Proposal Exclusively Prepared For - welcometoues.com€¦Enclosed you will find the proposal rates....

Proposal Exclusively Prepared For:

abc company

Provided By

SUSAN SMITH

Phone Number:

FAX:

Email:

Delivery Date: 03/22/2007

March 22, 2007

UnitedHealthcare Broker

,

RE: abc company

Dear Jane Doe,

Thank you for your time and interest in UnitedHealthcare and our health care coverage plans. We are pleased toprovide this proposal for an effective date of 04/01/2007.

Enclosed you will find the proposal rates. Final Rates will be provided after all enrollment applications andappropriate documentation is received by UnitedHealthcare.

As a leading health services company, we are committed to providing a number of innovative services likemyuhc.com. To learn more about the wide spectrum of products and services you have come to expect fromUnitedHealthcare, please explore the information available at unitedeservices.com.

We look forward to the opportunity to work with you and all the employers you represent to meet each employee’shealth care coverage needs. Again, thank you for considering UnitedHealthcare.

Sincerely,

SUSAN SMITH(123) 123-4567

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Company Name: abc company

Effective Date: 04/01/2007

06070

Number of Locations: 1

Total Number of Employees: 2

Total Number of Eligible Employees: 2

Total Number of Non-COBRA Employees Applying: 2

Total Number of COBRA Employees Applying: 0

Total Number of Out of Network Employees: 0

Is Medicare the Primary Payer? Yes

Prior Dental Coverage? No

Employer Contribution Percentage - Employee Only for Medical: 100%

Employer Contribution Percentage - Employee Only for Dental: 100%

Employer Contribution Percentage - Employee Only for Life: 100%

Company InformationCompany Name: abc company Company City: HARTFORDCompany Street Address: 123 Main Street Zip Code: 06070Broker: SUSAN SMITH Broker Phone: Market: HARTFORDAccount Executive: JANE DOE Account Executive Phone: (123) 123-4567 SIC:Effective Date: 04/01/2007 Quote Number: 9999999 Quote Date: 03/22/2007UW ID#: B

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Changed with the DEMO VERSION of CAD-KAS PDF-Editor (http://www.cadkas.com).

1 Employee 001 EE EE EE EE M 21 0 Active N2 Employee 002 EE EE EE EE M 22 04/15/1984 0 Active N

Detailed CensusCompany Name: abc company Company City: HARTFORDCompany Street Address: 123 Main Street Zip Code: 06070Broker: SUSAN SMITH Broker Phone: Market: HARTFORDAccount Executive: JANE DOE Account Executive Phone: (123)123-4567 SIC:Effective Date: 04/01/2007 Quote Number: 9999999 Quote Date: 03/22/2007UW ID#: B

Employee Medical Dental Vision Life Emp. Emp. Spouse Spouse No. Emp. Annual Out ofName Enroll Enroll Enroll Enroll Gender Age DOB Age DOB Child Status Salary Area

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ID Employee Name Age Gender Spouse No. $2500/90%/$0Age Child USO w/2V

1 Employee 001 21 M 0 $ 67.412 Employee 002 22 M 0 $ 67.41

Premium Totals:Employee-Only Monthly Premium $ 134.82Dependent-Only Monthly Premium $ .00Total Monthly Premium Including Rx Benefit $ 134.82Employer Contribution Percentage - Employee Only 100%Employer Contribution Premium/Month - Employee Only $ 134.82Total Annual Premium Including Rx Benefit $ 1,617.84

Rate Adjustment Percent 0.00%Risk Factor 0.82Monthly Administration Fee $ .00Total Employee Count 2Total Number of Eligible Employees 2Total Dependent Count 0Total Member Count 2

Benefit Overview:Product Type CHOICE PLUSDeductible - Single (In/Out) $ 2500 / $ 5000

- Family (In/Out) $ 7500 / $ 15000Coinsurance (In/Out) 90% / 70%Office Visit Copay/Coinsurance 90%Out of Pocket Maximum - Single (In/Out) $ 4500 / $ 9000

- Family (In/Out) $ 9000 / $ 18000Eligible Financial Accounts HRAInd HRA Contribution Range $50 - $2,500Med/Rx Ded Combined NoMed/Rx OOP Combined NoPharmacy Copay/Coinsurance $ 10 / $ 35 / $ 60 / N/APharmacy Deductible N/A

