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1、[Carrier]PLANASMALLGROUPHEALTHBENEFITSBASICPOLICYPOLICYHOLDER:[ABCCompany]GROUPPOLICYNUMBER:[G-12345]GOVERNINGJURISDICTION:NewJerseyEFFECTIVEDATEOFPOLICY:[January1,2009]POLICYANNIVERSARIES:[January1stofeachyearbeginningin2010.]PREMIUMDUEDATES:[EffectiveDate,andthefirstdayof

2、themonthbeginningwithFebruary,2009.]AFFILIATEDCOMPANIES:[DEFCompany][Carrier]inconsiderationoftheapplicationforthisPolicyandofthepaymentofpremiumsasstatedherein,agreestopaybenefitsinaccordancewithandsubjecttothetermsofthisPolicy.ThisPolicyisdeliveredinthejurisdictionspecifi

3、edaboveandisgovernedbythelawsthereof.TheprovisionssetforthonthefollowingpagesconstitutethisPolicy.TheEffectiveDateisspecifiedabove.ThisPolicytakeseffectontheEffectiveDate,ifitisdulyattestedbelow.Itcontinuesaslongastherequiredpremiumsarepaid,unlessitendsasdescribedintheGener

4、alProvisionssection.[SecretaryPresident][Dividendsareapportionedeachyear.]102[Includelegalname,tradename,phone,faxande-mailnumbersbywhichconsumersmaycontactthecarrier,includingatleastonetoll-freenumberforCoveredPersons]]102POLICYINDEXSECTIONPAGE(S)ScheduleofInsuranceandPrem

5、iumRatesGeneralProvisionsClaimsProvisions[Planholders]DefinitionsEmployeeCoverage[DependentCoverage][PreferredProviderOrganizationsProvisions][PointofServiceProvisions][AppealsProcedure][ContinuationofCare]HealthBenefitsInsurance[UtilizationReviewFeatures][SpecialtyCaseMana

6、gement][CentersofExcellenceFeatures]ExclusionsContinuationRights[ConversionRightsforDivorcedSpouses][EffectofInteractionwithaHealthMaintenanceOrganizationPlan]CoordinationofBenefitsandServicesBenefitsforAutomobileRelatedInjuriesMedicareasSecondaryPayor102SCHEDULEOFINSURANCE

7、ANDPREMIUMRATESPLANAThisPolicy'sclassifications,andtheinsurancecoveragesandamountswhichapplytoeachclassareshownbelow:CLASS(ES)[Alleligibleemployees]EMPLOYEE[ANDDEPENDENT]HEALTHBENEFITSCalendarYearCashDeductible:•forHospitalConfinementNone(Note:SeeHospitalConfinementCopaymen

8、t)•forPreventiveCareNone•forimmunizationsandleadscreeningforchildrenNone•forAllOth