Accident Specific-Sum Injuries · PDF fileAccident Specific-Sum Injuries Amounts AFLAC will pay $25Œ$10,000 for: ... We will pay for no more than two fractures per covered off-the-job

$Page 1: Accident Specific-Sum Injuries · PDF fileAccident Specific-Sum Injuries Amounts AFLAC will pay $25Œ$10,000 for: ... We will pay for no more than two fractures per covered off-the-job$
Accident Specific-Sum Injuries AmountsAFLAC will pay $25�$10,000 for:

Dislocations Burns Skin GraftsEye Injuries Lacerations FracturesBroken Teeth Comas Brain ConcussionsParalysis Surgical Procedures

If a covered person receives treatment for injuries sustained in a covered accident, we will pay the followingbenefit for the treatment listed:1. Dislocations (reduced under general anesthesia):

Must be diagnosed by a physician within 72 hours after the date of the accident. We will pay for no more than twodislocations per covered accident, per covered person. Benefits are payable for only the first dislocation of a joint. If adislocation is reduced with local anesthesia or no anesthesia by a physician, we will pay 25% of the amount shown for theclosed reduction dislocation.

Open Reduction Closed Reductiona. Hip $2,000 $ 500b. Knee or shoulder 500 200c. Collar bone 800 150d. Ankle or foot (excluding toes) 500 150e. Lower jaw 500 250f. Wrist or elbow 400 200g. Toe or finger 100 50

2. Burns (treated by a physician within 72 hours after a covered accident), based on size of the body surface burned:

2nd Degree 3rd Degreea. Less than 20 square centimeters $ 100 $ 200b. More than 20 but less than 40 square centimeters 200 500c. More than 40 but less than 65 square centimeters 400 1,000d. More than 65 but less than 160 square centimeters 600 3,000e. More than 160 but less than 225 square centimeters 800 7,000f. More than 225 square centimeters 1,000 10,000

3. Skin Grafts:If a covered person receives one or more skin grafts for a covered burn, we will pay a total of 50% of the Burn Benefitamount we paid for the burn involved.

4. Eye Injuries:Benefit

Surgical repair $250Removal of foreign body by a physician 50

5. Lacerations requiring sutures (must be repaired within 72 hours after the accident and repaired under theattendance of a physician):

BenefitLaceration(s) not requiring sutures and treated by a physician $ 25Single laceration less than 5 centimeters 50Lacerations at least 5 centimeters but not more than 15

centimeters (total of all lacerations) 200Lacerations over 15 centimeters (total of all lacerations) 400

Refer to the policy for details, limitations, and exclusions.

A-34175-SS A34175-SS.1

American Family Life Assurance Company of Columbus (AFLAC) Worldwide Headquarters: Columbus, Georgia 31999

6. Fractures:Must be diagnosed within 14 days by a physician. We will pay for no more than two fractures per covered accident, percovered person. For chip fractures and other fractures not reduced by open or closed reduction, we will pay 25% of thebenefit amount shown for the closed reduction.

Open Reduction Closed Reductiona. Hip $2,000 $1,000b. Leg 1,000 500c. Hand (excluding fingers) 500 250d. Foot (excluding toes/heel) 500 250e. Wrist, elbow, ankle, or kneecap 500 250f. Shoulder blade or forearm 500 250g. Lower jaw 500 250h. Vertebrae (body of), pelvis (excluding

coccyx), or sternum 1,000 500i. Upper jaw, upper arm, or face (excluding nose) 600 300j. Rib 1,000 100k. Nose, heel, or finger 500 100l. Coccyx 200 100m. Toe 200 100n. Vertebral processes 1,000 150o. Skull: depressed � $1,500; simple � $500

7. Concussion (brain): Benefit � $50

8. Emergency dental work:We will pay for no more than one dental benefit per covered accident, per covered person.

BenefitBroken teeth repaired with crowns $150Broken teeth resulting in extractions 50

9. Coma (duration of at least 7 days): Benefit � $10,000

10. Paralysis (duration of least 30 days):This benefit will be payable once per covered person. BenefitQuadriplegia (paralysis of four limbs) $10,000Paraplegia (paralysis of lower limbs) 5,000

11. Surgical Procedures:Treatment must be performed within one year of a covered accident. Two or more surgical procedures performedthrough the same incision will be considered one operation, and benefits will be paid based on the most expensiveprocedure. Only one miscellaneous surgery benefit is payable per 24-hour period even though more than oneprocedure may be performed. Repair of: Benefit

Tendons and/or ligaments $ 500Torn rotator cuffs 500Ruptured discs 500Torn knee cartilages 500

Arthroscopy without surgical repair 250Open abdominal (including exploratory laparotomy),

cranial, hernia, or thoracic surgery 1,000Miscellaneous surgery requiring general anesthesia that is

not covered by any other Specific-Sum Injury Benefit 250

A34175-SS.1

Accident Specific-Sum Injuries AmountsAFLAC will pay $35�$12,500 for:


If a covered person receives treatment for injuries sustained in a covered accident, we will pay the followingbenefit for the treatment listed:1. Dislocations (reduced under general anesthesia):

Must be diagnosed by a physician within 72 hours after the date of the accident. We will pay for no more than twodislocations per covered accident, per covered person. Benefits are payable for only the first dislocation of a joint. If adislocation is reduced with local anesthesia or no anesthesia by a physician, we will pay 25% of the amount shown for theclosed reduction dislocation.

Open Reduction Closed Reductiona. Hip $2,500 $ 625b. Knee or shoulder 625 250c. Collar bone 1,000 200d. Ankle or foot (excluding toes) 625 200e. Lower jaw 625 325f. Wrist or elbow 500 250g. Toe or finger 125 65

2. Burns (treated by a physician within 72 hours after a covered accident), based on size of the body surface burned:

2nd Degree 3rd Degreea. Less than 20 square centimeters $ 125 $ 250b. More than 20 but less than 40 square centimeters 250 625c. More than 40 but less than 65 square centimeters 500 1,250d. More than 65 but less than 160 square centimeters 750 3,750e. More than 160 but less than 225 square centimeters 1,000 8,750f. More than 225 square centimeters 1,250 12,500




5. Lacerations requiring sutures (must be repaired within 72 hours after the accident and repaired under theattendance of a physician):




A-34275-SS A34275-SS.1


6. Fractures:Must be diagnosed within 14 days by a physician. We will pay for no more than two fractures per covered accident, percovered person. For chip fractures and other fractures not reduced by open or closed reduction, we will pay 25% of thebenefit amount shown for the closed reduction.




8. Emergency dental work:We will pay for no more than one dental benefit per covered accident, per covered person.




11. Surgical Procedures:Treatment must be performed within one year of a covered accident. Two or more surgical procedures performedthrough the same incision will be considered one operation, and benefits will be paid based on the most expensiveprocedure. Only one miscellaneous surgery benefit is payable per 24-hour period even though more than oneprocedure may be performed. Repair of: Benefit

Tendons and/or ligaments $ 625Torn rotator cuffs 625Ruptured discs 625Torn knee cartilages 625




A34275-SS.1

Off-the-Job Accident Specific-Sum Injuries AmountsAFLAC will pay $25�$10,000 for:


If a covered person receives treatment for injuries sustained in a covered off-the-job accident, we will pay thefollowing benefit for the treatment listed:1. Dislocations (reduced under general anesthesia):

Must be diagnosed by a physician within 72 hours after the date of the accident. We will pay for no more than two dislocationsper covered off-the-job accident, per covered person. Benefits are payable for only the first dislocation of a joint. If adislocation is reduced with local anesthesia or no anesthesia by a physician, we will pay 25% of the amount shown for theclosed reduction dislocation.

Open Reduction Closed Reductiona. Hip $2,000 $ 500b. Knee or shoulder 500 200c. Collar bone 800 150d. Ankle or foot (excluding toes) 500 150e. Lower jaw 500 250f. Wrist or elbow 400 200g. Toe or finger 100 50

2. Burns (treated by a physician within 72 hours after a covered off-the-job accident), based on size of the bodysurface burned:

2nd Degree 3rd Degreea. Less than 20 square centimeters $ 100 $ 200b. More than 20 but less than 40 square centimeters 200 500c. More than 40 but less than 65 square centimeters 400 1,000d. More than 65 but less than 160 square centimeters 600 3,000e. More than 160 but less than 225 square centimeters 800 7,000f. More than 225 square centimeters 1,000 10,000




5. Lacerations, due to a covered off-the-job accident, requiring sutures (must be repaired within 72 hours afterthe accident and repaired under the attendance of a physician):




A-34375-SS A34375-SS.1


6. Fractures:

Must be diagnosed within 14 days by a physician. We will pay for no more than two fractures per covered off-the-job accident,per covered person. For chip fractures and other fractures not reduced by open or closed reduction, we will pay 25% of thebenefit amount shown for the closed reduction.




