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Y <br /> '4 Proposed benefits: rates, covered lives, and aggregate deductible factors <br /> Specific Benefit Premium Rates: <br /> Single Family Other <br /> $ $ $ composite: $22.82 <br /> Specific Covered Benefits: <br /> ® Medical including Prescription Drug ❑ Medical excluding Prescription Drug <br /> Aggregate Benefit Premium Rates: <br /> ® Monthly rate ❑Annual rate(if applicable) ❑ Other: <br /> $ 1.50 $ $ <br /> Total Employees Total Family <br /> 1553 n/a composite rates <br /> Aggregate Deductible Factors(ADFs): <br /> Covered Benefit ADF <br /> ® Medical .. $691.34 <br /> ® Prescription Drug Plan $242.87 <br /> ❑ Dental $ <br /> ❑ STD $ <br /> ❑ Vision $ <br /> ❑ Other . ....... $ <br /> ❑ Monthly Aggregate Accommodation (MAA) <br /> '5 Claims Basis <br /> Specific Aggregate <br /> Contract Basis Benefit Benefit <br /> 12/12 Incurred and Paid ❑ ❑ <br /> 15/12 3 Month Run-In ❑ ❑ <br /> 18/12 6 Month Run-In ❑ ❑ <br /> 24/12 12 Month Run-In ❑ ❑ <br /> 12/15 3 Month Run-Out ❑ ❑ <br /> 12/18 6 Month Run-Out ❑ ❑ <br /> 12/24 12 Month Run-Out ❑ ❑ <br /> Incurred. ❑ NA <br /> Paid NA ❑ <br /> Other 36/12 <br /> Terminal Liability Option: ❑ ❑ ❑ 3 Months ❑ Other <br /> XGR/2989 • Stop-Loss Application Page 2 of 4 <br />