American Fidelity Assurance Company s Accident Only Insurance This is not a policy of Workers Compensation insurance. The employer does not become a subscriber to the Workers Compensation system by purchasin this policy. And, if the employer is a non-subscriber, the employer loses those benefits which would otherwise accrue under the Workers Compensation laws. The employer must comply with the Workers Compensation law as it pertains to non subscribers and the required notifications that must be filed and posted. Accidents Happen Are You Prepared?
Accident Only Accidents can happen to anyone at any time. Whether it s turnin left when you should have one riht or just findin yourself in the wron place at the wron time, accidents happen. If you think you re immune, the numbers tell a different story. Consider the facts... On averae, a fatal injury occurred every 4 minutes in 2006.* On averae, a disablin injury occurs every 1.2 seconds.* About 1 out of every 9 Americans souht medical attention for an injury in 2005.* Accidents continue to be the fifth leadin cause of death for Americans.* *National Safety Council, Injury Facts, 2008 Edition, p 2. You cannot predict when or if an accident will even happen, but you can protect yourself and your family aainst the hih cost of accidental injury or death. American Fidelity will help you prepare for the expenses associated with accidental injury. American Fidelity Assurance Company s (AFA) Limited Accident Only Insurance Policy lets you take precautions today to help keep you and your family from financial harm in the future. AFA s Accident Only provides: payments made directly to you. s reardless of other coverae. and family plans. Guaranteed renewability for the base plan for as lon as you pay your premiums as required. Accident Enhancement available to primary insured, spouse and child(ren).
Help When You Need It. A Covered Person under AFA s Limited Accident Only Policy can expect the followin benefits when a covered accident happens: (All benefits are only paid as a result of injuries received in an Accident that occurs while coverae is in force. All treatment, procedures, and medical equipment must be dianosed, recommended and treated by a Physician. All benefits are paid once per Covered Person per Covered Accident unless otherwise specified.) Accident Emerency Treatment Hospital Emerency Room - $100 - $150 Doctor s Office - $75 - $100 These benefits are provided for a Covered Person who receives emerency treatment in a Physician s office or hospital emerency room within 72 hours of the Covered Accident, includin physician fees, x-rays and emerency services. Accident Follow-up Treatment $50 per treatment for both and s This benefit provides for necessary follow-up treatment of injuries in addition to the emerency treatment administered within 72 hours of a Covered Accident for up to four treatments per Covered Person per Covered Accident. This benefit is not payable for a visit in which a Physical Therapy is paid. This benefit is also not payable if the Non-Emerency Accident Follow-up benefit is paid under the Enhancement. MEDICAL IMAGING BENEFIT $150 for both and s You receive this benefit for a Covered Person who has either a Manetic Resonance Imain (MRI), a Computed Tomoraphy (CT) scan, a Computed Axial Tomoraphy (CAT) scan, a Positron Emission Tomoraphy (PET) scan or an ultrasound. Hospital Confinement s Hospital Admission - $500 - $1,000 Intensive Care Confinement - $300 - $600 Hospital Confinement - $100 - $200 You will receive a one-time Hospital Admission per Covered Accident if a Covered Person is Hospital Confined due to accidental injuries (does not include emerency room and outpatient treatment). You will also receive a daily benefit for a Hospital Confinement that is loner than 18 hours for up to 365 days and an additional daily benefit for Confinement in an Intensive Care Unit up to 15 days. A hospital is not an institution, or part thereof, used as: a hospice unit, includin any bed desinated as a swin bed; a convalescent home; a rest or nursin facility; a rehabilitative facility; an extended-care facility; a skilled nursin facility; or a facility primarily affordin custodial, educational care, or care or treatment for persons sufferin from mental diseases or disorders, or care for the aed, or dru or alcohol addiction. Wellness - $50 - $75 After coverae is in force 12 months, you or any other Covered Person can receive a benefit for an annual routine physical exam, includin immunizations and preventive testin. Services must be supervised by a Physician and a chare must be incurred for the service. The benefit does not apply to dental or eye exams and is payable once per policy per calendar year.