8. Emergency dental work:We will pay for no more than one dental benefit per covered off-the-job accident, per covered person.




11. Surgical Procedures:

Treatment must be performed within one year of a covered off-the-job accident. Two or more surgical procedures performedthrough the same incision will be considered one operation, and benefits will be paid based on the most expensive procedure.Only one miscellaneous surgery benefit is payable per 24-hour period even though more than one procedure may be performed.

Repair of: BenefitTendons and/or ligaments $ 500Torn rotator cuffs 500Ruptured discs 500Torn knee cartilages 500




Off-the-Job Accident Specific-Sum Injuries AmountsAFLAC will pay $35�$12,500 for:


If a covered person receives treatment for injuries sustained in a covered off-the-job accident, we will pay thefollowing benefit for the treatment listed:1. Dislocations (reduced under general anesthesia):

Must be diagnosed by a physician within 72 hours after the date of the accident. We will pay for no more than two dislocationsper covered off-the-job accident, per covered person. Benefits are payable for only the first dislocation of a joint. If adislocation is reduced with local anesthesia or no anesthesia by a physician, we will pay 25% of the amount shown for theclosed reduction dislocation.

Open Reduction Closed Reductiona. Hip $2,500 $ 625b. Knee or shoulder 625 250c. Collar bone 1,000 200d. Ankle or foot (excluding toes) 625 200e. Lower jaw 625 325f. Wrist or elbow 500 250g. Toe or finger 125 65

2. Burns (treated by a physician within 72 hours after a covered off-the-job accident), based on size of the bodysurface burned:

2nd Degree 3rd Degreea. Less than 20 square centimeters $ 125 $ 250b. More than 20 but less than 40 square centimeters 250 625c. More than 40 but less than 65 square centimeters 500 1,250d. More than 65 but less than 160 square centimeters 750 3,750e. More than 160 but less than 225 square centimeters 1,000 8,750f. More than 225 square centimeters 1,250 12,500




5. Lacerations, due to a covered off-the-job accident, requiring sutures (must be repaired within 72 hours afterthe accident and repaired under the attendance of a physician):




A-34475-SS A34475-SS.1


6. Fractures:

Must be diagnosed within 14 days by a physician. We will pay for no more than two fractures per covered off-the-job accident,per covered person. For chip fractures and other fractures not reduced by open or closed reduction, we will pay 25% of thebenefit amount shown for the closed reduction.




8. Emergency dental work:We will pay for no more than one dental benefit per covered off-the-job accident, per covered person.




11. Surgical Procedures:

Treatment must be performed within one year of a covered off-the-job accident. Two or more surgical procedures performedthrough the same incision will be considered one operation, and benefits will be paid based on the most expensive procedure.Only one miscellaneous surgery benefit is payable per 24-hour period even though more than one procedure may be performed.

Repair of: BenefitTendons and/or ligaments $ 625Torn rotator cuffs 625Ruptured discs 625Torn knee cartilages 625




Optional Off-the-Job Accident Disability Benefit Rider Summary PageRider A34050CA

Form A34076B1CA IC(8/06)

Coverage is provided for off-the-job accidents* only. The riderdoes not apply to the spouse or dependents.

Choose the Coverage You NeedAflac’s Personal Accident Indemnity Off-the-Job AccidentDisability Benefit Rider allows you to choose a level ofcoverage that best meets your individual financial needs.

• Monthly Benefits: From $100 to $2,000, subject to incomerequirements

• Benefit Periods: 6 or 12 months

• Elimination Periods: 0 or 7 days

Provisions of CoverageDisability benefits are available for ages 18 through 69 or forage 70 and above.

Ages 18 through 69: While this coverage is in force and acovered off-the-job accident causes you to become partiallydisabled or totally disabled, we will pay you one-thirtieth ofthe benefit shown in the Policy Schedule for each day youremain partially disabled or totally disabled.

Disability must begin within 90 days of your last treatmentfor the covered off-the-job accident. This benefit is payableup to the benefit period selected and is subject to theelimination period shown in the Policy Schedule. A full-timejob is a job at which you work 30 or more hours per week forpay or benefits.

Age 70 and above: While coverage is in force, if you requirehospital confinement resulting from a covered off-the-jobaccident within 90 days of your last treatment for theaccident, we will pay you one-thirtieth of the benefit shown inthe Policy Schedule times three for each day you areconfined. This benefit is payable regardless of whether youare working at a full-time job. It is payable up to the benefitperiod selected and is not subject to the elimination periodshown in the Policy Schedule.

Benefits will be paid for only one disability at a time, even ifthat disability is caused by more than one injury. If you haveany other disability benefit in force with Aflac, only onedisability benefit is payable. Turning age 70 will not stopbenefits otherwise payable. Aflac reserves the right to meet

with you during the pendency of a claim or to use anindependent consultant and physician’s statement to determinewhether you are partially disabled or totally disabled. Benefitswill cease on the date of your death.

Partially disabled is defined as your continuing inability toperform with reasonable continuity the substantial andmaterial acts necessary to pursue your usual occupation in theusual or customary way, while still able to work at any joband earning less than 80 percent of your base pay earnings atthe time you become partially disabled or totally disabled. Ifyou return to work at any job and are earning 80 percent ormore of your predisability base pay earnings, you will nolonger be considered partially disabled.

Totally disabled is defined as your continuing inability toperform with reasonable continuity the substantial and materialacts necessary to pursue your usual occupation in the usual orcustomary way or to engage with reasonable continuity inanother occupation in which you could reasonably be expectedto perform satisfactorily considering education, training,experience, station in life, physical and mental capacity.

Successive periods of disability resulting from the same or arelated condition, and not separated by 180 days or more, areconsidered a continuation of the prior disability. Separateperiods of disability resulting from unrelated causes areconsidered a continuation of the prior disability unless theyare separated by your returning to work at a full-time job for14 working days, during which you are performing thematerial and substantial duties of this job and are no longerqualified to receive disability benefits.

*An off-the-job accident is an injury that occurs while you are not working at any job for pay or benefits.

Pre-Existing ConditionsDisability or hospitalization caused by a pre-existingcondition or reinjuries to a pre-existing condition will not becovered unless it begins more than 12 months after theeffective date of coverage. A pre-existing condition is aninjury for which, within the 12-month period before theeffective date of coverage, medical advice, consultation, ortreatment was recommended or received, or symptoms existedthat would ordinarily cause a prudent person to seekdiagnosis, care, or treatment.

What Is Not Covered• We will not pay benefits for a disability that is being treated

outside the territorial limits of the United States or, ifoutside the United States, the territorial limits of the placewhere your policy was issued.

• Refer to your policy for additional limitations andexclusions.

We will not pay benefits for an accident that occurs while youare working at any job for pay or benefits.

We will not pay benefits for any sickness.

TerminationThe rider will terminate if the policy to which it is attachedterminates, if the premiums for the rider are not paid, or uponyour death.

Effective DateThe effective date of the rider is the effective date of thepolicy or the effective date of the rider as stated in the PolicySchedule, if later.

The rider to which this sales material pertains is written only in English; the rider prevails if interpretation of thismaterial varies.

Refer to the policy and rider for complete details, limitations, and exclusions.

American Family Life Assurance Company of Columbus (Aflac)Worldwide Headquarters · 1932 Wynnton Road · Columbus, Georgia 31999 · aflac.com



Optional Sickness Disability Benefit Rider Summary PageRider A34052CA


Coverage is provided for sickness only. The rider does not apply tothe spouse or dependents.

Choose the Coverage You NeedAflac’s Personal Accident Indemnity Sickness DisabilityBenefit Rider allows you to choose a level of coverage thatbest meets your individual financial needs.

• Monthly Benefits: From $100 to $2,000, subject to incomerequirements

• Benefit Periods: 6 or 12 months

The Sickness Disability Benefit Rider includes a 14-dayelimination period.

Provisions of CoverageDisability benefits are available for ages 18 through 69 or forage 70 and above.

Ages 18 through 69: While this coverage is in force and acovered sickness causes you to become partially disabled ortotally disabled, we will pay you one-thirtieth of the benefitshown in the Policy Schedule for each day you remainpartially disabled or totally disabled.

Disability must begin within 90 days of your last treatmentfor the covered sickness. This benefit is payable up to thebenefit period selected and is subject to the 14-dayelimination period shown in the Policy Schedule. A full-timejob is a job at which you work 30 or more hours per week forpay or benefits.

Age 70 and above: While coverage is in force, if you requirehospital confinement resulting from a covered sickness within90 days of your last treatment for the sickness, we will payyou one-thirtieth of the benefit shown in the Policy Scheduletimes three for each day you are confined. This benefit ispayable regardless of whether you are working at a full-timejob. It is payable up to the benefit period selected and is notsubject to the 14-day elimination period shown in the PolicySchedule.

