BENEFITS AMOUNTS 1 Initial Care & Emergency – Most treatment / service required within 72 hours of accident; Once per accident per insured person Emergency Room $0 Urgent Care Center $0 Initial Physician Office Visit $0 Ambulance Up to $0 Specified Injuries1,2 Fractures (Surgical / Non-surgical) Up to $0 Dislocations (Surgical / Non-surgical) Up to $0 Lacerations Up to $0 Burns Up to $0 Dental Up to $0 Hospital, Surgical & Diagnostic1,3 Admission $0 Daily Confinement (Up to 365 days per accident) $0 per day ICU Confinement (Up to 15 days per accident) $0 per day Rehab. Facility Confinement (Up to 30 days per $0 per day accident) Surgical Up to $0 Diagnostic Up to $0 Follow-Up Care1 – Treatment / service required within 365 days of accident; Medical device is once per accident per insured person Physician Follow-Up Office Visit $0; Up to 6 per accident Therapy Services $0; Up to 6 per accident Medical Device $0 Prosthetic Device(s) $0; Up to 2 per accident 1 Additional Benefits – Benefits are payable within 365 days of accident; Health screening benefit is payable once per calendar year Transportation (Up to 3 trips per accident) $0 per trip Lodging (Up to 30 nights per accident) $0 per night Childcare (Up to 30 days per accident) $0 per day Health Screening $0 Catastrophic Benefits1,4 – Benefits are payable within 365 days of accident; Once per accident per insured person Principal Sum (PS) You: $0 Spouse: $0 Child(ren): $0 Common Carrier Accidental Death 0% of PS Transportation of Remains Up to $0 Dismemberment & Paralysis Up to 0% of PS Reasonable Modifications Up to 0% of PS Coma 0% of PS SERVICES Hearing Discount Program The Hearing Discount program provides you and your family discounted hearing products, including hearing aids and batteries. Call 1-888-534-1747 or visit www.amplifonusa.com/mutualofomaha to learn more. 1Additional limitations apply as described in the certificate. 2Fractures and dislocations require treatment within 90 days of accident, burns and lacerations within 72 hours of an accident, and dental care within 30 days. If an insured person sustains both a fracture and dislocation as the result of the same accident, the maximum amount payable is up to 200% of the amount payable for the injury with the highest applicable benefit amount. 3Daily confinement must begin with 90 days of accident and ICU confinement within 30 days. Surgical treatment timeframes vary. If applicable, diagnostic services must be received within 90 days of accident. Except for confinement benefits, most benefits are payable once per accident per insured person. If any surgery occurs concurrently with an open reduction for a fracture or dislocation of the same bone or joint as a result of the same accident, only the highest applicable benefit is payable. 4The principal sum for you and your spouse reduces by 50% when you reach the age of 70.