Fuhr Industrial. Small Group Proposal

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1 Small Group Proposal Options and Offers: IM2 DM2 TEFRA: N Maternity: Y Name DOB mm/dd/yyyy Age Gender Zip M/F Code Type EF Last Name 06/08/ M EF EF Last Name 03/05/ F EF ES Last Name 07/25/ M ES ES Last Name 06/14/ M ES Complete this section: BlueChoice Network BlueChoice Solutions Network Please check one of the boxes and write the plan number in the space provided: Select Plan Type Description Plan 1 Plan 2 Plan 3 PPO HMO One HMO plan N/A N/A Dual Option PPO Any two plans (PPO, HSA, HCA) from the same network N/A Multiple Option Product (MOP) A PPO, HSA, or HCA plan from either network and an HMO plan N/A Triple Option Product One PPO, HSA, or HCA plan from either the BlueChoice or BlueChoice Solutions network. (BlueChoice Solutions is a subset of our larger BlueChoice PPO network.) Three HSA plans or HCA plans are allowed Note: One HSA or HCA plan is required one HMO plan is allowed N/A N/A All non-hmo plans must be from the same network. Dental plan selection: Dental Plan Select one Dental plan Dual Option Dental Allowable combinations for group sizes 2-9 are: D101 and D201 D101 and D202 N/A Group Administrator This conditional rate quotation from Blue Cross and Blue Shield of Texas (BCBSTX) and/or HMO Blue Texas is based on the demographic information furnished. Acceptance for coverage and/or final rates will be determined by the statements made and information furnished on the employer's application. Any change in census, zip codes, SIC, or effective date may affect the final rates. No insurance or charges will be effective without approval by BCBSTX. The Underwriting Department of BCBSTX and HMO Blue Texas will make the final decision regarding policy issuance and rates. BCBSTX and HMO Blue Texas appointed agents are not authorized to guarantee coverage or rates. This proposal assumes the group contract will be issued in Texas. EMPLOYERS SHOULD NOT CANCEL COVERAGE UNTIL NOTIFIED IN WRITING BY BCBSTX and HMO Blue Texas THAT THEIR EMPLOYER APPLICATION HAS BEEN APPROVED AND FINAL RATES ARE DETERMINED. Date A Division of Care Service Corporation, a Mutual Legal Reserve Company,

2 Based on enrollment data, your Fort Dearborn Life Insurance Company rates and benefits are listed below. All contractual provisions detailed in the proposal originally issued to you are still applicable. If coverage amounts exceed the Guaranteed Issue (GI) amounts, you will need to submit evidence of insurability forms for each individual above those limits with your enrollment materials. s shown are subject to change based on final approved amounts if any of these coverages shown exceed the GI amounts. Group Life/STD Options Name DOB MM/DD/YYYY Age Gender M/F Zip Code Cvg Type Life/AD&D Life Volume STD STD Volume Dep Life EF Last Name 06/08/ M EF $ ,000 $ N/A $10.80 EF Last Name 03/05/ F EF $ ,000 $ N/A $10.30 ES Last Name 07/25/ M ES $ ,000 $ N/A $17.05 ES Last Name 06/14/ M ES $ ,000 $ N/A $23.45 s: $ ,000 $ N/A $61.60 The Dental s reflect coverage types for the census entered in the quote. BlueCare Freedom Dental Plan Ded Ind/Fam Annual Max Benefit Levels Allocation