CONFIRMATION LETTER

Insured Person:

Insurance ID: Insurance Plan:

Group number: Policy Number:

Effective Date: Termination Date:

Summary Schedule of Benefits:

Lifetime Maximum Medical Benefit:

Annual Maximum Benefit

Per Injury/Sickness Maximum:

Deductible per Event:

SHC / In-network / Out-of-network:

Co-pay Student Health Center:

Co-pay Physician:

Annual Maximum Deductible:

Emergency Medical Evacuation:

Repatriation of Remains:

Insurance Carrier:

Insurance Carrier address & phone:

A.M. Best Rating:

� Policy benefits are in effect while insured person is eligible for coverage. Policy is valid worldwide with limited or no coverage at insured home country/country of permanent residence.

� Please refer to the brochure for complete benefits.

Claims are handled by HealthSmart, 3320 West Market Street, Suite 100, Fairlawn, OH 44333

ISO - Trusted experience always on your side!

DEBALINA GHOSH

225184202 COMPASS Silver

ISOD331 UFL4110S

1/1/2014 6/1/2014

$400,000

N/A

$150,000

$45 / $100 / $100

N/A

N/A

N/A

$60,000

$50,000

United States Fire Insurance Company

150 W 30th Street, New York, NY 10001. 800-244-1180.

A

Medical Expense Benefit: After deductible and subject to policy limitations and exclusions, the plan will pay100% up to the benefit limits described under Covered Medical Expenses.