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-4- <br />Life and Accidental Death and Dismemberment benefits reduce <br />50% upon attainment of age 65. <br />Non Occupational (Off the Job) <br />Indemnity is ,payable on the FIRST day of disability caused <br />by non-occupational accidental injury and from the EIGTH <br />day of disability caused by non occupational partional <br />illness. The maximum period for which Indemnity is payable <br />for either cause is THIRTEEN weeks per period of disability. <br />Maternity benefits are not included. <br />EMPL1YEEANa DEPENDENT migau Islugala <br />Hospital xpense <br />Room Board daily benefit $20,00 <br />Room Board Maximum No. of days (70) <br />Other Hospital charges up to $400.00 <br />Surgical Expense <br />Maximum Benefit $300.00 <br />Maternity Expense. <br />Hospital Expense Dep. wife <br />Normal Delivery Dep. wife <br />Caesarean Section Dep. wife <br />Extra- Uterine Dep. wife <br />Miscarriage or Abortion <br />(Dep. wife <br />In Hospital Medical Expense <br />Per treatment maximum <br />Maximum No. of days <br />only $150.00 <br />only $125.00 <br />only $250.00 <br />only $250.00 <br />only)$ 62.50 <br />54.00 <br />70 days <br />piagnostic)( Rav L bora�oxy Expense <br />Up to (Non-Schedules) $25.00 <br />Supplemental Accident Expense up to <br />$150.00 <br />TOTALS <br />employee dependent <br />3.80 7.18 <br />incl. incl. <br />.73 1.73 <br />2.96 <br />incl. incl. <br />incl. incl. <br />incl. incl. <br />indl. incl. <br />.20 .35 <br />.25 .60 <br />.20 .33 <br />$5.18 $13.15 <br />Total Employee and Dependents $18.33 <br />SCHEDULE OF RATES <br />AND MONTHLY COST Monthly rate <br />(1) Employee is Class I Single 8.82 <br />(10) Employees in Class I with Depd. 21.97 <br />TOTAL MONTHLY PREMIUM <br />Presented by: Norman A. Lockert, Agent <br />Penn Mutual Life <br />2637 Park Avenue South <br />Minneapolis, Minnesota <br />FE -3 -2545 <br />000079 <br />M Dthly Prem. <br />8.82 <br />219.70 <br />5228.52 <br />May 14, 1962 <br />