of Services Ortho %/ LifeMax +Child(ren) D101 $25/$75 $ /80/0 Value 0%/$0 $13.21 $39.18 $28.37 $61.31 $ D201 $50/$150 $ /80/50 Value 0%/$0 $30.20 $67.55 $66.12 $ $ D202 $50/$150 $ /80/50 Value 0%/$0 $32.66 $72.98 $71.44 $ $ **If services are provided by a BlueCare Dentist, the benefits described above will be paid based on the Allowable Amount for BlueCare Dentists which is a reduced fee schedule (this means less out-of-pocket). The BlueCare Dentist cannot balance bill for charges in excess of the Allowable Amount. If services are provided by a non-bluecare Dentist, the benefits will be based on the lesser of the billed charges or the amount BCBSTX would have considered for payment for the same covered procedure, service or supply provided by a Dentist with similar experience and/or skill in the same locale. It is possible for the non-bluecare Dentist to balance-bill for amounts above that which BCBSTX allows, resulting in higher out-of-pocket expenses. A Division of Care Service Corporation, a Mutual Legal Reserve Company,

3 Options and Offers: IM2 DM2 TEFRA: Maternity: N Y BestChoice PPO Plans Network The reflects coverage types for the census entered in the quote. +Child(ren) S01 $250 $15 90%/70% $1000/$2000 $15/$30/$45 $ $ $ $ $ S02 $500 $15 90%/70% $2000/$4000 $15/$30/$45 $ $ $ $ $ S03 $500 $15 80%/60% $2000/$4000 $15/$30/$45 $ $ $ $ $ S04 $500 $20 80%/60% $2500/$5000 $20/$35/$50 $ $ $ $ $ S05 $750 $20 80%/60% $3000/$6000 $15/$30/$45 $ $ $ $ $ S06 $1000 $20 100%/70% $0/$8000 $15/$30/$45 $ $ $ $ $ S07 $1000 $20 80%/60% $2500/$5000 $15/$30/$45 $ $ $ $ $ S08 $1000 $25 90%/70% $3000/$6000 $15/$30/$45 $ $ $ $ $ S09 $1000 $25 80%/60% $3000/$6000 $20/$35/$50 $ $ $ $ $ S10 $1000 $25 75%/50% $4000/$8000 $20/$40/$60 $ $ $ $ $ S11 $1000 $30 80%/60% $4000/$8000 $20/$35/$50 $ $ $ $ $ S12 $1000 Ded/Coins 80%/60% $3000/$6000 $20/$35/$50 $ $ $ $ $ S14 $1500 $20 80%/60% $3000/$6000 $15/$30/$45 $ $ $ $ $ S15 $1500 $25 75%/50% $3000/$6000 $15/$40/$55 $ $ $ $ $ S16 $1500 $30 80%/60% $3000/$6000 $20/$35/$50 $ $ $ $ $ S17 $1500 $30 75%/50% $4000/$8000 $20/$40/$60 $ $ $ $ $ S18 $2000 $20 80%/60% $3000/$6000 $15/$40/$55 $ $ $ $ $ S19 $2000 $25 75%/50% $3000/$6000 $15/$40/$55 $ $ $ $ $ S20 $2000 $30 75%50% $4000/$8000 $20/$40/$60 $ $ $ $ $ S21 $2000 Ded/Coins 100%/70% $0/$ %/50%/50% after cal yr ded $ $ $ $ $ S22 $2500 $25 80%/60% $3000/$6000 $10/$40/$60 $ $ $ $ $ S23 $2500 $25 70%/50% $3000/$6000 $20/$40/$60 $ $ $ $ $ S24 $2500 $30 70%/50% $4000/$8000 $20/$40/$60 $ $ $ $ $ S25 $3000 $30 100%/70% $0/$10000 $10/$40/$60 $ $ $ $ $ S26 $3000 $40 70%/50% $5000/$10000 $20/$40/$60 $ $ $ $ $ S27 $3000 Ded/Coins 80%/60% $4000/$8000 $20/$40/$60 $ $ $ $ $ S28 $4000 $40 70%/50% $5000/$10000 $20/$40/$60 $ $ $ $ $ S29 $4000 $40 50%/50% $7500/$15000 $20/$40/$60 $ $ $ $ $ S30 $5000 $30 100%/70% $0/$10000 $10/$40/$60 $ $ $ $ $ S31 $5000 $40 80%/60% $3500/$7000 $20/$40/$60 $ $ $ $ $ S32 $5000 $40 70%/50% $5000/$10000 $20/$40/$60 $ $ $ $ $ S33 $7500 $40 75%/50% $5000/$10000 $20/$40/$60 $ $ $ $ $ S34 $10000 $40 75%/50% $5000/$10000 $20/$40/$60 $ $ $ $ $ S35 $1000 Ded/Coins 100%/70% $0/$ %/50%/50% after cal yr ded $ $ $ $ $ S36 $2000 $30 100%/80% $0/$8000 $20/$35/$50 $ $ $ $ $ S37 $4000 $30 100%/70% $0/$10000 $20/$40/$60 $ $ $ $ $ AM13* $2000 Ded/Coins 50%/50% $5000/$ %/50%/50% after cal yr ded $ $ $ $ $ * AM plan has an annual maximum of $100,000 A Division of Care Service Corporation, a Mutual Legal Reserve Company,

