The URL can be used to link to this page

Item C25 BOARD OF COUNTY COMMISSIONERS AGENDA ITEM SUMMARY Meeting Dater January 21,2015 Division: Emy)loy—ee Services Bulk Item: Yes X No _ Department: Employee Benefits Staff Contact Person/Phone#:Maria Fernandez-Gonzalez X4443 AGENDA ITEM WORDING: Approval to advertise a solicitation for Proposals for a Fully Insured Dental Policy. ITEM BACKGROUND: A Request for Proposals was approved by the BOCC and issued earlier this year with a bid opening date of July 10, 2014. Eleven proposals were received. Administration has since decided to re-issue the Request for Proposals with there being less penalty for using out of network providers (which was included in the most recent RFP) in addition to adding a higher annual benefit maximum($2,000 to$5,000). The BOCC approved renewing of the United Concordia insurance Company policy at the October 17, 2014 meeting for up to one year effective January 1, 201 S. This will allow time to complete this RFP. The policy with UCCI has a notice requirement of sixty (60) days and steps will be taken to ensure a smooth transition from the current provider to the new provider. PREVIOUS RELEVANT BOCC ACTION: At the October 17, 2014 meeting, the BOCC approved to renew for one (1) year with United Concordia; At the May 21, 2014 meetinp, the BOCC approved the draft Request for Proposal. CONTRACT/AGREEMENT CHANGES; N/A STAFF RECOMMENDATIONS: Approval. Approximate for advertising TOTAL COST $800.00 INDIRECT COST:— BUDGETED: Yes No DIFFERENTIAL OF LOCAL PREFERENCE: Approximate for Advertising Internal Service Fund COST TO COUNTY:—$800.00 SOURCE OF FUNDS:Primarily Ad Valorem REVENUE PRODUCING: Yes— No X AMOUNT PER MONTH Year L / KJIL APPROVED BY: County Atty OMB/Purchtr,asing_ Fisk Management kb DOCUMENTATION: Included X Not Required DISPOSITION: AGENDA ITEM# Rowed 7/09 MONROE COUNTY REQUEST FOR PROPOSALS FOR FULLY INSURED DENTAL BENEFITS h N rAyfa cad BOARD OF COUNTY COMMISSIONERS Mayor, Danny L. Kolhage, District 1 Mayor Pro Tem, Heather Carruthers, District 3 George Neugent, District 2 David Rice, District 4 Sylvia J. Murphy, District 5 COUNTY ADMINISTRATOR Roman Gastesi CLERK OF THE CIRCUIT COURT EMPLOYEE SERVICES DIVISION Amy Heavilin Employee Benefits January 27, 2015 TABLE OF CONTENTS SECTION ONE - INSTRUCTIONS TO PROPOSERS SECTION TWO - COUNTY FORMS EXHIBITS: EXHIBIT A - SCOPE OF SERVICES EXHIBIT B - DENTAL QUESTIONNAIRE EXHIBIT C NETWORK DISRUPTION EXHIBIT D BENEFIT COMPARISON 0 ATTACHMENTS: A. DENTAL CERTIFICATES 4 B. DENTAL CLAIMS HISTORY C. CENSUS AND ENROLLMENT D. CURRENT DENTAL RATES 2 of 2 SECTION ONE: INSTRUCTIONS TO PROPOSERS 1. Objective of the Request for Proposals (RFP) The County is seeking an insurance vendor to provide the County with a dual choice fully insured Dental PPO Proposal for its active employees, dependents, COBRA, and retired employees in accordance with the specifications outlined in this Request for Proposals. The County anticipates that this contract will be awarded for an effective date of September 1, 2015 or earlier, if possible. The initial policy term may be up to thirty six (36) months and the County may elect to renew for up to two (2) additional consecutive I year terms. The policy term will be dependent upon the acceptability of premium guarantees, coverage, service, provider stability and market conditions. The County is requesting Proposals for Dental PPO insurance as follows: Contributions: 1 00% Participant Paid Plans Requested: The County is requesting that Proposers provide forgiveness of the deductible for the remainder of 2015 for all plan variations. 1, Low Option PPO and High Option PPO, 2. For both the Low Option PPO and the High Option PPO please provide the incremental cost to add coverage for composite fillings. 3. For both the Low Option PPO and the High Option PPO please provide the incremental cost to add coverage for adult Ortho. 4,. For both the Low Option PPO and the High Option PPO please provide the incremental cost to add coverage for both composite fillings and adult Ortho. Low Option plan shaill miirror the current plan: Out of network Claims are to be reimbursed at the Maximum Allowable Cha�e for Network rov ers. e uctible $50 individuaill$150 Famijiv Maximums $2,000 Annual/$1,5 0 lifetime Ortho max ......... In—Network Out of Network ..........................—1-1........ 100%, 100% Basic 90% 80% -M2Lq—r 60% 50% Orthodontics-- 50% 50% High Option 0iiW benefits shall be as follows: Passive PPO with Out of network claims -- to be reimbursed at the 80th Percentile of R&C. Deductible $50 individuall/$150 F�ifl2�y mi' Maximums $5,000 Annual/$13,000 lifetime&dthho max ......................... In Network Out of Network ....... Did nostic 100% 100% 0 Basic 90% 90% Major 60% 60% Orthodontics .............1 3 of 29 .......... ..........I—— Proposals are requested to be submitted net of commissions, although it is not required. If any compensation for an agent is included in the rates, this must be fully disclosed along with the exact services the agent will be providing to the County. Please note that any entity and/or person who participated in the drafting of this RFP is disqualified from submitting a proposal in response to this RFP or receiving a commission as a result of the award of a contract for services arising out of this RFP. Calendar -___________ Date Activi ----------- Janu s _ ua_q 27, 2015 RFP Release Date Deadline for Vendor Questions Addendum Release Date March 17, 2015 d April 27, 2015 Selection Committee Rankin Meeting May20, 2015 Monroe CoMny BOCC,M I I I ti 1,1 —A A:!1 _,.Rproyal jton_pe�otiat olio artier if feasible .... 2. Background Information Monroe County is a non-charter county and a political subdivision of the State of Florida. The County population is approximately 76,000. The Board of County Commissioners, constituted as the governing body, has all the powers of a body corporate, including the powers to contract; to sue and be sued; to acquire, purchase, hold, lease and convey real estate and personal property; to borrow money and to generally exercise the powers of a public authority organized and existing for the purpose of providing community services to citizens within its territorial boundaries. In order to carry out this function, the County is empowered to levy taxes to pay the cost of operations. Monroe County is the southernmost county in the United States. It is comprised of the Florida Keys and a portion of the Florida Everglades. The Florida Keys are an archipelago of islands stretching from Key West, only 90 miles from Cuba, up to the mainland. In addition to the unincorporated county, there are five municipalities in the Florida Keys: Key West, Marathon, Key Colony Beach, Layton, and Islamorada. Further information about the demographics of the County can be found here: httl?://www.monroecouniy-fl.gov/index.aspx?NlD=27 . Approximately one-third of the population is situated in the City of Key West, which is the county seat; however, the County offers services throughout the Keys, and has government buildings throughout the Lower Keys (primarily Big Pine Key), Middle Keys (primarily Marathon), and Upper Keys (primarily Plantation Key and Key Largo) in addition to Key West, with employees stationed in all locations. 3. Present Information Monroe County currently offers two voluntary fully insured dental plans to active employees, dependents, retirees, COBRA eligibles, and Surviving Spouses. Premiums are paid for by active employees through payroll deductions. Premiums for active employees may be paid on a pretax basis through the County's Section 125 Plan. Premiums for Retirees and Surviving Spouses are collected and forwarded to the carrier 4 of 29 by Monroe County. Coverage is currently tracked by the following groupings: • The Board of County Commissioners; • The Clerk of the Circuit Court; • Tax Collector; • Property Appraiser; • Supervisor of Elections; • Sheriff's Office; • Land Authority, and; • Court Administration. Domestic Partners are included as dependents subject to the,criteria in Monroe County's Resolution (Resolution Number 081-1998). Active participant (along with their dependents') premiums are deducted bi-weekly and retiree/surviving spouses and COBRA premiums are paid on a monthly basis. All invoices are paid monthly. Current rates are included in Attachment D and do not include commissions. The rates for the Low Option PPO have not changed since implementation in 2011. The High Option PPO is a new plan effective 1/1/2015. The current plans, are offered by United Concordia, which has provided coverage since 2011.� The Low Option PPO, plan has been in place since 10/0112011 and the High i Option PPO plan was introduced in 01/01/2015, There is no experience available for the high option plan. Compensation: Proposer shall be in compliance with Section 624.428, Florida Statutes. If any commissions and/or service fees are included in your rate quotation, you shall specify the amount of the comissions and/or service fees, to whom they may be paid and your reason(s) for including em. The Monroe County Board of County Commissioners has engaged an independent consultant, Gallagher Benefit Services, Inc., to develop the RFP, provide analysis of Proposals to the Selection Committee with regard to the RFP, and for ongoing servicing of the contract. Additionally, the Monroe County Board of County Commissioners has separately engaged another independent consultant, Adams Benefit Corporation, to analyze and provide analysis of Proposals to the Selection Committee with regard to this RFP. The consultants are paid a fee from the County for these services and are not eligible to receive a fee or commission from any proposer or to submit a proposal on behalf of any agency, broker, or carrier with regard to this RFP. 4. Evaluation Criteria A Selection Committee will be convened to review the Proposals and recommend which Insurance vendor should be selected for the project. The successful Proposer will be selected based on the following criteria, 5 of 29 Network .............. _ -, mmmmmm. �_.. ....... — ,_... disruption analysis—higher points will be granted 20 paints according to the higher percentage of participating providers as compared to Exhibit —Network C�isru flan. PPO Network accessibility for all artici ae�ts 15 orts _ _. Costs and rate uara�ntees 25 oints__ Ability to provide the Scope of Services(implementation 20points timeframe will be critical in assessin services Com )lance with RFP S ecifwcations 1tl olints Prior eqx erience with avernme,nt clients 5 aints Location of firm(local preference if applicable: up to 5 5 points 2additional oints Total paints earned are on a scale of 1 — 100 points 1 = lowest 100 = highest A Selection Committee will be analyzing Proposals and providing recommendations to the County Administrator who will ultimately make a recommendation to the Board of County Commissioners regarding which Insurance vendor should be hired. 5. )Requests for Additional Information or Clarification Requests for additional information or clarification relating to the specifications of this Request for Proposals shall be submitted in writing directly to: Maria Fernandez-Gonzalez, Benefits Administrator 1100 Simonton Street, Suite 2-268 Key West, Florida 33040 Facsimile (305) 2924452 All requests for additional information must be received no later than 3:00 PM February 12, 2015. Any requests received after that date and time will not be answered. All requests for additional information will be answered via an, addendum to the RFP, which shall be distributed to all interested Proposers on the schedule listed above. Oral requests will not be answered. All addenda are a part of the contract documents and each Proposer will be bound) by such addenda, whether or not received by him/her. It is the responsibility of each Proposer to verify that he/she has received all addenda issued before responses are opened. 6. Content of Submission The Proposal submitted in response to this Request for Proposals (RFP) shall be printed on 8-1/2"x 11"white paper and bound; shall be clear and concise, tabulated, and provide the information requested herein. Statements submitted without the f 2 ----------------------- ................................................................................................. required information will not be considered. Responses shall be organized as indicated below. The Proposer should not withhold any information from the written response in anticipation of presenting the information orally or in a demonstration, since oral presentations or demonstrations may not be solicited. Each Proposer must submit adequate documentation to certify the Proposer's compliance with the County's requirements. Proposer should focus specifically on the information requested. 7. Format. The Proposal shall include the following: A. Cover Page A cover page that states "Request for Proposals for Fully Insured Dental Benefits". The cover page should contain Proposers name, address, telephone number, and the name of the Proposer's contact person(s). B. Table of Contents C. Tabbed Sections Tab 1. Letter of Transmittal The Proposer shall provide a letter confirming that the Proposal is an authorized offer by the Proposer and shall list the names of the persons who will be authorized to make representations for the Proposer, their titles, addresses and telephone numbers. Tab 2. Minimum Qualifications • The Proposer shall be licensed in the State of Florida to provide the requested insurance. • The Proposer shall have an A.M. Best rating of A- or higher and a financial size category of VI or higher. • If the Proposer is not rated by A.M. Best or the A.M. Best rating is below A-NI, Proposer must submit three (3) years of independent audited financial statements. • The Proposer shall provide a minimum of five (5) customer references for which they have provided dental insurance coverage within the past three (3) years. At least two (2) of these references must be from other city or county governments within the State of Florida. Each reference at a minimum shall include: * Name and full address of the client; * Name, address, title, and telephone number of the client contact; * Identification of coverage provided, including years for which the coverage was offered. • The Proposer shall include at least two letters of reference from clients which describes the services performed and the client's satisfaction with the services 7 of 29 -------- -----————————------------———----------- provided. Letters of reference are preferred, however, if the Proposer desires to include surveys, completed by clients regarding the service of the Proposer, they will be considered. Documents from, governmental/public entity clients are preferred. Copies are acceptable. Only those Proposers who provide references along with their Proposal will be awarded points. Tab 3. Scope of Services • Please include your completed Exhibit A—Scope of Services under this Tab. • If your response indicates that you can comply with deviations, you must fully explain the deviations in this Tab. Tab 4. Questionnaire and Cost Proposal Please include the completed Questionnaire (Exhibit B) under this tab in the file format as provided in the RFP package. Responses should be succinct while providing sufficient information to reply to the specific question. Excessive language is not desired. The fee (premiums) for the insurance coverage described in this RFP shall be included in the Questionnaire, The fee shall be an all-inclusive cost. No additional costs,or fees will be plaid, including but not limited to travel costs, per diems, telephone charges, facsimile charges, and postage charges. It is not ipated that contingencies will be included in the Proposal. However, please include your underwriting assumptions under this Tab 4, immediately after the Questionnaire. Tab 5�. Staffing for this Project and Qualifications of Key Personnel The Proposer shall describe the composition and structure of the firm (sole proprietorship, corporation, partnership, joint venture) and include names of persons with an interest in the fin-n. If the Proposer is anything other than an individual or sole proprietorship, the Proposer shall include a list of the proposed staff that will perform the work required and shall identify any sub-contractors that will be used, if awarded this contract. The Proposer shall also describe the qualifications for each employee on the project team and identify his/her role on the team. Include in this section the location of the main office and the location of the office proposed to work on this,project. 8 of 29 ........... ............... ........... Tab 6. Other Information Tab 6 shall include: • Exhibit C— Network Disruption; • Exhibit D — Benefit Comparison • GeoAccess Reports; • List of PPO network providers as described in Question 18 of the Dental Questionnaire. • Specimen Policy Proposer shall provide any additional project experience not already described in other tabs that will give an indication of the Proposer's overall abilities. If the Proposer cannot fully comply with any of the terms (other than those addressed in the Scope of Services) contained in the Request for Proposals, all deviations to the terms must be spelled out in this section, i.e. Tab 6. Tab 7. Litigation In accordance with Section 2-347(h) of the Monroe County Code, the Proposer must provide the following information: (1)A list of the person's or entity's shareholders with five (5) percent or more of the stock or, if a general partnership, a list of the general partners; or, if a limited liability company, a list of its members; or, if a solely owned proprietorship, names(s) of owner(s); (2) A list of the officers and directors of the entity; (3) The number of years the person or entity has been operating and, if different, the number of years it has been providing the services, goods, or construction services called for in the bid specifications (include a list of similar projects); (4) The number of years the person or entity has operated under its present name and any prior names; (5) Answers to the following questions regarding claims and suits: a. Has the person, principals, entity, or any entity previously owned, operated or directed by any of its officers, major shareholders or directors, ever failed to complete work or provide the goods for which it has contracted? If yes, provide details; b. Are there any judgments, claims, arbitration proceeding or suits pending or outstanding against the person, principal of the entity, or entity, or any entity previously owned, operated or directed by any of its officers, directors, or general partners? If yes, provide details; 9 of 29 L---- --------1 c. Has the person, principail of the entity, entity, or any entity previously owned, operated or directed by any of its officers, major shareholders or directors, within the last five (5) years, been a party to any lawsuit, arbitration, or mediation with regard to a contract for services, goods or construction services similar to those requested in the specifications with private or public entities? If yes, provide details; d. Has the person, principal of the entity, or any entity previously ownedi, operated or directed by any of its officers, owners, partners, major shareholders or directors, ever initiated litigation against the county or been sued by the county in connection with a contract to provide services, goods or construction services? If yes, provide details,; e. Whether, within the last,five (5) years, the owner, an officer, general partner, principal, controlling shareholder or major credlitor of the person or entity was an officer, director, general partner, principal, controlling shareholder or major creditor of any other entity that failed to perform services or furnish goods similar to those sought in the request for competitive solicitation. Tab 8. County► Forms Proposer shall complete, execute, and attach the forms specified below which are located in Section Two in this RFP, as well as a copy of a business, tax receipt from the Tax Collector's Office and shall include it in, this section, i.e. Tab 8: Forms• • Submission Response Form • Lobbying and Conflict of Interest Ethics Clause • Non-Collusion Affidavit • Drug Free Workplace Form • Public Entity Crime Statement • Any Proposer claiming a local preference as defined lin Monroe County Ordinance 023-2009 must complete the Local Preference Form and attach to,the Proposal. 8. COPIES OF RFP DOCUMENTS A. Only complete sets of RFP Documents will be issued and shall be used in preparing responses. The County does not assume any responsibility for errors, or misinterpretations resulting from the use of incomplete sets. B. Complete sets of RFP Documents,may be obtained in the manner andl at the locations stated in the Notice of Request for Proposals. 10 of 29 C. Each Proposer is responsible for obtaining all Addenda for this RFP and for acknowledging receipt of all Addenda on the RESPONSE FORM. 9. STATEMENT OF PROPOSAL REQUIREMENTS See also Notice of Request for Competitive Solicitation. Interested firms or individuals are requested to indicate their interest by submitting a total of two (2) signed originals, nine (9) complete copies of the Proposal, and two (2) complete copies on CD or other electronic media, in a sealed envelope, clearly marked on the outside with the Proposer's name and " PROPOSAL FOR FULLY INSURED DENTAL BENEFITS", addressed to Monroe County Purchasing Department, 1100 Simonton Street, Room 2-213, Key West, FL 33040, which must be received on or before 3:00 P.M. local time on March 17, 2015. The electronic copies must retain all of the Exhibits in the original or requested format(not PDF) in order to be considered compliant with the Bid Specifications. Hand delivered Proposals may request a receipt. No Proposals will be accepted after 3:00 P.M. Faxed or e-mailed Proposals shall be automatically rejected. It is the sole responsibility of each Proposer to ensure its Proposal is received in a timely fashion. 10. DISQUALIFICATION OF PROPOSER A. NON-COLLUSION AFFIDAVIT: Any person submitting a proposal in response to this invitation must execute the enclosed NONI-COLLUSION AFFIDAVIT. If it is discovered that collusion exists among the Proposers, the proposals of all participants in such collusion shall be rejected, and no participants in such collusion will be considered in future proposals for the same work. B. PUBLIC ENTITY CRIME: A person or affiliate who has been placed on the convicted vendor list following a conviction for a public entity crime may not submit a proposal on a contract to provide any goods or services to a public entity, may not submit a proposal on a contract with a public entity for the construction or repair of a public building or public work, may not submit Proposals on leases or perform work as a contractor, supplier, subcontractor, or contractor under a contract with any publlic entity, and may not transact business with any public entity in excess of the threshold amount provided in Section 287.017, Florida Statutes, for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list. Category Two: $25,000.00 C. DRUG-FREE WORKPLACE FORM: Any person submitting a bid or proposal in response to this invitation must execute the enclosed DRUG- FREE WORKPLACE FORM and submit it with his/her proposal. Failure to complete this form in every detail and submit it with the bid or proposal may result in immediate disqualification of the bid or proposal. I 1 of 29 ................ D. LOBBYING AND CONFLICT OF INTEREST ETHICS CLAUSE: Any person submitting a bid or proposal in; response to this invitation must execute the enclosed LOBBYING AND CONFLICT OF INTEREST CLAUSE and submit it with his/her bid or proposal. Failure to complete this form in every detail and submit it with the bid or proposal may result in immediate disqualification of the bid or proposal. 11. EXAMINATION OF RFP DOCUMENTS A. Each Proposer shall carefully examine the RFP and other contract documents, and inform himself/herself thoroughly regarding any and all conditions and requirements,that may in any manner affect cost, progress, or performance of the work to be performed under the contract. Ignorance on the part of the Proposer shall in no way relieve him/her of the obligations and responsibilities assumed under the contract. B. Should a Proposer find discrepancies, or ambiguities in, or omissions from, the specifications, or should he be in doubt as to their meaning, he shall at once notify the County. 12. GOVERNING LAWS AND REGULATIONS The: Proposer is required to be familiar with and shall be responsible for complying with all federal, state, and local laws, ordinances, rules, professional license requirements and regulations that in any manner affect the work. Knowledge of business tax requirements for Monroe County and municipalities within Monroe County are the responsibility of the Proposer, 13. PREPARATION OF RESPONSES Signature of the Proposer- The Proposer must sign the response forms in the space provided for the signature. If the Proposer is an individual, the words "doing business as or"Sole Owner' must appear beneath such signature. In the case of a partnership, the signature of at least one of the partners must follow the firma name and the words "Member of the Firm" should be written beneath such signature. If the Proposer is a corporation, the title of the officer signing the Response on behalf of the corporation must be stated along with evidence of his authority to sign the Response must be submitted. The Proposer shall state in the response the name and address of each person having an interest in the submitting entity. 14. MODIFICATION OF RESPONSES Written modifications will be accepted from Proposers if addressed to the entity and address indicated in the Notice of Request for Competitive Solicitation and received prior to Proposal due date and time. Modifications must be submitted in a sealed envelope clearly marked on the outside, with the Proposer's name and 12 of 29 --------...................................... "MODIFICATION TO Proposal for Fully Insured Dental Benefits ." If sent by mail or by courier, the above-mentioned envelope shall be enclosed in another envelope addressed to the entity and address stated in the Notice of Request for Proposals. Faxed or e-mailed modifications shall be automatically rejected. 15. RESPONSIBILITY FOR RESPONSE The Proposer is solely responsible for all costs of preparing and submitting the response, regardless of whether a contract award is made by the County. 16. RECEIPT AND OPENING OF RESPONSES Responses will be received until the designated time and will be publicly opened. Proposers names shall be read aloud at the appointed time and place stated in the Notice of Request for Competitive Solicitation. Monroe County's representative authorized to open the responses will decide when the specified time has arrived and no responses received thereafter will be considered. No responsibility will be attached to anyone for the premature opening of a response not properly addressed and identified. Proposers or their authorized agents are invited to be present. The County reserves the right to reject any and all responses and to waive technical error and irregularities as may be deemed best for the interests of the County. Responses that contain modifications that are incomplete, unbalanced, conditional, obscure, or that contain additions not requested or irregularities of any kind, or that do not comply in every respect with the Instruction to Proposer, may be rejected at the option of the County. 17. PROPRIETARY AND CONFIDENTIAL INFORMATION All Proposals received as a result of this RFP are subject to Chapter 119, Florida Statutes and will be made available for inspection by any person in accordance with Florida Statutes. Any Proposer asserting that any portion of its Proposal is confidential or exempt from disclosure under Florida's public records laws must specifically identify the portions of the Proposal asserted to be confidential and must provide specific citations of the Florida Statutes that establish the confidentiality or exemption, All material that is designated as exempt from Chapter 119 must be submitted in a separate envelope, clearly identified as "PUBLIC RECORDS EXEMPT"with your name and the Proposal name marked on the outside. If that material is requested through a public records request, the County will notify the Proposer o the request and give the Proposer five (5) calendar days to obtain a court order blocking the production of the material. If court order is issued during that time to block the production, the material will be produced. Please be aware that the designation of an item as exempt from disclosure as a Public Record may be challenged in court by any person. By your designation of material in your Proposal as "Public Records Exempt", you agree to defend and 13 of 29 ---------------------- hold harmless the County from any claims, judgments, damages, costs, and attorney's fees and costs of the challenger and for costs and attorney's fees incurred by the County by reason of any legal action challenging your designation. Please be advised that the designation of an item as exempt from disclosure as a Public Record may impact the ability of the Evaluating Body to adequiateiy assess a Proposal and may therefore affect the ultimate award of the contract. 