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UnitedHealthcare Insurance Company <br /> A Stock Company <br /> 185 Asylum Street,Hartford,Connecticut <br /> Phone: 1-860-702-5000 <br /> SCHEDULE OF BENEFITS <br /> This Schedule of Benefits is only applicable to Excess Loss Insurance provided by the Company during the <br /> Policy Period shown below. <br /> Policyholder: Orange County <br /> Policy Number: GA-743058GL <br /> Effective Date: January 1,2014 <br /> Administrator: United HealthCare Services,Inc. <br /> Coverage specified herein is applicable only during the Policy Period from January 1, 2014 through <br /> December 31,2014,and is further subject to all terms and conditions of this Policy. <br /> SPECIFIC EXCESS LOSS INSURANCE <br /> Benefit Period: Covered Expenses Incurred from January 1, 2014 through December 31, 2014 and Paid <br /> from January 1,2014 through December 31,2014. <br /> Specific Deductible per Covered Person:$100,000 <br /> Specific Percentage Reimbursable: 100% <br /> Maximum Specific Benefit per Covered Person:Unlimited <br /> Specific Excess Loss Insurance includes: <br /> • Medical <br /> • Stand Alone Prescription Drug Program <br /> Specific Excess Loss Premium:$88.80 per subscriber per month <br /> AGGREGATE EXCESS LOSS INSURANCE <br /> Benefit Period: Covered Expenses Incurred from January 1, 2014 through December 31, 2014 and Paid <br /> from January 1,2014 through December 31,2014. <br /> Aggregate Excess Loss Insurance includes: <br /> • Medical <br /> • Stand Alone Prescription Drug Program <br /> Aggregate Percentage Reimbursable: 100% <br /> Maximum Aggregate Benefit: $2,000,000 per Policy Year <br /> Minimum Annual Aggregate Deductible: $8,291,417 or 95% of the first Monthly Aggregate Deductible <br /> amount times 12,whichever is greater <br /> UHIELIP-NC(07/06) 2 SCHED <br />