4 Options and Offers: IM2 DM2 TEFRA: Maternity: N Y BestChoice Basic PPO Plans (Coins) * Network +Child(ren) SB1 $1000 $20 80%/60% $3000/$6000 $15/$40/$55 $ $ $ $ $ SB2 $2500 $30 80%/60% $4000/$8000 $20/$40/$60 $ $ $ $ $ * applies to the Physician Visit BestChoice Basic PPO Plans (Ded & Coins) * +Child(ren) SB3 $3000 $30 80%/60% $3000/$6000 $10/$40/$60 $ $ $ $ $ SB4 $5000 $40 70%/50% $5000/$10000 $20/$40/$60 $ $ $ $ $ * applies to the Physician Visit BestChoice HSA Qualified Plans Embedded Deductible * +Child(ren) SH1 $2500/$5000 Ded/Coins 100%/70% $0/$ % after cal yr ded $ $ $ $ $ SH2 $3000/$6000 Ded/Coins 100%/70% $0/$ % after cal yr ded $ $ $ $ $ SH3 $5000/$10000 Ded/Coins 100%/70% $0/$ % after cal yr ded $ $ $ $ $ SH6 $3500/$7000 Ded/Coins 80%/60% $1500/$ % after cal yr ded $ $ $ $ $ BestChoice HSA Qualified Plan Aggregate Deductible * +Child(ren) SH4 $1500/$3000 Ded/Coins 80%/60% $3000/$ % after cal yr ded $ $ $ $ $ SH5 $3000/$6000 Ded/Coins 100%/70% $0/$ % after cal yr ded $ $ $ $ $ * HSA plans do not have a combined in/out of network deductible Note: Deductible plus Coinsurance Stoploss equals Out of Pocket Maximum Wellness Rewards HCA Plans +Child(ren) SW1 $500 $20 80%/60% $2500/$5000 $20/$35/$50 $ $ $ $ $ SW2 $1000 $20 100%/70% $0/$8000 $15/$30/$45 $ $ $ $ $ SW3 $1000 $20 80%/60% $2500/$5000 $15/$30/$45 $ $ $ $ $ SW4 $3000 $30 100%/70% $0/$10000 $10/$40/$60 $ $ $ $ $ A Division of Care Service Corporation, a Mutual Legal Reserve Company,

5 Options and Offers: IM2 DM2 TEFRA: N Maternity: Y BestChoice PPO Plans Network The reflects coverage types for the census entered in the quote. +Child(ren) S01S $250 $15 90%/70% $1000/$2000 $15/$30/$45 $ $ $ $ $ S02S $500 $15 90%/70% $2000/$4000 $15/$30/$45 $ $ $ $ $ S03S $500 $15 80%/60% $2000/$4000 $15/$30/$45 $ $ $ $ $ S04S $500 $20 80%/60% $2500/$5000 $20/$35/$50 $ $ $ $ $ S05S $750 $20 80%/60% $3000/$6000 $15/$30/$45 $ $ $ $ $ S06S $1000 $20 100%/70% $0/$8000 $15/$30/$45 $ $ $ $ $ S07S $1000 $20 80%/60% $2500/$5000 $15/$30/$45 $ $ $ $ $ S08S $1000 $25 90%/70% $3000/$6000 $15/$30/$45 $ $ $ $ $ S09S $1000 $25 80%/60% $3000/$6000 $20/$35/$50 $ $ $ $ $ S10S $1000 $25 75%/50% $4000/$8000 $20/$40/$60 $ $ $ $ $ S11S $1000 $30 80%/60% $4000/$8000 $20/$35/$50 $ $ $ $ $ S12S $1000 Ded/Coins 80%/60% $3000/$6000 $20/$35/$50 $ $ $ $ $ S14S $1500 $20 80%/60% $3000/$6000 $15/$30/$45 $ $ $ $ $ S15S $1500 $25 75%/50% $3000/$6000 $15/$40/$55 $ $ $ $ $ S16S $1500 $30 80%/60% $3000/$6000 $20/$35/$50 $ $ $ $ $ S17S $1500 $30 75%/50% $4000/$8000 $20/$40/$60 $ $ $ $ $ S18S $2000 $20 80%/60% $3000/$6000 $15/$40/$55 $ $ $ $ $ S19S $2000 $25 75%/50% $3000/$6000 $15/$40/$55 $ $ $ $ $ S20S $2000 $30 75%50% $4000/$8000 $20/$40/$60 $ $ $ $ $ S21S $2000 Ded/Coins 100%/70% $0/$ %/50%/50% after cal yr ded $ $ $ $ $ S22S $2500 $25 80%/60% $3000/$6000 $10/$40/$60 $ $ $ $ $ S23S $2500 $25 70%/50% $3000/$6000 $20/$40/$60 $ $ $ $ $ S24S $2500 $30 70%/50% $4000/$8000 $20/$40/$60 $ $ $ $ $ S25S $3000 $30 100%/70% $0/$10000 $10/$40/$60 $ $ $ $ $ S26S $3000 $40 70%/50% $5000/$10000 $20/$40/$60 $ $ $ $ $ S27S $3000 Ded/Coins 80%/60% $4000/$8000 $20/$40/$60 $ $ $ $ $ S28S $4000 $40 70%/50% $5000/$10000 $20/$40/$60 $ $ $ $ $ S29S $4000 $40 50%/50% $7500/$15000 $20/$40/$60 $ $ $ $ $ S30S $5000 $30 100%/70% $0/$10000 $10/$40/$60 $ $ $ $ $ S31S $5000 $40 80%/60% $3500/$7000 $20/$40/$60 $ $ $ $ $ S32S $5000 $40 70%/50% $5000/$10000 $20/$40/$60 $ $ $ $ $ S33S $7500 $40 75%/50% $5000/$10000 $20/$40/$60 $ $ $ $ $ S34S $10000 $40 75%/50% $5000/$10000 $20/$40/$60 $ $ $ $ $ S35S $1000 Ded/Coins 100%/70% $0/$ %/50%/50% after cal yr ded $ $ $ $ $ S36S $2000 $30 100%/80% $0/$8000 $20/$35/$50 $ $ $ $ $ AM83* $2000 Ded/Coins 50%/50% $5000/$ %/50%/50% after cal yr ded $ $ $ $ $ * AM plan has an annual maximum of $100,000 A Division of Care Service Corporation, a Mutual Legal Reserve Company,

6 Options and Offers: IM2 DM2 TEFRA: N Maternity: Y BestChoice Basic PPO Plans (Coins) * Network +Child(ren) SB1S $1000 $20 80%/60% $3000/$6000 $15/$40/$55 $ $ $ $ $ SB2S $2500 $30 80%/60% $4000/$8000 $20/$40/$60 $ $ $ $ $ * applies to the Physician Visit BestChoice HSA Qualified Plans Embedded Deductible * +Child(ren) SH1S $2500/$5000 Ded/Coins 100%/70% $0/$ % after cal yr ded $ $ $ $ $ SH2S $3000/$6000 Ded/Coins 100%/70% $0/$ % after cal yr ded $ $ $ $ $ SH3S $5000/$10000 Ded/Coins 100%/70% $0/$ % after cal yr ded $ $ $ $ $ BestChoice HSA Qualified Plan Aggregate Deductible * +Child(ren) SH4S $1500/$3000 Ded/Coins 80%/60% $3000/$ % after cal yr ded $ $ $ $ $ * HSA plans do not have a combined in/out of network deductible Note: Deductible plus Coinsurance Stoploss equals Out of Pocket Maximum Wellness Rewards HCA Plans +Child(ren) SW1S $500 $20 80%/60% $2500/$5000 $20/$35/$50 $ $ $ $ $ SW2S $1000 $20 100%/70% $0/$8000 $15/$30/$45 $ $ $ $ $ SW3S $1000 $20 80%/60% $2500/$5000 $15/$30/$45 $ $ $ $ $ A Division of Care Service Corporation, a Mutual Legal Reserve Company,

7 Options and Offers: IM2 DM2 TEFRA: N Maternity: Y PCP/Spec In Hospital The reflects coverage types for the census entered in the quote. ER +Child(ren) Plan 9 $20/$20 $500 per admission $75 $10/$25/$40 $ $ $ $ $ Plan 11 $25/$25 $750 per admission $75 $15/$30/$45 $ $ $ $ $ Plan 12 $30/$30 $1000 per admission $75 $20/$35/$50 $ $ $ $ $ Plan 13 $10/$30 $350 per admission $100 $10/$25/$40 $ $ $ $ $ Plan 14 $15/$35 $500 per admission $125 $15/$30/$45 $ $ $ $ $ Plan 15 $20/$45 $600 per admission $150 $15/$30/$45 $ $ $ $ $ Plan 16 $25/$45 $1000 per admission $150 $20/$35/$50 $ $ $ $ $ Plan 17 $30/$50 $1250 per admission $150 $20/$40/$60 $ $ $ $ $ Plan 18 $35/$55 $1250 per admission $150 $20/$40/$60 $ $ $ $ $ Plan 19 $40/$60 $1500 per admission $150 $20/$40/$60 $ $ $ $ $ A Division of Care Service Corporation, a Mutual Legal Reserve Company,