18. AWARD OF CONTRACT A. The County reserves the right to award separate contracts for the services based on geographic area or other criteria, and to waive any informality in any response, or to re-advertise for all or part of the work contemplated. B. The County also reserves the right to reject the response of a Proposer who has previously failed to,perform properly or to complete contracts of a similar nature on time. C. The recommendation of staff shall be presented to the Board of County Commissioners of Monroe County, Florida, for final selection and award of contract. 19. CERTIFICATE OF INSURANCE AND INSURANCE REQUIREMENTS The Proposer shall be responsible for all necessary insurance coverage as indicated below. Certificates of Insurance must be provided to Monroe County within fifteen (15) days after award of contract, with Monroe County BOCC listed as additional insured as indicated. If the proper insurance forms are not received within the fifteen (15) day period, the contract may be awarded to the next selected Proposer. Policies shall be written by companies licensed to do business in the State of Florida and having an agent for service of process in the State of Florida, Companies shall have an A.M. Best rating of VI or better, The required insurance shall be maintained at all times while Proposer is providing service to County. Worker's Compensation Statutory Limits Employers' Liability Insurance Bodily Injury by Accident $100,000 Bodily Injury by Disease, policy limits $5010,000 Bodily Injury by Disease,, each employee $1010,000 General Liability, including Premises, Operation Products and Completed Operations Blanket Contractual Liability 14 of 29 Personal Injury Liability Expanded Definition of Property Damage $300,000 Combined Single Limit If split limits are provided, the minimum limits acceptable shall be: $200,000 per person $300,000 per occurrence $200,000 property damage Professional Liability $300,000 per Occurrence $500,000 Aggregate Monroe County shall be named as an Additional Insured on the General Liability. 20. INDEMNIFICATION The Proposer to whom a contract is awarded shall defend, indemnify and hold harmless the County as outlined below. The Proposer covenants and agrees to indemnify, hold harmless and defend Monroe County, its commissioners, officers,, employees,, agents and servants from any and all claims for bodily injury, including death, personal injury, and property damage, including damage to property owned by Monroe County, and any other losses, damages, and expenses of any kind, including attorney's fees, court costs and expenses, which arise out of, in connection with, or by reason of serviices provided by the Proposer or any of its Subcontractor(s), occasioned by the, negligence, errors, or other,wrongful act or omission of the Proposer, its Subcontractor(s), their officers, employees, servants or agents. In the event that the service is, delayed or suspended as a result of the ProposerNendor's failure to purchase or maintain the required insurance, the Vendor shall indemnify the County from any and all increased expenses resulting from such delay. The first ten dollars ($10.00) of remuneration paid to the Proposer is consideration for the indemnification provided for above. The extent of liability is in no way (limited to, reduced, or lessened by the insurance requirements contained elsewhere within this agreement. 21. EXECUTION OF CONTRACT The County intends to make an award to the Proposer that has complied with the terms, conditions and requirements of the RFP. Any agreement resulting from this RFP 15 of 29 ---- -------- must be governed by the laws of the State of Florida, and must have venue established in the State of Florida. The agreement will be submitted to the Monroe County Board of County Commissioners for final approval. 16 of 29 SECTION TWO: COUNTY FORMS AND INSURANCE FORMS [This page intentionally left blank, with forms to follow.] 17 of 29 RESPONSE FORM .... ......... ......... RESPOND TO: MONROE COUNTY BOARD OF-COUNTY COMMISSIONERS Purchasing: Department GATO BUILDING, ROOM 2-213 1100 SI STREET KEY WEST, FLORIDA 33040 01 acknowledge receipt of Addenda No.(s) I have included: • Response Form 0 • Lobbying and Conflict of interest Clause 0 • Non-Collusion Affidavit 0 • Drug Free Workplace Form 01 • Public Entily Crime Statement 13 • Copy of business tax receipt from the D Tax Collectors office • Local Preference,Form(if applicable) 13 0 1 have included a current copy of the following professional and occupational licenses: If the applicant Is,not an Individual(sole proprietor), please supply the following Information: APPLICANT ORGANIZATION: (Registered business name must appear exactly as it appears on www.sunbizorg). Any applicant other than an Individual(sole proprietor)must submit a printout of the"Detail by Entity Name"screen from Sunblz,and a copy of the most recent annual report filed with the Florida Department of State,Division of Corporations. Fee for services included in contract: $---- The fee is an all-inclusive cost. No additional costs or fees will be paid, including but not limited to travel costs, per dliems, telephone Mailing Address: Telephone: Fax: Date_ Signed: Witness: (Print Name) (Title) STATE OF: COUNTY OF: Subscribed and sworn to(or affirmed) before me on (date)by (name of affiant). He/She is personally known to me or has produced (type of identification)as identification. NOTARY PUBLIC My Commission Expires: 18 of 29 —————------------ LOBBYING AND CONFLICT OF INTEREST CLAUSE SWORN STATEMENT UNDER ORDINANCE NO. 010-1990 MONROE COUNTY, FLORIDA ETHICS CLAUSE (Company) U.-warrants that he/it has not employed, retained or otherwise had act on his/her behalf any former County officer or employee in violation of Section 2 of Ordinance No. 010- 1990 or any County officer or employee in violation of Section 3 of Ordinance No. 010- 1990. For breach or violation of this provision the County may, in its discretion, terminate this Agreement without liability and may also, in its discretion, deduct from the Agreement or purchase price, or otherwise recover, the full amount of any fee, commission, percentage, gift, or consideration paid to the former County officer or employee." (Signature) Date: STATE OF: COUNTY OF: Subscribed and sworn to (or affirmed) before me on (date) by (name of afflant). He/She is personally known to me or has produced (type of identification) as identification NOTARY PUBLIC My Commission Expires: 19 of 29 L—------------ ......................---......... ..... NON•COLLUSION AFFIDAVIT 1, of the city of according to law on my oath, and under penalty of perjury, depose and say that 1. 1 am of the firm of the bidder making the Proposal for the project described in the Request for Proposals for and that I executed the said proposal with full authority to do so; 2. The prices in this bid have been arrived at independently without collusion,, consultation, communication or agreement for the purpose of restricting competition, as to any matter relating to such prices with any other bidder or with any competitor; 3. Unless otherwise required by law, the prices which have been quoted in this bid have not been knowingly disclosed by the bidder and will not knowingly be disclosed by the bidder prior to bid opening, directly or indirectly, to any other bidder or to any competitor; and 4. No attempt has been made or will be made by the bidder to induce any other person, partnership or corporation to submit, or not to submit, a bid for the purpose of restricting competition; 5. The statements contained in this affidavit are true and correct, and made with full knowledge,that Monroe County relies upon the truth of the statements contained in this affidavit in awarding contracts for said project. (Signature) Date,: STATE OF: COUNTY OF: Subscribed and sworn to (or affirmed) before me on (date) by (name of affil:ant), He/She is personally known to:me or has produced (type of identification) as identification. NOTARY PUBLIC My Commission Expires: 20of29 .......... DRUG-FREE WORKPLACE FORM The undersigned vendor in accordance with Florida Statute 287,087 hereby certifies that: (Name of Business) 1. Publishes a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition. 2. Informs employees about the dangers, of drug abuse in the workplace, the business' policy of maintaining a drug-free workplace, any avaiilable drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations. 3. Gives each employee engaged in providing the commodities or contractual services that are under bid a copy of the statement specified in subsection (1). 4, In the statement specified in subsection (1), notifiles the employees that, as, a condition of working on the commodities or contractual services that are under bid, the employee will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contendere to, any violation of Chapter 893 (Florida Statutes) or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than five (5) days after such conviction. 5. Imposes a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available in the employee's community, or any employee who is so convicted. 6. Makes a good faith effort to continue to maintain a drug-free workplace through implementation of this section. As the person authorized to sign the statement, I certify that this firm complies fully with the above requirements. (Signature) Date: STATE OF: COUNTY OF: Subscribed and sworn to(or affirmed)before me on 'date)by (name of affiant), He/She is personally known to me or has produced (type of identification)as identification. NOTARY PUBLIC My Commission Expires: 21 of 29 .................... PUBLIC ENTITY CRIME STATEMENT "A person or affiliate who has been placed on the convicted vendor list following a conviction for public entity crime may not submit a bid on a contract to provide any goods or services to a public entity, may not submit a bid on a contract with a public entity for the construction or repair of a public building or public work, may not submit bids on leases of real property to public entity, may not be awarded or perform work as a contractor, supplier, subcontractor, or CONTRACTOR under a contract with any public entity, and may not transact business with any public entity in excess of the threshold amount provided in Section 287.017, Florida Statutes, for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list." I have read the above and state that neither I (Proposer's name) nor any Affiliate has been placed on the convicted vendor list within the last 36 months. (Signature) Date: STATE OF: COUNTY OF: Subscribed and sworn to (or affirmed) before me on (date) by (name of afi•iant). He/She is personally known to me or has produced (type of identification) as identification. NOTARY PUBLIC My Commission Expires: 22,of 29 ----------------- MONROE COUNTY, FLORIDA RISK MANAGEMENT POLICY AND PROCEDURES CONTRACT ADMINISTRATION MANUAL Indemnification and Hold Harmless For Other Contractors and Subcontractors The Contractor covenants and agrees to indemnify and hold harmless Monroe County Board of County Commissioners from any and all claims for bodily injury (including death), personal injury, and property damage (including property owned by Monroe County) and any other losses, damages, and expenses (including attorney's fees) which arise out of, in connection with, or by reason of services provided by the Contractor or any of its Subcontractor(s) in any tier, occasioned by negligence, errors, or other wrongful act of omission of the Contractor or its Subcontractors in any tier, their employees, or agents. In the event the completion of the project (to include the work of others) is delayed or suspended as a result of the Contractor's failure to purchase or maintain the required insurance, the Contractor shall indemnify the County from any and all increased expenses resulting from such delay. The first ten dollars ($10.00) of remuneration paid to the Contractor is for the indemnification provided for above. The extent of liability is in no way limited to, reduced, or lessened by the insurance requirements contained elsewhere Within this agreement. 23 of 29 ----------- ................. WORKERS' COMPENSATION INSURANCE REQUIREMENTS FOR CONTRACT BETWEEN MONROE COUNTY, FLORIDA AND Prior to the commencement of work governed by this contract, the Contractor shall obtain Workers' Compensation Insurance with limits sufficient to respond to the applicable state statutes. In addition, the Contractor shall obtain Employers' Liability Insurance with limits of not less than: $100,000 Bodily Injury by Accident $500,000 Bodily Injury by Disease, policy limits $100,000 Bodily Injury by Disease, each employee Coverage shall be maintained throughout the entire term of the contract. Coverage shall be provided by a company or companies authorized to transact business in the state of Florida. If the Contractor has been approved by the Florida's Department of Labor, as an authorized self-insurer, the County shall recognize and honor the Contractor's status. The Contractor may be required to submit a Letter of Authorization issued by the Department of Labor and a Certificate of Insurance, providing details on the Contractor's Excess Insurance Program. If the Contractor participates in a self-insurance fund, a Certificate of Insurance will be required. In addition, the Contractor may be required to submit updated financial statements from the fund upon request from the County. 24 of 29 ----------------------- ----------- GENERAL LIABILITY INSURANCE REQUIREMENTS FOR CONTRACT BETWEEN MONROE COUNTY, FLORIDA AND Prior to the commencement of work governed by this contract, the Contractor shall obtain General Liability Insurance, Coverage shall be maintained throughout the life of the contract and include, as a minimum: • Premises Operations • Products and Completed Operations • Blanket Contractual Liability • Personal Injury Liability • Expanded Definition of Property Damage The minimum limits acceptable shall be: $300,000 Combined Single Limit(CSL) If split limits are provided, the minimum limits acceptable shall be: $,200,000 per Person $300,000 per Occurrence $1200,000 Property Damage An Occurrence Form policy is preferred. If coverage is provided on a Claims Made policy, its provisions should include coverage for claims filed on or after the effective date of this contract. In addition, the period for which claims may be reported should extend for a minimum of twelve (12) months following the acceptance of work by the County. The Monroe County Board of County Commissioners shall be named as Additional Insured on all policies issued to satisfy the above requirements. 25 of 29 --------------- PROFESSIONAL LIABILITY INSURANCE REQUIREMENTS FOR CONTRACT BETWEEN MONROE COUNTY, FLORIDA AND Recognizing that the work governed by this contract involves the furnishing of advice or services of a professional nature, the Contractor, shall purchase and maintain, throughout the life of the contract, Professional Liability Insurance which will respond to damages resulting from any claim arising out of the performance of professional services or any error or omission of the Contractor arising out of work governed by this contract. The minimum limits of liability shall be: $300,000 per occurrence/$500,000 aggregate 26 of 29 MONROE COUNTY, FLORIDA RISK MANAGEMENT POLICY AND PROCEDURES CONTRACT ADMINISTRATION MANUAL WAIVER OF INSURANCE REQUIREMENTS There will be times when it will be necessary, or in the best interest of the County, to deviate from the standard insurance requirements specified within this manual. Recognizing this potential and acting on the advice of the County Attorney, the Board of County Commissioners has granted authorization to Risk Management to waive and modify various insurance provisions. Specifically excluded from this authorization is the right to waive; The County as being roamed as an Additional Insured — If a letter from the Insurance Company (not the Agent) is presented, stating that they are unable or unwilling to name the County as an Additional Insured, Risk Management has not been granted the authority to waive this provision. and The Indemnification and Hold Harmless Provisions Waiving of insurance provisions could ex ose the Coun to economic loss. For this reason, emery attempt should be made to obtain the standard insurance requirements. If a waiver or a modification is desired, a Request for Waiver of Insurance Requirement form should be complleted and submitted for consideration with the proposal. After consideration by Risk Management and if approved, the form will be returned, to the County Attorney who will submit the Waiver with the other contract documents for execution by the Clerk of the Courts. Should Risk Management deny this Waiver Request, the rather party may file an appeal with the County Administrator or the Board of County Commissioners, who retains the final decision-makinig authority. 27 of 29 MONROE COUNTY, FLORIDA Request For Waiver of Insurance Requirements It its requested that the insurance requirements, as specified in the County's Schedule of Insurance Requirements, be waived or modified on the following contract: Contractor: Contract for: Address of Contractor: Phone: Scope of Work: Reason for Waiver: Policies Waiver wild apply to: Signature of Contractor: Approved Not Approved Risk Management; Date: County Administrator appeal: Approved Not Approved Date: Board of County Commissioners appeal: Approved Not Approved Meeting Date,: PROPOSER SIGNATURE 28 of 29 ...................................-1-1...................—--------............................................. LOCAL PREFERENCE FORM A.Vendors claiming a local preference according to Ordinance 023-2009 must complete this form. Name of Bidder/Responder-,-,,,— ...................................................... I.Does the vendor have a valid receipt for the business tax paid to the Monroe County Tax Collector dated at least one year prior to the notice or request for bid or proposal? _ (Please furnish copy.) 2. Does the vendor have a physical business address located within Monroe County from which the vendor operates or performs business on a day to day basis that is a substantial component of the goods or services being offered to Monroe County? - List Address: TelephoneNumber:................................... ......................................................................................... B.Does the vendor/prime contractor intend to subcontract 50%or more of the goods,services or construction to local businesses meeting the criteria above as to licensing and location?............................... Ifyes,please provide: 1.Copy of Receipt of the business tax paid to the Monroe County Tax Collector by the subcontractor dated at least one year prior to the notice or request for bid or proposal. 2.Subcontractor Address within Monroe County from which the subcontractor operates: Tel.Number Print Signature and Title of Authorized Signatory for Bidder/Responder STATE OF: COUNTY OF: Subscribed and sworn to(or affirmed)before me on (date)by (name of afflant), He/She is personally known to me or has produced (type of identification)as identification. NOTARY PUBLIC My Commission Expires: 29 of 29 .......... ..........................................--........... This page intentionally left blank ATTACHMENT A-DENTM APPLICATION AND CERTIRCATE I UNITED CONCORDIA APPLECATION FOR GROUP DENTAL I14SU111 NCIE APPLICANT'S LEGAL NAME AND ADDRIESS' For generW coinraspon¢WZ;�,—mcelpt—W U—Afflln-qs-a—ndae'M f"t'e—mas"'i l'44d4mfls dlffwom than ft�ed,placecontact Name Pollcymalker Name I p 00 SmartonSirrd,Sudc.'.268 Tifle Phone Fax: Kc.y Wem kl- 33040 Emad -------- ----IWDU;S,-TRYT§1-1C--ICON EEK7 GrOUp,AdminisilrWor .............. 9lH Phone, 305 291-;4-lg Flax, 305-292.4432 ........... Lc!! Ernadi M71rd n 50" �Ilsl APPH t exempt from E-JU ................................................ ................................................... r rS. P FS PRODUCTS, FLEX. PIREFERRED: [kj SELEVI` F_j C;0110Ef j 017'11IER� ACCESSE] STANDARD opnON.- ........... ...................................... IF NOT STANDAND orinvN,COMPLETE SERVICE GRID. FFS RIDERS:: IMP112611 Ej "m --——----------- ............ ................... ............; I�ns I�IariPay14 Plairl, top Plans Onilywwwservka Coltnsurance: % % T—xarns ---------- lN UT-Yr I Tr Yir3 Yr4-4- 100 too maximurn: $....... $ � i �C f, -.— i��Cs — 100 too A is Prooram 0 P .L-LaL it _RLZ2L2Jjtr�XRa , I Mgra Cl Year arfings, Fluoride freaftnent I —----- ------ -Y —T—Yr 2 -r -3-1 ............ 'llWaMog Porlod� Ws._ 90 all Paiirmive"rreatmefll 1 1001 1100 ..... ........................................ Other Ridet:� El eAtilach DetaH) Pico,i� §PRCP i� 810 ............. ——-----——------- Z 2 90 1 80 FFS NETWORK RMMBURSEWENI� .................................... Faun warm pcaU P�ennmon—hcs--- AdvairdaW.� Advantage Pilus R'Rr� 1 -wi e p,—mr ...........................1—2' --9-0- so ------ —----- Nalional FF�S'b No Netwark[i 0 r 2 90 8 Access DFin r16Fe IFIP-Fi— -7 ----9-0 Pr4ng--Ira __10iut 2 40 C . ............................................... DENTAL PREPAID PRODUCT: ry ETN.7-r V 10 7 ................. 90 ----------- PLUSIThIrd Coklmnf--] Piz�x(7 xat Surgery. -——----------------- ------- Standard Plan 2 90 80 --v----—------------------- aftacth detait 9'j -T Non-Standard P�7, W6 Ti F 5 5-c 6() so ETO 61hodanZ,s bependeni 4 50, 50 1-—--------------- Standald Plan Adult Ad Nrin-S�an R dard w). attach delapU ..................--u --------------i............... COMPLETETHIS SOX FO" STANDARD 01IR NON-STANDARD OPTION. IN QUIT STEP PLANS RATES: 28 33 Programm DeducillbW($ndJFa It W l50 50 tso 5562 Deductible, Yr Li�fobirr COMAIC010 Holder&One,Aduj: -------- Prograln 'Max. VrEXI Ldewle D �-2xi000- s ,!,00000 CeMfiraiie Holder&One cndd, 57A6 OW00 IROX: YrE] Ufefirne[X] $ FT(WT67 $T500—00 Canificalle lqWder amChildran: .5786 DoduchbIa Max Perwd� Conhrarl Year ID Calendar Year2l Lffetime ll:)eduicUb�loAppllodtoWlSory cesz Yes O No El CeAflcalle,HoWer&Famly 8381 VfV o,,Service,sExevnlptfromvaiC)educffble. CtBssUZS CWW117J C118WH[I Onho[R] WalflnqPevllodsIMos.)u Class Classli ClasslH __0 real o --------- RATF-PERIOD� (MMMOryyyy) PREMIUM PAYMENT PER00. GROUP EFFE01VIE DATE: From OH0."yL`20H 12 01 AM M0111MY Servil-AnnuNly El S1 Of irno0h),, I t 2,0 11 J— 0 st d ffw)nlhji Ouarterly AnniuMly ED To _12 00 AM (Last day oil mi��n#�) PRIOR COVERAGE.Yes Z Iqrto Premilum must be pe,ld In advance., Choc$rs' PRYMIM-0 to UnItiod Concordia, Camer ............. ............................. ---------------- - PAR'nCWA'n0N SUMMARY ELIGBUTY WAITING PERIOD; DEPEI9113ENT CUVERAGE INCLUD'S: New Ce0cale Holdera are e4giWe ifor coverage on Spmxse #EflgdWe empiloyees 6D Howing d the of the nvnih to w1mos in Chiidren EXI #Enrolled an W;—pWc�class,or other: #Waived Non-Stludents, to Age ———————--------------- StudenIs to Age -6 ....... #Spouse Opt-Outs Dornesfic Partners 791 ------—-------------- ——------------- 91 A"T'TACI-IMENT A-DENTAL APPLICATION AND CERTIFICATE THE APPLICANT REPRESENTS that by signing this applicalion helshe agrees that the gtoup dental Insurance described above Wil become effeclive upon acceptance of this appilicallon by Unfled Concordia(UC) Applicant further ackinalvilliedges that no coverage will be effective before the date determined by UC and only if the first Premium has been paid arid undemiling No quakfirations are met It lih,s rapplication is accepted, it becomes a part of the linslurance contract beNveen Applicant anid UC. If this application Is no,t accepted arry loremAilm advanced by the Applicant wilt be refunded. Applicant warrants that alll infoorralion an this applicationi is true and coirnplele and acknowledges that coverage may be rescinded If there are material misstatements on this application, If errors or omissions in this application are disecireired by UC, It is authorized to amend this application by noting the changes an this form,aind the acceptance,evidenced'by Premium payment of array policy issued on this applicalivoll so arriended,shall consfilarle a ratification of any such cfI1WJqeS or emendirrients Upon policy renewal date pay"ild of the renewal premium mill confiffni acceptance of tiriat renel for the subsequent rate period. No agent or brolker Ihas the right to accept this application or bind Coverage, Any first prenrifurn or application submitted W UC or its sales personnel by a non-appointed producer Mist be accompanied by completed appoinIrniant paperwork or it will be returned to the nonappoiried producer Any person who knowingly,aired with literal to defrall any Insurance Company or othar presion,Hies;an application for Insurance containing any materially false Information or concoals,, far the purpose of misleading, Infortnallon concerning any fact material thereto comnill a fraud ulant Insurance act which Is a crime. Applicant: ol'Couray Cornnri5swncrs,, I at By ww Prolucer� ...... s8i Tifle Mar Agency. Tax 110: ................... L.ICProdu1cerLD# Agency Producer ............... State Law Provisions CA: California law prohibits an HIV test from being required or used by health,nsurance companies as a condillarr of obtaining hearth insur- once coverage. FL: Any person who knovAngly,and w1th Intent to Injure,defralud,or deceive any Insurer fifes a staternent of claim or an a pplicallon containing arr false,incomplete or atisileading information Its game ty or a lejony of the third degree AZ, A. All statements made by the Policyholder or by any insured Member shall be deemed representations and not warranties,and no state-rinentp., KY.NE rnade for the purpose of effel coverage shall void I.i coverage or reduce benefits unless contained in writing and signed by lhd &pill Policyholder K& Any person who knoWngly and with intent to defraud, as stalled on this Application, maybe cmmirlifiling a fraudulent insurance act which maybe,a crime. LA, Any person vvho knowingly presents a false I fraudulent claim lair payment of a loss or beril or knowingly presents false Information In an apphr,,atlon for Insurance is guilty of a crime and maybe!Subject to Fines land confinement in pirison IN,MO AP stalernents made by the Poticylpolder or by the persons insured shall be deemed representatrons, and riot warranties and that ro, &ND statement made by any person insured shalt be used in any contest unless a copy lot the linistrilyment containing the statement is or has been furnished to such person or, lin the event of the death or incapacity of the insured person, to the indivil bereficiary or personal representative, NJ AA Statements made by applicant are true and complete to the best of the applicant's WOMiedge and betef Any person who Includes am False 'Pir misloading informabol,,,on an application for air insuril policy is siijb�ed lo crini aric civil pell NY: Any person who knoviringly arid with Intent to defraud,as started on fts Applicaliiorr.shaft also be subject to a civil penally not to exceed five thousand dol and thie stated vallue of the claim for each such viloWlion OR! Any Pelson who knowingly and with, Intent to defraud as stated on this Application, rinaybe committing a frauduleni Insurance act which maybe a crime. Confestabitty is ilirniled 10 two,years as stated In the Group Policy, TN It is a cr;me to knavvingly provide false,incomplete or misleading information to an Insurance company for the purpose of defrauding the company Penalties include imprisonall fines arid denial of Insurance benefits. full Any person wtira wil the intent to defraud or knowng that he is fairiblafinq a fraud against an insiureir, Sub"'Ris, an applicallOn or files a Claim Containing a false or deceptive Watement may tiave violated the state law, United ConCiallidia programs ate underwritten by the following contliames in Me listed staios° United Concordia Dental Corporation of kabarna-At. United Concordia Dental Plans of Pennsylvania, Inc.-PA United Concordia Denial Plans,Inc,-MD,NJ Untled Concordia Dental Plans of Texas„Inc.-TX United Concordia Denial Plans of CW!1fm,Na, 111I-CA United Concordia Insurance Complany-AK,AR,AZ,CA,CO,CT,FL,GA,IA,0,IN,KS United Coricordia Dental Plans of Delaware, Inc.