Supplemental Maternity Benefits

Family Planning
Employees who are in a family planning mode may take advantage of the following maternity related benefits as long as the employee or spouse is not pregnant at the time of application. Benefit eligibility is also subject to a 9 month Birth Exclusion rule (NJ: conception occurred prior to the 30th after the effective date of this policy) and a 12 month preexisting conditions rule.

Employee Coverage
Individual Disability can pay the following benefits for delivery: o Maximum 60% of salary up to $6,500.00 monthly benefit o 6 weeks for normal delivery (less the selected elimination period) o 8 weeks for C-section (less the selected elimination period) o Medically related pregnancy complications covered as any other illness, i.e., early disability, etc. (not subject to Birth Exclusion rule) o Medically related complications after delivery, i.e.: blood clots, etc. up to the maximum Benefit Period o Health Screening Benefit

Potential Benefits
$ ____________

50.00

Employee or Spouse Coverage

Medical Bridge Hospital Confinement can pay the following benefits for delivery in New Jersey: o $1,050.00 for normal delivery based on 2 days overnight hospitalization o $1,200.00 for C-section delivery based on 5 days overnight hospitalization o $50.00 per day for each additional 20 hour overnight hospital stay New York Hospital Confinement (Birth Exclusion see mos below, & 12 mo pre-ex): o $2,000.00 admission benefit (10 mo) or $240.00 / day confinement benefit (9 mo) $ ____________

Spouse Coverage
Employees spouse is not eligible for an Individual Disability policy but employee may apply for the Spouse Disability Sickness Rider on the Accident Care plan: Accident Care Disability Sickness Rider For a female spouse, the plan can pay the following benefits for delivery (10 month Birth Exclusion, except NJ): o Maximum 50% of salary up to $1,500.00 monthly benefit (N/A in NY) o 6 weeks for normal delivery o 8 weeks for C-section o Complications of pregnancy as any other illness, i.e. mandatory bed rest, etc. o Complications after delivery, i.e.: blood clots, etc. up to max Benefit Period $ ____________

Newborn Coverage
Well Baby Care Limitation: We will not pay benefits for hospital confinement of a newborn child following his birth unless he is injured or sick. (NJ) However, we will pay for a newborns hospital confinement (following birth) which is the result of a covered sickness or accident including congenital defects, birth abnormalities and/or premature birth. (NY) Medical Bridge Hospital Confinement can pay the following benefits in NJ: o $1,000.00 for the first day of hospital confinement + $50.00 per day, second and subsequent days of hospital confinement, max 75 days per confinement. New York Hospital Confinement (10 mo Birth Exclusion and 12 mo pre-ex): o $2,000.00 admission benefit or $240.00 per day confinement benefit $ ____________

Total Potential Benefits

$ ____________

Birth Limitation: We will not pay benefits for hospital confinement due to any covered person giving birth within the first nine (9) months after the effective date of the policy as a result of a normal pregnancy, including Cesarean. Complications of pregnancy will be covered to the same extent as any other covered sickness.

PLEASE DO NOT return this form completed to your employer! This worksheet is solely for personal educational purposes. Please note: Benefits are subject to state variations, actual policy definitions, final carrier underwriting and issuance of coverage.