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<br />SUNNYISLES <br />5395246 <br /> <br />City of Sunny Isles Beach <br /> <br />COVERED SERVICES <br />TYPE I - Diagnostic & Preventive <br />TYPE II - Basic Services <br />TYPE III - Major Services <br />TYPE IV - Orthodontia* <br /> <br />oral exams, cleanings & x-rays <br />fillings, extractions, sealants, endodontics & periodontics <br />bridges, crowns & dentures <br />for Children <br /> <br />*To include Orthodontic Coverage for children in your Lincoln Financial Group Group Dental Policy, the <br />policyholder must meet the following dependent enrollment criteria: <br />On the Policy's Effective Date and at each annual Renewal Date, 8 dependent units must be enrolled. <br />A 'dependent unit' is a 'spouse' or 'child(ren)' or 'spouse and child(ren)' covered by the dental plan. <br />If dependent enrollment in the group policy does not meet this minimum requirement, Orthodontic Coverage <br />(Type IV Services) will not be issued or continued. This requirement does not change the minimum <br />participation requirements, described below. <br /> <br />PROPOSAL ASSUMPTIONS: <br />Quoted rates are based on the following assumptions. If these assumptions are not correct, the rates may be <br />adjusted or the proposal may be withdrawn. <br /> <br />Employer contribution to employee premium - <br />Employer contribution to dependent premium - <br />Minimum employee participation - <br />Minimum dependent participation - <br /> <br />100% <br />100% <br />100% (A minimum of 10 employees must be enrolled) <br />100% (A minimum of 8 dependent units must be enrolled in <br />order to include orthodontic benefits in the policy) <br /> <br />Employees covered by another dental plan may be excluded from participation calculations, as long as they do <br />not exceed 30% of eligible employees. <br /> <br />Final rates will be calculated based on: <br />the agreed-upon plan; <br />employer contribution (changing the percentage of employer contributions for employee and/or dependent <br />coverage may affect quoted rates); <br />enrolled census; <br />employee location(s); <br />correct industry code (SIC); and <br />other pertinent underwriting factors. <br />If there are changes in these factors, the plan may be re-rated or coverage may be refused. <br /> <br />THIS IS NOT A CONTRACT: This illustration was prepared based on the information provided in the Request <br />for Proposal. It is a description of dental coverage available from Lincoln Financial Group and not an offer to <br />contract. More detailed information is available upon request concerning the terms, conditions and limitations <br />contained in the master policy, if issued. If there are discrepancies between the information contained in this <br />proposal and the master policy, the terms of the master policy will control. State-specific restrictions and <br />requirements may not be addressed in this proposal. <br /> <br />An Application for Group Insurance must be completed by the Employer and approved by Lincoln Financial <br />Group before coverage can become effective. <br /> <br />This proposal is subject to revision if not accepted on or before the Proposed Effective Date shown on the <br />Benefits and Cost Summary page of this proposal. <br /> <br />The Lincoln National Life Insurance Company <br />5 <br /> <br />2/9/2009 <br />