Page 20 - Summit LTC Management LLC - Benefit Guide GROUP 1 Effective Dec 1, 2019 Revised July 2020

24 Hour Accident (On or Off the Job):

Allstate Benefits

Even when you live well, accidents happen. Treatment can be vital to recovery, but it can also be expensive. And
if an accident keeps you away from work during recovery, the financial worries can grow quickly.

Most major medical insurance plans only pay a portion of the bills. Our coverage can help pick up where other
insurance leaves off and provides cash to help cover the expenses.

BENEFIT AMOUNTS BENEFIT ENHANCEMENT RIDER (CONTINUED)
Initial Hospital Confinement (Pays once/year) $1,000 $2,000 Open Abdominal or Thoracic Surgery
Tendon, Ligament, Rotator Cuff or Knee Cartilage: Surgery
Daily Hospital Confinement (Pays daily) $200 $400
Exploratory
Intensive Care (Pays daily) Ruptures Spinal Disc Surgery
Eye Surgery
$200
Accident / Urgent Care Rider Ambulance: Ground

$400

$600
Air

$1,
200
Accident Physician’s Treatment Blood and Plasma
X-ray $200 $400 Appliance
Urgent Care $100 $200 Medical Supplies
Dislocation or Fracture Rider $4,000 $6,000
Emergency Room Services Rider $200 $400
Outpatient Physician’s Treatment for Accident and
Preventive Care Benefit Rider $50.00 $50.00
(Medical, Dental or Vision)
Accidental Death, Dismemberment, and Functional
$40,000 $80,000
Loss Rider
Common Carrier Accidental Death $100,000 $200,000
BENEFIT ENHANCEMENT RIDER Family Member Lodging $200 $300
Accident Follow—Up Treatment (Pays daily) $100 $150 Post Accident Transportation (Pays once / year)
Lacerations $100 $150 Broken Tooth
Burns <15% body surface $200 $300
Residence / Vehicle Modification
> 15% or more $1,000 $1,500
Skin Graft (% of Burns Benefit) 50% 50%
Brain Injury Diagnosis $600 $900 Miscellaneous Outpatient Surgery
Computed Tomography (CT) Scan and Magnetic
$100 $150 COMPLETE DISLOCATION
Resonance Imaging (MRI) (Pays once/year)
Paralysis (Pays once) Paraplegia $15,000 $22,500
Two or more fingers or toes
Quadriplegia $30,000 $45,000
One finger or toe $120 $180
Please see summary of benefits for additional information

Plan 1 Plan 2

Semi-Monthly Semi-Monthly

Employee Only $ 7.52 $11.97
Employee + Spouse $12.99 $20.69

Employee + Child(ren) $15.96 $25.30
Family $20.95 $32.75
*These rates lock in when coverage first begins. Coverage is portable and eligible for continuation as long as premiums continue to be paid.
20