Ambulance $150 for round ambulance transport for both and s $500 for air ambulance transport for both and s This benefit is provided when accidental Injuries due to a Covered Accident require a Covered Person to be transported by a licensed ambulance to a Hospital or emerency center. If air and round ambulance transportation is required for the same Covered Accident, only the hihest benefit amount will be paid. Transportation $300 per round trip for both and s You will receive this benefit for transportation of a Covered Person requirin specialized treatment and Hospital Confinement in a non-local Hospital. The non-local Hospital must be at least 100 miles away, one way (50 miles if Enhancement is elected), usin the most direct route, from the closer of the Covered Person s residence or site of the Covered Accident. Travel must be by scheduled bus, plane, train or car and excludes Ambulance service. The treatment must be prescribed by a Physician and not be available locally. s are provided for up to three round trips per Calendar Year per Covered Person. Transportation benefit will only be provided for the Injured Covered Person. Family Member Lodin and Meals $100 per day for of Confinement for both and s You will receive this benefit for lodin and meals for a family member to be near a Covered Person who is Confined in a non-local Hospital. The non-local Hospital must be at least 100 miles one way (50 miles if Enhancement is elected) from the Covered Person s residence or site of the Covered Accident. This benefit is payable only durin the period the Injured Covered Person is Hospital confined. This benefit is paid for up to 30 days of Hospital Confinement per Covered Accident. Accidental Death or Dismemberment Accidental Death Primary Insured Spouse Child Common Carrier $50,000 $100,000 $25,000 $50,000 $10,000 $20,000 Other Accident 15,000 30,000 7,500 15,000 5,000 10,000 Accidental Dismemberment Primary Insured Spouse Child Both arms and both les $15,000 $30,000 $7,500 $15,000 $5,000 $10,000 Both: eyes, hands, feet, les or arms 7,500 15,000 3,750 7,500 2,500 5,000 One: arm, le, eye, hand or foot 3,000 6,000 1,500 3,000 1,000 2,000 One or more finers or toes 300 600 150 300 100 200 The applicable benefits above apply when a Covered Person s Accidental Death or Dismemberment occurs within 90 days of a Covered Accident. In the event that Accidental Death and Dismemberment result from the same Covered Accident, only the Accidental Death benefit will be paid. Accidental Death or Dismemberment must be independent of any disease or bodily infirmity or any other cause. Only the hihest sinle benefit will be paid. Loss of use does not constitute dismemberment except as stated for eye injuries in the policy.
Additional Medical Expense s and s APPLIANCES $100 for both and s This benefit provides for one of the followin: crutches, le braces, back braces, walkers, or wheel chairs. This benefit is not payable for Prosthetic Devices. Blood, Plasma and Platelets $250 for both and s This benefit does not include payment for immunolobulins. Burns $100-$10,000 for both and s This benefit is provided for burns received in a Covered Accident when treated by a Physician within 72 hours. Skin Graft 25% of the covered Burn This benefit is based on burn severity and treatment must be provided by a Physician beinnin within 72 hours of the Covered Accident. Dislocations $100 - $3,000 for both and s amount varies by the joint involved, type of treatment, and type of anesthesia. If a Covered Person receives more than one Dislocation in a Covered Accident, we will pay for all Dislocations up to two times the amount shown in the Schedule of s for the Dislocation involved that has the hihest benefit amount. No other amount will be paid under this benefit. s are payable only for the first dislocation of a joint which occurs while this policy is in force and requires open or closed Reduction. Exploratory Surery without Surical Repair $250 for both and s This benefit is payable for only one exploratory surery without surical repair per Covered Accident per Covered Person. Eye Injury $250 for surical repair;$50 for removal of forein body These benefits will be paid for one or both eyes requirin treatment by a Physician due to a Covered Accident. If permanent loss of use of one or both eyes occurs, benefits will be paid under the Accidental Dismemberment. Fractures $100 - $3,000 varies based on the bone involved, type of fracture and type of treatment. If the Covered Person fractures more than one bone in a Covered Accident, payment is made for all Fractures up to two times the amount for the bone