plus DENTAL Willamette Dental of Idaho, Inc W. Emerald St., Suite 108, Boise, ID DENTAL INSURANCE Idaho

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1 Summary of Exclusions Coverage does not include: Conscious sedation/general anesthesia Any condition resulting from military service or war Injuries sustained while practicing or competing in a professional athletic contest Bleaching of a tooth Cast dowel post Endodonics, bridges, crowns or other services or prosthetic devices or fittings if treatment was ordered prior to the Patient's effective date or if the item was installed or delivered more than 60 days after the Patient's coverage under the Policy has terminated Charges by any person other than a licensed dentist, licensed denturist, or licensed hygienist Charges that the patient would have had no obligation to pay in the absence of this Policy Charges incurred to comply with Occupational Safety and Health Administration (OSHA) requirements Any benefits paid or payable by Medicare unless required by law Full-mouth reconstruction Cosmetic dentistry or surgery Dental implants or implant supported prosthetics Excision of a tumor; biopsy of soft or hard tissue; removal of a cyst or exostosis Dental services started prior to coverage under the Policy Extraction of permanent teeth for tooth guidance procedures; procedures for tooth movement; correction of malocclusion, preventive orthodontic procedures, or other orthodontic treatment Habit or stress breaking appliances. Dental procedures in a hospital. Intentionally self-inflicted injuries Investigational services or supplies Materials not approved by American Dental Association For occupational injury or disease Occlusal guards Personalized restoration, precision attachments, and special techniques Prescription drugs, medications or supplies. Accidental injury to teeth more than 12 months after date of accident Repair or replacement of lost, stolen or broken items Replacements of an existing denture, crown, or bridge less than 5 years from the most recent placement Replacement of sound restorations Services or supplies that are not listed as covered Services not necessary or not approved by Licensed Dentist Services for Temporomandibular Joint Disorders (TMJ) Veneers; composite surfaces on posterior teeth Splints, nightguards, and other appliances used to increase vertical dimension and restore bite Orthognathic surgery DENTAL To receive the benefits under this plan you must receive services from a Willamette Dental Office. If you elect to go to a non-willamette Dental Office, then you will be responsible for any charges exceeding $10. Dental Plus Customer Service Number This dental plan is provided by Willamette Dental of, Inc W. Emerald St., Suite 108, Boise, ID THE POLICY PROVIDES DENTAL BENEFITS ONLY. PLEASE REFER TO YOUR POLICY FOR A COMPLETE DESCRIPTION OF EXCLUSIONS AND LIMITATIONS. DENTAL INSURANCE Form No DP (7/09) Policy No ID (1/1/02)

2 DENTAL Dental Offices With more than 50 dental office locations conveniently located throughout, Washington and Oregon there is probably a Willamette Dental Office near your work or home. Locations Boise 8950 W. Emerald St. Boise, ID Coeur d'alene 943 W. Ironwood Dr. Coeur d'alene, ID EASTERN WASHINGTON Pullman 1646 S. Grand Ave. Pullman, WA Affordable Quality Dental Care for You & Your Family Falls 2860 Valencia Dr. Suite 100 Falls, ID Meridian 2365 Gala St. Suite 1 Meridian, ID Spokane - Northpointe 9717 N. Nevada Spokane, WA Spokane - South Hill 501 S. Bernard, Ste 203 Spokane, WA No Annual Maximums No Deductibles No Claim Forms Emergency Dental Care Low Co-Pays on Preventative Services Orthodontia for All Ages To Find A Dental Office Near You

