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4 <br /> 4. TYPE OF COVERAGE DESIRED: <br /> (Please Check One): 5/0 ( ) 10/0 (X) 5/50 ( ) 10/100 ( ) <br /> 5. OPTIONAL RIDERS DESIRED: <br /> A) $5/25% Prescription Drug (X) Yes ( ) No <br /> B) 50%/50% Prescription Drug ( ) Yes (X) No <br /> 6. INITIAL PREMIUM RATE INFORMATION: <br /> • (Employee = Subscriber) Monthly Premiums <br /> A) Single Subscriber 89.00 <br /> B) Subscriber Plus Spouse $ 187.00 <br /> C) Subscriber Plus Children $ 169.00 <br /> D) Family $ 266.00 <br /> The Group hereby requests coverage for eligible members of the Group and <br /> hereby allows CPHP to solicit to and enroll such eligible members. Should <br /> CPHP enroll such eligible members, the Group hereby agrees to execute a <br /> Employer Group Contract with CPHP which includes the Type of Coverage, <br /> Optional Riders and Initial Premium Rates listed above. Group agrees to <br /> return signed Group Contract thirty days prior to the effective date. <br /> Other Remarks: • <br /> APPLICANT: APPROVED BY: <br /> (Signature) (Date) (Signature) (Date) <br /> Keith G. Benoit <br /> (Type of Print Name & Title) Chief Financial Officer <br /> (Group Name & Number) <br /> • <br /> 4 <br /> • <br /> • <br />