BENEFIT DESCRIPTION
ONE-UNIT
TWO-UNITS
$375/150* for 2nd degree burns on at least 36% of the body $750/300* for 3rd degree burns on at least $5,000/2,000* for 3rd degree burns on 20% or more of the body $150 repairs with crown $50 for extraction 1% but less than 20% of the body
$750/300* for 2nd degree burns on at least 36% of the body $1,500/600* for 3rd degree burns on at least $10,000/4,000* for 3rd degree burns on 20% or more of the body $300 repairs with crown $100 for extraction 1% but less than 20% of the body
Burn Treated within 72 hours of a Covered Accident. Once per Covered Accident. *Spouse** and Child
Emergency Dental Work Once per Covered Accident regardless of teeth involved. Dislocation (separated joint) Diagnosed within 90 days, correction with anesthesia by Physician and corrected by Open (surgical) or Closed (non- surgical) reduction. Fracture (broken bone) Fractures requiring Surgical or Non-Surgical reduction within 90 days of Covered Accident. Gunshot Wounds Unintentional wound requiring confinement within 24 hours and surgery within 72 hours of Covered Accident. Primary insured only. Laceration Lacerations requiring repair by a physician within 72 hours of a Covered Accident. Lodging Companion Lodging when Insured is confined to a hospital more than 100 miles from home. Maximum of 30 days Eye Injury Treated by a physician within 90 days of Covered Accident. Must require surgery or removal of a foreign object.
$50 - $2,000 (policy contains complete schedule) $25 - $2,500 (any Insured) (policy contains complete schedule)
$100 - $4,000 (policy contains complete schedule) $50 - $5,000 (any Insured) (policy contains complete schedule)
$500
$500
$50 - $400 (based on length of lacerations, see policy)
$100 - $800 (based on length of lacerations, see policy)
$100 per night
$100 per night
$200
$200
$500 $100 for exploratory surgery
$1,000 $200 for exploratory surgery
Knee Cartilage - Torn Treated by a physician within 60 days of Covered Accident. Must be repaired within 180 days.
Transportation Round trip when hospital confined and distance is more than 100 miles round trip from residence. Three round trips per Covered Accident.
$300 round trip
$300 round trip
$1,000 for thoracic, open abdominal $100 for exploratory surgery
$1,000 for thoracic, open abdominal $100 for exploratory surgery
Surgery Within 72 hours after a Covered Accident to repair internal injuries caused by the Covered Accident. Hernia repair not covered. Once per Covered Accident.
**Spouse and Child in NJ, Spouse/Civil Union Partner
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