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Presented to City of Sunny Isles Beach EYEMED VISION CARE in conjunction with FIDELITY SECURITY UFE INSURANCE COMPANY Premier-Plus Benefit Funded Vision Benef"rt with a $100 Frame Allowance and $115 Contact Lens Allowance 2 Tier Rates Groups of 10 - 500 Eligible Employees Non-Voluntary Rates valid with a Minimum of 10 Enrolled Employees 24 Month Contract Term Valid for Groups Domiciled in the State of: Florida Beneftt Design Summary: (See attached detailed benefit design summary for description of Lens Options, Laser Vision Discount and Out of Network Benefits) Exam with dilation as necessary $100 Frame Allowance Standard Plastic Lenses $115 Contact Lens Allowance Once every 12 months Once every 24 months Once every 12 months Once every 12 months Member Co-pay at time of Service: $10 Exam Co-pay $25 Lens Co-pay Monthly Fee: Employee Only Employee + Family $4.79 per month $11A2 per month Plan Terms and Conditions: . Fees quoted are valid for plan start dates of 10/1/01 through 1211102. . The above selected plan requires a 24 month contract term and the rates are guaranteed for 24 months. . Non-Voluntary Rates assume 100% employer contribution for employees and dependents or that the vision program is bundled with medlcaVdental benefit. Minimum 10 enrolled employees required. . Children eligible as dependents included in coverage are defined as unmarried children up to age 19 and full time students up to age 25 who are primarily dependent on subscriber for support. . Rates are valid for groups with 10 - 500 eligible employees. . Rates are valid for commercial groups, government agencies, municipalities, churches, school districts, public or private colleges, unions and charitable organizations. . Vision plan is underwritten by Fidelity Security Life Insurance Company of Kansas City Missouri, If City of Sunny Isles Beach has chosen this benefit design, stated monthly rates, plan frequency and co-pay options, attach this document to the group application and sign here: City of Sunny Isles Beach Representative Signature: Date: Print Name: Internal Plan Code: 131 N14B-2T EyeM~d.___.____.. The Eye Care Plan of America.. Exhibit "B"