Page 34 - E. Cohen & Co. Allstate Benefits Flipbook

supplemental health insurance

HOSPITALIZATION BENEFITS B ASIC
Daily Hospital Confinement' $100
...........................................
Hospital Intensive Care Unit' $100
Waiver of Premium Yes
ADDITIONAL RIDER BENEFITS B ASIC
Initial Hospitalization $ 500
....................................
Surgery and Anesthesia 2 Surgery $20-$ 500
Anesthesia(% of surgery) 25%
Inpatient Physician's Benefit' $25
Outpatient Emergency Accident 3 $50
Outpatient Physician's Benefit 3 $25 1 daily
At Home Nursing Benefit' $50 2 according to schedule of
...........................................
Transportation Ambulance 3 Ground $100 operations
Air $ 200 3 per occurrence
Non-Local Transportation 4 $ 200 4 per trip

premiums

WEEKLY MONTHLY
AGES EE EE+ SP EE+ CH F AGES EE EE+ SP EE+CH F

18-35 $6.42 $12.83 $12.03 $17.54 18-35 $27.80 $55.60 $52.10 $76.00
36-49 $7.18 $14.36 $12.79 $19.07 36-49 $31.10 $62.20 $55.40 $82.60
50-59 $8.66 $17.31 $13.13 $20.89 50-59 $37.50 $75.00 $56.90 $90.50
60-64 $10.85 $21.70 $13.73 $23.68 60-64 $47.00 $94.00 $59.50 $102.60
.......................... ............................ ························ . ... .............................
EE= Employee; EE+ SP= Employee+ Spouse; EE+ CH = Employee+ Children; F = Family Issue Ages: 18 to 64

•Allstate®

This insert is for use in: KY, MD, OH, TN BENEFITS
This insert is part of brochure ABJ26570 and is not to be used on its own. Allstate Benefits is the marketing name used by American
Heritage Life Insurance Company (Home Office, Jacksonville, FL), a subsidiary of The Allstate Corporation. ©2014 Allstate Insurance
Company. www.allstate.com or allstatebenefits.com.

ABJ26570-lnsert-GLT-B Page 2a (Basic)