Benefit Schedule (Refer to your application for the Level elected.) Level 1 Level 2 Level 3 Level 4 AO22OCFL 7 Severe Burns 2nd Degree less than 10% of the body surface $150 $150 $150 $150 10% to less than 25% of the body surface $450 $450 $450 $450 25% to less than 35% of the body surface $750 $750 $750 $750 35% or more of the body surface $1,500 $1,500 $1,500 $1,500 3rd Degree less than 10 sq. in. of the body surface $2,250 $2,250 $2,250 $2,250 10 sq. in. to less than 25 sq. in. of the body surface $3,750 $3,750 $3,750 $3,750 25 sq. in. to less than 35 sq. in. of the body surface $7,500 $7,500 $7,500 $7,500 35 sq. in. or more of the body surface $15,000 $15,000 $15,000 $15,000 Skin Graft 50% of Burn Benefit Laceration Not requiring sutures $25 $50 $75 $100 Requiring sutures Lacerations totaling less than 2 inches in length $100 $150 $200 $250 Lacerations totaling 2 inches to less than 6 inches in length $200 $250 $300 $350 Lacerations totaling 6 inches or more in length $400 $500 $600 $700 Ambulance Air Ambulance $1,500 $1,500 $1,500 $1,500 Ground or Water Ambulance $500 $500 $500 $500 Emergency Dental Work $150 $200 $250 $300 Physical, Occupational, or Speech Therapy $25 $25 $25 $25 Blood, Plasma, and Platelets $250 $300 $350 $400 X-ray $50 $100 $150 $200 Medical Imaging $200 $200 $200 $200 Gunshot Wound $500 $1,000 $1,500 $2,000 Epidural Pain Management $100 $150 $200 $250 Coma $5,000 $10,000 $15,000 $20,000 Paralysis Uniplegia $10,000 $15,000 $20,000 $25,000 Paraplegia $10,000 $15,000 $20,000 $25,000 Quadriplegia $20,000 $30,000 $40,000 $50,000 Appliance $100 $150 $200 $250 Prosthesis (per device) $500 $500 $500 $500 Transportation $300 $300 $300 $300 Family Member Lodging and Meals $100 $100 $100 $100 Concussion $200 $250 $300 $350 Traumatic Brain Injury $1,000 $1,500 $2,000 $2,500 Accident Screening $50 $50 $75 $75 THE REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK Continued on next page