8 This Quote was rated to include Options/Offers as follows: Options and Offers PPO Options PPO and/or HMO Options HMO Options Home Care Maternity Serious Mental Illness In-Vitro Fertilization Speech and Hearing Inpatient Mental Vision Services Decline Accept Decline Decline Decline IM2 Decline Durable Medical Equipment DM2 Listed below are brief descriptions of all available Options and Offers: Options and Offers PPO Description Home Care Decline - Receive standard benefit of $10,000 maximum. $10,000 maximum benefit per calendar year. Accept - Limited to 60 visits. 60 visits maximum per year with no dollar limit. Maternity PPO and/or HMO Accept - Services provided for the condition of pregnancy are covered the same as any other illness. Decline - services for Complications of Pregnancy are allowable. Serious Mental Illness Decline - Included in Mental Benefit. Accept SM1 - Maximum of 45 inpatient days per calendar year. Accept SM2 - Mandatory for Public Entities - Covered same as any other illness. Note: If you selected Yes on the Prospect Information page to indicate that the prospect is a Public Entity, you will be forced to select Accept Mandatory for Public Entities. For a complete description of the benefits, please contact your local Blue Cross Blue Shield of Texas sales office. In-Vitro Fertilization Decline - PPO: Limited benefits. HMO: No benefits. Accept - PPO: Subject to same copay as any other illness. HMO: Limited coverage. Speech and Hearing Decline - PPO: Hearing Aids limited to $1,000 every 36 months. HMO: No benefits. Accept - PPO Subject to same copay as any other illness; No limits. HMO: Subject to the same copay as any other illness. HMO Inpatient Mental Decline - No benefits Accept IM1 - Inpatient copay with 30-day maximum. Medical hospital inpatient copayments apply with 30 days maximum per calendar year. Accept IM2-50% with 30 -day maximum per calendar year. 50% of medical hospital inpatient copayments apply with 30 days maximum per calendar year. Vision Services Decline - No benefits Accept IC - Exam, Lenses, Standard Frames. Eye exam every 12 months with a $5 copayment. Contact lens exam included in the cost of contact lenses every 12 months with $5 copayment. $5 copayment every 24 months for standard frames. Higher copayment for non-standard frames. Accept O2 - Eye Examinations. Routine eye examinations for either eyeglasses or contact lenses, limited to one examination per member in any 12-month period. $10 copay for eyeglass vision examination or $20 copay for contact lens vision examination. Durable Medical Equipment Decline - No benefits Accept DM1 - No. 100% coverage for durable medical equipment; $1,000 total benefit for hearing aid device(s) every three years. Accept DM2-20%. 20% copayment for durable medical equipment; $1,000 total benefit for hearing aid device(s) every three years. Drugs and medicine must be approved by FDA and dispensable upon written prescription. Members are limited to a 30-day supply from a participating pharmacy and up to a 90-day supply through mail order. One copay applies to each 30 day supply. This document summarizes selected options and offers to Blue Cross and Blue Shield of Texas Small Group BestChoice plans and/or HMO Blue Texas. It is not a contract or any part of one. For a more complete description of the benefits available, including procedures, exclusions and limitations, please contact your local Blue Cross Blue Shield of Texas sales office. A Division of Care Service Corporation, a Mutual Legal Reserve Company,