1. Rates are valid through the end of the proposal effective date month.2. Medicare Part D regulations require employers to provide creditable coverage notification to Medicare eligible participants of their prescription drug plan, as well as to Centers for Medicare & Medicaid Services (CMS) at least once ayear at specified times. Please contact your UnitedHealthcare Representative for information on the support and services UnitedHealthcare can provide employers to help them meet these requirements.3. The A-2 medical plans are PacifiCare plans. HMO products are underwritten by PacifiCare of Arizona and Insurance products are underwritten by United Health Insurance Company and Pacificare Life and Health InsuranceCompany. Please refer to plan documents for specific carrier information.4. A 6% rate load will be applied to all PacifiCare Dual Choice medical plan rates upon final underwriting approval.5. In states where composite rates are available, if Medicare is the primary payer, PacifiCare rates will be calculated using the total census of the group to determine the four tier composite rates. These rates will be inclusive ofindividuals age 65 or older for whom Medicare is primary. PacifiCare plan rates will not have separate Medicare rates from non-Medicare rates.6. Effective 9/1/05: UnitedHealthcare's Packaged Savings (SM) program allows you the opportunity to realize an administrative savings during the first twelve months when you bundle our medical products with our dental, life, disabilityand vision specialty products. Beginning 7/1/2006, employer sponsor vision plans with 75% or more participation will be part of the program. Our Packaged Savings (SM) program makes it easy to one-stop-shop for comprehensive

Medical RatesEmployee and Family Details

The above rates and benefits are for general information and discussion purposes only and not valid unless approved by UnitedHealthcare. This rate quote is not an offer or a guarantee of coverage. This group should not, under anycircumstances, cancel its existing coverage unless and until coverage is offered by us and final rates have been accepted by and initial premium paid by the group. Final rates are determined by UnitedHealthcare's underwritingguidelines and final enrollment. The insurance policy, not general rates and descriptions in this Web site or printed output, will form the contract between the insured and UnitedHealthcare, and the Certificate of Coverage issued to thesubscriber will provide the legal description of coverage. of 21


benefit plans that fit your needs and the needs of your employees. UnitedHealth Group Incorporated owns the federal trademark registration for United eServices and has a federal trademark application pending for Packaged Savings(SM). Both marks used by permission of UnitedHealth Group Incorporated. UnitedHealthcare's Packaged Savings(SM) program does not apply to PacifiCare products.7. Dual Option is available in this state. Please refer to the unitedeservices.com Product section for a detailed description document.8. Agents may receive commissions, bonuses and other compensation for selling the products presented in this proposal. The cost of this compensation may be directly or indirectly reflected in the premium or fees for those products.Contact your agent if you have questions on their compensation for the products in this proposal.9. Employer Contribution Premium / Month (Employee Only) is the amount of the total monthly employee premium contributed by the employer and does not include any additional amounts contributed for dependents. This amount willchange depending on the number of employees and the contribution percentage. If no contribution percentage has been provided, this amount assumes a 100% contribution level and represents the total monthly employee onlypremium. This information is for illustrative purposes only and the actual employer contribution level is subject to UnitedHealthcare underwriting guidelines.10. For the DY, FY, HY, LY, and VY Medical plan series, the deductible/out-of-pocket maximum includes both medical and pharmacy expenses. For 80% coinsurance plans, once the annual deductible is satisfied, pharmacy copays willapply until the out-of-pocket maximum is satisfied. For 100% coinsurance plans, the out-of-pocket maximum is satisfied and no pharmacy copays ever apply.11. For the DH-E Medical plan, the deductible/out-of-pocket maximum are separate for single coverage. For family coverage, no one in the family is eligible to receive benefits until the family deductible is satisfied. Thedeductible/out-of-pocket maximum includes both medical and pharmacy expenses. For 80% coinsurance plans, once the annual deductible is satisfied, pharmacy copays will apply until the out-of-pocket maximum is satisfied. For 100%coinsurance plans, the out-of-pocket maximum is satisfied and no pharmacy copays ever apply.12. For the RT, RU, RV, and RW Medical plan series, the deductible/out-of-pocket maximum includes both medical and pharmacy expenses. For 80% coinsurance plans, once the annual deductible is satisfied, pharmacy copays willapply until the out-of-pocket maximum is satisfied. For 100% coinsurance plans, the out-of-pocket maximum is satisfied and no pharmacy copays ever apply. For this medical plan, Preventive Care is covered at 100%.UnitedHealthcare charges no administrative fee for HRA products for groups size 2-99.

