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(2) Monthly Aggregate Retention Amount Factor Medical Dental WDI Vision Other Single $249.78 $ $ - $ $ Family $671. 92 $ $ - $ $ Composite $ $ $- $ $ (3) Number ofInitial Covered Units: Medical Dental Single 249 Family 182 Composite WDI Vision Other (4) Estimated Initial Annual Aggregate Retention Amount $2,213,816 (5) Minimum Annual Aggregate Retention Amount SI,881,744 (6) Percent of Annual Aggregate Attachment Amount (Included in Above) 125% (7) Percentage Applicable to Minimum Annual Aggregate Retention Amount 85% (8) Reimbursement Factor Percent of payments in excess of the Annual Aggregate Retention Amount 100% (9) Maximum Limit of Reimbursement Liability $1,000,000 (10) Benefit Payment Basis Incurred on or after the effective date of the Treaty Year and Paid within the Treaty Year. o Incurred within the Treaty Year and Paid within the Treaty Year Plus _ months following the expiration date of the Treaty Year o Paid within the Treaty Year X Paid within the Treaty Year. Claims are limited to those incurred 12 months prior to the Treaty Effective Date and are limited to $ (11) Composite Monthly Aggregate Premium Rate Per Employee Per Month $5.06 PEPM (12) Aggregate Accommodation Rate $1.18 PEPM (13) Total Aggregate Premium Rate (11 + 12) $6.24 PEPM Premium Paid X Monthly 0 Annual (C) Medical conversion is applied for this Company. 0 yes X no Medical conversion coverage is provided by Celtic Life Insurance Company. (0) EMPLOYEES TO BE COVERED. Unless otherwise indicated and approved by Us, this Treaty covers employees who are actively at work and dependents who are non-hospital confined. This Treaty is not intended to cover persons who cannot meet an actively at life requirement whether a covered employee/dependent, retired person or COBRA Beneficiary. Disabled persons are excluded unless disclosed and endorsed on the Qualification of the Offer. Application is made to cover: Check Retired Persons COBRA Persons Disabled Persons Yes X X X No o o o We strongly recommend you review your Plan Document for appropriate wording and limitations.