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<br />(2) \iontbly Aggregate Retention Amount Factor <br /> <br />Siegle <br />Family <br />Composite <br /> <br />Medical <br />S 211. 76 <br />S 569.64 <br />S <br /> <br />Dental <br />S <br />$ <br />S <br /> <br />WDl <br />$- <br />$- <br />$_ <br /> <br />VlSioa <br />S <br />S <br />S <br /> <br />Other <br />$ <br />S <br />S <br /> <br />(3) ~umber ofInltial Covered Units: <br />Medical Dental <br />231 <br />189 <br /> <br />WDI <br /> <br />V isioo <br /> <br />Other <br /> <br />Single <br />Family <br />Composite <br /> <br />(4) Estimated Initl.aJ Annual Aggregate Retention Amount S 1,878,962 <br />(.5) :\1inimum Annual Aggregate Racntioo Amount S 1,597,118 <br />(6) Percent of Annual Aggrcgale Attachment Amount (Included in Above) 125% <br />(7) p~ Applicable to Minimum Annual Aggregate Retention Amount 85 % <br />(8) Reimbursement Factor Percent of paym:nts in excess of <br />the Annual Aggrega1C Retention Amount 100% <br />(9) Maximum Limit ofReimbu.rsemc:nt Liability S 1,000,000 <br />( 10) Benefit Payment Basis <br />Incurred on or after the effective date of the Treaty Year and Paid within the Treaty Year <br />Incurred withill1he Treaty Year and Paid within the Treaty Year <br />Plus _1nQntbs following the expiration date of the Treaty Year <br />Paid within the Treaty Year <br />x Paid wrthin the Treaty Year- Claims are linu1ed to those incurred <br />2- months prior to the Treaty Effective Dare and arc limited <br />toS <br />( 11) Composite MmthJy Aggregate Premium IWe <br />P~~~PaM~ S4.19P~M <br />(12) Aggregate Accommodation Rate $1.18 PEPM <br />(13) Total Awegate Premium RAte (11 + 12) $5.37PBPM <br />Premium Paid x Monthly Annual <br /> <br />(C) Medical conveniOl1 is applied for this Company.' yt1 X DO <br />Me:dieal conversion coverage is provided by Celtic Life Insurance Company_ <br /> <br />(D) EMPLOYEES TO BE COVERED. Unless otherwise indicated and approved by Us, this Treaty <br />CO\'U'S employees who are actively at 'NOrk and dependents who arc noo-hospital c.onfined. This Treaty IS <br />not intended to cover persons who cannot meet an actlvcly at life requirement 'o!rilcther a covered <br />employee/dependent. reored peTSOD. or COBRA Beneficiary. Disabled persons are excluded unlen <br />disclosed and endorsed on the Qualification of the Offer. <br /> <br />Application is made to covtr: <br /> <br />Retired Penons <br />COBRA Penon, <br />Disabled Persons <br /> <br />Ch.eclc <br /> <br />;es 16 <br /> <br />x <br />x <br /> <br />No <br /> <br />We st:rongJy recommend you review your Plan Document for appropriate wording and limitations. <br />