Medical RatesEmployee and Family Details



Age $2500/90%/$0USO w/2V

Male Female

<25 $ 67.41 $ 154.5740-44 ** $ 170.18 $ 240.48

1 Child $ 107.702 Children $ 215.403 + Children $ 323.10

Rate Adjustment Percent 0.00%Risk Factor 0.82Monthly Administration Fee $ .00

Benefit Overview:Product Type CHOICE PLUSDeductible - Single (In/Out) $ 2500 / $ 5000

- Family (In/Out) $ 7500 / $ 15000Coinsurance (In/Out) 90% / 70%Office Visit Copay/Coinsurance 90%Out of Pocket Maximum - Single (In/Out) $ 4500 / $ 9000

- Family (In/Out) $ 9000 / $ 18000Eligible Financial Accounts HRAInd HRA Contribution Range $50 - $2,500Med/Rx Ded Combined NoMed/Rx OOP Combined NoPharmacy Copay/Coinsurance $ 10 / $ 35 / $ 60 / N/APharmacy Deductible N/A

1. Rates are valid through the end of the proposal effective date month.2. Medicare Part D regulations require employers to provide creditable coverage notification to Medicare eligible participants of their prescription drug plan, as well as to Centers for Medicare & Medicaid Services (CMS) at least once ayear at specified times. Please contact your UnitedHealthcare Representative for information on the support and services UnitedHealthcare can provide employers to help them meet these requirements.3. The A-2 medical plans are PacifiCare plans. HMO products are underwritten by PacifiCare of Arizona and Insurance products are underwritten by United Health Insurance Company and Pacificare Life and Health InsuranceCompany. Please refer to plan documents for specific carrier information.4. A 6% rate load will be applied to all PacifiCare Dual Choice medical plan rates upon final underwriting approval.5. In states where composite rates are available, if Medicare is the primary payer, PacifiCare rates will be calculated using the total census of the group to determine the four tier composite rates. These rates will be inclusive ofindividuals age 65 or older for whom Medicare is primary. PacifiCare plan rates will not have separate Medicare rates from non-Medicare rates.6. Effective 9/1/05: UnitedHealthcare's Packaged Savings (SM) program allows you the opportunity to realize an administrative savings during the first twelve months when you bundle our medical products with our dental, life, disabilityand vision specialty products. Beginning 7/1/2006, employer sponsor vision plans with 75% or more participation will be part of the program. Our Packaged Savings (SM) program makes it easy to one-stop-shop for comprehensivebenefit plans that fit your needs and the needs of your employees. UnitedHealth Group Incorporated owns the federal trademark registration for United eServices and has a federal trademark application pending for Packaged Savings(SM). Both marks used by permission of UnitedHealth Group Incorporated. UnitedHealthcare's Packaged Savings(SM) program does not apply to PacifiCare products.7. Dual Option is available in this state. Please refer to the unitedeservices.com Product section for a detailed description document.8. Agents may receive commissions, bonuses and other compensation for selling the products presented in this proposal. The cost of this compensation may be directly or indirectly reflected in the premium or fees for those products.Contact your agent if you have questions on their compensation for the products in this proposal.9. Employer Contribution Premium / Month (Employee Only) is the amount of the total monthly employee premium contributed by the employer and does not include any additional amounts contributed for dependents. This amount willchange depending on the number of employees and the contribution percentage. If no contribution percentage has been provided, this amount assumes a 100% contribution level and represents the total monthly employee onlypremium. This information is for illustrative purposes only and the actual employer contribution level is subject to UnitedHealthcare underwriting guidelines.

