Additional Benefits

Burn

Up to $5,000

Coma

$15,000

Concussion

$500

Dental injury

$500

Dislocation

Up to $7,500

Eye injury with surgical repair

$500

Fracture

Up to $10,000

Injuries not specifically listed

$100

Internal injury

$1,500

Knee cartilage injury with surgical repair

$1,500

Ruptured disc with surgical repair

$1,500

Tendon/Ligament/Rotator cuff with surgical repair

$1,500

Accidental Death & Dismemberment

Employee: $25,000
Spouse: $12,500
Child: $6,250

Wellness

If you or your covered dependent has an eligible
wellness test performed, you each may receive a $50
benefit once per calendar year.

Portability

If you no longer qualify for coverage, you may be
able to continue coverage for yourself andyour
covered dependents.

Employee

$4.27

Employee + Spouse

$7.04

Employee + Child(ren)

$7.89

Employee + Family

$12.42

You

$5,000
increments

$5,000

$15,000

$50,000

Your Spouse

$2,500
increments

$2,500

$10,000

$25,000,
not to exceed 50%
of the employee’s
amount

Your Child(ren)

Automatically covered for 25% of the employee’s benefit

Automatically covered for 25% of the employee’s benefit

Automatically covered for 25% of the employee’s benefit

Automatically covered for 25% of the employee’s benefit

Health Screening

If you or your covered dependent has an eligible health screening performed, you may
receive a $50 benefit once per calendar year per family.
Claims must be filed within a year of the date of service.

Portability

If you no longer qualify for coverage, you may be able to continue coverage for yourself
and your covered dependents.

Cancer
benefit varies depending on type and severity

Heart Attack

Major organ failure
you must be receiving dialysis or be on a transplant list

Stroke

Coronary artery bypass graft
pays 25% of benefit