Additional Benefits

You have the option to purchase accident insurance, which helps to protect your finances after an accident. You are paid a lump sum if you have a covered injury and can use the money to help pay out-of-pocket medical costs or everyday expenses.

Benefits	Amounts
Initial Care & Emergency Most treatment / service required within 72 hours of accident; Once per accident per insured person
Emergency Room	$150
Urgent Care Center	$100
Initial Physician Office Visit	$75
Ambulance	Up to $1,000
Specified Injuries
Fractures (Surgical / Non-surgical)	Up to $5,000/Up to $2,500
Dislocations (Surgical / Non-surgical)	Up to $6,000/Up to $3,000
Lacerations	Up to $600
Burns	Up to $10,000
Dental	Up to $200
Hospital, Surgical & Diagnostic
Admission	$1,000
Daily Confinement (Up to 365 days per accident)	$200 per day
ICU Confinement (Up to 15 days per accident)	$400 per day
Rehab. Facility Confinement (Up to 30 days per accident)	$100 per day
Surgical	Up to $1,500
Diagnostic	Up to $200
Follow-Up Care Treatment / service required within 365 days of accident; Medical device is once per accident per insured person
Physician Follow-Up Office Visit	$75; Up to 6 per accident
Therapy Services	$25; Up to 6 per accident
Medical Device	$100
Prosthetic Device(s)	$750; Up to 2 per accident
Additional Benefits Benefits are payable within 365 days of accident
Transportation (Up to 3 trips per accident)	$300 per trip
Lodging (Up to 30 nights per accident)	$125 per night
Childcare (Up to 30 days per accident)	$20 per day
Catastrophic Benefits Benefits are payable within 365 days of accident; Once per accident per insured person
Principal Sum (PS)	You: $25,000 Spouse: $10,000 Child(ren): $5,000
Common Carrier Accidental Death	300% of PS
Transportation of Remains	Up to $5,000
Dismemberment & Paralysis	Up to 100% of PS
Reasonable Modifications	Up to 10% of PS
Coma	50% of PS
Services
Hearing Discount Program	The Hearing Discount program provides you and your family discounted hearing products, including hearing aids and batteries. Call 1-888-534-1747 or visit www.amplifonusa.com/ mutualofomaha to learn more.

	Per 26 Pay Period Cost
Employee Only	$9.59
Employee + Spouse	$14.90
Employee + Children	$21.66
Employee + Family	$27.27

You have the option to purchase critical illness insurance, which provides a fixed, lump-sum benefit upon the diagnosis of a serious illness like heart attack, stroke, or cancer. Benefits are paid directly to you and may be used for any reason from deductibles and prescriptions to travel expenses, childcare or other everyday expenses.

Benefit Category	Benefit
Heart/Circulatory/Motor Function Category
Heart Attack (Myocardial Infarction)	100% of the Critical Illness Principal Sum
Heart Valve Surgery	25% of the Critical Illness Principal Sum
Coronary Artery Bypass	25% of the Critical Illness Principal Sum
Aortic Surgery	25% of the Critical Illness Principal Sum
Stroke	100% of the Critical Illness Principal Sum
ALS (Lou Gehrig’s) Disease	100% of the Critical Illness Principal Sum
Advanced Alzheimer’s Disease	100% of the Critical Illness Principal Sum
Advanced Parkinson’s Disease	100% of the Critical Illness Principal Sum
Organ Category
Major Organ Transplant/Placement on UNOS List	100% of the Critical Illness Principal Sum
End Stage Renal Failure	100% of the Critical Illness Principal Sum
Acute Respiratory Distress Syndrome (ARDS)	25% of the Critical Illness Principal Sum
Childhood/Developmental Category (These benefits are available to children only.)
Cerebral Palsy	100% of the Critical Illness Principal Sum
Structural Congenital Defects	100% of the Critical Illness Principal Sum
Genetic Disorders	100% of the Critical Illness Principal Sum
Congenital Metabolic Disorders	100% of the Critical Illness Principal Sum
Type 1 Diabetes	100% of the Critical Illness Principal Sum
Cancer Category
Cancer (Invasive)	100% of the Critical Illness Principal Sum
Bone Marrow Transplant	50% of the Critical Illness Principal Sum
Carcinoma in Situ (Non-Invasive Cancer)	25% of the Critical Illness Principal Sum
Benign Brain Tumor	25% of the Critical Illness Principal Sum

	Critical Illness Amounts
Employee
Benefit Maximum	$5,000 increments up to $50,000 This amount is your Principal Sum
Guaranteed Issue	$15,000
Spouse
Benefit Maximum	$5,000 increments up to $50,000 Not to exceed 100% of Employee's Principal Sum
Guaranteed Issue	$15,000
Child(ren)
Benefit Maximum	25% of Employee's Principal Sum, but in no event more than $12,000
Guaranteed Issue	$5,000


Critical Illness rates are based on age and $5,000 benefit increment chosen; available up to $50,000 benefit

You have the option to purchase hospital indemnity insurance, which pays you benefits while you are confined to a hospital. This type of coverage is helpful because it covers your out-of-pocket expenses not covered by your medical plan.

	Benefits
Initial Hospital Admission Non-ICU or ICU Group Hospital Indemnity pays a lump-sum benefit for the first hospital confinement in a calendar year.	$1,500 combined 1x annually
Daily Hospital Confinement Non-ICU or ICU Pays a daily benefit for hospital confinement	Non-ICU: $100 per day ICU: $200 per day Up to combined 30 days annually
Newborn Care	$75 up to 2 days per policy year
Maternity	Included
Pre-Existing Condition Clause	None

	Per 26 Pay Period Cost
Employee Only	$7.15
Employee + Spouse	$14.52
Employee + Child(ren)	$12.23
Family	$18.90

Group Number

G000C835

Provided By

Mutual of Omaha

Provider Website

https://www.mutualofomaha.com/

Customer Service

800.228.7104