-DIE LA,MA,li ME,ii MIN,MS,ill NE,NV,NH,Nil IAD,Cil Oi< Opt pill SC SD United Concordia Dental Ptans of Floni full-FL TN,TX,I VT,VA,WA I„'WSJ VVY United Concordia Dentall Pi oil Kentucky, Inc. , KY United Conical ILifie and Health Insurance Company-DIE,DC,IL.KY,MiD,MO NC United Concordia Dental Plans of the Nfidwesi,Inc W NJ,PA Mo,OH United Concordia Insurance Company of Now York-NY roducts not avaikable in any state where prohibited by law or where United 10oncordia does not have repkitory approvat I. ........... ' l—,-'-i-....... ATTACHMENT A®DENTAL APPLICATION AND CERTIFICATE C mm r mmmm www ww mipllB � . JNI ddd� wwow �� uuuuww wwwwwwwu �Www� o„�� ,�ww� MAILEDNEEDS TO BE WITHIN z DAYS FROM THE PRINTT UCD CONTRACT FULFILLMENT PACKET MAILING INSTRUCTIONS CORPORATE PRINTING COPY PARENT ACCOUNT NUMBER: 0000 POLICY ID 38300 ACCOUNT NMBER 000 ACCOUNT/GROUP NAME Monroe County BOCC COST CENTER 2872 PRODUCT FFB PRINT v 1 L HE BANNER PAGES AND STAPLE BEFORE FORWARDING THE COPIES TO OUTPUT o i SERVICE 2BLL BRIGITTE / / JOHNSON / ATTACHMENT A-DENTAL APPLICATION AND CERTIFICATE UN �ITED C'ONCORE) 1��A Insuring Arneris Dent � Health PRINT DATE" September 10, 2013 BEDS TO BE MAILED WITHIN2 DAYS FROM THE PRINT DATE ABOVE SERVICESOUTPUT PARENT ACCOUNT tJ 0000 POLICY ID 36300 ACCOUNT NMBER 0204405 COST ACCOUNTIGROUP NAME Monroe Countre E TER 2672 i POSTCARD/PAPER Form B 06107 DAVISI IO N SEND TO SUBSCRIBERN i,. im PO T A DIPAPER TO TOTAL CIL.I Y A y INSERTS 1606 MAILING ENVELOPE 11 3135 3103 INCLUDE T RETURN UCCI AI ENVELOPE ENVELOPE AIL PACKET TO E AC H 1 0 F TFIE FOLLOWING: FOREIGN NAME Faris Fernandez Gonzalez ADD N TITLE Policy Maker ADDRESS 1100 Simonton Street ADDRESS Suite 2-266 CITYISTATEIZIP Key West, FL 33040 SPECIAL MAILING INSTRUCTIONS ATTACHMENT A-DENTAL APPLICATION AND CER1 IFICATE UNITED CONCOR ��DIA Insuring Arnerica's De-ital Heafth� September 10, 2013 Maria Fernandez Monroe County SOCC 1100 Simonton St Suite 2 268 Key West, FIL 33040 Dear Maria Fernandez: Your group recently had a benefit change to its dental coverage with United Concordia effective January 1, 2012. Please destroy any old Certificates of CoverageAnsurance you may have on hand. In an effort to more efficiently administer your group, United Concordia has placed the Certificates of Coverage/Insurance on our website at www.unit dconcordia.com under the feature, My Dental Benefits. Enclosed, please find a supply ref postcardsfor your employees explaining how to access their Certificates of Coverage/insurance online. If you have questions about your dental benefit program, please contact your Sales/Service Representative. Other questions may be referred to United Concordia's website at www,unitedconcordia.com or to our Customer Service Department at 800-332-0366. We thank you for your continued relationship with United Concordia. Please know that it is our sincere pleasure to serve you and your members. Sincerely, Lori Clouser Director, Undmvriting Operations and Administration Maintenance 2008 ATTACHMENT -DENTAL APPLICATION AND CERTIFICATE UNITED f UNITED CONCORDIA 1 Deer Path Road Harrisburg, 111 CertificateDental Plan Monroe County BOCC: Network Plan 897129099 Certificate Enter your name on the line provided This Certificateprovisionas shown on the Schedule of . Benefits. In AL, United Concordiais underwritten by United ConcordiaDental Corporation of Alabama In AK, r r r CO, r L, GA, Hl, I , ID, IN, r r r , } MN, Ir MS, : r NV, NH, r r : r r I, SC, r TN, r Tr VT, r WI,WV, , United cri is underwritten by Unitedonc+o is Insurance In r r IL, r r r r r : United Concordiais underwritten United r ia Life and HealthInsurance In NY, United Concordiais underwritten United cri Insurance Co of New York Incorporated in and made pert of 9 (07/02) FL9804- (0 109) ATTACHMENT A-DENTAL APPLICATION AND CERTIFICATE CERTIFICATE OF INSURANCE INTRODUCTION This Certificate of Insurance provides information about Your dental coverage. Read it carefully and keep it in a safe place with Your other valuable documents, Review it to become familiar with Your benefits and when You have a specific question regarding Your coverage. To offer these benefits, Your Group has entered into a Group Policy of insurance with United Concordia The benefits are available to You as long as the Premium for You and any enrolled Dependents is paid and obligations under the Group Policy are satisfied. In the event of conflict between this Certificate and the Group Policy, the Group Policy will rule, This Certificate is not a summary plan description under the Employee Retirement Income Security Act(ERISA). If You have any questions about Your coverage or benefits, please call our Customer Service Department toll-free at: 800-332-0366 For general information, Participating Dentist or benefit information, You may also log on to our website at: www,unifedconcordia,corn Claim forms should be sent to: United Concordia Companies, Inc. Dental Claims PO Box 69421 Harrisburg, PA 17106-9421 9804-B(071o2) ATTACHMENT A- DENTAL APPLICATION AND CERTIFICATE TABLE D'UNATION . ....,. ..... .w. .,,,.,..., ... ,..... . ..,..„ ....,...................................... . . LK," SRJ Am)EN"moN.LMENt �...... .. .... .,...... .. ..... ., a 4.Yo THN"w D, ��,TA,I,.PLA ,rK,S ..... ........,.. , -....... .. ...... . .... . ..... .. .... ONTNINllUAT[ON Q F ovr-..' AGE ..w ..... It h! � Appeall Proredbre A d n 1,rn: State Law Provisions Addendum Schedule re fit 2 ATTACHMENT A-DENTAL APPLICATION AND CERTIFICATE DEFINITIONS Certain to used throughout this Certificate begin with capital letters, When these terms are capitalized, use the following definitions to understand their meanings as they pertain to Your benefits and the way the dental plan works. Certificate Holder(s) - An individual who has enrolled him/herself and his/her Dependents for dental coverage and for whom Premium payments are due and payable, Also referred to as "You" or "Your" or "Yourself'. Certificate of Insurance ("Certificate") - This document, including riders, schedules, addenda and/or endorsements, if any,which describes the coverage purchased from the Company by the Policyholder, Coinsurance - Those remaining percentages or dollar amounts of the Maximum Allowable Charge for a Covered Service that are the responsibility of either the Certificate Holder or his/her enrolled Dependents after the Plan pays the percentages or dollar amounts shown on the Schedule of Benefits for a Covered Service. Company -United Concordia,the insurer. Also referred to as"We","Our"or'Us". Coordination of Benefits ("COB") - A method of determining benefits for Covered Services when the Member is covered under more than one plan to prevent duplication of payment so that no more 'than the incurred expense is paid. Cosmetic-Those procedures which are undertaken primarily to improve or otherwise modify the Members appearance. Covered Service(s)-A service or supply specified in this Certificate and the Schedule of Benefits for which benefits will be covered subject to the Schedule of Exclusions,and Limitations, when rendered by a dentist, or any other duly licensed dental practitioner under the scope of the individual's license when state law requires independent reimbursement of such practitioners, Deductible(s) -A specified amount of expenses set forth in the Schedule of Benefits for Covered Services that must be paid by the Member before the Company will pay any benefit. Dentally Necessary - A dental service or procedure is determined by a dentist to either establish or maintain a patient's dental health based on the professional diagnostic judgment of the dentist and the prevailing standards of care in the professional community. The determination will be made by the dentist in accordance with guidelines established by the Company, When there is a conflict of opinion between the dentist and the Company on whether or not a dental service or procedure is Dentaily Necessary, the opinion of the Company will be final. Dependent(s) - Certificate Holder's spouse or domestic life partner and their dependents as defined by the Policyholder and/or state law, and any unmarried child or stepchild of a Certificate Holder or unmarried member of the, Certificate Holder's household resulting from a court order or placement by an administrative agency'r enrolled in the Plan: (a) until the end of the calendar year which the/she reaches age 26, or (b) until the end of the calendar year which he/she reaches age 26 if he/she is afull-time student at an accredited educational institution and chiefly reliant upon the Certificate Holder for maintenance and support; or (c) to any age if helshe is and continues to be both incapable of self-sustaining employment by reason of mental or physical handicap and chiefly dependent upon the Certificate Holder for maintenance and support Effective Date-The date on which the Group Policy begins or coverage of enrolled Members begins, Excluslon(s)—Services, supplies or charges that are not covered under the Group Policy as stated in the Schedule of Exclusions and Limitations, 3 ATTACHMENT A-DENTAL APPLICATION AND CERTIFICATE Experimental or Investigative-'The use of any treatment, procedure, facility, equipment, drug, or drug usage device or supply which the Company, determines is not acceptable standard dental treatment of the condition being treated,or any such items requiiring federal or other governmental agency approval which was not granted at the time the services were rendered. The Company will rely on the advice of the general dental community including, but not limited to dental consultants, dental journals and governmental regulations, to make this determination. Grace Period -A period of no less than 31 days after Preni payment is due under the Policy, in which the Policyholder may make such payment and during which the protection of the Group Policy continues, subject to payment of Premium by the end of the Grace Period, Group Policy-The agreement between the Company and the Policyholder, under which the Certificate Holder is eligible to enroll. Limitation(s) -The maximum frequency or age limit applied to a Covered Service set forth in the Schedule of Exclusions and Limitations incorporated by reference into this Certificate, Maximum(s)-The greatest amount the Company is obligated to pay for all Covered Services rendered during a specified period as shown on the Schedule of Benefits. Maximum Allowable Charge - The maximum amount the Plan will all for a specific Covered Service. Maximum Allowable Charges may vary depending upon the contract between the Company and the particular Participating Dentist rendering the service, Depending upon the Plain purchased by the Policyholder, Maximum Allowable Charges for Covered Services rendered by Non-Participating Dentists may be the same or higher than such charges for Covered Services rendered by Participating Dentists in order to help limit out-of-pocket costs of Members choosing Pion-Participating Dentists. Member(s)-Certificate Holder(s)and their Dependent(s), Non-Participating Dentist -A dentist who has not signed a contract with the Company or an affiliate of the Company. Participating Dentist-A dentist who has executed a Participating Dentist Agreement with the Company or an affiliate of the Company, under which he/she agrees to accept the Company's Maximum AJlowwable Charges as payment in full for Covered Services. Plan - IDental benefits pursuant to this Certificate and attached Schedule of Exclusions and Limitations and Schedule of IBenefits. Policyholder-Organization that executes the Group Policy.Also referred to as"Your Group", Premium - Payment that the Policyholder must remit to the Company iin exchange for coverage of the Policyholder's Members, Renewal Date-The date on which the Group Policy renews. Also known as anniversary date. Schedule of Benefits - Attached summary of Covered Services, Plan payment percentages, Deductibles, Waiting Periods and Maximums applicable to benefits payable under the Plan Schedule of Exclusions and Limitations —Attached list of Exclusions and Limitations applicable to benefits, services,supplies or charges under the Plan. State Law Provisions Addendum—Attached document containing specific provisions required by state law to be modified,deleted from, and/or added to the Certificate of Insurance, Termination Date-The date on which the dental coverage ends for a Member or the Group Policy terminates. Waiting Period(s)-A period of time a Member must be enrolled under the Group Policy before benefits will be paid for Covered Services as shown on the attached Schedule of Benefits, 4 ATTACHMENT A-DENTAL APPLICATION AND CERTIFICATE ELIGIBILITY AND ENROLLMENT—WHEN COVERAGE BEGINS New Enrollment If You have already satisfied Your Group's eligibility requirements when the Group Policy begins and Your enrollment information is supplied to Us, Your coverage and Your Dependents' coverage will begin on the Effective Date of the Group Policy provided'We receive the Premium. If You join the Group or become employed after the initial Effective Date of the Group Policy, in order to be eligible to enroll, You must first satisfy any eligibility requirements of Your Group, Your Group will inform You of these requirements, You must supply the required enrollment information on Yourself and Your Dependents within 31 days of the date You meet these requirements. Your Dependents must also meet the requirements detailed in the definition of Dependent in the Definitions section of this Certificate, Your coverage and Your Dependents' coverage will begin on the date specified in the enrollment information supplied to Us provided Premium is paid, The Company is not liable to pay benefits for any services started prior to a Members Effective Date of ,coverage, Multi-visit procedures are considered "started" when the teeth are irrevocably altered. For ,example, for crowns, bridges and dentures, the procedure is started when the teeth are prepared and impressions are taken. For root canals, the procedure is started when the tooth is opened and pulp is removed, Procedures started prior to the Member's Effective Date are the liability of the Member or a prior insurance carrier. Enrollment Changes After Your initial enrollment, there are certain life change events that permit You to add Dependents.These events are: • birth ® adoption • court order of placement or custody • change in student status for a child • marriage, To enroll a new Dependent as a result of one of these events, You must notify Your Group and supply the required enrollment change information within 31 days of the date You acquired the Dependent. The Dependent must meet the requirements detailed in the definition of Dependent in the Definitions section of this Certificate. Except for newly born or adoptive children, coverage for the new Dependent will begin on the date specified in the enrollment information provided to Us as long as the Premium is paid. Newly born children of a Member will be considered enrolled from the moment of birth, Adoptive children will be considered enrolled from the date of adoption or placement, except for those adopted or placed within 31 days of birth who will be considered enrolled Dependents from the moment of birth. In order for coverage of newly born or adoptive children to continue beyond the first 31 day period, the child's enrollment information must be provided to Us and the required Premium must be paid within the 31 day period. For an enrolled Dependent child who is a full-time student, evidence of his/her student status and reliance on You for maintenance and support must be furnished to Us within 30 days after said Dependent attains the limiting age shown in the definition of Dependent. Such evidence will be requested annually thereafter until the Dependent reaches the limiting age for students and his/her coverage ends. For an enrolled Dependent child who is mentally or physically handicapped, evidence of This/her reliance on You for maintenance and support due to his/her condition must also be supplied to Us within 30 days 5 ATTACHMENT A-DENTAL APPLICATION AND CERTIFICATE after said Dependent attains the limiting age shown in the definition of Dependent. If the Dependent is a 'full-time student at an accredited educational institution, the evidence must be provided within 30 days ,after the Dependent attains the limiting age for students. Such evidence will be requested based on information provided by the Member's physician but no more frequently than annually. Dependent coverage may only be terminated when certain life change events occur including death, divorce or reaching the limiting age or during open enrollment periods. Late Enrollment If You or Your Dependents are not enrolled within 31 days of initial eligibility or a life change event, You or Your Dependents cannot enroll until the next open enrollment period conducted for Your Group unless otherwise required by applicable state or federal law or permitted by Your Group under the rules of its benefit plans, If You are required to provide coverage for a Dependent child pursuant to a court order, You will be permitted to enroll the Dependent child without regard to enrollment season restrictions. HOW THE DENTAL PLAN WORKS Choice of Provider You may choose any licensed dentist for services, However, Your out-of-pocket costs will vary depending upon whether or not Your dentist participates with United Concordia. If You choose a Participating Dentist, You may limit Your out-of-pocket cost. Participating Dentists agree by contract to accept Maximum Allowable Charges as payment in full for Covered Services. Participating dentists also complete and send claims directly to Us for processing. To find a Participating Dentist, visit Find a Dentist on Our website at www.u,tiitedconcordia.com or call Our Interactive Voice Response System at the toll- free number in the Introduction section of this Certificate. If You go to a dentist who is not a United Concordia Participating Dentist, You may have to pay the ,dentist at the time of service, complete and submit Your own claims and wait for Us to reimburse You, You will be responsible for the dentist's full charge which may result in higher out-of-pocket costs for You When You visit the dental office, let Your dentist know that You are covered under a United Concordia program and give the dental office Your contract ID number and group number. if Your dentist has questions about Your eligibility or benefits, instruct the office to call Our Interactive Voice Response System at the toll-free number in the Introduction section of this Certificate or visit Dental Inquiry on Our website at www t.,wiledconicoidia.corn. Claims Submission Upon completion of treatment, the services performed must be reported to Us in order for You to receive benefits, This is done through submission of a paper claim or electronically. Participating Dentists will report services to Us directly for You and Your Dependents. Most dental offices submit claims or report services for patients. However, if You do not receive treatment from a Participating Dentist, You may have to complete and send claims to Us in the event the dental office will not do this for You, To obtain a claim form, visit the Members link on our website at ivavw,unifeciric,iricordir),com. Be sure to include on the claim • the patient's name • date of birth • Your contract ID number • patient's relationship to You • Your name and address • the name and policy number of a second insurer if the patient is covered Iby another dental plan, 61 ATTACHMENT A- DENTAL APPLICATION AND CERTIFICATE Your dentist should complete the treatment and provider information or supply an itemized receipt for You to attach to the claim form. Send the claim form or predetermination to the address in the Introduction section of this Certificate, For orthodontic treatment, if covered under the Plan, an explanation of the planned treatment Must be submitted to Us. Upon review of the information, We will notify You and Your dentist of the reimbursement schedule, frequency of payment over the Course of the treatment, and Your share of the cost. Should You have any questions concerning Your coverage, eligibility or a specific claim, contact Us at the address and telephone number in the Introduction section of this Certificate or log onto My Dental Benefits at wwwunitedconcordia,com, Predetermination A predetermination is a review in advance of treatment by Us to determine patient eligibility and coverage for planned services. Predetermination is not required to receive a benefit for any service under the Plan. However, it is recommended for extensive, more costly treatment such as crowns and bridges. A predetermination, gives You and Your dentist an estimate of Your coverage and how much Your share of the cost will be for the treatment being considered. To have services predetermined, You or Your dentist should submit a claim showing the planned procedures but leaving out the dates of services. Be sure to sign the predetermination request. Substantiating material such as radiographs and periodontal charting may be requested by Us to estimate benefits and coverage. We will determine benefits payable, taking into account Exclusions and Limitations including alternate treatment options based upon the provisions of the Plan. We will notify you of the estimated benefits. When the services are performed, simply have Your dentist call Our Interactive Voice Response System at the telephone number in the Introduction section of this Certificate, or fill in the dates of service for the completed procedures on the predetermination notification and re-submit it to Us for processing. Any predetermination amount estimated is subject to continued eligibility of the patient. We may also make adjustments at the time of final payment to correct any mathematical errors, apply coordination of benefits, and comply with Your Plan in effect and remaining program Maximum dollars on the date of service. BENEFITS Schedule of Benefits Your benefits are shown on the attached Schedule of Benefits. The Schedule of Benefits shows: • the classes and groupings of dental services covered, shown with a "Plan Pays" percentage greater than "0%", • the percentage of the Maximum Allowable Charges the Plan will pay. • any Waiting Periods that must be satisfied for particular services before the Plan will pay benefits Waiting Periods are measured from date of enrollment in the Plan. • any Deductibles You and/or Your family must pay before any benefits for Covered Services will be paid by the (Plan, and the Covered Services for which there is no deductible, The Deductible is applied only 'to expenses for Covered Services and on either a calendar year or contract year basis(yearly period beginning with the Effective Date of the Group Policy) • any Maximums for Covered Services for a given period of time for example, annual for most services and lifetime for orthodontics, Annual Maximums are applied on either a calendar or contract year basis. Your Out-of-Pocket Costs In order to keep the Plan affordable for You and Your Group, the Plan includes certain cost-sharing features. If the class or service grouping is not covered under the Plan, the Schedule of Benefits will 7 ATTACHMENT A- DENTAL APPLICATION AND CERTIFICATE indiGate either "not covered" or "Plan Pays OW'. You will be responsible to pay Your dentist the full charge for these uncovered services. Classes or service groupings shown with "Plan Pays" percentages greater than 0% but less than 1100% require you to pay a portion of the cost for the Covered Service. For example, if the Plan pays 80%, Your share or Coinsurance is 20% of the Maximum Allowable Charge, You are also responsible to pay any Deductibles, charges exceeding the Plan Maximums or charges for Covered Services performed before satisfaction of any applicable Waiting Periods, Services The general descriptions below explain the services on the Schedule of Benefits The descriptions are not all-inclusive — they include only the most common dental procedures in a class or service grouping, Specific dental procedures may be shifted among groupings or classes or may not be covered depending on Your Group's choice of Plan, Check the Schedule of Benefits attached to this Certificate to see which groupings are covered ("Plan Pays percentage greater than '0'%") Also, have Your provider call Us to verify coverage of specific dental procedures or log on to My Dental Benefits or My Patient's benefits at wvw,t,ii7itedcor)c,-r)i,mclia.cotp,t to check coverage, Services covered on the Schedule of Benefits are also subject to Exclusions and Limitations. Be sure to review the Schedule of Exclusions and Limitations also attached to this Certificate. • Exams and X-rays for diagnosis—oral evaluations, bitewingsll periapical and full-mouth x-rays • leaninals, Fluoride Treatments Sealants for prevention • Palliative Treatment for relief of pain for dental emergencies • a2ggk_MgLa1gjM to prevent tooth movement • Basic Restorative to treat caries (cavities,, tooth decay) —amalgam and anterior composite resin lings, stainless steel crowns, crown build-ups and posts and cores, • Enclodontics to treat the dental pulp, pulp chamber and root canal — root canal treatment and re_treatment, pulpotoilmy, pulpal therapy, apicoectomy, and apexification • ENIgonnz-surgical Periodonfics for non-surgical treatment of diseases of the gums and bones supporting the teeth —periodontal scaling and root planing, periodontal maintenance • Be airs of Cirownginla s Orl Brid es Dentures—repair, recementationll re-fining, re-basing and adjustment • Simple Extractions®non-surgical removal of teeth and roots • Surgical Sul,�i l Periodo�nfi for surgical treatment of the tissues supporting and surrounding the teeth (gums and bone) — gingivectomy, gingivoplasty, gingival curretage, osseous surgery, crown lengthening, bone and tissue replacement grafts • Coll olex Oral Su for surgical treatment of the hard and soft tissues of the mouth —surgical extractions, impactions, excisions, exposure, root removal-, alveoplasty and vestibuloplasty • Anesthesia for elimination of pain during treatment—general or nitrous oxide or IV sedation 71n ii�7s�Qnla s, Crowns when the teeth cannot be restored by fitlings Prosthetics—fixed bridges, partial and complete dentures 3 hodontics for treatment of poor alignment and occlusion — diagnostic x-rays, active treatment 'and—retention for eligible dependent children Exclusions and Limitations Services indicated as covered on the Schedule of Benefits are subject to frequency or age Limitations detailed on the attached Schedule of Exclusions and Limitations, The existence of a Limitation on the Schedule of Exclusions and Limitations does not mean the service is covered under the Plan. Before reviewing the Limitations, You must first check the Schedule of Benefits to see which services are covered. No benefits will be provided fair services, supplies or charges detailed under the Exclusions on the Schedule of Exclusions and Limitations, EUMIUL9-muffli If You have treatment performed by a Participating Dentist, We will pay covered benefits directly to the Participating Dentist, Both You and the dentist will be notified of benefits covered, Plan payment and any 8 ATTACHMENT A-DENTAL APPLICATION AND GERTIFICATE amounts You owe for Coinsurance, Deductibles, charges exceeding Maximums or charges for services not covered. Payment will be based on the Maximum Allowable Charge the treating Participating Dentist has contracted to accept. If You receive treatment from a Non-Participating Dentist, We will send payment for covered benefits to You unless You indicate on the claim that You wish payment to be sent directly to Your treating dentist. You will be notified of the services covered, Plan payment and any amounts You owe for Coinsurance, Deductibles, charges exceeding Maximums or charges for services not covered, The Plan payment will be based on the Maximum Allowable Charges for the services, You will be responsible to pay the dentist any difference between the Plan's payment and the dentist's full charge for the services, The Company does not disclose claim or eligibility records except as allowed or required by law and then in accordance with federal and state law. The Company maintains physical, electronic, and procedural safeguards to guard claims and eligibility information from unauthorized access, use, and disclosure. Overnaments When We make an overpayment for benefits, We have the right to recover the overpayment either from You, from the person to whom it was paid, or from the dentist to whom the payment was made on behalf of the Member. We will recover the overpayment either by requesting a refund or offsetting the amount overpaid from future claim payments. Recovery will be done in accordance with any applicable state laws or regulations. Coordination of Benq fit jf � If You or Your Dependents are covered by any other dental plan and receive a service covered by this Plan and the other dental plan, benefits will be coordinated. This means that one plan will be primary and determine its benefits before those of the other plan and without considering the other plan's benefits. The other plan will be secondary and determine its benefits after the primary plan. The secondary plan's benefits may be reduced because of the primary plan's payment Each plan w1l provide only that portion of its benefit that is required to cover expenses, This prevents duplicate payments and overpayments. Upon determination of primary or secondary fiabifity, this Plan will determine payment. 