2.   Name of Participating Group:

3.   Permanent Mailing Address: 

4.  EFFECTIVE DATE_________________  (Will be determined by the insurance agency)

5.   SELECT WHICH COVERAGE OPTION YOU WANT

The PRIMARY option pays first.  It pays covered expenses regardless of what other health insurance
plans the injured party may have.  The EXCESS option will pay only after other plans pay first.  If the
injured person has no other medical coverage plan, your excess coverage will automatically become
primary coverage for that person.  Excess offers greater flexibility by filling in other plan's deductibles
and coinsurance as well as paying remaining covered expenses after other plans have exhausted their
benefits.
 

   PRIMARY   EXCESS
 
 

6.  MAXIMUM BENEFIT AMOUNT FOR EACH PLAN OPTION
      [Review carefully before selecting Plan Option in item #7 below]

:

ACCIDENTAL DEATH AND DISMEMBERMENT, LOSS OF SIGHT, SPEECH, HEARING & THUMB & INDEX FINGER 

Plan 1	Plan 2	Plan 3	Plan 4	Plan 5
$ 5,000.	$10,000.	$20,000.	$30,000.	$ 30,000.

 
 

ACCIDENTAL MEDICAL EXPENSE BENEFIT AMOUNTS

Plan 1	Plan 2	Plan 3	Plan 4	Plan 5
$2,500.	$5,000.	$10,000.	$25,000	$50,000.

 
 

IN-HOSPITAL INDEMNITY BENEFIT AMOUNTS 

Plan 1	Plan 2	Plan 3	Plan 4	Plan 5
$25.	$50.	$75	$100.	$100.

 
 

ACCIDENT REPATRIATION EXPENSE 

Plan 1	Plan 2	Plan 3	Plan 4	Plan 5
$1,000.	$2,000.	$2,500.	$5,000.	$5,000.

7.  SELECT WHICH PLAN YOU WANT:
      [Item 6 above gives you details regarding each option]
 

PLAN  BENEFITS	PRIMARY COVERAGE	EXCESS COVERAGE
Plan 1	$2.70	$2.00
Plan 2	$4.10	$3.30
Plan 3	NA	$5.50
Plan 4	NA	$7.50
Plan 5	NA	$11.50

8.  IT IS UNDERSTOOD & AGREED THAT:  [a] the participating group is located in the United States of America; [b]the premium  will be paid entirely by the participating group with no contribution made by the eligible persons toward the cost of the  insurance; and [c] the premium will be paid annually in advance based on the total number of eligible persons anticipated to be insured during the coverage term.

9.  DATE:

10.  NAME & TITLE OF GROUP OFFICIAL.

11.  TELEPHONE

12.  FAX

13.  E-MAIL

    THE TOTAL NUMBER OF ELIGIBLE PERSONS TO BE COVERED BY THE POLICY

X

    ANNUAL PREMIUM RATE PER ELIGIBLE PERSON
                             (SEE ITEM 7 ABOVE FOR PER PERSON RATES)

=

    TOTAL PREMIUM DUE [SUBJECT TO ANNUAL PREMIUM MINIMUM]*
 
 

   SIGNATURE
 

   DATE
 
 

ACCIDENTAL DEATH & DISMEMBERMENT - If accidental bodily injuries result in any of the following losses within one year after the date of the accident, the plan provides the following benefits:

The company will pay 100% of the AD & D benefit amount if there is Accidental Loss of: life, both hands, or both feet, one hand and one foot, the entire sight of both eyes, speech and hearing, or the entire sight of one eye and one hand.

The company will pay 75% of the AD & D benefit amount if there is Accidental loss of: One hand or one foot, the entire loss of sight of one eye, or loss of speech or hearing.

The company will pay 25% of the AD & D benefit amount if there is Accidental Loss of the thumb and index finger.

The term "Loss" means, with respect to a hand, complete severance through or above the knuckle joints of at least 4 fingers on the same hand; with respect to a foot, complete severance through or above the ankle joint.  The Company will consider it a loss of hand or foot even if they are later reattached.  Only one amount, the largest to which you are entitled, is paid for all losses resulting from one accident.

MEDICAL EXPENSE -  If as a result of an accidental bodily injury, the insured incurs medically necessary expenses from medical services, the company will pay the reasonable and customary charges for those expenses up to the maximum benefit amount subject to any specified deductible amounts and in *excess of other benefits if applicable. Medically necessary means any medical or dental service, supply or course of treatment which is ordered by a licensed physician or dentist. Medical services means the cost for the following medically necessary services:  medical care and treatment by a physician or dentist, diagnostic test and x-rays, use of a professional ambulance, and dental care to injury of functional, natural teeth.  The medical expense benefit does not apply to the following charges and services: (1) charges for which the Insured has no obligation to pay, (2) eyeglasses, contact lenses and other vision or hearing aids and artificial limbs, (3) any injury for which Worker's Compensation benefits or occupational injury benefits are payable.

*If the coverage is payable on an excess basis, the company will determine the reasonable and customary charges for the covered medical expense.  The company will then reduce that amount by amounts already paid or payable by any other plan from which the Insured is entitled to receive benefits.  The company will pay the resulting amount, plus amounts paid by the insured to satisfy cash deductibles or coinsurance amounts.  In no event will the company pay more than the specified medical expense benefit amount.

IN-HOSPITAL BENEFIT - If an accidental bodily injury causes an Insured to be hospitalized for more than 7 days, this coverage pays a specified daily benefit amount for each day of hospitalization beyond 7 days, up to a maximum of 365 days.  To be eligible for In-Hospital Benefits, the covered person must be registered as an in-patient and confined to a hospital while being treated by a physician.  Confinement solely for the purposes of convalescing or receiving nursing care is not covered.

REPATRIATION EXPENSE BENEFIT - If an insured suffers accidental loss of life while traveling, the company will pay the reasonable and customary repatriation expenses incurred up to the specified maximum benefit amount, to return the insured's remains to the insured's place of residence.  Repatriation Expenses means the charges incurred for the necessary embalming, cremation, transportation and purchase of a shipping container.

................................................................................................................................

If more than one insured suffers a loss in the same accident, the company will pay no more than the maximum limit of $100,000.  If an accident results in benefit amounts becoming payable, which when totaled, exceed the maximum limit of $100,000., the maximum limit will be divided proportionately among the Insureds based on each applicable benefit amount.

EFFECTIVE DATE OF COVERAGE

The effective date of the master policy is 5/1/98 12:01 A.M. Standard Time at the Policyholder's address.  Your coverage will be effective on the first day of the month following receipt of your completed enrollment form and full premium payment.  Your coverage will end on the date you are no longer eligible, or the 365th day after your coverage effective date, or the master policy is terminated, which first occurs.

The Plan Administrator:  Ponta, Castle & Ingram Agency Inc. 700 East Maple Road Birmingham MI 48009 telephone:  (800) 259 - 6720 facsimile:  (248) 258 - 1964

Plan Underwritten By:   Federal Insurance Company a member insurer of the Chubb Group of Insurance Companies

Best's 1997 Rating for Federal Insurance Company is A++ (Superior).  A.M. Best Co. has been a leading independent source of insurer financial ratings since 1899.