Laserfiche WebLink
jAn 11 n_ <br />Premium <br />Quotation: 5' Huployees. .43r •ss <br />City of Little Canada <br />For: <br />Sandy Seitel <br />Account Executive <br />e <br />515 Little Canada Road <br />Physicians of Minnesota <br />5601 Smetana Drive <br />P.O. Box 1587 <br />Minneapolis, Minnesota 55440 -7001 <br />(612) 936 -1889 <br />Attn: Kris Van <br />to <br />Phone: 484 -2177 <br />Little Canada, MN 55117 <br />Number of eligible employees: ro Total employees: <br />Census: <br />Premium Options > <br />8 <br />(Motc4t. Only') <br />Employee Dpndts # of EE EE Only EE +Dpndts Employee 4 DPnkS. <br />M/F Age M/F Age Chldrn Only Dpndts w /Dental* w /Dental* Total <br />1) M 54 F 50 3 108.31 227.15 37.43 335.46 <br />2) M 44 1 67.15 40.00 37.43 107.15 <br />3) F 63 M* 65 150.00 38.00 37.43 188.00 <br />4) M 35 F 34 3 57.19 194.68 37.43 251.87 <br />5) M 23 45.61 13.23 45.61 <br />6) M 25 F 23 1 45.61 119.42 37.43 165.03 <br />7) F 23 M 23 1 79.42 85.61 37.43 165.03 <br />8) F 20 79.42. 13.23 79.42 <br />9) <br />10) <br />11) <br />12) <br />13) <br />14) <br />15) <br />16) <br />17) <br />18) <br />19) <br />20) <br />* Dental quotes are an average <br />TOTALS <br />Comments: <br />Note: <br />632.71 704.86 <br />ALL GROUPS add a $15.00 /month service fee. <br />(Dotal Total) (Medical Total) <br />251.04 1337.57 <br />* see enclosed:. . 5601 Smetana Drive <br />Medicare P.O. Box 1587 <br />plan #1= $38.00 Minneapolis.Minnesota 55440 -7001 <br />W121936-1200 <br />This is a premium quotation based on only your group census and the attached rate <br />sheet. The actual premium is based on application form data for age and sex. <br />Page 47 <br />