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ompany to initiate debit entries, and to initiate if

necessary, credit entries and adjustments for any debit entry corrections to m

y (our) account indicat-ed below

and the Financial Institution nam

ed below to debit and/or credit sam

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Sig

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re_______________________________________________ Date______________

Sample Copayments for the Select Prepaid Individual Dental PlanThe following is a sample of some frequently used dental procedures. When you enroll for the DentiCare plan, you willpay discounted fees called copayments. These discounts areonly available from providers who participate in our network.

After you enroll, a complete list of copayments will be mailed toyour home along with your Individual Prepaid Dental PlanAgreement. The sample below demonstrates potential savingswith the Select plan and may not reflect your actual results.

The Plan Dentist you select may not perform all procedures list-ed. The copayments shown apply to those Plan Dentists whoperform those services. Therefore, you are encouraged to discussavailability of the scheduled services with your Plan Dentist.Charges for procedures not listed on the Copayment Schedulethat are performed by your Plan Dentist are not covered underyour Plan with DentiCare.

Should you require dental services that your Plan Dentist isunable to provide, you may obtain those services from a PlanSpecialist at a discounted rate. No referral is needed from yourPlan Dentist in order for you to obtain services from PlanSpecialist. There is no applicable copayment schedule for PlanSpecialist services. Instead, the following discounts will apply.For treatment provided by an Endodontist you will receive 15%off his/her list charges. For treatment provided by an OralSurgeon, Orthodontist, Periodontist or Pedodontist you willreceive 25% off his/her list charges. You will be responsible forpaying the entire discounted charge at the time the service isreceived, or in accordance with the Plan Specialists’ billing proce-dures.

For a complete list of copayments contact:888.882.8233

*Members are responsible for additional lab fees for these services. 1The charges listed in this column were developed from chargesdentists in Georgia submitted to Assurant Employee Benefits in2003. The listed charges represent a mean average of those submit-ted charges rounded to the nearest dollar representing what youmay pay without the plan services.

YOUR COSTYOUR COST

Plan discounts forCosmetic Dentistry,

Orthodontics &Vision Care

Individual Prepaid Dental Plan from

Union Security DentalCareof Georgia, Inc.*

This is not an insurance policy. This plan is not under

the jurisdiction of the insurancelaws of the State of Georgia.

FOR USE IN GEORGIA

Select

For further information please contact: 888.882.8233

Union Security Insurance Company780 Johnson Ferry Road NE, Suite 450Atlanta, Georgia 30342

www.assurantemployeebenefits.com

*Products and services marketed byAssurant Employee Benefits, administeredby Union Security Insurance Company andprovided by Union Security DentalCare ofGeorgia, Inc.

Union Security Insurance Company does notinsure or guarantee the benefits of this plan.

DENTAL TREATMENTAPPOINTMENTS

Periodic Oral Evaluation $5 $29 Limited Oral Exam $25 $47Comprehensive Oral Evaluation $5 $49

DIAGNOSTIC DENTISTRY

Complete X-Ray Series, No Charge $89Including Bitewings Charge $63.00

PREVENTIVE DENTISTRY

Routine Cleaning - Adult (once every 6 mos.) $5 $58 Routine Cleaning - Child (once every 6 mos.) $5 $44Application of Fluoride (up to 18 years of age) No Charge $22Oral Hygiene Instruction No Charge $42Application of Sealant, Per Tooth $15 $36 Fixed Space Maintainer $70* $241

FILLINGS/CROWNSSilver Fillings

One Surface $25 $82Two Surfaces $30 $122 Three Surfaces $40 $150

White FillingsOne Surface, Anterior $40 $105 Two Surfaces, Anterior $50 $122 Three Surfaces, Anterior $60 $150 One Surface, Posterior $40 $111Two Surfaces, Posterior $50 $145 Three Surfaces, Posterior $60 $177

Crowns - Porcelain to High Noble Metal $320* $787(cost of precious & semi-precious metal is additional)

