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- ;,•_,?,.. <br />EXHIBIT A <br />to the Stop Loss Contract for <br />THE CITY OF NORTH OLMSTED <br />Group # 621634* <br />The Contract Period is from January 1, 2003 through December 31, 2003. Eligibie claims are those Paid <br />from January 1, 2003 through December 31, 2003. <br />AGGREGATE STOP LOSS <br />Percent of Payments: 110% <br />Line(s) of Business: Medical, Drug <br />Aggregate Stop Loss Premiums: Medical <br />' Dru <br />' <br />,. " <br />Q' ?Yn n'2 <br />:J` O t - l66 n.Z O <br />Single $3.73 $3.64 $3.10 $1.14 $0.99 $0.85 <br />Family 10.07 9.84 8.38 3.09 2.65 2.29 <br />Monthly Attachment Rates: Medical <br />, <br />??--- <br />r <br />-- ? ? -?, ? <br />-?.?? uq <br />Dr., .,.??? <br />Single $208.15 $204.20 $180.01 $73.09 <br />Family 562.01 551.33 $486.02 197.34 <br />Aggregate Minimum Threshold: $2,243,534 <br />The Aggregate Maximum Limit of Reimbursement Liability: $1,000,000 <br />SPECIFIC STOP LOSS <br />Specific Stop Loss Threshold per Covered Person: $50,000 <br />Annual Maximum per Covered Person: $1,000,000 <br /> <br />Lines of Business: Medical <br />Specific Stop Loss Premium s: Medical <br /> ?1o?t 'h, Opt?'? 2 <br />Single $30.15 $29.58 $26.07 <br />Family 81.40 79.86 70.40 <br />ENROLLMENT: <br />Single 76 <br />Family 247 <br />ENROLLMENT:: <br />Single 76 <br />Family 247 <br />CLAIMS ADMINISTRATOR <br />Medical Mutual Senrices, L. L. C. <br />2060 East Ninth Street <br />Cleveland, Ohio 44115-1355 <br />Exhibit Accepted By: <br />$62.83 $54.85 <br />169.65 148.11 <br />Date: <br />NOTE: Prisoners Section 777 is to be excluded from all stop loss. <br />"was 900299 <br />CCX0202 Page 12 090102 <br />03 eCityofN orthOlmstedSL <br />