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									                                     GROUP 1 AUTOMOTIVE, INC.
                                        IMPORTANT NOTICE


This Notice is provided to you on behalf of:

                                            Group 1 Automotive, Inc.
                            Don Bohn Ford, Inc. Group Flexible Employee Benefit Plan
                              California Motor Car Dealers Employee Benefits Trust

These plans comprise what is called an “Affiliated Covered Entity,” and are treated as a single plan for purposes of this
Notice and the privacy rules that require it. For purposes of this Notice, we’ll refer to these plans as a single “Plan.”

The Plan’s Duty to Safeguard Your Protected Health Information.
     Individually identifiable information about your past, present, or future health or condition, the provision of health
     care to you, or payment for the health care is considered “Protected Health Information” (“PHI”). The Plan is
     required to extend certain protections to your PHI, and to give you this Notice about its privacy practices that
     explains how, when and why the Plan may use or disclose your PHI. Except in specified circumstances, the Plan
     may use or disclose only the minimum necessary PHI to accomplish the purpose of the use or disclosure.
     The Plan is required to follow the privacy practices described in this Notice, though it reserves the right to change
     those practices and the terms of this Notice at any time. If it does so, and the change is material, you will receive a
     revised version of this Notice either by hand delivery, mail delivery to your last known address, or some other
     fashion. This Notice, and any material revisions of it, will also be provided to you in writing upon your request
     (ask your Human Resources representative, or contact the Plan’s Privacy Official, described below), and will be
     posted on any website maintained by Group 1 Automotive, Inc. that describes benefits available to employees and
     You may also receive one or more other privacy notices, from insurance companies that provide benefits under
     the Plan. Those notices will describe how the insurance companies use and disclose PHI, and your rights with
     respect to the PHI they maintain.

How the Plan May Use and Disclose Your Protected Health Information.
     The Plan uses and discloses PHI for a variety of reasons. For its routine uses and disclosures it does not require
     your authorization, but for other uses and disclosures, your authorization (or the authorization of your personal
     representative (e.g., a person who is your custodian, guardian, or has your power-of-attorney) may be required.
     The following offers more description and examples of the Plan’s uses and disclosures of your PHI.

     •    Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations.

          •    Treatment: Generally, and as you would expect, the Plan is permitted to disclose your PHI for
               purposes of your medical treatment. Thus, it may disclose your PHI to doctors, nurses, hospitals,
               emergency medical technicians, pharmacists and other health care professionals where the disclosure is
               for your medical treatment. For example, if you are injured in an accident, and it’s important for your
               treatment team to know your blood type, the Plan could disclose that PHI to the team in order to allow it
               to more effectively provide treatment to you.
    •    Payment: Of course, the Plan’s most important function, as far as you are concerned, is that it pays for
         all or some of the medical care you receive (provided the care is covered by the Plan). In the course of
         its payment operations, the Plan receives a substantial amount of PHI about you. For example, doctors,
         hospitals and pharmacies that provide you care send the Plan detailed information about the care they
         provided, so that they can be paid for their services. The Plan may also share your PHI with other plans,
         in certain cases. For example, if you are covered by more than one health care plan (e.g., covered by
         this Plan, and your spouse’s plan, or covered by the plans covering your father and mother), we may
         share your PHI with the other plans to coordinate payment of your claims.
    •    Health care operations: The Plan may use and disclose your PHI in the course of its “health care
         operations.” For example, it may use your PHI in evaluating the quality of services you received, or
         disclose your PHI to an accountant or attorney for audit purposes. In some cases, the Plan may disclose
         your PHI to insurance companies for purposes of obtaining various insurance coverage.

•   Other Uses and Disclosures of Your PHI Not Requiring Authorization. The law provides that the Plan
    may use and disclose your PHI without authorization in the following circumstances:

