ppo dental plus - standard brochure

Underwritten by: Security Life insurance Company of America 10901 Red Circle Drive Minnetonka, MN 55343 Policy GH-1112-40130 Form S11132 (11-11)

www.PPODentalPlus.com

Marketed by:

AIGILIS

Freedom to choose Dentist or use Preferred Provider Network Over 197,000 network provider locations nationwide No waiting periods on preventive care benefits Three plans to choose from Plans for ages 65+ Prices you can afford!

Personal Dental Insurance Coverage

Dental Network provided by:

Benefits Summary Dental Benefits PLAN 1 PLAN 2 PLAN 3

Initial & Periodic Exams * (Two per calendar year)

100% (Insured Benefit)



X-Rays including Bitewing* 100%

(Insured Benefit)100%

(Insured Benefit) 100%

(Insured Benefit) Cleaning * (Two per calendar year)




Fluoride Treatments to age 16 * (One per calendar year)




Space Maintainers* and Sealants to age 14* 100%

(Insured Benefit)100%

(Insured Benefit) 100%

(Insured Benefit)

Fillings

Non-insured Benefit PPO Discount Only


3 month waiting period



Simple Extractions






Oral Surgery





Endodontics





Periodontics





Crowns





Bridges




12 month waiting period Dentures





Orthodontics




Cosmetic Dentistry Implants Veneers Resin fillings




Maximum Insured Benefit

$ 500 per person $ 750 per person $ 1,500 per person

Maximum PPO Discount Benefits

No Maximum No Maximum No Maximum

Deductible None 50 Ind/150 Family Max 50 Ind/150 Family Max

*Deductible waived for this service regardless of plan selection. Important information: After annual maximum for insurance stops and for treatments not covered by the insurance policy, the plan will continue to provide discounted services through our Preferred Provider Network (PPO). This is because the PPO negotiated fees will apply to give a continued savings even after the insured benefits are exhausted. Please check with your Dental Provider for discounts available.

Plan Features ELIGIBLE EXPENSES We will pay for Eligible Expenses You Incur for Yourself or on behalf of

Your Insured Dependent. Expenses must be incurred while the Policy is

in force and the person is covered by the Policy. The description of

Eligible Expenses is shown in the Coverage Schedule. To be an Eligible

Expense, the dental service or procedure must be performed by a

Dentist, a Physician or a Dental Hygienist.

EXPENSES INCURRED An Eligible Dental Expense is considered incurred on the following dates:

For full and partial dentures – the date the final impression is taken; for

fixed bridges, crowns, inlays and onlays – the date the teeth are first

prepared; for root canal therapy – the date the pulp chamber is opened;

for periodontal surgery – the date surgery is performed; for all other

services – the date the service is performed.

DEDUCTIBLE AMOUNT The calendar year Deductible, if any, is shown in the Coverage

Schedule. The Deductible is an amount of eligible charges you must

incur for Yourself or on behalf of Your insured Dependent(s) before we

can begin paying benefits.

CALENDAR YEAR MAXIMUM The maximum limit payable for all Eligible Expenses in any calendar year

is shown in the Coverage Schedule. The Maximum Calendar Year Limit,

if any, will apply to each person covered under the Policy.

PRETREATMENT REVIEW If the Course of Treatment will exceed the amount shown in the

Coverage Schedule, We will request prior review. We must be given the

Dentist’s treatment plan consisting of a description of the planned

treatment with estimated charges and diagnostic x-rays. We will

determine Eligible Expenses and state how much We will pay for the

treatment. Our determination may suggest an alternate, less expensive

Course of Treatment if it will produce professionally satisfactory results. If

You do not request a pretreatment review, We will pay for the least

expensive method of treatment regardless of the method actually used.

COORDINATION OF BENEFITS (Does not apply in Maine, Maryland and South Dakota) This Plan will be

coordinated with any other group, blanket or franchise plan under which

an Individual will receive benefits.

ALTERNATE BENEFIT If: 1) We determine that a less expensive alternate procedure, service or

Course of Treatment can be performed in place of the proposed

treatment to correct a dental condition; and 2) the alternative treatment

will produce a professionally satisfactory result; then the maximum We

will allow will be the charges for the less expensive treatment.

