Page 3 Benefit plan and Features - Low Plan Fractures (Open reduction/Closed reduction) Employee Spouse Child Hip or thigh $5,000/$2,500 $5,000/$2,500 $5,000/$2,500 Skull — depressed $6,000/$3,000 $6,000/$3,000 $6,000/$3,000 Skull — simple $3,000/$1,500 $3,000/$1,500 $3,000/$1,500 Vertebral processes $1,000/$500 $1,000/$500 $1,000/$500 Bones of face or nose $1,000/$500 $1,000/$500 $1,000/$500 Leg (tibia or fibula) $3,000/$1,500 $3,000/$1,500 $3,000/$1,500 Vertebrae (body of) or sternum $2,000/$1,000 $2,000/$1,000 $2,000/$1,000 Pelvis (excluding coccyx) $3,000/$1,500 $3,000/$1,500 $3,000/$1,500 Upper jaw or upper arm $800/$400 $800/$400 $800/$400 Lower jaw $750/$375 $750/$375 $750/$375 Knee cap $750/$375 $750/$375 $750/$375 Ankle $750/$375 $750/$375 $750/$375 Foot $750/$375 $750/$375 $750/$375 Collarbone $750/$375 $750/$375 $750/$375 Shoulder $750/$375 $750/$375 $750/$375 Forearm $750/$375 $750/$375 $750/$375 Hand $750/$375 $750/$375 $750/$375 Wrist $750/$375 $750/$375 $750/$375 Elbow $750/$375 $750/$375 $750/$375 Heel $750/$375 $750/$375 $750/$375 Rib, finger, toe or coccyx $500/$250 $500/$250 $500/$250 Multiple ribs $1,000/$500 $1,000/$500 $1,000/$500 Chip fractures and other fractures not reduced 25% of the applicable closed reduction by open or closed reduction Additional injuries Employee Spouse Child Eye injury $300 $300 $300 Gunshot wound $250 $250 $250 Brain injury $500 $500 $500 Paralysis — monoplegia $1,000 $1,000 $1,000 Paralysis — diplegia $2,500 $2,500 $2,500 Paralysis — hemiplegia $2,500 $2,500 $2,500 Paralysis — paraplegia $12,500 $12,500 $12,500 Paralysis — quadriplegia $25,000 $25,000 $25,000 Coma $7,500 $7,500 $7,500 Concussion $150 $150 $150 Concussion lifetime maximum benefit $1,500 $1,500 $1,500