1. The following words and phrases regarding the Coordination of Benefits ("COB") provision are defined as set forth below: A) Allowable Amount is the Plan's allowance for items of expense,when the care is covered at least in part by one or more Plans covering the Member for whom the claim is made. B) Claim Determination Period means a benefit year. However, it does not include any part of a year during which a person has no coverage under this Plan, C) Other Dental Plan is any form of coverage which is separate from this Plan with which coordination is allowed, Other Dental Plan will be any of the following which provides dental benefits,, or services, for the following: Group insurance or group type coverage, whether insured or uninsured. It also includes coverage other than school accident type coverage(including grammar, high school and r college student coverages) for accidents only, including athletic injury, either on a twenty-four (24) hour basis or on a "to and from school basis," or group or group type hospital indemnity benefits of$100 per day or less. D) Primary Plan is the plan which determines its benefits first and without considering the other plan's benefits, A plan that does not include a COB provision may not take the benefits of another 1plan into account when it cletertnines its benefits. E) Secondary Plan is the plan which determines its benefits after those of the other plan (Primary Plan). Benefits may be reduced because of the other plan's(Primary Plan)benefits. F) Plan means this document including all schedules and all riders thereto, providing dental care benefits to which this COB provision applies and which may be reduced as a result of the benefits of other dental plans. 2. The fair value of services provided by the Company will be considered to Ibe the amount of benefits paid by the Company, The Company will be fully discharged from liability to the extent of such payment under this provision. 9 ATTACHMENT A-DENTAL APPLICATION AND CERTIFICATE 3, In order to determine which plan is primary, this Plan will use the following rules A) If the other plan does not have a provision similar to this one, then that plan will be primary- If both plans have COB provisions, the plan covering the Member as a primary insured is determined before those of the plan which covers the person as a Dependent, C) The rules for the order of benefits for a Dependent child when the parents are not separated or divorced are: I) The benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later in that year; 2) If both parents have the same birthday, the benefits of the plan which covered the parent longer are determined before those of the plan which covered the other parent for a shorter period of time, 3) The word"birthday" refers only to month and day in a calendar year, not the year in which the person was li 4) If the other plan does not follow the birthday rule, but instead has a rule based upon the gender of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule based upon the gender of the parent will determine the order of benefits, D) If two or more plans cover a person as Dependent child of divorced or separated parents, benefits for the child are determined in this order'. 1) First, the plan of the parent with custody of the child. 2) Then, the plan of the spouse of the parent with the custody of the child; and 3) Finally, the plan of the parent not having custody of the child, 4) If the specific terms of a court decree state that one of the parents is responsible for the dental care expenses of the child, and the entity obligated to pay or provide the benefits of the plan of that parent has actual knowledge of those terms, the benefits of that plan are determined first. The plan of the other parent will be the Secondary Plan. 5) If the specific terms of the court decree state that the parents will share joint custody, without stating that one of the parents is responsible for the dental care expenses of the child,the plans covering the child will follow the order of benefit determination rules outlined in Section 3-C)above, titled Dependent Child/Parents Not Separated or Divorced. E) Active/inactive Member 1) For actively employed Members and their spouses over the age of 65 who are covered by Medicare, the plan will be primary. 2) When one contract is a retirement plan and the other is an active plan, the active plain is primary. When two retirement plans are involved, the one in effect for the longest time is primary. If another contract does not have this rule, then this rule will be ignored. F) If none of these rules apply, then the contract which has continuously covered the Member for a longer period of time will be primary. G) The plan covering an individual as a COBRA continuee will be secondary to a plan covering that individual as a Member or a Dependent 4. Certain facts are needed to apply these COB rules. The Company has the right to decide which facts it needs. It may get needed facts from or give them to any other organization or person. Any health information furnished to a third party will be released in accordance with federal law. Each person claiming benefits under This Plan must give any facts needed to pay the claim, 5. f1Q&_2LRlyMRW—A payment made under another plan may include an amount which should have been paid under this Plan. If it does, the Company may pay the amount to the organization which made that payment, That amount will then be treated as though it were a benefit paid under This Plan, and the Company will not pay that amount again. The term "payment made" includes providing (benefits in the form of services, in which case "payment made" means reasonable cash value of the services prepaid by the Company. 16. Right of Recovery— If the payment made by the Company is more than it should have paid under this COB provision, the Company may recover the excess from one or more of the following: (1)persons it has paid or for whom it has paidi or (2) insurance companies: or (3) other organization. Members are required to assist the Company to implement this section, 10 ATTACHMENT A-DENTAL APPLICATION AND CERTIFICATE Vorkers' Coienatfon When a Member is eligible for Workers' Compensation benefits through employment, the cost of dental treatment for an injury which arises out of and in the course of Member's employment is not a covered benefit under this Plan. Therefore, if the Company pays benefits which are covered by a Workers' Compensation policy, the Company has the right to obtain reimbursement for those benefits paid. The Member must provide any assistance necessary, including furnishing information and signing necessary documents, for the Company to receive the reimbursement. Review of a Benefit Determination If You are not satisfied with the Plan's benefit, please contact Our Customer Service Department at the toll- free telephone number in the Introduction section of this Certificate, If, after speaking with a Customer Service representative, You are still dissatisfied, refer to the Appeal Procedure Addendum attached to this Certificate for further steps You can take regarding Your claim. TERMINATION —WHEN COVERAGE ENDS Your coverage and/or Your Dependents'coverage will end: • on the date You lose eligibility under Your Group's eligibility requirements; or • on the date Premium payment ceases for You and/or Your Dependents, as specified by your Group; or • on the date Your Dependent(s) cease to meet the requirements in the definition of Dependent in the Definitions section of this Certificate; If Your coverage or Your Dependents'coverage is terminated as described above, coverage for completion of a dental procedure requiring two or more visits on separate days will be extended for a period of 90 days after the Member's Termination Date in order for the procedure to be finished. The procedure must be started prior to the Member's Termination Date. The procedure is considered "started"when the teeth are irrevocably altered. For example, for crowns, bridges and dentures, the procedure is started when the teeth are prepared and impressions are taken. For root canals,the procedure is started when the tooth is opened and pulp is removed. For orthodontic treatment, if covered under the Plan, coverage will be extended through the end of the month of the Member's Termination Date, If Your coverage ends, Your Dependents'coverage will end on the same date unless otherwise specified in a State Law Provisions Addendum to this Certificate. If the Group Policy is cancelled, Your coverage and Your Dependents' coverage will end on the Group Policy Termination Date. In the event of a default in Premium payment by the Policyholder, coverage will remain in effect for the Grace Period extended for payment of the overdue Premium, If the Premium is not received by the end of the Grace Period, the Group Policy will be cancelled and coverage will terminate the first day following the end of the Grace Period, The Company is not liable to pay any benefits for services, including those predetermined, which are performed after the Termination Date of a( ember's coverage or of the Group Policy. CONTINUATION COVERAGE Federal law may require certain employers to offer continuation coverage to Members for a specified period of time upon termination of employment or reduction of work hours for any reason other than gross misconduct. You should contact Your employer to find out whether or not this requirement applies to You and Your employer. Your employer will advise You of Your rights to continuation coverage and the cost. If this requirement does apply, You must elect to continue coverage within 160 days from Your qualifying event or notification of rights by Your employer, whichever is later. You may elect to extend Dependent(s') coverage, or the Dependent(s) may elect to continue coverage under certain circumstances or qualifying events. Dependent(s) must elect to continue coverage within 60 days from the event or notification of rights by 'Your employer, whiclhever is later. You must pay the required premium for continuation II ATTACHMENT A-DENTAL APPLICATION AND CERTIFICATE coverage directly to your employer. The Company is not responsible for determining who is eligible for continuation coverage. GENERAL PROVISIONS This Certificate includes and incorporates any and all riders, endorsements, addenda, and schedules and together with the Group Policy represents the entire agreement between the parties with respect to the subject matter. The failure of any section or subsection of this Certificate shall not affect the validity, legality and enforceability of the remaining sections. Except as otherwise herein provided, this Certificate may be amended, changed or modified only in writing and thereafter attached hereto as part of this Certificate. The Company may assign this Certificate and its rights and obligations hereunder to any entity under common control with the Company. This Certificate will be construed for all purposes as a legal document and will be interpreted and enforced in accordance with pertinent laws and regulations of the state indicated on the State Law Provisions Addendum, ATTACHMENT A-DENTAL APPLICATION AND CERTIFICATE ADDENDUM TO CERTIFICATE APPEAL PROCEDURE This Addendum is effective on the Effective Date stated in the Group Policy, It is attached to and made part of the Certificate. If You are dissatisfied with Our benefit determination on a claim, You may appeal Our decision, by following the steps outlined in this procedure. We will resolve Your appeal in a thorough, appropriate, and timely manner to ensure that You are afforded a full and fair review of claims for benefits. Benefit determinations will be made in accordance with the Plan documents and consistently among claimants. You or Your authorized representative may submit written comments, documents, records and other information relating to claims or appeals. We will provide a review that takes into account all information submitted whether or not it was considered with its first determination on the claim. Any notifications by Us required under these procedures will be supplied to You or Your authorized representative, DEFINITIONS The following terms when used in this document have the meanings shown below. "Adverse benefit determinafiori" is a denial, reduction, or termination of or failure to make payment (in whole or in part) based on a determination of eligibility to participate in a plan or the application of any utilization review: or a determination that an item or service otherwise covered is Experimental or Investigational or not Dentally Necessary or appropriate. "6AMu!bh2oErjig�edr resentat' is a person granted authority by You and the Company to act on Your behalf regarding a claim for benefit or an appeal of an adverse benefit determination, An assignment of benefits is not a grant of authority to act on Your behalf in pursuing and appealing a benefit determination, "Relevant"A document, record, or other information will be considered"relevant"to a given claim: a) if it,was relied on in making the(benefit determination: b) if it was submitted, considered, or generated in the course of making the benefit determination (even if the Plan did not rely on it); c) if it demonstrated that, in making the determination, the Plan followed its own administrative processes and safeguards for ensuring appropriate decision-making and consistency; d) or if it is a statement of the Plan's policy or guidance concerning the denied benefit, without regard to whether it was relied upon in making the benefit determination. PROCEDURE You or Your authorized representative may file an appeal with Us within 180 days of receipt of an adverse benefit determination, To file an appeal, telephone the toll-free number listed in Your Certificate of Coverage or on Your ID card. We will review the claim and notify You of Our decision within 60 days of the request for appeal. Any dentist advisor involved in reviewing the appeal will be different from and not in a subordinate position to the dentist advisor involved in the initial benefit determination. Notice of the appeal decision will include the following in written or electronic form: a) the specific reason for the appeal decision; b) reference to specific plan provisions on which the decision was based; c) a statement that You are entitled to receive upon request and free of charge, reasonable accessibility to and copies of all relevant documents, records, and criteria including an explanation of clinical judgment on which the decision was based and identification of the dental experts; d) a statement of Your right to bring a civil action under ERISA; and e) the following :statement: "You and your Plan may have other Voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your State insurance regulatory agency." FFS Appeal-ADD(07/02) ATTACHMENT A- DENTAL APPLICATION AND CERTIFICATE STATE LAW PROVISIONS ADDENDUM TO CERTIFICATE OF INSURANCE This addendum is effective on the Effective Date as stated in the Certificate of Insurance"Certificate" and attached to and made part of the Certificate. The following Definition of We is deleted from the "DEFINITIONS" section of the Certificate and the following substituted. Dependent(s)-Certificate Holder's enrolled spouse or domestic life partner and their dependents as defined by the Policyholder and/or state law, and any enrolled child, adoptive child or stepchild of a Certificate Holder., or an enrolled child subject to a court order or placed by an administrative agency with a Certificate Holder: (a) until the end of the calendar year the child reaches the limiting age of 26-or (b) to any age beyond the limiting age listed above if the child is and continues to be iboth incapable of self-sustaining employment by reason of mental or physical handicap and chiefly dependent upon the Certificate Holder for maintenance and support; or (c) until 18 months from the child's birth date for a newly born child of a covered Dependent of the Certificate Holder. For a child under the limiting age listed above, the following factors will not affect eligibility to enroll as a Dependent: financial dependency on or residency with the Certificate Holder; marital status; student status prior to age 26; employment; eligibility to enroll for coverage under another policy or contract; or any combination of these factors. The Enrollment Changes subsection of the "'ELIGIBILITY AND ENROLLMENT — WHEN COVERAGE BEGINS"section of the Certificate is deleted and the following substituted. Enrollmen1j khan ges After Your initial enrollment, there are certain life change events that permit You to add Dependents, These events are: • birth of a child; • adoption of a child; • court order of placement or custody of a child; • change in student status for a child age or older; • marriage of the Certificate Holder; • domestic partnership of the Certificate Holder, To enroll a new Dependent as a result of one of these events, You notify Your Group and supply the required enrollment change information within 31 days of the date You acquired the Dependent, The Dependent must meet the requirements detailed in the definition of Dependent in the Definitions section of this Certificate. Except for newly born or adoptive children, foster children or children in Your custodial care, coverage for the new Dependent will begin on the date specified in the enrollment information provided to Us as long as the Premium is paid within 60 days. F19804A(11/08) t, ATTACHMENT A-DENTAL APPLICATION AND CERTIFICATE Newly born children of a Member will be considered enrolled from the moment of birth, Adoptive, foster children or children in Your custodial care will be considered enrolled from the date of adoption or placement, except for those adopted or placed within 31 days of birth who will be considered enrolled Dependents from the moment of birth. In order for coverage of newly born or adoptive children to continue beyond the first 31 day period, the child's enrollment information must be provided to Us within the 60 day period. For an enrolled Dependent child who is mentally or physically handicapped, evidence of his/her reliance on You for maintenance and support due to his/her condition must also be supplied to Us within 31 days after said Dependent attains the limiting age shown in the definition of Dependent. Such evidence will be requested based on information provided by the Members physician but no more frequently than annually. Dependent coverage may only be terminated when certain life change events occur. These events Include.- • death of the Certificate Holder or a Dependent,or • divorce or dissolution of domestic partnership of the Certificate Holder; or • for a child, reaching the limiting age, or no longer meeting the other eligibility requirements as specified in the definition of Dependent; The following provision is added to the"Time of Payment of Claims" subsection of the"How the Dental Plan Works" Section of the Certificate! HOW THE DENTAL PLAN WORKS Time of PgXMIU12Lqlair�rs All benefits payable under this Certificate for any loss other than loss for which this Certificate provides any periodic payment will be paid immediately upon receipt of due written proof of such loss. Subject to due written proof of loss, all accrued indemnities for loss for which this policy provides periodic payment will be paid 30 days and any balance remaining unpaid upon the termination of liability will be paid immediately upon receipt of due written proof. Notice of Claim Written notice of claim must be given to Company within twenty days after the occurrence or commencement of any loss covered by the certificate, or as soon thereafter as is reasonably possible Notice given by or on behalf of the Member or the beneficiary, to the Company at 4401 Deer Path Road Harrisburg, PA 17110 or to any authorized agent of the Company, with information sufficient to identify the Member, shall be deemed notice to the Company. Proofs of Loss Written proof of loss must be furnished to Company at its said office in case of claim for loss for which this Certificate provides any periodic payment contingent upon continuing loss within 90 days after the termination of the period for which the Company is liable and in case of claim for any other loss within 90 days after the date of such loss. Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity, later than I year from the time proof is otherwise required. Leal Action No action at law or in equity shall be brought to recover on this Certificate prior to the expiration of sixty days after have been filed in accordance with the requirements of this Certificate. No such action shall be brought after the expiration of five years after the time a claim is required to be filed FL9804A(11/08) 2 ATTACHMENT A-DENTAL APPLICATION AND CERTIFICATE The following provision is added to the"Services"subsection of the"Benefits" section of the Certificate, BEINEFITS Services Coverage will be provided to Members for diagnostic or surgical dental (not medical) procedures related to Ihard tooth structure or tooth malformation when such procedure is medically necessary to treat a condition caused by congenital or developmental deformity, disease, or injury. The following language in the "Termination —When Coverage Ends" Section is deleted and replaced with the following� TERMINATION—WHEN COVERAGE ENDS Your dental coverage may be extended 90 days for specific procedures as described in the Extension of Benefits subsection, Your coverage and/or Your Dependents' coverage will end: • on the date You lose eligibility under Your Group's eligibility requirements;, or • on the date Premium payment ceases for You and/or Your Dependents, as specified by your Group; or • on the date Your Dependent(s) cease to meet the requirements in the definition of Dependent in the Definitions section of this Certificate; If Your coverage ends, Your Dependents' coverage will end on the same date unless otherwise specified in a State Law Provisions Addendum to this Certificate. If the Group Policy is cancelled, Your coverage and Your Dependents' coverage will end on the Group Policy Termination Date, In the event of a default in Premium payment by the Policyholder, coverage will remain in effect for the Grace Period extended for payment of the overdue Premium. If the Premium is not received by the end of the Grace Period, the Group Policy will be cancelled and coverage will terminate the first day following the end of the Grace Period. Extension of Benefilts The extension of benefits applies if all the following: • the course of dental treatment was recommended in writing and commenced, in conjunction with a specific dental problem or accident incurred while the Group Policy was in effect, by the dentist to You or Your dependent's while You were covered by the Group policy, • the dental procedures are for other than routine examinations, prophylaxis, radiographs, sealants or orthodontic services. • the dental procedures were performed within 90 days after You or Your dependent's coverage ceased under the Group Policy and the termination of coverage did not occur as a result of You or Your dependent's voluntary termination of coverage, The extension of benefits terminates upon the earlier cif: • the end of the 90-day period described above • the date You become covered under another plan for similar dental services FL9804A(11/08) 3 ATTACHMENT A-DENTAL APPLICATION AND CERTIFICATE If coverage for dental procedures are excluded by the succeeding dental plan through the use of an elimination period, You and Your dependent's are not covered by the succeeding dental plan and the extension of benefits does not terminate until the 90 day period. All Policy, Exclusions and Limitations apply to the specific covered dental procedures under Your Plan, apply during the extension of benefits. The following provisions are added to the"General Provisions"Section of the Certificate. GENERAL PROVISIONS In the absence of fraud, all statements made by applicants are deemed representations and not warranties and that no statement made for the purpose of effecting insurance will avoid such insurance or reduce benefits unless contained in a written instrument signed by You or Your Group, a copy of which has been furnished to You or Your Group or to Your beneficiary. The pertinent laws and regulations for interpretation and enforcement of the Certificate are the laws and regulations of Florida. FL9804A(11/06) 4 ATTACHMENT A-DENTAL APPLICATION AND CERTIFICATE. ATTACHMENT A-DENTAL APPLICATION AND CERTIFICATE UNITED CONCORDIA ADDENDUM TO GROUP POLICY AND CERTIFICATE OF INSURANCE This Addendum is effective on the Effective Date as stated in the Group Policy and attached to and made part of the Group Policy and Certificate of Insurance. The following language is added to the Group Policy and Certificate of Insurance: The Company uses Maximum Allowable Charge schedules to determine claim payments Payment is the lesser of the dentist's submitted charge or the Maximum Allowable Charge Maximum Allowable Charges for Covered Services are determined by geographical area of the dental office, The Maximum Allowable Charges in the geographical area of the dental office are used to calculate the Company's payment on claims, Maximum Allowable Charges are reviewed periodically and adjusted as appropriate to reflect increased dentist fees within the geographical areas, Participating Dentists accept their contracted Maximum Allowable Charges as payment in full for Covered Services, REIM-ADD 9802(11/07) ATTACHMENT A-DENTAL APPLICATION AND CERTIFICATE Schedule of Benefits Concordia Preferred sm Group Name: Monroe County BOCC Group Number., 897129000, 897129001, Effective Date: January 1, 2012 897129099 Out-of- In-Network Network a pla id Class I Services 0 Exams 1001% 100% 0 All X-Rays '100% 100% 0 Cteanings &Fluoride Treatments 100% 100% 0 Palliative Treatment(,�merqen 100% 100% 00% 100% '1 Class H Services • Sealants 90% to% • Basic 90% 80% • Endodontics 90% 80% 90% 80% 90% 80% • Repairs of Bridges 90% 80% • Dentu sir 90% 80% • Simple Extractions 9 80% • Surgical Periodontics 90% 80% • CompLex Oral Surgery 90% 80% • General Anesthesia 90% 80% Class fit Services • Ways, Onlays, Crowns 60% 50% • Prosthetics(B"fidges, Dentures) 60% 50% Orthodontics 50% 50% Limit t children crra r the Of Deductibles &Maximums * $50 per Calendar Year Deductible per Member(excluding Class l Services and Orthodontics) not to exceed$150 per family 0 $2000 per Calendar Year Maximum per Member * $1500 Lifetime Maximum per Member for Orthodontics All services on this Schedule of Benefits are subject to the Schedule of Exclusions and Limitations. Consult Your Certificate for more details on the services listed Network providers accept the Maximum Allowable Charge as payment in full. 9508(07105) A17ACHMENT`A-DENTAL APPLICATION AND CERTIFICATE SCHEDULE OF EXCLUSIONS AND LIMITATIONS Exclusions and limitations may differ by state- Some exclusions and/or limitations may be waived depending on the Member's medical condition. Only American Dental Association procedure codes are covered, EXCLUSIONS—The following services,supplies or charges are excluded: 1. Started prior to the Member's Effective Date or after the Termination Date of coverage under the Group Policy(e.g, multi-visit procedures such as endodonfics, crowns, bridges, inlays, onlays, and dentures), �2, For house or hospital Its for dental services and for hospitalization costs(e g facility-use fees). 3. That are paid by Workers' Compensation or employer's liability insurance, or for treatment of any automobile-related injury in which the Member is entitled to payment under an automobile insurance policy. The Company's benefits would be in excess to the third-party benefits and therefore,, the Company would have right of recovery for any benefits paid in excess. For Group Policies issued and delivered in Georgia, Missouri and Virginia, only services that are the responsibility of Workers Compensation or embloyer's liability insurance shall Ibe excluded from this Plan For Group Policies issued and delivered in North Carolina, services or supplies for the treatment of an Occupational Injury or Sickness which are paid under the North Carolina Workers" Compensation Act are excluded only to the extent such services or supplies are tlhe liability of the employee according to a final adjudication under the North Carolina Workers' Compensation Act or an order of the North Carolina Industrial Commission approving a settlement agreement under the North Carolina Workers' Compensation Act. For Group Policies issued and delivered in Maryland,this exclusion does not apply. 4. For prescription and non-prescription drugs, vitamins or dietary supplements, For Group Policies issued and delivered in Arizona and New Mexico, this exclusion does not apply, 6. Administration of nitrous oxide and/or IV sedation, unless specifically indicated on the Schedule of Benefits. For Group Policies issued and delivered in'Washington, this exclusion does not apply when required dental services and procedures are performed In a dental office for covered persons under the age of seven (7)or physically or developmentally disabled, For Group Policies issued and delivered in New York, this exclusion does not apply if dental services are required for sound teeth as a result of accidental injury. 