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L�J <br />The remaining Health Contract Administration Charge amount as calculated above, if <br />any, will be carried forward each Contract Year. The cumulative remaining Health <br />Contract Administration Charge amount deferred from prior accounting periods, if <br />any, is shown in the Remaining Health Contract Underwritten Calculation Schedule <br />provided to the Employer after the end of each Accounting Period. <br />II VII <br />The SPECIFIC HEALTH CONTRACT STOP LOSS PREMIUM for the Contract Year shall be <br />calculated monthly by multiplying, respectively, the number of Health Certificates <br />exposed for a particular month by $4.63 for each single Health Certificate, $8.09 <br />for each Health Certificate with child(ren), $12.09 for each Health Certificate with <br />spouse, and $14.93 for each Health Certificate with family. These amounts are <br />guaranteed for the indicated Contract Year and are included in the Health Contract <br />Underwritten Premium. <br />ITEM VIII <br />The MINIMUM BALANCE to be maintained by the Employer in the Employer's Account at <br />The Bank is $10,193 for November 1, 1986 through October 31, 1987. <br />s r: <br />The HEALTH CONTRACT UNDERWRITTEN PREMIUM rates for the Contract Year shall be: <br />Employee <br />Employee & <br />Employee & <br />Employee & <br />Only <br />Children) <br />Spouse <br />Family <br />Hospitalization: $32.93 <br />$ 57.55 <br />$ 85.92 <br />$106.12 <br />OME: $21.96 <br />$ 38.36 <br />$ 57.28 <br />$ 70.75 <br />TOTAL: $54.89 <br />$ 95.91 <br />$143.20 <br />$176.87 <br />Signature of the Employer's Group Executive <br />Signature of Representative of <br />Blue Cross and Blue Shield of Texas, Inc. <br />Date <br />Date <br />U <br />