Examples of out-of-pocket expenses are:

• Co-payments
• Deductibles
• Co-Insurance
• Other out-of-pocket amounts left after the major medical plan has paid.

Additional Features:

• Benefits are paid regardless of other insurance you may have with other insurance companies.
• Benefits are paid directly to you unless you specify otherwise.
• Your coverage is portable. If you change jobs or leave your employer you can take your coverage with you.
• Your coverage is guaranteed renewable for life as long as premiums are paid when they are due.**
• Coverage is available for you, your spouse and your family.

Plan Features

This plan is flexible, allowing you to choose coverage that best meets your needs. Four different coverage options are available for you and your family.

• Coverage for you (the employee)
• Coverage for you and your spouse
• Coverage for you and your dependent children
• Coverage for you, your spouse, and your dependent children

Nearly 24% of insured families spend $2,000 or more out-of-pocket in their health care in a year (including their share of health care premiums)⁺.

This plan provides coverage for:

• Hospital Confinement
• Outpatient Surgery

Hospital Confinement

We will pay this benefit when an insured person is confined to a hospital due to injuries received in a covered accident or due to a covered sickness. This benefit is paid once for each period of confinement to a hospital.

Outpatient Surgery

We will pay up to the maximum benefit amount selected, with a minimum benefit of $250, when:

• An insured person requires a surgical procedure due to a covered accident or covered sickness and is not confined to a hospital at the time of surgery.
• Outpatient surgical procedures are performed by a doctor using anesthesia administered by a licensed anesthesiologist, or a licensed nurse anesthetist, in a hospital or ambulatory surgical center.

How to calculate this benefit:

Dollar Amount Per Unit ($50) x Surgical Unit Value = Benefit Amount (up to the maximum per plan level)

Here are some examples of the benefit we would pay for commonly performed procedures. These are only examples. Remember, there's a minimum benefit payment of $250 and the maximum payment is the benefit level you choose.

Read your policy carefully. Your outline provides a very brief description of the important features of your policy. This is not an insurance contract and only the actual policy provisions will control. The policy sets forth in detail the rights and obligations of both you and us. It is, therefore, important that you READ YOUR POLICY CAREFULLY. Renewability. Your policy is guaranteed renewable. The premium can be changed only if we change it on all policies of this kind in force in the state where the policy was issued. Limited Benefit Coverage. Your policy is designed to provide coverage ONLY for losses that result from covered accidents or sicknesses. It does not provide coverage for basic hospital, basic medical-surgical or major medical expenses.

Hospital Confinement Benefit: $________________ per covered confinement

We will pay the amount shown on the Policy Schedule when any covered person is confined due to injuries received in a covered accident or due to a covered sickness while the policy is in force. We will pay this benefit once per confinement. If the covered person is confined and is discharged and he is confined again for the same or related condition within 90 days, we will treat this confinement as a continuation of the previous confinement. If more than 90 days have passed between the periods of hospital confinement, we will treat this confinement as a new and separate confinement.

Outpatient Surgery Benefit: $________________per covered surgery

We will pay the amount shown on the Policy Schedule when any covered person requires a surgical procedure due to a covered accident or covered sickness, and he is not confined at the time of the surgery. The procedure must be performed by a doctor using anesthesia administered by a licensed anesthesiologist or licensed nurse anesthetist and performed in a hospital or ambulatory surgical center. We will pay this benefit once per covered outpatient surgical procedure. We will pay this benefit for only one outpatient surgical procedure performed at the same time, even if caused by more than one injury or sickness. The surgical procedure must occur while this policy is in force. We will pay for only one surgery for the same covered accident or covered sickness in a 90-day time period. If a covered person receives a subsequent surgery for the same covered accident or same covered sickness, we will pay an additional benefit only if the subsequent surgery was performed more than 90 days after the last covered surgery was performed. If any covered person has an outpatient surgical procedure and is confined as a result of complications from the surgery within 90 days following the surgery, we will: (1) Pay only the Hospital Confinement Benefit; and (2) Not pay the Outpatient Surgery Benefit. If we have already paid the Outpatient Surgery Benefit, we will deduct the Outpatient Surgery Benefit amount paid from any Hospital Confinement Benefit that is payable.

