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SUNNYISLES 1703779 COVERED SERVICES 4P.TYPE I - Diagnostic & Preventive YPE II - Basic Services TYPE III - Major Services TYPE IV - Orthodontia* City of Sunny Isles Beach oral exams, cleanings & x -rays fillings, extractions, sealants, endodontics & periodontics crowns & dentures for Children *To include Orthodontic Coverage for children in your Jefferson Pilot Financial Group Dental Policy, the policyholder must meet the following dependent enrollment criteria: On the Policy's Effective Date and at each annual Renewal Date, 8 dependent units must be enrolled. A'dependent unit' is a'spouse' or 'child (ren)' or 'spouse and child(ren)' covered by the dental plan. If dependent enrollment in the group policy does not meet this minimum requirement, Orthodontic Coverage (Type IV Services) will not be issued or continued. This requirement does not change Jefferson Pilot Financial's minimum participation requirements, described below. PROPOSAL ASSUMPTIONS: Quoted rates are based on the following assumptions adjusted or the proposal may be withdrawn. If these assumptions are not correct, the rates may be Employer contribution to employee premium - 100% Employer contribution to dependent premium - 50% Minimum employee participation - 100% (A minimum of 10 employees must be enrolled) Minimum dependent participation - 60% (A minimum of 8 dependent units must be enrolled in order to include orthodontic benefits in the policy) •Employees covered by another dental plan may be excluded from participation calculations, as long as they do not exceed 30% of eligible employees. Final rates will be calculated based on: - the agreed -upon plan; - employer contribution (changing the percentage of employer contributions for employee and /or dependent coverage may affect quoted rates); - enrolled census; - employee location(s); - correct industry code (SIC); and - other pertinent underwriting factors. Jefferson Pilot Financial reserves the right to re -rate or refuse to issue coverage if there are changes in these factors. THIS IS NOT A CONTRACT: This illustration was prepared based on the information provided in the Request for Proposal. It is a description of dental coverage available from Jefferson Pilot Financial and not an offer to contract. More detailed information is available upon request concerning the terms, conditions and limitations contained in the master policy, if issued. If there are discrepancies between the information contained in this proposal and the master policy, the terms of the master policy will control. State - specific restrictions and requirements may not be addressed in this proposal. An Application for Group Insurance must be completed by the Employer and approved by Jefferson Pilot Financial before coverage can become effective. Whis proposal is subject to revision if not accepted on or before the Proposed Effective Date shown on the Benefits and Cost Summary page of this proposal. Jefferson Pilot Financial Insurance Company 25 11/02/01