Page 26 - Enrollment Guide
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Plan Highlights
Beneits are paid for injuries
which are not work-related Schedule of Fractures Closed Reduction Open Reduction
Hip $4,000 $8,000
Beneits are payable regardless of Thigh (femur) $4,000 $8,000
any other insurance programs
Pelvis $3,200 $6,400
Coverage is guaranteed-issue Leg $2,400 $4,800
Inpatient and outpatient Bones of the face or nose $1,200 $2,400
treatment of covered accidents Upper jaw, upper arm $1,400 $2,800
included Lower jaw, mandible $1,600 $3,200
Shoulder blade, collar bone $1,600 $3,200
Beneits are available for spouse Forearm, hand, or wrist $2,000 $4,000
and/or dependent children
Foot, ankle, or kneecap $2,000 $4,000
There’s no limit on the number of Coccyx, rib, inger, or toe $320 $640
claims an insured can ile Vertebrae, vertebral process $3,600 $800
Premiums are paid by convenient Skull (depressed/simple) $3,000 $1,400
payroll deduction Schedule of Dislocations Closed Reduction Open Reduction
Hip $3,000 $6,000
Knee $1,950 $3,900
Ankle or foot $1,200 $2,400
This plan includes a $50 wellness Lower jaw $900 $1,800
beneit payable after the plan is Shoulder $1,500 $3,000
in-force 12 months. Beneits are
payable annually for the following: Hand (other than ingers) $1,050 $2,100
Annual physical exam, mammogram, Elbow $600 $1,200
pap smear, PSA test, ultrasound, Wrist $750 $1,500
blood screening, eye examination, Finger/toe $240 $480
immunization, and lexible Additional Beneits
sigmoidoscopies. Burns (second and third degree) $100 to $20,000
Blood/plasma/platelets $100
Coma $10,000
Concussion $200
Knee cartilage—torn/exploratory $400 ($100 in irst year of policy)
Lacerations $25 to 400
Lodging (per night) $100
Ruptured disc (with surgical repair) $400 ($100 in irst year of policy)
Transportation $150 (bus)/$300 (train or plane)
Plan Highlights
Beneits are paid for injuries
which are not work-related Schedule of Fractures Closed Reduction Open Reduction
Hip $4,000 $8,000
Beneits are payable regardless of Thigh (femur) $4,000 $8,000
any other insurance programs
Pelvis $3,200 $6,400
Coverage is guaranteed-issue Leg $2,400 $4,800
Inpatient and outpatient Bones of the face or nose $1,200 $2,400
treatment of covered accidents Upper jaw, upper arm $1,400 $2,800
included Lower jaw, mandible $1,600 $3,200
Shoulder blade, collar bone $1,600 $3,200
Beneits are available for spouse Forearm, hand, or wrist $2,000 $4,000
and/or dependent children
Foot, ankle, or kneecap $2,000 $4,000
There’s no limit on the number of Coccyx, rib, inger, or toe $320 $640
claims an insured can ile Vertebrae, vertebral process $3,600 $800
Premiums are paid by convenient Skull (depressed/simple) $3,000 $1,400
payroll deduction Schedule of Dislocations Closed Reduction Open Reduction
Hip $3,000 $6,000
Knee $1,950 $3,900
Ankle or foot $1,200 $2,400
This plan includes a $50 wellness Lower jaw $900 $1,800
beneit payable after the plan is Shoulder $1,500 $3,000
in-force 12 months. Beneits are
payable annually for the following: Hand (other than ingers) $1,050 $2,100
Annual physical exam, mammogram, Elbow $600 $1,200
pap smear, PSA test, ultrasound, Wrist $750 $1,500
blood screening, eye examination, Finger/toe $240 $480
immunization, and lexible Additional Beneits
sigmoidoscopies. Burns (second and third degree) $100 to $20,000
Blood/plasma/platelets $100
Coma $10,000
Concussion $200
Knee cartilage—torn/exploratory $400 ($100 in irst year of policy)
Lacerations $25 to 400
Lodging (per night) $100
Ruptured disc (with surgical repair) $400 ($100 in irst year of policy)
Transportation $150 (bus)/$300 (train or plane)
