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CITY OF PARIS <br />PLAN YEAR 04-05 <br /> <br /> ITEM <br />Aggregate Stop Loss (ASL) <br />15/12 - Includes Medical & Rx <br /> Composite <br /> <br />American Stop Loss <br /> <br /> Standard Security <br /> <br />Individual Stop Loss (ISL) <br /> <br />15/12 - Includes Medical & Rx <br /> EE <br /> <br /> Dependent <br /> <br /> Total ISL <br /> <br /> Total Stop Loss <br /> <br />RATE E...~E MONTHLY .ANNUAL <br />$3.68 393 $1,446 $17,355 <br /> <br />$75.000 Deductible <br />$32.24 393 <br />$44.46 262 <br /> <br />STANDARD FIXED COSTS <br />A$OFEEMEDICAL* $12.85 393 <br />ASOFEEDENTAL $2.10 393 <br />ASOFEEVISION $0.00 393 <br />U.R. FEE** $2.75 393 <br />PPNFEE** $3.85 393 <br /> TOTALADMINISTRATION $21.55 <br /> <br /> Total Fixed Cos~ <br /> <br />$12,670 $152,044 <br />$11,649 $139,782 <br />$24,319 $291,826 <br />$25,765 $309,181 <br /> <br /> $5,050 $60,601 <br /> $825 $9,904 <br /> $0 $0 <br /> $1,081 $12,969 <br /> $1,513 $18,157 <br /> $8369 $101,630 <br /> $8,469 $101,630 <br /> <br />$179,327 $2,151,930 <br />$179~27 $2,151~30 <br /> <br />$224,159 $2A$9,912 <br />$224,159 $2~89~12 <br /> <br />EXPECTED IVIED CLAIMS - Comp $456.30 393 <br />Expected Clahn, Stop Loss & Admin. Liability <br /> <br />IVIED ATTACHMENT POINT - Comp $570.38 393 <br />Maximum Claim, Stop Loss & Admin. Liability <br /> <br />OPTIONAL FIXED COSTS <br />COC ADMINISTRATION $0.50 <br />TOTAL OPTIONAL FIXED COSTS $0.50 <br /> <br />393 $197 $2,358 <br /> <br />$197 $2,358 <br /> <br />NOTE - SEE MGU QUOTE SHEET FOR ANY QUALIFICATIONS TO OFFER <br /> <br />1. Actively. at. work and pre-exls#ng conditions, ff applicable, may be v41ved upon receipt, review and acceptance of a signed Disclosure $tatsmenL <br /> Please fill out the Disclosure Statement carefully in consultation with your Claims Admlnistretor and each of your medical management vendors, <br /> ff appropriate, and include all applicable parsons even ff Shay were previously reported to ASL or dlrsctiy to the Carrier. <br /> <br />2. Need diagnosis/prognosis on all large, potentlally large, ongoing or pending eislms as higher deductibles (teaors) may apply. <br /> <br />3. Need monthly paid claims, enrollment through April 30, 2004. <br /> <br />4. Assumes duplication of current plana and noa~orks. <br /> <br />5. Nead current ur proposed plan document[s) and all amondmenis. <br /> <br />$. Need updated census as of the effective data. <br /> <br />7. ]'PA is the TML IEBP. <br /> <br />8. Access fees are not covered. <br /> <br />9. Proposal assumes Madicare is primary for retirees age 65 and older. <br /> <br />10. Coverage fur Disabled and COBRA participants Is subject to disclosuro and cartier approval. <br /> <br />11. Rates and attachment factors are subject to re. rating if enrollment changes by more than 10~. <br /> <br />12. $ee atiached addltional contingenclea from $tandard Security of Naw York. <br /> <br />12. In ot~lar to ensure accuracy, all data should bo transmitted In an electronic funnat. <br /> <br />Susan Smith, Executive Director <br /> <br />Date <br /> <br />Authorized Signature of Acceptance <br /> <br /> <br />