Accident

Accidental Death

Employee

$25,000

Spouse

$12,500

Child

$5,000

Dismemberment

ONE Hand, Foot, or Eye

50%

BOTH Hands ,Feet, or Eyes

100%

Speech or Hearing (both Ears)

100%

Thumb or Index Finger - Same Hand

25%

Multiple Fingers or Toes - Same Hand/Foot

25%

Paralysis

Quadriplegia

100%

Paraplegia

50%

Initial Care

Emergency Room

$200

Urgent care

$100

Hospitalization

Admission

$1,000

Confinement

$250/day (up to 1 Year)

ICU Admission

$2,000

ICU Confinement

$500/day (up to 15 days)

Rehabilitation

$100/day (up to 15 days)

Surgery

Cranial, Open Abdominal, Thoracic

Schedule up to $1,250

Repair of Tendon, Ligament, Rotator Cuff

$500 (up to $1,000)

Exploratory/Arthroscopic

$400

Other Benefits

Appliances (Wheelchairs, Crutches, etc.)

Covered if deemed necessary

Burns

Up to $12,000

Childcare

$20/day (up to 30 days)

Coma

$10,000

Concussions

$200

Dislocations

Schedule up to $5,000

Emergency Dental Work

Crowns

$300

Extractions

$75

Eye Injury

$300

Fractures

Schedule up to $6,000

Lacerations

Schedule up to $400

Lodging

$125/day, up to 30 days for companion hotel stay

Major Diagnostic Exams

$200

Physical Therapy

$100/day (up to 15 days)

Prosthetics

$500 (up to $1,000)

Transportation

Ambulance

$200

Air Ambulance

$1,000

Plan Highlights

Portability

Included

Termination

Upon employee termination

Child Eligibility

Birth to 26 years

Employee Only

$11.30

EE + Spouse

$18.89

EE + Children

$19.87

EE + Family

$27.46