Medical Rates



10. For the DY, FY, HY, LY, and VY Medical plan series, the deductible/out-of-pocket maximum includes both medical and pharmacy expenses. For 80% coinsurance plans, once the annual deductible is satisfied, pharmacy copays willapply until the out-of-pocket maximum is satisfied. For 100% coinsurance plans, the out-of-pocket maximum is satisfied and no pharmacy copays ever apply.11. For the DH-E Medical plan, the deductible/out-of-pocket maximum are separate for single coverage. For family coverage, no one in the family is eligible to receive benefits until the family deductible is satisfied. Thedeductible/out-of-pocket maximum includes both medical and pharmacy expenses. For 80% coinsurance plans, once the annual deductible is satisfied, pharmacy copays will apply until the out-of-pocket maximum is satisfied. For 100%coinsurance plans, the out-of-pocket maximum is satisfied and no pharmacy copays ever apply.12. For the RT, RU, RV, and RW Medical plan series, the deductible/out-of-pocket maximum includes both medical and pharmacy expenses. For 80% coinsurance plans, once the annual deductible is satisfied, pharmacy copays willapply until the out-of-pocket maximum is satisfied. For 100% coinsurance plans, the out-of-pocket maximum is satisfied and no pharmacy copays ever apply. For this medical plan, Preventive Care is covered at 100%.UnitedHealthcare charges no administrative fee for HRA products for groups size 2-99.** The rates displayed above are applicable only to the individuals as entered for the group census with the exception of the row with Age 40 rate information. The row with Age 40 rate information is displayed for internal purposes only.The group census included in the proposal does not include individuals in this age category and rates and premiums included within this proposal do not reflect information from this age category. To see the full age table, generate theproposal with the 'Entire Age Table' option selected.

Medical Rates



$2500/90%/$0USO w/2V

Male Employee Female Employee Male Spouse Female Spouse Child

Part A and B $ 257.34 $ 257.34 $ 257.34 $ 257.34 $ 188.47

Note: Proof of Medicare eligibility will be required to be billed Medicare primary rates.

Medicare Rates



Class # ofEmployees

P0042

Employee 2 $ 31.22Employee + Spouse 0 $ 66.21Employee + Child(ren) 0 $ 62.44Employee + Family 0 $ 100.65

Premium Totals:Total Monthly Premium $ 62.44Employer Contribution Percentage - Employee Only 100%Employer Contribution Premium/Month - Employee Only $ 62.44Total Annual Premium $ 749.28

Benefit Overview:Product Type PPODeductible - Single (In/Out) $ 50 / $ 50

- Family (In/Out) $ 150 / $ 150Coinsurance - Preventive & Diagnostic (In/Out) 100% / 80%

- Minor Restorative (In/Out) 80% / 60%- Endodontic/Periodontic/Oral Surgery (In/Out) 80% / 60%- Major (In/Out) 50% / 50%- Orthodontia (In/Out) N/A / N/A

Waiting Period - Major 12 months- Orthodontia N/A

Annual Maximum (In/Out) $ 1500 / $ 1000

1. Product availability may vary based upon group size and prior dental coverage.2. Effective 9/1/05: UnitedHealthcare's Packaged Savings (SM) program allows you the opportunity to realize an administrative savings during the first twelve months when you bundle our medical products with our dental, life, disabilityand vision specialty products. Beginning 7/1/2006, employer sponsor vision plans with 75% or more participation will be part of the program. Our Packaged Savings (SM) program makes it easy to one-stop-shop for comprehensivebenefit plans that fit your needs and the needs of your employees. UnitedHealth Group Incorporated owns the federal trademark registration for United eServices and has a federal trademark application pending for Packaged Savings(SM). Both marks used by permission of UnitedHealth Group Incorporated. UnitedHealthcare's Packaged Savings(SM) program does not apply to PacifiCare products.3. The employer must meet minimum contribution and eligible employee participation requirements. Dental employer contribution: 50% of the employee rate for contributory plans. Dental employee participation: 51% participation overalland 75% participation of eligible employees who do not waive coverage for contributory and non-contributory plans. For voluntary dental plans: 2 or more employees enrolled; for plans with Orthodontia, 8 or more employees enrolled.4. Proposed rates are valid to the Effective Date or 90 days from the Quote Date, whichever is sooner.5. A benefit grid of our most popular Dental plan designs is available. Please refer to the unitedeservices.com Product section for this document.6. Agents may receive commissions, bonuses and other compensation for selling the products presented in this proposal. The cost of this compensation may be directly or indirectly reflected in the premium or fees for those products.Contact your agent if you have questions on their compensation for the products in this proposal.7. Employer Contribution Premium / Month (Employee Only) is the amount of the total monthly employee premium contributed by the employer and does not include any additional amounts contributed for dependents. This amount willchange depending on the number of employees and the contribution percentage. If no contribution percentage has been provided, this amount assumes a 100% contribution level and represents the total monthly employee onlypremium. This information is for illustrative purposes only and the actual employer contribution level is subject to UnitedHealthcare underwriting guidelines.8. Please note that for some Dental Plans minor restorative services (i.e.,fillings, space maintainers) may be paid at a higher benefit level.

