Page 30 - Complete Hi-Res 7-product Kit

Accident Insurance | [Choice Plan] Summary of Benefits

Prepared for: [Class Employees at Sample Company]
Enrollment Deadline: [Month XX, 2017]

Group rates for [Sample employees] make accident insurance
more affordable than ever. This coverage provides cash
benefits if you or a covered family member[/domestic
partner] is injured in an accident. The types of injuries
covered and the cash benefits for each — along with
additional plan benefits, options, and services — are outlined
on the following pages.

[To take advantage of this coverage, simply complete and
return your Enrollment Form by Month XX, 2017. Your
premium comes out of your paycheck, so no money is due
now.]

Cash Benefit Amounts

Emergency Care Your Cash Benefit

Ambulance/air ambulance [$0/$0]
Initial physician office visit/ER visit [$0/$0]
Major diagnostic exam [$0]

Hospitalization & Follow-up Care Your Cash Benefit
Hospital admission [$0]

Hospital confinement daily benefit [$0]
Intensive care daily benefit [$0]
Alternate care and rehabilitative facility daily benefit [$0]
Follow-up doctor/patient care (up to 6 sessions) [$0]
Transportation for care (up to 3 times per accident) [$0]

Companion lodging (up to 30 days per accident) [$0]
Family care per child (up to 30 days) [$0]

Fractures & Dislocations Your Cash Benefit

Bone fracture treated surgically [$0-$0]
Bone fracture treated without surgery [$0-$0]
Chip fracture [00%] of fracture benefit

Dislocation injury treated surgically [$0-$0]
Dislocation injury treated without surgery [$0-$0]
Partial dislocation [00%] of dislocation benefit

[Form Filing Number] Accident Insurance | [Choice Plan] Summary of Benefits