Accident Coverage This insurance pays a benefit for each injury, treatment or service included in the BENEFITS AMOUNT policy that occurs as the result of a covered accident. Ambulance $0 For example, Jeff’s son, Jake, was playing soccer during recess at school. He was ER Visit $0 tripped and falls hard, injures his shoulder, and is transported by ambulance to CT Scan $0 the ER due to concerns of head trauma. The ER doctor orders a CT scan to check X-ray $0 for any facial or head injuries and a shoulder X-ray. Concussion $0 Jake was diagnosed with a concussion and a broken collarbone. His arm was set Broken Collarbone $0 in a sling, and he was released to his pediatrician for follow-up care. Jake visits Follow-Up Visit 1 $0 his pediatrician at two weeks and one month after the accident to make sure he’s healing well. Follow-Up Visit 2 $0 In the meantime, Jeff starts receiving bills for the care Jake received. The Total Benefit $0 ambulance bill alone was $556. He’s a pretty healthy kid, so a health insurance Note: The benefits shown in this deductible of $1,500 had to be met before Jeff’s health insurance would begin example are for a sample design covering Jake’s care, and after that, there’s a 20% copay. and may vary from the benefits Accident benefits pay in addition to other insurance, and can be used to help that are available to you. cover gaps in health insurance or other expenses if the unexpected happens. Voluntary Accident Premium Rates The amounts shown below are WEEKLY amounts (52 payments / deductions per year). You may elect insurance for you only, or for your family. Premiums will be automatically deducted from your paychecks as authorized by you during the enrollment process. Premiums must be paid by you to the policyholder. COVERAGE TIER PREMIUM AMOUNT Employee/Member $0 ($0 per day) Employee/Member + Spouse $0 ($0 per day) Employee/Member + Child(ren) $0 ($0 per day) Employee/Member + Family $0 ($0 per day) Note: The amount(s) above may vary due to rounding and are subject to change based on the final terms of the policy.