    •    To the Plan Sponsor: The Plan may disclose PHI to the employers (such as Group 1 Automotive, Inc.)
         who sponsor or maintain the Plan for the benefit of employees and dependents. However, the PHI may
         only be used for limited purposes, and may not be used for purposes of employment-related actions or
         decisions or in connection with any other benefit or employee benefit plan of the employers. PHI may be
         disclosed to: the human resources or employee benefits department for purposes of enrollments and
         disenrollments, census, claim resolutions, and other matters related to Plan administration; payroll
         department for purposes of ensuring appropriate payroll deductions and other payments by covered
         persons for their coverage; information technology department, as needed for preparation of data
         compilations and reports related to Plan administration; finance department for purposes of reconciling
         appropriate payments of premium to and benefits from the Plan, and other matters related to Plan
         administration; internal legal counsel to assist with resolution of claim, coverage and other disputes
         related to the Plan’s provision of benefits.
    •    Required by law: The Plan may disclose PHI when a law requires that it report information about
         suspected abuse, neglect or domestic violence, or relating to suspected criminal activity, or in response
         to a court order. It must also disclose PHI to authorities that monitor compliance with these privacy
    •    For public health activities: The Plan may disclose PHI when required to collect information about
         disease or injury, or to report vital stat istics to the public health authority.
    •    For health oversight activities: The Plan may disclose PHI to agencies or departments responsible for
         monitoring the health care system for such purposes as reporting or investigation of unusual incidents.
    •    Relating to decedents: The Plan may disclose PHI relating to an individual's death to coroners,
         medical examiners or funeral directors, and to organ procurement organizations relating to organ, eye, or
         tissue donations or transplants.
    •    For research purposes: In certain circumstances, and under strict supervision of a privacy board, the
         Plan may disclose PHI to assist medical and psychiatric research.
    •    To avert threat to health or safety: In order to avoid a serious threat to health or safety, the Plan may
         disclose PHI as necessary to law enforcement or other persons who can reasonably prevent or lessen the
         threat of harm.
    •    For specific government functions: The Plan may disclose PHI of military personnel and veterans in
         certain situations, to correctional facilities in certain situations, to government programs relating to
         eligibility and enrollment, and for national security reasons.

•   Uses and Disclosures Requiring Authorization: For uses and disclosures beyond treatment, payment and
    operations purposes, and for reasons not included in one of the exceptions described above, the Plan is
    required to have your written authorization. Your authorizations can be revoked at any time to stop future
    uses and disclosures, except to the extent that the Plan has already undertaken an action in reliance upon your
    •    Uses and Disclosures Requiring You to have an Opportunity to Object: The Plan may share PHI with
         your family, friend or other person involved in your care, or payment for your care. We may also share PHI
         with these people to notify them about your location, general condition, or death. These individuals may
         receive claim status information and eligibility information; however, they must be able to supply member
         identity information (i.e., the member’s name, ID number and date of birth). The Plan may only disclose
         your PHI related to a treatment or diagnosis only if it informs you about the disclosure in advance and you do
         not object (but if there is an emergency situation and you cannot be given your opportunity to object,
         disclosure may be made if it is consistent with any prior expressed wishes and disclosure is determined to be
         in your best interests; you must be informed and given an opportunity to object to further disclosure as soon
         as you are able to do so).
Your Rights Regarding Your Protected Health Information.
    You have the following rights relating to your protected health information:

    •    To request restrictions on uses and disclosures: You have the right to ask that the Plan limit how it uses or
         discloses your PHI. The Plan will consider your request, but is not legally bound to agree to the restriction.
         To the extent that it agrees to any restrictions on its use or disclosure of your PHI, it will put the agreement in
         writing and abide by it except in emergency situations. The Plan cannot agree to limit uses or disclosures that
         are required by law.

    •    To choose how the Plan contacts you: You have the right to ask that the Plan send you information at an
         alternative address or by an alternative means. The Plan must agree to your request as long as it is reasonably
         easy for it to accommodate the request.

    •    To inspect and copy your PHI: Unless your access is restricted for clear and documented treatment
         reasons, you have a right to see your PHI in the possession of the Plan or its vendors if you put your request
         in writing. The Plan, or someone on behalf of the Plan, will respond to your request, normally within 30
         days. If your request is denied, you will receive written reasons for the denial and an explanation of any right
         to have the denial reviewed. If you want copies of your PHI, a charge for copying may be imposed but may
         be waived, depending on your circumstances. You have a right to choose what portions of your information
         you want copied and to receive, upon request, prior information on the cost of copying.