Dental Rates



Class # ofEmployees

V0012

Employee 2 $ 6.94Employee + Spouse 0 $ 14.23Employee + Child(ren) 0 $ 14.92Employee + Family 0 $ 21.52

Premium Totals:Total Monthly Premium $ 13.88Total Annual Premium $ 166.56

Benefit Overview:Product Type 100% EE PAID/0%

DEP PAIDFrequency - Exam 12 months

- Lenses 12 months- Frames 24 months

In-Network Copays - Exam $ 10.00- Materials $ 25.00

Out-of-Network Allowance - Exam Up to $ 40.00- Single Vision Lenses Up to $ 40.00- Frames Up to $ 45.00- Contact Lenses Up to $ 105.00

1. UnitedHealthcare's Packaged Savings (SM) program allows you the opportunity to realize an administrative savings during the first twelve months when you bundle our medical products with our dental, life, disability and visionspecialty products. Beginning 7/1/2006, employer sponsor vision plans with 75% or more participation will be part of the program. Our Packaged Savings (SM) program makes it easy to one-stop-shop for comprehensive benefit plansthat fit your needs and the needs of your employees. UnitedHealth Group Incorporated owns the federal trademark registration for United eServices and has a federal trademark application pending for Packaged Savings (SM). Bothmarks used by permission of UnitedHealth Group Incorporated.2. Product availability may vary based upon group size.3. This quote assumes Carrier replacement.4. Proposed rates are valid to the Effective Date.5. The employer must meet the minimum contribution and eligible employee participation requirements. For voluntary Vision plans: minimum 2 or more enrollees required; no participation percentage required. For employer sponsoredplans, if offered with medical 75% participation net of waivers required. For employer sponsored plans and if standalone only, 100% participation net of waivers is required.6. Agents may receive commissions, bonuses and other compensations for selling the product in this proposal. The cost of the compensation may be directly or indirectly reflected in the premium or fees for these products.7. Out-of-Network Allowances for lenses will vary by lens type with a maximum of $80. Medically necessary contacts have a maximum allowance of $210.8. Spectera offers 24 month rate guarantees on all plan designs.

Vision Rates



Basic Life/AD&D Products Flat $ 15000

Basic Life Rate/1000 Volume $ 0.17AD&D Rate/1000 Volume $ 0.04Total Rate/1000 Volume $ 0.21Total Rate per Employee $ 3.15

Total Life Volume $ 30,000.00

Basic Life Monthly Premium $ 5.10AD&D Monthly Premium $ 1.20Total Monthly Premium $ 6.30Employer Contribution Percentage - Employee Only 100%Employer Contribution Premium/Month - Employee Only $ 6.30Total Annual Premium $ 75.60

1. Life Insurance Reduction at age 65 reduces to 65% of the original amount and at age 70 reduces to 50% of the original amount.2. Effective 9/1/05: UnitedHealthcare's Packaged Savings (SM) program allows you the opportunity to realize an administrative savings during the first twelve months when you bundle our medical products with our dental, life, disabilityand vision specialty products. Beginning 7/1/2006, employer sponsor vision plans with 75% or more participation will be part of the program. Our Packaged Savings (SM) program makes it easy to one-stop-shop for comprehensivebenefit plans that fit your needs and the needs of your employees. UnitedHealth Group Incorporated owns the federal trademark registration for United eServices and has a federal trademark application pending for Packaged Savings(SM). Both marks used by permission of UnitedHealth Group Incorporated. UnitedHealthcare's Packaged Savings(SM) program does not apply to PacifiCare products.3. The employer must meet minimum contribution and eligible employee participation requirements. Life: 25% of the employee rate; 75% participation for contributory plans, 100% for non-contributory plans.4. Agents may receive commissions, bonuses and other compensation for selling the products presented in this proposal. The cost of this compensation may be directly or indirectly reflected in the premium or fees for those products.Contact your agent if you have questions on their compensation for the products in this proposal.5. Employer Contribution Premium / Month (Employee Only) is the amount of the total monthly employee premium contributed by the employer and does not include any additional amounts contributed for dependents. This amount willchange depending on the number of employees and the contribution percentage. If no contribution percentage has been provided, this amount assumes a 100% contribution level and represents the total monthly employee onlypremium. This information is for illustrative purposes only and the actual employer contribution level is subject to UnitedHealthcare underwriting guidelines.

