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? <br />MEDic.AL Mt1'rt7Ar <br />Fully Insurcd Proposal <br />for <br />Mayfield Village <br />Rates Effective: <br />Generel Description of Benef'ds: <br />1 ) SMP 0100-2000 (NGF) <br />Fbc $5125/40, 2x MO, HD, GI <br />Single <br />Employee/Spouse <br />Employee/Child(ren) <br />Family <br />Premium / Month <br />January 1, 2019 - December 31, 2019 <br />Contracts Rates <br />17 $662.28 <br />20 $1,457.02 <br />5 $1,192.10 <br />29 $1,986.84 <br />71 $103,978.02 <br />Rate Acceptance: ? oq?t exJ,7?0?-' ? <br />?iR6C:`T 6? D j= roup Official <br />F/A?,4 n) C. c <br />Date: /a' 6 ". j 8 <br />Quote ID: 0066524-01