    •    To request amendment of your PHI: If you believe that there is a mistake or missing information in a
         record of your PHI held by the Plan or one of its vendors, you may request, in writing, that the record be
         corrected or supplemented. The Plan or someone on its behalf will respond, normally within 60 days of
         receiving your request. The Plan may deny the request if it is determined that the PHI is: (i) correct and
         complete; (ii) not created by the Plan or its vendor and/or not part of the Plan’s or vendor’s records; or (iii)
         not permitted to be disclosed. Any denial will state the reasons for denial and explain your rights to have the
         request and denial, along with any statement in response that you provide, appended to your PHI. If the
         request for amendment is approved, the Plan or vendor, as the case may be, will change the PHI and so
         inform you, and tell others that need to know about the change in the PHI.

    •    To find out what disclosures have been made: You have a right to get a list of when, to whom, for what
         purpose, and what portion of your PHI has been released by the Plan and its vendors, other than instances of
         disclosure for which you gave authorization, or instances where the disclosure was made to you or your
         family. In addition, the disclosure list will not include disclosures for treatment, payment, or health care
         operations. The list also will not include any disclosures made for national security purposes, to law
         enforcement officials or correctional facilities, or before the date the federal privacy rules applied to the Plan.
         You will normally receive a response to your written request for such a list within 60 days after you make the
         request in writing. Your request can relate to disclosures going as far back as six years. There will be no
         charge for up to one such list each year. There may be a charge for more frequent requests.
How to Complain about the Plan’s Privacy Practices.
    If you think the Plan or one of its vendors may have violated your privacy rights, or if you disagree with a
    decision made by the Plan or a vendor about access to your PHI, you may file a complaint with the person listed in
    the section immediately below. You also may file a written complaint with the Secretary of the U.S. Department
    of Health and Human Services. The law does not permit anyone to take retaliatory action against you if you make
    such complaints.
Contact Person for Information, or to Submit a Complaint.
     If you have questions about this Notice please contact the Plan’s Privacy Official or Deputy Privacy Official(s)
     (see below). If you have any complaints about the Plan’s privacy practices or handling of your PHI, please
     contact The Privacy Official or an authorized Deputy Privacy Official.
Privacy Official.
     The Plan’s Privacy Official, the person responsible for ensuring compliance with this Notice, is:

          Brooks O'Hara
          Vice President of Human Resources
          Telephone Number: (713) 647-5700

     The Plan’s Deputy Privacy Official(s) is/are:

          Christine Anderson, Human Resources Manager (713) 647-5734
          Deborah Lord, Human Resources Manager (713) 647-5724
          Regina Roat, Human Resources Director (Sterling McCall) (713) 586-2358
          Clyde Wheeler, Chief Financial Officer (Group 1 Atlanta) (678) 802-4262
          Matt Baer, Chief Financial Officer (Bohn) (504) 349-9539
          Debbie Neal, Human Resources Manager (Casa) (505) 260-2286
          Kerry Laws, Human Resources Manager (Howard) (405) 302-5720
          Michele Talanian, Human Resources Director (Ira) (978) 739-8802
          Sheila Fisher, Office Manager (Luby) (303) 716-6450
          Debby Hector, Human Resources Director (Maxwell) (512) 249-3292
          Pete Ruiz / Julie Thompson, CFO / Payroll Representative (Messer) (806) 788-2289
          Don Lawrence, Chief Financial Officer (Courtesy) (972) 671-7808
          Dodie Dye / Carol Calogero, Human Resources Managers (Miller) (818) 787-8400
          Cindy Powell, Controller (Smith) (409) 833 – 7100
          Theresa Strom, HR Director (Group 1 Florida) (954) 443 – 6919
          Rich Lang / Diane Smith, CFO / Human Resources Manager (Hassel) (516) 378-6300
          John Sears, Chief Financial Officer (Peterson) (916) 353-2080
          Bob Satz, Chief Financial Officer (David Michael) (732) 462-5300

Organized Health Care Arrangement Designation.
     The Plan participates in what the federal privacy rules call an “Organized Health Care Arrangement.” The
     purpose of that participation is that it allows PHI to be shared between the members of the Arrangement, without
     authorization by the persons whose PHI is shared, for health care operations. Primarily, the designation is useful
     to the Plan because it allows the insurers who participate in the Arrangement to share PHI with the Plan for
     purposes such as shopping for other insurance bids.
     The members of the Organized Health Care Arrangement are:

