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5 . Individual Lifetime Reimbursement Maximum $ 1 , 000 , 000 . 00 (Select one ) ❑ per Covered Unit ❑ per Covered Family Unit 6 . Premium Rates Covered Units Composite $ 11 . 86 7 . Reimbursement Option : Covered expenses incurred on or after the Policy Effective Date and paid during the Policy Period with : Run -in Period of months Run - in Limit $ Run -out Period of 3 months Run -out Limit $ 8 . Individual Excess Loss Terminal Provision (Available at initial policy issue only ) ❑ Yes ❑✓ No Terminal Run -out Period : months 9 . Individual Excess Loss Advantage Provision ✓❑ Yes No Individual Advantage Deductible $ 50 , 000 . 00 10 . Individual Advantage Deductible applies toward the Aggregate Attachment Point? ❑ Yes R] No 11 . Individual Excess Loss Transplant Provision ❑ Yes ❑✓ No D . Aggregate Excess Loss Insurance 0 Yes ❑ No 1 . Eligible Covered Expenses ❑ Medical excluding all Prescription Drugs ❑✓ Medical including Prescription Drugs defined as ONE of the following : 0 Rx Card and Mail Order ❑ Rx Card Only ❑ Rx Mail Order Only OR ❑ Rx as part of Medical Plan subject to a Deductible and Coinsurance ❑ Short Term Disability ❑ Dental ❑ Vision ❑ Other 2 . Aggregate Attachment Point will be set by SAFECO . 3 . SAFECO 's Reimbursement Percentage : (Select one ) a . 100 % of Covered Expenses in excess of the Aggregate Attachment Point ; or b . % of the first $ of Covered Expenses in excess of the Aggregate Attachment Point , and % thereafter; or C . % of Covered Expenses in excess of the Aggregate Attachment Point that are incurred at the Applicant medical facility or any affiliated or subsidiary medical facilities of the Applicant ; and % of all other Covered Expenses in excess of the Aggregate Attachment Point ; or d . % of Covered Expenses that are incurred at the Applicant medical facility or any affiliated or subsidiary medical facilities of the Applicant ; and % of all other Covered Expenses will apply to the Aggregate Attachment Point , LG 1320 10/02 2