MISSING TOOTH When covered under your plan, benefits are provided for placement of

dentures, fixed bridgework, implants or the addition of teeth to existing

dentures only when the service includes replacement of a natural tooth

extracted or lost while covered under this plan. This limitation ends after

the individual receiving care has been covered under this plan for 36

consecutive months.

ELIGIBILITY Individuals, 18 years of age or older, plus their eligible dependents

(spouse and unmarried children from birth to age 26). This is subject to

individual state regulations.

TERMINATION OF COVERAGE Coverage terminates on the earliest of the following dates: (a) the last

day of the month in which You cease to be eligible for coverage; (b) the

last day of the month in which Your Dependent is no longer a dependent

as defined; (c) subject to the Grace Period, the last day of the month for

which a premium has been paid by you or on your behalf; (d) or the date

the Master Policy ends.

EFFECTIVE DATE You and Your Dependents are covered on the later of: the date We

accept Your enrollment and determine an effective date; or the date You

first acquire a Dependent, if the date is after Your coverage begins.

REASONABLE AND CUSTOMARY Reasonable and Customary means the usual, customary and regular

charges for the area where such expenses are incurred.

DENTAL EXPENSES NOT COVERED ‐ for overdentures and associated procedures;

‐ for charges in excess of those considered Reasonable and

Customary;

‐ for cosmetic procedures;

‐ for the replacement of dentures, bridges, inlays, onlays or crowns that

can be repaired or restored to normal function;

‐ for implants and for replacement of lost or stolen appliances,

replacement of retainers, athletic mouthguards, precision or semi-

precision attachments, denture duplication;

‐ for oral hygiene instructions, and for: plaque control, completion of a

claim form, acid etch, broken appointments, prescription or take-home

fluoride, or diagnostic photographs;

‐ for services not completed by the end of the month in which coverage

ends unless continuation of coverage has been requested and

accepted by Us;

‐ for procedures that are begun, but not completed;

‐ for services and treatment provided without charge, or for which there

would be no charge in the absence of insurance;

‐ for services in connection with war or any act of war, whether declared

or undeclared, or condition contracted or accident occurring while on

full-time active duty in the armed forces of any country or combination

of countries;

‐ for a condition covered under any Worker’s Compensation Act or

similar law;

‐ that are applied toward satisfaction of a Deductible, if any;

‐ that are generally considered by the dental profession as experimental

or investigational;

‐ for the treatment of cleft palate and anodontia;

‐ for services or supplies payable under any medical expense plan;

‐ for orthodontia, unless included within the Coverage Schedule;

‐ prior to the date the Insured is covered under the Policy;

‐ for the diagnosis or treatment of Temporomandibular Joint Dysfunction

(TMJD);

‐ for hospital services;

‐ if you voluntarily end your insurance You will not be eligible to re-enroll

for a period of 2 years after the date Your coverage first ended;

‐ charges for infection control, sterilization, and waste disposal.

ADDITIONAL DENTAL EXPENSES NOT COVERED UNDER PLAN 2—Discount Benefits Only

If you select Plan 2 the following expenses are not covered in addition to

those listed above in ―Dental Expenses Not Covered All Plans -

Discount Benefits Only.

- for oral surgery, including postoperative care.

- for endodontic treatments.

- for periodontic services.

- for study models.

ADDITIONAL DENTAL EXPENSES NOT COVERED UNDER PLAN 1 – Discount Benefits Only If you select Plan 1 the following expenses are not covered, in addition to

those listed under Plan 2, and ―Dental Expenses Not Covered All

Plans—Discount Benefits Only

- for crown build-ups.

- for recementing inlays, onlays, crowns and bridges.

- for repair of dentures or bridges. -- for restoration services.

- for prosthetic services.

-for fillings;

- for simple extractions;

- for antibiotic injections

IMPORTANT FRAUD NOTICES Any person who knowingly presents a false or fraudulent claim for payment at a loss or benefit or knowingly presents false information in an application for

insurance is guilty of a crime and may be subject to fines and confinement in prison.

