Page 25 - 2019 Allstate Benefits Flipbook

Accident (AP6)

On- and Off-the-Job Accident Insurance
from Allstate Benefits

BENEFIT AMOUNTS
Benefits are paid once per accident unless otherwise noted here or in the brochure PLAN 1 PREMIUMS
BASE POLICY BENEFITS PLAN 1 PLAN 2
Initial Hospital Confinement (once per year) $ 1,000 $ 2,000
MODE EE EE + SP EE + CH F
Daily Hospital Confinement (daily) $ 200 $ 400
Intensive Care (daily) $ 400 $ 800
Weekly $3.58 $6.85 $8.34 $10.21
Objective Second Opinion $ 100 $ 200
RIDER BENEFITS PLAN 1 PLAN 2
Bi-Weekly $7.16 $13.70 $16.68 $20.42
Accident Treatment and Urgent Care Rider
Ambulance Ground $200 $400
Semi-Monthly $7.74 $14.83 $18.07 $22.12
Air $600 $1,200
Accident Physician’s Treatment $100 $200
Monthly $15.48 $29.66 $36.13 $44.23
X-ray $200 $400
Urgent Care $100 $200
Dislocation or Fracture Rider¹ $4,000 $8,000 PLAN 2 PREMIUMS
Emergency Room Services Rider $200 $400
OPTIONAL/ADDITIONAL RIDERS PLAN 1 PLAN 2
MODE EE EE + SP EE + CH F
Outpatient Physician’s Treatment for
Accident and Preventive Care Benefit Rider See note 2 below: $50.00 $50.00
Weekly $6.56 $12.70 $15.55 $18.68
Accidental Death*, Dismemberment¹,*
$40,000 $80,000
and Functional Loss¹,* Rider
Bi-Weekly $13.12 $25.40 $31.10 $37.36
Common Carrier Accidental Death
$100,000 $200,000
(fare-paying passenger)
Semi-Monthly $14.21 $27.50 $33.69 $40.46
ADDITIONAL BENEFIT ENHANCEMENT RIDER PLAN 1 PLAN 2
Accident Follow-Up Treatment (daily) $100 $200
Monthly $28.41 $55.00 $67.37 $80.92
Lacerations $100 $200
Burns < 15% of body surface $200 $400
> 15% or more $1,000 $2,000 EE=Employee; EE + SP = Employee + Spouse;
Skin Graft (% of Burns Benefit) 50% 50% EE + CH = Employee + Child(ren); F = Family
Brain Injury Diagnosis $600 $1,200 Issue ages: 18 to 99
Computed Tomography (CT) Scan $100 $200 *Each benefit pays the amount shown.
and Magnetic Resonance Imaging (MRI) (Pays once per year) ¹ Up to amount shown; actual amount paid depends on
Paralysis (Pays once) Paraplegia $15,000 $30,000 injury and is based on Schedule of Benefits and Factors in
Quadriplegia $30,000 $60,000 your rider(s). Multiple losses from same injury pay
Coma with Respiratory Assistance $20,000 $40,000 only up to amount shown above.
Open Abdominal or Thoracic Surgery $2,000 $4,000
2 Outpatient Physician’s Treatment for Accident and Preventive
Tendon, Ligament, Rotator Cuff Surgery $1,000 $2,000
or Knee Cartilage Surgery Exploratory $300 $600 Care Benefit Rider: Pays a benefit for treatment by a physician
Ruptured Disc Surgery $1,000 $2,000 outside a hospital for injuries caused by an accident, or for any
Eye Surgery $200 $400 preventive care physicians visit (including dental and vision
General Anesthesia $200 $400 wellness visits). Payable once per day, per covered person, and is
Blood and Plasma $600 $1,200 limited to two days per person, per year. Or, four days per year if
Appliance $250.00 $500.00 coverage includes dependents.
Medical Supplies $10.00 $20.00 For Internal Home Office use only
Prosthesis 1 device $1,000 $2,000 Opt 1 - 2AP6; 2AP6DF; 2AP6AUC; 2AP6ERS; 2AP6ADD; 2AP6BER; 2AP6OPH
2 or more devices $2,000 $4,000 Opt 2 - 4AP6; 4AP6DF; 4AP6AUC; 4AP6ERS; 4AP6ADD; 4AP6BER; 2AP6OPH
Physical, Occupational or Speech Therapy (Pays daily) $60 $120 For use in: Maryland
Rehabilitation Unit (daily) $200 $400 This rate insert is part of the approved brochure
Non-Local Transportation $500 $1,000 and is not to be used on its own.
Family Member Lodging (daily) $200 $400 This material is valid as long as information remains current,
Post-Accident Transportation (Pays once per year) $400 $800 but in no event later than May 21, 2022. Allstate
Broken Tooth $200 $400 Benefits is the marketing name used by American Heritage
Residence/Vehicle Modification $1,000 $2,000 Life Insurance Company (Home Office, Jacksonville, FL), a
Pain Management (Epidural Injection) $100 $200 subsidiary of The Allstate Corporation. ©2019 Allstate
Miscellaneous Outpatient Surgery $200 $400 Insurance Company. www.allstate.com or allstatebenefits.com.

AP6-Insert-27083