Voluntary Benefits

Employee

$5,000

$20,000

$5,000

$20,000

Spouse

$5,000

Up to 100% of
employee/member
benefit amount, up to
$20,000**

$5,000

$20,000

All Children

Up to 50% of employee/member benefit, up to $5,000**

Child amounts are
guaranteed

**The amount of insurance for any dependent will be rounded to the next higher multiple of $1,000, if not already an even multiple of
$1,000.

Child coverage begins at birth and terminates at age 26 unless the child is incapacitated.

Age

Rate

<30

$0.51

30-39

$0.67

40-49

$1.19

50-59

$2.50

60-69

$5.38

70-79

$9.88

80-99

$14.46

*Employee/member and spouse premiums are calculated with the employee/member’s
age as of the effective date of the plan. Rates are adjusted once each year on the plan
anniversary date that coincides with or follows the day an employee/member reaches the
starting age of the next age band.

Child insurance is automatic. A separate premium is not required.

Hospital Admission

$1,500 per admission

ICU Admission

$1,000 per admission

Hospital Confinement

$200 per day

ICU Confinement

$200 per day

Daily Newborn Nursery Care
Confinement

$75 per day
up to 2 days per policy
year

Express Benefit

(equal to one daily hospital
confinement benefit)

$200 per hospital
admission

Employee Only

$25.03

Employee + Spouse

$55.65

Employee + Children

$33.39

Employee + Family

$66.77

Initial Care & Emergency Benefits

Most Initial Care/Emergency benefits require treatment or service within 72 hours
of an accident
and are payable once per accident per insured person.

Specified Injury Benefits

Fractures and dislocations require treatment within 90 days of an accident.
Burns and lacerations require treatment within 72 hours of an accident. Dental
care requires treatment within 30 days of an accident.
If an insured person sustains both a fracture and dislocation as the result of the
same accident, the maximum amount payable is up to 200% of the amount
payable for the injury with the highest applicable benefit amount.
Additional limitations apply as described in the policy.

Hospital, Surgical & Diagnostic
Benefits

Initial hospital admission and confinement must begin within 90 days of an
accident. ICU confinement must begin within 30 days of an accident. Surgical
treatment timeframes vary by the type of surgery. Diagnostic services, except
for X-Ray, must be received within 30 days of an accident. X-Ray services must
be received within 90 days. Except for confinement benefits, most benefits are
payable once per accident per insured person.
If any surgery listed below occurs concurrently with an Open Reduction for a
Fracture or Dislocation of the same bone/bone group or joint/joint group as
a result of the same Accident, only the highest applicable benefit is payable.
Additional limitations apply as described in the Certificate.

Follow-Up Care Benefits

Follow-Up Care benefits require treatment or service within 365 days of an
accident. The number of benefits varies by the type of follow-up care. The
medical device benefit is payable once per accident per insured person.

Additional Benefits

Additional benefits are payable within 365 days of an accident. The number of
benefits varies by
type of additional benefit

Employee
Only

$7.62

Employee+Spouse

$12.50

Employee+Children

$17.40

Employee+ Family

$23.00