Note: This page contains a brief summary of coverage. It does not state all provisions and limitations of the plan. The terms and provisions of each plan, as outlined in the plan document, will determine coverage and eligibility.

Waiting Period Information
Eligible employees are eligible as of the 1st of the month following the employee's hire date.

Termination of Coverage Information
When a plan participant is terminated from the company, the plan coverage ends on the last day of the month following the employee's termination date.

  (per month)

Base Plan Rate: Employee contributes 5% per month.
Per $1,000 of benefit. (see rates below)

Age Band Structure Coverage Rates Male Female Smoker Non-Smoker Smoker Non-Smoker 0-14 $2 $2 $2 $2 15-19 $2 $2 $2 $2 20-24 $2 $2 $2 $2 21-29 $2 $2 $2 $2 30-34 $2 $2 $2 $2 35-39 $2 $2 $2 $2 40-44 $2 $2 $2 $2 45-49 $2 $2 $2 $2 50-54 $2 $2 $2 $2 55-59 $2 $2 $2 $2 60-64 $2 $2 $2 $2 65 and over $2 $2 $2 $2

Fortis Benefits
http://www.fortis.com

Member Services
John Carpet
One Chase Manhattan Plaza
New York, NY 10005
212-859-7233

- Summary Plan Description