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.dun 22 217 D4 3:30PM HP Lf~SER.7ET 3330 <br />OS-a;-EQ04 a2;38pn From-GU1lRDlAry REGIONpI. GRDUP OFFICE <br />2~6-ea7-1912 T-e 68 P.DDZ/DDd F-Be6 <br />'7'7At+GauEitn Life[nsuranccCotnpsnyafno~iao <br />G Ufi R D f A f~I" 7 Fl-aorcr st,vt~, nra. York WY 1a0oa <br />.SCH.E.iDIJL,+E OF ~~NE.FITSr - .U.L'N'~',4.L .BENEFIT <br />FMSDCC7 lnf prAr a[iaar . <br />Prasp~cr Ivs-ne: Mayfield Yi11Qgt: I <br />i~tx: S] <br />CasCNo: <br />Ptiaposal No: 6K <br />) . <br />S1C: q J l ~ <br /> <br />PropPosal Rate <br />5/6(1004 Sttuc s;adr: <br />QPAae: OK <br />Clevelon0 <br />Vo1id Vniit: <br />P1na No: 8/3l7.pDd <br />) ~/ake/Aesnr (.rmce dt Co. <br /> 8a1rs Atop: Eric Sp1cRc <br />~entgiGua rd <br />SeQ~f!!!Ld .117 Blig~ble Employers <br />t7aeml~warrd r'rrferrs~B in Olio <br />PPO P1prt Type - W 7 <br />~cligdwBc nPBcne1,rx <br />52 rmp)ayeos <br />y~vvauvY <br />p.2 <br /> In~Vrnmrk pyt,. p jN,~,,,,o~ <br />CarcaderYea-$cducrShlc SSD 550 <br />J.n~us1 Myclmum S I,S00 S 1 <br />500 <br />Preventive and 131e~teosrie Scrvi~ 1QDSo , <br />J OOYu <br />Basic Services IOOY. Ay0°i5 <br />N)~for services 6Q5G S09's <br />DMuciible Waive,! Pre~on4ve Sotviner lr[eweneivs Se:viers <br /> <br />Schederfes Fdafturas <br />Child ot'diodomi. it: oovetY:d ac SDit. to o asruc)mrun of5_OOD fas bodA ia-aetwork n1Q nur.of-rietvrork honeC-ts coIDbinod. <br />The deSucriblc Boat not nQytey to Orrbodontin. <br />Chita afVAOtloe7ti>• is covered Tithe ocova ozAl7odo7IIiC opplfarieefs placed belhte d,e child reaehce qge 19. For all other <br />drawl Oanaftts; children ttra eoverop ap ro t'he age 2p or w taro 36 if iWJ-time studs ac. <br />Thtre individual deduextblr3 pax fiassUy. 7f IUrec lelrrlily manberspvy the aaeh desda6aa-~te in a colrndoryear the derloe:tibk <br />for al(adtcr ine7ucd lsrnlJy mGtnbo~ ew:ll be waived !br the rasa oCOrt: ycnr. A two deducsiLl~ pcr.fwmily limit in also <br />rvnileblc. <br />No dcioftod aetriecs 4ave been sclecooa. <br />ScAetlRNe E7t'c/aArions . <br />Fxetpt.as eviplained ia'~teylrecmene plot(, we do otsipsy fOf • 1pt'asmetit Cevit:e repfaclnp rceth tout bdbre a coact>:d peraoo <br />Eeeom<lnaured fbr fiie p17,n. Hut wp will pry Par a device to itiplaeo tbe:rc recth it it also rapt Haas reot711oce oz rseraeted <br />,(bile the ceveird pereota is irasAtred by i7Ais plip, <br />We donotpr,Y farcmbeieE eat appliaae7s arpaost-Aatic'deviec wlrh s lflce appliwr[e vraaytoppliaaee or pawitAeoie deviee~ <br />urn ,o t: (>.) it is ar la-gr ran years old erld t7~a's'bt glade usable, or (b) h !s damage d while in $Ar eom~ed pcrson5s mouth is <br />Jury sulii:rea while msttrrd sad easel: be /ixetL <br />we po Act paey fasgeneraf anestLesi,,lar+7AbtndCNlgraad0tion, ihtrnl+enoOS scdarian, noD-init7iv4tyou3 Seflatiaal ar inlnlhien <br />sreetlna, inrtnding bwtwt IimizeJ tea niua7ta axial except wham odpti)adsrero0 ita t Onjut:[iem wleh coveted paiodonral <br />surgery, sttsglci! cxa~oos, the at7tglesl removal rsf'impacrcd remh, apievacswrAUa9r soar atttpuladons oati'thho Oral <br />3aapcsl •pausadotrs ~s da6nccl by73ae cnnt7au; total anlrsrhetio i! billed at: a zeptrote proccelwe <br />t-d <br />I - • ~ ~ ~ ~ ~ ~ EXHIBIT <br />d9tr rfr~ fr~ SZ unr <br />