BENEFIT PROVISIONS Please refer to the Schedule of Benefits for benefit amounts payable. AMBULANCE BENEFITS: Air Ambulance Transportation: An Air Ambulance Transportation benefit will be payable if you or your Insured Dependent sustain an Injury as a result of a Covered Accident and: (1) a licensed ambulance company provides air transport: (a) to or from a Hospital; or (b) between medical facilities; and (2) the air ambulance transportation is provided within 48 hours of the Covered Accident. Only one benefit will be paid for each person insured per Covered Accident. This benefit may be payable in addition to an Ambulance Transportation benefit. Ground Ambulance Transportation: An Ambulance Transportation benefit will be payable if you or your Insured Dependent sustain an Injury as a result of a Covered Accident and: (1) a licensed ambulance company provides ground transport: (a) to or from a Hospital; or (b) between medical facilities; and (2) ground transportation is provided within 90 days of the Covered Accident. Only one benefit will be paid for each person insured per Covered Accident. This benefit may be payable in addition to an Air Ambulance Transportation benefit. BLOOD, PLASMA AND PLATELETS: A Blood, Plasma and Platelet benefit will be payable if you or your Insured Dependent sustain an Injury as a result of a Covered Accident requiring a transfusion of blood, plasma or platelets provided such transfusion is administered within 90 days of the Covered Accident. Only one benefit will be paid for each person insured per Covered Accident. BURNS: A Burn benefit will be payable if you or your Insured Dependent sustain a 2nd or 3rd degree burn as a result of a Covered Accident provided treatment is received from a Physician within 72 hours of the Covered Accident. If you or your Insured Dependent sustain Burns in more than one 1 classification as shown on the Schedule of Benefits, only one Burn benefit, which is the highest, will be paid for each person insured per Covered Accident. Skin Graft (due to Burns): A Skin Graft benefit will be payable if you or your Insured Dependent require skin grafting as a result of a Burn sustained in a Covered Accident and were paid a benefit under the Burn benefit. Only one benefit will be paid for each person insured per Covered Accident. CHIROPRACTIC SERVICES: A Chiropractic Services benefit will be payable if you or your Insured Dependent suffer a structural imbalance as a result of a Covered Accident and receives spinal manipulation by a Medical Professional in their office. Treatment must begin within 6 months of the Covered Accident. Benefits are not payable for services for massage therapy or treatment of chronic conditions or other injuries not related to structural imbalance. This benefit is payable for up to 6 visits for each person insured per Covered Accident, but no more than 12 visits per calendar year. COMA: A Coma benefit will be payable if you or your Insured Dependent are in a Coma, as diagnosed by a Physician, for 168 hours as a result of a Covered Accident. However, benefits will not be paid when a Coma has been medically induced. Only one benefit will be paid for each person insured per Covered Accident. LRS-9548-0318-IN Page 7.0