Definitions:

Accident means bodily harm caused by external and unexpected means and not contributed to by any other cause. Ambulatory Surgical Center means a place equipped for surgical procedures performed by qualified physicians, which provides anesthesia administered by a licensed anesthesiologist or nurse anesthetist and which has written agreements with local hospitals to immediately accept patients who develop complications. Confined or Confinement means the assignment to a bed as a resident inpatient in a hospital on the advice of a physician or confinement in an observation unit within a hospital for a period of no less than 20 continuous hours on the advice of a physician. Covered Accident means an accident which occurs after the effective date of the policy, occurs while the policy is in force, and is not excluded by name or specific description in the policy. Covered Sickness means an illness, infection, disease or any other abnormal physical condition, not caused by an accident, which occurs after the effective date of the policy, occurs while the policy is in force, and is not excluded by name or specific description in the policy. A covered sickness also includes pregnancy or complications of pregnancy of a covered spouse or named insured. Dependent Children means any natural children, step-children, legally adopted children or children placed into your custody for adoption who are: (1) Unmarried; (2) Chiefly dependent in you or your spouse for support; (3) Living with you in a regular parent-child relationship, and (4) Younger than age 25. Doctor or Physician means a person, other than you or a family member who is licensed by the state to practice a healing art and performs services for a covered person which are allowed by his license. Family member means a covered person's spouse, son, daughter, mother, father, sister or brother. Emergency Room means a specified area within a hospital which is designated for the emergency care of accidental injuries or sicknesses. This area must be staffed and equipped to handle trauma, be supervised and provide treatment by physicians and provide care seven days per week, 24 hours per day. Hospital means a place that is run according to law on a full-time basis, provides overnight care of injured and sick people, is supervised by a doctor, has full-time nurses supervised by a registered nurse, and has at its location or uses on a pre-arranged basis: X-Ray equipment, a laboratory and an operating room where surgical operations take place. A hospital is not a nursing home, an extended care facility, a skilled nursing facility, a rest home or home for the aged, a rehabilitation center or a place for alcoholics or drug addicts. Observation Unit is a specified area within a hospital, apart from the emergency room, where a patient can be monitored following outpatient surgery or treatment in the emergency room by a physician and which is under the direct supervision of a physician or registered nurse, is staffed by nurses assigned specifically to that unit and provides care seven days per week, 24 hours per day. Pre-existing Condition means any covered person having a sickness or physical condition for which he was treated, had medical testing, received medical advice or had taken medication within 12 months before the effective date of the policy.

What is Not Covered

We will not pay benefits for injuries received in accidents or sicknesses which are caused by: 1. Any covered person's addiction to alcohol or drugs, except for drugs taken as prescribed by his doctor. 2. Any covered person giving birth within the first nine months after the effective date of this policy as a result of normal pregnancy, including Cesarean. Complications of pregnancy will be covered to the same extent as any other covered sickness. 3. Any covered person's treatment for dental care or dental procedures, unless treatment is the result of a covered accident.4. Any covered person undergoing elective procedures or cosmetic surgery. This includes procedures or hospital confinement for complications arising from elective or cosmetic surgery. This does not include congenital birth defects or anomalies of a child or reconstructive surgery related to a covered sickness or injuries received in a covered accident. 5. Any covered person participating or attempting to participate in an illegal activity. 6. Any covered person having a pre-existing condition as described and limited by the policy. We will not pay benefits for a hospital confinement or an outpatient surgery resulting from a pre-existing condition that began during the first twelve months after the effective date of the policy. 7. Any pregnancy of a dependent child, including services rendered to her child after birth. However, complications of pregnancy of a dependent child will be covered to the same extent as any other covered sickness. 8. Any covered person having a psychiatric or psychological condition including but not limited to affective disorders, neuroses, anxiety, stress and adjustment reactions. However, Alzheimer's Disease and other organic senile dementias are covered under this policy. 9. Any covered person committing or trying to commit suicide or injuring himself intentionally, whether he is sane or not. 10. Any covered person's involvement in any period of armed conflict, even if it is undeclared. 11. Any covered person having routine well care, treatment of examinations including, but not limited to; a newborn child following birth.

_{*2001 AHA Annual Survey; Henry J. Kaiser Family Foundation State Health Facts}

_{**Please refer to the "Renewability" section on the Outline of Coverage}

_{⁺"Underinsured in America: Is Health Coverage Adequate?" Kaiser Commission on Key Facts, Publications, July 2002.}