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SUNNYISLES <br />1703779 <br />City of Sunny Isles Beach <br />• <br />SCHEDULE OF RATES AND COSTS <br />Number of <br />Monthly <br />Coverage <br />Employees <br />Volume Rate <br />Premium <br />Life Insurance <br />95 <br />4,992,500 $.24 /per $1,000 of benefit <br />$1,198.20 <br />AD &D <br />95 <br />4,992,500 $.040 /per $1,000 of benefit <br />$199.70 <br />Total Premium <br />$1,397.90 <br />The above rates assume the Life coverage is on a non - contributory basis and 100% participation is required. <br />The above rates are guaranteed for Two Years from the effective date of coverage. <br />This proposal describes certain insurance coverages available from Jefferson Pilot Financial and should under <br />no circumstances be construed as a contract or offer to contract for such coverages. An application must be <br />completed and submitted to our Omaha Office, before a group will be considered for coverage. <br />If the proposed policy qualifies as a replacement plan, then coverage for an otherwise eligible person who is <br />disabled on the policy effective date will be administered in accord with any applicable state discontinuance <br />and replacement law. <br />The proposal is based on preliminary census data received by Jefferson Pilot Financial. Actual costs will be <br />leased on the final enrollment data of employees insured under the plan on its effective date. Rates quoted for <br />the proposed benefits shown are effective for 90 days from the date shown on the proposal. A complete <br />listing of the terms, conditions, and limitations, that will apply to your coverage, if issued, is available upon <br />request. <br />• <br />Jefferson Pilot Financial Insurance Company <br />L.30A.050 4 11/16/2001 <br />