Page 110 - Benefits Summary 2018-2019

Hospital Indemnity (GIM2)
Group Indemnity Medical Insurance
from Allstate Benefits
See attached Important information About Coverage.

BENEFIT AMOUNTS
PLAN 1 PREMIUMS
BASE POLICY BENEFITS PLAN 1 PLAN 2 MODE EE EE + SP EE + CH F
First Day Hospital Confinement Benefit $500 $1,000
Limit to Number of Occurrences One per Month One per Month Semi-Monthly $5.27 $13.46 $6.83 $14.17
Pregnancy (Normal and Complications) Covered Covered Covered
Daily Hospital Confinement Benefit $100 $100 EE=Employee; EE + SP = Employee + Spouse; EE + CH = Employee +
Maximum Number of Days¹ 10 Days Max 10 Days Max Child(ren); and F = Family
Hospital Intensive Care Benefit $100 $100
Maximum Number of Days² 10 Days Max 10 Days Max
¹ payable for each day, up to the max per continuous confinement in a hospital; not paid for
any day the First Day Hospital Confinement Benefit is paid
² payable for each day, up to the max per continuous confinement in a hospital intensive
care unit; pays in addition to the First Day Hospital Confinement Benefit and Daily Hospital
Confinement Benefit

PLAN 2 PREMIUMS
MODE EE EE + SP EE + CH F

Semi-Monthly $8.58 $21.52 $11.38 $22.56
OPTIONAL EXCLUSIONS PLAN 1 PLAN 2
Mental and Nervous Disorders Covered No No EE=Employee; EE + SP = Employee + Spouse; EE + CH = Employee +
Drug Addiction and Alcoholism Covered No No Child(ren); and F = Family
Pregnancy Waiting Period None None
ADDITIONAL OPTIONS PLAN 1 PLAN 2
Removal of Pre-Existing Conditions Limitation No No

43287
For use in enrollments sitused in: VIRGINIA. This rate insert is part of the approved brochure; it is not to be used on its own.

This rate insert is valid as long as information remains current, but in no event later than 9/11/2021. Allstate Benefits is the marketing name used by American Heritage Life Insurance Company (Home Office,
Jacksonville, FL), a subsidiary of The Allstate Corporation. ©2018 Allstate Insurance Company. www.allstate.com or allstatebenefits.com.
ABJ30067-2 - Insert - 43287