6. Which are Cosmetic in nature as determined by the Company (e.g. (bleaching, veneer facings, personalization or characterization of crowns, bridges and/or dentures), For Group Policies issued and delivered in New York, this exclusion does not apply if dental services are required for sound teeth as a result of accidental injury. For Group Policies issued and delivered in New Jersey, this exclusion does not apply for Cosmetic services for newly born children of Members. For Group Policies issued and delivered in Washington, this exclusion does not apply in the instance of congenital abnormalities for covered newly born children from the moment of birth, 7 Elective procedures(e.g. the prophylactic extraction of third molars) 8 For congenital mouth malformations or skeletal imbalances(e,g, treatment related to cleft lip or cleft palate,, disharmony of facial bone, or required as the result of orthognathic surgery including orthodontic treatment), For Group Policies issued and delivered in Kentucky, Wnnesota and Pennsylvania, this exclusion shall not apply to newly born children of Members including newly adoptive children, regardless of age. For Group Policies issued and delivered in Colorado, Hawaii, Indiana, Missouri, New Jersey and Virginia, this exclusion shall not apply to newly born children of Members, For Group Policies issued and delivered in Florida, this exclusion shall not apply for diagnostic or surgical dental(not medical) procedures rendered to a Member of any age For Group Policies issued and delivered in Was4ington,this exclusion shall not apply in the instance of congenital abnormakfies for covered newly born children from the moment of birth. FL9809(03/07) 1 ATTACHMENT A-DENTAL APPLICATION AND CERTIFICATE 9, For dental implants and any related surgery, placement, restoration, prosthetics (except single implant crowns),, maintenance and removal of implants unless specifically covered under the Certificate, 10. Diagnostic services and treatment of jaw joint problems by any method unless specifically covered under the Certificate Examples of these faw joint problems are temporomandibular joint disorders (TMD)and craniomandibuiar disorders or other conditions of the joint tiWing the jaw bone and the complex of muscles, nerves and other tissues related to the joint. For Group Policies issued and delivered in New York, diagnostic services and treatment of jaw joint problems related to a medical condition are excluded unless specifically covered under the Certificate, These jaw joint problems include but are not limited to such conditions as temporomanclibular joint disorder(TM D) and craniomandibular disorders or other conditions of the joint linking the jaw bone and the complex of muscles, nerves and other tissues related to the joint. For Group Policies issued and delivered in Florida, this exclusion does not apply to diagnostic or surgical dental (not medical) procedures for treatment of temporomandibular joint disorder i(TMD) rendered to a Member of any age as a result of congenital or developmental mouth malformation, disease or injury and such procedures are covered under the Certificate or the Schedule of Benefits. For Group Policies issued and delivered in Minnesota, this exclusion does not apply. 11, For treatment of fractures and dislocations of the jaw. For Group Policies issued and delivered in New York, this exclusion does snot apply if dental services are required for sound teeth as a result of accidental injury, 12. For treatment of malignancies or neoplasms. 11 Services and/or appliances that alter the vertical dimension (e.g.full-mouth rehabilitation, splinting, fillings) to restore tooth structure lost from attrition, erosion or abrasion, appliances or any other method. 14, Replacement or repair of lost, stolen or damaged prosthetic or orthodontic appliances, 15 Preventive restorations, 16. Periodontal splinting of teeth by any method. 117. For duplicate dentures, prosthetic devices or any other duplicative device, I& For which in the absence of insurance the Member would incur no charge. 19. For plaque control programs, tobacco counseling, oral hygiene and dietary instructions, 20 For any condition caused by or resulting from declared or undeclared war or act thereof not to include terrorism, or resulting from service in the National Guard or iin the Armed Forces of any country or international authority. For Group Policies issued and delivered in Oklahoma, this exclusion does not apply, 21. For treatment and appliances for bruxism (e.g. night grinding of teeth). 22, For any claims submitted to the Company by the Member or on behalf of the Member in excess of twelve(12)months after the date of service. For Group Policies issued and delivered in Maryland,failure to furnish the claim within the time required does not invalidate or reduce a claim if it was not reasonably possible to submit the claim within the required time, if the claim is furnished as soon as reasonably possible, and, except in the absence of legal capacity of the Member, not later than one (1)year from the time the claim is otherwise required, For Group Policies issued and delivered in Florida, failure to furnish the claim within the time required does not invalidate or reduce a claim if it was not reasonably possible to submit the clairn within the required time due to the claimant being legally incapacitated. 23. Incomplete treatment(e.g, patient does not return to complete treatment)and temporary services(e.g, temporary restorations). 24. Procedures that are� • part of a service but are reported as separate Services • reported in a treatment sequence that is not appropriate • irnisireported or that represent a procedure other than the one reported FL9809(03107) 2 ATTACHMENT A-DENTAL.APPUCATION AND CERTIFICATE 25. Specialized procedures and techniques(e.g, precision attachments, copings and intentional root canal treatment). 26. Fees for broken appointments. Those not Dentally Necessary or not deemed to be generally accepted standards of dental treatment. If no clear or generally accepted standards exist, or there are varying positions within the professional community, the opinion of the Company will apply. FL9809(ON07) 3 ATTACHMENT A -DENTAL APPLICATION AND CERTIFICATE LIMITATIONS—Covered services are limited as detailed below.Services are covered until 12:01 a.m. of the birthday when the patient reaches any stated age: 1. Full mouth x-rays—one(1)every 5 year(s). 2. Bite wing x-rays one(1) set(s) per 6 months underage fourteen (14) and one (1)sel(s)per 12 months age fourteen (14) and older, 1 Oral Evaluations: • Comprehensive and periodic—two(2)of these services per 12 months. Once paid,comprehensive evaluations are not eligible to the same office unless there is a significant change in health condition or the patient is absent from the office for three(3)or more year(s). • Limited problem focused and consultations—one (1) of these services per dentist per patient per 12 months, • Detailed problem focused—one(1) per dentist per patient per 12 months per eligible diagnosis. 4, Prophylaxis—two(2) per 12 months, One(1) additional for Members under the care of a medical professional during pregnancy, 5. Fluoride treatment—two (2) per 12 months underage nineteen (19). 6. Space maintainers—one(1) per three (3)year period for Members underage nineteen (19)when used to maintain space as a result of prematurely lost deciduous molars and permanent first molars, or deciduous molars and permanent first molars that have not, or will not, develop. 7. Sealants—one(1) per tooth per 3 year(s) under age sixteen (16) on permanent first and second molars, 8. Prefabricated stainless steel crowns—one (1) per tooth per lifetime for Members underage fifteen (15). 9, Periodontal Services: • Full mouth debridement—one (1) per lifetime. • Periodontal maintenance following active periodontal therapy—two(2) per 12 months in addition to routine prophylaxis. • Periodontal scaling and root planing —one (1) per 24 months per area of the mouth. • Surgical periodontal procedures—one (1) per 24 months per area of the mouth. • Guided tissue regeneration —one (1) per tooth per lifetime. 10, Replacement of restorative services only when they are not, and cannot be made, serviceable: • Basic restorations—not within 12 months of previous placement. • Single crowns, inlays, onlays—not within 5 year(s) of previous placement, • Buildups and post and cores—not within 5 year(s) of previous placement, ® Replacement of natural tooth/teeth in an arch®not within 5 year(s)of a fixed partial denture, full denture or partial removable denture. 11. Denture relining, rebasing or adjustments are considered part of the denture charges if provided within 6 months of insertion by the same dentist. Subsequent denture relining or rebasing limited to one (1) every 3 year(s) thereafter. 12. Pulpal therapy—one(1)per eligible tooth per lifetime. Eligible teeth limited to primary anterior teeth under age six (6) and primary posterior molars under age twelve (12). 13. Root canal retreatment—one (1) per tooth per lifetime, 14. Recementation—one (1) per 12 months, Recementation during the first 12 months following insertion of the crown or bridge by the same dentist is included in the crown or bridge benefit. I& ,Aug alternate benefit provision (ABP) will be applied if a covered dental condition can be treated by means of a professionally acceptable procedure which is less costly than the treatment recommended by the dentist, The ABP does not commit the member to the less costly treatment. However, if the member and the dentist choose the more expensive treatment, the member is responsible for the additional charges beyond those allowed under this ABP, I& Payment for orthodontic services shall cease at the end of the month after termination by the Company. This limitation does not apply to Group Policies issued and ddivered in Maryland, 17. Intraoral Films. a Occlusal—two(2) per 24 months. E �;. �•, �, C, �� Z•• �,�, as• U.a �.y°�. ��4 LO 0 rp of — co 6 rya 6 — n� 0 to �; r- rKK V- rn OD in �tr) N o w V, TD M al) Line ram. W M a) r r rm� cl)7 uq up�� a, �d r,�'s ,�.. ,��" � arty M �,T' 0 •q 0 4. %T i["t4 a` W N�+ Q 41% W fA ffY (a) f.4 IA rl ui f!J .. a�u u a rwp r'y rroro r•, - ur^7 L urnM CN to' CO r q a 0 �CD r r. USA (D V) V'z a44 W 001, IS IS Uwe CC) U) CIDC) ra'.� N �a"aW U.f'S U.E' rF:d' Sr R�'. "r m_.r "emu Nr CO,ra� °�; u u " °' °' 44 ,gyp V, V V V V wg•' V Nt IX 0 n 0 0 C) Uri w.... V, 0 z10 &r'J a IU 2 IW a a u! B� B.R toti Xa c a a Bay a&� CCU 2CA �r� �• ��.. ow.. �' �� °,�' LB7 G°Y (N G) C'.Y`k B G.?x Illl'J Ih* ILB"$ U, CBr o u o Bw, Xlra Ira B � O Ba (i � � U) ` tl� BD BPa V: aI B , i c4 (a a eM c-u 't a Bea NT 00 //i, % M CO NTv»^ 00 00 N (C) 0 FAY vlj t- W � � � e� �k 4� "�" Cab B""b 0.^"°b Ow•,. -r- "�" �"^» fA Df* B 4.4 111 C-) m C'^., •r.. V 'V) to G) M 01) ON COaSb RaU +r ^ (wP rIY U) t, IT tG'A P, ¢d"5 0 / m re)I ce) d'y' C""p vi 4 1 Bea era M s) Bn M M M Byb M M M a-' v-- r- w°- e-^ v-- — c-^ v^ r- -- Q'wq F+-) 4 ii, 25 II"» v^ b C^� Bead 111 t y i CL ui ' w M CO P "I P, 0 a0 P- (0 N CCU (0 CO0) CCO @, T: CAP M ass CO rm WN Cs Cn taro . r Ua ar/ LO �t,�a Pam. a-w air on aka -- a� ¢� w n 00 Caw Asa M, taA q P- aka CO ate` IN (0 Pro. 1 q" U) n m ,�j, • t3k C°S +^^^ A d%'k 'm^^^ Y0 C�7 i„CT v� to r ,q CO �(0 V) W P°» N M C,,,b w�- WS°S CS'k "tT P"'." '.. . V .. cX Vi K!° a w vlD Vk Uu Uk lq Cj) V) m ii.C'1 ^.^ C;r Nr C") CN co Y„9'k V, a;1 c"a m q CC'S, Pw"'8 r- 0) 0 LO U') LO LO LO to ILO 0 Ul) U) to eq u (A ears k V) m tO lv� M 0 a0 V aCk .., CN to CO t- a0 P'•^� 00 M 0) M (77, CT'C a) CO CO CO CO W C'^rY a"M6' N N CN 04 C"V CN 4' CACIP N miu Cl' rq CAP C"J N 04 aA CA CA 04 COY COY 1 0 0 Cam, 0 Cr"`a 10 Cl 0 C„Y 0 CD C V- C—N,C, C) 4 W P+w r" "*I C'�b Cb �' C'Y rt *•4' 0 Q CJ C�1 "5 to no as bA w LIO LM 99 V V qp pq LID ti0 V qh v V Wqt� 32 2 ° Cd 06 06 06 66 06 a� as ae ar rxr a� a as a� as a� as as a� �a a� r1a ar a, + a� o� as a as o� a, a, as a� as a� a� � ar as as � as �a nr as �s ar as as as as as �a as as a, N >- C# O 2 2 C7 C> C3 C7 2 £] C� 2 C} C7 C� Cb 2 C1 2 C> C� sue. cl CL CL CL . . . CL CI CL . CL CL a . CL . �a.. E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E ui uj ui LU uJ w w w w ui w w uj ua w w ui w w LU u.r w LU uJ u s w w w ui w w w 0 0 0 a 0 0 CD CA CA CA CA 0 CA CA CA C> CA C) C7 CA CA CA CA CA C7 C7 CD C3 CA Cc CA CA CA CA 0 CA C7 CA CA CA CA CA CA CA CA CA CS CA CA CA CA CA C7 C) CA CA CA CA CD CO CA s CA Ca CA C> CA CA CA CA Cs CA CA CA CA CA CA cl CA Ca CA CA 0 CA CA CA CA CA 0 cc 9 9 9 9 9 9 9 9 C? CA C) CA C? C? C? cp C7 CA C, CA CA CA C? C9 W 0 0 r� rw CA CO A N 6 QQ 6 CA CA N CA CA Q C N A 6 6 A N to CO LLJ r, cr -* cn m e qf on on m on nr w r� �z * 4 -tir cr g g v on TT CA 00 on Om r^r1 rpt rat m rn r*t rYt rra rat rr"I rrt rra sat e^rt rrl r�`a a^n rra rn rn rrr � c*vt rrr ert rrro rrt ra'y rrt ct rrt err 00 rwr rri r+t cn rat rat rat rat rvy en rrt wra trt rrt rn r� r� rn rrt rat rrs rr a rra rr� e� r�1 rr1 c�'r ct aCs +fit cp +[� tC� ut crs cts rw + a a u� cts r• n r r% r us Ch H t cys t H rrs r-a r-a r-a �+ �a �a rda HH r�l �+ r-a r-e �-+ «-� �a Hq-o � t CA A N A AS SO A CA on A a CA Un 00 ND r* Cs +rs M aid P, on ri Ln itf 00 on CA ""*^+ N CA N CA by - A -- CA CA V -- CA8 CAW C"d CA r4 on H H "'�. s�^I "` ri "�+ CV CA �t . �. -- t�s . . r% , . � Cyr ^� -- . � . . �. . . . "I CArA - . VI N w u. u- Um w U- w w u_ u. u_ u- w U. w 2 um L cc a� ar �a ara ar as �a ru as a� as as a� as ru na ry s as ar a� as ar > z > t„b 4 CJ C b u u u t b u u u u u u u u u u u u u u tad w u u 4,„b u w u u u 4,} u 4J qJ CEJ 4J �d 43 Qd Ctd 41 &It al dl d,7 f28 fLd p9 Qr C$9 4r pe �1 6!r tlr tlJ tlJ for qa C3J G9 QR � 4r qa 03 4tr Clb pJ C1 qs �a 4J Os � cka � a3 mr asr � 419 car 4J Qa Qr da Qr 6L4 qJ OJ w ur w w ur ur ur w w uj LU w ur w w w w w w w w w w w w w w ear tar w w w 0 0 0 0 0 0 0 0 0 0 0 0 �6y p+I 1 1 I A I 1 1 I ryes ys�0 1 Y 0 9 1 p0 1 4 Y I Iky I d 9 I B �eaY.� o 6 m 6 m 6 w m 6 r, �b rid 6 6 6 4.a.+ 6 p6 6 r4 a� M' 6 to 4tr p'5 q pry ,�tr �se4y r pm m{�W o, �gy g ; �qr � y"F ON�y m g g vr yay vt 11 ar m m m CCb m m CO CO CO N m 0 H w 0 m CA CA 0 m m m v Izr Cf1 "I m Ch H H w w mm w m 0 C4 01 Wa al CA CA CA CAON ON ON CA41 W1 C1 CACAtoCA CA CA V1' 0 CA rd4 r4 R4 r"4 r^4 B4 r°°4 r4 R r 4 r4 r^# r4 r A r A 4rµ-.4 r-4 ra4 W K W K r l K CA r l kDMIA 0 m CA CA an� eywu^) 9JI ++xnn l n'nnn i"�"rm 'm w�Wp,re rpm�^pr MCA w�'Myn fin. `w t1a tf4 C�7 CIA r-i �4 C71 CF1 N C-i CY'4 Per 4�°b N i E� C�J 6� z� F*^ Ruu9 Ce7 '4 nd4t �J V tP`� lyrd CA u"*+ ri CA Pal CA r-i A IS r�4 r�4 by 'p", -- A ry CA rA iW CA K of A CA CA ^^. CA A A , i nn M d `W.r - -- ,�°`? ��ry 03 �1 A m t� r� w r- r, hn* r-4 H 4� W CA w (14 we•4 m r, CA C'C'b CA w 0 r^i r-°4 C-4 H r'"'e r-d r-4 LK tin Lb tb,. u. L, W W- LL LL LL Ub U- LL LL L, U. W I 1 1 1 1 � as �r as e� as e14 � as sar � a� ar a� qr � as ar ar qa as aps as �r � ear ar ar ar ar aaa ar err o� � r� ✓ w� � i o-� � � +� +� � a� � w� �m�d ,,,�PUp ccU •,4�„.^F „U U ,U QJ ,�U �U eU ,pU �U ',�U ,„„U�p ,,�wj+ ,e,�Ggd+ 61 0U U t�+ ,4U U �U U ,,CU UVU G C„pr e�U ,U LA ,��tury 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 a 0 0 0 a 0 0 0 0 0 0 0 0 0 a 0 0 0 -j -j -j -j -j -j -j -j -j -j -j -j -i -j -j -i " :2 :2 :2 3? :2 :2 22 22 M 2 F- u u u u w w u tj w w u w w u w w w u Q w u w u v u u u u u u u u u u > > > > > > > > .2 2 .2 .2 .2 .2 .2 .2 .2 .2 .2 .2 .2 .2 .2 .2 .2 .2 .2 -2 .2 -2 .2 -2 -2 0. a CL CL CL CL CL CL CL CL CL CL CL CL CL CL CL CL CL CL CL a m a a CL m a a a CL 0. E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E LU w uj ui uj uj w LU LU ui LU L" ui ui w w w w w w w w w w w w w w w w LU w LU w 0 a 0 0 0 0 0 0 CD CD 0 0 0 0 0 0 0 0 0 a 0 0 a 0 0 0 0 0 a a 0 a 0 0 0 0 CD CD 0 CD 0 0 CD CD CD 0 CD CD 0 0 0 0 0 0 0 C� CD 0 0 0 0 a a 0 0 a 0 0 0 0 0 0 0 0 a 0 0 a 0 0 0 0 a 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 a 0 0 0 0 0 a 0 0 0 0 0 0 0 0 0 0 0 c 0 C) 0 0 CD 0 0 0 0 0 a 0 0 6 A 0' 6 r�, LA 0, 6 rl 0, CS c6 LA C1,4 6 ob 6 M Itr II.T 14T tO Itr It r "Zr %T r. PI Itr M 4tt nr M 1-4 0 Mr M r' U) tl- M Itr ltk r" ItT 00001-100000000000000OOOOOOMOCH r-ic m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m r-I r-4 H r-I r-i r-A H r l H r-i H H H H H H H H H H H H H H H H H H H - -- "I m N V-1 V-4 H H N N H H m T-1 N N N m m co rl w N H r-q N r- T-4 H N m m m rl N m V-4 w a) H r-I r-4 H u- U- U- LJL U- U- U- Li- LL U- LL Li- U- LL 2 U- W- 2 U- U- U- U- U- U. u- U- U- w 3 -j -j -j -j E E off$ off! s� cw�# �a oa � 0� as as a� as c� as ar ax as a� da 0a as qs as as �a QA a� as > E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E w w w w w w w w w w w w w w w w w w w w w w LU w w w w w w w w w w w 0 0 0 0 0 0 0 a 0 0 0 0 0 0 0 0 0 0 0 0 0 0 a 0 0 0 0 Yk B 6 a d B B d LYA a 6 9 m C' C 7 6 6 C 0 4 o � n 0 0 C a m zr w Ln � LC z * ,tr m r -* FZ a, g i P- g g rr � 4 � Ln C 0 0 0 0 a 0 C;Y 0 0 0 a 0 0 T-4 0 C:A ¢w"b �'�"! Cv'4 a"a"1 C!b CY'B P'a7 4'r'1 M 4'Y'8 tY! CV1 &Y"1 Ct"k fY'1 P'�'i 4"I) 4�`"d P4'! 8n"B 8"�8 4�"1 Cv"1 M9 t✓T Cro"b P7"D tY'! iY'y e�8 C�`F CR"P B'�'B 8`g"Y rr1 abY C4B 8 Pv6 C�4 m m m m m m m m m m m m m m m m m m m m m m ref m m m m m w Ln H w w N m cr m m m q Ln m tr o c N ado r®4 N w �e Lt3 & Q"U m � C`^< i71 � P'^* 6Sy C%3 tw,w hw Pw* L� td0 �" t h•- £ P`* C°w tCf P"^• L!"tl t„� LCa cd 1 I"* t`w L� r^9 R"°i r•°9 x-4 r-tl 8'-0 rd rd a-^4 a^°f r°4 x-i r-4 �«d x4 r^# r-4 ¢-4 r 4 r� c®9 e-^I r-4 aw'4 r-4 rw4 e-1 Y"°9 e°°4 � e4 . 'm '0 "tr 0 .. �, r"w. T 'w . w °m CN rl* r- ^w . "w^w '4 "*) "r° Ln Cx"b C*w C"8 C�7 4C! C'�8 CY"Y LfY C'w �° LC} �° lCS d`'^ �$' L� 1,C9 lLa @M$ t°J C"w+ C*• P"d f`* 4C? l P°* Ld1 C47 H H C^J """w "'� f'�d N ""� "'� °"`* '"�» hd CV hJ "*+. "'"w N r4 H r-tl ri "" r�i ``^w °`�« -- H f -* *�.. f J �,""w. `*�» 41 C°J �'1 1" "�, ""..•.. `w.w r 9 PEE *w. `mow w "^w a `"'w. a�9 d 1. `ww ""wCO VI a-1 H H LM N rwd lL'a e°^4 C$b v-4 t°w4 V-1 rq H H ri r"^9 H r A 1*4 U- LL. 2 u. U. w U U- w w w w 2 U U- U- U- uw u_ L9w, w w tad 0k w 0 0J w 0 co Q1 Val w w w w 0 w 01 0 03 0} 0) v 0u ad w w w w 0) 09 w Qa w u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u 0 0 0 4z G& � qk ar ai a) aJ a1 as OJ ar � Qa ad as ak 4G4 as 41t a2 aJ d8 ai � �& Gk ai 4L4 Q3 qa ai qJ ad di qJ aI 6J a? OJ a1 fii ad qJ � ad a1 6! tlB �! aJ aP ai 0.9 DP• a .. ' a * 'a0- fit, C1. .a ' a ' E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E w w LU w Lu LU ui LU LU ui w W w UJ w w w LU w w w LU LU LU LLi w w LU w w LU LU LLB 6 r- 6 6 A A Ms a r� r 6 rw rr C r-• r r rd s 6 rs"4 r¢ 6 Lb 6r a ra. r r r� m m m m CC4 CCB @°Cti CC`4 S"CM e'rl Ca°i C'PS m m m m m m m m Cr"4 m m m m m m Cr"i m m m m m m @' CCS rr CY'i CY$ Pa"6 C�5 ra°4 #'r'4 CC1 CrM CC4 C'C9 m m m m m m m m m m m C'P"I r'^4 r-9 t^V I`^� rJ ef' C$M LfS LYB O'9 Nt ri e°"d 1, Lrt Lib lf� C �3" Lft r" Ln LA co r"w L(7 r" r~ f"» 4Y� r°• Lf1 4°L7 LCl r»� LP') 4.� t� f r"^ r«. 4,{9 6i"P &,� r`» Lei r"* L/'i '�° 4,CS LC°M P`» &d"S Eat (n Ch m ISM a) al 0) 0) �`M �'M 0) C?'M im (n & c1 a) 0) a) m m a) m m a) 0) 0) CiM m cn 0) a3 M rm4 H H ri H r-4 r^l H H r l H V 4 r°^4 r H 4 H r l H rw8 VH H H °r4 rq H H H r4 eat r�4 H C r"� rr4 E""J w Co o) H vH rn m r,. rd w r"» a) H ram, vi w P, W 0 H co iiE "It r4 m -- r4 "I f" -" rq C"J `- r q N rl H 1* " `5. rn """� 4"J v 4 1^ -^ m d H rH 4 a) 0) r^4 r-i rJ mr-4 H r°� r1 rJ rl rn w LM H H r l N r-4 d 13 rq r�4 w"4 ri r-I as as w w w w w w as w w w as 0 w 0 0 w 0 as w as ai w w ar as w w w as ' , 43 t.D and t„i u u u u LAM u t o u u u w L,4 u u u u u w Q u u u u u u u u Q u Q < < < < < < < < < < < < < < < < < < < < < < < < < N N I I I w w I I w LL U6 LL LK LL LL u_ LK LK L& UL U- L.L w LL 6L. LL U- W. LB. LL. 0 x x x x x x x x x X x X X X X N X X X X X X Cl CL CL CL CL CL CL CL C CL CL Cl CL CL CL CL CL CL CL m CL E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E w w LU w uj ui w uj ui w w w w w w w w w w w w w w ui w w uj w w uj w uj ua ui CDCOOOOCAOCACD 0000 4 B 1 B A /�� I BB y Y gY B q� 1 W Y B W Y 1 9+W Y 1 d p.® W 1 B Y 1 B W aO nm 14) c^J 6 6 6 6 6 6 E c J 6 ems! On' 6 A A A 6 m tmt 6 &A 6 vh 6 6 rr r� 6 M ,wry' A 0 Q �Q P��^re K may` LO OM at ��S a' P, �t yby a I/�t°y� t° IT U) al` � LY 0 I' 0 , 'N ar r- 0 a 0 0 0 0 0 0 0 'Noel 0 a a 0 H 0 0 0 0 0 klo 0 0 0 0 0 0 mm m m m mm H WIT 0 J w w � �dm C�0 �w^apd� d WD Ch Ch r' at a w V*4 N m 00 h- h H M1ar.�w H m 0 CA W Y Ch Ch Ch Ch Ch Ch 0 CA 0 M✓Y 0 ma's CA m Ch CA C7 CA m m m m CA CA CA Ch Ch Ch CA CA CA CA a"% Ma"ma fie. a. °m l 1 MCA .01 d q 00 CA 00 a"^w ^0 "CA "CA 4 , next r .a ul Mw un n "p�y4yx as �^M �nx .r ^,MpY °n q,J r4 rq pcp�y7 rq r4 "mow rq r4 I- prq 4 A """^n r-1 A Q A CJ .�m+n, "gym, N H r4 •»'.', °ter, •.'"+n, ""aW and m""ma r^4 "4 r4 rl TM rq 'wdY s " . , s r r s a e s r e t5 §� $.6 $«e 5 y® did t5 $W $wM .Y+aa dmN bd +bW betl d�+° +d +w u u u �u u u u Cgwt uey� u u �C� C�pJ' u ,emu ,4w 't�7 0 0 ,a�..wa 0 Q tg,®8 brpt �u �u 4pJ✓ �iys ,emu bd 0) Qj ,emu ,mow 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2�- a 2� ,Z- 2- 2. z z z z z 2 .2t Z .2:- 21 z m m m m m m m m m m m m m LL LL U- LL LL. U- UL I.L U- W- LL 06 0� cz co 0 cz co tz cz cz 0� 0 co co 06 06 06 04 cz ca 06 ca 06 tz 04 cz cz 0 cz (o co ca co co aj a) 4) w aj w v a) 43 07 w a) w 0) (v 0) 0) 01 (U 0) w w w w a) w w w 0 w 0 w w w > -2 .2 .2 .2 .2 9 2 -2 2 -2 -2 2 -2 -2 2 .2 -2 CL CL CL CL a CL CL CL CL CL a CL CL m CL CL a a cx CL a CL CL CL CL CL CL CL CL CL CL CL CL CL E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E ui w ui w uj ui ui ui ui LU w LU uj w w w ui ui w LU LU LU ui w LU ui w LU w uj W uj ui LU 0 a 0 0 0 0 0 0 0 0 0 a 0 0 0 0 0 0 0 0 0 0 a 0 a 0 0 a 0 a 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 a a a 0 a a 0 0 0 0 0 0 0 0 a 0 0 a 0 9 9 9 0 a , 0 0 a 0 0 0 0 0 c.) 0 0 0 0 a a a 0 0 0 0 a 0 0 0 , 0 a 0 ' 6 r, 6 rL ' r� 6 6 6 r; A 6 6 6 r� 6 6 r,� r� ' 6 r� 6 A LA 6 6 6 LA a N en ZT o *, o cr m o m m -4 :r -5, v m �* m o LA -zr -zr wx r- t 4 tzr r, -4 zr m <r r, 0 0 0 0 CD 0 0 0 0 0 0 0 0 0 0 0 0 0 a a 0 0 0 0 0 0 a 0 0 0 0 0 0 m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m 0 -zr -4 r-4 0 w w m a lqr m m 1-4 0 m w Ln w m m m m rl� v� Y-4 Y-1 r-i v-4 v-i r-4 r-i r-4 v-4 r-I "4 r-I v-i rl H r-I r-I rl rl H r-i H H r-q r-I r-4 r-I r-I H H H ;r rIq C14 m m Q v qr Ln A N m H H N N C-i " "i N H N N N r� T-1 N N `mowW T-4 LO Ln rn r.4 rn V"q rn 00 0 co a) Go w w rl r" N m w H r, r, w V-4 U- LL U- w ��! 4� 4' 41 h� *. t 4� 41 4-1 41 41 -4,1 +1 -6-1 4-1 41 4� -41 u u w u w u u u u u u u u w u u u u u u u u u 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 M M M M M M M M M M M M M M M M W M M M M M M M M M M M M M CL M CL CL U- LL Ll- LL U- LL LL Lt. U. LL UL LL U- W- U- LL U- LL LL. U- LL LL. U. U- LL LL- U- LA- LL V) to (/) co co cz cz co 06 06 06 06 04 06 06 06 06 0 06 a co 0 06 0 0 06 cz 06 66 06 06 0 06 06 0 06 06 4) w a) v a) a) ci a) a) ai cu ai ci w aj ci di w w 4) a) w w 04) W (DQJCUWQJOJ (U (U .2 .2 .2 2 .2 2 A .2 2 .2 .2 .2 -2 -2 -2 -2 -2 2 -2 CL CL CL 0. a = a a = a a a a a a a a a a m a m m a a a CL a a = a a a a E E E E E E E E E E E E E E E E E E E E E S E E E E E E E E E E E E w ui uj uj ui ui LU w ui w w w ui ui w ui uj w LU w LU LU w uj uj LU ui w LU w ui ui LU LU a 0 0 0 0 a a 0 0 0 0 0 0 0 0 0 0 a 0 0 0 0 a 0 0 a 0 a 0 0 CD 0 0 CD CD 0 CD CD 0 0 CD 0 0 0 0 0 0 CD CD 0 0 CD 0 0 0 0 a 0 0 a 0 0 0 a 0 0 0 0 0 0 0 9 9 9 0 0 0 0 0 , 0 0 , 0 , 0 0 0 a 0 0 0 0 0 0 0 a a 0 0 0 0 0 0 0 ' 6 6 ch tA 6 6 6 6 6 N 6 6 6 r� 6 6 6 r� 6 r� r� A 6 6 4 6 6 A r-� 6 r, m 6 rl% a 0 C14 0 0 m Q!T le'r r, 4*1 qT I�T m Itr rl LA -T ell 0 rl w m rl rl Kr m 0 m 14T 11* ICT r6 �* lgr *T 1* le Tr 0 0 a V.-I 0 0 a 0 0 0 a 0 a 0 0 0 H 0 0 a a 0 0 0 0 a 0 0 0 0 0 0 0 H m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m pay p m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m tD N m w H w m m 0 r" m Ln r, It* m o m %r w ri cT A A Lp r- A w co Ln H CIA H -- H r4 I r14 t4 tq rq r,4 '2� r, ;� rN Ln A '- co ul m rl w (N cn rl m r- co w r, Ln m H t-4 V-4 H T-4 H H LL LL 2i 2i Lt. 2E U. U. 2 U. 2 :E 2 :2 2 :E U. W- 2 2i 2 Z> 2i U- U- U- U. 2 U- U- 2 U- w �w -W -W -W lw Ali u u u u u u w u u w u w u u u w u u u u u u u u u u u w u u u w Q qo w L4 .2p Lw LW L10 w SP .� 9p P w .9p P V V AP V Llo V V .�60 V V V LAD V V V V .50 .9 .�p 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 = CL CL = CL CL CL CL CL m CL m m CL m CL CL CL m CL CL CL m CL CL CL m w m m m A CL CL to on on 01 on on ON Ul on on on to ON 01 ON ON on on 01 Go Ul to to on 01 to on on Ul Ul to Ul Ul un 06 06 06 06 66 06 06 06 06 06 04 06 06 06 66 66 61 06 06 06 06 06 06 06 06 06 06 04 do 06 06 06 06 00 a CL CL a a CL 0- 0- CL CL CL CL CL CL CL a a CL CL a CL CL CL 0. CL a CL CL CL KAL CL CL a a E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E LU uj w uj LU LU ui uj ui uj uj wi ui LU ui w ui w LU ui LU ui uj ui ui U4 uj w uj w w uj w ui 0 0 0 0 0 0 0 On 0 0 0 0 0 0 0 0 0 0 0 0 w 0 0 0 0 0 a a 0 0 0 0 a 0 ON 0 a 0 CA CA CA CA CA CA CA CA CA Ul CA CA Cr CA CA C) cm CA CA CA C? C? CA C? cp r cp CA CA CA CA CA CA CA CA CA CA rq CA CA CA CA CA CA CD CA CA Cc r- CA ON ON H CA CA CD CA CA CA CA CA CA CA CA 4 6 6 6 6 6 A u� r", 6 r� 6 6 6 6 w P, -�T Ar TV At -zr Ar Ir 0 Ar Ar to Ln At Ar V,- r- CA r� At 0 TV Tr ON, TV rol (14 Lo TV r- r- ON rl r-1 r-1 0 0 0 0 0 0 0 0 CA 0 CA CA CA CA ry CA CA CA CA CO 0 0 a 0 0 0 0 0 0 CA CA cc to 01 on 01 01 on 01 01 01 to to ON to 01 01 01 to on on ON on on sm ON, on, ON on m to m ON m on CryON On ON ON ON AN, ON ON ON on to on on ON on on on on on ON on co An, to on to ON ON on on ON on to om 00 r, WD CA r, CA ON Ul r4 At ON K 01 It M rl H rl r% CA CA H VA oo uD v ON ri w) CA ;0 ry CA cy Ul Ul Ul U0 Ul Lo Lo Ul UD Ul W At Lo LD W to Ll 00 CO r, QD P, QO ul AD 00 LD on TV WO 40 to LN UW 04 CA ON 0) ON ON ON ON ON Ch 01 ON ON On 0) ON ON ON ON 01 01 CA ON (M ON ON 0) 0) C) a) Ch 0) On a) K CA H CA r4 W ry ry rd M K K W wi M K K A ry P, on P, on On ry It rs Cs 0 QD QD 01 CA P, 64 00 ON Ul 00 CN 00 vj r% & un CA CA CA CA -- CA rq M A v rs , A SO A ly A CA A CA C'q -- T-4 CA T-4 CA T-1 M K 614 T-4 , -, %, -, Lf) V-4 P, -% �, -1 mow. a �� I., rq ON 0 C11 m 0) 00 Ln m r-4 0) H H rl *-I At f-1 TV to -4 00 U) r-1 ON CA to rl H rl WH 1 LL W LL LL UL LL LL W- LL M U- 2 2E U. :E :E 2 2 U. 2 t QjQ) QLJL) LJUwUUUUU Cc < of At 41 at At At < < At -f < to C9n by by ba mO op op w op op t o to tta txD W tlO tlO CEO tlO W W MD W W i Y 0 V) (A 0 ea) Vr 0 taro trr air 0 0 0 (A cal 0 0 0 to Lm (A Ul 0 Ln Ln vi v) crr vi 0 e co 0 06 co a� as as w 0) ar a) a, a) au a, w as ae w a, a) as a) w oj as as w a) as w w w a9 as ad as Qj W as as W W W W as aJ as ar ad 4) aY w as a) as qJ aj a) (U w at £ri as W CU a9 E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E w w w w w w w w w w w w w w w w w w w LU w ia.a w w w w w w w w w w w w M, 6 4 6 a;c 6 ob A 6 rw r• r* r� r+ r; z 6 of 6 oa r 6 6 4 r° rya era 6 Era a 0 mt 0 0 m m m m m m m m m m m m m m m m era m era m m m m m m rya m m m m m m m m m err m m m m m m m m m m m m m m m m m m era m era rya m m m m err m m m m a�a r� w m m N tD 4r m m r»a N Ln Ln ry ri er M N 0 rya 0 0 M W ltzr N r, �a aca a aaa �r arro m o w o w too Ln w w co w w i.n w a,rr w co w w wD o4 w w ram. w w H ear eta taro H � �a H H csa H H car H cra N rw^< NqT r°- m 0 w a-# ua c%r w er m N N N to ,-i NoplGale srr a-R m z-i w N `^w N e-4 N -4 N N I H N '"�. H H ""�. H N N m r-i i r� '"�, N '`�. -1 ` 1 N -1 ar oa as as as as as as as ay as as a� as � ar a� a� as as as a,i as as �s ai �+ as as as as ar ar u u u u u u u u u u u u u u u u u u u w u w u u w u w u u a u u r- 00 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 a 0 0 0 V) Ln 0 0 V7 0 0 0 V9 0 0 V9 V1 VS (In to V) (A V) vi V4 (A (A V) vi V) V) V) sal V'9 VY 0 co 0 cad 0 0 0 0 0 0 co cz 0 C6 cz 0 00 as ar au as a� as au au as as as as nr ar as 4$9 as 4aa a� �a � as E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E Laa Lai w Lai w w w W Lo W w Lea w w w w w w w w w Lai uj w W LU W w w w ui r 1" ¢ r a 60a r, taJ a a Aa LC a rt 8 6 6 Ma 6 rr ra4 I`*a ,-4 r r rl" r` a rw r4* m m m m m m Cal m m m m m m COY m m C`r"S m m m m m m m m w m m m m m m m m L8`4 CA°'9 t Ld'9 LCy r- r- o o w cr w r- w W o w o w o o w 4p o w w w Ln o w ip o Ln CF4 C77 6J'8 CT'@ 8�7 (31 f7'1 C9'1 C'$'Y C9'5 b3'9 "1 f�"9 �'1 K�'1 f71 t71 CX"Y 4�'9 C7"t �"4 C41 C$1 CTl CT1 �1 rn "1 L Ln m Ln rq 4 H 1 W Ln w m7 m w e-I 0 CAS m m C`J ""«. r-4 "^*-, a'y t^r# "; H %11 H H H H H Ca"B ri N H '-. "I H f"d "I H " , C'�4 -4 Ln � H H 0 eq H r14 Lid"& LL. U. U- L. U- U- U. U. La» LL° La. U. U- U- U- ° W 4-1 .4.1 4, 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 .a w w w ..a -i -i w w w w w -j � w w w w 0 m m 0 m m m 0 0 0 m m m = 0 = 0 0 = = = 0 0 0 m 0 = 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 cn cn cn V) cn cn V) V) car Ln va air Lw 0 V) V) V) vi cn Ln Vr car cn cn cn V) Ln Ln V) V) 0 V) cer LIn 06 cad ca b6 06 06 06 06 06 06 06 cz cad 0 co 0 0 co 0 co 06 co 0 06 0 06 06 06 06 06 06 cz �r qk �a ara �a 4a Cs �r 4.