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<br />ANALYSIS OF COST <br />For <br />HAYFIELD VILLAGE <br />CORPORATE I <br />10 SINGLES @ <br />25 FAMILIES @ <br />35 TOTAL EMPLOYEES <br />$ 93.91 = <br />$280.57 = <br />TOTAL MONTHLY PREMIUM= <br />$ 939.10 <br />$7,014.25 <br />$7,953.35 <br />* FIRST PRIORITY - Corporate I <br />10 SINGLES @ $ 93.91 = <br />25 FAMILIES @ $280.57 = <br />35 TOTAL EMPLOYEES TOTAL MONTHLY PREMIUM= <br />$ 939.10 <br />$7,014.25 <br />$7,953.35 <br />~ PRESCRIPTION DRUG CARD $2 Deductible <br />10 SINGLES @ <br />25 FAMILIES @ <br />35 TOTAL EMPLOYEES <br />$ 10.51 = <br />$ 27.72 = <br />TOTAL MONTHLY PREMIUM= <br />$ 105.10 <br />$ 693.00 <br />$ 798.10 <br />~ MAJOR DENTAL II $25 Deductible with 100$ payment for A.P.D. <br />10 SINGLES @ $ 15.72 = $ 157.20 <br />25 FAMILIES @ $ 40.61 = $1,015.25 <br />35 TOTAL EMPLOYEES TOTAL MONTHLY PREMIUM= $1,172.45 <br />MAJOR DENTAL II $50 Deductible with 100 payment for A.P.D. <br />10 SINGLES @ $ 13.50 = $ 135.00 <br />25 FAMILIES @ $ 35.41 = $ 885.25 <br />35 TOTAL EMPLOYEES TOTAL MONTHLY PREMIUM= $1,020.25 <br />Rates are guaranteed for twelve months from the original <br />effective date. Final rates shall be determined by actual <br />enrollment demographics. Proposed rates assume an effective date <br />during the month of March. Should the effective date be later, <br />rates will be subject to revision. <br />This proposal is issued based upon the assumption that this group <br />is in compliance with all Community Mutual's current underwriting <br />and actuarial guidelines. A determination that the group is not <br />in compliance with these guidelines would render this proposal <br />invalid. <br />