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1111 GROUP <br />■ IHFALTH <br />■ ■ INC. <br />2829 UNIVERSITY AVE., S.E. MINNEAPOLIS, MN 55414 <br />BASED ON THE CENSUS PROVIDED, THE MONTHLY PREMIUM IS AS FOLLOWS: <br />. EMPLOYEE SPOUSE NUMBER OF MONTHLY <br />SEX AGE AGE CHILDREN MEDICAL <br />PREMIUM <br />MALE 54 50 3 $376.00 <br />MALE 44 1 $112.50 <br />FEMALE 63 55 CS290.50 <br />MALE 35 34 3 $284.00 <br />MALE 23 $ 46.50 <br />MALE 25 23 1 $170.00 <br />FEMALE 23 23 1 $170.00 <br />TOTAL MONTHLY PREMIUM $1,449.50* <br />5 /ghf ,j9.c� <br />Ann $10.00 MONTHLY BILLING CHARGE <br />WE THANK YOU FOR YOUR INTEREST IN GROUP HEALTH INC. AND WOULD APPRECIATE <br />THE OPPORTUNITY TO SERVE YOU. <br />`THIS IS AN ESTIMATE OF PREMIUM ONLY• FINAL RATES AND PREMIUM WILL BE <br />BASED ON ACTUAL ENROLLMENT. ACCEPTANCE OF GROUP IS CONTINGENT ON <br />UNDERWRITING APPROVAL. <br />AN EQUAL OPPORTUNITY EMPLOYER <br />Page: -.51 <br />