Type of Benefit Benefit Amount Fractures: Surgical Non-Surgical Ankle $1,200 $600 Arm $1,200 $600 Bones of Face $600 $300 Coccyx $600 $300 Collarbone $1,200 $600 Elbow $1,200 $600 Finger $200 $100 Foot $1,200 $600 Hand $1,200 $600 Hip $6,400 $3,200 Jaw $1,200 $600 Kneecap $1,200 $600 Leg $3,200 $1,600 Nose $600 $300 Pelvis $3,200 $1,600 Rib $600 $300 Shoulder Blade $1,200 $600 Skull (Except bones of face or nose – Depressed) $10,000 $5,000 Skull (Simple) $3,000 $1,500 Sternum $1,200 $600 Toe $200 $100 Vertebrae $1,200 $600 Vertebral Column $3,200 $1,600 Wrist $1,200 $600 Chip Fractures 37.5% of benefit for non-surgical fracture Multiple Fractures 150% of the highest benefit for any one fracture among all fractures sustained Hospitalization Initial Hospital Admission $1,000 Initial Intensive Care Unit (ICU) Hospital Admission $1,500 Hospital Confinement $300 per day Intensive Care Unit (ICU) Confinement $600 per day Lacerations No Sutures Required $50 Sutures Required (Total length of all sutured Lacerations) Less than 2” long $100 2” but less than 6” long $400 6” long or greater $800 Lodging $150 per day Medical Appliance $150 Organized Youth Sports 5% of Benefit Amount(s), excluding the Accidental Death and Dismemberment Benefit Paralysis Paraplegia or Hemiplegia $7,500 Quadriplegia $15,000 LRS-9548-0318-IN Page 1.3