Bronze= 1 UNIT Silver= 2 UNITS Gold= 3 UNITS

Benefit Amount per UNIT
Accidental Death (within 90 days of covered accident) $25,000
Common Carrier or School Bus Accidental Death (within 90 days of covered accident while riding as a passenger) $50,000
Dismemberment of: (within 90 days of covered accident)
BOTH eyes, hands, arms, feet, legs or ONE hand, arm, foot, or leg. $15,000
ONE eye, hand, arm, foot, leg. $7500
ONE or MORE toe or finger $1000

ACCIDENTAL EMERGENCY TREATMENT BENEFIT AMOUNT PER UNIT: $50
(within 72 hours of a covered accident)

ACCIDENT FOLLOW-UP TREATMENT BENEFIT PER UNIT: $15 PER TREATMENT

Follow-up treatments must occur within 30 days of the covered accident or discharge from the hospital, and must be furnished by a physician in a physician’s office or in a hospital on an outpatient basis. Benefit NOT payable for the same visit that the physical therapy benefit is payable or on the same day for which the accidental emergency treatment benefit is payable.

AMBULANCE BENEFIT AMOUNT PER UNIT:

GROUND: $75

LIFE FLIGHT: $500

(Benefit only payable if accidental emergency treatment benefit is payable.)

BURN BENEFIT AMOUNT PER UNIT: 3rd Degree Burns covering-

10-20%: $500

20-30%: $1000

more than 30%: $2500
(Treatment must be received within 72 hours following a covered accident.)

DISLOCATION BENEFIT AMOUNT PER UNIT:
(If physician treats the dislocation without anesthesia, benefit will be 25% of the applicable sum.)

DISLOCATED JOINT OPEN REDUCTION CLOSED REDUCTION
Hip $1700 $450
Knee (NOT kneecap) $450 $150
Shoulder $450 $150
Foot/ ankle $450 $150
Wrist $200 $200
Elbow $200 $200
Lower Jaw (mandible) $450 $250

FAMILY LODGING BENEFIT AMOUNT PER UNIT: $50 PER DAY

Hospital and lodging must be more than 100 miles from the residence of the insured person. Benefit is limited to a maximum of 30 days of lodging for each covered accident.

FRACTURE BENEFIT AMOUNT PER UNIT:

Open or closed fracture must be diagnosed within 14 days of covered accident. If insured person sustains more than one fracture, the benefit will be for all fractures up to a maximum amount equal to two times the principle sum of the fracture type with the highest principle sum. If the physician diagnosis the fracture as a chip fracture, the benefit will be 25% of the applicable principle sum.

FRACTURE OPEN/COMPOUND CLOSED
Hip/ Thigh $2000 $1000
Leg $1000 $500
Hand, Wrist, or Forearm $500 $250
Foot, Ankle, or Kneecap $500 $250
Shoulder blade/ Collarbone $500 $250
Lower Jaw (mandible) $500 $250
Vertebrae (body)/ Pelvis $1000 $500
Upper Jaw, Upper Arm, or Face $500 $250
Rib $200 $100
Nose/ Heel $350 $100
Coccyx $200 $100
Vertebral processes $1000 $150
Skull (simple) $400
Skull (depressed) $1250

LACERATION BENEFIT AMOUNT PER UNIT: $50
(Repair of laceration must occur within 72 hours of a covered accident. NOT payable is injury requires stitches and any other benefit is payable.)

MAJOR DIAGNOSTIC EXAMINATIONS BENFIT AMOUNT PER UNIT: $75 PER EXAM.
Benefit is limited to one major diagnostic exam per year for each insured person. Exam covered are: CT, MRI, EEG.

PARALYSIS BENEFIT AMOUNT PER UNIT:
(Duration of paralysis must be at least 30 days and must be expected to be permanent.)

PARAPLEGIA: $1000

HEMIPLEGIA: $1500

QUADRIPLEGIA: $2500

PHYSICAL THERAPY BENEFIT AMOUNT PER UNIT: $10 PER TREATMENT.

Physical therapy must begin within 30 days of the covered accident or discharge from the hospital and must be completed within 6 months after the covered accident. Benefit is limited to one physical therapy treatment per day, up to a maximum of 10 treatments for each covered accident.

PROSTHESIS BENEFIT AMOUNT PER UNIT: $250 PER DEVICE.

Benefit limited to a maximum of one prosthetic device received within one year of the covered accident.

SURGERY BENEFIT AMOUNT PER UNIT:
Two or more surgical procedures performed with the same incision will be considered 1 surgery and benefits will be based on the most expensive surgical procedure.

SURGERY FOR THE REPAIR AT: AMOUNT PER UNIT
Tendons/Ligaments $200
Torn Rotator Cuff $200
Ruptured Disc $200
Torn Knee Cartilage $100
Arthroscopy without surgical repair $100
Open Abdominal Wound $400
Cranial/Hernia/Thoracic $400
Miscellaneous Surgery (1 per accident) $100

TRANSPORTATION BENEFIT AMOUNT PER UNIT: $150 PER ROUND TRIP.
Limited to 3 round trips per year per injured person. NOT payable for transportation to any hospital located within 100 mile radius of the site of the covered accident or the residence of the insured person.

GLOSSARY OF TERMS

ACCIDENT: the unforeseen occurrence of am event, which result in an accidental injury to an insured person wholly independent of disease, bodily infirmity, illness, or infection, or any other physical condition.

ACCIDENTAL INJURY: bodily injury to an insured person as the result of an accident after the coverage takes effect and while the policy is in force.

AMBULANCE: a specially equipped vehicle , licensed and used to transport the sick or injured.

EMERGENCY ROOM: a specified area within a hospital thst is dedicated for emergency care if accidental injuries which is open 24 ours a day, seven days per week.

HOSPITAL: a facility operated pursuant to law and is licensed as a hospital by the responsible state agency which provides 24-hour nursing and is not a facility affording primarily custodial care.

INSURED PERSON: all persons who are indicated as an insured person in the policy data as being covered by the policy.

PHYSICIAN: a person who is legally qualified practitioner of the healing arts and is licensed in the US or its territories.

PROSTHETIC DEVICE: a removable artificial substitute or replacement for a part of the body not including: eye glasses, dental aids, or cosmetic prosthesis.

SURGERY: a surgical operation or procedure , especially one involving the repair or removal of a organ or tissue due to an accidental injury.

UNITED STATES (US): The 50 states plus the District of Columbia, Guam, US Virgin Islands, and Puerto Rico.