$3,000,000 $250 $250 $250 $500 $500 $500. Deductible for Family is two (2) times the chosen indivudal deductible. $1,000 $1,000 $1,000

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1 Penalties to the benefits payable under this policy may apply if the requirements are not met. Please refer to the section labeled Pre Certification of Services for a more detailed description. You must contact the pre certification provider number listed on your identification card. In patient hospitalization Home Health Care Organ Transplant Emergency Air Ambulance Cardiac Care Emergency Transportation of a Family Member Repatriation of Mortal Remains Evacuation Oncology Treatment/ Radiation and Chemotherapy Inpatient and Outpatient Failure to perform the pre certification requirements within a minimum of 72 hours in advance of a non emergency service or within 48 hours of an emergency service will result in a penalty of 30% of the allowable charge for the entire episode of care. This out of pocket and co insurance amount will not be applied towards your defined limit shown on your Certificate of Coverage. $3,000,000 80% 50% $250 $250 $250 Deductible for Family is two (2) times the chosen indivudal deductible. $500 $500 $500 $1,000 $1,000 $1,000 $2,500 $2,500 $2,500 Family Maxium out of pocket for Family is two (2) times the chosen indivudal out of pocket. $0 $1,000 Unlimited After the Deductible, all benefits under this policy outside of the United States are payable atof UCR. Benefits within the United States within the network are subject to twenty (20%) coinsurance for the first $5,000 of covered expenses up to an out of pocket limit per covered person, per policy year. 30 days All Benefits are Subject to Usual, Customary and Reasonable Charges [UCR]. All benefits are subject to the deductible first, unless otherwise specified. All amounts are in USD. IN PATIENT BENEFITS Payable up to 365 days per policy year Limited to semi private accomodations 80% 50% Including but limited to X rays, drugs, bandages, operating rooms fees. 80% 50% Payable up to 365 days per policy year 12 month waiting period. Policy Year Maximum: $10,000 Maximum Lifetime: $50,000 80% 50% Assistant Surgeon20% of the Primary y Surgeon Approved Fees Anesthesiologist30% of the Primary y Surgeon Approved Fees 80% 50%

2 Limited to one visit per day per specialty 80% 50% Care must begin upon discharge from a hospital confinement of no less than 3 days. 30 days Max per Policy Year. 80% 50% To accompany a hospitalized minor child under the age of 18 Limited to $50 up to 10 days per policy year 80% 50% Including Primary Surgeon 80% 50% Covered for devices, which are an integral part of a surgical procedure when medically necessary 80% 50% The covered Transplants are: Heart, Lung, Kidney, Pancreas, Liver, Cornea Bone Marrow, Transplants are covered only for approved diagnoses; Aplastic anemia, Severe immune deciency, Hodgkins disease, acute and chronic Myelogeneous, Granulocytic Ileukenia, multiple Myeloma Limited to $1,000,000 lifetime per organ (up to 3 organs) 80% Not covered Benefit is subject to 10 month waiting period Normal Delivery/Elective C SectionIncludes all cost associated including but not limited to hospital fees for mother,newborn, obstetrician fees or midwife, childbirth, prenatal and postnatal care. Max Benefit$5,000 per policy year / per pregnancy 80% 50% Medical necessary cesarean, all cost associated including hospital fees for mother and newborn, obstetrician fees,prenatal and postnatal care: physician must submit complete medical records for review of Medical Necessity. Limited to $7,500 per pregnancy/ per policy year Lifetime Maximum Benefit combined with Maternity Care: $50,000 80% 50% Premature newborns, congenital conditions and birth anomaliesfor newborns enrolled within 31 days from the date of birth. Limited to $250,000 Lifetime Maximum 80% 50% OUT PATIENTBENEFITS Including Primary Surgeon Fees 80% 50% Assistant Surgeon20% of the Primary y Surgeon Approved Fees Anesthesiologist30% of the Primary y Surgeon Approved Fees

