SUPPLEMENTAL HEALTH PLAN 

RETURN BETWEEN: Dates Listed on your flyer from work.

Includes All Employees: 

To be included go to: mutualagentportal.com 

(click get free quote – and return form) 

Pays directly to you in addition to any other insurance … You may use for medical and non-medical expenses. 

Supplemental Insurance Coverage pays cash directly to you in addition and on top of any other insurance you may have to help with rising medical and non-medical expenses such as: Deductibles and co-Insurance, experimental treatments, traveling and lodging expenses, lost pay from work, mortgage and car payments, bills and more...  

• Portable – You may continue coverage if you leave for any reason or retire at the same rates. 
• On Employee & Children, Family Plans dependent children covered to age 21 or 25 if a full-time student.  
• Guaranteed Coverage for life.

MONTHLY PREMIUMS:  NO PREMIUM INCREASE WHEN YOU MOVE TO THE NEXT AGE BRACKET

Issue Ages:   Employee Only:     Employee & Children:     2-Adults or Family:

(18-39)                $19.90                           $26.00                             $36.70

(40-49)                $20.30                           $26.50                             $37.40

(50-54)                $22.10                           $29.10                            $41.00

(55-59)                $24.70                           $33.00                            $46.90 

(60-64)                $31.60                           $42.80                            $60.10 

Coverage: Hospital Intensive Care Unit or a Critical Care Unit

Pays $500 per day (Any Accident or Sickness)

Confinement to an Intensive Care Unit or a Critical Care Unit can result from: 

Heart attack and stroke                                                   Complications from Surgery

Serious Trauma Accident                                                Other Serious Medical Conditions

Coverage: Any type of Cancer                                                                                                                                        

• First-Occurrence Express Payment: $1,000. 
• Reconstructive Breast Surgery: Actual Charges. 
• Hospital Daily Room: $200 per day, 1-30 days. $400 per day, 31 + days.                                           
• Radiation and Chemotherapy (injected by medical personnel): $250 per day.
• Chemotherapy (self-administered): $250 per drug. 
• Comfort Drugs (outpatient): Up to $100 per month.                                                                         
• Bone Marrow Transplant: $5,000.
• Stem Cell Transplant: $1,250.
• Skilled Nursing Facility: Up to $100 per day, limited to number of days hospital confined.
• Hospice: Up to $100 per day, 1 – 60 days. Up to $50 per day, 61+ days.
• Second and third surgical opinion: Up to $225 per opinion. 
• Surgery: Up to $7,500.
• Anesthesia: Up to $1,875. 
• Blood and Plasma: Actual Charges. 
• Wigs and Hairpieces: Up to $250.
• Ambulance: $200. 
• Inpatient Drugs and Diagnostic Testing: Up to $40 per day.
• Attending Physician: Up to $30 per day. 
• Prosthetics: (surgical) up to $2,000, (non-surgical) up to $250. 
• Transportation: Up to $1,500 coach-class plane, train, bus or 40 cents per mile personal auto. 
• Family Member Lodging: Up to $60 per day.   

This is a brief description of benefits  – Refer to your policy for complete details