ROOT CANALS

Anterior $225 $536Bicuspid $345 $623 Molar $545 $770

PERIODONTICS

Periodontal Scaling and Root Planing $75 $172Per Quadrant

Full Mouth Debridement (complicated cleaning) $95 $108

DENTAL TREATMENTDENTURES

Complete Denture - Upper $350* $755 Complete Denture - Lower $350* $658Partial Denture - Upper $395* $659 Partial Denture - Lower $395* $585

ORAL SURGERY

Single Tooth Extraction $30 $91 Removal of Impacted Tooth

Soft Tissue $80 $225 Partial Bony $90 $279 Complete Bony $115 $313 Complete Bony, with Complications $165 $354

ORTHODONTICS

Orthodontic treatment for children and adults is provided at 25% reduction from the Plan Specialist or Plan Dentist’s list charges.

With theSelect Plan

Withoutthe Plan1

With theSelect Plan

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Complete the attached application form. Be sure to include the Dental Facility Number of each dentist you have selected in the space provided and detach theapplication form from the brochure.

Choose your payment option. If you choose the annual prepayment fee method, include the appropri- ate prepayment fee, the $35 enrollment fee, the com-pleted application form and mail to us. The annual prepayment fee may be paid by credit card for your convenience. You may enroll over the phone if you are choosing the annual prepayment fee method.

If you choose the automatic monthly bank draft method complete the Authorization Agreement on the reverse side of the application form, include a voided check, the first month’s prepayment fee, the $35 enroll-ment fee and mail to us. Monthly prepayment fees will thereafter be drawn automatically from your bankaccount. While we accept automatic bank drafts from checking or savings accounts, we cannot accept per-sonal checks on a monthly basis.

When will I receive a membershipcard?Once your application has been processed, you will receivea membership card, the Individual Dental Prepaid PlanAgreement, and a complete list of copayments.

What if I need to change my dentist?You may make a request to change dentists at anytime bysimply calling Customer Service at 800.443.2995 to selectanother participating provider.

Who is eligible?You, your spouse and legal dependents under the age of28 are eligible for dental benefits.

2

3

Plan Features

How does the plan work?Dentists who participate in this prepaid dental plan haveagreed to offer services to plan members at a discount.Members pay the Plan Dentist his or her discounted feedirectly. These discounted fees are called copayments. Notall services are subject to discounts. A sample of the copay-ments for this plan is included in this brochure.

Cosmetic dentistryWe know how important a great smile is to you, as well asthe benefits of having the smile that you want and deserve.That’s why we have included some cosmetic procedures,such as bleaching and bonding, in the list of copayments.

Vision discount benefitsA vision discount plan is included with your dental plan.The vision plan includes discounts on eye exams, eyeglass-es, and other perscription eyewear when provided by par-ticipating providers. Upon your enrollment, informationregarding the vision plan will be mailed to you.

Orthodontic benefitsThe Select Plan includes discounts on Orthodontic proce-dures for children and adults. Plan Orthodontists providediscounts of 25% off his or her list charge. Orthodonticservices are available only in areas where DentiCare hasPlan Orthodontist(s) or Plan Dentist(s) who provides thoseservices. Orthodontic treatment begun prior to your planeffective date is not eligible for this discount.

Specialist benefitsShould the service of a specialist (Oral Surgeon, Endodon-tist, Orthodontist, Periodontist, or Pedodontist) be neces-sary you may seek treatment from any Plan Specialist list-ed in our printed or online directory. If an Oral Surgeon,Orthodontist, Periodontist or Pedodontist provides treat-ment you will receive 25% off list charges. For treatmentby an Endodontist you will receive 15% off list charges.Specialist services are available only in areas whereDentiCare has Plan Specialist(s).

Please note that payment for a service performed by a Non-Plan Specialist is your responsibility.

