Benefit Schedule (Refer to your application for the Level elected.) Level 1 Level 2 Level 3 Level 4 AO22OCFL 5 Accidental Death and Dismemberment Benefits Primary Insured: 100% of Benefit Amount Spouse: 100% of Benefit Amount Dependent Child: 50% of Benefit Amount Accidental Death $40,000 $60,000 $80,000 $100,000 Common Carrier Accidental Death $100,000 $150,000 $200,000 $250,000 Dismemberment Both Arms and Both Legs $40,000 $60,000 $80,000 $100,000 Both Eyes / Both Arms / Both Legs / Both Hands / Both Feet / One Arm and One Leg / One Hand and One Foot $20,000 $30,000 $40,000 $50,000 One Eye / One Arm / One Leg / One Hand / One Foot $10,000 $15,000 $20,000 $25,000 One or More Fingers or Toes $2,800 $4,200 $5,600 $7,000 Internal Injuries Surgery $1,000 $1,500 $2,000 $2,500 Exploratory Surgery $250 $300 $350 $400 Tendons, Ligaments, and Rotator Cuff Surgery Repair of One Tendon / Ligament / Rotator Cuff $500 $500 $500 $500 Repair of Multiple Tendon / Ligament / Rotator Cuff $750 $750 $750 $750 Ruptured Disc or Torn Knee Cartilage Surgery $500 $500 $500 $500 Miscellaneous Surgery $250 $250 $250 $250 Outpatient Hospital or Ambulatory Surgical Center $150 $250 $350 $450 Anesthesia $150 $200 $250 $300 Hospital Admission $500 $1,000 $1,500 $2,000 Hospital Confinement $100 $200 $300 $400 ICU Admission $1,000 $1,500 $2,000 $2,500 ICU Confinement $400 $800 $1,200 $1,600 Rehabilitation $50 $100 $150 $200 Initial Treatment $150 $200 $250 $300 Follow-Up Treatment $50 $50 $50 $50 Eye Injury $200 $250 $300 $350 Dislocation (Open Reduction) Hip $4,000 $6,000 $8,000 $10,000 Knee (except Patella) $2,400 $3,600 $4,800 $6,000 Ankle / Bones of the Foot (excluding toes) $800 $1,200 $1,600 $2,000 Collarbone (Clavicle, Sternum) $800 $1,200 $1,600 $2,000 Elbow $600 $900 $1,200 $1,500 Lower Jaw $600 $900 $1,200 $1,500 Bones of the Hand (excluding fingers) $600 $900 $1,200 $1,500 Shoulder (Glenohumeral) $600 $900 $1,200 $1,500 Wrist $600 $900 $1,200 $1,500 Collarbone (Acromioclavicular and Separation) $600 $900 $1,200 $1,500 One Finger or Toe $300 $450 $600 $750 Dislocation (Closed Reduction) Hip $2,000 $3,000 $4,000 $5,000 Knee (except Patella) $1,200 $1,800 $2,400 $3,000 Ankle / Bones of the Foot (excluding toes) $400 $600 $800 $1,000 Collarbone (Clavicle, Sternum) $400 $600 $800 $1,000