� p.a 4.a q.! p� ftJ as qa aJ 0 � q8 0 aJ 09 r1J a� s� c� Qa QJ 4J 0 as 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ui ui ui w ui ui w w w w w w tea w w w w w w w w w w w w w w wi w w w w w w rw 0j 0> 0a 0a 0> 0a 0 05 0 0 0 0 0 0 0 0 0a 0a 09 0 0 00 0 0 0 0 0a rya 0r 0a 0a 0a 0a c0 0a 0Y 0 0 00 07 0 0 00 0 00 0 0 0 00 0 0 0 CD 00 0 0 00 0 0 0 00 0 0 0 0 a 0 0 a 0 0 0 08 0 0 0 03 0 0 0 0 0 09 00 0 07 0 0 0 v 0 07 0 0 0 C3 00 0 a 0 0 07 a 0 07 0 03 0 0 0 0 a 0 0 0 0 03 40 r� + r4. r; 6 6 6 6 6 6 a � cr s 6 6 6 6 r� A a a c rl A r A rya m r. m 0Tr 'AT arr err Wr 14 ram. 14r �r -* � "r «T 0 'ITq* m m � 0 "1 0 07 07 07 000 0 0� 0 0a 0 0a a 00 0� 07 0� 07 00 0a 000 0� m m m m m m m m m m m m mm m err m m m m m m m m m rya raw m raw rn m m m m m m m m m m m m m m m m m m m m m m m m m m m m raw r e a m m 0 r� 10 00 TT 0 r- ,—a �r TT 0 crr a " m r, 0 N 0 m m �a r- m caw 0a ram. uw as 00 Ln vns Ln err Ln w uw r, 0Lo 0 0 w r- r- 0r- 0 ICT Ln 0r rw 4cs H0a cry H rr H r N ca A uw H ra uw m � r , �-e -� r� r a a-a ra «»� a r, rq c e-4 + r rw r. r rat T" rJ rsa r a s co G ra 0w + crw r4 oo ra 00 m cme"a ry csy a H a-+ r U. U. U. w U. u- U. �a asw w aj Qr w as w cu as cu as w w w ca w as w w w as w w as w w as w w w w na ' 4� " 41 ' u u u w u u u u w u cr a u u u u u as u u a u u u u u u u u u u u o 1 as as as w w v w q w w w w w w w w as w w Cu �d as ns a 9 vJ va Lra uw vt s t a t wa cet ua ut err ¢t ert err n en aaa cr i e v� vt I eta va Ln ara ut est uta srr aq CX ± ± on on 01 No on on 01 01 4n on on Ul on 01 on on on Ln 00 LP/ Ln GoUlLC°9 on Ln 01onLP9 c c c 0 tl3 dd 2 i Ctl BV Cil t Gd qd t CL9 2 tll 6d tll C49 Cil T CU OA C9k C1.6 2 C93 T @.I Qt 2 QJ 4S9 QA Q1 X >- x x x x 0 0 0 CJ 2 0 2 2 1 0 9 2 2 2 2 C] 2 C) C] 2 2 2 C) 2C� C7 UJ UJ UJ LU LU UJ LU LU Lad tad UJ LU UU UJ LIJ WA UJ UJ UJ UJ LL1 ui LLI LLI LU ui LL7 ui uj LL9 w LU uj LLI CA CA CA CA CA CA CA CS CA CA CA CA 0 CA CA CA CA CA 0 0 0 0 0 a 0 0 0 CA 0 CA cc CA CA 0 CA CA CA CA CA CA CA CA CD CA CA CA CA CS CA C) 0 0 0 0 0 0 0 0 0 CA CA C 01 CAI LD CA on UD CA ul C) P- LD CA CA CA CA CA WO CA CA on on r, K CA CA CA cy A e i Cam. r- JS A Cn TV ot IS on or on of r d If An I If of If I r, ram. IT or on TV co on Of N Q Q W T Of on If on CD CA CA CA CA CA CA Cs CD CA CA K CA CA CA CA CA & CA CA CA 0 r°°9 0 0 0 0 a CD CA 0 0 0 on erg rn on m on on on on on m on ontoon m m rn on m rn on on on on m on m on ro on rn m m rn m rr9 on on on m rn on on CAA on rr1 rn rn rr7 eel m on ro m on ro m rrt on on m m on on m m rrt m o° on Ln on UM rV H H r• -1 r" 00 N t'ra 00 Ste+ 0) 00 al on m r- 0 to WIT 0 Ln on to C, 0) or 0) P- Ln V) to LC9 Ln Ln co 00 r- C~ 00 LCA r r� P� LO 00 rl co co rl rl 00 r" 00 Ln Ln w w of KT P- r°-tl i,C1 r`d r^i YV C°*I ri w°i t'*J rr9 CCJ 6a7 rr9 6L2 CTY W'^. r. C`r4 m r-i CA C'Yl "i !"°» a"6 CFt IZT ot 1`** CPI CLo a 9 CW e'+A -, 1, ch l ly SO vi WA A emsby Aby A Is -, -- Q orb IS '""• ""� "'�. CA H Cad CA H CA m CA 00 ry P- ti! r- LnCtt C eee 01 01 r, CA QD ot CA rl H K rKrq on rl rq r4 La. 1 1 La. LL. La. 2 LL, LIB z.L, UL C,I tlJ 4D 6? C$I OJ CU 0,9 �} tld 4Sd tlA w w w w w w w w 0 w Od tlJ qd CII QJ Q! w 0 w ,V an Lw w w w W as w w as Vas qp LAO 'SO w SP Llo L10 V q.0 V V v No .5D IW .5 V L)D w W � 0 CA C) CA 0 CA 0 CA CA CA CA 0 CA CA CA CA 0 CA CA CA CA CA CA CA CA CA 0 CA CA CA CA CA CA co x X x x X X x x x x X X X x x x X x X X x E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E uj w w LU uj w LU LU w w uj w uj W w ui w w w uj w w uj uj w uj LU uj w w w w w LU 0 0 rq 0 0 0 0 0 0 0 0 0 0 0 a 0 0 c) 0 0 0 a 0 0 0 0 0 0 0 0 w 0 0 0 0 rj 0 0 0 0 0 0 0 0 0 0 0 0 a 0 0 0 0 a 0 0 0 a 0 0 0 0 0 lqr 0 a c a Ln 5 a 6 (5 6 6 0 0 0 a 0 0 0 0 0 0 0 0 CD 0 0 0 0 0 0 0 0 r, 0 0 9 9 w 0 0 0 a 0 0 0 0 0 0 0 0 0 cl CD CD CD CD CD cm CD CD CD CD CD CO to CO CO r, m rA 6 r� T-'l 6 ra A c r� 6 6 r� c� u r 6 6 6 r^ r� 6 4 6 r. 6 6 !1 6 A 6 6 m ar at 45 m 4 ,-r at at to m m to un H to ar at to ar on m m at m in to to to to r- 0000000000000HOCOCC) cDCICICICDCDCIC) CDCICDCtctcDco on ON Q5 on on on on Q5 on A on on m An on on on Q5 A on on on on rm m m m on III on on on on om on on mi on AN on on on on AN on on m AN m An m At 66 AN AN on WK, on on m An on on So ro AN AN WON a po co QD cy un QD CA ry P, cq ON mi rA P, CA v4 oo yo vA go Qo oo ON on c q CA w m w my r, ul) r, ul ul 2) ul .1 at to ul P, at 00 Cc 00 00 ul ul ul ul ul ul v at to r- UD LD Lo XT Q0 QD ul ul Uw CA 01 ON ot 01 CA ON CA ON ON CA on ON 01 01 on Cl 01 CA 01 CA Ch ON ON 0) on 0) a) CA a) ON a) ON 0) rl H H rq rq H r_4 rl H rH H r4 H H H H "I H rl T-4 rq H T-4 H H H rq rq s H H r4 H rl -H- H H -- Nry N '- fq -- -- eq rq -- Pq -- H rl -- Vq tq C" -- N H — ,- tH on A H N T-4 -, -Z rs -_ A A Q Q A vo ZZ 0 A Q. _ -,. 00 " -, V" Ln ar -, Ln -,, --- -, -, m w H r-4 00 0 N rl P� N un ON i�_- C4 H 00 w rN a H H H r-I L" W W_ 1 2 :F L6 2 2 2 W I M 2 M I W_ M 2 L" L, :E :E :E :Eww W_ LL uj > 'a 2 A A z z z A 2 z z A z A z A A A A A z z z z A, " 4- t � � � 4� � t �11 *1 � � � � *� *� � *1 � � 41 u u t u u u u b u u u u u u w u u u u u u u u u u u u u u u u < < < < < < < at < < < < < < < < < < < < < at < < < < < < < < < < < < 40 00 OD MO MO tO W W tlO W W OD b)D bO W W W W CD E on CD MD .rAO W W to tIO 40 OD OD bn bO tLD bD z 2t 2!- � 2:- z z z z z 2. -2L, 2L, as z z z z z z 0000000000000000000000000000000000 as > > > o 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 a 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 E E E E E E E E E E E E E E E E E 2 E E E E E E E E E E E E E E E E LU LU w w w w uj ui uj w ui w LU w w ui w w ui w uj LU uj w w LU ui w w w w w ui LU 0 0 0 0 0 0 0 0 0 0 0 a a 0 0 0 0 0 0 0 0 0 0 0 0 CD 0 CD 0 0 a a 0 0 C> 0 0 0 0 0 0 0 0 C) 0 0 0 0 0 0 0 0 9 9 9 , 9 0 0 0 0 0 0 0 CD . 0 0 0 a a 0 0 0 0 0 0 0 0 0 0 0 0 � I . � 1 0 0 1 � . I I . I . . I I I I . . � . I to m 0 0 0 0 0 0 r- 0 0 r- 0 0 0 0 0 a a 0 0 0 N 0 r- Ln 0 0 0 0 0 0 C'4 0 1*1 * 0 Itr r- IV %T Itr m Itr "I m KT okr vt "It Irr * rw IkT �r -T lqr IV m m I* Iti- T-4 m -* Tr Icr lzr 0 0 0 0 0 0 0 0 0 a 0 0 0 0 0 0 0 0 0 0 0 0 0 0 m a 0 0 0 0 0 0 0 0 m m m m m m m m m m m m m m m m m m m m m m m m N m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m r- q p t- N vr o r• c q ,t rr Ln m m Ln w Ln a o w w r- w m w r� v-i tr " w o - r- o 0 LO 4Z w 0 r- w w w r. tl. to tD 0 w rl w r" 0 w w r- w r, w r- 0 w w Ln r, W w m m m m m m m w m a) cn m cn a) a) 4m m m c� m c) a) en crs m cn b) cn 6) in m a) m m r4 r4 r-I e-4 rA r-4 q-4 rl r-4 H rl --i r-4 r-i "4 V-1 V-1 V4 TH H e 4 ?-4 v4 T-4 a l r-I r-4 rq t-I TI-q r-I "q r-I H -4 1 -4 N N m hi w-4 P4 r-4 N r-9 H N H M r-I f-I N M N H N r"I t-i i N r1i m 00 In m m w N r-4 "I T-4 T-4 r-I H U- > > > > > > > > > 2 2 Z Z Z 2 2 2 < < < < < < < < < < < < < < < < < < < < < < < < < < < < < < < W MO Wp W 00 Wp tamp 0.0 bA tO 00 tip tI6 UD UD OD 40 40 tap tXp 2. 2- a -2t- 2 z z z z z z z z z as ps � as ar c�a as as as eta as ps oe as ar �,a ar ps as a+ �a � ar �a as � a.a oa ala a9r U.a ar � eu aLr ata esa q& qa ala �a �r eta ps qa �a Qa QJ ps Aa dJ �S eta p.a Ra as QJ pJ ps sa. ca. c°a.. a D. a a zaa 'a 7a ra. a a a a a a a a a a E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E w w w w w tar w uj w w w tar w w w w w w w w w w w ass w w w w w w w w w �p�yy ,pay B Y 1 R �+�Yy g 8 g+�p Y 9 11y Y q�0� �y q�B� 4 9 �ry 6 q�0y p 1ry B �9y �1q 1 6 Y y 6� Ass{ '�pe�nµf pch pC�+�7� fr' cn' '�M+m�vyQ ed'9 A yRee��b' 6 te'�I 6 pc° M+.may CAP M,.,� °p+x�.� q6 A q6 4yo��i ¢('��+'�¢ 0' .��,+^�yyR s�wy6, 6 �r�n+.✓y 6 6 �barr�.,� mm mm N tom" 0 '^Y pf�,7 pcli 0 6 ma's N w r` m t m r• m 0 fl- t U:" 3 Cs 6 6"� rH 0 N �CcYq'r4 m H 0 wa+w Ln 0 0 ttr 9.0 � 0 0 r, r" Y" 0 w t ap w kD w am w yw y0 yyy 0 w r- `W r- r- r. r-I x-� r-i r-9 r•°9 c-4 rW9 r-1 ri r9 x-4 w^9 r-9 z-1 r-8 rW8 e°-I r-e c-4 e-i r-4 c°4 a-d a°^9 r4 a-d f r� a-8 ri atlt va4 r"9 e^-9 x^1 m 0 °c8` 0.4 T-4 N r" e'er m w rI r-1 m "7 kO 0 r, N m H N H 0 m en u ro'"ww 'an+v "+6 w r- to m Ln N 0) r"** H N N H 0) ar u, as as as eta as ar ar �a pa ar as as e� pr as � as as ar ar as a� ar as � �s as pa �a ° Z ° CA OD *0 W bD tko bo NO txo bo CLO on OD w on OD 00 tM OD W OD 00 40 MO b.0 00 bD OD tW tW OD W .00 OD Z � 0 0 a 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E LU LU LU ui uj w w to LU w uj LU LU ui LU LU LU w w w w LU w w w w w w ui ui LU w w LU 0 0 0 0 0 0 0 0 0 0 0 a 0 00 0 0 r- 0 0 0 0 0 a 0 0 0 0 0 0 0 0 0 o o c5 o o a o 5 o o 5 o o a o o in r-j 0 0 0 0 0 0 0 0 a 0 0 0 CD 0 0 0 0 0 0 0 0 0 0 0 0 0 O 0 en rq 0 CD C) C) 0 CD 0 0 0 c 0 0 0 0 0 0 0 CD 0 CD 0 0 0 0 0 a 0 0 'gr Ln a 0 0 0 0 0 0 0 0 0 0 0 0 0 CD 6 6 r� 6 6 c� Ln' LA 6 e�) 6 uI A 6 V'i rn' �n 6 c� 6 6 r� 6 A LA 6 6 6 6 6 6 tT lzr -til lzr nr r- Tr N m Tr -cr Ln vil Kr m llzt em m -tr CD -41 Rrr m RT Ln 'Ir Itr 'Tr r lqr *tr Itr 0 0 0 0 T-i 0 0 0 0 0 0 a 0 0 a a r4 0 0 0 0 0 0 0 0 0 0 1-1 a 0 0 0 m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m 0 Ln 0 of 0 m 0 0 0 0 W LD W Cn W W 0 0 0 r- 0 0 r- 0 0 W W W r- lD r-4 V-4 r-4 �4 r-I rq r-i r-I r°l H H H r-I V-1 1-4 H m w r- m m 0 m m w w m r- T-4 m fli m m N N w N m T-1 m m m N N N N Ni -4 -- H -- N , N m N -- N 4 1 N -4 N H N -, N m N — -a w ri H H t-A lt;r H H N Cw w rl "I N r, t-q em7 H "T m T-1 m 0 N H �4 Vi t-4 V-4 U- W- W- U- 2 2 U- U- U- 2 U. U. U- U. W. U. U- U- U- 0 4-- u u u u u u u u 0 u u u u u u u w w w w u u u u u u u u u u Q .w .LW P SP 2p M 'LIP .2p ,L)D 2D w M .9p M ,LO M SP 99 M .9 vcxaM .LLO W Lin .Vp Llo LAO LID M M V .9p z ZZ- Z- z z27 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 CD 0 0 0 0 0 0 0 0 0 0 0 0 co w w 0 w w 0 0 w 0 0 w w w w 0 as w 0 w 0 0 0 w w w w w 0 0 0 w w w w w w w 0 w v w 0 w w w w w CA w w CA 0 w CA w CA w w w w w w w w w w 0 w >- >- >- >- >- "IP- > >- >- >- >- >- >- 2 2 .2 .2 2 .2 .2 2 2 A A 2 -2 -2 -2 -2 2 2 2 .2 2 A 2 A .2 a a a a a a 0. a a a CL CL CL CL CL CL CL Cl CL CL CL CL Cl CL Cm E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E uj LU ui LU wi LU uj uj uj LU w uj w ul w uj w uj ui ul uj ui LU w uj w ui w ui ui w uj LU LU 0 0 0 CA CA co 0 CA 0 0 0 0 0 0 0 a 0 0 a 0 CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA 0 CA CA CA CA CA CA 0 CA CA CA cl CA CA CA CD CA CA 0 CD CT CA CA CA CA CA CA CA CA CA cc CA CA CD CS CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA 0 0 0 cl CD 0 CA CA CA CA CO 0 CA CD 0 0 CA CA CA CA CA CA CA CA CA CA CA CA cl CA CA CA CO A A CA Cr ch A 0, A C5 cs C5 A cs ch 0' cs 6 04 A A 6 A A C5 cs C5 6 C5 6 &A ro A r-, 0 N LA 4 LA 0ts on 4 tr -* r -r CA CA CA Ln -T 4 w on, on m 0 0 0 0 a CA 0 a 0 0 0 a 0 0 0 CA CA CA CA CA CA CA CA CA CA CA CA rK CA CA CO on on on 00 on on on on on on on on on on on M M on M M M M M M M M M M rn M on M M M m m on on m on on on on m m on m m m On m on m m m on on, m on m on On m on m on m On N rq m m w m w f"I � 0 V-4 0 w 0 w w 0 a m w C 0 t.0 N m Ln t- 0 0 N Cn o CO 0 w CO rl- r- CO N RT It N r- r- r- w N w in w In r~. kb w WO m w rl. w w N w CM Ch m m m m m m m 0 Ch m m m m m m m m Ch m m m CM, CM m Ch Cn Cl m m 0 0 m m w m CM vr 0 T-i 0 0 (N w CM CIA 6L1 r� r4 en M on on e-q 0 00 0 (N on r4 w t-I K M on rq ry A Is A rA ry A IS A W Q Q eq H A r-A %-- -- M -, -- q:l* -- %, -�� -�, -, --, -, -, -, W W -,, -_ N --_ rl -% 00 N H T-1 N w H 0 H 0 Ch rq r4 r- on N w rq T-4 0 ri H H M r-I rl H H H r-4 H rq U- U- U- U- 2 U- 2 LL LL 2 U- U- L, LW L- LL LL LL LL LL U- LL L. CA w w w w QJ w w 0 w w w w CA 0 Of w w w w w 0 w w 0 w Q) 0 w w w w w w *J 4Q W +5 +J W 44 +4 +J 40 +J +4 +J *W w US Q Q Q U CA CA CA U CA U CA CA W U Of U CA QJ CA 0) CA QJ CA U U U U U U L) Qu .a LW 90 n 5.0 9p an cis VO V 99 Can as v V LID SP V rua can Sn qO V ad aea V LIn LIn m � � pa a� oa na as �a ar ar � as pa � as as ps as as a� as as as as � pe ar a, as as �r as a�a1 «� as as a, as pa a� nr �s a� pa oa as �a ar as as n, as p� a� as a, as t2 2 E 2 Ca Cb 2 2 2 A 2 2 2 a C) 2 2 2 2 2 2 2 9 2 2 2 2 C? Q E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E UJ UJ UJ UJ UJ UJ UJ taa WU UU UU UJ UJ UJ WU UJ UJ LU rya LU LU UJ LU UJ UJ UJ UJ UJ u a UJ WU CA CA CA CA CA CA CA CA CA CA CA cm +A CA CA CA CA CA 0 CA CA CA CA CA CA CA CA cs CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA Cs CA CA CA CA CA CA CA CO on N to CA M CA CA Ca c7 e"a A A 6 6 6 rl I A rK A A cS 6 cS 6 A 6 ch ram« cis At on to At At P, To To Let rm at n To at no rw at at At to on at on j At In A at TV co To At to A ca CA CA CA CA M CA CA to Ca ca CA CA CA CA rM CA CA CA CA CO 0 0 0 rM ca 0 0 0 0 0 CA CA cc on rn on to on on rn rn to on on on An on on rn rn no on to on In mm m rn to rn on to to on on 01 Om rn rn to, to rh rn rn to on on on on on on IN on Al No rn on AM on to on ro rn on on rn on rn on to m �, tr1 s.er eel rn rrr u°r �-, c� r�s �° ra r�r rn ara � r*a rr1 s m cr1 w r- m r,, u r m w w w w Ln w rd m rZ tlp w w car a r- w m rm cK im ch 6) cm m m a) a) m 8) cis cn cn im En m car as m cn m o) a1 a) m err m m rM r-t rM rM rM ¢-� rM r"9 z9 rM e4 rM r-i r-i �-, rM ri rM v-°9 rM r-# rM rd r1 rM rM r9 rM rM e4 r-8 r-s e-4 t rl w At 0 At Ln rr ter r" 0 ra 0 0 N N �t l� r• 0 m h C rM r" Tr r". r"N A K rM '"�. to rM H rd 04 "'"% W N '"�- N rM rM 01 M """- N rM CJ V ` '"n rM "`�*. 4"J 8"0l rM rM "I to At I A r, H rs A, ul Ul N rA at UD CO M r W 04 P, H rM H 00 r4 K 9 r-8 rM rM rM to u 1 s, U— to v u u u u U U U U U 1 to to to to to to to t5 < < < < < < < < < < < < < At At < < < < < At At < At At at < At < art < < at < bra .2t« X x x x X x x E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E Lt w w w w uj LU w w w uj w w w w w w w w w w w w w w w w w w w w w w w 0 0 0 0 0 0 on a 0 0 0 0 0 a 0 0 0 0 a a 0 0 0 0 0 0 a 0 0 �wY+.� 1 B 1 1 �1q 1 6 sky 0 q 1 1 B pe1� 6 �r1� B y�9� �y �y Y p+�y g Y 1 B B 1 9 9 1 9 a' 0 US C 9 to b 6 6 6 CA CA a Wd on CA Ln 6 CA Aex/� a Fecal U" �y7a r14 A UC r� Y�yy� e-4, yp-�y mp� par pay ar ar r- air at yr -F 4q teer g* �X %r �y p ay yy H air Imo %* Sara- fey" p� at pang 0 0 0 0 W W' 4d came CA CA Wson NJ A on on 0 CA CA \A CAon on on CD CA Min Faso( CA . edon on m CA CD CD CA CA CA Cc Sm 01on on 01 mlml ml 01 on on on 01 yam. re) en Mon 00 r" M �ry r q 0 N m r-a 1 r i r" 0 0 0 a Lin TT r-� M m m rig 1-4 r" Cn 0LA tp op rq o) m m cm cY a) cm m cm c1 4 1 a) 48 F m ) cm a4 aY abCn c, cY a1 o6cm 1 C4 a1 ak m+ayy Ln Ln H w �-I M'0 ^ 0 r" �roa 4 H p��4y. "'«+r �+a �4 �aT Pl. w gnu ri "emu rq w �*a n ll� wryMy� ax„^'TM Wyw n hi A -, my ry by Pq e-i A A by r y A by "'�•"•yw Q `""+» by A 44 by A N1 AtN x°yw xp'ga "*mra y �Hau� M r""caw nr "Ma "�Ms ��+aro `�Ww p��4Mg�yyMr "«M w M w w 2 2i w 2 2 w w w w w w w ca w 0 0 ca a a ® C5 C3 CJ 2 2 2 2 2 2 2 Cb 2 2 2 2 2 E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E w w w w wr w w w w w w spa wi wr w w w w w w w w uj w w w w w w w w w w w CA CA 0 CA cp cD CA CA CA r, CA CA CA CA CA co 1 1 1 1 a 1 1 Y X Y 4 1 6 A 1 9 X B Y 1 1 CO rq raj m r*d m r°W Y A 6 A ¢.w.� 0 r-q 0 W14 try C CA r• ,cr Ln r- r^ a- w Z5y un Z° 'r ail on cis o eat r m on cry s &A Lnr, on CA 0 rq H C H V CA CA CA CA CA CA �y CA CA CA CD CA CA CA CA CA CA CA CA Q CA CA CA CA CO no An An An m on on T on on on co m m on on no on rya In SK Sm m on rn m on m m rm m on, An Sm on on on on on on no on An on on no no on on on on, no m AS on Sm on, on m m on m on on on on on ran r- LA 0 00 P"* r4 w a Ch Ch to 0 H on m N a no Clt N w 0 on H Ch to r^* w 0 ran am Ln Cn W N bo to A P% co urn In un r4 A Q to I AD co um to r. Ln wn LID co N to W w wn asp w Ch CY) a) Cn a) 0 a) CM 0) 0) 0) 0) Co m 0 Cry Ch 0) 9 CN CM, 0) Ch &'S"3 0) Can Cn ch 0) V< ) at 01 Ch r^1 r-I H H rl r-4 r4 C4 rq r"'a r"9 r'0a H H H *-4 r'"a r-9 r—i r4 r"°j r'°4 rl r-@ H rl °*w, 0s. "�"- ` . "�*., 1" %11 °°�'.e - zit '�»n ^^^.w -- -1 '°ws wm "mow. °�1 °"- -1 -- ""mow.. 1� 1" -1.n `^*+w,. �"'i (14 d,' ` Ln to CA CYn lC')b C#3 Ch Can rq tt �#' try tC? H r-i on, H ° tC8 LLB r, to ` Cm of t� rl ry N VI VI - , ry ry N "O - 1, (y Z5. A or, "� Q ^"`~A °""•w �w min by TO "py A A IS `, r9 I, ',, `*- ri , -cos %— Ul ., +.j -^„% m H C D. -- %, 4 -- -, r'"^ ^`°°°w 4 4�Y 4 1-1 ^'maw bd �""mv. -- 1, @fit rq rl to rq t) Ca H N H r'� m on r"a w ¢�6 p u u u t 4 to v Lu to Pia c5 u u u ask is u v w u u u to to 8o Pia to w so co ca j, it � as as as or au �s au as as a �s a.r as as � as �s as � � � as Cu ar as as �s as a1 � ar as E t E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E LU w w LU w w w LU w w w w w w w w w w w LU w w us w w LU w w Ls w CA CA CA CA CA CD CA CA CA CA CA CA CA CA CA CA a CA CA CA CA co C C C C7 C7 C) ? CA 8 CA CA C t C 8 CA CA CA CA CA CA C) 0 CA CA CA CA C7 CA CA CD CA C3 C7 CA CA C� C� C7 C7 CA CA CA CA CA CA CA C7 CA CA cc C,t Ca 9 CA Ct C? C? C? C? � � C7 C? C9 Y 6 r tl 1 1 9 pw1 B B 1 B 1 B 1 F B 1 1 B Y A Y 1 B Y 1 tl 1 B k Y 1 B c; TV 01 C'; �y �Pya T` Wv� on 8 A C p- CA A CA to A ch A CAP f% C7 CA K u1 v CA C7 CA 4V I, CywAy ppant�. It p^M�, pry+ p`a�d, �e�ryq* pp �wrn �q° p�p��*yy p�rya �^s+d�y �z� pwy pq �AS at ol .s y aY�e N at at �wwy Hwy e on �e�a a M ee�qq Of f a�a �My � �aw��ya a��qa 0.✓ 4d Ord bM' Tw"a Ord C CAA C bd CA ewe CA CA CA C A CA C CD CA CA cl CA CA C'� cc of on aft aft 01 on fit fA of ON ofon On M 0M On rat mi on CAS onCYO AN of on on to p a on WK on on on tea on CAS on of on C on to won Al on on on WK om To aft W e as V 1 0 01 CA „e Ch Ch CA t ON Cl ON, ON ON ON CA CA ON CA On of CA CA 0) ON 0) as CA fat O1 "I H @p°Yry� rwa r°f �@�e�y4��r f v� py4pe�y C�n 4p��. CA H"f era CA of r- � Y tD K al M on 'W aka `M W..✓ CA 14 ON W.rd *4 at Wwd K at r4 0) t14 M 00 A on �¢°p�g rA eel CV ��¢�µpd� ""»�. SO Y J by C'^�a W """�«» "°^°•x e�i t'�k RAY yr�^yB '""�n J, rwP MI "I ems@ H ""«, "'�,» H �cq �'"«+. e°�1 cli CA Cai 4 4d o Ln a�}i to $—d M r- To � t--f r, C J H " 4d m H rq M a 8� l M � dot M H rWS k-A Yw� Cct < CX cy < �t ar � as cLr a� as ar as � �a �s a, � na a2 as as as as a� as a a� �a as z �a uu su as E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E 0 C7 C f0 0 0 0 a a 0 a 0 a a 0 0 0 0 0 0 0 a 0 Y Y B p� �I Y6y 1 B A tl �1y y Imo, pq I Y y�y �Yy X 9 1 p�{q p�8p q�6, pI� �y Y �y 1 pry per. �Bg /� p�q r"° 6 �Wy 0' Hwy 0' 6 p4m�f, 6 o A 6 4W y'ri go' o 9r, 6mf 'y4�Wy' 6 6 6 0' 6 6 m m m m m m m m m m m m m m m M W fey H W r" 0 M i6n H 0 fit' C J H W fl,, 0 W rq r4 M yr W M rl W W r"� W 6X2 L9`I C�"k a gyp,` �9 R$"4 k8'f t�6 W, '6� 6 f"+ l,� 0.l1 Lf9 Ld'8 q,C3 1,47 C�8 l l�2 Ld`1 445 C'"4 is°'{ Ld°1 6d$ 4f$ 4� 6d`4 H LM m f`. Lf3 P"" M Lt'8 $ LL3 rM 4T1 87'f 2 681 Ld7 4,t,3 t3't eel CV r^i "I H 0 w (14 H H N N m ar r 1 r i COf r! 2 i 4 $ r 5 ¢/ f*f I f l CM rN 4 rrd f<I e®9 ami rw9H T-i r-8 r-9 H u u u u u u u w u u u ✓ u u u 0 u u u u .0 u u u u s u u u u u u u �a ray as as as � a� ar �a �a at ar as � as as Ca as o, �.+ as as as � as a� ar a� ar as � as 'E "U -E "E *E 'E 'Ea a a a ca. a , �00 a ea. E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E uiuiuiwwwwwwuiwuiwuiwwwuiuiwwuiwwuiwwwuiwwwwui r C? C? C? C CA at CA Cr r r C C CC a C C r r r a CA cc r rCA C3 Q CA CA CA CA CA QQ CA CA Ch CA on CA ch A A 6 6 A Q on CA on A On M on on m CC9 CCt m Co"b on On m on m m m m m 4`e 1 on m On m on, m on m m m m m m On on C�°Y C�"I CVS f1"1 CY°6 C�"Y C"fp Mg a°a"! Cql fl"�'$ CC1 S"C} t°�"6 CC`1 fw`6 Cp`Y rf1 Cr`4 fv°Y Cv"g f'a7 CrA C'�k C�'9 t�B a"�9 cYt aT mod+° 0 f- H m 0 r-i m t,S"} &D m H all 0 m 0 m Ln Ch Ch w 0 H It W-4 CCU WD 0 0 0 w N ul ar W Ln 0 0 N CCa 0 0 44' 0 0 0 w N 0 0 0 w w w 0 w w N r- Ch C31 C1 Ch C71 Ch 0 m m ON m Cn Ch Ch COY ON 0 m Co, m m Ch m m m Ca Cal C1 m m CCt ON m m H emi H t 9 '" "ww. °", 1, w "^ww ""emu °`w. , "�, �, °*�. ^w *m w � "«w„ . .ew . � �w . `"�, , ». N a) 00 to Ln > w w Pr9 On `* at y r � CC1 0 � U- w w w U. us. u W- U. U. w w U. w U- U- w w w w w � as as a� ar as a� as C, o� as as �a �a as as as as �a � C.a as as as as as as � ax a� C < < < < < < < < < < < < < < < < < < < < < < < < < < < a� a, eu �a a9 as as � qa �J � pa as � as � as nz �+ � aJ aJ �d va aJ of pa na oa E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E uj uj ul uj uw uj uj uj uj uj uj uj uj w w uj w w uj uj uj uj W UJ uJ W W W uJ W W W us uJ CA CA CA CA CA CA CA CA CA Cs CA CA CA CA CA CA CA CA 0 CA CA CA Cs CA CA CA CA CA co CD cc CA CD CA CA 0 CA 0 CD CA CD CA CA CA CA CA 0 CA CA CA cc 0 0 0 0 0 0 0 a 0 CA cc A 1 6 A 1 pa6� 9 Y B Y B peir�. �aa1u�, 8 1 µrap 9 1 B 6 Y B Y �1y 1 B 0 1 �y �1y /��1p 6 0 W Iy"^a«y qy rr.'p �pn.�� p� a�aytat ar Cam,a 0 pLa"ys .,aane�y p4eu�� c0 0 pWzu�� pq pCA r^"v�yti§ po eft 0 m f�°.4J 0 r, 0 dN �9 0 4o CA kWe.4� CA 4d W..✓ 4.� 4A a.✓ 4.W 4ad Wd Ld Wd 4d rows+' 4d 4A We+s 4 '�✓ 'ti✓ ^� +xW .d M✓ sf 4WD w,w< Mn 4.r➢ of on Cut Cut N1 Cal Cal "1 Kul k 01 01 ml ml M 01 Cal Ku'd Cl 01 of "I Cut Cal m m Cal ro Kul Cut A m om ml on g it 01 on of fe y may 01 fn on ml fm on on M M M M Kn ol rm Lf b wD t° o un P, C`" V ° C r4 p, Y4 ^4 '"M C`J a+w✓� Cut CD a° co cy C11 Cab h, MI Ln rd lD h* CA CF1 1 C"+ w I'" 'ar r, w u5 r- r,, r. r,, w kD 4o r- r, LK1 a L1 Ln 6 LA c& o w lye Lo w tit L1 a) m m m `! a) m a1 ) CT't C31 c1 'b c 6 V 1 b6 6 a9 CS1 C11 m Cr1 a1 cr1 a4 a m a1 81 m a) ai a) c1 cm .,y„ w `pwr.*�Ma ern ""^+a� "*mra a �"�wr ya a "mat mt 1 n n �n S �"4 �, �, 11% it �Wt 1%, x;' 1 *11 maw ��+'I "w�"�"«, 1M 1 �x"nma '- any w 9 f°" u,,.re Lf'9 t r' C7 C?'9 ri r, rZl r, Ln e`"d o Ln A Lm m tJ� it C$b L89 A Ln Ln '^a w Ln m v-I ll� P"W "- ry ""- Cat �y^w«•�n�. Al '"°- VA -- "�"- A 6'W IS rid *"^w,r a�6 a Cal cq 'TM- H a°"�8 H H "p'TM�4 rf rf K"�J ri ep9 a"V mn'ywr "mau+a. "A -, fir. CA ww"_ ry -_ Ul V -1 �9 �" "q�x s�"wa+y e��'_ "M '+KNi yxgra "'n"� �M Ln cn ° m r-t C°J ri C"* ("J C"' r- V) � fN Lid F � Ul C14 C"+k CCa " VA aJ aJ aJ as as aJ ar a� aJ �d aJ �d � � as aJ as as a� aJ aJ a� � aJ � as oa � as aJ A z z z A > z z za R«& C.dd a.e 47 Cad 85 49 u d«} u uL.8 PJ G.& 6.b 4J Gee 6.d 4.4 t.B 41 4,9 4J 4.d U U U U u u u W U U < < c < cc <1 41 cy CX < < < < < IT < < a 0 aw » t i i as I T I as T i i i i i i i I as i as as i as T as T i TV T t I T x x x x x � x x - X X X x x x E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 H 0 C a m H ors 0 H 0 0 0 0 N m a r, r- rya W 0 ry m 0 r- 0 0 m "T Itr m R!t m m 14T On le Irt T 0 0 m R° 'I m on Itil era � le Itr -° On on &n IcIr 0 CA CA CD CA CA CA CA CA CD CA CA CA CA CA CA CA CA C9 CA CA C.7 CD CA CA CA CA CD CA CA CA CA CA cc m m m 01 m m spa On On on orb m m m rn on m m On on on mm m On on m on m m on m on m ors rn nj m on rn m on of m on "I on on on on on on rn on on ml m on on On rn sror m on m m on m on rA q oo Cao QD go to r, st a`n ri ri q ry up up r* yo ry ma rq ry q rq Ca1 r% a my a cc P, e a ¢tea r,4 to to 00 QD to 60 to r, yea 00 r% r l U3 00 Ua P% ram. Uy 00 aO LD to ul 00 Lin sn to to w Lrn ram. r- W 0) Cy m cry a) 0) cry rya 0) 0) `y 0) as m Ch Cc 01 aw C) a) ors any s Ch CM (n cry cal a) �i TH H en 00 LAI H On m N m O -4 u IA N r- to w 5 t t t5 t t t t5 Z is tt t t w) u aLU a E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E w w w w w ui w w w w w w w w w w w w w w w w w w w Li w w w w w w w w 0 0 0 d a 0 0 0 0 CD 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 r a r a a a r a a r a r a r a a rn a e r a r a ` 0 .r yr �r r-i vr Ln co 0 M6 H vr Q!T co .0' m "tr r- w .Y N 'o' fit` r- ":1" lib m w C�P6 i` Cg'8 Cv1 m m m m m m m m CYO m Pw B m m m Cat m m CAS m m m m m m m m m m m m BPS P C h C9! Lf9 i°! Cs6 K CYI �d W`+ CY7 i h+ I 4C9 lLS i CJ C I` CV " &°1 f° L C% C7 b H 1 H H H ¢-a r-i t-I F q S 4 C q �4 a � L 4 r-I C q r-I E3i r-I t o C$9 L}1 H fib H H H H H H ¢^'! ri e-i e°-B r-^d e-B r-1 r 1 a-8 wm{ �8 a'$ a-9 z i a-8 e-i e�i ems@ end ¢�°9 z�ffi s�i 'P"8 C"'1 wi e�-9 C"`i ri ri e-9 ew9 �^"tl C a i I C* r t r-s k lCb .S 4G# a i P00 to N rya rl w r- .tr w &.0 r^ t* m Cd1 rsi z - m 040 .- ' u ` S Q.a ma —a w w w w —a w w w —j —j —i —j " —i ._.a w w w w zzz > -2� 2» z z w w w w w w LU uj w w w w w w w w w w w w uj w w LU ui ui w uj u.a w w w w w r CD 0 CD 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 a a 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 c 0 0 0 0 0 0 0 0 0 0 rim r czs 4 4 era 6 6ea6 6 6 A r� c, 6 6 6 6 r° 6 6 6 6 6 6 r4 m a m 0r-I 0 0 0 0 0 0 0 0 0 a 0 0 a 0 a 0 0 aim H m m err m m m m m m m mm m m m m m m m m era m m era m m m m era m m m m m era m m m m en era rn m rn m rn m m err rn m m rn m m m m m m m m m m rn rn rya m em T-4 H V4 Hq-q H H qT H a H CX'a w ars r- �° c� co ara �+ «� m � � un �a A rN rat � � ra �• rN cN ~� "� m �• r a H ra m A ~� A �a � rya rN ~. rev m "' `" i ca' a r� .01 02, 0 0 0 0 0 a E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E w w w wa w w w W w w w w w w w w w w w w w w w w w w w w w w w w w w CA CA CA CA CA CA CA 8 CA CA CA CA 9 1 4 p Yy B y�9 B 9 0 CA 9 B pry B 1y p*B+� Y p1 1 1 1 11y B �1p B p�1y Y B Y y?B 9 �Yy CA CA 4W CA "1 CA CA to A, atyto apµ rq � MCA AR CA CA P- 4d bd `"tl ko CA CA CA to Ca C C C C r4 dw9 C CA CA CA 2 C CA CA to CA r4 CA LA Mw CA C Wf C r4 CA AS In In on An on A In to An to on on on on on In In on on In 01 to con 01 on erg rya raw 01 CA 01 on 01 01 on on on on to Cl 01 to on Cis r, oo rq pay � M °* on bon wLn on 1 i Co pt-i o4 r,4 fA m Ln r- 4 pr, oo m caw Caw CA 0) CA m M CA Ch m Ch sew caw Ch caw aw Ch caw CA �e C, , air m Cs r r4 M K ri rl rl H H w°R r4 rl rq ri M V K r�1 rl r8 M TH r- r4 rah end V rs V ry rl rq H CA /Z, rl "m- rK rA to 1, 1- d� H &� H CA per* M v-4 -- f� r-4 '- °"' H . rd OH Maw pa 'bw u --on Ul , , Q -, , ns ern„.nyva:r �a , � w�'r*ww�.,. W4 -w -M. Al � J, CA Caw un ri a CA P, A 00 K LIP V CA W CA LA CO w w w w w w w w w w w wuu < < < < < < < < < <1 < < < m4 m9 ..a.t " —j —j —1 -4 —a -j -j .-j —R and and ®J —j " " —j -i —i m& —j m8 —i awl » 2. 21 z z z z z 2 2� 21 > da �a �a as + as as as cu oa �r as as �r � as as as E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E w LU w w w w w w w w w w w ui ui w w w w w w w w w w w w w w w w w w w 00000000 0 0 Oda r a r a a a e a r a a a a a r r a e r r r m m m m Cry m m m m m m m m ero Y m m m m m m C'v°B m m m m m C'a°4 m m m m m m m m m m Cal m m m m m Cry m m m m m m m m m m m m m m m m CAB m tab m Ca'"1 m m m C�4 �$'6 L71 C$1 Cr'@ O�Y C9"9 CT4 CYl 9� d3"9 C7"1 C1"1 C�'9 �"k f�`9 �"1 C3`S P.#3 L`81 C61 C1`1 C9'Y �6 C�'"8 "1 eW4 r en4 �4 b c i r4 r9 r-d C"4 c^i 9"�t C"'4 ¢ 4 eW4 a^°4 w'^! �4 e4 c 4 r6 c-9 4 9 aM "www `^ *rw „ " . "nw. -1 ",�. `""r �,„ `" ""� "" ""�. "'"w. "*w, """+w ""�.. °+w„ "w. "^*w ""a., "ww, �.. . � �. , P r" m C%1 rl� r`^• 0 0 H P J rq S ram. ram» N 8« 4 N Tr N � cq TT H H r-6 m PJ C"d "" r^� x C"t ""*�. f`J C^J C^J 1"1 P"d H "`^w . &b$ �, r•k r1i 0 4 rq a-4 0 H 0 ri in M Ln H m —4 ram" H w H H eq e°4 w 0 L� a—i e-4 t d 4 r°i rq � qJ qJ CJ �3 QP Qd LL8 tlJ E3J Lli Qd 41 41 tl6 qd tl1 qJ q„8 6�,& Q3 416 qA p.F 44J OA$ Qd qi q,Y Cam@ c„a r.a �.. as a� a� as �r aJ as a� as a� Cs a �a vJ a� a� as eo Ca �a �r as a� �a as Cs a� as a� ar � � na as a,o ar a� rya �a nr au a,a as C Ca ra c < ca c c �a ra e� .2 cr 2 2 2a E E E E E E E E E E E E E E E E E E E E E E E E E E E ECaa as as uJ uJ uJ UJ UJ UJ uJ UJ UJ uJ UU UJ UJ uJ uJ uJ w ui ui uJ uJ uJ w uj uJ uj uJ air CC CC CC CC ac cc CA CA CA CA CA CA CA CA CA CA CA CA C) CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA C} CA CA cc CA CA CA CA CA CA CA cm CA CA 0 CA CA CA CA CA CA CA CA CA 0 CA CA CA CA CA CA CA CA CS co cc 9 9 9 C2 CA C? C? C? C? C? C7 C Cy C? C? Cp C'? C? C9 rya pia pis wS r, is A CA CAm Ar Ar At CA a 6 CA r�a rn CA A CA s e A 6 ram. r CA om rat ar r4 r-+ 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 a 0 0 0 H rra rra sra era ra°o- rra rra rra rea rra rn rra � � rra rva rra rra anti era rya rra era rra rr1 rra era rya rea art rrp ara r�r rra rra rra rrm er1 rra rra rr� r+a rra err rra rra era era r�Y erb rra rra rrt Ar ens cap r, Ln At m m CA w o m Ln ea°a r- CA r- rq H w r, wr CA m m r, Ar 0 At, m rya 0 rl� Ln r- 0 m c-i a) m m lD m m r_a ri r-a 00 At r- !, ON CA H tP9 w 6 44 A "- A A cy A A A rA H A IS by -- -- A A -, A Q A A tz� ram! r-a N °""w r,4 N e A Ca co er rl. r�l rra err rq r l �r � > > > > ca aJ za ca cr v c.a c� �a Ls w ,� ca cJ ca �,a as cJ ca a„a c.r C3 a„t ca aJ ca ax ca Ca eaa qa su as q� ONE 2 3 2 2 3 . . . . poll Impli E E E E 0 t^ 0 Ln Ln V) 0 v) ul Ln V) Ln Ln vi Ln V) V) 0 un V) V) v) 06 06 025 06 06 os 06 0 0 06 cz co Cz ca co Cz 04 04 06 06 06 06 06 06 06 06 06 06 06 06 06 06 06 oa at cc cc cc cc cc cc of cc oc cc cc cc cc cc cc cc cc ca cc cc cc cc cc cc cc cc cc 0: cc cc Ot 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 CA 0 0 0 8 8 8 104 8 8 8 8 0 a 0 0 0 0 0 a 0 0 0 0 0 0 0 0 0 0 0 0 0 0 CA CA CA CA CA CA CA CA CA CA CA co CA CA CA CA co CA 0 cq CA CA CA cc 0 CA CA CA CA CA CA CA CA CA 0 CA CA 0 CA CA 0 0 CA CA M CA CA CA CO Ph CS CS PC C5 6 CS C5 CA -i 06 LA 6 ch CA 6 6 6 S rl 4 CC Ph Ci Ul rk Ci 0 MN SL6 171 "T "T VI C`14 113' 0 �ZC H rn LA Ln m m Ln in tj, Ln tr m vi m tzr W 0 C. _1 0 r, 0 0 0 CA I In 0 0 r 0 r, 0 0 rn 'Ir Lo M M I", "I In M" m III ol ass ml Pq rO el om m m MM I' 9i AM r� co a' 00 m w im w Lr, �i Ln �zr w zi 31 Ln oIzr lo�:Or ",:Ir "U'l Imn OM 131 14, VMI 10"Or ""It, �L�o IUIP L�Itl 2�0 lun, MM 1040 IVD) 13 -LIP IUDI ",;*r it to I I I it I T I it It I it it I it It I it I I it T I M I it I I it I i-Ill Is 1-1 co In- 1 1; 1 1 to in A 1; 1 11 A 1; it A I I- Zr- I it I T rq A rl rK r4 ro 114 64 rl M LO kn N 0 r4 cn Ln ,v m w '�t mm W- U- LL LL U- L- w w me cc cc mc 0: cc cc cc at at cc at at 0: cc cc cc cc at 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 V3 0 0 0 0 CL CL CL CL CL CL CL In In In In VI V) un Ln Ln Ln cn Ul Ql 'n jn un V) un 0 0 LA Ln (A V) 06 03 06 01 06 06 *8 06 06 08 06 06 06 66 06 06 06 06 06 06 06 66 06 66 06 06 06 06 65 06 06 06 06 0Q.Y6 cc cc cc cc cc cc cc CC!cc cc Qc cc cc cc ON cc Do cc cc cc cc ON CC ON "*' 0 0 11114 CA 0 0 0 1-1 0 CA 0 CA 0 CA 0 rl 0 0 1-4 0 0 0 0 Z 0 0 0 CA 0 CA CA 00 cc 00 Cc, IrD- 18 00 Ul CA CA CA CD CA CD CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA 0 CA CA CA CA CA on CO CA V CA CO 0 0 '4 0 0 a 0 0 0 0 CA CA CA CD CA CA ul CA CA CA CA CA CA co PI rL uh A A C5 Ci A p A A 0; Ci 6 4 6 A 4 p6 6 6 H' 6 A 6 4 6 r�' 6 0 6 4 Cat z A A CS un %T m m H on Ln WT on a) K Ul I or rq 00 01 00 rM ul Cot000 rat cm, IMD Irl, OM cm, NO tloq un on on on M 01 on rM on on ml on on on cq on on on on om m m m On On m An m Tr on 0 wIr OH IHn 0m, I; Wlt 10, 9 am Irl.