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03/13/01 10:36 FAX <br />1 y <br />PHIL BRETT <br />MAYFlELD VILLAGE <br />S61305901 <br />s104?c'il_ /, Aoa ? <br />Renewal Effective: , <br />-? LAW DIR U005 <br />TRAD{TIONAL FtRST DOLLAR <br />Benefii Pian Highlights <br />-Major Medical (Deductibles and Coinsurance may Apply) -Health Care Management Program <br />-InpafienUOutpatient Hospital Care -Emergency and Accident Care <br />-Physician Charges -Diagnostic Services <br />-Prescription Drugs: $5 -Lifetime Maximum Benefit of $2,000,000 <br />-Maternity, Well Baby & Well Child Care -Psychiatric Care & Substance Abuse <br />-Pre-existinq Clause Waived -Human Organ 7ransplant (Limitations Apply) <br />After the emp/oyee reaches the maximum, Anthem Blve Cross and Blue Shield covers the remaining eligible charges. <br />(Refer to your Community Insurance Company benefit hooklet(s) for benefit detafls and limitatfons) <br />PREMIUM RENEWAL tNFORMATION <br />I CURRENT RATES ? <br />ICoverage ` Contracts HEALTH Drug Dental Vision Premium <br /> <br />Empfoyee 10 $258.83 $0.00 $0.00 $0.00 $2,588.30 <br />Emp/Sps 11 $618.66 $0.00 $0.00 $0.00 $6,805.26 <br />Emp/Child 2 $475.11 $0.00 $0.00 $0.00 $950.22 <br />Family 24 $868.88 $0.00 $0.00 $0.00 $20,853.12 <br />SUBTOTAL 47 $31,196.90 <br />ADMIN_ FEE $25.00 <br />TOTAL $31,221.90 <br /> <br /> RENEWAL RATES <br />JCoverage Contracts HEAL7H Drug Dental Vision Premium <br /> <br />Employee 10 $284.71 $0.00 $0.00 $0.00 $2,847.13 <br />Emp/Sps 11 $680.53 $0.00 $0.00 $0.00 $7,485.79 <br />Emp/Child 2 $522.62 $0.00 $0.00 $0.00 $1,045.24 <br />Family 24 $955.77 $0.00 $0.00 $0.00 $22,938.43 <br />Medicare 0 $0.00 $0.00 $0.00 $0.00 $0.00 <br />SUBTOTAL 47 $34,316.59 <br />ADMIN. FEE $25.00 <br />TOTAL $34,341.59 <br />Premium is increasing by 10% <br />EXHIBIT <br />A <br />j