Individual Evidence of Insurability may be required if amounts exceed the Guarantee Issue limit. Allowable Plan Maximums vary by employer group size. Refer to table below.

Group Size (eligible employees) Guarantee Issue Limit Plan Maximum Limit

2 – 5 ees $ 0 $ 50,000

6 – 19 ees $ 50,000 $ 175,000

20 – 50 ees $ 100,000 $ 250,000

Life / AD&D Rates



Product Grid

ArizonaSmall Business

Get Started Today

For Employers with 2-99Employees:

Contact your localUnitedHealthcare sales office,or visitwww.UnitedeServices.comand select “Preferred Plans”when prompted to generate a Benchmark Solutions quote

For Individuals:

Simply call 1-888-457-4672to get appointed with GoldenRule Insurance Company, and receive product details and quotes

Introducing UnitedHealthcare Benchmark SolutionsSM

Benchmark Solutions, only from UnitedHealthcare, is an entirely new health plan portfolio featuring our highly-proven plan designs with a special focus on the affordable, integrated Health Savings Account (HSA) and HealthReimbursement Account (HRA) consumer-driven plans for individuals and small businesses up to 99 employees.

Benchmark Solutions: proven and effective for the long haulWhether your customer is an individual or a growing enterprise, BenchmarkSolutions contains three approaches designed to meet their needs

• Traditional Benefits – Proven plans with deductibles up to $500

• Balanced Plans – Tailored plans with deductibles of $501-1,000

• Consumer-Driven – Affordable HSA and HRA plans with deductibles greater than $1,000

Designed to keep your customers’ business healthy • Tailored – Products that match employer priorities; designed to grow and change with their

business needs.

• Affordable – Leveraging innovation and efficiency to maintain benefits; making plans more affordable.

• Proven – Largest national carrier with extensive network; leading the industry in HSAs and HRAs.

• Proactive – Simple, self-service tools save time and money on administration; plus programs thatkeep your employees healthy and productive.

A proven and sustainable pattern of performance in lowering health care costs The systems and tools we’ve developed over the years are working. That means:

• Improved Quality – Superior quality of care based on evidence-based treatments, highlighted inour UnitedHealth PremiumSM program.

• Reduced Health Care Costs – Industry-leading discounts with physicians, facilities, pharmaciesand other health care professionals.

• Reduced Administration Costs – Driving down expenses through industry-leading claimsadjudication automation, online quoting, and an outstanding suite of automated consumer,employer, agent and physician tools.

Consumer-directed plans save money two waysOur consumer-directed plans are engaging consumers in the most intimate waythey can — through their pocketbooks and their health care choices. The potentialbenefits are large.

• Lower Premiums – Switching to a higher-deductible plan can offer dramatically lower premiumsand improved cash flows.

• Reduced Health Care Utilization – Our proven consumer activation techniques encourage wisehealth care purchasing decisions through incentive-driven plan designs and our member Webtools on myuhc.com®.

UnitedHealthcare Benchmark SolutionsSM — new solutions for you andyour customers.

Small Business

or Individual

BrokerUnitedHealthcare

Easy to sell

Easy

tous

e

Easy tobuy

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Consumer-Driven Affordable HSA and HRA plans with deductibles greater than $1,000

Balanced Plans Tailored plans with deductibles of $501-1,000

Traditional Benefits Proven plans with deductibles up to $500

Pharmacy PlansPlan Code

CO-PAY Mail Order (90-Day Supply)

Deductible (per coveredperson, 3 per family)Tier 1 Tier 2 Tier 3

H9 $10 $30 $50 2.5x each retail category N/A 2V $10 $35 $60 2.5x each retail category N/A

ArizonaSmall Business

* Preventive coverage: 100%

For “EA” and “LI” Plans: Deductible applies toward out-of-pocket maximum.For “HY” Plans: Combined medical and pharmacy deductible and out-of-pocket maximum. After deductible is met, coinsurance and pharmacy copayments apply.For “HD” Plans: Combined medical and pharmacy deductible and out-of-pocket maximum. After deductible is met, coinsurance and pharmacy copayments apply.Plan has non-embedded family deductible and out-of-pocket maximum, meaning no individual in the family has satisfied the deductible or out-of-pocket maximum until the entire family amounthas been met. Plan is HSA-eligible. In 2006, maximum HSA contribution is the lesser of the plan deductible or $2,700 single/$5,450 family for 2006. These amounts are subject to change by IRS and do notinclude catch-up contributions for subscribers age 55 and over.