Benefits will be paid for only one disability at a time, even ifthat disability is caused by more than one sickness. If youhave any other disability benefit in force with Aflac, only onedisability benefit is payable. Turning age 70 will not stopbenefits otherwise payable. Aflac reserves the right to meet

with you during the pendency of a claim or to use anindependent consultant and a physician’s statement todetermine whether you are partially disabled or totallydisabled. Benefits will cease on the date of your death.

Partially disabled is defined as your continuing inability toperform with reasonable continuity the substantial andmaterial acts necessary to pursue your usual occupation in theusual or customary way, while still able to work at any joband earning less than 80 percent of your base pay earnings atthe time you become partially disabled or totally disabled. Ifyou return to work at any job and are earning 80 percent ormore of your predisability base pay earnings, you will nolonger be considered partially disabled.

Totally disabled is defined as your continuing inability toperform with reasonable continuity the substantial andmaterial acts necessary to pursue your usual occupation in theusual or customary way or to engage with reasonablecontinuity in another occupation in which you couldreasonably be expected to perform satisfactorily consideringeducation, training, experience, station in life, physical andmental capacity.

Successive periods of disability resulting from the same or arelated condition, and not separated by 180 days or more, areconsidered a continuation of the prior disability. Separateperiods of disability resulting from unrelated causes areconsidered a continuation of the prior disability unless theyare separated by your returning to work at a full-time job for14 working days, during which you are performing thematerial and substantial duties of this job and are no longerqualified to receive disability benefits.

Pre-Existing ConditionsDisability or hospitalization caused by a pre-existingcondition will not be covered unless it begins more than 12months after the effective date of coverage. A pre-existingcondition is a sickness for which, within the 12-month periodbefore the effective date of coverage, medical advice,consultation, or treatment was recommended or received, orsymptoms existed that would ordinarily cause a prudentperson to seek diagnosis, care, or treatment.

A sickness is a disease, disorder, infection, or any otherabnormal physical condition that is not caused by an injuryand that is first manifested or treated after your effective dateof coverage and while coverage is in force. Sickness includesdiseases or conditions resulting from insect bites orinfestations by microorganisms. Sickness only applies if theOptional Sickness Disability Rider is issued.

What Is Not CoveredWe will not pay benefits for a disability that is being treatedoutside the territorial limits of the United States or, if outsidethe United States, the territorial limits of the place where yourpolicy was issued.

We will not pay benefits for a disability that is caused by oroccurs as a result of your:

• Becoming partially disabled or totally disabled due to anyof the following: bipolar affective disorder (manicdepressive syndrome), delusional (paranoid) disorders,psychotic disorders, somatoform disorders (psychosomaticillness), eating disorders, schizophrenia, anxiety disorders,depression, stress, or post-partum depression. The rider willpay, however, for covered disabilities resulting fromAlzheimer’s disease, or similar forms of senility or seniledementia, first manifested while coverage is in force;

• Giving birth within the first ten months of the effective dateof the rider as a result of a normal pregnancy, includingcesarean (complications of pregnancy will be covered to thesame extent as a sickness);

• Donating an organ within the first 12 months of theeffective date of the rider.

Refer to your policy for additional limitations and exclusions.

TerminationThe rider will terminate if the policy to which it is attachedterminates, if the premiums for the rider are not paid, or uponyour death.

Effective DateThe effective date of the rider is the effective date of thepolicy or the effective date of the rider as stated in the PolicySchedule, if later.

The rider to which this sales material pertains is written only in English; the rider prevails if interpretation of thismaterial varies.

Refer to the policy and rider for complete details, limitations, and exclusions.

American Family Life Assurance Company of Columbus (Aflac)Worldwide Headquarters · 1932 Wynnton Road · Columbus, Georgia 31999 · aflac.com



Level 1

Personal AccidentIndemnity PlanAccident-Only Insurance

Plan Benefits

• Emergency Treatment

• Follow-Up Treatment

• Initial Hospitalization

• Hospital Confinement

• Physical Therapy

• Accidental-Death

• Wellness

• Plus ... much more


*Hospital confinement is defined as a covered person’s confinement to a bed in a hospital for which a room charge is made. Theconfinement must be on the advice of a physician and medically necessary. Benefits are also payable for confinement in hospitalsoperated by or for the United States government. Confinement must start within 30 days of the accident.

Personal Accident Indemnity PlanPolicy Series A-34000

Benefits are payable for a covered person’s death,dismemberment, or injury caused by a covered accident thatoccurs on or off the job.

Accident Emergency Treatment BenefitAflac will pay $120 for the insured and the spouse, and $70 forchildren if a covered person receives treatment for injuriessustained in a covered accident. This benefit is payable forX-rays, treatment by a physician, or treatment received in ahospital emergency room. Treatment must be received within72 hours of the accident for benefits to be payable. Thisbenefit is payable once per 24-hour period and only once percovered accident, per covered person.

Accident Follow-Up Treatment BenefitAflac will pay $25 for one treatment per day for up to amaximum of six treatments per covered accident, per coveredperson for follow-up treatment received for injuries sustainedin a covered accident. Treatment must begin within 30 days ofthe covered accident or discharge from the hospital.Treatments must be furnished by a physician in a physician’soffice or in a hospital on an outpatient basis. This benefit isnot payable for the same visit that the Physical TherapyBenefit is paid.

Initial Accident Hospitalization Benefit Aflac will pay $1,000 when a covered person is confined to ahospital for at least 24 hours for injuries sustained in acovered accident. If the covered person is admitted directly toan intensive care unit, Aflac will pay $1,500. This benefit ispayable only once per hospital confinement* or intensive careunit confinement and is payable only once per calendar year,per covered person.

Accident Hospital Confinement BenefitAflac will pay $200 per day for which a covered person ischarged for a room for hospital confinement* of at least 18hours for treatment of injuries sustained in a covered accident.This benefit is payable up to 365 days per covered accident,per covered person. The Accident Hospital ConfinementBenefit and the Rehabilitation Unit Benefit will not be paidon the same day; only the highest eligible benefit will be paid.

Intensive Care Unit Confinement BenefitAflac will pay an additional $400 per day for each day a coveredperson is receiving the Accident Hospital ConfinementBenefit and is confined to and charged for a room in anintensive care unit. This benefit is payable up to 15 days percovered accident, per covered person. Confinements muststart within 30 days of the accident.

Accident Specific-Sum Injuries BenefitAflac will pay $25–$10,000 for:

Dislocations Burns Skin Grafts

Eye Injuries Lacerations Fractures

Broken Teeth Comas Brain Concussions

Paralysis Surgical Procedures

Treatment must be performed on a covered person forinjuries sustained in a covered accident. We will pay for nomore than two dislocations per covered accident, per coveredperson. Dislocations must be diagnosed by a physicianwithin 72 hours after the covered accident. Benefits arepayable for only the first dislocation of a joint. If a physicianreduces a dislocation with local or no anesthesia, we willpay 25 percent of the amount shown for the closed reductiondislocation. A physician must treat burns within 72 hoursafter a covered accident. A total of 50 percent of the burnbenefit will be paid for one or more skin grafts. Lacerationsrequiring sutures must be repaired under the attendance of aphysician within 72 hours after the covered accident.Fractures must be diagnosed by a physician by X-ray within14 days after a covered accident. For chip fractures and otherfractures not reduced by open or closed reduction, we willpay 25 percent of the benefit amount shown for the closedreduction. We will pay for no more than two fractures percovered accident, per covered person. We will pay no morethan one benefit for broken teeth per covered accident, percovered person. Coma duration must be at least seven daysand must require intubation for respiratory assistance.Paralysis must result from spinal cord injuries that arereceived in a covered accident and that result in completeand total loss of use of two or more limbs for a period of atleast 30 days, and the loss must be confirmed by aphysician. Surgical procedures must be performed withinone year of a covered accident. Two or more surgicalprocedures performed through the same incision will beconsidered one operation, and benefits will be paid basedupon the most expensive procedure. Only one miscellaneoussurgery benefit is payable per 24-hour period even thoughmore than one procedure may be performed.

Major Diagnostic ExamsAflac will pay $150 if a covered person requires one of thefollowing exams for injuries sustained in a covered accident:CT (computerized tomography) scan, MRI (magneticresonance imaging), or EEG (electroencephalogram). Theexam must be performed in a hospital, a physician’s office, oran ambulatory surgical center, and a charge must be incurred.This benefit is limited to one payment per calendar year, percovered person. No lifetime maximum.

Physical Therapy BenefitAflac will pay $25 for one treatment per day up to a maximumof ten treatments per covered accident, per covered person if aphysician advises the person to seek treatment from a physicaltherapist. Physical therapy must be for injuries sustained in acovered accident and must start within 30 days of the coveredaccident or discharge from the hospital. Treatment must takeplace within six months after the accident. This benefit is notpayable for the same visit that the Accident Follow-UpTreatment Benefit is paid.

