HomeMy WebLinkAboutattachmentsEXHIBIT 1
SCHEDULE OF PREMIUM RATES
The Initial monthly Premium rates for the Insurance provided by this policy are as follows:
Rate Guarantee Period
Subject to the Right to Change Premium Rates provision on page 5, the Dental Premium rates for
Class I — Executives will be in effect for the period which begins on January 1, 2005 and ends on
December 31, 2007,
Class I - Executives
Dental Expense Benefits: - $50.17per Employee insured hereunder for Dental Expense Benefits on his or
her own account and $153.35 per Employee insured hereunder for Dental Expense Benefits on his or
her own account and on account of all Dependents.
Class II — All Other Employees
Dental Expense Benefits: - $36.81 per Employee insured hereunder for Dental Expense Benefits on his
or her own account and $75.80 per Employee insured hereunder for Dental Expense Benefits on his or
her own account and on account of his and her Dependent Spouse and $75.13 per Employee Insured
hereunder for Dental Expense Benefits on his or her own account and on account of dependent children)
and $134.02 per Employee insured hereunder for Dental Benefits on his or her own account and on
account of all Dependents.
GPNP99
EXH IBIT1
DATE: January 1, 2005
EXHIBIT 2
CERTIFICATE FORMS
Certificate
Number Certificate Form Applies To Effective Date
1
2
GPNPS9
EXHIBIT2
G.23000 Series with
any numerical and
alphabetical suffix as
shown in the
Certificate
Class I — Executives January 1, 2005
G.23000 Series with Class 2 —All Other Employees January 1, 2005
any numerical and
alphabetical suffix as
shown In the
Certificate
DATE: January 1, 2005