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03110/99 16:35 FAX PHIL BRETT <br />®3103/1999 @8:10 44@7775638 FORTIS <br />F®rtis ®encfir~ Insurance ~®rnpany <br />24957 Coa~ntry Glub Blvd, Suite 330, North dlmst®tl, OH 44070 <br />(440)777-3170 (840)472-0678 FAX; {4777-561 S <br />~I~~OSED PLAN ®@SIGRI ~1~YIf+1G ®EDUCTIBLES RIND COIt~SU~1NCE5: <br />~ LAW DIR ~ 009 <br />PAGE 03 <br />.® <br />.arm=~• <br />d? ~ ~~ • <br />~~ <br />F~RTIS~' <br />Monthly <br /> EE ~ Premium <br />59500131500 Annual Maximum <br />$2S 4Vaived,100/90/60 525 Combined, iOpl8o/50 22.70 36.135 2132.43 <br />$251'Vaived, 4001®0150 $50 Combined, 80!60140 16.55 25.79 1520.42 <br />$50 LVeived, 100/90/60 $50 Combined,100l130/50 19.64 30.7x3 1809.69 <br />$50 4VSived,100/80/50 $50 Combined, 80/60140 16.10 24.81 1470.35 <br />Wife $10001$750 Ortho ' Lifetime Maximum, 50°/a, 550 dedudtible <br />S25 dYaivaO, 100190/60 $25 Com'bicsed, 100/80/50 22.70 40.68 2251.80 <br />S25 VltBivQd,100/80/50 $50 C®fnbined, 80160140 16.55 29.59 1642.OZ <br />$50 4Veived,100/901110 S50 Gib+ned,100l80/50 19,64 34.54 1930.0® <br />350 vv~ed, 9 onrsaso S50 Combined, 80160!40 16.10 28.61 1591.95 <br />Wlf~h $1500!$100® Orthu " Lifetirrte Maximuirl, 50e/n, $~u0 deduetlble <br />$25 Waived, 100/90/@90 $2fi Combined, 100/80/50 22.7'0 41 _B4 2285.64 <br />$25 OrYeived, 100!80/50 $60 Combined, 80160/AO 16.56 30.66 1676.07 <br />S50 Waived, 100/90/60 $50 Cmmbined, 100!80/50 49,64 35-51 1S6a_12 <br />$50 Waived, 90d/80/50 $60 Combined, 80160!40 96,90 29.89 1®26.31 <br />31000!3750 Annual Maximum, witlsaut Qrthodontia <br />525 Waived, 100!90160 S25 Combined, 100180!50 19.43 32.E 7860.50 <br />525 WaiveQ, 700/80/50 S50 Combined. 80/60140 14.73 23.x7 1389.4 <br />350 Vyaived, 100190/B0 S50 Corolbined, 100/80/50 17.15 27.58 9 602-71 <br />$50 Waived, 100!80/50 $50 Combined, 80/60/40 14.41 22.70 1331.84 <br />'C1rQi0 ~Op~98 ~ ellild Only_ <br />rpup Noma: Mayttot0 Vliaaga v~sneipm„ass+w,.s, w~emo <br />