To comply with section 52.54 of this Part, policies of individual insurance meeting the definition of section 52.10 of this Part, which provide only dental insurance coverage, shall use the following statement only, except that appropriate policy identification may be included:

COMPANY NAME

DENTAL INSURANCE

REQUIRED DISCLOSURE STATEMENT

This policy provides dental insurance only and pays for dental care subject to a copayment by you of to __%^* and a deductible of ($ to __ per person)^** ($__ per family) ($__ per year) ($ __ per benefit period) and a total maximum of $__

This policy:

( Accurately list benefits, exclusions, reductions and limitations of the policy in a manner which does not encourage misrepresentation of the actual coverage provided.)

This disclosure statement is a very brief summary of your policy.

The policy itself sets forth the rights and obligations of both you and the Insurance Company. It is therefore important that you READ YOUR POLICY carefully.

The expected benefit ratio for this policy is ___%. This ratio is the portion of future premiums which the company expects to return as benefits, when averaged over all people with this policy.