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EXHIBIT A <br />Deductible <br />Single <br />Family <br />Dependent Age Limit <br />Waived for Preventive <br />Preventive Services <br />Basic Services <br />Major Services <br />Annual Maximum <br />Orthodontia <br />Lifetime Maximum <br />Benefit Detail <br />Endodontic <br />Periodontal <br />Oral Surgery <br />Out of Network <br />Reimbursement <br />Rate Guarantee <br />Employee 19 <br />EE/Spouse 17 <br />EE/Child(ren) 8 <br />Family 31 <br />TOTAL 75 <br />Monthly Premium <br />Annual Premium <br />$ +/- Current <br />%+/- Current <br />This illustration is intended to outline the basic plan and is not intended to describe the contract <br />provision. Each employee will receive a plan booklet which will outline in detail the plan provisions <br />and limitations. Should there be a discrepancy between this outline and the pion document the plan <br />document prevails. <br />2 <br />