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03/10/99 16:35 FAX PHIL BRETT -~ LAaY DIR ~ 008 <br />FORTIS PAGE s32 <br />03/63/I999 68.10 4407775618 <br />_ - ~. <br />Fortis Benefits Insurance Company . ^ ~ ^ ~•+ <br />z4ss~ Country Gob Hivd. Suite 330. North Olmsted. OH 4x070 ~ i' ~ • <br />^ <br />(x.40)?77-3170 (800)472-0678 FAX: (4A0)777-5618 F~ R~ ~ s~ <br />DENTAL <br />CirOLR Name: Maytieid Ylilaga Presented by: LAWRENCE l9ARRETT <br />E1fEdive Date: 04!0111999 pools Expires- 04101!1999" <br />DHA PPO NETWORK ACTIVE PLAN: <br /> 1N OUT IN <br />CoinsutanCO_ Preventive 100% 100% Timely Applicant Wa'rtiny Period 0 months 0 months <br />Basic ' 00°1° 80°/® Por Class III Major Services <br />Major 64% 609b Open Enrollment No No <br />Calendar Year Maximum S 1 SOl) 51500 <br />Calendar Year Deductible 525 $25 NO Orthodor+tie benefit <br />Waned for Preventive Yes Yes <br />Fatuity Deductible Yes Yens <br />(2 rr:ember limit) <br />Fourth QueRetCarry~ver No No <br />PROPOSED PLiLN RAPES: <br />Total Monlhty <br />Ellglble LrveB Partleip8tien Enroll9~4 Rates Premltrm <br />Employee (EE) 43 X 98°~ = 42 X 52521 = 51058.82 <br />DepsndsrR (DP) 33 X 86% = 32 X 541.76 = 57336-32 <br />52385.14 <br />Total Mvnifrly Premium is taas®d on 98% employee and 9a7rL dependant participatior+. <br />Prior d®rtLal coverage is assumdd. >>f group dos¢ not have prior dertMdl coverage, rates are aubjvct to change. <br />VARIATIONS TO Tl^tE PROP4SEb PLAN DESIGN: <br />Monthly <br />With Participation %: Ec: 100 06p= 75 <br />Timgty Applicant Deferral ^ 1z mOrrths <br />Child Orltty, $15001$1000 Life Max, 50%, 550 dad <br />Cost Management Op lion <br />Indudin® Preferred Vision Care <br />EE pP Premium <br />25.29 49.90 2134.60 <br />2423 40.66 2318.97 <br />2521 46.46 254S.B1 <br />x2.97 38.90 220727 <br />26.50 d1.7s 2407.30 <br />fr one E.lreClire Ua~te is delaped, Please wntact yptir FOrti9 Bertehb re0n~6n$rtive for a new qu°4e. <br />Cost Mianapement OpgOn moves Penoaonuc, EndoOoatlc are Oral SUryery from Crass It to Class ~ II Major Services. <br />' This rat®as~unlee ell ernplo~reaa have coverage (no opt ou~j- If q+i6 is not the case, a+e 8q9(, Participntfa^ emDlp~e rdsos vn11 gppty. <br />miwrtwvaxzA *«+n ~ w.oao <br />~~=~~r~ s <br />