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AD&D Application
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AD&D Beneficiary Form
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AD&D Rate Sheet
(As of 1/1/2011)

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Endorsed by PSEA and underwritten by the
National Union Fire Insurance Company of Pittsburgh, Pa

PLAN BENEFITS - If injuries occur while insured result in paralysis, death, or dismemberment, this Plan will pay these benefits:

Life 100%
Both Hands or Both Feet 100%
Sight of Both Eyes 100%
One Hand and One Foot 100%
One Hand and the Sight of One Eye 100%
One Foot and the Sight of One Eye 100%
Speech and Hearing in Both Ears 100%
The Sight of One Eye 50%
One Hand or One Foot 50%
Speech or Hearing in Both Ears 50%
Hearing in One Ear 25%
Thumb & Index Finger of the Same Hand 25%
Quadriplegia 100%
Paraplegia 50%
Hemiplegia 50%

*Quadriplegia means total paralysis of both upper and lower limbs; PARAPLEGIA MEANS TOTAL PARALYSIS OF BOTH LOWER LIMBS; HEMIPLEGIA MEANS TOTAL PARALYSIS OF UPPER AND LOWER LIMBS ON ONE SIDE OF THE BODY.

Coverage for loss resulting from paralysis terminates at age 70.

Only one amount, the largest to which the insured is entitled, is paid for all losses resulting from one accident.† for members and retirees who are age 70 or older at the time of a covered accident, the benefit amount payable reduces as follows:

At age 70 - to 70% of the selected Benefit amount
At age 75 - to 45% of the selected Benefit Amount
At age 80 - to 30% of the selected Benefit Amount
At age 85 - to 15% of the selected Benefit Amount

SEATBELT BENEFIT - A special benefit is paid if an insured person dies as a result of a covered accident which occurs while driving or riding in a private passenger automobile if it is verified that such person was wearing a properly-fastened, original, factory installed seat belt or, if the covered person is a child(ren), a properly installed and fastened child(ren) restraint device as defined by state law.