Accident

The Hartford

ABOUT ACCIDENT

Do you have kids playing sports, are you a weekend warrior, or maybe accident prone? Accident plans are designed to help pay for medical costs associated with accidents and benefits are paid directly to you.

For full plan details, please visit your benefit website: www.mybenefitshub.com/annaisd

EMPLOYEE BENEFITS

COVERAGE INFORMATION

You have a choice of two accident plans, which allows you the flexibility to enroll for the coverage that best meets your needs. This insurance provides benefits when injuries, medical treatment and/or services occur as the result of a covered accident. Unless otherwise noted, the benefit amounts payable under each plan are the same for you and your dependent(s). Employee Accident Low

High $12.37 $17.10 Employee + Spouse $19.48 $26.94 Employee + Child(ren) $20.58 $28.52 Family $32.41 $44.88

PLAN INFORMATION Coverage Type BENEFITS EMERGENCY, HOSPITAL & TREATMENT CARE Accident Follow-Up Up to 3 visits per accident Acupuncture/Chiropractic Care Up to 10 visits each per accident Ambulance – Air Ambulance – Ground Blood/Plasma/Platelets Child Care Daily Hospital Confinement Daily ICU Confinement Diagnostic Exam Emergency Dental Emergency Room

Health Screening Benefit Hospital Admission Initial Physician Office Visit Lodging Medical Appliance Physical Therapy Rehabilitation Facility Transportation Once per accident Once per accident Once per accident Up to 30 days per accident while insured is confined Up to 365 days per lifetime Up to 30 days per accident Once per accident Once per accident Once per accident

Once per year for each covered person Once per accident Once per accident Up to 30 nights per lifetime Once per accident Up to 10 visits each per accident Up to 15 days per lifetime Up to 3 trips per accident

Urgent Care X-ray Once per accident Once per accident LOW PLAN

HIGH PLAN On and off-job (24 hour)

LOW PLAN HIGH PLAN

$100 $50 $2,000 $750 $300 $35 $150 $75 $2,500 $1,000 $400 $50

$400 $600 $300

$600 $800 $400 Up to $450 Up to $600 $200 $250

$50 $1,500 $100 $150 $200 $75 $300 $600 $150 $150

$50 $2,000 $150 $175 $300 $100 $450 $800 $200 $200

The Hartford

EMPLOYEE BENEFITS

SPECIFIED INJURY & SURGERY Abdominal/Thoracic Surgery Once per accident Arthroscopic Surgery Once per accident

Burn Burn – Skin Graft Once per accident Once per accident for third degree burn(s)

Concussion Dislocation Eye Injury Fracture Hernia Repair

Joint Replacement Knee Cartilage Up to 3 per year Once per joint per lifetime Once per accident Once per bone per accident Once per accident

Once per accident Once per accident

Laceration Once per accident

Ruptured Disc

Once per accident Tendon/Ligament/Rotator Cuff Once per accident CATASTROPHIC Accidental Death Common Carrier Death Coma Dismemberment Home Health Care Paralysis

Prosthesis FEATURES Within 90 days; Spouse @ 50% and child @ 25% Within 90 days Once per accident Once per accident Up to 30 days per accident Once per accident

Once per accident

Ability Assist® EAP – 24/7/365 access to help for financial, legal or emotional issues HealthChampionSM – Administrative & clinical support following serious illness or injury LOW PLAN HIGH PLAN

$3,000 $500

$4,000 $750 Up to $15,000 Up to $20,000 50% of burn benefit $200 $250 Up to $8,000 Up to $12,000

Up to $750 Up to $1,000 Up to $10,000 Up to $12,000 $400 $600

$4,000

$6,000 Up to $2,000 Up to $3,000 Up to $1,000 Up to $1,500 $2,000 $3,000 Up to $2,000 Up to $3,000

LOW PLAN HIGH PLAN

$75,000

$100,000 2 times death benefit $15,000 $20,000 Up to $75,000 Up to $100,000 $75 $100 Up to $75,000 Up to $100,000

Up to $3,000 Up to $4,000

LOW PLAN HIGH PLAN

Included Included Included Included

THIS POLICY PROVIDES GROUP ACCIDENT INSURANCE ONLY. Please refer to the benefit website for complete plan details, limits and exclusions, and claim instructions at www.mybenefitshub.com/annaisd