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B1ueCiross B1ueShield <br /> B1uePlus O O 3 Ala <br /> ® of Minnesota O� <br /> Independent licensees 61 the Blue Cross and Blue Shield Association <br /> } <br /> OTQ089-000 3 May 29, 2003 <br /> CITY OF PEQUOT LAKES <br /> 409 GOVERNMENT DR <br /> P.O. BOX 361 <br /> PEQUOT LAKES MN 56472 _ <br /> Renewal date : 08-01-03 <br /> The following changes are being made to your master group contract effective on your renewal <br /> date. <br /> 1. Your monthly rates will be as follows: <br /> Current coverage : COMPREHENSIVE MAJOR MEDICAL COPAY PLAN <br /> Plan Number: 113 <br /> Small Employer Plan <br /> AGE RENEWAL <br /> Under 30 $ 198.00 <br /> 30 - 34 5213.00 <br /> 35 - 39 $ 269.00 <br /> 40 - 44 $ 223.00 <br /> 45 - 49 $ 275.00 <br /> 50 - 54 $ 361.00 <br /> 55 - 59 $ 461.00 <br /> 60 - 64 $ 594.00 <br /> 65+ $ 325.00 <br /> NOTE: The 65+ rate with Medicare is no <br /> longer available. Refer to the Group Renewal <br /> Bulletin for details. <br /> 1 CHILD $ 156.00 <br /> 2 CHILDREN $ 312.00 <br /> 3 OR MORE $ 468.00 <br /> Average single rate based upon current census of 3 : $ 315.00 <br /> Average family rate based upon current census of 7 : $ 606.57 <br /> SS2A 0285 NW <br /> YK 4344 A <br /> �.. 3 035 5.5 <br /> For Office Use Only <br /> SGR10-00 <br />