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Total and permanent loss of sight in both eyes.

$100,000

Total and permanent loss of hearing in both ears.

$100,000

Loss of both hands at or above wrist.

$100,000

Loss of both feet at or above ankle.

$100,000

Quadriplegia.

$100,000

Hemiplegia.

$100,000

Paraplegia.

$100,000

3rd degree or worse burns, covering 30% of the body or 30% of the face.

$100,000

Loss of one hand at or above wrist and one foot at or above ankle.

$100,000

Loss of one hand at or above wrist and total and permanent loss of sight in one eye.

$100,000

Loss of one foot at or above ankle and total and permanent loss of sight in one eye.

$100,000

Total and permanent loss of speech and total and permanent loss of hearing in one ear

$75,000

Loss of one hand at or above wrist and total and permanent loss of speech.

$100,000

Loss of one hand at or above wrist and total and permanent loss of hearing in one ear.

$75,000

Loss of one hand at or above wrist and loss of thumb and index finger of other hand.

$100,000

Loss of one foot at or above ankle and total and permanent loss of speech.

$100,000

Loss of one foot at or above ankle and total and permanent loss of hearing in one ear.

$75,000

Loss of one foot at or above ankle and loss of thumb and index finger of same hand.

$100,000

Total and permanent loss of sight in one eye and total and permanent loss of speech.

$100,000

Total and permanent loss of sight in one eye and total and permanent loss of hearing in one ear.

$75,000

Total and permanent loss of sight in one eye and loss of thumb and index finger of same hand.

$100,000

Total and permanent loss of thumb of both hands, regardless of the loss of any other digits.

$100,000

Total and permanent loss of speech and loss of thumb and index finger of same hand.

$100,000

Total and permanent loss of hearing in one ear and loss of thumb and index finger of same hand.

$75,000

Loss of one hand at or above wrist and coma.

$50,000 for loss of hand

Loss of one foot at or above ankle and coma.

$50,000 for loss of foot

Total and permanent loss of speech and coma.

$50,000 for total and permanent loss of speech plus the amount paid for coma as noted in Item 37 of this schedule up to a combined maximum of $100,000.

Total and permanent loss of sight in one eye and coma.

$50,000 for total and permanent loss of sight in one eye plus the amount paid for coma as noted in Item 37 of this schedule up to a combined maximum of $100,000.

Total and permanent loss of hearing in one ear and coma.

$25,000 for total and permanent loss of hearing in one ear plus the amount paid for coma as noted in Item 37 of this schedule up to a combined maximum of $100,000.

Loss of thumb and index finger of same hand and coma.

$50,000 for loss of thumb and index finger of the same hand plus the amount paid for coma as noted in Item 37 of this schedule up to a combined maximum of $100,000.

Total and permanent loss of sight in one eye and inability to carry out activities of daily living due to traumatic brain injury.

$50,000 for loss of sight in one eye plus the amount paid for the inability to carry out activities of daily living due to traumatic brain injury as noted in Item 37 of this schedule up to a combined maximum of $100,000.

Loss of one hand at or above wrist and inability to carry out activities of daily living due to traumatic brain injury.

$50,000 for loss of hand plus the amount paid for the inability to carry out activities of daily living due to traumatic brain injury as noted in Item 37 of this schedule up to a combined maximum of $100,000.

Loss of one foot at or above ankle and inability to carry out activities of daily living due to traumatic brain injury.

$50,000 for loss of foot plus the amount paid for the inability to carry out activities of daily living due to traumatic brain injury as noted in Item 37 of this schedule up to a combined maximum of $100,000.

Loss of thumb and index finger of same hand and inability to carry out activities of daily living due to traumatic brain injury.

$50,000 for loss of thumb and index finger plus the amount paid for the inability to carry out activities of daily living due to traumatic brain injury as noted in Item 37 of this schedule up to a combined maximum of $100,000.

Total and permanent loss of hearing in one ear and inability to carry out activities of daily living due to traumatic brain injury.

$25,000 for total and permanent loss of hearing in one ear plus the amount paid for the inability to carry out activities of daily living due to traumatic brain injury as noted in Item 37 of this schedule up to a combined maximum of $100,000.

Total and permanent loss of speech and inability to carry out activities of daily living due to traumatic brain injury.

$50,000 for total and permanent loss of speech plus the amount paid for the inability to carry out activities of daily living due to traumatic brain injury as noted in Item 37of this schedule up to a combined maximum of $100,000.

Coma from traumatic injury and/or the inability to carry out activities of daily living due to traumatic brain injury.

Note 1: Benefits will not be paid under this schedule for concurrent conditions of coma and traumatic brain injury.

Note 2: Duration of coma includes the day of onset of the coma and the day when the member recovers from coma.

Note 3: Duration of the inability to carry out activities of daily living due to traumatic brain injury includes the day of the onset of the inability to carry out activities of daily living and the day the member once again can carry out activities of daily living.

At 15th consecutive day in a coma, and/or the inability to carry out activities of daily living - $25,000

At 30th consecutive day in a coma, and/or the inability to carry out activities of daily living - Additional $25,000

At 60th consecutive day in a coma, and/or the inability to carry out activities of daily living - Additional $25,000

At 90th consecutive day in a coma, and/or the inability to carry out activities of daily living - Additional $25,000

(Benefits can be paid for both conditions only if experienced consecutively, not concurrently.)

Total and permanent loss of speech.

$50,000

Loss of one hand at or above wrist.

$50,000

Loss of one foot at or above ankle.

$50,000

Total and permanent loss of sight in one eye.

$50,000

Loss of thumb and index finger of same hand.

$50,000

Total and permanent loss of hearing in one ear.

$25,000

The inability to carry out activities of daily living due to loss directly resulting from a traumatic injury other than an injury to the brain.

Note: Duration of the inability to carry out activities of daily living includes the day of onset of the inability to carry out activities of daily living and the day when the member can once again carry out activities of daily living.

At 30th consecutive day of the inability to carry out activities of daily living - $25,000

At 60th consecutive day of the inability to carry out of activities of daily living - Additional $25,000

At 90th consecutive day of the inability to carry out activities of daily living - Additional $25,000

At 120th consecutive day of the inability to carry out activities of daily living - Additional $25,000