Additional Benefits

Hospital Admission (once per benefit year)

$1,000

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

$250

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 30 days, payable in
addition to any Hospital Confinement benefit)

$550

Ambulance (Ground)

$200

Ambulance (Air)

$1,500

Emergency Room Admission

$150

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

$100

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

$600

Rehabilitation Unit (per day up to 365 days per covered accident)

$150

Employee Only

$8.72

Employee + Spouse

$11.75

Employee + Child(ren)

$12.96

Family

$15.99

For You

You can choose between $5,000 and $50,000 of coverage, in increments of $5,000.
No medical questions asked up to the Guaranteed Issue amount of $10,000.
Your benefit amount is reduced to 50% at age 70.

For Your Spouse

If you elect coverage for yourself, you can choose between $2,500 and $25,000 of
coverage, in increments of $2,500.
No medical questions asked up to the Guaranteed Issue amount of $5,000.
Not to exceed 50% of your coverage amount.
The benefit may be reduced when the employee benefit amount is reduced.

For Your Child(ren)

If you elect coverage for yourself, you can choose $2,500 or $5,000 of coverage. No
medical questions asked.
Not to exceed 50% of your coverage amount.
The benefit may be reduced when the employee benefit amount is reduced.
An eligible child is defined as your child from birth to age 26.

Core Conditions

Heart Attack
End-Stage Kidney DiseaseR
Occupational HIV/Hepatitis B, C, or D

StrokeR
Coronary Artery Bypass Graft (pays 25%)
Major Organ FailureR

Cancer Conditions

Invasive Cancer

Noninvasive Cancer (pays 25%)

Wellness Screening
Benefit

Payable to any covered person on
your plan one time each year, once
you provide proof of an eligible health
screening

Employee $50
Spouse $50
Child $50

R = Recurrence Benefit Available

Coverage is provided for

A covered person who is diagnosed with cancer after the effective date of
insurance.
Coverage is available for you and your family.
An eligible child is defined as your child from birth to age 26.

Additional plan features

Benefits are payable directly to you, the employee.
This plan pays benefits in addition to any other coverage you may have.

Employee Age

Employee

Employee+Spouse

Employee+Child(ren)

Employee+Family

Thru 49

$5.28

$8.98

$5.80

$9.50

50-59

$6.51

$11.07

$7.03

$11.59

60-64

$10.38

$17.64

$10.90

$18.16

65+

$13.90

$23.62

$14.42

$24.14

Employee Age

Employee

Employee+Spouse

Employee+Child(ren)

Employee+Family

Thru 49

$12.40

$21.08

$13.64

$22.32

50-59

$15.29

$25.99

$16.53

$27.23

60-64

$24.38

$41.45

$25.62

$42.69

65+

$32.65

$55.50

$33.89

$56.74