3 Limited to one visit per day per specialty 80% 50% With the pre approval of the Claims Administrator. 80% 50% Including but not limited to chemotherapy, antibiotic therapy, human growth hormone, pain management, aerosol therapies, transfusions, IV Gamma Globulin, Epogen and Neupogen, total parenteral nutrition, enteral nutrition. 80% 50% Chemotherapy and Radiation treatment. 80% 50% Including but limited to Echocardiography, Ultrasound CAT Scan, PET Scan.MRI, Endoscopy, (e.g., gastroscopy, colonoscopy, cytoscopy), X rays, laboratory 80% 50% Care must begin upon discharge from a hospital confinement of no less than 3 days. 30 days Max per Policy Year. 80% 50% Limited to treatment resulting from surgery or illness. Treatment plan must be provided to include length of time and the number of treatments weekly. Speech therapy covered for restoration of lost function only. Limited to $50 per visit. 80% 50% Limited to 30 days per policy year 12 month waiting period 80% 50% Limited to $75 per visit. Max 20 visits per policy year 80% 50% Subject to $250 USD co payment per visit, if not admitted as as patient. This co payment does not count towards your Policy Year Deductible or Co Insurance. Plan coinsurance and Deductible will apply whithin the 48 hours of injury or medical emergency. 80% 50% Limited to 180 days lifetime Limited to30 days per policy year 80% 50% 80% 50% Coverage is provided for treatment necessary to restore or replace sound natural teeth, damaged or lost as a consequence of a covered accident when treatment is received in a hospital emergency room or while confined in a hospital, provided that it takes place within the first 90 days. 80% 50% Maximum benefit $100 80% 50%

4 Limited to $3,000 per policy year Limited to $3,000 per policy year $15,000 Lifetime Maximum Includes organ harvesting, acquisition, transportation and living transplant donor Limited to $10,000 per transplant 80% 50% Due to a covered injury or illnesssustained under the plan.surgery must be performed within the specified timeframe as per the terms and conditions of policy wording. 80% 50% Limited to $300 per policy year ADDITIONAL BENEFITS 1 to 18 years of age. Bene ts are provided for routine physical exams including o ce visit, routine blood, urinalysis and immunizations. Limited to $200 per policy year. Born under this plan to 1 year of age. Bene ts are provided for routine physical exams including o ce visit, routine blood, urinalysis and immunizations. Limited to $200 per policy year. 80% 50% Limited to $20,000 per policy year 80% 50% Limited to one trip to the nearest hospital. 80% 50% ALTERNATIVE MEDICINE 80% up to $150 per policy year maximum 80% up to $50 per policy year maximum 80% up to $50 per policy year maximum 80% up to $150 per policy year maximum 80% up to $100 per policy year maximum

5 EMERGENCY ASSISTANCE Pre certification must be coordinated as defined in the policy. Failure to pre certify and gain approval will result in no coverage. Transportation for the covered member will be provided to the nearest hospital or medical facility equipped to treat the injury, illness or medical emergency. Deductible waived Limited to $25,000 Lifetime Max for local burial in Lieu of repatriation. Deductible waived Limited to $10,000 lifetime maximum The benefits, coverage, and exclusions, listed herein are only a summary and are subject to the specific terms and conditions of the plan concerning eligible benefits, limitations,eligibility, and exclusions. Please refer to your Policy Wording for specific terms, conditions and other details concerning your benefits, limitations, eligibility, and exclusions.

6 Penalties to the benefits payable under this policy may apply if the requirements are not met. Please refer to the section labeled Pre Certification of Services for a more detailed description. You must contact the pre certification provider number listed on your identification card. In patient hospitalization Home Health Care Organ Transplant Emergency Air Ambulance Cardiac Care Emergency Transportation of a Family Member Repatriation of Mortal Remains Evacuation Oncology Treatment/ Radiation and Chemotherapy Inpatient and Outpatient Failure to perform the pre certification requirements within a minimum of 72 hours in advance of a non emergency service or within 48 hours of an emergency service will result in a penalty of 30% of the allowable charge for the entire episode of care. This out of pocket and co insurance amount will not be applied towards your defined limit shown on your Certificate of Coverage. $3,000,000 $250 Individual / Family Deductible for Family is two (2) times the chosen indivudal deductible. $500 $1,000 $2,500 Family Maxium out of pocket for Family is two (2) times the chosen indivudal out of pocket. $0 After the Deductible, all benefits under this policy outside of the United States are payable atof UCR. 30 days All Benefits are Subject to Usual, Customary and Reasonable Charges [UCR]. All benefits are subject to the deductible first, unless otherwise specified. All amounts are in USD. IN PATIENT BENEFITS Payable up to 365 days per policy year Limited to semi private accomodations Including but limited to X rays, drugs, bandages, operating rooms fees. Payable up to 365 days per policy year Assistant Surgeon20% of the Primary y Surgeon Approved Fees Anesthesiologist30% of the Primary y Surgeon Approved Fees