3 Willamette Dental is pleased to offer you Dental Plus. This plan is true individual dental insurance that will cover the cost of dental care above and beyond a plan member s co-payment. There is no maximum to the amount of dental services that this plan will cover, nor are there any deductibles that need to be met. Your coverage gives you simple access to total dental care. From the benefit summary you can see that routine and preventive services are available to you at a low co-payment. Major services like crowns, bridges and dentures are provided at substantial savings with predictable costs. Orthodontia is available with this plan for both adults and children after a six month waiting period. Plan participants do not need to fill out or submit claim forms. As a plan member, you simply schedule your appointments, see the dentist and pay at that visit. Willamette Dental makes access to quality dental care easy, while Dental Plus keeps that care affordable for you and your family. To participate in the Dental Plus of Insurance plan you must be a resident of and receive your care at a Willamette Dental Office. An advance appointment is required to receive care. For your dental appointments, please call When you speak to a Willamette Dental representative or arrive at the dental office for your appointment, simply identify yourself as a Dental Plus member. You will then receive dental care in accordance with your plan. Most offices are open Monday through Saturday, 7 AM to 6 PM. In making your appointments you can anticipate being seen within the following time-lines: Emergencies Within Approximately 24 Hours First Appointment (new Patients): 30 Days Regular Hygiene (Cleanings): 45 Days Operative (Restorative Treatment): 60 Days With the exception of emergencies, the number of days are averages. The length of wait-time for an appointment may vary based on your choice of dentist, location, and your desired day or time of appointment Benefit Summary Benefit Annual Maximum Deductible Co-Payment No Annual Maximum No Deductible Office Visit Covered at 100% Dental Exams $20 Bitewings X-ray $20 Panoramic X-ray $20 Teeth Cleaning with $50 Fluoride Treatment Sealants $30 Head & Neck Cancer Screening Covered at 100% Oral Hygiene Instruction Covered at 100% Periodontal Charting Covered at 100% Periodontal Evaluation $20 Filling $50 Permanent Crowns $300 Complete Upper or $425 Lower Denture Bridge per tooth $300 All Lab Fees Covered at 100% Root Canal Therapy Anterior $200 Bicuspid $200 Molar $200 Osseous Surgery (Per Quadrant) $250 Root Planing (Per Quadrant) $50 Routine Extraction $50 Surgical Extraction $100 Pre-Orthodontic Service $150* Comprehensive $3,000** Orthodontia *Six month waiting period for orthodontia only. Local Anesthesia (Novocain) Covered at 100% Nitrous Oxide (Per Visit) $20 After Hours Emergency Care $30 Missed Appointment Fee $10 *Applies toward comprehensive orthodontic co-payment if patient accepts treatment plan. ** Six month waiting period applies for orthodontia.

4 Premium Member Only Member/Spouse Member/Children Family Semi-Annual $ $ $ $ Annual $ $ $ $ Premium payment can be semi-annual or annual and is payable by credit card, check or money order. The Company reserves the right to change the Premium Rate, Benefits and any other provisions of the Contract subject to 30 days written notice to the Subscriber. Dental Plus of must be renewed annually to continue your membership. Make checks payable & mail to: Willamette Dental Insurance, Inc. Dental Plus 6950 NE Campus Way Hillsboro, OR For Credit Card Payment, please complete the following: o Visa o MasterCard o Discover Card Credit card number: CSC (3 digit card security code): Expiration date: Signature: Date: Agreement To the best of my knowledge and belief, the statements and answers shown in this application form (front and back) are true and complete. I understand the following: (a) if any information stated in this application is incorrect, coverage may be voided; (b) if the application is declined and coverage is not issued, Willamette Dental of, Inc. s only obligation will be to return any premium paid; and (c) the policy effective date will be the first day of the month if your check and application are received by the 25th of the previous month. In no event will the policy effective date be the same as the date of receipt. Delivery of the contract will be subsequent to the Company receiving the completed application and premium. I hereby apply for coverage under policy form 1918-ID provided by Willamette Dental of, Inc. Applicant s signature: Date: How to Enroll To enroll in the Dental Plus plan, simply complete the entire application form and submit it along with payment. No physical examinations are required to be considered for coverage and there is no waiting period** for access to most dental services once you have obtained coverage. Your premiums may be paid either semi-annually or annually. Payment must be received by the 25th of the month preceding the renewal date or effective date for coverage to be active. Family coverage may include a legal spouse and unmarried dependent children through 24 provided the child receives more than one-half (1/2) of his or her financial support from the Member. Please note that dependent children are not eligible for single coverage. This policy renews on an annual basis except in the case of nonpayment of premium, fraud, intentional misrepresentation or if the company no longer offers this type of policy in. In you wish additional information please call or visit us on the web at: ** Six month waiting period applies for orthodontia.

5 IDAHO Willamette Dental Dental Plus Application Form Please print or type Shaded areas are for producer or office use only Account Number: DENTAL Name of Subscriber: Last, First, Middle Initial Address: City: State: Zip: ID Home Phone: Date of Birth: M/F: Effective Date: Renewal Date: Subscriber (check one): o Subscriber Only o Subscriber/Spouse o Subscriber/Children o Family Premium Payment Mode (check one): o Semi-Annual o Annual List All Persons Below That You Wish to Enroll Spouse Name: Date of Birth: M/F: Pay Commissions To: Agent Agency Agent SSN or Agency Tax ID: Agent or Agency Name: Agent or Agency Address: Agent or Agency State License Number: Phone: Form No. 1921A-DP (4/09)