Rehabilitation Unit BenefitAflac will pay $100 per day when a covered person is chargedfor confinement in a hospital and transferred to a bed in arehabilitation unit of a hospital for a covered injury. Thisbenefit is limited to 30 days for each covered person perperiod of hospital confinement and is limited to a calendaryear maximum of 60 days. The Accident HospitalConfinement Benefit and the Rehabilitation Unit Benefit willnot be paid on the same day; only the highest eligible benefitwill be paid. No lifetime maximum.

A period of hospital confinement is a time period ofconfinement that starts while the policy is in force. If theconfinement follows a previously covered confinement, it willbe deemed a continuation of the first unless it is the result ofan entirely unrelated injury or the confinements are separatedby 30 days or more.

Appliances BenefitAflac will pay $100 if a covered person requires, as advised bya physician, the use of a medical appliance as an aid inpersonal locomotion resulting from injuries sustained in acovered accident. This benefit is payable for crutches,wheelchairs, leg braces, back braces, and walkers, and ispayable once per covered accident, per covered person.

Prosthesis BenefitAflac will pay $500 if a covered person requires a prostheticdevice as a result of injuries sustained in a covered accident.This benefit is payable once per covered accident, per coveredperson and is not payable for hearing aids, wigs, or dentalaids, to include false teeth.

Blood/Plasma/Platelets BenefitAflac will pay $100 if a covered person requires blood, plasma,or platelets for the treatment of injuries sustained in a coveredaccident. This benefit is not payable for immunoglobulins andis payable only once per covered accident, per covered person.

Ambulance BenefitAflac will pay $150 for ground ambulance transportation or$1,000 for air ambulance transportation if a covered personrequires ambulance transportation to a hospital or emergencycenter for injuries sustained in a covered accident. A licensedprofessional ambulance company must provide thetransportation within 72 hours of the covered accident. If theprovider of service does not receive payment for servicesprovided from any other source, and provided the benefitunder the policy has not been paid, we will directly reimbursesuch provider of service.

Transportation BenefitAflac will pay $400 per round trip to a hospital if a coveredperson requires special treatment and hospital confinement*for injuries sustained in a covered accident. The hospital mustbe more than 100 miles from the covered person’s residenceor site of the accident. This benefit will be paid for only thecovered person for whom the treatment is prescribed, or if thetreatment is for a dependent child and commercial travel isnecessary, one of the dependent child’s parents or legalguardians who travels with the child will also receive thisbenefit. The local attending physician must prescribe thetreatment, and the treatment must not be available locally.This benefit is payable for up to three round trips per calendaryear, per covered person. This benefit is not payable fortransportation by ambulance or air ambulance to the hospital.

Family Lodging BenefitAflac will pay $100 per night for one motel/hotel room for amember of the extended family to accompany the coveredperson if treatment of injuries sustained in a covered accidentrequires hospital confinement.* The hospital and motel/hotelmust be more than 100 miles from the covered person’sresidence. This benefit is payable up to 30 days per coveredaccident and only during the time the covered person isconfined in the hospital.

American Family Life Assurance Company of Columbus (Aflac)

Accidental-Death and -Dismemberment BenefitsAflac will pay the following benefit for death if it is the resultof injuries sustained in a covered accident:

Insured/Spouse Child

Common-Carrier Accidents $100,000 $15,000

A covered person must be a passenger at the time of thecommon-carrier accident, and a proper authority must havelicensed the vehicle to transport passengers for a fee.Common-carrier vehicles are limited to airplanes, trains,buses, trolleys, and boats that operate on a regularly scheduledbasis between predetermined points or cities. Taxis are notincluded.


Other Accidents $25,000 $7,500

(Other accidents are accidents that are not classified ascommon-carrier accidents and that are not specificallyexcluded in the limitations and exclusions of the policy.)

Aflac will pay the following benefit for dismembermentresulting from injuries sustained in a covered accident:


Both arms and both legs $25,000 $7,500

Two eyes, feet, hands,arms, or legs $25,000 $7,500

One eye, foot, hand,arm, or leg $ 6,250 $1,875

One or more fingers and/orone or more toes $ 1,250 $ 500

Death or dismemberment must be independent of disease,bodily infirmity, or any other cause other than a coveredaccident and must occur within 90 days of the accident. Onlythe highest single benefit per covered person will be paid foraccidental dismemberment. Benefits will be paid only oncefor any covered accident. If death and dismemberment resultfrom the same accident, only the Accidental-Death Benefitwill be paid. Loss of use does not constitute dismemberment,except for eye injuries resulting in permanent loss of visionsuch that central visual acuity cannot be corrected to betterthan 20/200.

Wellness BenefitAfter the policy has been in force for 12 months, Aflac will pay $60if you or any one family member undergoes routineexaminations or other preventive testing during the followingpolicy year. Eligible family members are your spouse and thedependent children of you or your spouse. Services covered are:annual physical examinations, dental exams, mammograms,Pap smears, eye examinations, immunizations, flexiblesigmoidoscopies, prostate-specific antigen tests (PSAs),ultrasounds, and blood screenings. This benefit will becomeavailable following each anniversary of the policy’s effectivedate for service received during the following policy year and ispayable only once per policy each 12-month period followingthe policy anniversary date. Service must be under thesupervision of or recommended by a physician and receivedwhile your policy is in force, and a charge must be incurred.

Continuation of Coverage BenefitAflac will waive all monthly premiums due for the policy andriders for up to two months if you meet all of the followingconditions: (1) Your policy has been in force for at least sixmonths; (2) we have received premiums for at least sixconsecutive months; (3) your premiums have been paidthrough payroll deduction and you leave your employer forany reason; (4) you or your employer notifies us in writingwithin 30 days of the date your premium payments ceasebecause of your leaving employment; and (5) you re-establishpremium payments, either through your new employer’spayroll deduction process or direct payment to Aflac. You willagain become eligible for this benefit after you re-establishyour premium payments through payroll deduction for aperiod of at least six months, and we receive premiums for atleast six consecutive months. (Payroll deduction means yourpremium is remitted to Aflac for you by your employerthrough a payroll deduction process.)

Guaranteed-RenewableThe policy is guaranteed-renewable for your lifetime, subjectto Aflac’s right to change premiums by class upon anyrenewal date.

Effective DateThe effective date of the policy is the date shown in the PolicySchedule, not the date the application is signed. The policy isavailable through age 64. The payroll rate may be retainedafter one month’s premium payment on payroll deduction.

This brochure is for illustration purposes only.

Refer to the policy for complete details, limitations, and exclusions.

What Is Not CoveredWe will not pay benefits for services rendered by a memberof the extended family of a covered person or for an accidentthat occurs while coverage is not in force.

We will not pay benefits for an accident or sickness that iscaused by or occurs as a result of a covered person’s:

• Participating in any activity or event, including theoperation of a vehicle, while under the influence of acontrolled substance (unless administered by a physicianand taken according to the physician’s instructions) or whileintoxicated (intoxicated means that condition as defined bythe law of the jurisdiction in which the accident occurred);

• Mountaineering using ropes and/or other equipment,parachuting, or hang gliding;

• Participating in, or attempting to participate in, an illegalactivity that is defined as a felony (felony is as defined bythe law of the jurisdiction in which the activity takes place);

• Intentionally self-inflicting bodily injury or attemptingsuicide, while sane or insane;

• Having cosmetic surgery or other elective procedures thatare not medically necessary, or having dental treatmentexcept as a result of injury;

• Being exposed to war or any act of war, declared orundeclared;

• Actively serving in any of the armed forces, or unitsauxiliary thereto, including the National Guard or ArmyReserve;

• Participating in any form of flight aviation other than as afare-paying passenger in a fully licensed, passenger-carrying aircraft;

• Participating in any sport or sporting activity for wage,compensation, or profit, including officiating or coaching;or racing any type vehicle in an organized event.

Hospital does not include any institution or part thereof usedas a rehabilitation unit; a hospice unit, including any beddesignated as a hospice or a swing bed; a convalescent home;a rest or nursing facility; an extended-care facility; a skillednursing facility; or a facility primarily affording custodial oreducational care, care or treatment for persons suffering frommental disease or disorders, care for the aged, or care forpersons addicted to drugs or alcohol.

Aflac shall not be liable for any loss to which a contributingcause was the insured’s commission of or attempt to commit afelony or to which a contributing cause was the insured’sbeing engaged in an illegal occupation.

A physician does not include you or a member of yourextended family, or anyone who normally resides in yourhome or residence.

Family CoverageFamily coverage includes the insured; spouse; and dependent,unmarried children to age 19 (23 if full-time students). Thisincludes the relationship created by a domestic partnership.Newborn children are automatically insured from the momentof birth. One-parent family coverage includes the insured andall unmarried, dependent children to age 19 (23 if full-timestudents). A dependent child must be under the age of 19 atthe time of application to be eligible for coverage.

