Employee Only $ 12 . 50 Employee + Spouse $ 20 . 00 Employee + Child ( ren ) $ 21 . 50 Employee + Family $ 29 . 00 Description of Benefits Plan Pays Hospital Admission $ 1 , 000 Dislocation Benefit Up to $ 5 , 000 Fracture Benefit Up to $ 6 , 000 Accident Hospital Confinement - Up to 365 Days $ 250 / Day Accident Hospital ICU Confinement - Up to 15 Days $ 500 / Day Accident Emergency Room Treatment $ 200 Major Diagnostic Examination Benefit $ 200 Physical Therapy Benefit - Up to 10 Days $ 35 / Day Ambulance Benefit $ 200 Traumatic Brain Injury $ 4 , 000 Burns Up to $ 12 , 000 Coma $ 10 , 000 Emergency Dental / Eye Injury Up to $ 300 Child Organized Sports Benefit ( Children Under the Age of 18 ) 25 % Increase to Child Benefits Annual Wellness Benefit for Employee & Covered Spouse $ 125 / Year * * Must Complete Annual Wellness Screenings or Porcedures Injury - Free Benefit - Automatically Pays $ 300 / 5 Years if no accident claims are filed for 5 Years ACCIDENT COVERAGE An unexpected accident can be a serious financial burden . The Guardian Accident Plan : pays benefits directly to you – for deductibles , copays , or anything else . Best of all , the cost can be offset : Guardian pays YOU and your SPOUSE $ 125 * each for a completed wellness exam . * Wellness Benefit covers screenings & procedures such as well visits , mammography , colonoscopy , pap smear , PSA , cholesterol tests , smoking cessation and weight reduction programs , and more . Payable once per calendar year for the covered employee and spouse . Annual Net Cost Monthly Premium Employee Only Annual Premium = $ 150 . 00 Annual Wellness Benefit = $ 125 . 00 * Net Annual Cost = $ 25 . 00 Employee + Spouse Annual Premium = $ 240 . 00 Annual Wellness Benefit = $ 250 . 00 * Net Annual Cost = ($ 10 . 00 ) Employee + Child ( ren ) Annual Premium = $ 258 . 00 Annual Wellness Benefit = $ 125 . 00 * Net Annual Cost = $ 133 . 00 Employee + Family Annual Premium = $ 348 . 00 Annual Wellness Benefit = $ 250 . 00 * Net Annual Cost = $ 98 . 00