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Additional Plan Benefits, Options, and Services
[Health Assessment (Wellness) Benefit]
Employee only [Included]
Employee & spouse[/domestic partner] [Included]
Employee & child/children [Included]
Employee & family [(spouse/domestic partner and child/children)] [Included]
[Health Assessment (Wellness) Benefit]
• You receive a [$0 annual] cash benefit every year you have one or more covered screening tests.
This is in addition to what your health insurance may cover.
• There are 24 covered screening tests, including mammograms and colonoscopies.
• [This benefit is also available to family members/domestic partners.]
[Monthly [Biweekly [Weekly
[Accident Disability Benefit Option] Premium] Premium] Premium]
Employee only [$0.00] [$0.00] [$0.00]
Employee & spouse[/domestic partner] [$0.00] [$0.00] [$0.00]
[Accident Disability Benefit Option]
• You receive a [$0 monthly] cash benefit if you have an accident while off the job that results in your
not being able to work.
• There is a [0-day] period before you begin collecting disability benefits. After this period, you receive
the monthly cash benefit until you are able to return to work or your [0-month] coverage period ends.
• This benefit [option] is available to employees and spouses[/domestic partners].
[Monthly [Biweekly [Weekly
[Accident Sickness Disability Benefit Option] Premium] Premium] Premium]
Employee only [$0.00] [$0.00] [$0.00]
Employee & spouse[/domestic partner] [$0.00] [$0.00] [$0.00]
[Accident Sickness Disability Benefit Option]
• You receive a [$0 monthly] cash benefit if you have either an accident while off the job or an illness
that results in your not being able to work.
• There is a [0-day] period before you begin collecting disability benefits. After this period, you receive
the monthly cash benefit until you are able to return to work or your [0-month] coverage period ends.
• This benefit [option] is available to employees and spouses[/domestic partners].
[Form Filing Number] Accident Insurance | [Choice Plan] Summary of Benefits
