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Attachment A Schedule Cass County Personnel Contract Period: January 1,2003 through December 31,2003 Stop-Loss Insurance coverages are based on claims incurred in the period January 1, 1984 through December 31,2003, and paid during the 12-month Contract Period. Individual Stop-Loss maximums are $65,000 per member per Contract Period and the Aggregate Stop-Loss Maximum is 120% of expected claims. Expected monthly enrollment: Single: SPD: Family: SC '100 144 Contracts 54 Contracts 116 Contracts SC 100 OOA 0 Contracts 0 Contracts I Contracts Aggregate Stop-Loss Attachment Point per Subscriber: (x 12 for Contract Period) Single: $266.75 $277.35 SPD: 446,17 460.45 Family: 707.54 730.10 Aggregate Stop-Loss Attachment Point, Maximum Administrative Fees and Conversion Coverage Costs per Contract Period based on the figures shown in Section I and 2 above: Aggregate Stop-Loss Attachment Point: $1,747,176 Maximum Administrative Fees and Conversion Coverage Costs: $124,049 ( 7.1% of claims) Monthly premium for Stop-Loss insurance coverage (Aggregate and Individual): Single: $24.00 $24.00 SPD: 42.16 42.16 Family: 62.20 62.20 8. Summary of estimated Maximum Contract Period Cost at enrollment levels in Section I above: Aggregate Stop-Loss Attachment Point: Maximum Administrative Fees & Conversion Coverage Costs: Stop-Loss Insurance Premium: $1,747,176 124,049 186,120 Total Maximum Cost: $2,027,345 The par~ies have caused this Agreement to be executed by their respective authorized officers. CASS COUNTY PERSONNEL BLUE CROSS BLUE SHIELD Box 2806 OF NORTH DAKOTA Fargo, North Dakota 58102 4510 13th Avenue SW Fargo, North~Dakota 58.1%0001 By: By: Title: Title: p Date: Date: 4;~ ~ ./.~.-- 0 ~ Group Numbers: 10033