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<br />ADMINISTRATIVE SERVICES AND PREMIUM COST <br />(HEALTH ONLY) <br /> <br />AGGREGATE STOP LOSS AT: <br />RIA <br /> <br />PROPOSED INCREASE <br />WITH $200 DEDUCTIBLE <br /> <br />80t COINSURANCE WITH <br />$1,500 LIMIT <br /> <br />EXPECTED PAID CLAIMS PER EMPLOYEE <br />PER MONTH FOR 1988 <br /> <br />RIA <br /> <br />X <br /> <br />, <br /> <br />RIA <br /> <br />AGGREGATE STOP LOSS RATE <br />PER EMPLOYEE PER MONTH <br /> <br />PER CLAIM STOP LOSS RATE <br />PER EMPLOYEE PER MONTH <br />AT S <br /> <br />RIA <br /> <br />AT <br /> <br />s <br /> <br />'MIA <br />'MIA <br /> <br />SERVICE FEE' OF PAID CLAIMS <br />ADVANCE (IF ANY - BE SPECIFIC) <br /> <br />RIA <br />RIA <br /> <br />~THER (SPECIFY) <br /> <br />RIA <br /> <br />TOTAL FIRST MONTH : <br />ESTIMATED TOTAL FOLLOWING MONTHS: <br /> <br />'MIA <br />RIA <br /> <br />OTHER: <br /> <br />B-3 <br />