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Attachment A Schedule Cass County Personnel Contract Pedod: January 1, 2004 through December 31, 2004 Paid Claims Basis Stop-Loss insurance coverages are based on Plan Benefits incurred in the period January 1, 1984 through December 31, 2004 and paid dudng the Contract Period. Individual Stop-Loss Attachment Point is $65,000 per Member and the Aggregate Stop-Loss Attachment is 120% of expected Plan Benefits paid during the Contract Period. 1. Expected monthly enrollment levels: SC 100 8-03 SC 100 OOA 8.03 Single: 141 Contracts 0 Contracts Single Plus Dependent: 63 Contracts 0 Contracts Family:. 112 Contracts 1 Contracts Aggregate Stop-Loss Attachment Point per Subscriber: (x 12 for Contract Period) Single: $276.81 Single Plus Dependent: 459.56 Family: 728.77 $285.85 474.57 752.58 3. Aggregate Stop-Loss Attachment Point, maximum administrative fees (net of BlueCard fees and compensation) and conversion coverage costs per Contract Pedod based on the figures shown in Section 1 and 2 above. Aggregate Stop-Loss Attachment Point: Maximum administrative fees and conversion coverage costs: $1,804,288 $124,496 (6.9% of Claims) Monthly premium for stop-loss coverage (aggregate and individual): Single: $27.84 Single Plus Dependent: 48.92 Family: 72.16 $27.84 48.92 72.16 5. Summary of estimated Maximum Contract Pedod Cost at enrollment levels in Section I above: Aggregate Stop-Loss Attachment Point: Maximum administrative fees and conversion coverage costs: Stop-Loss coverage premium: $1,804,288 124,496 181,938 Total Maximum Cost: $2,110,720 In addition to the Total maximum cost, applicable BlueCard fees and compensation will apply. The parties have caused this Agreement to be executed by their respective authorized officers. CASS COUNTY PERSONNEL Box 2806 Fargo, North Dakota 58102 By: Title: Title: Date: Date: BLUE CROSS BLUE SHIELD OF NORTH DAKOTA 4510 13th Avenue SW Fargo, North Dakota 58121~0001 ~ Vi~ce'President, Actuarial "--'~nd Membership Services Group Numbers: 10033