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<br />'?' <br /> <br />American ' v Stop Loss <br /> <br /> <br />4l Insurance Brokerage Services, Inc. <br /> <br /> <br />In connection with brokering Medical Stop Loss Coverage for City of La Porte for <br />the policy period of April 1 ,2002 through March 31,2003, it is acknowledged that <br />service fees are included in the quoted monthly specific charges of <br />$19.57/lndividual, $47.60/Family and monthly aggregate of $4.78/PEPM: <br /> <br />DEDUCTIBLE <br />$115,000 <br /> <br />Specific <br />Individual Family <br /> <br />Aggregate <br />PEPM <br /> <br />NET RATE <br />SERVICE FEE <br />QUOTED CHARGE* <br /> <br />$17.61 <br />$ 1.96 <br />$19.57 <br /> <br />$42.84 <br />$ 4.76 <br />$47.60 <br /> <br />$4.30 <br />$0.48 <br />$4.78 <br /> <br />*Quoted Charge is the Monthly Billed Charge <br /> <br />City of La Porte <br />l~T. ~ <br />ht#L~-- <br /> <br />American Stop Loss Insurance <br />Brokerage Services, Inc. <br /> <br />kJ~~ <br /> <br />Walter Coolidge, President <br /> <br />Date: <br /> <br />03 flY/ {la(, <br />I <br /> <br />Date: <br /> <br />3/15 I/)2- <br /> <br />, <br /> <br />V 10/15/01 <br /> <br />250 Commercial Street. Suite 200. Worcester, MA 01608. Phone 800-944-7659. FAX 508-799-0161 <br />Email: info@americanstoploss.com · Website: www.americanstoploss.com <br />