The Essential Plan

Benefits

Base Policy

Accidental Death

Common Carrier Accidental Death

Dismemberment

Dislocation or Fracture

Hospital Confinement

Initial Hospital Confinement

Intensive Care

Ambulance

Medical Expenses

Outpatient Physician’s Treatment

INJURY BENEFIT SCHEDULE

Benefit amounts for coverage per occurrence are shown below.

Coverage type, on and off the job.

Loss of Life or Limb

Employee

Spouse / Child

Life

$ 50,000

$ 15,000

Both Eyes

$ 50,000

$ 15,000

One Eye

$ 25,000

$ 7,500

Both Hands or Arms

$ 50,000

$ 15,000

Both Feet or Legs

$ 50,000

$ 15,000

One Hand or Arm and One Foot or Leg

$ 50,000

$ 15,000

One Hand or Arm

$ 25,000

$ 7,500

One Foot or Leg

$ 25,000

$ 7,500

One or More Entire Toes

$ 4,000

$ 1,200

One or More Entire Fingers

$ 4,000

$ 1,200

Complete Dislocation

Employee

Spouse / Child

Hip Joint

$ 4,000

$ 4,000

Knee Joint (except Patella)

$ 1,600

$ 1,600

Bone or Bones of the Foot (except Toes)

$ 1,600

$ 1,600

Ankle Joint

$ 1,600

$ 1,600

Wrist Joint

$ 1,400

$ 1,400

Elbow Joint

$ 1,200

$ 1,200

Shoulder Joint

$ 800

$ 800

Bone or Bones of the Hand (except Fingers)

$ 600

$ 600

Collarbone

$ 600

$ 600

Two or More Fingers

$ 280

$ 280

Two or More Toes

$ 280

$ 280

One Finger or Toe

$ 120

$ 120

Simple or Closed Fracture

Employee

Spouse / Child

Skull (except Bones of Face or Nose)

$ 3,800

$ 3,800

Hip, Thigh (Femur)

$ 4,000

$ 4,000

Pelvis (except Coccyx)

$ 4,000

$ 4,000

Arm, between Shoulder and Elbow (Shaft)

$ 2,200

$ 2,200

Shoulder Blade (Scapula)

$ 2,200

$ 2,200

Leg (Tibia or Fibula)

$ 2,200

$ 2,200

Ankle

$ 1,600

$ 1,600

Knee Cap (Patella)

$ 1,600

$ 1,600

Collarbone (Clavicle)

$ 1,600

$ 1,600

Forearm (Radius or Ulna)

$ 1,600

$ 1,600

Foot (except Toes)

$ 1,400

$ 1,400

Hand or Wrist (except Fingers)

$ 1,400

$ 1,400

Lower Jaw (except Alveolar Process)

$ 800

$ 800

Two or More Ribs, Fingers or Toes

$ 600

$ 600

Bones of Face or Nose

$ 600

$ 600

One Rib, Finger or Toe

$ 280

$ 280

Coccyx

$ 280

$ 280

ACCIDENT INSURANCE

Economy Plan

Coverage Type

On and Off-the-Job

AD&D

Employee:

$50,000

Spouse:

$50,000

Child:

$15,000

Common Carrier AD

Employee:

$200,000

Spouse:

$200,000

Child:

$50,000

Dislocation or Fracture

Employee:

$4,000

Spouse:

$4,000

Child:

$4,000

Initial Hospital Confinement (Pays once)†

$1,000

Hospital Confinement (Pays daily)‡

$300

Intensive Care (Pays daily)§

$500

Medical Expenses**

Up to $1000

Ambulance

Ground: $200 Air: $600

Outpatient Physician’s Treatment*

$50

(Pays per visit)

Bereavement and Trauma Counseling

$150 per session for up to 10 sessions


 ‡70 Day Limit - §90 Day Limit
† This benefit is payable only once per Hospital Confinement and only once per Covered Person per Accident
* Pays up to 2 times for employee. If spouse or children are covered the maximum benefit of 2 per person, 4 maximum per calendar year.
**Any expense associated with a covered accident