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EXCESS LOSS SCHEDULE OF BENEFITS <br /> Applies to Policy Period : from 10-01 -2004 to 10-01 -2005 <br /> 7 , Reimbursement Option : <br /> Covered Expenses incurred on or after the Effective Date of Coverage and paid during the Policy <br /> Period with : <br /> Run -in Period 0 months Run-in Limit $ N/A <br /> Run-out Period 3 months * Run-out Limit $ Unlimited <br /> * See Section G: Additional Information <br /> 8 . Individual Excess Loss Terminal Provision applicable? ❑ Yes ❑✓ No <br /> 9 . Individual Excess Loss Advantage Provision applicable? ❑✓ Yes ❑ No <br /> Individual Advantage Deductible $ 50 , 000 <br /> 10 . Individual Advantage Deductible applies toward the Aggregate Attachment Point? ❑ Yes ❑✓ No <br /> 11 . Individual Excess Loss Transplant Provision ❑ Yes ❑✓ No <br /> D . Aggregate Excess Loss Insurance ❑✓ Yes ❑ No <br /> 1 . Covered Expenses : <br /> ❑ Medical excluding all Prescription Drugs <br /> ❑✓ Medical including Prescription Drugs defined as ONE of the following : <br /> ❑✓ Rx Card and Mail Order ❑ Rx Card Only ❑ Rx Mail Order Only OR <br /> ❑ Rx as part of Medical Plan subject to a Deductible and Coinsurance <br /> ❑ Vision <br /> ❑ Dental <br /> ❑ Short-Term Disability <br /> ❑ Other <br /> 2 . Aggregate Attachment Point will be set by SAFECO . <br /> 3 . SAFECO's Reimbursement Percentage <br /> 100 % of Covered Expenses in excess of the Aggregate Attachment Point. <br /> 4 , Aggregate Reimbursement Maximum per Policy Period $ 1 . 000 . 000 <br /> 5 , Monthly Aggregate Accommodation Provision applicable? El Yes ❑✓ No <br /> 6 , Reimbursement Option : <br /> Covered Expenses incurred on or after the Effective Date of Coverage and paid during the Policy <br /> Period with : <br /> Run - in Period 0 months Run-in Limit $ N/A <br /> Run-out Period 3 months * Run-out Limit $ Unlimited <br /> * See Section G: Additional Information <br /> LGC 8802 03/02 2 of 3 <br />