1. BENEFIT HIGHLIGHTS Hospital Confinement (per day up to 365 days $150 $250 per Covered Accident) Intensive Care Unit admission (once per $750 $1,500 Benefit Year; payable instead of Hospital admission benefit if Confined immediately to ICU) Intensive Care Unit Confinement (per day up $300 $500 to 15 days per Covered Accident; payable in addition to any Hospital Confinement benefit) Ambulance (Ground) $100 $200 Ambulance (Air) $750 $1,500 Emergency Room admission $100 $150 Family lodging Maximum Lodging Night Stays: 1 benefit $50 $100 per day, 30 days per Benefit Year Transportation (100 or more miles up to 3 $250 $500 times per Covered Accident) Rehabilitation Unit (per day up to 30 days per $50 $100 Covered Accident) Surgery Low Plan High Plan Miscellaneous Surgery requiring general $150 $300 anesthesia that is not otherwise listed (once per 24 hour period even though multiple surgical procedures may be performed) Open Surgery $625 $1,250 Exploratory Surgery or debridement $125 $250 Tendon/Ligament/Rotator cuff tear $300 $625 Torn Knee Cartilage $300 $625 Ruptured / herniated disc $300 $625 Emergency Dental Low Plan High Plan Emergency dental extraction $30 $65 Emergency dental crown $100 $200 Wellness Screening Benefit Low Plan High Plan (once per Benefit Year) $50 $50 Contributions: The cost of your insurance is paid for entirely by you. This is your Contributory insurance. 16-AC-C-01 Page9