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~;~ a~j.nLry~°~ti Q • ~~-~ A G °: ~ 90D1'Q ~: J ICT~; Delta Dental Contract For Ma~eld Village This revised ("Contract") is entered into by and between Mayfield Village (the "Contractor") and Delta Dental Plan of Ohio, Inc., an Ohio non-profit corporation ("Delta Dental"). This is a legally binding contract between the Contactor and Delta Dental and is effective on April 1, 2015, the ("Effective Date"), replacing any previous Declarations, Section I, with the balance of such Contract continued as if fully set forth herein. SECTIONI -DECLARATIONS The Benefits afforded are only with respect to such benefits as are indicated in this Contract, including the Summary of Dental Plan Benefits. Delta Dental's liability is linrited to the Benefits stated herein; subject to all the terms of this Contract having reference thereto. This Declarations Section and the Summary of Dental Plan Benefits supersedes any contrary provision of the subsequent sections of this Contract. A.. Effective Date: 12:01 AM. Standard Time, April 1, 2015 B. First Renewal Date: April 1, 2017 C. Client Number: 0421-0001 D. Rate(s): Subscriber only - $30.99 per month per Subscriber Subscriber and spouse - $62.70 per month per Subscriber Subscriber and child(ren) - $73.58 per month per Subscriber Subscriber, spouse and child(ren) - $114.85 per month per Subscriber These rates are contingent upon the enrollment of a minimum of 95 percent of the eligible members of the defined group and their eligible dependents with 98 percent of the cost paid by the Contractor for member coverage and 97 percent of cost paid by the Contractor for dependent coverage. Rates do not include any applicable claims taxes. DELTA DENTAL PLAN OF OffiO, INC. CONTRACTOR BYe E~ ~~~~?~ ~ ._ .LitlL/c~d~rJ. BY: . 4_ _ iesiderit and CEO.;- (AuthorAr~Signature) (Title) x~~i~< BY: ut orize ignature Council Preside ~ _ ~ ~%h~ /' (Title) ~ _ ^/ DATE: February 17, 201 S DATE: ~,~ !!~~ ~~// -" [cxlw~§ts~ a~