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1 SHELTERPONT Life nsurance Company Dental Rates for NY effective: 10/01/16-12/31/16 Type of Service Annual maximum deductible per person/family Annual Max/ Person Bene it evels Claim Allowance Preventive Basic J Preventive in-network $2/$7 waived waived waived waived waived waived waived waived Preventive out-of-network $2/$7 waived $100/$300 $100/$300 waived waived waived waived waived Basic and major in-network $2/$7 $0/$10 $0/$10 $0/$10 $0/$10 $0/$10 $0/$10 $0/$10 $0/$10 Basic and major out-of-network $2/$7 $0/$10 $100/$300 $100/$300 $0/$10 $0/$10 $0/$10 $0/$10 $0/$10 n-network $00 $00 $00 $1,000 $1,000 $1,000 $1,20 $1,00 $1,00 $2,000 Out-of-network $00 $00 $00 $1,000 $1,000 $1,000 $1,000 $1,000 $1,00 $2,000 n-network co-insurance 80/0/0 100/0/0 80/0/0 100/0/0 100/80/0 100/80/0 100/80/0 100/90/60 100/80/0 100/90/60 Out-of-network co-insurance 80/0/0 100/0/0 80/0/0 100/0/0 100/80/0 100/80/0 100/80/0 100/80/0 100/80/0 100/80/0 n-network Out-of-network Cleanings Routine exams Fluoride X-rays (bitewings) X-rays (all other) Sealants X-rays (all other) Sealants Space maintainers Fillings Resin restorations Basic repairs Nonsurgical endo/perio Surgical endo/perio Anesthesia Oral surgery Extractions Tests & lab exams Emergency treatment Professional consultation Major restorations (crowns) Dentures Fixed prosthodontics Major Major repairs mplants Orthodontia 0% up to $1,000 lifetime max/dep optional optional optional optional optional This brochure is for producer (agent and broker) use only. t is not intended for viewing by the general public. The information in this material is not intended as an offer of coverage.

2 Dental Rates for NY Upstate* effective: 10/01/16-12/31/16 *Albany, Allegany, Broome, Cattaraugus, Cayuga, Chautauqua, Chemung, Chenango, Clinton Columbia, Cortland, Delaware, Dutchess, Erie, Essex, Franklin, Fulton, Genesee, Greene, Hamilton, Herkimer, Jefferson, Lewis, Livingston, Madison, Monroe, Montgomery, Niagara, Oneida, Onondaga, Ontario, Orleans, Oswego, Otsego, Rensselaer, Saint Lawrence, Saratoga, Schenectady, Schoharie, Schuyler, Seneca, Steuben, Sullivan, Tioga, Tompkins, Ulster, Warren, Washington, Wayne, Wyoming, and Yates Counties Employer-Paid (Noncontributory) Rates Contributory Rates Voluntary Rates +SP +CH +SP+CH +SP +CH +SP+CH +SP +CH +SP+CH +SP +CH +SP+CH +SP +CH +SP+CH +SP +CH +SP+CH +SP +CH +SP+CH +SP +CH +SP+CH +SP +CH +SP+CH +SP +CH +SP+CH Additional J Ortho Cost NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

3 Dental Rates for NY Downstate* effective: 10/01/16-12/31/16 *NYC, NASSAU, & WESTCHESTER COUNTES Employer-Paid (Noncontributory) Rates Contributory Rates +SP +CH +SP+CH +SP +CH +SP+CH +SP +CH +SP+CH +SP +CH +SP+CH +SP +CH +SP+CH +SP +CH +SP+CH +SP +CH +SP+CH +SP +CH +SP+CH Additional J Ortho Cost NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA Voluntary Rates +SP +CH +SP+CH +SP +CH +SP+CH NA NA NA NA

4 Dental Rates for NY Downstate* effective: 10/01/16-12/31/16 *SUFFOLK, ROCKLAND, ORANGE, & PUTNAM COUNTES Employer-Paid (Noncontributory) Rates Contributory Rates +SP +CH +SP+CH +SP +CH +SP+CH +SP +CH +SP+CH +SP +CH +SP+CH +SP +CH +SP+CH +SP +CH +SP+CH +SP +CH +SP+CH +SP +CH +SP+CH Additional J Ortho Cost NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA Voluntary Rates +SP +CH +SP+CH +SP +CH +SP+CH NA NA NA NA

