ACCIDENTAL-DEATH AND -DISMEMBERMENT (within 90 days) EMPLOYEE SPOUSE CHILD ACCIDENTAL-DEATH $50,000 $25,000 $5,000 ACCIDENTAL COMMON-CARRIER DEATH (plane, train, boat, or ship) $100,000 $50,000 $15,000 SINGLE DISMEMBERMENT $12,500 $5,000 $2,500 DOUBLE DISMEMBERMENT $25,000 $10,000 $5,000 LOSS OF ONE OR MORE FINGERS OR TOES $1,250 $500 $250 PARTIAL AMPUTATION OF FINGERS OR TOES (including at least one joint) $100 $100 $100 If the Accidental Common-Carrier Death Bene昀椀t is paid, we will pay the Accidental-Death Bene昀椀t. Accidental-Death Bene昀椀t We will pay the amount shown if, because of a covered accident, you are injured, and the injury causes you to die within 90 days after the accident. Accidental Common-Carrier Death Bene昀椀t We will pay the amount shown if you are a fare-paying passenger on a common carrier, as de昀椀ned below, are injured in a covered accident, and die within 90 days after the covered accident. We will pay the Accidental-Death Bene昀椀t in addition to the Accidental Common-Carrier Death Bene昀椀t. Dismemberment Bene昀椀t We will pay the appropriate amount shown if, because of a covered accident, you are injured and lose a hand, a foot, or sight within 90 days after the accident as a result of the injury. If you lose one hand, one foot, or the sight of one eye in a covered accident, we will pay the single dismemberment bene昀椀t shown. If you lose both hands, both feet, the sight of both eyes, or a combination of any two, we will pay the double dismemberment bene昀椀t shown. If you lose one or more 昀椀ngers or toes in a covered accident, we will pay the 昀椀nger/toe bene昀椀t shown. If the Dismemberment Bene昀椀t is paid and you later die as a result of the same covered accident, we will pay the appropriate death bene昀椀t, less any amounts paid under this bene昀椀t. MAJOR INJURIES (diagnosis and treatment within 90 days) EMPLOYEE/ SPOUSE/CHILDREN FRACTURES (closed reduction) Fracture* is a break in the bone that Hip/Thigh $4,000 can be seen by X-ray. If a bone is fractured in a covered accident, we Vertebrae (except processes) $3,600 will pay the appropriate bene昀椀t shown. Pelvis $3,200 Multiple fractures* means having Skull (depressed) $3,000 more than one fracture requiring open or closed reduction. If these fractures Leg $2,400 occur in any one covered accident, we will pay the appropriate bene昀椀ts Forearm/Hand/Wrist $2,000 shown for each fracture, but no more Foot/Ankle/Kneecap $2,000 than double the amount for the bone fractured that has the highest bene昀椀t Shoulder Blade/Collar Bone $1,600 amount. Lower Jaw (mandible) $1,600 Chip fracture* means a piece of bone that is completely broken off Skull (simple) $1,400 near a joint. If a doctor diagnoses a chip fracture, we will pay 25% of the Upper Arm/Upper Jaw $1,400 appropriate bene昀椀t shown. Facial Bones (except teeth) $1,200 *If a fracture requires open reduction, Vertebral Processes $800 we will pay double the amount shown. Coccyx/Rib/Finger/Toe $320 The plan has limitations and exclusions that may affect benefits payable. The plan has limitations and exclusions that may affect benefits payable. This brochure is for illustrative purposes only. Refer to your certificate for complete details, definitions, limitations, and exclusions.This brochure is for illustrative purposes only. Refer to your certificate for complete details, definitions, limitations, and exclusions.