Plan Code

DEDUCTIBLE In $ / Out $ COINSURANCE

In / Out

OUT-OF-POCKETIn $ / Out $

CO-PAYAvailable Pharmacy Plans

Office UrgentCare

ERSingle Family Single Family PCP Specialist

USB $250$500 $750/$1,500 80% / 60% $1,500/$3,000 $3,000/$6,000 $20 $20 $50 $100 2VUSA $250/$500 $750/$1,500 90% / 70% $1,500/$3,000 $3,000/$6,000 $20 $20 $50 $100 H9, 2VEAA $500/$1,000 $1,500/$3,000 80% / 60% $2,000/$4,000 $4,000/$8,000 $20 $35 $50 $100 2VLIG $500/$1,000 $1,500/$3,000 80% / 60% $3,000/$6,000 $6,000/$12,000 $25 $50 $75 $200 2VUSD $500/$1,000 $1,500/$3,000 80% / 60% $2,000/$4,000 $4,000/$8,000 $20 $20 $50 $100 2V

Plan Code


In / Out



Office UrgentCare


ANA $1,000/$2,000 $3,000/$6,000 100% / 80% $1,000/$5,000 $3,000/$10,000 $20 $20 $50 $100 2VANB $1,000/$2,000 $3,000/$6,000 100% / 80% $1,000/$5,000 $3,000/$10,000 N/A N/A N/A N/A 2VUSF $1,000/$2,000 $3,000/$6,000 80% / 60% $2,500/$5,000 $5,000/$10,000 $20 $20 $50 $100 2VLIH $1,000/$2,000 $3,000/$6,000 80% / 60% $3,500/$7,000 $7,000/$14,000 $25 $50 $75 $200 2V

Plan Code


In / Out



Office UrgentCare


RTA1 $1,100/$2,200 $2,200/$4,400 100% / 80% $1,100/$4,400 $2,200/$8,800 N/A N/A N/A N/A H9USK $2,000/$4,000 $6,000/$12,000 90% / 70% $4,000/$8,000 $8,000/$16,000 N/A N/A N/A N/A 2VUSG $1,500/$3,000 $4,500/$9,000 90% / 70% $3,500/$7,000 $7,000/$14,000 N/A N/A N/A N/A H9, 2VUSM $2,000/$4,000 $6,000/$12,000 80% / 60% $4,000/$8,000 $8,000/$16,000 N/A N/A N/A N/A H9, 2VUSR $2,500/$5,000 $7,500/$15,000 80% / 60% $4,500/$9,000 $9,000/$18,000 $25 $25 $75 $125 H9, 2VUSO $2,500/$5,000 $7,500/$15,000 90% / 70% $4,500/$9,000 $9,000/$18,000 N/A N/A N/A N/A H9, 2VUSP $2,500/$5,000 $7,500/$15,000 90% / 70% $4,500/$9,000 $9,000/$18,000 $25 $25 $75 $125 H9, 2VUST $3,000/$6,000 $9,000/$18,000 90% / 70% $5,000/$10,000 $10,000/$20,000 $30 $30 $100 $150 H9, 2VUSI $1,500/$3,000 $4,500/$9,000 80% / 60% $3,500/$7,000 $7,000/$14,000 N/A N/A N/A N/A 2VANC $2,000/$4,000 $6,000/$12,000 100% / 80% $2,000/$8,000 $6,000/$16,000 $25 $25 $75 $125 2VAND $2,000/$4,000 $6,000/$12,000 100% / 80% $2,000/$8,000 $6,000/$16,000 N/A N/A N/A N/A 2VUSL $2,000/$4,000 $6,000/$12,000 90% / 70% $4,000/$8,000 $8,000/$16,000 $25 $25 $75 $125 2VHYA $2,500/$5,000 $5,000/$10,000 100% / 80% $2,500/$10,000 $5,000/$20,000 N/A N/A N/A N/A H9Split Co-Pay PlansEAC $1,500/$3,000 $4,500/$9,000 80% / 60% $3,500/$7,000 $7,000/$14,000 $25 $50 $75 $125 2VEAE $2,000/$4,000 $6,000/$12,000 100% / 80% $2,000/$8,000 $6,000/$16,000 $25 $50 $75 $125 H9, 2VLIC $3,000/$6,000 $9,000/$18,000 100% / 80% $3,000/$10,000 $9,000/$20,000 $25 $50 $75 $200 H9, 2VLIL $1,500/$3,000 $4,500/$9,000 80% / 60% $4,500/$9,000 $9,000/$18,000 $25 $50 $75 $200 2VLIB $2,500/$5,000 $7,500/$15,000 100% / 80% $2,500/$9,000 $7,500/$18,000 $25 $50 $75 $200 2VNon-embedded Deductible PlansHDF* $2,850/$5,000 $5,600/$10,000 100% / 80% $2,850/$10,000 $5,600/$20,000 N/A N/A N/A N/A H9HDD* $2,000/$4,000 $4,000/$8,000 100% / 80% $2,000/$8,000 $4,000/$16,000 N/A N/A N/A N/A H9

