2015-393-E HR - UnitedHealthCare (UHC) for UHC Application for Excess Loss Insurance Policy $1,265,095

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DocuSign Envelope ID: EE765B38-37EF-4402-B4E9-8B82F98E2EE8 permit a Covered Person to have a direct right of action against the Company. The Company will not be considered a parry to the Plan of the Policyholder,or to any supplement or amendment to it. MISSTATED DATA, CONCEALMENT,FRAUD The Company has relied on the information provided by the Policyholder, the Administrator or any agent of the Policyholder, in the issuance of this Policy, or for any Subsequent Policy Period.In the event of a misrepresentation,concealment or omission of a fact,or a mistake of fact (whether or not a mutual mistake), any of which materially affect the underwriting, premium,rating or terms and conditions of this Policy,the Company may,at its option: (a) increase premium rates, attachment points and/or otherwise change the terms and conditions of this Policy. Such increase or change to be effective retroactively to the Effective Date or as of any premium due date thereafter,or (b) terminate this Policy as of the next premium due date. The Company may declare this Policy null and void in its inception if,whether before or after a claim, the Policyholder, Administrator or any agent of the Policyholder has willfully or intentionally misrepresented, concealed, omitted any material fact affecting terms, conditions, or underwriting of this Policy. In such event, the Company's liability under this Policy shall be limited to refunding premiums paid by the Policyholder after deducting therefrom the amount of any Covered Expenses reimbursed by the Company to the Policyholder prior to the date of termination. If the amount of the Covered Expenses reimbursed by the Company to the Policyholder exceeds the premiums paid by the Policyholder, the Policyholder shall pay the Company the difference within thirty (30) days of the date the Company notifies the Policyholder of such difference. NOTICE OF COMPLAINT, APPEAL, LEGAL ACTION As a condition precedent to the Company reimbursing the Policyholder in any settlement or judgment for a disputed Covered Expense, the Policyholder shall immediately inform the Company of any notice of appeal, notice of legal action, or objection,demand or complaint which the Policyholder received regarding any Covered Expense that may be reimburse under this Policy. OTHER COVERAGE The reimbursement provided by this Policy is in excess of other coverage such as group insurance,excess insurance,insurance,plan benefits, including insurance or plan benefits established by any federal,state,or local law. PARTIES TO THE POLICY The parties to this Policy are the Policyholder and the Company. The Company's sole liability under this Policy is to the Policyholder. This Policy does not create any right or legal relation between the Company and a Covered Person under the Plan. This Policy will not be deemed to make the Company a party to any agreement between the Policyholder and the Administrator. POLICYHOLDER REQUIREMENTS The Policyholder agrees to provide funds for Payment of all eligible expenses under the Plan.If the Policyholder fails to provide funds for timely Payment: (a)coverage under this Policy will immediately terminate; and (b) any Aggregate and/or Specific Deductible will be deemed not satisfied. RECORDS The Policyholder will maintain records of all Covered Persons under the Plan during the Policy Period and for a period of seven(7)years after the end of the Policy Period. The Policyholder will make all such records available to the Company as needed to evaluate its liability under this Policy. The Policyholder will maintain a separate record of any and all amounts Paid in excess of benefits eligible under the Plan. SEVERABILITY CLAUSE Any clause deemed void,invalid,or otherwise unenforceable,whether or not such a provision is contrary to public policy,will not render any of the remaining provisions of this Policy invalid. TERMINATION OF THE POLICYHOLDER'S PLAN The Policyholder will immediately notify the Company,if the Plan is terminated. UHIELIP-NC(07/06) 8 GEN