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MetLife <br />Benefits Provided by SafeGuard Health Plans, Inc., a MetLife company <br />200 Park Avenue, New York, Now York 10166-0188 <br />COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE STATEMENT <br />SafeGuard Health Plans, Inc. ("SafeGuard"), a MetLife company, certifies that You and Your dependents are <br />covered for the benefits described in this evidence of coverage and disclosure statement , subject to the <br />provisions of this evidence of coverage. This evidence of coverage Is Issued to You under the group contract <br />and it Includes the terms and provisions of the group contract that describe Your benefits. PLEASE READ <br />THIS EVIDENCE OF COVERAGE CAREFULLY. <br />This evidence of coverage is part of the group contract. The group contract is a contract between SafeGuard <br />and Your Organization and may be changed or ended without Your consent or notice to You. <br />THIS EVIDENCE OF COVERAGE ONLY DESCRIBES DENTAL BENEFITS. <br />REVIEW THIS CERTIFICATE CAREFULLY. IF YOU ARE 65 OR OLDER ON YOUR <br />EFFECTIVE DATE OF THIS CERTIFICATE, YOU MAY RETURN IT TO US WITHIN 30 <br />DAYS FROM THE DATE YOU RECEIVE IT AND WE WILL REFUND ANY PREMIUM <br />YOU PAID. IN THIS CASE, THIS CERTIFICATE WILL BE CONSIDERED TO NEVER <br />HAVE BEEN ISSUED, <br />WE ARE REQUIRED BY STATE LAW TO INCLUDE THE NOTICE(S) WHICH APPEAR ON THIS PAGE <br />AND IN THE NOTICE($) SECTION WHICH FOLLOWS THIS PAGE. PLEASE READ THE(SE) NOTICE(S) <br />CAREFULLY. <br />OCERT2011-DHMO-EOC <br />25C-15 <br />