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<br /> - 0-- !f)'/If .f:. uU,J <br /> Attachment to Resolution Page 2 of 3 <br /> ~"'Yate E:a::ass Less includes (not Ì11cluded unlesS checked): <br /> ( X x ) z.s::di cal (XX) Free St:arxiin:;' Drug 5erVÌca <br /> ( X X ) Cental Care. ( ) Weekly (Disability) Irx:x:1II:e <br /> ( ) Vision Care ( ) Other <br /> . <br /> ~~te Perœrr!:age ~la (exoass of derluctible) 100 % <br /> M3.xim.Jm ~ ~ te Ðæ:ess L::ss ~ 1, 000, 000 <br /> M::rrthly ~~te Act'! m..4aticn ( ) Yes (xx) No <br /> ~~te Tenninal Liability ( ) Yes (XX) No <br /> B . Specific E:«:e:ss I.css Ç<X) Yes ( )No <br /> Benefit Pericd: Eligible E'lrployer r ~c:es :fram Plarl ~.:ses <br /> Incurred:frc:m 5/1/97 t:hrt:u;h 7/31/98 , and <br /> Paid from 8/1/97 t:hrt:u;h 7/31/98 . ' <br /> r nc=;..=-=.; Inolrrerl Friar to the Effect:ive Date -will œ l.i:mitci to the alOCJunt <br /> re.iJDh:Irsable as set for"'..h in the Scherlule of Ðc:::.ess Less. <br /> Sp=c.ific Eligible Ex?=r'.ses L'1Cluds:s: <br /> (XX) Medical (X x j Free St:arx:tirq Drug Se.... rvi ce <br /> St=ecif i c Ca:lucti.b 1 e ( p;r ¡:erson) $ 40,000 <br /> SJ::ecific pc.-~ga Feiml:ursa.ble (e."'æe:SS of deducti.ble) 100 % <br /> Maximum Sp;cific~5 I..œs $ I,OCO,ooo <br /> <br /> (per person in øa::ess of SþEcific lJec:ÌIJCti.ble) <br /> c. ~CaJ. Data: '!he Caripany will rely on t.."le data Celcw 'to assist in <br /> ~ ~.e Etployer far Insuranoa. Note that '-'itl-..cut Cc:nrçany revie-..¡ <br /> a.rxi ~ of each risk, the Participat:i.rq ~loyer's Losses -,.;ill not <br /> œ J::'e.Ìl11bJrsae urrler the Ða::ess Less In:surancs Ccntract¡ therefore, <br /> please answer the follcr.orin:; questions to the best of your kno;.rleège. <br /> - <br /> a) Has an eligible erployee or depanjent received or exp:çted to rec.ei ve <br /> more than 50% of the sr:ecified Deductible in :redic:al exp€..l"JSeS in t.1.e <br /> last 1.2 n::mt. >Js? <br /> ( ) Yes ( )No <br /> If yes, list!'Ja!I:e , status , !JL. '-"j b~~ is , an::l a1IX:\1I1t 0 f claim : <br /> Nal:re COB Sex <br /> sta b.Js <br /> (Ee, Dep, a:J8RA, Fatiree) <br /> Diagrxsis <br /> Progrn:; is <br /> A1n:::unt or Cl.a.il!1 <br /> Please att:a.è:t a separate sheet of paper if l'1e9:ied.. <br /> b) Are ext:.eI:de:i 1:::erefits available frcm the priar ÌI'-SULer for <br /> presently disabled eligible ~loyees arrl/ar deper:èerrt:s? <br /> ( ) Yes ( )No <br /> c) Are any eligible employees or dep=r:rlents prese..rrt:ly disabled or <br /> confined in a hcspital or símil;:n- facility? ( ) Yes ( ) No <br /> d) Will arr;r far:œr employee or ~ œ c:ont:i.nui.n:; c::overage un::ier <br /> the Plan in a~ with Fe:leral, S"""l...3.te, or L-r-:=;J. La....- on tl't.e <br /> Eff~--ive I:aœ of this ~rrt:ract.? ( ) Yes ( ) No <br />