BENEFIT TYPE

 DESCRIPTION

 OPTION
ONE

 OPTION
TWO

 OPTION
THREE

 Hospital
Expense Benefit

Pays a daily benefit for hospitalization due to sickness or accident beginning on the first day of hospitalization.  Payable for up to 365 days of confinement per insured.

 $30

 $80

 $250

 Annual First
Occurrence Hospital
Confinement Rider

 This benefit is payable when a covered person is admitted and confined in a hospital for at least twenty-four (24) consecutive hours.  Payable once per covered person in a calendar year.

 $200

$250

$500

 Emergency Accident
Rider

 Pays the actual cost up to the benefit amount, for emergency care by a physician in a hospital or physician’s office when incurred within 30 days of an accident.  Benefits are payable for up to four covered accidents for the employee, four for the spouse, and four for all covered children.

 $100

 $200

$300

 Outpatient Sickness
Rider

 This benefit pays actual charges not to exceed the amount stated per treatment for a covered sickness by a physician or surgeon in their office, clinic, or other out-of-hospital facility.  Payment will be limited to the maximum stated, for all insureds combined, in a calendar year.

 $25
per visit

$150
maximum

 $25
per visit

$250
maximum

 $50
per visit

$400
maximum

 Intensive
Care/Coronary Care
Benefit Rider

 Pays a daily intensive care benefit for each day an insured person is confined in a hospital’s intensive care or coronary care unit due to an injury or sickness.  Benefits begin on the first day of confinement, not to exceed 20 days per period of confinement.

 $100

 $200

 $200

 Surgery
Anesthesia Benefit
Rider**

 Pays actual charges, up to the amount shown in the schedule of operations, for surgery performed by a physician.  Pays an additional 25% of the surgical benefit for anesthesia administered by a physician in connection with surgery.

 $1000
maximum

$1500
maximum

 $4000
maximum