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B1ueCross BlueShield BROKER COPY <br /> �.� B1uePlus <br /> • of Minnesota <br /> Independent licensees of the Blue Cross and Blue Shield Association <br /> OT0089-000 3 May 27, 2004 <br /> CITY OF PEQUOT LAKES <br /> 409 GOVERNMENT DR <br /> P.O. BOX 361 <br /> PEQUOT LAKES MN 56472 <br /> Renewal date 08-01-04 <br /> Your new monthly renewal rates are indicated below for your review. <br /> Current coverage : COMPREHENSIVE MAJOR MEDICAL COPAY PLAN <br /> Plan Number: 113 <br /> Small Employer Plan <br /> AGE RENEWAL <br /> Under 30 $ 229.00 <br /> 30 - 34 $ 262.00 <br /> 35 - 39 $ 252.00 <br /> 40 - 44 $ 276.00 <br /> 45 - 49 $ 341.00 <br /> 50 - 54 $ 433.00 <br /> 55 - 59 $ 573.00 <br /> 60 - 64 $ 687.00 <br /> 65+ $ 433.00 <br /> 1 CHILD $ 190.00 <br /> 2 CHILDREN $ 380.00 <br /> 3 OR MORE $ 570.00 <br /> Average single rate based upon current census of 4 : $ 480.00 <br /> Average family rate based upon current census of 8 : $ 651.63., <br /> SS2A 0318 NE <br /> YK 4344 A <br /> L 3 035 008 <br /> For Office Use Only <br /> SGR10-00 <br />