          Group 1 Automotive, Inc.
          Don Bohn Ford, Inc. Group Flexible Employee Benefit Plan
          California Motor Car Dealers Employee Benefits Trust
          Humana Insurance Company
          Health Options, Inc.
          Kaiser Foundation Health Plan (CADA)
          Blue Cross Blue Shield of Massachusetts, Inc.
          Vision Service Plan
          Delta Dental Plan of Texas, Inc.
          Aetna Life Insurance

Effective Date.
The effective date of this Notice is: April 14, 2003.
                                       VERY IMPORTANT NOTICE


The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires GROUP 1
AUTOMOTIVE INC. to notify its employees and their family members who are covered under the
Employee Benefits Program of their right to temporarily continue insurance coverage, at group rates,
when coverage would otherwise terminate. This notice is intended to inform you, in summary fashion,
of your rights and obligations under the continuation of coverage provision.


If you are a covered employee of the GROUP 1 AUTOMOTIVE INC. Employee Benefits Program, you
have the right to choose continuation of coverage if you lose your group health coverage due to
reduction in your hours of employment or the termination of your employment (for any reason other
than gross misconduct).

Spouse of Employee
If you are the spouse of an employee and covered by the GROUP 1 AUTOMOTIVE INC. Employee
Benefits Program, you have the right to choose continuation coverage for yourself if you lose health
coverage under the plan for any of the following reasons:
1.          The death of your spouse.
2.          The termination of your spouse’s employment (for reasons other than gross misconduct) or
            reduction in your spouse’s hours of employment.
3.          Divorce or legal separation from your spouse.
4.          Your spouse becomes entitled to Medicare.

Dependent Children of Employee
Dependent children of an employee who are covered under the GROUP 1 AUTOMOTIVE INC.
Employee Benefits Program have the right to choose continuation coverage if group health coverage
under the Plan is lost for any of the following reasons:
1.          The death of a parent employed by GROUP 1 AUTOMOTIVE INC.
2.          The termination of a parent’s employment (for reasons other than gross misconduct) or
            reduction in a parent’s hours of employment.
3.          Parent’s divorce or legal separation.
4.          A parent employed by GROUP 1 AUTOMOTIVE INC. becomes entitled to Medicare.
5.          The dependent ceases to be a “dependent child” as defined by the GROUP 1 AUTOMOTIVE
            INC. Employee Benefits Program.

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Notification Requirements
Under the law, the employee or family member has the responsibility to inform GROUP 1
AUTOMOTIVE INC. in writing of a divorce, legal separation or child losing dependent status within 60
days of the event in order to be eligible to continue all or some of your current benefit coverages.
In the event of an employee’s death, termination of employment, reduction in hours or entitlement to
Medicare, GROUP 1 AUTOMOTIVE INC. will inform participants and/or their covered dependents of
their right to choose continuation coverage.
If you or a covered dependent are certified by the Social Security Administration as having been totally
or permanently disabled at the time your hours were reduced, you terminated your employment or if a
total or permanent disability occurs within the 60 day election period after your reduction in hours or
termination of employment, you must notify GROUP 1 AUTOMOTIVE INC. within 60 days of such
certification in order to be eligible to elect extended continuation coverage. Extended continuation
coverage will not be available if disability information is provided to GROUP 1 AUTOMOTIVE INC. after
the initial 18-month continuation period. Should the Social Security Administration determine that you
or your disabled dependent is no longer disabled, you must notify GROUP 1 AUTOMOTIVE INC. within
30 days of this determination.
If you do not choose continuation coverage, your group health coverage will end.

Type of Coverage
If you choose continuation coverage you are entitled to be provided with coverage that is identical to
the coverage being provided by GROUP 1 AUTOMOTIVE INC. for active employees and/or family
members. However, you will only be able to elect the same type of coverage that you were previously
covered under or less, before the qualify event and will be subject to any changes in coverage and/or
cost which affect the active participants. You do not have to show evidence of good health to choose
continuation coverage.

