"The policy described in this outline provides limited benefits only which are less than the minimum standards for benefits for (state category of coverage) as prescribed by the insurance regulatory authority of your state.

(Company Name)

Limited Benefit (state category of 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)

This policy is designed to provide you with limited (state category of coverage: basic hospital expense, basic medical-surgical expense or disability income protection) coverage, but it provides benefit amounts which are less than those prescribed by the insurance regulatory authority of your state as minimum benefit amounts for this type of coverage. 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."