Type of Benefit Benefit Amount Physical Therapy $38 per session Physician Visit Initial Physician Office Visit $75 Follow-up Physician Office Visit $75 Prosthesis One $750 Two or more $1,500 Rehabilitation Facility Confinement $100 per day Surgery Abdominal or Thoracic Surgery (Surgically Repaired) $1,500 Exploratory Surgery (No Repair) $150 Knee Cartilage (Surgically Repaired) $450 Ruptured Disc (Surgically Repaired) $750 Tendon, Ligament or Rotator Cuff (Surgically Repaired) One Repair $450 Two or more Repairs $900 Transportation $450 X-Ray $50 ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS: Loss of Life: Employee $50,000 Spouse $25,000 Child(ren) $10,000 per child Loss of Life on a Common Carrier: 100% of Loss of Life Loss of one of the following: 50% of Loss of Life Arm Foot Hand Hearing in one ear Leg Sight in one eye Loss of finger, thumb or toe: One Loss 1% of Loss of Life Two or more Losses 3% of Loss of Life Catastrophic Loss as follows: Speech 100% of Loss of Life Two or more Losses, except the Loss of fingers, thumbs or toes 100% of Loss of Life Wellness Benefit: $50 LRS-9548-0318-IN Page 1.4