- 'ZIrl 'Lln- or ll;r ",Or lrl�, 4 Wlt 00 MO 0m, a, it I it "ID, 01 it M T M it I 1 51 it it it it it OH 1171, IHTI it it it it it, it -Z-t H lir �M- r4 H rq �H, Z� �H, N W- IN, Z,_4 rl-4 1,'0 ,'4 �N, H- -0- -- -- -- '6 rq rq V-4 Ln w 0 r, r1l 1 4 1 rz I H LL LL LL w w w w ON E cc cc cc cc cc Do cc cc cc 0C 4c cc OW ON cc cc cc cc cc cc ON cc cc ON cc cc cc cc cc cc cc ON cc ON K K LW W SP W 2D sp 'SP 2D V M M V w w LA LA m w 0 0 0 0 0 0 0 0 tn Ln 0 Ln Ln 0 0 0 c = c c c c c c c c c c c c C: c c c c c c c a 06 06 66 06 06 06 06 od 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 CD 0 0 0 0 0 0 0 CO w 0 to cc cc W cc cc cc cc cc cc cc cc cc cc cc cc cc cc cc W cc cc 0: CC cc CC CC CC CC CC CC CC CC CC C= CA CA CA CA CA CD CA 00 CA CA CD CD U) CA 0 CA CA CA CA CA CA CA CA CA CA CA 0 0 CA 0 CA CA CA cc CA CA CA CA CA CA CA rl 0 CA CA 0 CA Cc 0 CA a 0 0 CA CA CA CA CA CA CA CA CA CA CA CA CA 0 Cc CA 0 CA CA CA CA CD CA CA CA CA CA CA 0 CA CD CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CD cc C? C? c? C? CA CA CA co CA CA CA CA py CA CA CA CA CA CA CD CA CA CA CA CA CA CA CA CA CA CA CA c: cc CA CA UD r- CA P, CA ml rq CA CA A M' LA rI r_' 0' d uI cB cI 114- 6 A 6 ob 6 4 4 6 u� r4- A ,tr cr -q, CA t,,r m r� CA R4, r- H r- Fri m m o r-i o Ln r° op nr 4 4zF w v) rn CA m r- Ln m w m m m 0 m m m m m m m m m m m m m m m m m m m m m N m (10 m r-vt CA H w r, �* rl N w " CA w 00 Ln �* QD CA 00 on Ch wq �* * 0 vr 0) CA w 0) 04Clt 00 -:T Ln -m -�r th m tj* uj u) m (,q �i m �T ti Ln Ln kr -* u) Ln F4 in Rzr tr rn ,zr Ch m m a) 0) m 0 m m m m m CM Ch m m m m m m m m m m Ch CM 0 m m ry al Z5e Z5 H 0 0 ,T r, m N H CA, w r, cq H w m ko CA H 0 § m 0 H rl CA So CA A A is - jj Q ry hi W A -- W -, H CA r-i H "I CA "I rl 14 m Q rd rl 01 Ul CM rK VH 04 rl CCU or Ul CA rl H H V) o Ln Cn QD H rq r-4 LL :3 LL LL LL 2 LL 2 2 2 W- :R 2 TE UL 2 2 LL LL 2 LL M W :F LU 04 :2 a -0 -0 LU Z, 'Z,- z r, Z; w 0 w I I 1 0 1 1 L 0 w w as as w w w w w as cc cc cc cc cc Cz cc mc cc cc cc cc cc cc cc cc cc cc cc cc cc cc cc W cc cc of cc cc cc cc cc cc C= 2 - » as as as a� ar as ab u� w as as ar as as w w as as w as w w ar as as cc cc w 1= 9= w = cc of cc cc O O O cs 0 0 0 0 0 0 0 0 0 0 0 0 0 CD 0 0 CD 0 0 0 0 n � 6 6 � � m � � m m m m fq m m m m m aura m m m m m m rya sus m m m w rya �* rq " m m m m m m m m m m m m m air m ,-a apt m m aro t m m m m e�a m ry m m m m m m m m m m m m ern r- t, r� t a oY ry o w rr� sew apt �r rat tta o H un r, r^» an r-a m w are r, m r �rm cn r~s 'n cr, m ry 0 r� r-. 0 Tr w «-a m r, rl r - --, m M --,. " , '-,», -,. ar , ry r, r, 0 »� N r, �. H -I m r-i Ln as aj w w 0 as as 0 as ai w as as w ar as w w w w w as 0 as as ad w mar w w w . z z Z Z 2 -2t» a 0000000000000000000000000000000000 as as as as a� as ad as as as a� as as a as 0 as 0 w 0 w 0 as as as as as w as as as as a� at as as � as as ar as � a� as � a� � as oa as as as as a� a� as as csa as as a� as ar as a� a as a a a (a (U W ua a a a w a as a oa a a a as a 0 a s �q Y I1 6 6 I 1 B B 1 1 1 B ! B B 9 6 8 tl 1 ob 1 , a crh &A 6 rya ? iC,� 6 6 r^ a�a �A s "' �i kb h A A r� 4 r� p� cry CO �' �' �' o� 1RT ICT W p�;r %T K+r cn RT M {in V r,Ln KT tat r� qT r, pr+r+g1 pry y� ems, "I �a r s r. rra M f rya rra rba MIM M M M M M M rra M M M M M rra rya M m N m m w 1 - 0 0 w w T-t 0 V Ln w w " m KT m m rl* m m cJtm m m 0 m m m m m m m m V a 0 m m m ON m m ass +sF e m m m era m m 00 qr, n qn �µ"+hyr npg*n +m ry pn q P"° rya T-4 C�a N H H H N rq rya N � N r'a N N rrY '. T"� m @"� gym. t"� Y 6'°"{ r'�a Q'°� B^"� r"V� Q"� C'°� e"� °am'ns 5°A X� 1'4 T� @"I r� r� °x+rnu "ems �a r� r� a py,r u u. nr maw Y"4 e�y�n ""Mn M h 'inn �Wvn 4n ° eM 'Mwn r ' wu 'tlWn v �^»uw l� ,µe -, "emu "��araw V p*yY g,a "�^m 4ua 7"� CN r^a rya r- rW @°"t @°"I N rfir $la r`.. rq T� 4aa-0 r-I (✓ TH 4W 1 rl as u. LL U. U- Li- u_ Li- u- L6 U. w LL LL. U- Li- t.L LL LL �a as aJ a1 w as as a3 as as as aJ as ci ad a& w as w as w w as 0 w w ar as as as w as w au ar ad as as as �a as as as �r a� a� ar as as as ar as a.s as a� as � as as as qa nz as ar na as a� a� 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 CD 0 0 0 0 0 0 0 0 0 0 0 0 co Qj (u a) w w Cc cc cc cc cc cc w MC = w w cc cc cc w CA 0 0 0 0 0 0 0 0 0 0 0 0 CA 0 0 0 0 0 0 0 CA 0 0 0 0 CA 0 0 0 0 CA 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 a 0 a a 0 a 0 0 0 0 a 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 a 0 0 0 0 0 0 0 0 0 0 0 0 0 0 a 0 0 0 0 N 0 0 0 0 0 0 0 0 CA CA C) CA CA CA CA CA CA CA CA CA CA CA CD CA CA CA CA CA CA CA CA CA CA CA CA cc 6 ch 6 uh ob 6 Q ' cS ch 6 A cS ch 6 A I f ' I A A 6 6 6 6 6 A I cS cS A I S; 1; 1 -r �T 00 In , A 11 a :4 , UD A A A Q Q P, In P 23 13 8 120" In 00 Q cq I I A 12 2 In In on CA ;? WR ;I PQ A gj ij ij i; t J ii rq N M NJ In In bi In In An on A An mW mi on WK on on A Pq A An as AM on m m on m m on on 01 Om IPM" m m 10, W�, 10, Im, A lm* III-r, 4 4 r.- Rzr IMO 4 4 4 4 lwt 4 2 m Im, OM OM A m,4 'Wrl ulir M.* "Or 2 "In, OV44 IQ it it I I I it It It it It it it It It it it it it it it it It it it it It it T it it it it 00- 1; 1; A A in in V; A T A 14- "T To I S V; I A T 0; A- to I W L, LL OW W W- M M LL M LL LL LL L, LL :E 2 LL LL LL L, 2 LL M M LL M L6 U- 2 U- "D 10 IA C) M m w Oc cc cc cc cc cc cc cc cc cc cc cc cc Oc cc of W cc cc cc cc cc cc cc Ow cc cc cc Cr C7 0 C) C°J C) 8 C) C) C) C) C) C) C) C) co C) C) C) C) 0 C) C) 0 0 C) C) C) co � � cc cc cc cc Cc mc � � cc ccas ar a� a� a c c �p Y 1 X % B 1 pB� 1 B B f B 1 6 B Y B 1 B 0 1 1 1 1 f B 1 9 ye�1 1 6p.��y® p� c�i ¢�V p�Y at C, p' +y8 tV p6at ry at 6 ' 4 6 to P, itffi� � A LP5 on F, � r° wry A C71 yD p4 f0 M9 o3 Co on fvi 2 K A I C"J t'8 A �` �J9 Pp9 B°V I t'�9 9?'Y A 6,6N gi e�"�^{+. t 8""JJ R CV S 920 on Al on to on Pal I on AS on on Mn So on to on V tit to In M7 IS An om "'0 4"d 'n M W 'n M &�? P- 1771 O11 �` COM1 e"68 f' e� C C�8 sro J 4� a�0 4 Cis 0 14 N 0 Y68 M M M M at �1 at �!° 'CY v Cv ' M M a' M 4.8°'6 w Ln &d"e c 4 4 cn 1 35 0 „++ C7°t Y CTr CYt 7 874 Gfi5 L7'8 Cl8 f�9 9�`e ¢�5 K7's C7t �S C�"r 471 �1 �'9 �t`r �S C°'4 Y'9 C"� k"'� 9"'9 C°'� 4"0iQ Y^�B P"'� @ fl°�'R i""'� Y°"'t P^I P'"'� H H H H P^E @"""i T"B n 'W- �^# r1l "emu —4 n ^h a "fin yu awn ems awn I n S H "Lin ',-i "'fin 'N 'm w "mow. ""*wn "`'M "^q"w `u- � v-1 H "M^ "'^W. T'� " 4°� pp prp�r. @^� x°° y`ror�r "fin. "'qM Ln r-i 1-4 14 ui LZ � qa as ar as qa �s � as a� ua as �r as as as as �a �a � nz a� a� ers �r �r as cc w cc cc cc Oc 0: 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 a as w cu w w as w cr- w w w w CD 0 C3 0 0 0 r- 0 a 0 0 0 0 0 0 0 0 0 0 a a 0 a 0 a 0 0 0 0 0 0 0 0 0 0 0 r4 0 0 0 0 0 0 r-q 0 0 C3 0 0 0 0 0 0 0 0 0 0 0 a 0 0 0 0 0 0 0 0 0 r- 0 a 0 0 0 0 m 0 0 a 0 a a 0 0 0 0 0 0 CD 0 0 0 0 0 0 0 0 0 0 a 0 0 H 0 0 0 0 CD 0 m 0 0 0 a 0 0 0 0 0 0 0 0 0 0 C�) r� r�l 6 r In C� 6 6 6 6 4 m m 0 Ln rq lqr �° 0 r- r- N H 0 0 a M C4 Tr M M M W r14 r- M NT H m a N w m q-4 m a lqt m w m m m m m N N lqr lqr r 0 H 0 m r4 0 M M 0 a 0 0 H 0 w w m m C4 r- m r-4 w lzt 0 0 0 a 0 0 m 0 0 0 N 0 M 00 " M M � M M N M M M N M N W M M M W M a v M M M M M r%. M M M M rn co oo m m m m Ln m m m m �rn m im m m m N m m m r- m m m m m q-4 m m m m T-4 w r� flq 0 m w 1�- 0 w m r% m H Ln 0 H w m LM N r" w m I't Itt 1* 0 'IT 0 0 H w ItT Ln ,t I* m Ln ItT m to w m Ln m Iti Ln irn qq, Ln Itr m w %r 41' m Lo un u) qT m m let Zdr Z CN H m H H H e-1 T-4 H (N H H N N N H 00 m rq a) rl- -1 0 a m rq (N m H Ln r� C 9 N rn 0 r-1 H m (N rq Tlq rq H H H T-1 TH H V-1 T-1 LL LL LL LL U- LL U- LaL LL 2 LL W. LL. Lt. L,- U- U-as a U. 2 4) 0 as as as a) a) as as as (v as as as as a) d) as a) w as a) a) di as as 4) tu as 0) 4) Qj 4-1 4� = = = w = w cc cc ot cc of oc cc of cc cc cc CC ot cc cc cc cc cc cm co CA co CD CA co 0 0 0 0 0 CA 0 a 0 a a 0 0 CA CA CA CD CA CD CA CA CA CA CA CA CA CA CA CA 0 CA CA M C? a C.? CA A C? 9 a 0 C 0 CA 9 C C? a a 6 Ley aCA CA CA 6 r^a r" a a r,4 r-. m C rm a�1 trot m c m m It m m m 00 m m m r- m m m C\fi E"md &" tP1RT m CwJ P>2 1 r a"�p a�1 �° m m %In M CT"s Y m m C�'1 C�'3 i91 CB7 CS"1 i5 4 e�"5 C7"5 m Ch m 1 rl H r-4 t-4 H wd4 em4 rr4 rm4 4 H r4 e-4 c^4 4 H ri cv-0 ri e--8 N rl � '». C` t17 t C ri r-0 4r 8wd rl Ln cq H h� r^^W m H r-4 r-4 TH ri R.A. LL. 2 2 U. U. U. U. U. U. Lk. LY LL U. Lk. W. LL- LL. U- LL. as as + as as as a� as a� W cc cc cc cc cc oc cc cc ot cc cc cc cc of cc cc cc cc cc or_ Dental Proposal fora Monroe County Effectis Date:ve 011 /01/2015 Presented United healthierWant to have employees and save Mousands in annual medical costs'.) ornmitted to oral Ilneallth At United Concordia,we know how important oral health is to overall health,as we've specialized in dental insurance for over 40 years. Our landmark UCINeflness Oral(Health Study is a three- year look at the fink between serious health conditions and gum(periodontal)disease,Research revealed that patients vwho were pregnant or had certain chromic conditions saved thousands of dollars a year in medical costs when treated for guurmn disease, That means getting the right dental plan for your employees ccwanld make a big difference to your brot'tomn lime. Thoughtfully designed dental plans Our dermal plans are designed to ensure flexibility meets msairrngiafter affordability,while retMinirng the quality of coverage and MM orrWRI, pex odonO vfsks, ;service that customers have crorrue to expect from us. And our opt io nal wellrness features focus on getting PlE EXICAL COST SAVINGSWITH members engaged in their oral health---erntic:ing them to GUM v 1 EASE T T get the preventive care they need to avold complex dental problems,arid it nprove their health overall. Cernverniernt access to information Quality eleritist access where you need it e strive to rrnake:sure information is available*where and when Our ciustorrners need it: With extensive,ongoing recruitment efforts,we have built some of the largest dentist networkss in the country, I irmnplo ees can access details on their benefits, ensuring our members can easily fiend a nearby network fiord a network dentist,review claims and more, dentist,no utter where they live.INN hold our deunfists in their My Dental Benefits account„accessible on to the highest standards,rigorously screening their crur vwebsite our our united Concordia rrnrubile app. crederntiak and clairnns to veirif3/quality care its provided to a Employers can easily add,change or delete all of our members, enrollment—or vier or pay bills—all in the account enanegemernt portal chin our wvebsitew Making your ermnlployees healthier First standalone dental Our approach is simple—it's all about the member.The carrier to receive U � one vwwhro actually sits in the dental clh�air.Thnat's why we'veatccredit tion key deveilopred plans that crover whatrrnernbers really need, rnd lrn rrst�ry measure of why wPw'e'°re committed to getting theunn engaged in their coral network quality ACCREDI'FED health.And because rnairn'tairnir-ng oral health can keep your ermployees healthier in many lather ways,choosing United Concordia is a great way to benefit your orgarnizaticon's bottormn lime, n itiedCo n cord ia.com PRO 3041mG nm r�1 �ii l i !I!I!I!I!I!I!I!I!I!I!I!I!I!I!I!II !I!I!I!I!I!I!IIIIIIIIIIIIIIIIIIIIIIIIIIIII�IIIIIIIIIIIIIIIIIIIIIIIIIII II � Proposed Pl«/i�r, SULI (1 (�,aUy 'for MdJ,(roe Co y BOCC Effective01/01/2015 Concordia Flex is a passive PPO program that allows members to receive care trcrru any licensed dentist-, however, members receive the greatest value and convemernce when they receive care from a participating dentist. This means that members who receive care from a participating dentist are resprarnsl le only for those deductibles and coinsurance amounts that are part of the plragrarna design. F-PQarn7 In Netwau I d�alri I t arls Alliance 80th Percentile lass d ... .. 100 1 � ..... ....Lass Ill � 01% I. 9t�% la s Qll.. .. % 0% ".ro. .... .. . ........... ........... .. .... . .. ..... Class QV111 �I n�r� 50% Annual Program Maximum $5000 $5 00 Class II) L. J Annual F�rracrarra edmoctoh0� 5�1`�150(eXcluldes Mass Q)�...55 / 150(excl�udes dlbt�d+ao�tuc Maximum .., ,. d.. J 5t➢0 tteto�t r os ed erntal gates 12 rntn Rates .... rrn !e ee Only Y . .mm d nplaayee auatt ouJse 7 01 � Enripiloyee _..,,_... ildrero 47 Employee+ Familly ��.:. 11 .1 Bfd Qualifications: Rates and benefits for effective dates thereafter must be approved by Undervwwruturwg Rates assw.urrre 13,10 eligible employees,vaoth 1310 part cipaling Upon sale,quoted rates and benefits may be adjusted our coverage denied, based on achieved parlidpation levelns. Required partucipalion Must be met and rruainta raed throughout the policy pedod. Commissions inciuuded 041 Rates are based upon Standard Industry cnassificaltarn crude gtN United Conrocordia's standard exclusions and Uirniiations apply Class Iv Services are excI udeod from Annuoan Program DeduuctiNe and Annual Program Maximum High Option Dual option with current plan t. r 61nrilb urserment is based on our sclhuedWe car mmaxirmum all'ovvable charges(IMACs),Network,dentists a lree to accept our alloy alrnces as paymroent in fuullll for cawrered services Mess applicable deduucll',Iibl'es and o 6risuural ice perce niages . Unlit Unlited Concordia creates cnut>cr-rnetwork charges utulltairag FAIR Health data supplemented vvi0i our charge data as appropriate We then calculate the o ut-air-rwetvwork charge at the 80th Perceritille or such data, Nolru«rnetvwortr dentists may Mill tlhnis mruelnniber for rarny difference betvween our allowance anid 11helir fee. IIII I� t�IIIIIIIIIIIIII/ MI P r q� ,'J1 p s edl De� r'j°t a l JI1,In On ,'I�JI'O C O lLIH.,ir l y BO C C Effective [late; 01/01/2015 �C diu . itu rorro...... ... .. 1 sat j ary 12 u"antU°rs and rr. . � � auv'.."-1 s t ev .o,..1_B rrorrth �a. 1�9, ,....a r ever 13 months �..�........ an �yr t,_ ..w_ ..„_... w� . ... __.... ....... every 5 years ter uH Mouth and Panoramic X-Rays �.�.IFta � CCU Others) ........�............ ... Y .... ��.� „U ..t t"' rruwa a ny dp� rtU ,ytu p..uwH w_p s Ur�r" ratC� very .e cry 12 rnrarrdis rumder agr 14 . aapaurtss p"Il�uorC�da'1�u�saihrrnant , .. every 1 irun�m�7�s � �r. .....°° °.....��, .._°....M... °w• _ .�.. .��gar..°..me.uwr�au�io�t�urt ar�c�seuA�rudP�r�ttrorrnUars . i"aU atrva Treatment(Emergency)... n U°rs rrr combination°.....t�as� °.................... ............. ... ptUn p�UpaU derUdaunnarnt �11,� �� log'IIII oil 3as3 IF st atU.ars _. .. .. ...°.. Ir ant of i r 4 rm�1 rpftUv��rOf garO001luus iacermarnt...hICI rudas coverage for. ... ,....°..rl ace Maintainers p p � ve...�w ...... ........°............................................ rcu��r�rtuu°,tu . ° .............°......... ..,.. s Any frrr uar�ucy(no turarrtaattonsV . r�� Bra I��tr�awtU�rara. �.....�........._ �.. .....�.......... .... .°... ....... ....m..... ..... .. ......, w ...... .......w ...... .... d apalr>of rr:awrns,, Uii OnWys, Dentures anid 1 per.36 months rid es .._..................°_ ndadantUs Pulpa�therapy, pirini-iiary teeth rdr � rrrtn mrlptthat have no permanent tooth to r pUaar e it Nrarn , ruu° u Y�p°arU�a�d rrt�ums caiing an md root pUa ing: 1 per�3 months, (per area of rnrauatta) Perk)dontM ma�ntanarriceW 3 every 12 months (in adidifiarr to routpma �. 'uarugrmaIR..... . ...._.... �...�._ rta i Ua rs�pdmantall p°rocedu ,s. 1 pier, months(per �) ....... .!qy UUruv�ga� ggt ve errurydrnrntW th ra w°au°rradrantus r.air ur;ad rurr (per area gut n°a�a�rtlCn Guid u rn a•Uva� r day . ...procedure ��. ....... ..�m may vary sy ri m it arm y�r too r r a in �narap apt ,spa �Umged to d rnuun�utas per sessiinin nd Crowns Not within 5 years of prev�ous placement ostUne Jcs 'h ag s, Dentures)s�..v ... _....oNot within,.. . years of previiii pWcement qiagnostic, Actrnrar Retenfion Treatment for peru �rrt�1.�. ..... ...... . ._..age 19 ...........,�. .. ...... ..... .... Deppendent chHdri covered to age 26,raa to state and' to airat u�aruda it,A ap,plytrnrt t_ra a-ttwe_r statasa dsrparr�tarrR at a��r�udrty rruay dr�`a�r fro"r net grrated MEMEMMEM This summary is a representative Usting of covered services and'fimitstions tka OtP Ilru u r sss7 Ji I ?�+ l fl i dl, r�l rl n,/I,,,�J,li i i I I'r r„� `�� for i r M t Ji i iJ o�,i %�,,,/if��Jd ill �� ;;1��,,.��,6�„///r ir� �J a�„ f �, L,/.i U� ! r /� ,oG. r, „� m, , a� Effective 011/01/2015 oncordila F'refeirred is an active PPO pnrogr rrt that cornblnes ffie cost s virt lup available in a rinanaged d rnpap care program 'lpini greater�access availabile in tr dldoonal h'rolrdeu in ity programs. It Wso allows nrnemb rs tiro receive care from any licensed dentist and increases the plain coverage w1h n rrn rnb rs recelve care fr rn parficip,afing d npisps. ..... ................................... ....�.�.�.�.�.�.�.�.�.�.�.�.�.�.�. P-Plla n ''(OON Ded applies Its 1,20) 1.11 ............................. in-Networkry Non-Network 2 .._,,,,,, ,,,...... AlHaince Advantage p A ............................................................................................................................................ .................................9 0",,... Class .......................................................................................................... '' rm Class. ...�. p I................................................................................................................................................... I , �� II '��.,..,..,..,..,..,..,..,..,..,..,..,..,..,..,..,..,..,..,.,�......� .. .. ............................................. L�__Class 11l ......I � p s's II 50 � ... .......... .. ... Annual Program .... ....................... ............. .............. Annual ro'cir rn Deductible p ` � � x,pnwl.............. Class Y..�N1. 0��/�.��..$..�.%1.................................. , . , .......................................... ,..,..,...,..,....,.....,.....,.....,.....,.....,.....,.....,..... ,..,..,..,..,..n.,,.�.�.�.�.�...� .,I.Aefirne Orthodontic Mirrurn 1 00, 15 00 ............................ .................................. ., .,. d r �o dl ;rental-Rates 1 Month nth Id tes __________ I rrnpnloye Only Employee and Spouse $5162 Employee+ Child $57M Employee+ Children $57M Bid P rrifific rdrarrs: Rates and benefits for effective dates thereafter,rmuast be approved by u.UndenNn rmug Rates assume 1310 Ogible employees,with 1310 p�aiirtrcili Upuimra ssde,quoted rates and bu:rrocruts may the s�djuusted or coverage denied, based on ac6hievaed participation leveiis, Requiked participation must be met and mnaiantasr,dd throughout the poky p�edod Comrnissions Iii 0% Rates aura based upon Standard industry Classification Code 919 w United Corncardts`s standard exctuas'dc�ns and tiirmttallons apply w Class N Services are excluded trorra Annual Program Deductible and Ann u t IPro rsnn I10sxiimruurm Current plan,as Low Olatrom. f Refirnblurserneint is t asfxi an our sidiedute of m'IaxrrnD,JrY1 aHowab'e charges(MAC s),Network dentists agree to accept our raltovi,iance s as p a'ym'ent in Mutt for covered services„less apap liczalblVe deduaatllal'es and cctnsuarsrocm p�mrcemtmges. Rruomb ursermemt us based on our schedulle of maximum allaw&e charges QAA sy.Non-network,dentists rru y Will the meri any difference belviree n our attrruwauruce and therr fees Qusute nl) I115:51 7 ^ vii � � '1i VV uillllllllllllllll Vup Pr(iYt,))�),cs d Dfwf Berniefil's fur COlLIHIfAf[;Y IB0C)l�� Effective Date: 01101/2015 1UQB I mW aV 1� Exams 2 every 12 omraruths .. 1 every s...__..�._.. c etev ry 18 months age 19.. .._ set ...12 Iruruarutlua.m uauncf�,r age �.�srqud � ._.�.. .....,,.�.,,,,, �..... ...... X--Rays(AH Offs rors) 1 every 5 years for Full uGII°u and Panoramic m is X-Rays Ii..7ut��taf�ry wfuv� .p�u��U�_tia� fah o"t @�Pµf�f,&nR&A-.., PUus 1 every 12 months under age UeunUrrfps; E°U�sri Treatment ... 2 every....._1�2 m u .�.. ........ d 14m... ........... .. esU rats 1 per tooth every 3 year's to sage 16 on permanent first and second rrno*s a UUU tUwre Frestment)Ernergency) A per 12 Months in cu,currrtaUlruration vAtfr purtpsP debbderrment 1 r voy years ps�,e�t�Uantsiruers... � der.age 14-- ......... .. ....... .......m . awa...... ......., .. Basic Restor has of U w_..._ .. ...w previous as pBacerment imp Extra p ptati au;)� tlep�'Ur's oaf'Caruawarus� dmrU�� mo�� y�� ' ea��t�res errod 1 per �ro rrucaruttros rd _.. Eundaaa`tuanks Pu.u9p811 therapy primary teeth that have no,permanent t�ru*th to(replace ut ...... carat rpur _Grp. tour rrk. pno r t,car.2-12e ,itrafirne p"°UH mouth debrAernerrt, t per Wetiirmue Non-Surgical Eerioduarutics caiing and root planing : 1 per 3�6 months(per area of rriouaf i)i µ PeriodontsU maintenance: ew.:Ky 12 months(in addition to reuatirne arur ¢a B Eu rUrr�daao� prpphyq ts_ IP aru � °mtu oUr rant U ttzeo. lg Rtrs m. _ _ rrorauatUu) Sur _. � t c L YIt al periodon�cn ucr diure& I per 36 miCfnthss(per area of ..... . ......... rurr, Undo d r P au... procedure May very��Y Par eumleu°eU rtestUmesue „ V�UumUted to 0 r 4iu.utes..., ^per,sessUarra um i11 uin 5 ears f r. placer"ruent trrUs, C�raUs eunid Cr t' ""Y rUs .,.,,. ..�C7�t'Wa+gt. �f prev .........,.�. ........... ... .,.,,,,, ............... r prrastB°r tQuas)C ridges„ Deruturres) scat wit in,5 years of previous piacernerutSm G U rm�ast.P u,t'Yve, Retention Treatment for dependents to age 1 ... ..... ..... ... .... .... ....— ..... .................................. ................ t7taperudernt U7ildren covered to age 26. rr tca to Re rr f feu r aY rwre ndates app(ymg to f er states, ae rr derf edrgr'arty may differ frorr that quoted,. a This summary is a representative risting of covered services and firni'tations reuse 10 115507 ADDITIONAL INFORMATION: * United one ordi 's dental plan is the only p Wi offered for acceptance or coin side ration, The quoted information is invalid if any other dental arri r is offered for coverage. * In addition to the quoted overall participation require,rnnernt, a minimum of 2 enrolled contracts is required for every Dl""lMO program offered and a rmniNmurn of 10 enrolled contracts is required for every F S pro r rrn offered, a All proposed rates, guarantees and caps assurne no charnm us to the proposed benefit design. United fitted o nc ordi reserves the right to re-evaluate proposed rates and bmsrneffii$ if any state or federally mandated benefits or fees ;Brie unposed. * United d oncordi Dental is not able to accept business submitted by or pay commissions ttmm producers who are not appointed.d.Any binder check or other pr rmmiurrn payment collected from a group by rno n- ppaornted producers, and is then submitted for acceptance to United Cc ncordW Dental directly or through Urated Concordia Dental s lles personnel, will be rejected nd returned to the non-appointed producer, Your quotation of rates to groups or submission of business to United Concor6a Dental will constitute acceptance of and agreement,to coinnply wittlh these rules regarding papoiunttrmm ntt and co nnrnission playmnn nts. United Concordia Dental may posy the selling broker"or benefit consultant ("producer )compensation nsu ttion for the promotion arid sale of the products and services offered in this proposal.1. In addition to our standard compensation arrangements, we onl y make ddition l cash pn yii or reairnburs me ntts to selling producers in recognition of their marketing arnd disttdbuttio n activities, persistency levels and volumes of business. We encourage producers and their clients to discuss what a orrnmi,ssio ns or other compensation may be paid ion connection with the purchase of products and se Mces from United Concordia Companies, inc, llff you have(,Juesttions regarding compensation programs related to your insurance plan, you may view the information on producer compensation that is available bll on our websrte at www,u.uinitted o ncord i acom, * From time to ttirne United Concordia DentW offers premium r ttes discounts to groups that purchase ddittio nal IH n s of insurance coverage from other insurance o mnp ni s that are affiliated with United Concordia Dental. You may b eligible for one or more of these multiple policy discounts, lnffori n ttio n regarding your eligibility for these discount programs is available from United d oncordb De ntt l s U s representatives, The multiple policy discount programs offered by United d Concordia lD ntt l may change our terminate at any time without primer notice, Quote nl):115507 The Proposer will be evaluated on compliance with the below service requirements. submitting a pro os 1, the Proposer agrees that these provisions ill be part of the agreement between the parties® Deliverables: If necessary, the ProposerII provide a policy Amendment, Endorsement, r Rider to the Countyt non-standard lip provisions r to by the Proposer. .............................w�..wwwwwww��www.ww.....................�...w.��wwww..v...mw.w.�.....�wwwmwmmm.....m��www��.w��wwwwwwww�..w...,.................................�...................... Yes No Yes, Can Comply but with Service Requirement Can Cannot SpecifiedDeviations Comply Comply lease detail deviations o ...................................................................................................................................................................................................... .................dwww.adwwwwwwwa.....wdmw.w w. This rep nt shall be governed by and construed in accordance with the laws of the State of Florida applicable to Agreements ode and to be performed nir l .in the tat . . ... .......... . �a.v.................w ��w��w�....wwww��wwwwwwwwwwwwwwwwww.......................................................................................................... The Proposer shall maintain compliance with all federal, state, and local laws, ordinances, rules, professional license requirements and regulations that in any inner affect the work. ...................................................................................................... ......................dw.w...dw.mwmwwwwwwwwd.m............wd ...............w.....www............................................................... rovide firm rates for the effective ate of the policy based on the information provided in the RF . Variations in actual enrollment shalt have no effect on the rate proposal. The proposal shall be valid regardless of the final enrollment mix, number of Proposers, number of plan psi .............................dm......w dmwww ...or. t r t .:...w..www. wwww...w....w........................................................................................................... Waive the deductible for the rid from plan implementation through 1 Exhibit A - Scope of Services 2015 .:... .. .. .. .... ... .....M. des.........M. .. o.... ... .. s,..._are Comply. ....... but wit Service Requirement Can Cannot Specified Deviations Comply Comply (please detail deviations belcr , December 31, 2015. 11 charges for any service or optional service rest be clearly outlined in the ricirn ttac menI,. Disclose any commissions amdtor service fees (if any are included) in your rate quotation, including the amount of the comm ssions and/or service fees, to whom m they may be paid and your reason(s) for lncluding there. Disclosure must be on an annual basis. Provide a toll free nu..mber and sufficient staffing to handle inquiries directly frou staff anwl � bars. °he successful Proposer must provide an Account Manager responsible for the overall relationship! The successful Proposer must participate in open enrollment meetings on an anal basis, Provide estimated renewal rates 10 days in advance of renewal, Produce all appropriate materials, including not limited to; enrollment materials, plan booklets schedules of benefits, Summary of benefits, rovider lists, etc. and approve all open enrollment communication s p release rnt�nal.. .prior rely I Exhibit A - Scope of Services 2 0 11 �;'�r 'Yes o .,.. Yes, Can Comply but with Service Requirement Can Cannot Specified Deviations Comply Comply (please detail deviations be taw to employees. ...............� �.. ... � ,.. � ....... ......... .......... Provide standard reports to the County on a monthly basis and provide ad hoc reports„ upon request, ovide performance guarantees with financial penalties for non- performance. Performance guarantees should inclu e. • Maintaining Network Access • Claim turnaround time • Claim payment cr rrac . No party to this Agreement shall be required to eater into any arbitration proceedings related to the Ar�reernent. Comply with th 16'rid" a Local Government Prompt Payment Act, Section 218.70, Florida Statutes, The Provider shall submit to the County an invoice with supporting documentation in a form acceptable to the Clerk. Following receipt of the invoice, the County will have 45 days top y the invoice without interruption of service. ,.,w ... „', ----- ------ . Exhibit A - Scope of Services ......w.....................................................----................................................................................................................................................................... Yes, Can Comply ........ ............