The policy to which this sales material pertains is written onlyin English; the policy prevails if interpretation of this materialvaries.

Accidents Happen

• Unintentional injuries are the fifthleading cause of death overall andfirst among persons in age groupsfrom 1 to 44.

• On the average, there are 13unintentional-injury deaths andabout 2,650 disabling injuriesevery hour during the year.

• A disabling injury occurs in thehome about every four seconds.

• In 2003 about 35% of all hospitalemergency department visits in theUnited States were injury-related.

Injury Facts, 2005–2006 Edition, National Safety Council

Your local Aflac insurance agent/producer

American Family Life Assurance Company of Columbus (Aflac) · Worldwide Headquarters · 1932 Wynnton Road · Columbus, Georgia 31999 · aflac.com

1.800.99.AFLAC (1.800.992.3522)

En español:1.800.SI.AFLAC (1.800.742.3522)

Visit our Web site at aflac.com.

Aflac is ...• A Fortune 500 company with assets exceeding $56 billion,

insuring more than 40 million people worldwide.

• Rated AA in insurer financial strength by Standard & Poor’s(April 2004), Aa2 (Excellent) in insurer financial strength byMoody’s Investors Service (January 2006), A+ (Superior) byA.M. Best (June 2005), and AA in insurer financial strengthby Fitch, Inc. (April 2005).*

• Named by Fortune magazine to its list of America’s MostAdmired Companies for the sixth consecutive year in March 2006.

• A premier provider of insurance policies with premiums payrolldeducted for more than 350,000 payroll accounts nationally.

• Outstanding in claims service, with most claims processedwithin four days.

• Included by Forbes magazine in its annual Platinum 400 Listof America’s Best Big Companies for the sixth year inJanuary 2006.

• Named by Fortune magazine to its list of the 100 BestCompanies to Work For in America for the eighthconsecutive year in January 2006.

*Ratings refer only to the overall financial status of Aflac and are notrecommendations of specific policy provisions, rates, or practices.

Level 2

Personal AccidentIndemnity PlanAccident-Only Insurance

Plan Benefits







• Wellness



*Hospital confinement is defined as a covered person’s confinement to a bed in a hospital for which a room charge is made. Theconfinement must be on the advice of a physician and medically necessary. Benefits are also payable for confinement in hospitalsoperated by or for the United States government. Confinement must start within 30 days of the accident.

Benefits are payable for a covered person’s death,dismemberment, or injury caused by a covered accident thatoccurs on or off the job.

Accident Emergency Treatment BenefitAflac will pay $120 for the insured and the spouse, and $70 forchildren if a covered person receives treatment for injuriessustained in a covered accident. This benefit is payable for X-rays, treatment by a physician, or treatment received in ahospital emergency room. Treatment must be received within72 hours of the accident for benefits to be payable. Thisbenefit is payable once per 24-hour period and only once percovered accident, per covered person.

Accident Follow-Up Treatment BenefitAflac will pay $35 for one treatment per day for up to amaximum of six treatments per covered accident, per coveredperson for follow-up treatment received for injuries sustainedin a covered accident. Treatment must begin within 30 days ofthe covered accident or discharge from the hospital.Treatments must be furnished by a physician in a physician’soffice or in a hospital on an outpatient basis. This benefit isnot payable for the same visit that the Physical TherapyBenefit is paid.

Initial Accident Hospitalization Benefit Aflac will pay $1,000 when a covered person is confined to ahospital for at least 24 hours for injuries sustained in acovered accident. If the covered person is admitted directly toan intensive care unit, Aflac will pay $2,000. This benefit ispayable only once per hospital confinement* or intensive careunit confinement and is payable only once per calendar year,per covered person.

Accident Hospital Confinement BenefitAflac will pay $250 per day for which a covered person ischarged for a room for hospital confinement* of at least 18hours for treatment of injuries sustained in a covered accident.This benefit is payable up to 365 days per covered accident,per covered person. The Accident Hospital ConfinementBenefit and the Rehabilitation Unit Benefit will not be paidon the same day; only the highest eligible benefit will be paid.

Intensive Care Unit Confinement BenefitAflac will pay an additional $400 per day for each day acovered person is receiving the Accident HospitalConfinement Benefit and is confined to and charged for aroom in an intensive care unit. This benefit is payable up to15 days per covered accident, per covered person.Confinements must start within 30 days of the accident.






Treatment must be performed on a covered person for injuriessustained in a covered accident. We will pay for no more thantwo dislocations per covered accident, per covered person.Dislocations must be diagnosed by a physician within 72hours after the covered accident. Benefits are payable for onlythe first dislocation of a joint. If a physician reduces adislocation with local or no anesthesia, we will pay 25 percentof the amount shown for the closed reduction dislocation. Aphysician must treat burns within 72 hours after a coveredaccident. A total of 50 percent of the burn benefit will be paidfor one or more skin grafts. Lacerations requiring suturesmust be repaired under the attendance of a physician within 72hours after the covered accident. Fractures must be diagnosedby a physician by X-ray within 14 days after a coveredaccident. For chip fractures and other fractures not reduced byopen or closed reduction, we will pay 25 percent of thebenefit amount shown for the closed reduction. We will payfor no more than two fractures per covered accident, percovered person. We will pay no more than one benefit forbroken teeth per covered accident, per covered person. Comaduration must be at least seven days and must requireintubation for respiratory assistance. Paralysis must resultfrom spinal cord injuries that are received in a coveredaccident and that result in complete and total loss of use oftwo or more limbs for a period of at least 30 days, and theloss must be confirmed by a physician. Surgical proceduresmust be performed within one year of a covered accident. Twoor more surgical procedures performed through the sameincision will be considered one operation, and benefits will bepaid based upon the most expensive procedure. Only onemiscellaneous surgery benefit is payable per 24-hour periodeven though more than one procedure may be performed.

Personal Accident Indemnity PlanPolicy Series A-34000

Major Diagnostic ExamsAflac will pay $200 if a covered person requires one of thefollowing exams for injuries sustained in a covered accident:CT (computerized tomography) scan, MRI (magneticresonance imaging), or EEG (electroencephalogram). Theexam must be performed in a hospital, a physician’s office, oran ambulatory surgical center, and a charge must be incurred.This benefit is limited to one payment per calendar year, percovered person. No lifetime maximum.

Physical Therapy BenefitAflac will pay $35 for one treatment per day up to a maximumof ten treatments per covered accident, per covered person if aphysician advises the person to seek treatment from a physicaltherapist. Physical therapy must be for injuries sustained in acovered accident and must start within 30 days of the coveredaccident or discharge from the hospital. Treatment must takeplace within six months after the accident. This benefit is notpayable for the same visit that the Accident Follow-UpTreatment Benefit is paid.

Rehabilitation Unit BenefitAflac will pay $150 per day when a covered person is chargedfor confinement in a hospital and transferred to a bed in arehabilitation unit of a hospital for a covered injury. Thisbenefit is limited to 30 days for each covered person perperiod of hospital confinement and is limited to a calendaryear maximum of 60 days. The Accident HospitalConfinement Benefit and the Rehabilitation Unit Benefit willnot be paid on the same day; only the highest eligible benefitwill be paid. No lifetime maximum.


Appliances BenefitAflac will pay $125 if a covered person requires, as advised bya physician, the use of a medical appliance as an aid inpersonal locomotion resulting from injuries sustained in acovered accident. This benefit is payable for crutches,wheelchairs, leg braces, back braces, and walkers, and ispayable once per covered accident, per covered person.

Prosthesis BenefitAflac will pay $750 if a covered person requires a prostheticdevice as a result of injuries sustained in a covered accident.This benefit is payable once per covered accident, per coveredperson and is not payable for hearing aids, wigs, or dentalaids, to include false teeth.

Blood/Plasma/Platelets BenefitAflac will pay $200 if a covered person requires blood, plasma,or platelets for the treatment of injuries sustained in a coveredaccident. This benefit is not payable for immunoglobulins andis payable only once per covered accident, per covered person.

Ambulance BenefitAflac will pay $200 for ground ambulance transportation or$1,500 for air ambulance transportation if a covered personrequires ambulance transportation to a hospital or emergencycenter for injuries sustained in a covered accident. A licensedprofessional ambulance company must provide thetransportation within 72 hours of the covered accident. If theprovider of service does not receive payment for servicesprovided from any other source, and provided the benefitunder the policy has not been paid, we will directly reimbursesuch provider of service.

Transportation BenefitAflac will pay $600 per round trip to a hospital if a coveredperson requires special treatment and hospital confinement*for injuries sustained in a covered accident. The hospital mustbe more than 100 miles from the covered person’s residenceor site of the accident. This benefit will be paid for only thecovered person for whom the treatment is prescribed, or if thetreatment is for a dependent child and commercial travel isnecessary, one of the dependent child’s parents or legalguardians who travels with the child will also receive thisbenefit. The local attending physician must prescribe thetreatment, and the treatment must not be available locally.This benefit is payable for up to three round trips per calendaryear, per covered person. This benefit is not payable fortransportation by ambulance or air ambulance to the hospital.

