Common use of Eligible Expenses Clause in Contracts

Eligible Expenses. for current listing of eligible expenses please check out the American Fidelity Assurance Company website address: xxxx://xxx.xxxxxxxxxxx.xxx/for-individuals/flexible-spending-accounts/health-flexible- spending-accounts/health-fsa-eligible-expenses.aspx Partial List of Eligible Expenses: Acupuncture Obstetrics Alcohol and drug rehabilitation Optometrist Ambulance Orthodontia expenses-as treatment is provided* Anesthetist Osteopath Artificial limbs and teeth Outpatient care Birth control pills Pediatrician Chiropodist Physical therapy by licensed therapist Chiropractor Physician Podiatrist Practice nurse Dental care Prescription drugs Eye exam, eyeglasses, contact Psychiatrist Lenses Psychologist Gynecologist Rental or purchase of medical equipment Hospital and skilled nursing facility Supportive or corrective devices Insulin Surgery Laboratory fees Transportation expenses relative to illness Medical examinations Midwife Nursing care Home health care persons Lip-reading lessons (including doctor’s office at current IRS rate) Hearing aids and batteries including special equipment for handicapped * We cannot accept a claim for the entire contracted amount of orthodontia treatment. We will accept claims for the initial down payment usually associated with the appliances. Monthly payments will also be accepted as the charge for the medical services rendered for that month. Maximum amount that may be contributed to the plan is $2,650 per year.

Eligible Expenses. for current listing of eligible expenses please check out the American Fidelity Assurance Company website address: xxxx://xxx.xxxxxxxxxxx.xxx/for-individuals/flexible-spending-accounts/health-flexible- spending-accounts/health-fsa-eligible-expenses.aspx Partial List of Eligible Expenses: Acupuncture Obstetrics Alcohol and drug rehabilitation Optometrist Ambulance Orthodontia expenses-as treatment is provided* Anesthetist Osteopath Artificial limbs and teeth Outpatient care Birth control pills Pediatrician Chiropodist Physical therapy by licensed therapist Chiropractor Physician Podiatrist Practice nurse Dental care Prescription drugs Eye exam, eyeglasses, contact Psychiatrist Lenses Psychologist Gynecologist Rental or purchase of medical equipment Hospital and skilled nursing facility Supportive or corrective devices Insulin Surgery Laboratory fees Transportation expenses relative to illness Medical examinations Midwife Nursing care Home health care persons Lip-reading lessons (including doctor’s office at current IRS rate) Hearing aids and batteries including special equipment for handicapped * We cannot accept a claim for the entire contracted amount of orthodontia treatment. We will accept claims for the initial down payment usually associated with the appliances. Monthly payments will also be accepted as the charge for the medical services rendered for that month. Maximum amount that may be contributed to the plan is $2,650 2,500 per year.

Eligible Expenses. for current listing of eligible expenses please check out the American Fidelity Assurance Company website address: xxxx://xxx.xxxxxxxxxxx.xxx/for-individuals/flexible-spending-accounts/health-flexible- spending-accounts/health-fsa-eligible-expenses.aspx Partial List of Eligible Expenses: Acupuncture Obstetrics Alcohol and drug rehabilitation Optometrist Ambulance Orthodontia expenses-as treatment is provided* Anesthetist Osteopath Artificial limbs and teeth Outpatient care Birth control pills Pediatrician Chiropodist Physical therapy by licensed therapist Chiropractor Physician Podiatrist Practice nurse Dental care Prescription drugs Eye exam, eyeglasses, contact Psychiatrist Lenses Psychologist Gynecologist Rental or purchase of medical equipment Hospital and skilled nursing facility Supportive or corrective devices Insulin Surgery Laboratory fees Transportation expenses relative to illness Medical examinations Midwife Nursing care Home health care persons Lip-reading lessons (including doctor’s office at current IRS rate) Hearing aids and batteries including special equipment for handicapped * We cannot accept a claim for the entire contracted amount of orthodontia treatment. We will accept claims for the initial down payment usually associated with the appliances. Monthly payments will also be accepted as the charge for the medical services rendered for that month. Maximum amount that may be contributed to the plan is $2,650 2,850 per year.