Page 20 - DI5 Brochure New 2019.pdf

American Heritage Life Insurance Company

A Hospital Confinement Insurance Policy Illustration

Name: DJ Mullins
Age: 47
Application Signature State: Maryland
Case Name:
Agent Name: 9LTN0 WALLER ANDREW D

Policy: CHC Hospital Indemnity
(SHOP) (CHCMD)
Type of Coverage: Family
Benefit Level: 4 units

Optional Riders:
Initial Hospitalization Rider (IHR1) 4 units
Surgery And Anesthesia Rider (SAR1MD) 4 units
Outpatient Physician's Benefit Rider (OPBR1) 3 units
Transportation Rider (TR1) 1 unit
Premium Payment Mode: Weekly
Premium by Policy and Rider:
CHC Hospital Indemnity (SHOP) $14.59
Initial Hospitalization Rider $8.50
Surgery And Anesthesia Rider $3.42
Outpatient Physician's Benefit Rider $5.75
Transportation Rider $0.31
Total Modal Premium: $32.57

August 30, 2019

Allstate Benefits is the marketing name for American Heritage Life Insurance Company, a
subsidiary of the Allstate Corporation, Home Office: Northbrook, Illinois. All products are
underwritten by American Heritage Life Insurance Company. Home Office: Jacksonville, Florida.
This illustration highlights some features of the policy and riders, but is not the insurance contract.
Only the actual policy and rider provisions control. The policy and riders set forth, in detail, the
rights and obligations of both the insured and the insurance company. ©2019 Allstate Insurance
Company.

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