Family Lodging BenefitAflac will pay $125 per night for one motel/hotel room for amember of the extended family to accompany the coveredperson if treatment of injuries sustained in a covered accidentrequires hospital confinement.* The hospital and motel/hotelmust be more than 100 miles from the covered person’sresidence. This benefit is payable up to 30 days per coveredaccident and only during the time the covered person isconfined in the hospital.


Accidental-Death and -Dismemberment BenefitsAflac will pay the following benefit for death if it is the resultof injuries sustained in a covered accident:



A covered person must be a passenger at the time of thecommon-carrier accident, and a proper authority must havelicensed the vehicle to transport passengers for a fee.Common-carrier vehicles are limited to airplanes, trains,buses, trolleys, and boats that operate on a regularlyscheduled basis between predetermined points or cities. Taxisare not included.




Aflac will pay the following benefit for dismembermentresulting from injuries sustained in a covered accident:




One eye, foot, hand,arm, or leg $10,000 $ 3,750


Death or dismemberment must be independent of disease,bodily infirmity, or any other cause other than a coveredaccident and must occur within 90 days of the accident. Onlythe highest single benefit per covered person will be paid foraccidental dismemberment. Benefits will be paid only oncefor any covered accident. If death and dismemberment resultfrom the same accident, only the Accidental-Death Benefitwill be paid. Loss of use does not constitute dismemberment,except for eye injuries resulting in permanent loss of visionsuch that central visual acuity cannot be corrected to betterthan 20/200.

Wellness BenefitAfter the policy has been in force for 12 months, Aflac will pay $60if you or any one family member undergoes routineexaminations or other preventive testing during the followingpolicy year. Eligible family members are your spouse and thedependent children of you or your spouse. Services coveredare: annual physical examinations, dental exams, mammograms,Pap smears, eye examinations, immunizations, flexiblesigmoidoscopies, prostate-specific antigen tests (PSAs),ultrasounds, and blood screenings. This benefit will becomeavailable following each anniversary of the policy’s effectivedate for service received during the following policy year andis payable only once per policy each 12-month periodfollowing the policy anniversary date. Service must be underthe supervision of or recommended by a physician and receivedwhile your policy is in force, and a charge must be incurred.



Effective DateThe effective date of the policy is the date shown in the PolicySchedule, not the date the application is signed. The policy isavailable through age 64. The payroll rate may be retainedafter one month’s premium payment on payroll deduction.



What Is Not CoveredWe will not pay benefits for services rendered by a memberof the extended family of a covered person or for an accidentthat occurs while coverage is not in force.














Family CoverageFamily coverage includes the insured; spouse; and dependent,unmarried children to age 19 (23 if full-time students). Thisincludes the relationship created by a domestic partnership.Newborn children are automatically insured from the momentof birth. One-parent family coverage includes the insured andall unmarried, dependent children to age 19 (23 if full-timestudents). A dependent child must be under the age of 19 at thetime of application to be eligible for coverage.


Accidents Happen








1.800.99.AFLAC (1.800.992.3522)






• Named by Fortune magazine to its list of America’s MostAdmired Companies for the sixth consecutive year in March 2006.




• Named by Fortune magazine to its list of the 100 BestCompanies to Work For in America for the eighthconsecutive year in January 2006.


Level 1

Off-the-Job OnlyPersonal AccidentIndemnity PlanOff-the-Job Accident-Only Insurance

Plan Benefits







• Wellness


Form A34375BCA IC(9/05)

*An off-the-job accident is an accident that occurs while you are not working at any job for pay or benefits.**Hospital confinement is defined as a covered person’s confinement to a bed in a hospital for which a room charge is made. Theconfinement must be on the advice of a physician and medically necessary. Benefits are also payable for confinement in hospitalsoperated by or for the United States government. Confinement must start within 30 days of the accident.

Off-the-Job Only Personal Accident Indemnity PlanPolicy Series A-34000

Benefits are payable for a covered person’s death, dismemberment,or injury caused by a covered off-the-job accident.*

Accident Emergency Treatment BenefitAflac will pay $120 for the insured and the spouse, and $70 forchildren if a covered person receives treatment for injuriessustained in a covered off-the-job accident. This benefit ispayable for X-rays, treatment by a physician, or treatmentreceived in a hospital emergency room. Treatment must bereceived within 72 hours of the accident for benefits to bepayable. This benefit is payable once per 24-hour period and only once per covered off-the-job accident, per covered person.

Accident Follow-Up Treatment BenefitAflac will pay $25 for one treatment per day for up to amaximum of six treatments per covered off-the-job accident,per covered person for follow-up treatment received forinjuries sustained in a covered off-the-job accident. Treatmentmust begin within 30 days of the covered off-the-job accidentor discharge from the hospital. Treatments must be furnishedby a physician in a physician’s office or in a hospital on anoutpatient basis. This benefit is not payable for the same visitthat the Physical Therapy Benefit is paid.

Initial Accident Hospitalization Benefit Aflac will pay $1,000 when a covered person is confined to ahospital for at least 24 hours for injuries sustained in acovered off-the-job accident. If the covered person is admitteddirectly to an intensive care unit, Aflac will pay $1,500. Thisbenefit is payable only once per hospital confinement** orintensive care unit confinement and is payable only once percalendar year, per covered person.

Accident Hospital Confinement BenefitAflac will pay $200 per day for which a covered person ischarged for a room for hospital confinement** of at least 18hours for treatment of injuries sustained in a covered off-the-job accident. This benefit is payable up to 365 days percovered off-the-job accident, per covered person. TheAccident Hospital Confinement Benefit and the RehabilitationUnit Benefit will not be paid on the same day; only thehighest eligible benefit will be paid.

Intensive Care Unit Confinement BenefitAflac will pay an additional $400 per day for each day acovered person is receiving the Accident HospitalConfinement Benefit and is confined to and charged for aroom in an intensive care unit. This benefit is payable up to15 days per covered off-the-job accident, per covered person.Confinements must start within 30 days of the accident.






Treatment must be performed on a covered person for injuriessustained in a covered off-the-job accident. We will pay forno more than two dislocations per covered off-the-jobaccident, per covered person. Dislocations must be diagnosedwithin 72 hours of the covered off-the-job accident. Benefitsare payable for only the first dislocation of a joint. If aphysician reduces a dislocation with local or no anesthesia,we will pay 25% of the amount shown for the closedreduction dislocation. A physician must treat burns within 72hours after a covered off-the-job accident. A total of 50% ofthe burn benefit will be paid for one or more skin grafts.Lacerations requiring sutures must be repaired under theattendance of a physician within 72 hours after the coveredoff-the-job accident. Fractures must be diagnosed by aphysician by X-ray within 14 days after a covered off-the-jobaccident. For chip fractures and other fractures not reduced byopen or closed reduction, we will pay 25% of the benefitamount shown for the closed reduction. We will pay for nomore than two fractures per covered off-the-job accident, percovered person. We will pay no more than one benefit forbroken teeth per covered off-the-job accident, per coveredperson. Coma duration must be at least seven days and mustrequire intubation for respiratory assistance. Paralysis mustresult from spinal cord injuries that are received in a coveredoff-the-job accident and that result in complete and total lossof use of two or more limbs for a period of at least 30 days,and the loss must be confirmed by a physician. Surgicalprocedures must be performed within one year of a coveredoff-the-job accident. Two or more surgical proceduresperformed through the same incision will be considered oneoperation, and benefits will be paid based upon the mostexpensive procedure. Only one miscellaneous surgery benefitis payable per 24-hour period even though more than oneprocedure may be performed.

Major Diagnostic ExamsAflac will pay $150 if a covered person requires one of thefollowing exams for injuries sustained in a covered off-the-jobaccident: CT (computerized tomography) scan, MRI (magneticresonance imaging), or EEG (electroencephalogram). Theexam must be performed in a hospital, a physician’s office, oran ambulatory surgical center, and a charge must be incurred.This benefit is limited to one payment per calendar year, percovered person.

Physical Therapy BenefitAflac will pay $25 for one treatment per day up to a maximumof ten treatments per covered off-the-job accident, per coveredperson if a physician advises the person to seek treatmentfrom a physical therapist. Physical therapy must be forinjuries sustained in a covered off-the-job accident and muststart within 30 days of the covered off-the-job accident ordischarge from the hospital. Treatment must take place withinsix months after the accident. This benefit is not payable forthe same visit that the Accident Follow-Up Treatment Benefitis paid.

