)

Skin Cancer

$250 one time / N/A

Organ Category

Organ Failure

100% / 100%

Kidney Failure

100% / N/A

Childhood Illness

Cerebral Palsy

Early
Diagnosis: 10%
Advanced: 100%
N/A (2nd)

Structural Congenital Defects

100% / N/A

Other Conditions

ALS (Lou Gehrig's Disease)

100% / N/A

Alzheimer's

100% / N/A

Coma

100% / N/A

Loss of Speech, Sight or Hearing

100% / N/A

Paralysis

100% / N/A

Parkinson's

100% / N/A

Employee

Employee Benefit Level

$5,000 - $20,000

Employee GI

$20,000

Annual Wellness Benefit

$50 Per Person

Age Reduction Schedule

Not Included

Pre-Existing Condition

Not Included

Employee Portability

Not Included

Spouse

Spousal Benefit Level

100% of Employee's Amount

Spousal GI

$20,000

Spouse Rate Based on

Employee Age

Dependent Child(ren)

Dependent GI

All Amounts

Dependent Children Benefit
Level

50% of Employee's Amount

Dependent Child Maximum Age

26 Years

<25

$0.46

$0.46

25-29

$0.64

$0.56

30-34

$0.81

$0.63

35-39

$1.00

$0.73

40-44

$1.41

$0.95

45-49

$2.22

$1.36

50-54

$3.14

$1.79

55-59

$4.21

$2.31

60-64

$6.05

$3.10

65-69

$8.62

$4.39

70-74

$11.29

$5.72

75-79

$14.34

$7.25

80+

$17.38

$8.77

Monthly Employee Rates by Age
per $1,000 of Benefit

<25

$0.31

$0.31

25-29

$0.49

$0.41

30-34

$0.65

$0.47

35-39

$0.85

$0.58

40-44

$1.26

$0.79

45-49

$2.06

$1.21

50-54

$2.98

$1.64

55-59

$4.05

$2.15

60-64

$5.89

$2.94

65-69

$8.47

$4.23

70-74

$11.14

$5.57

75-79

$14.19

$7.09

80+

$17.22

$8.61

Monthly Spouse Rates by Age $1,000 of Benefit