Accident Insurance Benefit Accident Coverage Type Ambulance/Air Ambulance Blood/Plasma/Platelets Burns (2 nd Degree / 3 rd Degree)
Employee Coverage*
On and Off Job $300/$1,500
$300
9 sq inches to 18 sq inches: $0 / $2,000; 18 sq inches to 35 sq inches: $1,000 / $4,000; Over 35 sq inches: $3,000 / $12,000
50% of burn benefit 25% increase to child benefits $50 per visit up to 6 visits
Burn-Skin Graft Child Organized Sport Chiropractic Visits
$10,000 $200/ $25
Coma
Concussions/Concussion Baseline Study Diagnostic Exam (Major) Dislocations Doctor Follow Up Visits Emergency Dental Work Emergency Room Treatment Epidural Anesthesia Pain Management
$200
Schedule up to $5,000 $50 up to 6 treatments $300/Crown; $75/Extraction $100, 2 times per accident
$200 $300
Eye Injury Family Care Fractures
$20/day up to 30 days Schedule up to $6,000
Gun Shot Wound
$750
Hospital Admission/ Hospital Confinement Hospital ICU Admission/ Hospital ICU Confinement Initial Doctor’s Office/ Urgent Care Facility Treatment Joint Replacement (hip/knee/shoulder)
$1,000/ $225/day – up to 1 year $2,000/$450/day – up to 15 days
$100 $500
$2,500/$1,250/$1,250 Schedule up to $400 Schedule up to $500 $25 day, up to 10 days 1: $500; 2 or more: $1,000 $400 $150/day up to 15 days $1,250 (Hernia: $250) 1: $500; 2 or more: $1,000 $500 $250
Knee Cartilage Laceration Lodging Medical Appliance
$125/day, up to 30 days for companion hotel stay
Outpatient Therapies Post-Traumatic Stress Disorder Prosthetic Device/Artificial Limb Rehabilitation Unit Confinement
Ruptured Disc with Surgical Repair Surgery (Cranial, Open Abdominal, Thoracic) Surgery – Exploratory or Arthroscopic Tendon/Ligament/Rotator Cuff
$0.50 per mile, limited to $500, 3 times per accident
Transportation Traumatic Brain Injury
$4,000 $100
X-Ray
Provides a $75 per year benefit for completing certain routine wellness screenings or procedures
Wellness Benefit
Accidental Death and Dismemberment: Death Benefit
Employee: $30,000, Spouse: $30,000, Child: $15,000 Quadriplegia: 100% of AD&D Loss of speech and hearing (both ears): 100% of AD&D Loss of cognitive function: 100% of AD&D
Catastrophic Loss
Hemiplegia: 50% of AD&D Paraplegia: 50% of AD&D 200% of AD&D 200% of Spouse AD&D
Common Carrier Common Disaster Hand, Foot, Sight Thumb/Index Finger Same Hand, Four Fingers Same Hand, All Toes Same Foot Seatbelt and Airbags
Single: 50% of AD&D benefit; Multiple: 100% of AD&D benefit
25% of AD&D
Seatbelts: $10,000; Airbags: $15,000
$2,500
Reasonable Accommodation to Home or Vehicle
Benefit Amount: $400; Rollover Maximum: $200; Fund Maximum: $800
Rainy Day Fund
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