involved that has the hihest benefit amount. All fractures must be treated by a Physician. Internal Injuries $1,000 for both and s This benefit is provided for open abdominal or thoracic surery performed within 72 hours of a Covered Accident. Lacerations $25 - $400 for both and s This benefit varies based on the severity of the laceration. The lacerations must be repaired or treated by a Physician. Concussion $200 for both and s This benefit is provided for a Covered Person who sustains a concussion and is dianosed by a Physician within 72 hours of the Covered Accident usin any type of imain. Physical Therapy $25 per treatment for both and s This benefit is provided for up to one treatment per day for up to eiht treatments per Covered Person per Covered Accident. The benefit is not payable for the same visit that the Accident Follow-up Treatment is paid. This benefit is also not payable if the Non-Emerency Accident Follow-up benefit is paid under the Enhancement. Prosthesis $500 for both and s This benefit is not payable for hearin aids; dental aids; false teeth; eye lasses; cosmetic aids such as hair wis; joint replacements such as artificial hips or knees. Ruptured Disc or Torn Knee Cartilae $500 for both and s This benefit is provided for surical repair performed by a Physician. Tendons, Liaments and Rotator Cuff $500 for sinle surical repair;$750 for multiple surical repair The tendons, liaments or rotator cuff must be treated by a Physician and must be repaired throuh surery. Emerency Dental Work $150 for broken teeth repaired with crown; $50 for extraction of broken teeth reardless of number of teeth This benefit provides for repair to natural teeth when treated by a Physician or dentist. Initial dental treatment must be received within 72 hours of the Covered Accident. s paid only once per Covered Person per Covered Accident. Paralysis Quadripleia $10,000; Parapleia $5,000 The duration of the Paralysis must be a minimum of 3 consecutive months. This benefit is paid once per lifetime per Covered Person.
Family Coverae You can take advantae of several options to extend coverae to your family: and Spouse Covers you and your Spouse. Family Covers you, your Spouse and each Eliible Child, as defined in the policy. Sinle Parent Family Covers you and each Eliible Child, as defined in the policy. Guaranteed renewable You are uaranteed the riht to renew your base policy durin your lifetime as lon as you pay premiums when due or within the premium race period. Accident Disability Income s are Guaranteed Renewable until Primary Insured reaches ae 70. You cannot be sinled out for a rate increase for any reason. Rates can be chaned only if rates for all policies in this class chane. Limitations and Exclusions An Accident is defined as a sudden, unexpected and unintended event, which results in bodily injury, which is independent of disease or bodily infirmity or any other cause. The policy will not pay benefits for injuries received prior to the Effective Date of coverae that are aravated or re-injured by any event that occurs after the Effective Date. No benefits will be provided for an Accident or Total Disability that is caused by or occurs as a result of: intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; participation in any form of fliht aviation other than as a fare-payin passener in a fully licensed/passener-carryin aircraft; any act that was caused by war, declared or undeclared, or service in any of the armed forces; participation in any activity or event while under the influence of any narcotic unless administered by a Physician or taken accordin to the Physician s instructions; participation in, or attemptin to participate in, a felony, riot or insurrection. (A felony is as defined by the law of the jurisdiction in which the activity takes place.) participation in any sport for pay or profit; participation in any contest of speed in a power driven vehicle for pay or profit; participation in parachutin, bunee jumpin, rappellin, mountain climbin or han lidin. s will not be paid for services rendered or Total Disability verified by a member of the immediate family of a Covered Person. s will not be provided for medical treatment or Total Disability for an Accident received outside the United States or its territories. s provided by the Accident Disability Income s will only be paid for one disability at a time, even if the Covered Person becomes Totally Disabled due to more than one injury or more than one Covered Accident. s are not payable due to an Accident occurrin durin a period of time the Covered Person is incarcerated in any type of penal institution.