Colorado It is unlawful to knowingly provide false, incomplete, or misleading facts

or information to an insurance company for the purpose of defrauding or

attempting to defraud the company. Penalties may include

imprisonment, finds, denial of insurance and civil damages. Any

insurance company or agent of an insurance company who knowingly

provides false, incomplete, or misleading facts or information to a policy

holder or claimant with regard to a settlement or award payable from

insurance proceeds shall be reported to the Colorado division of

insurance within the department of regulatory agencies.

District of Columbia WARNING: It is a crime to provide false or misleading information to an

insurer for the purpose of defrauding the insurer or any other person.

Penalties include imprisonment and/or fines. In addition, an insurer may

deny insurance benefits if false information materially related to a claim

was provided by the applicant.

Florida Any person who knowingly and with intent to injure, defraud, or deceive

any insurer files a statement of claim or an application containing any

false, incomplete, or misleading information is guilty of a felony of the

third degree.

Kentucky Any person who knowingly and with intent to defraud any insurer or other

person files an application for insurance containing any materially false

information or conceals for the purpose of misleading, information

concerning any fact material thereto commits a fraudulent insurance act

which is a crime.

Maine It is a crime to knowingly provide false, incomplete or misleading

information to an insurance company for the purpose of defrauding the

company. Penalties may include imprisonment, fines or a denial of

insurance benefits.

New Jersey Any person who includes any false or misleading information on an

application for an insurance policy is subject to criminal and civil

penalties. New Mexico Any person who knowingly presents a false or fraudulent claim for

payment of a loss or benefit or knowingly presents false information in an

application for insurance is guilty of a crime and may be subject to civil

fines and criminal penalties. Ohio Any person who, with intent to defraud or knowing that he is facilitating a

fraud against an insurer, submits an application or files a claim

containing a false or deceptive statement is guilty of insurance fraud. Pennsylvania Any person who knowingly and with intent to defraud any insurance

company or other person files an application for insurance or statement

of claim containing any materially false information, or conceals, for the

purpose of misleading, information concerning any fact material thereto

commits a fraudulent insurance act, which is a crime and subjects such

person to criminal to and civil penalties.

Tennessee/Virginia It is a crime to knowingly provide false, incomplete or misleading

information to an insurance company for the purpose of defrauding the

company. Penalties include imprisonment, fines and denial of insurance

benefits.

IMPORTANT NOTICE:

This brochure provides a very brief description of some important

features of your Plan. It is not the Insurance Contract nor does it

represent the Contract. A full explanation of benefits, exceptions and

limitations is contained in the Certificate of Insurance Policy Form GH-

1112-40130 issued to the Voluntary Group Trust for all states except for

Maine, Maryland and South Dakota

A full explanation of benefits, exceptions and limitations is contained in

the Group Dental Insurance Policy form GH-1112(ME-IND) for Maine,

GH-1112(MD-IND) for Maryland and GH-1112(SD-IND) for South

Dakota.

Aigilis Dental Plan may not be available in all states.

No agent has the authority to change any benefits, to bind coverage with

Security Life Insurance Company, or to promise a certain effective date.

Underwritten by:

Security Life Insurance Company of America - 10901 Red Circle Drive - Minnetonka, MN 55343

Product Portfolio DN11 Careington Maximum Care Dental Network (PPO, CPPO & Dentemax) Careington has owned and managed dental networks for 30 years and has recently contracted with DenteMax, another quality dental network provider, to create a “combined” national PPO dental network with significant presence. This combined network is known as the Maximum Care Network. The Maximum Care Network consists of over 197,000 credentialed dental access points contracted to provide dental services at reduced rates nationwide. The network combines the outstanding network management skills of two great organizations and results in average aggregate discounts of 5% to 50% below the 80th percentile of Reasonable and Customary charges.

Members are able take advantage of savings offered by leaders in the dental care industry.