Rehabilitation Unit BenefitAflac will pay $100 per day when a covered person is chargedfor confinement in a hospital and transferred to a bed in arehabilitation unit of a hospital for a covered off-the-jobaccident. This benefit is limited to 30 days for each coveredperson per period of hospital confinement and is limited to acalendar year maximum of 60 days. The Accident HospitalConfinement Benefit and the Rehabilitation Unit Benefit willnot be paid on the same day; only the highest eligible benefitwill be paid.

A period of hospital confinement is a time period ofconfinement that starts while this policy is in force. If theconfinement follows a previously covered confinement, it willbe deemed a continuation of the first unless it is the result ofan entirely unrelated injury or the confinements are separatedby 30 days or more.

Appliances BenefitAflac will pay $100 if a covered person requires, as advised bya physician, the use of a medical appliance as an aid inpersonal locomotion resulting from injuries sustained in acovered off-the-job accident. This benefit is payable forcrutches, wheelchairs, leg braces, back braces, and walkersand is payable once per covered off-the-job accident, percovered person.

Prosthesis BenefitAflac will pay $500 if a covered person requires a prostheticdevice as a result of injuries sustained in a covered off-the-jobaccident. This benefit is payable once per covered off-the-jobaccident, per covered person and is not payable for hearingaids, wigs, or dental aids, to include false teeth.

Blood/Plasma/Platelets BenefitAflac will pay $100 if a covered person requires blood, plasma,or platelets for the treatment of injuries sustained in a coveredoff-the-job accident. This benefit is not payable forimmunoglobulins and is payable only once per covered off-the-job accident, per covered person.

Ambulance BenefitAflac will pay $150 for ground ambulance transportation or$1,000 for air ambulance transportation if a covered personrequires ambulance transportation to a hospital or emergencycenter for injuries sustained in a covered off-the-job accident.A licensed professional ambulance company must provide thetransportation within 72 hours of the covered off-the-jobaccident. If the provider of service does not receive paymentfor services provided from any other source, and provided thebenefit under the policy has not been paid, we will directlyreimburse such provider of service.

Transportation BenefitAflac will pay $400 per round trip to a hospital if a coveredperson requires special treatment and hospital confinement**for injuries sustained in a covered off-the-job accident. Thehospital must be more than 100 miles from the coveredperson’s residence or site of the accident. This benefit will bepaid for only the covered person for whom the treatment isprescribed, or if the treatment is for a dependent child andcommercial travel is necessary, one of the dependent child’sparents or legal guardians who travels with the child will alsoreceive this benefit. The local attending physician mustprescribe the treatment, and the treatment must not beavailable locally. This benefit is payable for up to three roundtrips per calendar year, per covered person. This benefit is notpayable for transportation by ambulance or air ambulance tothe hospital.

Family Lodging BenefitAflac will pay $100 per night for one motel/hotel room for amember of the extended family to accompany the coveredperson if treatment of injuries sustained in a covered off-the-job accident requires hospital confinement.** The hospitaland motel/hotel must be more than 100 miles from thecovered person’s residence. This benefit is payable up to 30days per covered off-the-job accident and only during the timethe covered person is confined in the hospital.


This is off-the-job accident-only insurance; it does not pay benefits for injuries occurring on the job or for sickness.

Accidental-Death and -Dismemberment BenefitsAflac will pay the following benefit for death if it is the resultof injuries sustained in a covered off-the-job accident:







Aflac will pay the following benefit for dismembermentresulting from injuries sustained in a covered off-the-jobaccident:




One eye, foot, hand,arm, or leg $ 6,250 $1,875


Death or dismemberment must be independent of disease,bodily infirmity, or any other cause other than a covered off-the-job accident and must occur within 90 days of theaccident. Only the highest single benefit per covered personwill be paid for accidental dismemberment. Benefits will bepaid only once for any covered off-the-job accident. If deathand dismemberment result from the same accident, only theAccidental-Death Benefit will be paid. Loss of use does notconstitute dismemberment, except for eye injuries resulting inpermanent loss of vision such that central visual acuity cannotbe corrected to better than 20/200.

Wellness BenefitAfter the policy has been in force for 12 months, Aflac will pay $60if you or any one family member undergoes routineexaminations or other preventive testing during the followingpolicy year. Eligible family members are your spouse and thedependent children of you or your spouse. Services covered are:annual physical examinations, dental exams, mammograms,Pap smears, eye examinations, immunizations, flexiblesigmoidoscopies, prostate-specific antigen tests (PSAs),ultrasounds, and blood screenings. This benefit will becomeavailable following each anniversary of the policy’s effectivedate for service received during the following policy year and ispayable only once per policy each 12-month period followingthe policy anniversary date. Service must be under thesupervision of or recommended by a physician and receivedwhile your policy is in force, and a charge must be incurred.



Effective DateThe effective date of the policy is the date shown on the PolicySchedule, not the date the application is signed. The policy isavailable through age 64. The payroll rate may be retainedafter one month’s premium payment on payroll deduction.


What Is Not CoveredWe will not pay benefits for an accident that is caused by oroccurs as a result of a covered person’s being injured on the jobor for an accident that occurs while coverage is not in force.

We will not pay benefits for services rendered by a memberof the extended family of a covered person.













Family CoverageFamily coverage includes the insured; spouse; and dependent,unmarried children to age 19 (23 if full-time students). Thisincludes the relationship created by a domestic partnership.Newborn children are automatically insured from the momentof birth. One-parent family coverage includes the insured andall unmarried, dependent children to age 19 (23 if full-timestudents). A dependent child must be under the age of 19 at thetime of application to be eligible for coverage.


Accidents Happen

• Unintentional injuries are theleading cause of death for peopleages 1 to 34 and the fifth leadingcause of death overall.




Injury Facts, 2004 Edition, National Safety Council



1.800.99.AFLAC (1.800.992.3522)





• Rated AA in insurer financial strength by Standard & Poor’s(April 2004), Aa2 (Excellent) in insurer financial strength byMoody’s Investors Service (March 2003), A+ (Superior) byA.M. Best (June 2004), and AA in insurer financial strengthby Fitch, Inc. (December 2003).*

• Named by Fortune magazine to its list of America’s MostAdmired Companies for the fifth consecutive year in March 2005.



• Included by Forbes magazine in its annual Platinum 400 Listof America’s Best Big Companies since 2000 (January 2004).

• Named by Fortune magazine to its list of the 100 BestCompanies to Work For in America for the seventhconsecutive year in January 2005.

* Ratings refer only to the overall financial status of Aflac and are notrecommendations of specific policy provisions, rates, or practices.

Level 2

Off-the-Job OnlyPersonal AccidentIndemnity PlanOff-the-Job Accident-Only Insurance

Plan Benefits







• Wellness



*An off-the-job accident is an accident that occurs while you are not working at any job for pay or benefits.**Hospital confinement is defined as a covered person’s confinement to a bed in a hospital for which a room charge is made. Theconfinement must be on the advice of a physician and medically necessary. Benefits are also payable for confinement in hospitalsoperated by or for the United States government. Confinement must start within 30 days of the accident.

Off-the-Job Only Personal Accident Indemnity PlanPolicy Series A-34000

Benefits are payable for a covered person’s death, dismemberment,or injury caused by a covered off-the-job accident.*

Accident Emergency Treatment BenefitAflac will pay $120 for the insured and the spouse, and $70 forchildren if a covered person receives treatment for injuriessustained in a covered off-the-job accident. This benefit ispayable for X-rays, treatment by a physician, or treatmentreceived in a hospital emergency room. Treatment must bereceived within 72 hours of the accident for benefits to bepayable. This benefit is payable once per 24-hour period andonly once per covered off-the-job accident, per covered person.

Accident Follow-Up Treatment BenefitAflac will pay $35 for one treatment per day for up to amaximum of six treatments per covered off-the-job accident,per covered person for follow-up treatment received forinjuries sustained in a covered off-the-job accident. Treatmentmust begin within 30 days of the covered off-the-job accidentor discharge from the hospital. Treatments must be furnishedby a physician in a physician’s office or in a hospital on anoutpatient basis. This benefit is not payable for the same visitthat the Physical Therapy Benefit is paid.

Initial Accident Hospitalization BenefitAflac will pay $1,000 when a covered person is confined to ahospital for at least 24 hours for injuries sustained in acovered off-the-job accident. If the covered person is admitteddirectly to an intensive care unit, Aflac will pay $2,000. Thisbenefit is payable only once per hospital confinement** orintensive care unit confinement and is payable only once percalendar year, per covered person.

Accident Hospital Confinement BenefitAflac will pay $250 per day for which a covered person ischarged for a room for hospital confinement** of at least 18hours for treatment of injuries sustained in a covered off-the-job accident. This benefit is payable up to 365 days percovered off-the-job accident, per covered person. TheAccident Hospital Confinement Benefit and the RehabilitationUnit Benefit will not be paid on the same day; only thehighest eligible benefit will be paid.

