Plans & Benefit Payment
Benefit Type
Option 1 Pays
Option 2 Pays
Option 3 Pays

Doctor's Visit
$50.00 per visit
Limit 5 per year
$50.00 per visit
Limit 5 per year
$75.00 per visit
Limit 7 per year
Lab & X-Ray
Not Included
$100.00 per day
Limit 3 days
per year
$100.00 per day
Limit 5 days
per year
Accident Benefit
100%
Limit $500.00
per accident
100%
Limit $1000.00
per accident
100%
Limit $1000.00
per accident
Daily in Hospital
$250.00 per day
30 day maximum
$500.00 per day
30 day maximum
$1000.00 per day
30 day maximum
Surgical Benefit
Per schedule of Surgical Indemnity Benefits
$1,200.00 maximum
Per schedule of Surgical Indemnity Benefits
$1,800.00 maximum
Per schedule of Surgical Indemnity Benefits
$2,400.00 maximum
Emergency Room
20% of Surgical Benefit Amount
20% of Surgical Benefit Amount
20% of Surgical Benefit Amount
Drug Card
Not Included
$20 per prescription
Limit 10 per year
$20 per prescription
Limit 15 per year

Plan Monthly Premium Rates
Option 1
Coverage Type
Base Premium
With $2.00 Direct Debit Payment Fee
With 2.5% Credit Card Payment Fee
Member
$68.20
$70.20
$69.91
Member + 1 dependent
$118.78
$120.78
$121.75
Member + 2 or more dependents
$167.66
$169.76
$171.85

 
Option 2
Coverage Type
Base Premium
With $2.00 Direct Debit Payment Fee
With 2.5% Credit Card Payment Fee
Member
$118.10
$120.10
$121.05
Member + 1 dependent
$211.97
$213.97
$217.27
Member + 2 or more dependents
$302.79
$304.79
$310.36

 
Option 3
Coverage Type
Base Premium
With $2.00 Direct Debit Payment Fee
With 2.5% Credit Card Payment Fee
Member
$164.80
$166.80
$168.92
Member + 1 dependent
$298.93
$300.95
$306.40
Member + 2 or more dependents
$428.95
$430.95
$439.67

 
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WORLDWIDE INSURANCE SERVICES, INC.
237 Melvin Drive
Northbrook, IL 60062