Accident Enhancement Enhance your benefit amount and options by addin the Accident Enhancement rider to your policy. Non-Emerency Accident initial Treatment - $75 - $100 We will pay the amount shown in the Schedule of s for a Covered Person who receives initial medical treatment for Injuries sustained in a Covered Accident when such treatment is received more than 72 hours after the Covered Accident. Initial medical treatment must: (1) be received in a Physician s office or emerency room for Injuries sustained in a Covered Accident; and (2) be the first treatment received by the Covered Person for such Injuries; and (3) occur within 30 days followin the Covered Accident. This benefit is payable once per Covered Person per Covered Accident. Non-Emerency Accident Follow-Up Treatment & - $50 This benefit provides for necessary follow-up treatment of Injuries in addition to the emerency treatment administered within 72 hours of a Covered Accident for up to two treatments per Covered Person per Covered Accident. This benefit is not payable for a visit in which a Physical Therapy or the Accident Follow-Up Treatment is paid. X-Ray - $50 - $100 We will pay the amount shown in the Schedule of s for a Covered Person who has an x-ray performed due to Injuries sustained in a Covered Accident. The x-ray must be done at the request of a Physician. This benefit is payable one time per Covered Person per Covered Accident. This benefit does not cover any tests payable under the Medical Imain or any other screenin or medical imain tests. Outpatient Hospital or Ambulatory Surical Center - $150 Enhance - $250 When a surical procedure is performed on an outpatient basis in a Hospital or at an Ambulatory Surical Center on a Covered Person for Injuries sustained in a Covered Accident, we will pay the indemnity amount shown in the Schedule of s for the facility fee chared by such Hospital or Ambulatory Surical Center. We will only pay one Outpatient Hospital or Ambulatory Surical Center per Covered Person in a 24-hour period even if more than one surical procedure is performed. This benefit will not be paid for surery performed in a Hospital emerency room or in a Physician s office. Anesthesia - $150 - $200 We will pay the amount shown in the Schedule of s for the services of an anesthesioloist received as a result of a surery performed due to Injuries sustained in a Covered Accident. Hospital Confinement is not required to receive this benefit. We will only pay one Anesthesia per Covered Person in a 24-hour period even if more than one surical procedure is performed. This benefit is not payable for local anesthesia. Additional Accident Emerency Treatment s Hospital Emerency Room benefit Additional $50 $150 $50 $200 Doctor s Office benefit Additional $75 $150 $100 $200 Medical Imain benefit Additional and s $50 $200 Ambulance & s equals the base policy benefit amount plus the additional amount of increase in rider. Additional Ground $150 $300 Air $1,000 $1,500
ACCIDENT BENEFIT ENHANCEMENT RIDER benefit amounts Accidental Death BASIC PLAN Accidental Dismemberment Primary Insured Spouse Child BASIC PLAN Both arms and both les $0 $15,000 $7,500 $15,000 $2,500 $7,500 Both: eyes, hands, feet, les or arms $0 $7,500 $3,750 $7,500 $1,250 $3,750 One: arm, le, eye, hand or foot $750 $3,750 $2,250 $3,750 $500 $1,500 One or more finers or toes $700 $1,000 $850 $1,000 $400 $500 ENHANCED PLAN Both arms and both les $0 $30,000 $15,000 $30,000 $5,000 $15,000 Both: eyes, hands, feet, les or arms $0 $15,000 $7,500 $15,000 $2,500 $7,500 One: arm, le, eye, hand or foot $1,500 $7,500 $4,500 $7,500 $1,750 $3,750 One or more finers or toes $900 $1,500 $1,200 $1,500 $550 $750 equals the base policy benefit amount plus the additional amount of increase in rider. Accident ONLY MONTHLY PREMIUMS - EDUCATION RATES (I) BASIC PLAN & Spouse (I & S) & Children Family 14.60 21.60 24.80 31.80 5.30 6.70 6.70 8.10 Spouse (I) ENHANCED PLAN & Spouse (I & S) Child Common Carrier $25,000 $50,000 $15,000 $25,000 Other Accident $7,500 $15,000 $2,500 $7,500 ENHANCED PLAN Common Carrier $50,000 $100,000 $30,000 $50,000 Other Accident $15,000 $30,000 $5,000 $15,000 & Children Family 20.40 27.50 32.80 39.90 5.70 7.40 8.20 9.90 The premium and amount of benefits may vary dependent upon the plan selected. This is a brief description of the coverae. For actual benefits, limitations, exclusions and other provisions, please refer to the policy and optional rider, Accident Only Enhancement, AMDI-258 Series. This coverae does NOT replace Workers Compensation Insurance. This product is inappropriate for people who are eliible for Medicaid coverae. SB-15986(TX)-1208 1-800-654-8489 2000 North Classen Blvd Oklahoma City, Oklahoma 73106 www.afadvantae.com AO-03 Series