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02/15/2011 Mayfield Village/chamber & life discount Proposed Effective Date: 04/01/2011 BGS ASSOCS LLC Estimated Monthly Premium Plan Count __ Emp.. 10 Emp/Sp 12 Emp/Child 5 Family 31 Monthly 58 IIealth Count Dental Count __ _ - $497.78 '^ $1,184.71 $1,000.53 $1,637.69 $74,965.36 * * * * Coverage not selected for this proposal. Vision ~ Total ~! _ __-$497.78, * $1,184.71 * $1,000.53 * $1,637.69 * $74,965.36 These rates exclude the medical premium savings of up to 3% that are available through our One Solution Savings program. The enclosed brochure illustrates the discount program that may save you thousands of dollars a year. Please contact your Broker or Anthem Representative for revised medical rates that reflect these savings. Rates are proposed for an effective date of 04/01@Ol 1. Rerate is required after this date. Final rates will be based on the actual etrective date. Rates are based on SIC H911 1, located primarily in the 44143 zipcode area. Final rates will be based on the actual location, enrolled census, final benefits selected,and the underwriting rules in etrect upon acceptance by Community Insurance Company and Anthem Life. This proposal is subject to underwriting approval by Community Insurance Company and Anthem Life; please do not cancel yoty coverage until the application has been approved in writing. This information is intended to present only a general overview of the benefits. (N-CDI 104 Elig-EE 58) New business rates calculnted using standard underwriting guidelines. (R=.7156; D~.85; V=0.9); Please note: as we receive additional guidance and clarification from the U.S. Department of Health and Human Se/vices, we maybe required to make additional changes to your benefits. This coverage has been selected for employees and eligible dependents; subject to the terms and conditions of this proposal and the application to which this is attached. Authorized Signature Date Anthem: 113130 -Blue 5.0 Page: 2