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-4 - <br />000079 <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 />EMPL 7YEF . LLL DEPENDENT HEALTH INSURANCE, <br />Lls ital Expense <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 />employee dependent <br />3.80 7.18 <br />incl. incl. <br />.73 1.73 <br />only $150.00 - 2.96 <br />only $125.00 incl. incl. <br />only $250.00 incl. incl. <br />only)$250.00 incl. incl. <br />only)$ 62.50 .indl. incl. <br />Di_ganostic X Ray & Laboratory <br />Up to (Non - Schedules) <br />Supplemental Accident Expense <br />$4.00 .20 .35 <br />70 days <br />E,_ _xper se <br />$25.00 .25 .60 <br />up to <br />$150.00 .20 .33 <br />$5.18 $13.15 <br />$18.33 <br />TOTALS <br />Total Employee and Dependents <br />SCHEDULE OF RATES <br />AND MONTHLY COST Monthly rate Monthly,,,_Prem. <br />(1) Employee is Class I Single @ 8.82 8.82 <br />(10) Employees in Class I with Depd. @ 21.97 219.70 <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 />$228.52 <br />May 14, 1962 <br />