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Cairnstane,���. RENEWAL NOTIFICATION <br /> 5201 Blue Lagoon Drive,Suite 500 <br /> �tiami,Florida 33126 <br /> Name of Em lo er: Decatur,Cit of Contract/Polic No.: PF003124 <br /> Address: 1 Gar K Anderson Plaza,Decatur,IL 62523 Carrier: Transamerica Life Insurance Com an <br /> Pre ared B : Ste hanie Nam el Macie'ewski Reinsurance Period: 11/1/07-10/31/08 <br /> Producer: Consociate-Dansi TPA: Consociate-Dansi <br /> SPECIFIC BENEFITS CURRENT PLAN OPTION A OPTION B OPTION C <br /> Deductible $200,000 $200,000 $225,000 $250,000 <br /> Maximum Reimbursement $1,800,000 $1,800,000 $1,775,000 $1,750,000 <br /> Contract Basis 12/12 12/12 12/l2 <br /> Advance Funding � <br /> Rx Covera e: ❑ <br /> AGGREGATE BENEFITS CURRENT PLAN OPTION A OPTION B OPTION C <br /> Contract Basis 12/12 12/12 12/12 12/12 <br /> Maximum Reimbursement $2,000,000 $2,000,000 $2,000,000 $2,000,000 <br /> Minimum Attachment Point(%) 100% 100% 100% 100% <br /> Monthly Aggregate Funding: ❑ COVERAGES: Medical � Rx(Only on the 3 Tier Plan) � Dental ❑ W.I. ❑ <br /> Vision ❑ <br /> AGCREGATE FACTORS: CURRENT FACTORS OPTION A OPTION B OPTION C <br /> Single Factor $486.07 $563.59 $565.10 $567.09 <br /> EE+Famil� $1,224.90 $1,420.25 $1,424.05 $1,429.07 <br /> PREMIUM RATES: CURRENT RATES OPTION A OPTION B OPTION C <br /> SPECIFIC PREMIUM: <br /> Single: $10.82 $11.91 $10.47 $8.57 <br /> EE + Family $27.27 $30.01 $26.38 $21.60 <br /> AGGREGATE PREMIUIVT: <br /> Composite: $5.70 $5.70 $5.70 $5.70 <br /> Monthl A re Iate Fundin : N/A N/A N/A N/A <br /> Premium is to be Remitted: Net ❑ Gross � Commission 5 % �I <br /> This is a tentative proposal based on the information furnished and does not constitute an offer to bind excess loss I <br /> reinsurance coverage.The proposal is subject to change and will be firm upon acceptance of risk by the carrier�nd <br /> applicable reinsurers based on receipt and review of the following: <br /> • We wiU need the following information on 2 individuals before we can determine if they are ok at the groups � <br /> specitic: <br /> 1. 070601 —What is his new plan of care? Without receipt and review of this information we are looking at a <br /> $275,000 Individual Specific Deductible <br /> 2. 037301 —What is his new plan of care? What is the cost of the Revlimid? Are there plans for another BMT <br /> as he responded will in 2004? Without receipt and review of this information we are looking at a$275,000 <br /> Individual Specific Deductible without a BMT and$375,000 with one <br /> • Benefits covered under the aggregate and specific coverage are the same as contained in the preceding policy period. <br /> • The final 3 months of paid claims from 8/1/07 to 10/31/07. Ifthe final 3 months of paid claims exceeds$1,538,000, <br /> �ve reserve the right to re-underwrite the Renewal Aggregate Factors. <br /> • Pended Specific and Aggregate claims reports through 10/31/07. <br /> • Effective month census. <br /> • Signed United Resource Network Access to Transplant Services Form(without this the group is not eligible for the <br /> step-do�vn deductible option for transplants-this can be signed anytime during the year). <br /> • Si ned Renewal Claim Notice. <br /> Please contact Gene Stevens or Stephanie Nampel Maciejewski with any questions or concerns you may have. <br /> Please sign the Renewal Notification and return to Stephanie Nampel Maciejewski by the Renewal Anniversary Date. <br /> Cairnstone reserves the ' ithdraw the renewal offer if this is not received b Renewal Anniversar Date. <br /> Accepted Renewal Plan: Date: <br /> eve Garma OPTION A �0 ' ��/' ��"/ <br /> : r ' ^ <br /> Renewal Notifi at' �� � <br /> v-10-2001 <br /> City Cler <br />