Length of Coverage
The law requires that you be afforded the opportunity to maintain continuation coverage for up to 36
months, unless you lose group health coverage due to termination of employment or reduction in
hours. In those cases, you will be eligible to continue coverage for 18 months. Continuation coverage
may be extended beyond the original 18 months to a maximum of 29 months for you and your covered
dependents if you or a covered dependent are certified by Social Security as having been totally or
permanently disabled at the time your employment ended, your hours were reduced or if a total or
permanent disability occurs within the 60 day election period after your termination of employment or
your hours were reduced.
Additional qualifying events can occur while the continuation coverage is in effect. Such events may
extend an 18-month continuation period to 36 months, but in no event will coverage extend beyond 36
months after the initial qualifying event. You must notify GROUP 1 AUTOMOTIVE INC. within 30 days
if a second qualifying event occurs during the continuation period.
Family status changes may occur while the continuation coverage is in effect. You must notify
GROUP 1 AUTOMOTIVE INC. within 30 days of such events as marriage, birth of a child, adoption of
a child or placement for adoption of a child in order for continuation coverage to be extended to those
newly acquired dependents.

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Termination of Coverage
The law provides that your continuation coverage may be cut short for any of the following reasons:
1.          The premium for your continuation coverage is not paid in a timely manner.
2.          You become covered under another group health plan, unless such plan contains an exclusion
            or limitation with respect to a pre-existing condition which affects you or your covered
            dependents. However, if because of the Health Insurance Portability and Accountability Act of
            1996 (HIPAA) you obtain enough creditable coverage to eliminate a new employer’s pre-
            existing condition limitation, coverage will end. If you do not have enough creditable coverage
            to satisfy a new employer’s pre-existing condition limitation, continuation coverage will continue
            until the pre-existing limits are satisfied. In no event will coverage extend beyond the maximum
            applicable continuation period.
            Note: Effective with HIPAA, pregnancy is no longer considered a pre-existing condition.
            Newborns, adopted children as well as children being placed with you for adoption are no
            longer subject to pre-existing condition limitations as long as you elect coverage for such
            dependent within 30 days of the birth, adoption or placement of adoption.
3.          You become entitled to Medicare.
4.          In the event you are receiving an additional 11 months of continuation coverage and Social
            Security determines that you are no longer disabled.
5.          GROUP 1 AUTOMOTIVE INC. no longer provides group health coverage to any of its

Once coverage is terminated, it cannot be reinstated.

Cost of Coverage
You will be required to pay the entire monthly group rate for continuation coverage plus a monthly
administrative fee equal to 2% of the total group rate. The cost of coverage generally changes once a
year, and you will be billed for any changes in cost as they occur.

How to Elect Coverage
You or your dependents have up to 60 days from the time coverage would otherwise end or you
receive the election notice (if later) to inform GROUP 1 AUTOMOTIVE INC. in writing that you wish to
elect continuation coverage.

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                                       HEALTH INSURANCE PORTABILITY
                                       AND ACCOUNTABILITY ACT OF 1996

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) includes important
new protections for people who have pre-existing medical conditions or who might suffer
discrimination in health coverage based on their health.

Change In The Law
HIPAA limits exclusions for pre-existing conditions, prohibits discrimination against employees
and dependents based on their health status, guarantees renewability and availability of health
coverage to certain employees and individuals, and provides better access to individual health
coverage for workers who lose group health coverage.

HIPAA allows individuals who have pre-existing conditions to change employment and reduce
the 12 month (or 18 month) limit by using prior health coverage as credit. However, there
cannot be more than a 63-day gap in coverage from one health plan to another.

Pre-Existing Conditions
A pre-existing condition is one that is present before you enroll in any health plan. It is a
condition for which you have received medical advice, diagnosis, care or treatment for 6
months prior to your enrollment date in a health plan.

Pre-Existing Condition Limitations
If you have been treated for a condition 6 months prior to your enrollment date in a health
plan, that condition would not be covered for a period of 12 months (18 months for late
enrollees). However, pre-existing condition limitations cannot be applied to pregnancy
regardless of any prior coverage. Newborns, adopted children and children placed for
adoption are not subject to pre-existing condition limitations if coverage is added within 30
days of the birth, adoption or placement of adoption.

