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P. 14
Open Enrollment
Accident Policy Covered Treatment/Services Plan Details
Emergency room $200
Allstate’s accident coverage is intended Primary care physician or urgent $100
to help you with the unexpected costs care
associated with an accident. Beneits Medical Services
are paid directly to you to help pay for Ambulance Ground: $200
Air: $600
your everyday expenses. All beneits Physician follow-up $100
are paid tax-free. Many employees Physical therapy $30
ind this plan to be of value when Rehabilitation unit $200
$250
Appliance beneit
considering higher deductibles and CT or MRI $100
medical out-of-pocket maximums. Xray $200
Hospital Beneits
Covers accidents which occur Hospital admission beneit $1,000
off-the-job Hospital daily beneit $200 per day (max 90-days per accident)
Beneits paid for emergency room, ICU daily beneit $400 per day (max 90-days per accident)
Accidental Death
doctors ofice visits, diagnostic Employee/spouse/each child $40,000/$20,000/$10,000
imaging or scans, broken bones or Schedule of Fractures (complete, simple or closed)
fractures, burns, cuts, and more Hip, thigh (femur) or pelvis (except $4,000
$50 outpatient physician’s coccyx) $3,800
Skull (except bones of the face or
treatment beneit payable two nose)
times per year (max four per Arm, between shoulder and elbow $2,200
(shaft), shoulder blade (scapula),
family) when a covered person is leg (tibia or ibula)
treated by a physician outside of a Foot (except toes), hand or wrist $1,400
(except ingers)
hospital for any cause, including an Lower jaw (except alveolar $800
annual wellness visit process)
Two or more ribs, ingers or toes, $600
bones of face or nose
One rib, inger or toe, coccyx $280
14
Accident Policy Covered Treatment/Services Plan Details
Emergency room $200
Allstate’s accident coverage is intended Primary care physician or urgent $100
to help you with the unexpected costs care
associated with an accident. Beneits Medical Services
are paid directly to you to help pay for Ambulance Ground: $200
Air: $600
your everyday expenses. All beneits Physician follow-up $100
are paid tax-free. Many employees Physical therapy $30
ind this plan to be of value when Rehabilitation unit $200
$250
Appliance beneit
considering higher deductibles and CT or MRI $100
medical out-of-pocket maximums. Xray $200
Hospital Beneits
Covers accidents which occur Hospital admission beneit $1,000
off-the-job Hospital daily beneit $200 per day (max 90-days per accident)
Beneits paid for emergency room, ICU daily beneit $400 per day (max 90-days per accident)
Accidental Death
doctors ofice visits, diagnostic Employee/spouse/each child $40,000/$20,000/$10,000
imaging or scans, broken bones or Schedule of Fractures (complete, simple or closed)
fractures, burns, cuts, and more Hip, thigh (femur) or pelvis (except $4,000
$50 outpatient physician’s coccyx) $3,800
Skull (except bones of the face or
treatment beneit payable two nose)
times per year (max four per Arm, between shoulder and elbow $2,200
(shaft), shoulder blade (scapula),
family) when a covered person is leg (tibia or ibula)
treated by a physician outside of a Foot (except toes), hand or wrist $1,400
(except ingers)
hospital for any cause, including an Lower jaw (except alveolar $800
annual wellness visit process)
Two or more ribs, ingers or toes, $600
bones of face or nose
One rib, inger or toe, coccyx $280
14
