R2004-163 AUTHORIZING APPLICATIONS FOR GROUP HEALTH INSURANCE COVERAGE

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� . ' . Item 4 AGGREGATE STOP LOSS,Continued (c) The Monthly Aggregate Deductible is determined monthly using the Monthly Aggregate Deductible Factors shown in 4(a) and multiplied by the number of Covered Units during each month, or part thereof,on a prorated basis. (d) Annual Aggregate Deductible Amount means the greater of the Minimum Annual Aggregate � Deductible or 12 times the Monthly Aggregate Deductible for the ninth month during the Coverage Year or the sum of the Monthly Aggregate Deductibles during the coverage Yeaz. (e) The Per Person Aggregate Maximum shall not exceed $ 2 0 0, o 0 0 (fl Reimbursement Factor: 10 0 % (g) Overall Company Limit of Liability-Maximum of $ 1, 0 0 0,o 0 0 (h) Premium Rates Payable for the Coverage Year Number of Covered Monthly Rate Per Premium Mode Deposit Premium Minimum Annual Units Employee Aggregate Premium 687 6.34 Monthly 4,355.58 52,267 (i) Run-in Maximum: None Item 5 SpecificPoliCyClaimBasis: Claims Incurred 11/O1/04 through 10/31/OS Paid by the Insured 11/O1/04 through 10/31/05 Coverage Includes: Medical Aggregate PoliCy Claim Basis: Claims Incurred 11/O1/04 through 10/31/05 Paid by the Insured 11/01/04 through 10/31/OS Coverage Includes: Medical Run-in Period: Specific o Aggregate o months prior to the Employer Effective Date. Run-out Period: Specific o Aggregate o months after the end of the Coverage Year. Item 6 Serious Loss Notice: Notify the Company within 30 days of the date claims reach 85% of the Aggregate Annual Deductible Amount and the date the claims for one individual reaches 50%of the Individual Stop Loss Amount and/or any claim which one has reason to believe as determined by a specific diagnosis and/or prognosis which would exceed the Individual Stop Loss Amount per Covered Person for Coverage Year. Item 7 Specified Excluded Charges:None Item 8 Minimum Participation Number 515 employees Item 9 Amendatory Endorsement(s)executed simultaneously herewith: Item 10 Claims Administrator: Consociate Group Item 11 Associated Companies of the Employer: Item 12 Drug and Alcohol Conditions: The maximum eligible reimbursement for drug and alcohol conditions excess of the Individual Stop Loss Amount per Covered Person for the Coverage Year is $ n/a,or the cunent benefit maximum under the Employee Benefit Plan,whichever is less. This is a Proposed Schedule of coverage, benefits and limits of liability for medical stop loss insurance, which is ef�'ective until 11/O 1/04 . The Coverage is subject to Definitions, Conditions, Limits,Exclusions and any other Policy Provisions,which are contained in the Policy. If there are any inconsistencies or ambiguities between the Proposed Schedule and the Policy,the Policy will govern. The Company reserves the right to change the Proposed Schedule if the underwriting information on which this Proposed Schedule is based is not accurate or if after the issuance of this Proposed Schedule there are material changes in the risk or exposure to the Company. Signature of Authorized Person: Printed Name of Authorized Person: C-� �'-��-rwa`� Title: C�� f�1,��h-- Signed at c tl ��d �S on ( '2 DD Witness: �--� (Licensed Resident Agent,where required) U-SL-D-100-A CW(1/97) Page 4 of 12