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CITY OF PARIS
<br />PLAN YEAR 04-05
<br />rrEnt
<br />Aggrcgate Srop Lov (ASG)
<br />I5111-!ncludes Medical & Rx
<br />Composite
<br />IndividualStop Loss(ISL)
<br />/S/Il - Includea Medica! & Rc
<br />EE
<br />Dependen[
<br />Total ISL
<br />TotslStop Lau
<br />STANDARD FIXED COSTS
<br />Americart Stop Loss
<br />StandardSecuAry
<br />RATE
<br />EE MONTHLY ANNUAL
<br />$3.68
<br />393
<br />$1,446
<br />S17,355
<br />575,000
<br />Deducrib(e
<br />$3224
<br />393
<br />512,670
<br />5152,044
<br />E44.46
<br />262
<br />$11,649
<br />E139,782
<br />.
<br />$24.319
<br />E291.826
<br />$35,765
<br />5309,181
<br />ASO FEE MEDICAL •
<br />$12.85
<br />393
<br />$5,050
<br />560,601
<br />ASOFEEDENTAL
<br />$2.10
<br />393
<br />E825
<br />$9,904
<br />ASOFEEVISION
<br />E0.00
<br />393
<br />SO
<br />EO
<br />U.R.FEE••
<br />$2.75
<br />393
<br />S1,081
<br />$12,969
<br />PPNFEE••
<br />E3.85
<br />393
<br />$1,513
<br />$18,157
<br />TOTALADWNI57RATION
<br />521.55
<br />- -
<br />E8,469
<br />5101,630
<br />7ota1 Fi:ed Cosb
<br />$8,469
<br />5101,630
<br />EXPEC7EDINEDCLAMIS-Comp
<br />E456.30
<br />393
<br />Y179,327
<br />E2,151,930
<br />Expechd QaLn. Smp Lmf & Admin. Liability
<br />5179.327
<br />52.151,930
<br />tv1EDA7TACFUIEMPOINT-Comp
<br />S570.38
<br />393
<br />E224,159
<br />22,689,912
<br />Maximum Claim, Srop Lmf A Admin. Liabiliry
<br />5234.159
<br />$2,689,912
<br />LT,O?'~'AL_,,,,y,L~W~1~TY'..,,.
<br />-13,562. 'S2,3627QJ
<br />5'O'I L~'E~~ TACHti1F,~. .~OI~'P1~I:iAB.~7TY~ 5894.: ~~3"+~M•%„'Q;%23~.~
<br />OPTIONAL FIXED COSTS
<br />WCADMINISI'RATION 50.50 393 S197 $2,358
<br />TO7AL OP710NAL FLCED COSTS 50.50 S197 E2,358
<br />NOTE • SEE MGU QU07E SHEET FOR ANY QUALIFICATIONS 70 OFFER
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<br />Suean Smith, Executive Dircctor Date
<br />Authoriud Signaturc of Acceptance ' Date
<br />
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