5 Underwriting Requirements Noncontributory groups: For groups of 2+ eligible employees. 100% participation of eligible employees is required at all times. don t contribute (employer pays 100% of the premium for all eligible employees). Noncontributory rates still apply if the employer requires employee contribution for dependent buy-up. Groups of lives must have prior (existing) dental coverage to qualify (evidence of prior dental coverage is required). Contributory groups: For groups of 2+ eligible employees. Participation: Number of eligible employees: Min. participation at all times: 2 to to % % Voluntary groups: For groups of 6+ eligible employees. Groups of eligible employees: at least 6 employees must participate at all times. Groups of 2+ eligible employees: at least 2% of eligible employees must participate at all times. Groups must be less than 0% family related. Quote now at: Visit our website to use our online quoting system for groups of 9. Compare plan options that fit your clients criteria, compare rates, generate attractive quote presentations for your clients, save your quote, and auto-populate the online application with your saved quote data. For groups of 0+ please contact your Sales Rep. Please Note: Groups of participating employees without prior (existing) coverage and Voluntary groups of any size without prior (existing) coverage must be submitted to the Underwriting Department. For all groups, late entrants have preventive benefits available immediately but must wait 6 months for basic benefits, 12 months for major benefits and 24 months for orthodontia, if applicable. f there is an average of four (4) or more children per dependent unit, the group must be referred to the Underwriting Department. Optional Orthodontia coverage is not available to any group where an average of four (4) or more children per dependent unit exists. This is a partial listing of benefits only. Ortho is only available on specified plans and requires at least + enrolled eligible employees. Please refer to the policy for details. Rates for new business are governed by the effective date and change quarterly. Not available in all jurisdictions. Policy may not be available in all counties of an approved state. These rates do not apply to groups of participating employees without prior (existing) coverage or Voluntary groups of any size without prior (existing) coverage. Please submit to the Underwriting Department. These rates do not apply to employers in the following industries (SC codes): 7920, 7922, 7929, 7941, 7948, 8021, 8072, Negotiated benefits are paid based on the for each procedure, which is the, discounted fee of participating DenteMax network providers. R&C (Reasonable & Customary) benefits are paid on average at the 90th percentile of the R&C charges for the geographic area where the Dental service is performed. Respective co-insurance percentages and deductibles may apply. with other dental coverage who have a signed waiver do not count toward the number of eligible employees. Only full-time employees working at least 30 hours per week are eligible. M#16-48 G1 02/ sales@shelterpoint.com facebook.com/shelterpointgroup