Sample Savings Description * Regular Cost ** Plan Cost Savings

Adult Cleaning $114 $60 48%

Child Cleaning $79 $43 45%

Routine Checkup $64 $30 53%

Four Bitewing X-rays $74 $39 47%

Composite (White) Filling $175 $97 44%

Crown (porcelain fused to noble metal) $1,301 $740 43%

Complete Upper Denture $1,763 $968 45%

Molar Root Canal $1,270 $710 44%

Extraction (single tooth) $219 $100 55%

* Regular cost is based on the average of the 80th percentile usual and customary rates as detailed in the Ingenix Report for 2010 in Los Angeles, Orlando, Chicago and New York City.

** These fees represent the average of Careington's MaximumCare Series fee schedule in Los Angeles, Orlando, Chicago and New York City.

Prices subject to change

About Careington: Careington International Corporation is a Discount Medical Plan Organization and PPO Dental Network Administrator that provides access to quality dental, health care and lifestyle services at reduced rates. The company provides a range of membership programs that deliver significant savings to more than seven million members nationwide. About DenteMax: DenteMax was founded in 1985 in Michigan. DenteMax eventually expanded into Ohio and California, and gradually throughout the entire United States to become the nation’s largest leasable dental PPO network.

This is a PPO plan. This is not a discount plan. Third party administrators will pay for covered services according to the plan design. All applicable co-pays, deductibles or co-insurance, outlined by the plan design, are to be paid directly to the dental office at the time service is rendered. Please ask the dentist or office staff to explain all charges before treatment begins.

PPO Plus Dental Plans PPO

Monthly Rates effective January 1, 2012 through September 1, 2012 effective dates

Rates are guaranteed for the initial 12 months of coverage. Once covered, premiums are likely to increase on a semi-annual basis.

Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8

Single 17.02$ 18.34$ 20.11$ 22.10$ 24.31$ 26.74$ 29.39$ 32.27$

Single Plus One 31.24$ 33.67$ 36.92$ 40.57$ 44.63$ 49.09$ 53.96$ 59.23$

Family 50.46$ 54.39$ 59.63$ 65.53$ 72.08$ 79.29$ 87.15$ 95.67$

Single 25.44$ 27.42$ 30.07$ 33.04$ 36.34$ 39.98$ 43.94$ 48.24$

Single Plus One 47.19$ 50.87$ 55.77$ 61.29$ 67.42$ 74.16$ 81.52$ 89.48$

Family 76.58$ 82.54$ 90.50$ 99.45$ 109.40$ 120.33$ 132.27$ 145.20$

Single 34.13$ 36.79$ 40.34$ 44.33$ 48.76$ 53.64$ 58.96$ 64.72$

Single Plus One 63.66$ 68.62$ 75.23$ 82.67$ 90.94$ 100.03$ 109.95$ 120.70$

Family 103.53$ 111.60$ 122.36$ 134.46$ 147.91$ 162.70$ 178.83$ 196.31$

Single 18.72$ 20.18$ 22.12$ 24.31$ 26.74$ 29.42$ 32.33$ 35.49$

Single Plus One 34.37$ 37.04$ 40.61$ 44.63$ 49.09$ 54.00$ 59.36$ 65.16$

Family 53.25$ 57.39$ 62.93$ 69.15$ 76.07$ 83.67$ 91.97$ 100.96$

Single 27.98$ 30.16$ 33.07$ 36.34$ 39.97$ 43.97$ 48.33$ 53.06$

Single Plus One 51.91$ 55.96$ 61.35$ 67.42$ 74.16$ 81.58$ 89.67$ 98.43$

Family 84.24$ 90.80$ 99.55$ 109.40$ 120.34$ 132.37$ 145.50$ 159.72$

Single 37.55$ 40.47$ 44.37$ 48.76$ 53.64$ 59.00$ 64.85$ 71.19$

Single Plus One 70.02$ 75.48$ 82.76$ 90.94$ 100.03$ 110.04$ 120.95$ 132.77$

Family 113.89$ 122.77$ 134.60$ 147.91$ 162.70$ 178.97$ 196.72$ 215.95$

65 A

ND

OV

ER

Plan 1

Plan 2

Plan 3

Rate Chart

UN

DE

R A

GE

65

Plan 1

Plan 2

Plan 3

Security Life Insurance Company of America

Zip Area Zip Area Zip Area Zip Area Zip Area Zip Area Zip Area

350-351 1 801 5 605-608 4 206 4 590 2 750-751 4354-355 1 802 4 611 3 207-209 5 592-597 2 743-745 1 752-753 5359 1 808-809 5 619 1 210-211 4 599 2 747-749 1 760-763 3360-361 1 816 4 624-626 1 214 4 All Other 3 All Other 2 770 4362-364 1 All Other 3 628 1 219 4 772-773 4367-368 1 All Other 2 All Other 3 978-979 2 774-775 3All Other 2 065-066 6 680 1 All Other 3 786-787 4

068-069 7 462-464 3 010-011 4 683-684 1 All Other 2995-997 6 All Other 5 All Other 2 012 3 686-693 1 157-158 1All Other 5 013-015 5 All Other 2 164-165 1 842-847 1

197-198 5 504-508 1 020 5 168 1 All Other 2850 4 All Other 3 512-517 1 023 5 893-895 4 179 1852 4 521 1 024 7 897-898 4 180-181 3All Other 3 All Areas 5 All Other 2 027 4 All Other 3 182 1

All Other 6 188 1716-721 1 661-662 3 189-191 4723-724 1 664-665 1 484-485 2 193-194 4728 1 301-302 4 667-669 1 488-499 2 All Other 2All Other 2 303 5 670-671 1 All Other 3 260 1

307 2 673-679 1 870 3 029 4 265 1902-908 5 310 2 All Other 2 550 3 871 4 All Other 2 All Other 2913 5 311 5 551 4 873-875 3919-921 5 312 2 403-404 1 553-555 4 877 3 293 2 530-532 3926,928 5 316-319 2 407-409 1 561-562 1 884 3 295 2 534 3931 7 398 2 411-418 1 All Other 2 All Other 2 All Other 3 543 4932-934 3 All Other 3 425-427 1 All Other 2935 5 All Other 2 386 1939-940 5 All Areas 3 All Other 2 All Areas 2 All Areas 2941 6 701 3943-944 6 All Other 2 630-631 3 370-371 3945-951 5 633-634 3 450-451 3 372 4All Other 4 601 4 039-041 5 635-639 1 456 3 379 3

602-603 4 044 4 641 3 All Other 2 382-384 1604 3 046 4 644-647 1 All Other 2

048 4 653-655 1 734-735 1All Other 3 All Other 2 S11155 PPO Plus 11-11

Not Available

Maryland

Illinois

Indiana

Iowa

Kansas

Kentucky

Georgia

New HampshireNot AvailableNew Jersey

West Virginia

Wisconsin

Wyoming

Rhode Island

Not AvailableWashingtonNot Available

Not AvailableNew Mexico

North CarolinaSeparate Rate Sheet

(Cont.)

Alaska

Arizona

Arkansas

Oklahoma

Missouri

Michigan

Minnesota

VermontNot Available

Louisiana

Maine

California

Mississippi

Pennsylvania

Alabama

Nebraska

Nevada

Utah

Montana

Massachusetts

Oregon

South Carolina

Plan 1 Only

Tennessee

Colorado

Delaware

Dist. Columbia

Florida

Texas

Connecticut

Illinois (Cont.)

Ohio

(Cont.)

Oklahoma (Cont.)

Separate Rate Sheet

Hawaii

Idaho

Virginia

North DakotaSeparate Rate Sheet

South Dakota

Zip Code ChartState State State State State State State

Security Life Insurance Company of America, Minnetonka, MN

GHA-1112 S11123 (STD) 8-11

PPO Plus Dental Plans MAIL - the application along with initial payment to:

Aigilis Dental Plans P.O. Box 953279

Lake Mary, FL 32795 Page 1 of 2

IMPORTANT FRAUD NOTICES Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Colorado - It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. District of Columbia - WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Kentucky - Any person who knowingly and with intent to defraud any insurer or other person files an application for insurance containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act which is a crime. Maine – It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits

New Jersey - Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. New Mexico - Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. Ohio - Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Pennsylvania - Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals, for the purpose of misleading, information concerning any fact material hereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Tennessee/ Virginia - It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

IMPORTANT INFORMATION Effective Date – The effective date is the first of the month following the day in which the application is received in the Service Center Office. Identification Card and Certificate of Insurance - Upon receipt of your completed application you will receive a copy of your Certificate of Insurance and Identification Card(s). Do not cancel any other dental coverage you may have until you receive written confirmation from Security Life. Please allow 3-4 weeks for processing.

