Laserfiche WebLink
<br /> ITEM IX <br />The HEALTH CONTRACT UNDERWRITTEN PREMIUM rates for the Contract Year shall be: <br /> Employee Employee & Employee & Employee & <br /> Only Child (ren) Spouse Family <br />HOSPITALIZATION: $32.93 $ 57.55 $ 85.92 $106.12 <br />OME: $21. 96 $ 38.36 $ 57.28 $ 70.75 <br />TOTAL: $54.89 $ 95.91 $143.20 $17 6.87 <br /> <br />Signature of the Employer's Group Executive <br /> <br />Date <br /> <br />Date <br /> <br />Signature of Representative of Blue Cross and <br />Blue Shield of Texas, Inc. <br /> <br /> <br />.. <br /> <br />