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1. Indicate the monthly premium for the vision care program: <br />Benefits Options Employee Only Full Family <br />2. Indicate any variations from the current coverages included in the plan(s) proposed: <br />3. Describe any dental care limitation or restrictions. Do not refer the City to a specimen <br />contact or booklet. <br />4. Is coverage Portable? <br />5. If Yes, at same premium? <br />DISABILITY <br />1. Please describe the disability plan(s) proposed: <br />2. Attach the proposed rates for disability plan(s) proposed. <br />3. Indicate the monthly premium for an employee with the following options included: (If <br />the exact benefit option combinations are not available, please indicate the differences.) <br />Benefit Options Monthly Premium <br />4. Indicate any variations from the current coverages included in the plan(s) proposed: <br />5. Complete the list below identifying the proposed plan provisions. Do not refer to <br />printed material in lieu of completion. <br />Maximum Monthly Benefit (Dollar Amount) <br />Available Issue Ages (Ages) <br />Waiver of Premium (Yes /No & # of days disabled <br />for waiting period.) <br />Minimum Monthly Benefit (Dollar Amount) <br />Maximum Benefit Period (months /age) <br />Pre - Existing Conditions Exclusions (Months) <br />Successive /Recurrent Disabilities (Months) <br />Pregnancy covered as any other illness (Yes /No) <br />Page 16 of 17 <br />Dental, Life, LTD, Vision PFP.Doc <br />