ANNUAL DENTAL RENEWAL INFORMATIONCoinj)Bcynr fits
Annual Dental Renewal Information
Group Name: City of Clearwater
Name of In-force Plans:
DHMO-CS 150-CD3044
Advantage AVF1-CP2877
PPO-EP510-CP3044
Renewal Date: 1/01/2010
A) 1 Year Rate Guarantee-3% Increase on Current Monthly Rates
B) 2 Year Rate Guarantee-6% Increase on Current Monthly Rates
Renewal Rates:
DRMO-CS 150
Employee Only
Employee + One
Employee + Family
Advantage AVF 1
Employee Only
Employee + One
Employee + Family
1 year Guarantee
$17.52
$32.62
$42.46
$26.40
$49.18
$64.02
2Year Guarantee
$18.05
$33.60
$43.73
$27.19
$50.66
$65.94
PPO- EP510
Employee Only
Employee + One
Employee + Family
$39.30
$79.66
$117.44
$40.48
$82.05
$120.96
We hereby acknowledge that we have received and reviewed the renewal listed within
this notification and agree with the terms of the renewal.
Renewal Option: A) X Renewal Option: B)
Acknowledgement of Renewal Rates:
Signature
Dated
Printed Name
.W, ,
Countersigned:
Frank V. Hibbard
Mayor
Approved as to form:
Leslie K. Dougall- i es
Assistant City Atto y
CITY OF CLEARWATER, FLORIDA
By: 4 A - ?
William B. Horne II
City Manager
Attest:
hia E. Goudeau
Clerk
FV