"(Company Name)

Basic Medical-Surgical Expense Coverage

Required Outline of Coverage (heading in caps)

(1) Read Your Policy Carefully. This outline of coverage provides a very brief description of some of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth, in detail, the rights and obligations of both you and your insurance company. It is, therefore, important that you Read Your Policy Carefully! (previous four words in caps).

(2) Basic medical-surgical expense coverage is designed to provide you with coverage for the expenses which you incur for the necessary services of a physician for treatment of a covered injury or sickness. Coverage is provided for the benefits outlined in paragraph (3). The benefits described in paragraph (3) may be limited by paragraph (4).

(3) Benefits.

(4) Exclusions, Limitations, and Reductions.

(5) Renewability.

(6) Premium."