6 Exclusions & Limitations No benefits are payable except as stated in the Policy and Certificate. Alternate Benefit and Pre-treatment Estimates Your dental plan provides that where two or more professionally acceptable dental treatments for a dental condition exist, your plan bases reimbursement on the least costly treatment alternative. f you and your dentist agreed on a treatment which is more costly than the treatment on which the plan benefits is based, you will be responsible for the difference between the fee for service rendered and the fee covered by the plan. n addition, a pre-treatment estimate is required for any service estimated to cost over $00. Please consult your dentist. Policy Exclusions A. Cosmetic Services - We do not cover cosmetic services, prescription drugs, or surgery, unless otherwise specified, except that cosmetic surgery shall not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered child which has resulted in a functional defect. Cosmetic surgery does not include surgery determined to be medically necessary. f a claim for a procedure listed in 11NYCRR 6 (e.g., certain plastic surgery and dermatology procedures) is submitted retrospectively and without medical information, any denial will not be subject to the Utilization Review process in the Utilization Review and External Appeal sections of the Certificate unless medical information is submitted. B. Experimental or nvestigational Treatment - We do not cover any health care service, procedure, treatment, or device that is experimental or investigational. However, we will cover experimental or investigational treatments, including treatment for the insured s rare disease or patient costs for his participation in a clinical trial, when our denial of services is overturned by an External Appeal Agent certified by the State. However, for clinical trials, we will not cover the costs of any investigational drugs or devices, non-health services required for the nsured to receive the treatment, the costs of managing the research, or costs that would not be covered under the Certificate for non-investigational treatments. See Utilization Review and External Appeal Section of the Certificate for further explanation of the nsured s Appeal rights. C. Felony Participation - We do not cover any illness, treatment or medical condition due to the nsured s participation in a felony, riot or insurrection. This exclusion does not apply to coverage for services involving injuries suffered by a victim of an act of domestic violence or for services as a result of the insured s medical condition (including both physical and mental health conditions). D. Government Facility - We do not cover care or treatment provided in a hospital that is owned or operated by any federal, state or other governmental entity, except as otherwise required by law. E. Medicare or Other Governmental Program - We do not cover services if benefits are provided for such services under the federal Medicare program or other governmental program (except Medicaid). F. Medical Services - We do not cover medical services or dental services that are medical in nature, including any hospital charges or prescription drug charges. G. Medically Necessary - n general, we will not cover any dental service, procedure, treatment, test or device that we determine is not medically necessary. f an External Appeal Agent certified by the State overturns our denial, however, we will cover the service, procedure, treatment, test or device for which coverage has been denied, to the extent that such service, procedure, treatment, test or device, is otherwise covered under the terms of the Certificate. H. Military Service - We do not cover an illness, treatment or medical condition due to service in the Armed Forces or auxiliary units.. Self-inflicted njury - We will not cover an illness, treatment or medical condition due to intentionally self-inflicted injury. J. Services not listed - We do not cover services that are not listed in the Certificate as being covered. K. Services provided by a Family Member - We do not cover services performed by a member of the covered person s immediate family. mmediate family shall mean a child, spouse, mother, father, sister or brother of you or your spouse. L. Services with No Charge - We do not cover services for which no charge is normally made. M. War - We will not cover an illness, treatment or medical condition due to war, declared or undeclared. N. Workers Compensation - We do not cover services if benefits for such services are provided under any state or federal Workers Compensation, employers liability or occupational disease law. The information in this material is for illustrative purposes only, providing a general overview of featured benefit highlights provided under the policy. t is not a contract. n the event of conflicting information with the policy/certificate, the policy/certificate will take precedence over what is shown in this material. The policy described in this material covers Dental benefits only. All coverage extends up to policy limits. Policies are reviewed annually and may be cancelled for nonpayment. Please refer to the policy for coverage details, a complete listing of covered services, policy provisions, conditions, exclusions, and terms under which the policy may be continued or cancelled. Not available in all jurisdictions. ShelterPoint is a registered Service Mark. All images licensed through istockphoto. Policy available in and underwritten by: ShelterPoint Life nsurance Company (principal office in Great Neck, NY) in: M (SPL GD021 P M), NY (SPL GD11 P NY). ShelterPoint nsurance Company (licensed in 48 jurisdictions, not including NY) in: AL (SP GD021 P AL), AZ (SP GD021 P AZ), AR (SP GD021 P AR), CO (SP GD021 P CO), CT (SP GD021 P CT), DC (SP GD021 P DC), DE (SP GD021 P DE), FL (SP GD021 P FL), GA (SP GD021 P GA), A (SP GD021 P A), D (SP GD021 P D), L (SP GD021 P L), N (SP GD021 P N), KS (SP GD021 P KS), KY (SP GD021 P KY), LA (SP GD021 P LA), MO (SP GD021 P MO), MS (SP GD021 P MS), ND (SP GD021 P ND), NJ (SP GD021 P NJ), NE (GD021 P NE), NM (SP GD021 P NM), NV (SP GD021 P NV), OH (SP GD021 P OH), OK (SP GD021 P OK), OR (SP GD021 SP OR), PA (SP GD021 P PA), R (SP GD021 P R), SC (SP GD021 P SC), TN (SP GD021 P TN), TX (SP GD021 P TX), UT (SP GD021 P UT), VT (SP GD021 P VT), WV (SP GD021 P WV), W (SP GD021 P W), WY (SP GD021 P WY). For the most updated list of available states, please visit our website ( This brochure only applies to NY. M# G2 3/16 sales@shelterpoint.com ( ) sheltering you facebook.com/shelterpointgroup