Page 18 - Saint Mary of the Woods CollegeFlipbook

Critical Illness Insurance (GVCIP4) Offered to the employees of:
from Allstate Benefits Saint Mary-of -the-woods College
BENEFIT AMOUNTS
Percentages below are based on the Basic Benefit Amount chosen by your employer.
† ISSUE AGE PREMIUMS
Covered dependents receive 50% of your benefit amount.
INITIAL CRITICAL ILLNESS BENEFITS † PLAN 1 PLAN 2 PLAN 1 - WEEKLY PREMIUMS
Heart Attack (100%) $10,000 $20,000 AGE EE, EE + CH EE + SP, F
Uni-Tobacco
Stroke (100%) $10,000 $20,000
18-29 $2.02 $3.62
End Stage Renal Failure (100%) $10,000 $20,000
30-39 $3.12 $5.32
Major Organ Transplant (100%) $10,000 $20,000
40-49 $5.29 $8.65
Coronary Artery Bypass Surgery (25%) $2,500 $5,000 50-59 $8.60 $13.73
Waiver of Premium (employee only) Yes Yes 60-64 $11.38 $17.98
CANCER CRITICAL ILLNESS BENEFITS † PLAN 1 PLAN 2 65+ $17.44 $27.18
Invasive Cancer (100%) $10,000 $20,000 PLAN 2 - WEEKLY PREMIUMS
Carcinoma In Situ (25%) $2,500 $5,000 AGE EE, EE + CH EE + SP, F
REOCCURRENCE OF CRITICAL ILLNESS BENEFITS † PLAN 1 PLAN 2 Uni-Tobacco
Initial Critical Illness 18-29 $2.85 $4.86
30-39 $4.97 $8.08
(same amount as Initial Critical Illness Benefit) Yes Yes
40-49 $9.12 $14.40
Cancer Critical Illness
50-59 $15.53 $24.12
(same amount as Cancer Critical Illness Benefit) Yes Yes
60-64 $20.93 $32.30
RIDER BENEFITS PLAN 1 PLAN 2 65+ $32.82 $50.25
Skin Cancer Rider $250 $250
EE = Employee; EE + SP = Employee + Spouse;
Cardiopulmonary Enhancement Rider†
EE + CH = Employee + Child(ren); F = Family
Sudden Cardiac Arrest (25%) $2,500 $5,000 See additional premiums on reverse
Pulmonary Embolism (25%) $2,500 $5,000
Pulmonary Fibrosis (25%) $2,500 $5,000
Lifestyle Enhancement Rider $25 $25
Second Evaluation, Transportation and Lodging Rider
Second Evaluation $1,000 $1,000
Non-Local Transportation 1 Air Fare $500 $500
3
(per trip or mile ) Personal Vehicle $0.50 $0.50
2 $100 $100
Outpatient Lodging (daily)
2
Family Member Lodging (daily) $100 $100
1 3 Air Fare $500 $500
and Transportation (per trip or mile )
Personal Vehicle $0.50 $0.50
Specified Chronic Illness Rider† (50%) $5,000 $10,000
Supplemental Critical Illness Rider†
Advanced Alzheimer’s Disease (100%) $10,000 $20,000
Advanced Parkinson’s Disease (100%) $10,000 $20,000
Benign Brain Tumor (100%) $10,000 $20,000
Coma (100%) $10,000 $20,000
Complete Loss of Hearing (100%) $10,000 $20,000
Complete Loss of Sight (100%) $10,000 $20,000
Complete Loss of Speech (100%) $10,000 $20,000
Paralysis (100%) $10,000 $20,000
Fixed Wellness Rider (per year) $100 $100
1 2 3
Limit of $5,000 in a calendar year. Limit of $1,000 in a calendar year. Maximum of 1,000 miles.

GVCIP4 - Insert - 17361-No Pre-Ex