7 12 month waiting period. Policy Year Maximum: $10,000 Maximum Lifetime: $50,000 Limited to one visit per day per specialty Care must begin upon discharge from a hospital confinement of no less than 3 days. 30 days Max per Policy Year. To accompany a hospitalized minor child under the age of 18 Limited to $50 up to 10 days per policy year Including Primary Surgeon Covered for devices, which are an integral part of a surgical procedure when medically necessary The covered Transplants are: Heart, Lung, Kidney, Pancreas, Liver, Cornea Bone Marrow, Transplants are covered only for approved diagnoses; Aplastic anemia, Severe immune deciency, Hodgkins disease, acute and chronic Myelogeneous, Granulocytic Ileukenia, multiple Myeloma Limited to $1,000,000 lifetime per organ (up to 3 organs) Benefit is subject to a 12 month waiting period. Normal Delivery/Elective C SectionIncludes all cost associated including but not limited to hospital fees for mother,newborn, obstetrician fees or midwife, childbirth, prenatal and postnatal care. Max Benefit$5,000 per policy year / per pregnancy Medical necessary cesarean, all cost associated including hospital fees for mother and newborn, obstetrician fees,prenatal and postnatal care: physician must submit complete medical records for review of Medical Necessity. Limited to $7,500 per pregnancy/ per policy year Lifetime Maximum Benefit combined with Maternity Care: $50,000 Premature newborns, congenital conditions and birth anomalies for newborns enrolled within 31 days from the date of birth. Limited to $250,000 Lifetime Maximum Including Primary Surgeon Fees Benefit is subject to 10 month waiting period OUT PATIENTBENEFITS

8 Assistant Surgeon20% of the Primary y Surgeon Approved Fees Anesthesiologist30% of the Primary y Surgeon Approved Fees Limited to one visit per day per specialty With the pre approval of the Claims Administrator. Including but not limited to chemotherapy, antibiotic therapy, human growth hormone, pain management, aerosol therapies, transfusions, IV Gamma Globulin, Epogen and Neupogen, total parenteral nutrition, enteral nutrition. Chemotherapy and Radiation treatment. Including but limited to Echocardiography, Ultrasound CAT Scan, PET Scan.MRI, Endoscopy, (e.g., gastroscopy, colonoscopy, cytoscopy), X rays, laboratory Care must begin upon discharge from a hospital confinement of no less than 3 days. 30 days Max per Policy Year. Limited to treatment resulting from surgery or illness. Treatment plan must be provided to include length of time and the number of treatments weekly. Speech therapy covered for restoration of lost function only. Limited to $50 per visit. Limited to 30 days per policy year 12 month waiting period Limited to $75 per visit. Max 20 visits per policy year Limited to 180 days lifetime Limited to30 days per policy year Coverage is provided for treatment necessary to restore or replace sound natural teeth, damaged or lost as a consequence of a covered accident when treatment is received in a hospital emergency room or while confined in a hospital, provided that it takes place within the first 90 days. Maximum benefit $100

9 Limited to $3,000 per policy year Limited to $3,000 per policy year $15,000 Lifetime Maximum Includes organ harvesting, acquisition, transportation and living transplant donor Limited to $10,000 per transplant Due to a covered injury or illnesssustained under the plan. Surgery must be performed within the specified timeframe as per the terms and conditions of policy wording. Limited to $300 per policy year 1 to 18 years of age. Bene ts are provided for routine physical exams including o ce visit, routine blood, urinalysis and immunizations. Limited to $200 per policy year. Born under this plan to 1 year of age. Bene ts are provided for routine physical exams including o ce visit, routine blood, urinalysis and immunizations. Limited to $200 per policy year. Limited to $20,000 per policy year Limited to one trip to the nearest hospital. 80% up to $150 per policy year maximum 80% up to $50 per policy year maximum 80% up to $50 per policy year maximum 80% up to $150 per policy year maximum ADDITIONAL BENEFITS ALTERNATIVE MEDICINE

10 80% up to $100 per policy year maximum EMERGENCY ASSISTANCE Pre certification must be coordinated as definedin the policy. Failure to pre certify and gain approval will result in no coverage. Transportation for the covered member will be provided to the nearest hospital or medical facility equipped to treat the injury, illness or medical emergency. Deductible waived Limited to $25,000 Lifetime Max for local burial in Lieu of repatriation Deductible waived Limited to $10,000 lifetime maximum The benefits, coverage, and exclusions, listed herein are only a summary and are subject to the specific terms and conditions of the plan concerning eligible benefits, limitations,eligibility, and exclusions. Please refer to your Policy Wording for specific terms, conditions and other details concerning your benefits, limitations, eligibility, and exclusions.