Page 11 Benefit plan and Features - High Plan Fractures (Open reduction/Closed reduction) Employee Spouse Child Hip or thigh $10,000/$5,000 $10,000/$5,000 $10,000/$5,000 Skull — depressed $12,000/$6,000 $12,000/$6,000 $12,000/$6,000 Skull — simple $7,000/$3,500 $7,000/$3,500 $7,000/$3,500 Vertebral processes $2,000/$1,000 $2,000/$1,000 $2,000/$1,000 Bones of face or nose $2,000/$1,000 $2,000/$1,000 $2,000/$1,000 Leg (tibia or fibula) $6,000/$3,000 $6,000/$3,000 $6,000/$3,000 Vertebrae (body of) or sternum $5,000/$2,500 $5,000/$2,500 $5,000/$2,500 Pelvis (excluding coccyx) $8,000/$4,000 $8,000/$4,000 $8,000/$4,000 Upper jaw or upper arm $2,000/$1,000 $2,000/$1,000 $2,000/$1,000 Lower jaw $1,500/$750 $1,500/$750 $1,500/$750 Knee cap $1,500/$750 $1,500/$750 $1,500/$750 Ankle $1,500/$750 $1,500/$750 $1,500/$750 Foot $1,500/$750 $1,500/$750 $1,500/$750 Collarbone $1,500/$750 $1,500/$750 $1,500/$750 Shoulder $1,500/$750 $1,500/$750 $1,500/$750 Forearm $1,500/$750 $1,500/$750 $1,500/$750 Hand $1,500/$750 $1,500/$750 $1,500/$750 Wrist $1,500/$750 $1,500/$750 $1,500/$750 Elbow $1,500/$750 $1,500/$750 $1,500/$750 Heel $1,500/$750 $1,500/$750 $1,500/$750 Rib, finger, toe or coccyx $1,000/$500 $1,000/$500 $1,000/$500 Multiple ribs $2,000/$1,000 $2,000/$1,000 $2,000/$1,000 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 $600 $600 $600 Gunshot wound $500 $500 $500 Brain injury $1,000 $1,000 $1,000 Paralysis — monoplegia $2,500 $2,500 $2,500 Paralysis — diplegia $5,000 $5,000 $5,000 Paralysis — hemiplegia $5,000 $5,000 $5,000 Paralysis — paraplegia $25,000 $25,000 $25,000 Paralysis — quadriplegia $50,000 $50,000 $50,000 Coma $10,000 $10,000 $10,000 Concussion $200 $200 $200 Concussion lifetime maximum benefit $2,000 $2,000 $2,000