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Delta Dental Contract <br />For <br />Mayfield Village <br />This Contract ("Contract") is entered into by and between Mayfield Village (the "Contractor") and Delta Dental Plan of <br />Ohio, Inc., an Ohio non-profit corporation ("Delta Dental"). This is a legally binding contract between the Contractor <br />and Delta Dental and is effective on April 1, 2022, the ("Effective Date"). <br />SECTION I - DECLARATIONS <br />The Benefits afforded are only with respect to such benefits as are indicated in this Contract, including the Summary of <br />Dental Plan Benefits. Delta Dental's liability is limited to the Benefits stated herein; subject to all the terms of this <br />Contract having reference thereto. This Declarations Section and the Summary of Dental Plan Benefits supersedes any <br />contrary provision of the subsequent sections of this Contract. <br />A. Effective Date: 12:01 A.M. Standard Time, April 1, 2022 <br />B. First Renewal Date: April 1, 2024 <br />C. Client Number: 0421-0001 <br />D. Rate(s): <br />Enrollee only - $32.87 per month per Enrollee <br />Enrollee and spouse - $66.51 per month per Enrollee <br />Enrollee and child(ren) - $78.05 per month per Enrollee <br />Enrollee, spouse and child(ren) - $121.82 per month per Enrollee <br />These rates are contingent upon the enrollment of a minimum of 95 percent of the eligible members of the <br />defined group and their eligible dependents. Rates do not include any applicable claims taxes. <br />DELTA DENTAL PLAN OF OHIO, INC. CONTRACTOR <br />BY: /, BY: <br />Presidellit and CEO (Authorized Signature) <br />(Title) <br />BY: <br />(Witnessed By) <br />(Title) <br />DATE: February 8, 2022 DATE: <br />KR#68547318 <br />