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SUNNYISLES <br />1703779 <br />City of Sunny Isles Beach <br />LTD Benefits & Cost Summary (continued) <br />SPROPOSAL ASSUMPTIONS & CONDITIONS <br />This proposal assumes that: <br />- there are no known uninsurable individuals in the group to be covered; and <br />- no employee is absent from work because of sickness or injury. <br />If any individual to be insured falls into either of these categories, Jefferson Pilot Financial requires full <br />disclosure of all information needed to evaluate the risk. After reviewing this information, we reserve the right <br />to revise or withdraw our proposal. <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 also assumes current and continued employer and employee participation in Workers' <br />Compensation or an equivalent plan, which would be used as a source of integration (offset) for the LTD plan <br />of benefits. <br />If the employer's LTD plan is currently insured by another carrier, this proposal assumes that the current carrier <br />will continue coverage on any insured employee who is disabled on the date the existing contract terminates — <br />even if the contract terminates before the disabled employee has satisfied the Elimination Period. <br />�uoted rates were developed based on the information contained in the Request for Proposal. Final rates will <br />be calculated based on: <br />- the agreed -upon plan; <br />- amount & tax status of employer and employee contributions; <br />- enrolled census; <br />- employee location(s); <br />- correct industry code (SIC); and <br />- other pertinent underwriting factors. <br />Jefferson Pilot Financial reserves the right to re -rate or refuse to issue coverage if there are changes in these <br />factors. <br />THIS IS NOT A CONTRACT: <br />This illustration was prepared based on the information provided in the Request for Proposal. It is a description <br />of the Long Term Disability Insurance coverage available from Jefferson Pilot Financial 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. <br />An Application for Group Insurance must be completed by the employer and approved by Jefferson Pilot <br />Financial before coverage can become effective. <br />This proposal is subject to revision if not accepted within 90 days of November 02, 2001. <br />L� <br />(continued on next page) <br />Jefferson Pilot Financial Insurance Company <br />FL 13 11/02/01 <br />