How do I join?Three easy steps to enrolling in the Select Plan:

Select a general dentist from the Plan Dentist Directory or online at www.assurantemployeebenefits.com under Find a dentist for Georgia Prepaid. Each family member may choose a different Plan Dentist.

� No deductibles

� No claim forms

� No annual dollar maximum for plandentists and specialists

� Fixed Copayment Schedule

� Discounts on Orthodontic procedures for children and adults

� No referral required for Specialist benefits

� Benefits for pre-existing dental conditions

Economical Annual Prepayment FeeIndividual . . . . . . . . . . . . . . . . . . . . . . . . $127.20Individual & One Dependent . . . . . . . . $211.56Family . . . . . . . . . . . . . . . . . . . . . . . . . . . $328.44

orAutomatic Monthly Bank Draft

Accounts are drafted on the 15th of eachmonth prior to the month of benefits.

Individual . . . . . . . . . . . . . . . . . . . . . . . . . $11.60Individual & One Dependent . . . . . . . . . $18.63Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . $28.37

$35.00 Enrollment Fee

Prepayment Fee Options

Select Individual Prepaid Dental PlanThe Select plan provides dental benefits with attractiveprepayment fees. To receive the benefits of the Select planyou will need to select a Plan Dentist for you and yourfamily members from the list of Plan Dentists. Pleasenote that you may choose a different Plan Dentist for eachfamily member.

Limitations and Exclusions1. Medical costs associated with dental procedures. 2. Dental services or procedures which are not listed on theBenefits and Copayment Schedule. 3. Emergency Services received from a dentist who is notMember’s selected Plan Dentist. 4. Certain services may only be obtained once in any sixcalendar months, with a maximum of twice in the samecalendar year. Those services are listed on the Benefits andCopayment Schedule as ADA Codes 0120, 0150, 0272 and0274.

5. Certain services may only be obtained once in any 3 cal-endar years. Those services are listed on the Benefits andCopayment Schedule as ADA Codes 0210 and 0330.

6. Services rendered by a Plan Provider because of behav-ior adjustment. Such services include, but are not limitedto, physical restraint or sedation.

7. Replacement of dentures or appliances received dur-ing enrollment in Plan, if Member has had dentures orappliance less than five years. (Note: If dentures orappliance becomes unserviceable due to illness or causesnot controlled by ordinary means, the following willapply. Replacement will be made only if existing den-ture or appliance cannot be made serviceable.)

8. Replacement of dentures, appliances or bridgeworkdue to loss or theft.

9. Dental treatment provided or started prior toMember’s eligibility to receive benefits.

10. Dental treatment started after Member’s termination.

11. Dental treatment caused by failure to follow pre-scribed treatment.

12. Ongoing orthodontic treatment past eighteen (18)consecutive months.

13. Orthodontic treatment involving therapy formyofunctional problems, T.M.J. dysfunctions, microg-nathia, macroglossia, cleft palate or hormonal imbal-ances causing growth and developmental abnormalities.

14. Orthodontic cases involving orthognathic surgery.

15. Treatment for malignancies, neoplasms or cysts(including biopsies).

16. Lab fees associated with services listed on theBenefits and Copayments Schedule.

17. Restorations and splints used to increase verticaldimension, restore occlusion, or replace/stabilize toothstructure loss by attrition.

18. Fixed prosthetic restoration of six (6) or more existingteeth, when performed as a single procedure or as partof a complete oral rehabilitation or reconstruction.

19. Complete oral rehabilitation or reconstruction involv-ing replacement of six (6) or more missing teeth usingfixed prosthetic restorations and/or appliances.

20. Dental treatment if Member’s general health or phys-ical limitations prevent Plan Provider from renderingappropriate dental treatment.

21. Costs associated with prescriptions or over the count-er medications.

22. Implants, surgery for the insertion of implants, allrelated implant appliances and restorations, whetherremovable or fixed.

23. Surgical removal of implants, or any surgery requiredto adjust, replace, or treat any problem related to anexisting implant, or implant appliance.

1

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