SHINE HWANG, DBA: SUNSHINE MUSIC

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SCHEDULE OF BENEFITS COVERAGE IS PROVIDED UNDER GROUP POLICY NUMBER: AH-GA26932-002 ISSUED TO GROUP POLICYHOLDER: The Group and Blanket Accident & Health Insurance Trust CERTIFICATEHOLDER: Sunshine Music CERTIFICATE NUMBER: US1298016 CERTIFICATE EFFECTIVE DATE: 10/01/2019 12:01 AM CERTIFICATE EXPIRATION DATE: 10/01/202012:01 AM Benefits are payable for 12 months from the date of an Injury, The Injury must occur after the Effective Date and prior to the Expiration Date and care must be Medically Necessary. PREMIUM: $150.00 DEDUCTIBLE AMOUNT: $100.00 COINSURANCE PERCENTAGE: 1GO% of Usual, Reasonable & Customary Charges, URC MAXIMUM BENEFIT AMOUNT: $10,000.00 ELIGIBLE PERSONS: All Participants & Staff of the Policyholder's Programs SPECIFIED ACTIVITY: Music Lessons for kids MEDICAL EXPENSE BENEFIT Hospital Room & Board Daily Maximum Benefit Amount: URC Intensive Care Room & Board Daily Maximum Benefit: URC Hospital Miscellaneous Maximum Benefit Amount: URC Outpatient Pre -Admission Testing Benefit Amount: URC Outpatient Hospital Emergency Room Treatment Maximum Benefit Amount: URC Surgical Benefits Primary Surgeons Maximum Benefit Amount: URC Assistant Surgeon, Second Surgical Opinion, Consultation Maximum Benefit: URC Anesthesia Maximum Benefit: URC Surgical Facility Maximum Benefit per Operating Session: URC Doctor's Visits In -Hospital Maximum Benefit: URC Office Visits Maximum Benefit: URC Maximum for All In -Hospital and Office Doctor's Visits: URC X-ray and Laboratory Maximum Benefit Amount: URC Nursing Maximum Benefit Amount: URC Physiotherapy Benefit Maximum Benefit Amount (Hospital Inpatient): URC Maximum Benefit Amount (Outpatient): URC Maximum for All Physiotherapy Combined (Inpatient & Outpatient): URC Ambulance Maximum Benefit Amount: URC GAC26932