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� <br />Blue Cross and <br />Blue Shield <br />of Minnesota <br />P.O. Box 645OV• St. Paul, Minnesota 55184 <br />AWARE COLD PROPOSAL FOR CITY OF LITTLE CANADA <br />BY KING <br />PAGE 1 <br />PREPARED 09/24/87 <br />EFFECTIVE 11/81/87 <br />AREA 1 PHYSICIAN AWARE YES DEDUCTIBLE $ N/A STD B <br />TABLE 01 HOSPITAL AWARE YES OUT OF POCKET SINGLE N/A DENTAL 4L <br />FAMILY N/A <br />-- EMPLOYEE -- SPS 4 HEALTH ~-- LIFE -- -- STD -- DENTAL <br />NAME AGE SEX AGE DEP MED RATE CVRG DL RATE CVRG RATE CV RATE TOTAL <br />1 54 M 50 3 390.37 818880 N 8^88 100 11^30 F 12.73 423+28 <br />2 44 M 80 1 130.13 818808 N 4^20 180 8^28 F 12.73 155^26 <br />3 63 F 65 347.34 010000 N 23.20 100 15.90 F 12^73 399+17 <br />• 4 35 M 34 3 296^45 818000 N 2^58 108 6^50 F 12^73 318.18 <br />5 23 M 00 53.81 810088 N 2^18 108 5.00 8 3.98 64.89 <br />6 25 M 23 1 181.98 810800 N 2^18 100 5+88 F 12.73 281^81 <br />7 23 F 23 1 181.98 018808 N 2.10 180 5^08 F 12+73 281^81 <br />HEALTH AVERAGE <br />8 53+81 F 254^71 TOTALS 1582^86 45.00 56.90 80.36 1764^32 <br />IF ACTUAL CENSUS WAS NOT RECEIVED/ THEN SPOUSE ACE AND t OF DEPS WAS ASSUMED <br />RATES & ACCEPTANCE ARE SUBJECT TO UNDERWRITING AND APPLICATION REVIEW <br />Page 50 <br />