Intensive Care Unit Confinement BenefitAflac will pay an additional $400 per day for each day acovered person is receiving the Accident HospitalConfinement Benefit and is confined to and charged for aroom in an intensive care unit. This benefit is payable up to15 days per covered off-the-job accident, per covered person.Confinements must start within 30 days of the accident.






Treatment must be performed on a covered person for injuriessustained in a covered off-the-job accident. We will pay forno more than two dislocations per covered off-the-jobaccident, per covered person. Dislocations must be diagnosedby a physician within 72 hours after the covered off-the-jobaccident. Benefits are payable for only the first dislocation ofa joint. If a physician reduces a dislocation with local or noanesthesia, we will pay 25 percent of the amount shown forthe closed reduction dislocation. A physician must treat burnswithin 72 hours after a covered off-the-job accident. A total of50 percent of the burn benefit will be paid for one or moreskin grafts. Lacerations requiring sutures must be repairedunder the attendance of a physician within 72 hours after thecovered off-the-job accident. Fractures must be diagnosed bya physician by X-ray within 14 days after a covered off-the-job accident. For chip fractures and other fractures notreduced by open or closed reduction, we will pay 25 percentof the benefit amount shown for the closed reduction. We willpay for no more than two fractures per covered off-the-jobaccident, per covered person. We will pay no more than onebenefit for broken teeth per covered off-the-job accident, percovered person. Coma duration must be at least seven daysand must require intubation for respiratory assistance.Paralysis must result from spinal cord injuries that arereceived in a covered off-the-job accident and that result incomplete and total loss of use of two or more limbs for aperiod of at least 30 days, and the loss must be confirmed bya physician. Surgical procedures must be performed withinone year of a covered off-the-job accident. Two or moresurgical procedures performed through the same incision willbe considered one operation, and benefits will be paid basedupon the most expensive procedure. Only one miscellaneoussurgery benefit is payable per 24-hour period even thoughmore than one procedure may be performed.

This is off-the-job accident-only insurance;it does not pay benefits for injuries occurring on the job or for sickness.

Major Diagnostic ExamsAflac will pay $200 if a covered person requires one of thefollowing exams for injuries sustained in a covered off-the-jobaccident: CT (computerized tomography) scan, MRI (magneticresonance imaging), or EEG (electroencephalogram). Theexam must be performed in a hospital, a physician’s office, oran ambulatory surgical center, and a charge must be incurred.This benefit is limited to one payment per calendar year, percovered person. No lifetime maximum.

Physical Therapy BenefitAflac will pay $35 for one treatment per day up to a maximumof ten treatments per covered off-the-job accident, per coveredperson if a physician advises the person to seek treatmentfrom a physical therapist. Physical therapy must be forinjuries sustained in a covered off-the-job accident and muststart within 30 days of the covered off-the-job accident ordischarge from the hospital. Treatment must take place withinsix months after the accident. This benefit is not payable forthe same visit that the Accident Follow-Up Treatment Benefitis paid.

Rehabilitation Unit BenefitAflac will pay $150 per day when a covered person is chargedfor confinement in a hospital and transferred to a bed in arehabilitation unit of a hospital for a covered off-the-jobaccident. This benefit is limited to 30 days for each coveredperson per period of hospital confinement and is limited to acalendar year maximum of 60 days. The Accident HospitalConfinement Benefit and the Rehabilitation Unit Benefit willnot be paid on the same day; only the highest eligible benefitwill be paid. No lifetime maximum.


Appliances BenefitAflac will pay $125 if a covered person requires, as advised bya physician, the use of a medical appliance as an aid inpersonal locomotion resulting from injuries sustained in acovered off-the-job accident. This benefit is payable forcrutches, wheelchairs, leg braces, back braces, and walkers,and is payable once per covered off-the-job accident, percovered person.

Prosthesis BenefitAflac will pay $750 if a covered person requires a prostheticdevice as a result of injuries sustained in a covered off-the-jobaccident. This benefit is payable once per covered off-the-jobaccident, per covered person and is not payable for hearingaids, wigs, or dental aids, to include false teeth.

Blood/Plasma/Platelets BenefitAflac will pay $200 if a covered person requires blood, plasma,or platelets for the treatment of injuries sustained in a coveredoff-the-job accident. This benefit is not payable forimmunoglobulins and is payable only once per covered off-the-job accident, per covered person.

Ambulance BenefitAflac will pay $200 for ground ambulance transportation or$1,500 for air ambulance transportation if a covered personrequires ambulance transportation to a hospital or emergencycenter for injuries sustained in a covered off-the-job accident.A licensed professional ambulance company must provide thetransportation within 72 hours of the covered off-the-jobaccident. If the provider of service does not receive paymentfor services provided from any other source, and provided thebenefit under the policy has not been paid, we will directlyreimburse such provider of service.

Transportation BenefitAflac will pay $600 per round trip to a hospital if a coveredperson requires special treatment and hospital confinement**for injuries sustained in a covered off-the-job accident. Thehospital must be more than 100 miles from the coveredperson’s residence or site of the accident. This benefit will bepaid for only the covered person for whom the treatment isprescribed, or if the treatment is for a dependent child andcommercial travel is necessary, one of the dependent child’sparents or legal guardians who travels with the child will alsoreceive this benefit. The local attending physician mustprescribe the treatment, and the treatment must not beavailable locally. This benefit is payable for up to three roundtrips per calendar year, per covered person. This benefit is notpayable for transportation by ambulance or air ambulance tothe hospital.

Family Lodging BenefitAflac will pay $125 per night for one motel/hotel room for amember of the extended family to accompany the coveredperson if treatment of injuries sustained in a covered off-the-job accident requires hospital confinement.** The hospitaland motel/hotel must be more than 100 miles from thecovered person’s residence. This benefit is payable up to 30days per covered off-the-job accident and only during the timethe covered person is confined in the hospital.


Accidental-Death and -Dismemberment BenefitsAflac will pay the following benefit for death if it is the resultof injuries sustained in a covered off-the-job accident:







Aflac will pay the following benefit for dismembermentresulting from injuries sustained in a covered off-the-jobaccident:




One eye, foot, hand,arm, or leg $10,000 $ 3,750


Death or dismemberment must be independent of disease,bodily infirmity, or any other cause other than a covered off-the-job accident and must occur within 90 days of theaccident. Only the highest single benefit per covered personwill be paid for accidental dismemberment. Benefits will bepaid only once for any covered off-the-job accident. If deathand dismemberment result from the same accident, only theAccidental-Death Benefit will be paid. Loss of use does notconstitute dismemberment, except for eye injuries resulting inpermanent loss of vision such that central visual acuity cannotbe corrected to better than 20/200.

Wellness BenefitAfter the policy has been in force for 12 months, Aflac will pay $60if you or any one family member undergoes routineexaminations or other preventive testing during the followingpolicy year. Eligible family members are your spouse and thedependent children of you or your spouse. Services covered are:annual physical examinations, dental exams, mammograms,Pap smears, eye examinations, immunizations, flexiblesigmoidoscopies, prostate-specific antigen tests (PSAs),ultrasounds, and blood screenings. This benefit will becomeavailable following each anniversary of the policy’s effectivedate for service received during the following policy year andis payable only once per policy each 12-month periodfollowing the policy anniversary date. Service must be underthe supervision of or recommended by a physician and receivedwhile your policy is in force, and a charge must be incurred.



Effective DateThe effective date of the policy is the date shown in the PolicySchedule, not the date the application is signed. The policy isavailable through age 64. The payroll rate may be retained afterone month’s premium payment on payroll deduction.



What Is Not CoveredWe will not pay benefits for an accident that is caused by oroccurs as a result of a covered person’s being injured on the jobor for an accident that occurs while coverage is not in force.

We will not pay benefits for services rendered by a memberof the extended family of a covered person.














Family CoverageFamily coverage includes the insured; spouse; and dependent,unmarried children to age 19 (23 if full-time students). Thisincludes the relationship created by a domestic partnership.Newborn children are automatically insured from the momentof birth. One-parent family coverage includes the insured andall unmarried, dependent children to age 19 (23 if full-timestudents). A dependent child must be under the age of 19 atthe time of application to be eligible for coverage.


Accidents Happen








1.800.99.AFLAC (1.800.992.3522)



Aflac is ...• A Fortune 500 company with assets exceeding $56 billion,insuringmore than 40million people worldwide.


• Named by Fortunemagazine to its list of America’sMostAdmired Companies for the sixth consecutive year inMarch 2006.

• Apremier provider of insurancepolicieswithpremiumspayrolldeducted formore than350,000payroll accounts nationally.

• Outstanding in claims service, withmost claims processedwithin four days.


• Named by Fortunemagazine to its list of the 100 BestCompanies toWork For in America for the eighthconsecutive year in January 2006.


Documents

Accident Specific-Sum Injuries · PDF fileAccident Specific-Sum Injuries Amounts AFLAC will pay $25Œ$10,000 for: ... We will pay for no more than two fractures per covered off-the-job