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<br />B. [Xl SPECIFICIINDIVIDUAL EXCESS LOSS INSURANCE: <br /> <br />1. BENEFITS COVERED: Medical and Prescription Drugs <br /> <br />2. POLICY BASIS/BENEFIT PERIOD: <br /> <br />Eligtble Expenses Incurred from April 01. 2001 through March 31. 2003; and <br /> <br />Eligible Expenses Paid from April 01. 2002 through March 31. 2003. <br /> <br />If this Policy terminates prior to the ExPiration Date, the Benefit Period will not extend past <br />the date of termination. In addition, the deductIble per Covered Person will apply as if the <br />Policy were in force for the entire Policy Vear. <br /> <br />3. DEDUCTIBLE PER COVERED PERSON: $115.000 <br /> <br />4. BENEFIT PERCENTAGE PAYABLE IN EXCESS OF THE SPECIFIC <br />DEDUCTIBLE: 100% <br /> <br />5. MAXIMUM SPECIFIC BENEFIT PAYABLE MINUS THE SPECIFIC <br />DEDUCTIBLE (pER LIFETIME PER COVERED PERSON), WHILE THIS <br />POLICY IS IN FORCE: $885.000 <br /> <br />6. SPECIFIC MONTHLY PREMIUM RATE: <br /> <br />Single: $17.61 Family: $42.84 <br /> <br />Est. Covered Units/enrollment: Single: 128 Family: 260 <br /> <br />[ l OPTIONAL RIDERS ELECTED: None <br /> <br />SL-200l <br /> <br />4 <br /> <br />(6/01) <br />