Creditable Coverage
Creditable coverage is defined as coverage that was provided to you or your dependents
under any of the following types of coverage:
• Group Health Plan (including a governmental or church plan)
• Health Insurance Coverage (either group or individual insurance)
• Medicare
• Medicaid
• Military-sponsored health care
• Program of the Indian Health Service or of a tribal organization

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•     State health benefit risk pool
•     Federal Employee Health Benefit Program
•     A public health plan
•     A health plan under section 5(e) of the Peace Corps Act

Benefits Not Subject to HIPAA
Generally only medical coverage is subject to HIPAA. The following coverages are not subject
• Life Insurance
• Accident Death and Dismemberment Insurance
• Short or Long Term Disability Insurance
• Liability Insurance
• Workers’ Compensation
• Credit Insurance
• On-site Medical Clinics
• Dental and Vision Insurance if provided under a separate policy than the medical
• Long Term Care Benefits
• Medicare supplements
• Specific disease or illness policies
• Section 125 Medical Flexible Spending Arrangements

Obtaining A Certificate of Creditable Coverage
Certificates of creditable coverage will be issued upon termination of coverage with a health
plan. This certificate will state the time period for which you and/or your dependents had
continuous coverage including any applicable waiting period. This certificate should be
presented to any new employer so that credit earned under your prior employer’s plan can be
credited towards the pre-existing condition limitation of your new employer’s plan. Upon
submission of this certificate of creditable coverage you will receive notice stating what portion
of your pre-existing condition limitation has been satisfied.

Special Enrollment Period
Eligible employees and dependents who did not enroll when they were initially eligible to do so
can enroll if certain events occur and if enrollment is requested within 30 days following the
event. These events are as follows:
•     If you or your dependents had other coverage at the time the group coverage was
      previously offered and
      8 Such coverage is exhausted (i.e. COBRA)
      8 There has been a loss of eligibility under another group plan or;

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      8 The employer terminated contributions towards the coverage.
•     Family status changes, such as marriage, birth, or adoption:
      8 In the event of birth or adoptions, the parent/spouse may enroll with the new child.
        However, any current children would not be eligible to enroll until the open enrollment
        period. Coverage is effective the date of the birth/adoption.
      8 In the event of a marriage, a previously eligible employee who was not enrolled may
        enroll along with the new spouse and any children. Coverage will be effective the first
        of the month following or coinciding with the date the enrollment form is completed.
        However, any current children of the employee would not be eligible to enroll until the
        open enrollment period.

Late Enrollees
A late enrollee is an eligible employee or dependent who requests enrollment in a group
health plan following the initial enrollment period. Late enrollees are subject to a pre-existing
condition limitation of 18 months. An eligible employee or dependent is not considered a late
enrollee if:
•     The individual requests to enroll within 63 days after termination of creditable coverage and
      was covered under creditable coverage at the time of the initial enrollment and lost that
      coverage as a result of termination of employment or loss of eligibility, reduction in work
      hours, death of a spouse, divorce or legal separation;
•     The employer offers multiple health plans and the individual elects a different plan during
      any open enrollment;
•     A court order provides for coverage for a spouse or dependent child.

Open Enrollment
Open enrollment under the GROUP 1 AUTOMOTIVE INC. Health Plan is from January 1,
through February 28. Coverage becomes effective on March 1. You may elect to add
dependents during open enrollment.

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             This law amends the Employee Retirement Income Security Act of 1974 and the
                                     Public Health Service Act.

The Law
Group health plans and health insurance issuers of both group and individual policies that
cover mastectomies must provide certain reconstructive and related services following a
mastectomy. Services to be covered include:
1. Reconstruction of the breast on which the mastectomy has been performed;
2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
3. Prostheses and physical complications of all stages of mastectomy, including

Effective Date of the Law
This change went into effect for the GROUP 1 AUTOMOTIVE INC. group health plan effective
January 1, 1999.

Benefit Changes
These services are elective and are chosen by the patient in consultation with the attending
physician. Coverage for these services is subject to annual deductibles and coinsurance
provisions that are consistent with those established for other benefits under the Plan.

This is a summary of the laws. If you have any questions about these laws,
please contact Stone Partners, Inc.

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The previous pages are required to be distributed to all employees who are benefit eligible.
This statement certifies that the below named employee has received a copy of the COBRA,
HIPAA, and Women’s Health and Cancer Rights Act. After this statement has been signed by
both the employee and an HR representative, this statement should be removed and placed in
the employee’s permanent personnel file.

Employee Name (printed)                                    SSN

Employee Signature                                         Date

HR Representative                                          Date

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