{"content":[{"text":"SCHEDULE OF BENEFITS \n HIGH PLAINS GOLD \n Health Insurance Policy","bbox":{"left":0.367484,"top":0.043409,"width":0.24284299999999998,"height":0.055712999999999985}},{"text":"Policy Number: [123456]","bbox":{"left":0.058824,"top":0.177182,"width":0.19259400000000004,"height":0.017484999999999973}},{"text":"Policy Effective Date:","bbox":{"left":0.529477,"top":0.177246,"width":0.1661640000000001,"height":0.017420999999999992}},{"text":"[January 1, 2021]","bbox":{"left":0.704771,"top":0.177182,"width":0.12621899999999997,"height":0.01738300000000001}},{"text":"Policyowner:","bbox":{"left":0.058824,"top":0.206261,"width":0.10168999999999999,"height":0.017420999999999992}},{"text":"[John Doe]","bbox":{"left":0.169641,"top":0.206198,"width":0.07909600000000003,"height":0.01738300000000001}},{"text":"Policy Anniversary Date:","bbox":{"left":0.529477,"top":0.206261,"width":0.19255699999999998,"height":0.017420999999999992}},{"text":"[January 1 of each Year]","bbox":{"left":0.731046,"top":0.206198,"width":0.17811699999999997,"height":0.01738300000000001}},{"text":"Issue Age:","bbox":{"left":0.058824,"top":0.235213,"width":0.081806,"height":0.017484}},{"text":"[35]","bbox":{"left":0.149651,"top":0.235213,"width":0.027309,"height":0.017382999999999982}},{"text":"Initial Premium:","bbox":{"left":0.529477,"top":0.235276,"width":0.12264600000000003,"height":0.017420999999999992}},{"text":"[$]","bbox":{"left":0.661144,"top":0.235213,"width":0.018178999999999945,"height":0.017382999999999982}},{"text":"Type of Coverage:","bbox":{"left":0.058824,"top":0.264367,"width":0.142588,"height":0.01742100000000002}},{"text":"[Individual/Family]","bbox":{"left":0.210523,"top":0.264304,"width":0.13082399999999997,"height":0.017382999999999982}},{"text":"Mode of Payment: [Monthly]","bbox":{"left":0.529477,"top":0.264304,"width":0.21616199999999997,"height":0.017484000000000055}},{"text":"Benefit Period:","bbox":{"left":0.058824,"top":0.293382,"width":0.11622900000000001,"height":0.01742100000000002}},{"text":"Calendar Year","bbox":{"left":0.18415,"top":0.293319,"width":0.105407,"height":0.017382999999999982}},{"text":"Premium Due Date: [The first day of each month]","bbox":{"left":0.529477,"top":0.293319,"width":0.362472,"height":0.017484}},{"text":"Benefit Plan: HIGH PLAINS GOLD","bbox":{"left":0.058824,"top":0.322473,"width":0.26152200000000003,"height":0.01742100000000002}},{"text":"BENEFIT INFORMATION","bbox":{"left":0.068039,"top":0.366576,"width":0.18798900000000002,"height":0.017382999999999982}},{"text":"IN-NETWORK","bbox":{"left":0.597222,"top":0.366576,"width":0.105379,"height":0.017382999999999982}},{"text":"OUT-OF-NETWORK","bbox":{"left":0.779281,"top":0.366576,"width":0.15165300000000004,"height":0.017382999999999982}},{"text":"Maximum Lifetime Benefit","bbox":{"left":0.068039,"top":0.405667,"width":0.188137,"height":0.017382999999999982}},{"text":"Unlimited","bbox":{"left":0.61585,"top":0.405667,"width":0.06817499999999999,"height":0.017382999999999982}},{"text":"Unlimited","bbox":{"left":0.820948,"top":0.405667,"width":0.06817499999999999,"height":0.017382999999999982}},{"text":"Deductible","bbox":{"left":0.068039,"top":0.444834,"width":0.077197,"height":0.017382999999999982}},{"text":"Individual Deductible (per Covered Person per Calendar Year)","bbox":{"left":0.070882,"top":0.484102,"width":0.483571,"height":0.017484}},{"text":"$1,000","bbox":{"left":0.624869,"top":0.484001,"width":0.05006699999999997,"height":0.017383000000000037}},{"text":"$2,250","bbox":{"left":0.830065,"top":0.484001,"width":0.05006699999999997,"height":0.017383000000000037}},{"text":"Family Deductible (per family per Calendar Year)","bbox":{"left":0.070882,"top":0.536475,"width":0.380989,"height":0.017484000000000055}},{"text":"$2,000","bbox":{"left":0.624869,"top":0.536374,"width":0.05006699999999997,"height":0.017383000000000037}},{"text":"$4,500","bbox":{"left":0.830065,"top":0.536374,"width":0.05006699999999997,"height":0.017383000000000037}},{"text":"Annual Out-of-Pocket Maximum","bbox":{"left":0.068039,"top":0.595086,"width":0.23160699999999995,"height":0.017383000000000037}},{"text":"Individual Annual Out-of-Pocket Maximum","bbox":{"left":0.070882,"top":0.634392,"width":0.332754,"height":0.01742100000000002}},{"text":"$6,000","bbox":{"left":0.624869,"top":0.634253,"width":0.05006699999999997,"height":0.017383000000000037}},{"text":"$17,250","bbox":{"left":0.825556,"top":0.634253,"width":0.05910499999999996,"height":0.017383000000000037}},{"text":"(per Covered Person per Calendar Year)","bbox":{"left":0.068039,"top":0.673597,"width":0.310604,"height":0.017484000000000055}},{"text":"Family Annual Out-of-Pocket Maximum","bbox":{"left":0.070882,"top":0.71265,"width":0.30814600000000003,"height":0.01742100000000002}},{"text":"$12,000","bbox":{"left":0.620359,"top":0.712511,"width":0.05910499999999996,"height":0.017383000000000037}},{"text":"$34,500","bbox":{"left":0.825556,"top":0.712511,"width":0.05910499999999996,"height":0.017383000000000037}},{"text":"(per family per Calendar Year)","bbox":{"left":0.068039,"top":0.751854,"width":0.23250699999999996,"height":0.017484000000000055}},{"text":"Coinsurance","bbox":{"left":0.068039,"top":0.790844,"width":0.091768,"height":0.017383000000000037}},{"text":"30%","bbox":{"left":0.633497,"top":0.790844,"width":0.032789999999999986,"height":0.017383000000000037}},{"text":"50%","bbox":{"left":0.838693,"top":0.790844,"width":0.032789999999999986,"height":0.017383000000000037}},{"text":"HIGH PLAINS GOLD-SOB","bbox":{"left":0.058824,"top":0.938218,"width":0.194382,"height":0.017383000000000037}},{"text":"1","bbox":{"left":0.409542,"top":0.938218,"width":0.009103000000000028,"height":0.017383000000000037}}],"images_bbox":[],"images_bbox_not_text_overlap":[]}