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8/11/2019 Adecco Insurance
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Page 4 of 4 ABJ25913X
This material is valid as long as information remains
current, but in no event later than November 15,
2016. Group Voluntary Accident benefits provided
by policy form GVAP1, or state variations thereof.
Off-the-Job Accident Disability Rider provided by rider
R1AP, or state variations thereof.
Coverage is provided by Limited Benefit Supplemental
Health Insurance. The policy is not a MedicareSupplement Policy. If eligible for Medicare, review
Medicare Supplement Buyers Guide available from
Allstate Benefits.
This brochure highlights some features of the policy
but is not the insurance contract. For complete details,
contact your Allstate Benefits Agent. This is a brief
overview of the benefits available under the Group
Voluntary Policy underwritten by American Heritage
Life Insurance Company (Home Office, Jacksonville,
FL). Details of the insurance, including exclusions,
restrictions and other provisions are included in the
certificates issued.
This brochure is for use in the Adecco enrollment
which is sitused in DE.
Allstate Benefits is the marketing name used by American Heritage Life Insurance Company(Home Office, Jacksonville, FL), a subsidiary of The Allstate Corporation.
2013 Allstate Insurance Company. www.allstate.com or allstatebenefits.com.
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BASE ACCIDENT BENEFITS PLANAccidental Death Employee $20,000
Spouse $10,000
Child $5,000
Common Carrier Employee $100,000
Accidental Death Spouse $50,000
Child $25,000
Dismemberment Employee up to $20,0001
Spouse up to $10,0001
Child up to $5,0001
Dislocation and Fracture Employee up to $2,0001
Spouse up to $1,0001
Child up to $5001
Initial Hospital Confinement2 $500
Hospital Confinement3 $100
Intensive Care3 $200
Ambulance Regular Ambulance $100Air Ambulance $300
Medical Expenses up to $250
Outpatient Physicians Treatment4 $25
DISABILITY RIDER BENEFIT PLANOff-the-Job Accident Disability Rider5 $1,000
group voluntary accident
injury benefit schedule
*Knee joint (except
patella). Bone or bones
of the foot (except
toes). Bone or bones
of the hand (except
fingers). **Pelvis(except coccyx). Skull
(except bones of face
or nose). Foot (except
toes). Hand or wrist
(except fingers).
Lower jaw (except
alveolar process).
LOSS OF LIFE OR LIMB PLAN
Life, or both eyes, hands, arms, feet, or legs, or
one hand or arm and one foot or leg $20,000
One eye, hand, arm, foot, or leg $10,000
One or more entire toes or fingers $2,000
COMPLETE DISLOCATION PLANHip joint $2,000
Knee or ankle joint*, bone or bones of the foot* $800
Wrist joint $700
Elbow joint $600
Shoulder joint $400
Bone or bones of the hand*, collarbone $300
Two or more fingers or toes $140
One finger or toe $60
COMPLETE, SIMPLE OR CLOSED FRACTURE PLAN
Hip, thigh (femur), pelvis** $2,000
Skull** $1,900
Arm, between shoulder and elbow (shaft),shoulder blade (scapula), leg (tibia or fibula) $1,100
Ankle, knee cap (patella), forearm (radius or ulna), collarbone (clavicle) $800
Foot**, hand or wrist** $700
Lower jaw** $400
Two or more ribs, fingers or toes, bones of face or nose $300
One rib, finger or toe, coccyx $140
Benefit amountsfor coverage andone occurrence areshown to the left.
Covered spousegets 50% of theamounts shownand children 25%.
Page 2aABJ25913X-Insert-ADECCO
1based on amounts
shown in the Injury
Benefit Schedule below
2payable once/covered
person
3per day, max. 90 days/
injury
4per visit, max. 2 visits/year, 4 if dependents are
covered
5per month, payable up to
12 months
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This insert is part of brochure ABJ25913Xand is not to be used on its own. Allstate Benefits is the marketing name used by American Heritage
Life Insurance Company (Home Office, Jacksonville, FL), a subsidiary of The Allstate Corporation. 2013 Allstate Insurance Company.
www.allstate.com or allstatebenefits.com.
This insert is for use in: DE
ABJ25913X-Insert-ADECCO Page 2b
MODE EE EE + SP EE + CH F
Monthly $22.50 $29.18 $30.67 $34.38
EE =Employee; EE + SP =Employee + Spouse; EE + CH =Employee + Child(ren); and F =Family
premiums
Issue Ages: 18 and over if Actively at Work