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i <br /> DocuSign Envelope ID: 7DB9202D-FDA8-426E-8A84-EAE7538E9310 <br /> 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-743058 <br /> Effective Date: January 1,2015 <br /> Administrator: United HealthCare Services,Inc. <br /> Coverage specified herein is applicable only during the Policy Period from January 1, 2015 through June <br /> 30,2015,and is further subject to all terms and conditions of this Policy. <br /> t <br /> SPECIFIC EXCESS LOSS INSURANCE <br /> Benefit Period: Covered Expenses Incurred from January 1, 2014 through June 30, 2015 and Paid from <br /> January 1,2015 through June 30,2015. <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: $107.03 per subscriber per month <br /> UHIELIP(07/06) 2 SCHED <br />