By my signature below, I hereby apply for coverage under Group Dental Insurance Policy GH-1112-40130 issued to the Voluntary Group Trust. I also certify I have read the applicable Fraud Notice above. California Law prohibits an HIV Test from being required or used by health insurance companies as a condition of obtaining health insurance coverage. Applicant Signature______________________________________________________________________________ Date_____________________________

Please refer to the reverse side for payment options and agent information

Plan Selection: Plan 1 Plan 2 Plan 3 Under age 65 Age 65 or Older I apply for coverage on: Single Only Single + 1 Family APPLICANT INFORMATION (PLEASE PRINT CLEARLY) Last Name First Name Initial Birth Date

/ / Address

Telephone Number Sex: MF

City

State Zip Marital Status

Married Single Billing Address (If Different)

City State Zip

LIST ALL YOUR ELIGIBLE DEPENDENTS BELOW Last Name (If Different) First Name Initial Sex M/F Age Birth Date Spouse / /

Dependent / /

Dependent / /

Dependent / / Does Spouse have a dental plan: Yes No With Whom? _________________________________________________________________ If answer is “Yes”, are dependents enrolled under spouses plan? Yes No

GHA-1112

Page 2 of 2 PPO PLUS DENTAL PLANS

PREMIUM RATE CALCULATION AND AUTHORIZATION AGREEMENT

The following sections must be completed and signed by the applicant and agent

FOR COMPANY USE ONLY Effective Date: ______/______/______ Plan Code: _________________

MODE OF PAYMENT Select your mode of payment Monthly – Bank Account Debit (ACH) (Checking or Savings) Complete Authorization Agreement below and submit one (1) month premium Checking Acct. - Attach voided check - DO NOT SUBMIT DEPOSIT SLIP. Savings Acct. - Attach savings deposit slip with account number including the bank routing number. Monthly Credit Card - Complete Authorization Agreement Select One Visa Master Card Card # __________________________________________________ Expiration Date _______/____/______

Monthly Rate

(Locate the first 3 digits of your zip code on the Zip Code Area Chart. Using the corresponding area number, determine applicable monthly premium found on the Rate Chart based upon your eligibility age, plan selection and coverage type

Enter Initial payment on

Bank draft and Credit Card under Total Monthly Premium

Total Monthly Premium

Zip Code: $

Applications received in the Service Center Office by the 20th of the month

will become effective the first day of the following month.

For Initial payment, make check payable to Security Life Insurance Company of America

AUTHORIZATION AGREEMENT: (When paying by ACH or Credit Card please complete the section below) As a convenience to me, I authorize Security Life Insurance Company of America/Meritain Health to initiate debit entries to my bank account or credit card account for my monthly dental premium. I understand this will occur by the third business day of each month and that such record will appear on my monthly statement. I agree that if any such charge be dishonored, whether with or without cause and whether intentionally or inadvertently, the bank or credit card company shall be under no liability whatsoever even though it might result in forfeiture of my insurance. I understand that this agreement will remain in effect until Security Life Insurance Company of America has received written notice from me that it should be cancelled. I understand that I have the right to stop payment by notification to Security Life Insurance Company of America, my bank or my credit card company at least ten business days prior to the next scheduled payment. ____________________________________________________ _______________ ___________________________________________________ Account Holder’s Name Date Account Holder’s Signature FOR AGENT USE ONLY – Please Print Clearly Producer Name Producer Phone # Street Address City St Zip Producer Email Producer SS#/TIN# Appointed with Security Life? Yes No Producer Signature

ppo dental plus - standard brochure

Health & Medicine