( ........................... Yes No but Service Requirement Can Cannot Specified Deviations ComplyComply (please detail deviations ............. . . . .................................. .. ..... '................................................. Thy roposer may terminate this Agreement with ninety (9 ) days' notice to the COUNTY. The COUNTY may terminate this Agreement with or without cause upon thirty (30) days' notice to the Proposer. COUNTY shall pay Proposer for work performed through the date of termination. F'ursuant ..t ... lr.d. .... ttut ................................................................................................ 119. ` 01, Proposer and its subcontractors shall comply with all Ipublic records laws of the State of Florida, specifically to: (a) Keep and maintain public records that ordinarily and necessarily world be required by Monroe County in the performance of this Agreement. (b) Provide the public with access to public records on the same terms and conditions that Monroe County would provide the records and at a cost that does not exceed the cost provided in Florida Statutes„ Chapter 119 or as otherwise provided by lave. (cEnsure that public records that are exempt or confidential and exempt from public records disclosure requirements are not disclosed except as authorized by lawn. (d)Meet all requirements for retaining public records and transfer„ at no cost, to Monroe County all public records in possession of the Proposer capon termination of this Agreement and destroy any duln lr.................frgbt.1c r por sn.that....are............................................... . ExhibitServices la Yes No........................... m ..... Y.esg.�Can Comply but with Service Requirement Can Cannot SpecifiedDeviations Comply Comply (please detail deviations exempt r r on�identis,.,. .. .... . .........._ eNo �.m land ................................... ....� w.w.� _, .........�.�. � exempt from public records d disclosure requirements. All records stored electronically rest be provided to Monroe County in a format that is compatible with the information technology systems of Monroe fount The Proposer does hereby l consent and agree to indemnify and hold harmless the COUNTY, its Mayor, the Board of County Commissioners, appointed Boards and Commissions, Officers„ and the Employees, and any other agents, individually and co lectiveiy, from all fines, suits„ claims, demands, actions, costs, obligations, attorney's fi fees, or liability of any kind arising out of the sole negligent actions of the Proposer or substantial and unnecessary delay caused by the willful nonperformance of the Proposer and shall be solely responsible and answerable for any and all accidents or injuries to persons or property arising out of its performance of this contract. The amount and type of insurance coverage requirements set forth hereunder shall in no way be construed as limiting the scope of indemnity set forth in this paragraph. Further the Proposer agrees to defend and ay all legal costs attendant to acts attributable to the sale ne li nt act of the Pro user Exhibit tad Questionnaire �� 015 �,� ,„.,�u, .nm,,., Organization Name: Primary t c res t tive: Title: Address: City, State, Zip Telephone Number: Number:Fax E-mailAddress: 1. Is your organization currently in compliance with Florida Department of Insurance Statutes and requirements? Yes -. ry No If no, describe why not. 2. Provide the location of the office that will manage the County account and provide the names of the individuals who will be responsible for all aspects of the ounty's account service, 3. Do you administer your own dental claims? If not, provide the name of your claims administrator and define your relationship. 4 hat are your standards for claim payment turnaround and accuracy? What are your results for claim turnaround and accuracy? 5. What percentage of claims is denied on an annual basis? What are the top 5 reasons for claimdenials? 5, Do you own or lease any portion of your networks? If you lease any portion of your networks, provide the name of the network owner and dune your relationship. 7. Regarding reimbursement levels for PPO providers: What is your average discount off P & C1 Usual and Customaryfees (please estimate if non-discount reimbursement methods are used)? 8. Are you willing to aggressively contract with dentists currently used by County employees, both during implementation and on an ongoing basis? Yes o 9. Regarding • What database do you use for R&C profiles? How often is it updated? • What percentile is typically used fordental? What are the options? 1 y....... „„w,.................... Can your system allow certain tolerance ranges to be applied to FC C limits? Describe. 10e ill the County be notified of any changes tote provider reimbursement profile prig to implementation of such changes? 11. hat protections do you provide to members against balance billing by providers? Under what circumstances is balance billing permitted? 12.Are members ever required to pay for services in advance? Under what circumstances? 13. re claims forms ever required of patients? Yes o If yes, in what instances? 14.Provide samples of the standard utilization/management reports that will be provided to the County, How frequently will the reports be distributed? 15.How are renewal rates and fees determined? Please provide sample methodology including experience credibility factors for renewal purposes (e.g., number of years' experience, number of insured lives, etc.). 15.1n the chart balm, provide information regarding Maximum Allowable Charges/contracted rates and R&C for County, (Using only zip a 33 ) .w.......ww. �.�.. ........ ....... C?escri piion PPS MAC ................ . . .ercentil.e Code fims . . ........................ ..... 'irwh wl................................................d.w.. ......w............................................. 274 R io raphs...-4 films D1110 Adult Ire ...... laxis .................................................. w1�...��._.�......... iId Pro lads......_ [ 2140 Arnal am .-.1 Surface ... CD2150 �rnal am �- Surface 215 _A,,m a1qam - 3Srfce A �.392 Composite r a Resin 2 Surfaces Posterior 12750 Crown - porcelain fused to high _.. noble a ..l.........._.._ _.......................... ,--- 27 1 Porcelain fused to Predominately Base Metal 2752 .... orc l in fused t ._...ole..... eta/ � . .... . .w, ._. ,._.__.._. ..._......�...._._............................. ........................................................... D2782 Crown % cast Noble Metal 27 o n Full Cast Noble Metal _....--a-vn .._ . ...... .. _____ old _µ. Molar _'_ .. w.. .www _ wwwwwww wwww wwwwwwww w mmW ww W W W W 4250 ssous Surgery 4 or more teeth J_pe,r,,gua d,rant 341Periodontal Scah R oot 2 Exhibiti i ....._..... ............ ........ ..._...................._w 40 Fixed Bridge/Porcelain Crown � used t wi h Iw eta..l. Fixed ridge/Porcelain errui reci s Crown .7 tractio , crnplete Bony 0 ho ontic: Global ate four Normal Adolescent Case 17,Complete the following chart for your network in Monroe County Number of Number of NumberNumber of Number of General nd dontists Periodontists, Orthodontistsedc ntis ntDentists Monroe 18.Provide a current PPO listing in a usable Excel format (NOT P F) of your network providers including the following information in the order presented. -Ti Last Fi___r idle,. Strd t........ _..hits _WI .... �et...._drk e ork. i pe (Number Berne Nerr►e i�iti�l Address Lode [description (PPO) (Leased) trRr eta 19.How many of your Monroe County providers practice at multiple locations throughout Monroe County? .Please list those providers practicing at multiple locations and the number of locations where they practice. 1.How many of your Monroe County providers practice at only one location in Monroe County? . ornplete the following GeoAccess summary for Monroe County employees. The census is included in Attachment C. Your report should include a summary for each of the items listed below. Each report should indicate the total number an percentage of employees with access by City. lnclude GeoAccess Reports. a) Number and percentage of employees with two General Dentists within 5 miles and 10 miles of the employee's zip cede. ) Number and percentage of employees without the desired access to General Dentists by City. c) Number and percentage of employees with two Specialists within 5 miles and1 Iles of the employee's zip code. The number and percentage of employees without the desired access t Specialists by City. U Exhibit B - Dental Questionnaire II 15 ...,,,,,,,,,,,,,,,,,,,, Number of General Denti ty-% general satiate -'% p i li -% p ci li -00 liib'l l 2 General EEs nil 2 General EEs wl 2 EEs wJ'2 �Employees Dentists Dentists SpecialistsSpecialists Dental within 5 miles within 10 miles within 5 miles within 10 miles Network PPO 23,Complete the following hibit for the following cities in Monroe County nosing your PPO network, Please include the information requested for Miami-Dade on consolidated basis. Number r of Nurnber,of Number of Number of Number of Lo;in ion general nd d nti t P ri d rnti t Orthodontists p rsd nti Dentists dig ley llrrnord Key Largo Ivey West Marathon rrnrrind Tavernier Mi rrni-Dade 24,Provide the turnover information for your network dentists as outlined below: Monroe County (Only) 2013 2014 Total Number of General (Dentist Total Number r of Terminated General Dentists on olunt bs`s Total Number of Terminated General (Dentists on n lrrooNnt bi Total Number of Specialty Dentists Total Number of Terminated Specialty Dentists on 1� Iunt basis Total Number r of Terminated Specialty Dentists on n Involuntary basis Miami-Dade Cunty 2013 2014 Total n:rnbr f inrl Dentist Exhibit st" i ", 01 5 ,,,'] Total Number of Terminated General Dentists on �foN�nta basis Total Number of Terminated General Dentists on an lnvolunta basis Total be of Specialty Dentists i"otal umber of Terminated Specialty Dentists on "�'olunta basis Total Number of Terminated Specialty Dentists on an Ir��rolrrnta basis 25. What are the top three (3) reasons that providers leave your ITC} network on a voluntary basis? Do the reasons differ betweenMiami-Dade County and Monroe County? 2 .Do you have a we site that provides provider information and directory information? "des No , If yes, describe your we site capabilities and your e site address. 27.Are members informed prior to their provider leaving the network? If not, how quickly after the provider leaves? 23,Describe the specific measures used by your organization to monitor provider access, Provide the most recent corresponding statistics available. (Examples: provider to member ratios; average wait time required for an appointment, etc.). .Explain your credenti ling process for participating dentists, Co you require periodic recredentialing of your participating dentists? Yes o If yes, how often are providers recredentialed? 30.Co you conduct on-site audits of providers in your network? Yes — No—. If yes, describe, and indicate the frequency? 31.Is member satisfaction information linked to prodder compensation? Yes No If yes, ow? 2.How will you implement corrective actions for identified service problems with providers? 33.Will prodders who fail to perform at an acceptable level be removed from the network? 34.Please describe any network challenges you encounter in Monroe County in contrast with Miami-Dade County. .Indicate how you track verbal and written complaints received by your organization. Are you able to report the number and types of complaints (both written and telephonic) received in a calendar year for all plan members (total population) and County members specifically? "yes o 36.Identify the grievance/dispute resolution system that would be implemented to respond to network disputes for both plan participants and prodders of care (i.e., participant disputes, referral or lack of referral, etc,), 5 Exhibit B - Dental Questionnaire 37.There should be no (pre-existing conditions in your plan. please list any limitations that are specific tote plans you are offering. 36. all you administer the proposed plain designs exactly as described? If not, what changes are suggested or required? .Fier acre treatment plans initiated prior to the effective date handled under the PPO network? Be specific with regards to orthodontia. 46.List the specific functions of the member services department (for example, assists members in choosing provider, answers members' questions about claims, receives and responds to members' complaints about providers, etc.), 41, ill you have personnel available to assist in enrollment or informational meetings? 42.Please provide an implementation plan outlining the minimum amount of time you need toe actively and accurately implement the dental program from notification to effective date. Please assume a notification date of May 21, 2015. 43. ill enrollment materials be (provided to educate employees on the benefit and how to use the plan? What is the target delivery time after notification of award"? 44. hat is your target delivery time for the policy and the certificates of coverage detailing the terms and conditions of receiving benefits and documentation of the complaint and appeals process? 5.ire ID cards provided? Report the schedule/time frame for ID card distribution. Include an explanation of how providers are instructed to handle members who have not yet been issued member ICE cards. . hat is your standard process for loading initial enrollment? How long do you need to ensure that your system is set up and that all eligibility is entered accurately? .Can the County Benefits Staff enter eligibility information directly into your eligibility system? Is the entry in real time? If not, hoer long does it take for eligibility information to be updated? 46. ill you accept self-reporting and payment in lieu of list bills? What eligibility audit process would you require internally (i.e, quarterly audits, semiannual)? 49. Please provide your proposed rates in the table format below. All costs for the services requested are to be included in the proposed rates. Your pricing should assume Out of Network reimbursement for the Long Option PPO at your PPCI participating allowance and for the High Option PPO at the 6t" percentile of R&C. The incremental costs should e shown as a (Percent to be added to the rates by fusing a multiplication factor i.e. 1.2% (Rate 1 . 12). L.. . '_m. ..._ _ ...... mm.......w ..... . r . ow on PPO Assumed payday Per month Enrollment (26 pay periods) s Exhibit 1 k),0 bra Employee only Frnployee Spouse ploy 11 ee ild(ren) FuI1 a „rt ti. ....--- . ily Increr e ntal Cost f.... m ..._.�.......... �,r. �... ........ or Composite Fillings ncrrnental C0000..o.........�_�,�.� v.�..��ost for Adult Orthodontics ombined Incremental Cost ... ..... ....... .��J ........... �. Ftic�t� t tion Assured Per payday Per month Passive Enrollment (26 pay periods) . .�. .._. ,... ... �� ,,,, ��,�....... ........... I�rr� Ioyee Ouse d;.. p p �m .............. , r to ee & h r �.. �„ p Y .C��.ild Wen) Full . .4j. 1i.. .�............................. .. Family _.......... ....... _. m . w Incremental Cost for oo�o....�.....�. horn osite Fillingsw.w��................. .. ,,, � ..� ,�rv.,�� .. ....... ...��. ,� � ��. Incremental Cost for Adult Orthodontics ornbine Incremental Cost 50.The County would like to obtain a more finely differentiated rate structure. Are you able to support additional rate tiers (for example, Employee, Employee + Spouse, Employee + 1 Child, Employee + 2 to 5 Children` Employee + Spouse + 1 Child, Employee Spouse Children)? Please provide sample rate structures your system can support for the County. 51, re you willingand able to implement a plan mid-year and waive the deductible until January 1, 201 ? if you are able to do this, please indicate if there is any incremental cost added to the rates. 52. re you willing to provide rate guarantees from the implementation date until December 31, 201 hat other rate guarantees are you able toprovide? 5 ,Will at least a 10 day notice be provided on any renewal rate increase or other modification of the policy2 How will this be reflected in the governing policy? 7 Dental1 t1 ,,,,,,,,,,,,,,,,,,,,,,,,,,,,.,,,,,,,,,. ,,,,,,,,,,,,,,,,,,,,,,,,,.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,»,,,n,,.,,,,,,,,u,,,,,,,,,,,,,,,,,,,,,,,»,N,n, � .......................................,,,,,,,,y„nn»»»»»»„ 54. 'lease outline each charge that has been added into your rates over and above the standard rates (for each quoted plan) on a PEPM basis with a description of the expense, 55.Lie you routinely offer implementation credits to employers to offset their costs to change insurance carriers? If so, what amount will you provide to assist with this implementation? n 56.Please advise of any special features available within year policy that may differentiate your offer, The Representative stated below is the authorized agent of the Proposer and is authorized to bind the Proposer upon acceptance by the County, Deviations from the requested program have been stated. Coverage(s) or services will be issued as proposed. Authorized Representative Print Name Firm Telephone gate Authorized representative Signature w +xa wPi to 14 ��. 0�� -W"4 uar w....4-MMwg� AiL. 82 W � 4ry w 52 a Wes, m ws �w A�, m� m 4� �� rus ` � wks�.s ",-•ram waa, eav www w v wwun w w w §�w to-,o� .o owxInzM ITMIMM,yl m 'y1 R P 0]a m�immmm mrnpZ gn pp o r ICY�A �. '7! _ Icy I �+ny. +" �7a1 A IG7 ct �'"ut-f w en��iy"4 Q D�<> nITt Rfi FIi C3 a M..{151I -<1^ �i 2 M �1 ""1 W �^ � tl CI�—' p �: 3C)bVS Cti. z� �svY, �z � dxcY ooa� � rn r aav - �o nc� ��m e zl ' ° x�m m w x•ua r�r o -� �, `� m m m�-<Ml g c v i�Cis r�i ffi ira�e 'c ml n m z Ka s t�ca Imo + w m-�o ern "o �� x � xry co� �m � x� m�ry}��w � cn,n' ;'� 'n z 6 r, C-0;L 2 y' p q. C}'wn TS M1'f 50 7y iXi 67 '"< rcn�,. F n�'ll?'y,S'2 C7 m 01 m �iY 7 .q I0 Ci �I asr 1 p 40 Ors Ono, ' m a. �t K7 cY m rn IiM C�n7 fp- Irrs en �' m m',m C��y o 7s x! O IC P�yY1mT gym, _. � 911�OplN '� z v�� mC��YCfcS gm y�miiiurS CzammmiIJ�tlAi �CA 0�Cv rn lv C1 o-�15'.,Y"7m H71i XC�7x S nXrm7->-II -i - 0_ 77� '� m ca<CmCrV�rJaustr0 � CidS0 k �t„ry p.�.qqi IY1 r O M P R7 tl ICM �7,-i�r-trr wm"'Y rn rtn �21 r Ib C7 iCll Ci rf'1 m l�C7 C!yy "2"'ti'CY "+-"b f? V� 31i 0 i� ;cn Icy I ro rya 'v �'�` fCfr y is,o M 5 6 i j �i�p C? rn'M III�ffi ^T�' ry ryr I �y�, a m M I� i0 'L7"+II u�q m � 6 Q IBC', C..X (Y�^�c.' 100 p C? C7 r cn �t�Q 0�� 'C7 O Ks� �. pl ! N" S vY �°I,Ip'y 0�' rc�f �;13 it il"nll i Ci M C7 Ste.Ca > �I 00 A I I 1 w mw�N yW or �� I awns awanwW a�a mo w� wm�-. vv , � owlrwo www w�=awl � Ib ''mo w W w 'QI Ir O �i rC W w0 ! CM4) w W !a tea:.. -� cn un O O 6 0°IImp Z i`"" mb ,l cn�w ..alb:.vni �m mm mZm� p''�uYl a2 �. "= �tn�'x�✓slm"llI"O I > � Idn� � -� �z mom 1�wIAm � u,�,.n om �amm v mmz ' 4no " I IzAr ; c� ' v'°' scY �_ rn rnua�Y�r�lrua w z ,iz mw w'c'nm m iml e"im en p �y IG7 G'�G) C'S to RIM M m W mlwfrr � x III � ur z 'a n B"CI G"J A. "'C7"`, -i"". r -1 I`a i � x xs x a " c x �' �m I � X w _ m m � ;' {� N pp � m m �I + w, I� � w I I mri ir-a.' �m-m -axlix .mmlxrrax _ I ,a�a , ��m�ca��sxx�xa��xx�gxsl mm mrn r; z � �I� � " � ° °« i �� m-mm-In mm- mo °' �, I ,� m�� w„I �m zia"�� ', cm r of to vnI� m �� + m 0 CY C -+ I-i a t � IMP, -a ? '! 'w;K x Im-i w� C)I��° �i Cr ',�' c� jam; �c aIa LO V v �I o m e�rY 2m, W l ' Icy I ra,9a rn n m 9r i�m i rn m rL+� rn f n n�i n m Cr-g.br!�y ww rrA wIC..A�Ot!rwAry Nrw6n rwpp1Y1 awpyiC-�S rvp,CI r?ewr�Ot.t.y{a�rG-t I�rA i�w4N u..n,rw rW luI wtp-aI,!Wor4 rWLVn n�W�+n rWwI�rw'rw r{O„�r"'p.w-W'W r r-Trr WWwW www wWwwW x-�rwn�rWn mrw�rrW wr wrwae i wwwri1r�W yI oW ow 7 7a 0oww C CC0p> n� HV w 0r Coto 0owwrnrR� -. '4N W W wGo I .�.�+AU.,.v..a..a�.•mY•w.-..-ioIvw.-w=roi wx.w+r SC.tlY.+�r�w W•-�+'.rkp�um.r." Ww zrr+.mr.` nIh wun r�W +ar GrW twoNA !6 I�w,u wur.os.�i rW"�,Orn ' f A.. . I I I I , I I III N N M CfA MII Val�11..Na iu .'. 'fA�j IM N,aM e4rpr oW ol1 w uuu�nn w u w Caa w m w Y,nY rw rp M uWv 6 9i+Ch to a7r*fpw I'vua 4Aw�C,ty tff w[a b aJl {{p��''� r'rJn nor w W ICJ G"�"pCi,W. lam» alr cr+.W I' sta I ' arb w Itlf y m A Jv. Iam w iw .�+�Iw E,�,,•I IW.. - W iw 'OA W 1 R.1n V'+J w ,p.w a*b 4 CD A 11 I 1 i fge� z z Y q • " i �! I� I II I w.bd W w.r...w W-W J6,w w eP6��T N N yw�l�bw®iHj rW(gAq1w�wgy-t�C9VJwYs Wiw"K) va r�f4 r W¢w wsG A (J9 W tpJ:j1l!w'w"V" CEA h IDa6 z www5w - Mco - �NAW w W M Nd� mM Aw,Gwv N Nm Agppr eg 'A 0 w LMa iOr W w bar t0 w. wJ C9 fD W. w o m CO d W w C:Y 19 I ms ixccr`ao �' `�ccca ' rnm �v °mnoa� m goo � mzz " m acc a rsc�n u, a� r 5 a� mC7 n = nmm A orr q_ _� Zz -roman crr c v� am gyaaz � mzm�ammCaarm mCat-cC�A m mam vaz�P,van ro22xxamvr om mo rrr ��a nam i m p m m 0m n wC.< a m mom* arum a va mn zm mb P-cn r, m m a " z m m 00m aicab cn m� a`x fi mn�yo x qa mm�mm amnG} put < n ' Moc o�t QC m ' GaEp D ooz nDo z nm am®4 � m* C - oO aaCas Lp Z C 0zm C'40 mm D maw n x b > C c Y $ " Oz ',r,13M u MW A O 0 0 ac A Qqm aO rm mmmm M 0. onno .ro m m: ar s .�wwm ca wwm��.dd "zn w�u�tisa uva mmti�wN ��aw�l WwW ' ® � ��ww r.d� wrw�e wda wd mw CIOO� w- a C00m � m am, x mznxmLAmX n0R zcm2cnm MMC m r aC0mom Oa x a v a �Aj ax �m ca aw *m mo b w m m m ��M Gm m ~ � wono o >0 to _a � r x x u?ea ua tas us vs rr va m us va us cn vas a cn va cA cn sn Ga ca m GO m m in mmmm m mmm m m min ww mww - mow- z _� x� �-nxx 2 enzgxa�x xsaex•o _nx�w °nxOr"enrnma's z x mm Y�AWp mm�2�ryryyy��yy ca m�ryainp�pry �rym-»......®a 1r-»mma�0`o p»� d'r Q Q gry -I -I. -1-9 s8 zz~,, Z � x. M 1 r � z p ro vv e-r m m �� 17 M m Cos m cn n m a Hll.. r° r�-rm°-ems°-pry-e�-a�1-v-w�wmwrrT°�rrrr�rrrr�ayrrT f_w�' ,.f- ff,'e rm° r�b :9 www�wwwwwwww �wwwwwwwswwwznwu�$'uwe �m�..4w wwca �' & CM ��f qa�t i kw w 0 CA 1, «s a((nnww�a av ww ara®sppryry wd®cry^� d V O t7rw Pd...O w �0 0000O�' w �i wtla W C GI O6g0^+!A tl'+9r," W � W d+w•L . ^�7 zn wt"ir e+��.sw�n.s th ed w esu ocn duns na w aowatew o..''.a w »a w+0 eaw cdW qn w v em v w ua Mpw m' ro rnao •• µaa w Mw avwt v wed w �.� d wed m � W cm ra ur w cn -d w w eh d c�ua srr as m crr oam messr.�cn ,. ao.....wawwrnw C,w a"' A.aOmwcar.Mpr:...�w®cr ww-+a,naa b tea x All Exhibit D - Benefit Comparison MONROE COUNTY BOARD OF COUNTY COMMISSIONERS 2015 FULLY INSURED DENTAL RFP INSTRUCTIONS Please note there are two tabs for each plan (4 Tabs in total) Please complete the requested information for both the Low and Nigh options Please ensure that your response will fit into the space allowed and that printed documents show your entire response. This Exhibit must be returned in the Excel version, not PDF, to be compliant. COUNTYMONROE COUNTY BOARD OF 1 1 2015 FULLY INSURED DENTAL RFP OPTIONLOW 1 Enter Vendor Name Below. vender nsame in-Network Out Indicate whether your Plan Pays quoted benefit matches current or explain BENEFITSl N deviations PLAN BASICS" Annual Deductible Individual: $ 0(Excluding Class 1) Family: $150 Waived for Diagnostic/Preventive Annual Maximum $2,000 Orthodontia Dependent Child$1, 00 o Waiting Periods o Missing Tooth Exclusion ------- Current Out of Network Reimbursement Maximum Allowable Charges In-Network Plan Out-of- Pays: Network Plan Pays: CLASS I Services Exams 1 00/0 100% All X a 100% 100% Cleanings&Fluoride Treatments 1 °/a 100% Palliative Treatment Emer enc 1000/0 100% Space Maintainers 1 % 100% CLASS li Services Sealants 90% 0% Basic Restorative ffillings,etc. 90% 80% ndodontics 90% 80% Nan-Sur ical Periodontics 90% 80% Repairs of Crowns,Inlays,Onla 90% 60% Repairs of BHd es 90% 80% Denture Re air 90% 60% Simple Extractions 90% 80% Surgical Periodontics 90% 60% Complex Oral Sure 90% 80% General Anesthesia 90% 80% CLASSIli Services lnlay2,Onla ,Crowns 60% 50% Prosthetics(Bridges,Dentures 60% 50% Orthodontimij," Diagnostic,Active,Retention Treatment 50% 50% Limited to Dependent children under the age of 25 Page 1 of 2 MONROE COUNTY BOARD OF COUNTY COMMISSIONERS 2015 FULLY INSURED E T L RFP LOW OPTIONL PPO BENEFITS Enter Vendor Name Below., vendor Name Indicate whether your quoted benefit matches current or explain LIMITATIONS deviations CLASS I Full mouth or Panoramic X-Ras 1 eve ears Bitewing X-Rays- 1 per 6 months under 14 1 per 12 months over 14 Oral Evaluations: Comprehensive/Periodic,2 per 12 months Limited problem focused and consultations—one(1)of these services per dentist per patient per 12 months Detailed problem focused—one(1) per dentist per patient per 12 months per eligible dia nosi's Cleanings: 2 in 12 months Matemi benefit: one additional prophylaxis during re nano , To ical Fluoride up to 19 years 2 PER YEAR Space maintainers 1 PER 3 YEARS UNDER AGE 19 BASIC ENEFITS Sealants—one(1) per tooth per 3 year(s)under age sixteen(16)on permanent first and second molars. Replacement of restorative services only when they are not, and cannot be made, serviceable. Replacements of Sealants or Fillings: Sealants 1 per tooth per 3 years. Fillings not within 12 months of placement, Pulpal therapy—one(1) per eligible tooth per lifetime. Eligible teeth limited to primary anterior teeth under age six(6)and primary posterior molars under age twelve(12) Root canal retreatment—one 1per tooth per lifetime. Ful'I mouth debridement—one 1 er lifetime, Periodontal maintenance following active perlodontal therapy—two(2)per 12 months In addition to routine prophylaxis, Periodontal scaling and root planing—one(1) per 24 months per area of the mouth. Surgical periodontal procedures—one(1)per 24 months per area of the mouth. Guided tissue regeneration—one 1 er tooth per lifetime, MAJOR BENEFITS' Single crowns,Inlays, onla s—not within 5 ears of ereviou,s placement. Buildups and post and cores—not within 5 ears of previous placement. Replacement of natural tooth/teeth in an arch—not within 5 year(s)of a fixed partial denture,full denture or partial removable denture, OTHER BENEFITS Payment for orthodontic services shall cease at the end of the month after termination Alternate Benefit Provision Applies-Least Costly Treatment Page 2 of 2 COUNTYMONROE COUNTY BOARD OF COMMISSIONERS 2015 FULLYI HIGH OPTIONBENEFITS Enter Vendor Name Below. ..m in-Network Out Indicate whether your Plan Pays: quoted benefit matches current or explain BENEFIT S1 deviations BASICS,PLAN Annual Deducflble Individual; $50(Excluding Class 1) Family: $150 Waived for Diagnostic p Preventive Annual Maximum $5,000 Orthodontia Dependent Child$3,000 No Waiting Periods No Missing Tooth Exclusion Out of Network Reimbursement 0th Percentile SM Percentile In-Network Plan Out-ot-Network Pays., Plan Pays: CLAS—S fSe-f-Aces Exams 1000/. 10% All X-Rays 100% 100% Cleanings&Fluoride Treatments 100% 100% Palliative Trealment mer anc 100% 100% $ ace Maintainers 100% 100% CLASS II Services Sealants 90% % Basic Restorative(Fillings,etc. 90% 90% Endodontics 90% % Nan-Sur ical Periodontics 90% % Re airs of Crowns,I la ,Onra 90% % Repairs of Bridges 90% /® Denture Repair 90% % Sim le Extractions 90% 90% Sur ical Periodontics 90% Cam lex Oral Sure 90°/® 90% General Anesthesia 90% 9010 CLASS Ili Services Inla ,Onla ,Crowns 0% 0% Prosthetics(Bridges, Dentures 60% 60°f Orthodanticw, Dia nostic,Active,Retention Treatment 50% 50% Limited to Dependent children under the age of 25 Page t of 2 COUNTYMONROE COUNTY BOARD OF COMMISSIONERS 2015 FULLY INSURED DENrAL HIGH OPTION DENrAL PPO BENEFIrS Enter Vendor Name Below., Indicate whether your quoted benefit LIMITATIONS matches current or explain deviations C I Full mouth or Panoramic X s i eve 5 years Bitewig -Rays-1 per 6 months under 14 1 per 12 months over 14 Oral Evaluations: Comprehensive/Periodic 2 per 12 months Limited problem focused and consultations—one(1)of these services per dentist per patient per 12 months Detailed problem focused—one(1)per dentist per patient per 12 months per eligible diagnosis Cleanings:2 in 12 months aterni benefit: one additional prophylaxis dudn2 pregnancy. Topical Fluoride uj to 19,years 2 PER YEAR Space maintainers 1 PER 3 YEARS UNDER AGE 19 BASIC BENEFITS Sealants—one(1)per tooth per 3 year(s)under age sixteen(16) on permanent first and second molars. Replacement of restorative services only when they are not,and cannot be made,serviceable. Replacements of Sealants or Fillings: Sealants 1 per tooth per 3 years. Fillings not within 12 months of placement. Pulpal therapy_one(1)per eligible tooth per lifetime. Eligible teeth limited to primary anterior teeth under age six(6)and primary posterior molars under age twelve(1 ) Root canal retreatment—one 1 er,tooth per lifetime. Full mouth debridement—one 1per lifetime. Periodontal maintenance following active periodontal therapy—two(2)per 12 months In addition to routine prophylaxis. Periodontal scaling and root planing—one(1)per 24 months per area of the mouth. Surgical periodontal procedures—one(1) per 24 months per area of the mouth. Guided tissue re eneration—one 1per tooth per lifetime. MAJOR BENEFITS Sin le crowns,inlays,onla s—not within 5 ears of previous placement. Buildups and post and cores not within 5 ears of previous 21acement. Replacement of natural tooth/teeth in an arch—not within 5 year(s)of a fixed partial denture,full denture or partial removable denture. OTHER BENEFITS Payment for orthodontic services shall cease at the end of the month after termination All-male Benefit Provision Applies-Least Costly Treatment Page 2 of 2