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<br />8. AGGREGA'l'E MONTHLY PREMIUM (PER EMPLOYEE): $4.81 <br />9. AGGREGA'l'E LOSS LIMIT: $115.000 <br /> <br />10. PAYMENT MODE: .....ODthly_ <br /> <br />B. X SPECMCIJNDIVIDUAL EXCESS LOSS INSURANCE: <br />1. BENEFITS COVERED: Medical, RX <br />2. POLICYBASISlBENEFIT PERIOD: <br />BligJ.Dle Expenses Jncmred ftom. 10/01/03 through 03/31105 ; and. <br />_ Elig1~le Expenses Paid from 04/0V04 through 03/31/05 , <br /> <br />Iftbis Policv terminAtes prior to the ~ Date. the Benefit Period will not extend past <br />the date of t~inAtion. In addition. the deductt"ble per Covered Person will auolv as if the <br />~olicy were in force for the entire Policy Year. <br /> <br />3. . DEDUCTIBLE PER COVERED PERSON: S115.000 <br /> <br />4. BENEJITl' 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: 5885.000 <br /> <br />6. SPECIFIC MONTHLY PREMIUM RATE: <br /> <br />Single: S17.22 <br /> <br />Family: $40.99 <br /> <br />Composite: <br /> <br />Covered UnitBlenroUment: Single: _143_ Family: _256_ Composite: _399_ <br /> <br />X OPTIONAL-RIDERS ELECI'ED: SL-2001-AFA-RDR- #1, SL-2001-RDR.:' #2 <br /> <br />- . <br />X - WAIVER OF ACTIVELY AT WORK ELECTED: <br /> <br />81.-2001 <br /> <br />4 <br /> <br />(6101) <br />