Health Screening Test Benefit Preventive Care Benefit Benefit Amount
$50 per day 1 per year
Maximum Benefit Period
Continuation Options
Applicable Coverage(s)
Accident Indemnity Benefits and Optional Benefits for Employee, His Spouse and Dependent Child
For Family Medical Leave Maximum Benefit Period
up to 6 months for family medical leave and up to 6 months for military family leave
For Leave of Absence
Maximum Benefit Period
up to 12 weeks
PORTABILITY
Portable Period
Coverage continues to age 100 for Employee, to age 100 for Spouse, to age 26 for Dependent Child, unless otherwise specified
Amount of Portable Insurance Coverage(s) that may be ported Benefits that may be ported
100%
Employee, Spouse, Dependent Child
All
Maximum Age
As of the date of porting, 100 for Employee, 100 for Spouse, 26 for Dependent Child, unless otherwise specified
PREMIUM INFORMATION
INITIAL PREMIUM
Premium:
Refer to your Plan and Rate Confirmation as provided at time of enrollment or application
Contribution(s):
The cost of coverage is paid by the Employee
PREMIUM DUE DATES
The Policy Effective Date and the first day of each succeeding modal period.
Premium rates are subject to change in accordance with the Changes in Premium Rates provision of the Administrative Provisions section of this Policy.
GAI-00-1100a.00
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