National Union Fire Insurance Company of Pittsburgh, Pa.
Insured: ________________________
Group Name: Adelphi University
Policy #: CHH0084931	Effective Date: __________
OPTION I PLAN
Identification No.: ________________________

The Covered Person on the reverse side of this card, and such dependents as are listed on the enrollment form are entitled to the benefits stated in the plan. For benefits please call: Maksin Management Corp. 1-877-775-5430 Send your itemized medical and hospital bills to: Maksin Management Corp. PO Box 2647 Camden, NJ 08101-2647 To secure a claim form, go to: www.maksin.com/adelphi.aspx NEIC# 22195

PLEASE FILL IN THE COVERED PERSON'S NAME, I.D. NO.,
AND THE EFFECTIVE DATE ON THE ABOVE TEMPORARY I.D. CARD.