Voluntary Group Accident Insurance Overview

This document outlines the coverage, eligibility, and premium details for Voluntary Group Accident Insurance provided by The Life is Good Company.

www.reliancematrix.com This Plan Highlight is not a complete description of the insurance coverage. Insurance is provided under group policy form LRS-9547, et al. This is not a binding contract. Should there be a difference between this Plan Highlight and the contract, the contract will govern. The Certificate of Coverage will be made available to you that describes the benefits in greater detail; however a benefit will not be paid if caused or contributed by an exclusion listed in the Certificate. Reliance Standard Life Insurance Company is licensed in all states (except New York), the District of Columbia, Puerto Rico, the U.S. Virgin Islands and Guam. In New York, insurance products and services are provided through First Reliance Standard Life Insurance Company, Home Office: New York, NY. Product features and availability may vary by state. Benefits Plan A Plan C Ambulance $100 Ground, $500 Air $300 Ground, $1,500 Air Blood, Plasma and Platelets $300 $600 Burns To $1,200 for 2nd degree burns; To $9,600 for 3rd degree burns; Skin Graft - 50% of benefit payable for Burns To $2,000 for 2nd degree burns; To $16,000 for 3rd degree burns; Skin Graft - 50% of benefit payable for Burns Chiropractic Services (per Visit) $25 per session, 6 sessions maximum $50 per session, 6 sessions maximum Coma $5,000 $12,500 Concussion $50 $300 Dental Injury $150 for Crown; $50 for Extraction $525 for Crown; $175 for Extraction Diagnostic Exams $50 per CT/MRI scan $300 per CT/MRI scan Dislocation To $2,400 for Non-surgical; To $4,800 for Surgical; Partial - 50% of full dislocation; Multiple - 200% of highest dislocation benefit To $4,800 for Non-surgical; To $9,600 for Surgical; Partial - 50% of full dislocation; Multiple - 200% of highest dislocation benefit Emergency Treatment $150 $450 Epidural Anesthesia Injection (per Injection) $100, 2 maximum $100, 2 maximum Eye Injury $75 for removal of foreign object, $150 for surgical repair $300 for removal of foreign object, $600 for surgical repair Fractures To $5,000 for Non-surgical; To $10,000 for Surgical repair; Chip fracture: 50% of non- surgical benefit; Multiple fractures: 200% of highest sustained fracture To $6,250 for Non-surgical; To $12,500 for Surgical repair; Chip fracture: 50% of non- surgical benefit; Multiple fractures: 200% of highest sustained fracture Initial Hospital Admission $500 $1,500 Initial Intensive Care Unit (ICU) Hospital Admission $1,000 $3,000 Hospital Confinement (per Day) $100, 365 days maximum $300, 365 days maximum Intensive Care Unit (ICU) Confinement (per Day) $200, 30 days maximum $600, 30 days maximum Lacerations To $600 To $800 Lodging (per Day) $100 per day up to 30 days if more than 100 miles from residence $300 per day up to 30 days if more than 100 miles from residence Medical Appliances $150 $300 Organized Youth Sports Benefit 25% of the benefit amount 25% of the benefit amount Paralysis $10,000 quadriplegia; $5,000 paraplegia/hemiplegia $25,000 quadriplegia; $12,500 paraplegia/hemiplegia Physical Therapy (per Session) $25, 12 sessions maximum $50, 12 sessions maximum Physician Visit $50 Initial, $50 Follow-up $100 Initial, $100 Follow-up Prosthesis $500 for one, $1,000 for two or more $1,000 for one, $2,000 for two or more Rehabilitation Facility Confinement (per Day) $50, 30 days maximum $150, 30 days maximum Surgery $150 for Exploratory; $450 for Knee Cartilage; $1,500 for Abdominal or Thoracic; $750 for Ruptured Disc; to $900 Tendon, Ligament, or Rotator cuff $300 for Exploratory; $900 for Knee Cartilage; $3,000 for Abdominal or Thoracic; $1,500 for Ruptured Disc; to $1,800 Tendon, Ligament, or Rotator cuff Transportation $300, if more than 100 miles from residence $600, if more than 100 miles from residence X-Rays $50 $100 Accidental DeathBenefits Plan A Plan C Employee AD&D $10,000 $50,000 Spouse AD&D $5,000 $25,000