www.reliancematrix.com Reliance Matrix is a branding name. Reliance Standard Life Insurance Company (Home Office Schaumburg, IL) is licensed in all states (except New York), the District of Columbia, Puerto Rico, the U.S. Virgin Islands and Guam. First Reliance Standard Life Insurance Company (Home Office New York, NY) is licensed in New York and Delaware. Standard Security Life Insurance Company of New York (Home Office New York, NY) is licensed in all states. Absence services are provided by Matrix Absence Management, Inc. Product features and availability may vary by state. BENEFIT PLAN B Rib $675 / $337.50 Shoulder Blade $1,350 / $675 Skull (Except bones of face or nose - Depressed) $11,250 / $5,625 Skull (Simple) $3,375 / $1,687.50 Sternum $1,350 / $675 Toe $225 / $112.50 Vertebrae $1,350 / $675 Vertebral Column $3,600 / $1,800 Wrist $1,350 / $675 Chip Fractures Amount of benefit for non-surgical fracture 50% Multiple Fractures Amount of highest benefit for any one fracture among all fractures sustained 200% Hospitalization Initial Hospital Admission $1,000 Initial ICU Hospital Admission $1,500 Hospital Confinement (per Day) $300 per day, 365 days maximum ICU Confinement (per Day) $600 per day, 30 days maximum Lacerations (Total length of all sutured lacerations) No Sutures Required $50 Sutures Less Than 2" $100 Sutures 2" but less than 6" $400 Sutures 6" or greater $800 Lodging (per day) $200 per day up to 30 days if more than 100 miles from residence Medical Appliances $225 Organized Youth Sports Benefit % of benefit amount, excluding the AD&D benefit, if applicable 25% Paralysis $20,000 quadriplegia; $10,000 paraplegia / hemiplegia Physical Therapy $37.50 per session; 12 sessions maximum Physician Visit $75 Initial, $75 Follow-up Prosthesis $750 for one, $1,500 for two or more Rehabilitation Facility Confinement $100 per day, 30 days maximum Surgery Abdominal or Thoracic $2,250 Exploratory Surgery (no repair) $225 Knee Cartilage (surgically repaired) $675 Ruptured Disc (surgically repaired) $1,125 Rotator Cuff (one surgically repaired) $675 Rotator Cuff (two or more surgically repaired) $1,350 Tendon or Ligament (one surgically repaired) $675 Tendon or Ligament (two or more surgically repaired) $1,350 Transportation $600, if more than 100 miles from residence X-Rays per covered accident $75 Accidental Dismemberment Benefits