Please talk to your UnitedHealthcare representative, or consult other UnitedHealthcare collateral with more detailed product information, foradditional details that could impact the benefits. Different UnitedHealthcare plans may have varying approaches to whether pharmacy costsare included or excluded from the medical deductible, whether preventive services are covered at 100%, and other benefit details.

Insurance coverage provided by or through United HealthCare Insurance Company. Administrative services to self-funded plans provided byUnited HealthCare Insurance Company or United HealthCare Service LLC. Health Plan coverage provided by or through: United HealthCare ofArizona, Inc.

M40272 5/06 © 2006 United HealthCare Services, Inc.

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Enterprise Series

NationalSmall Business Group

Multi-Site One Source Express

Notes

* Deductible applies toward out-of-pocket maximum; per covered person

** Office visit copays for PCPs and Specialists are the same

Family deductible: 3xFamily out-of-pocket maximum for US/NA plans: 2xFamily out-of-pocket maximum for AN/ND plans: 3xfor in network; 2x for out of network

For in-network coinsurance plans, you must meet the deductible first, before coinsurance isapplicable (excludes ER).

**Plan CodesEnterprise Series Lifetime Maximum = $5 million

Out-of-Network BenefitsOffice Visit: See Out-of-Network Coinsurance Urgent Care: See Out-of-Network CoinsuranceEmergency Room: Same as In-Network

100% plans are subject to market availability.

DEDUCTIBLE*IN / OUT

OUT-OF-POCKET MAXIMUMIN / OUT

COINSURANCEIN / OUT

IN-NETWORK PLAN CODE**

OFFICEVISIT**

URGENTCARE ER

CHOICEPLUS PPO

$250 / $500 $1,500 / $3,00090% / 70%

$20 $50 $100US-A NA-A

80% / 60% US-B NA-B

$500 / $1,000 $2,000 / $4,000 90% / 70%

$20 $50 $100US-C NA-C

80% / 60% US-D NA-D

$1,000 / $2,000 $2,500 / $5,00090% / 70%

$20 $50 $100US-E NA-E

80% / 60% US-F NA-F

$1,500 / $3,000 $3,500 / $7,000

90% / 70%90% 90% 90% US-G NA-G

$25 $75 $125 US-H NA-H

80% / 60%80% 80% 80% US-I NA-I

$25 $75 $125 US-J NA-J

$2,000 / $4,000 $4,000 / $8,000

90% / 70%90% 90% 90% US-K NA-K

$25 $75 $125 US-L NA-L

80% / 60%80% 80% 80% US-M NA-M

$25 $75 $125 US-N NA-N

$2,500 / $5,000 $4,500 / $9,000

90% / 70%90% 90% 90% US-O NA-O

$25 $75 $125 US-P NA-P

80% / 60%80% 80% 80% US-Q NA-Q

$25 $75 $125 US-R NA-R

$3,000 / $6,000 $5,000 / $10,000

90% / 70%90% 90% 90% US-S NA-S

$30 $100 $150 US-T NA-T

80% / 60%80% 80% 80% US-U NA-U

$30 $100 $150 US-V NA-V

$5,000 / $7,500 $7,500 / $10,000

90% / 70%90% 90% 90% US-W NA-W

$30 $100 $150 US-X NA-X

80% / 60%80% 80% 80% US-Y NA-Y

$30 $100 $150 US-Z NA-Z

100% PLANS

$1,000 / $2,000 $1,000 / $5,000

100% / 80%

$20 $50 $100 AN-A ND-A

100% 100% 100% AN-B ND-B

$2,000 / $4,000 $2,000 / $8,000$25 $75 $125 AN-C ND-C

100% 100% 100% AN-D ND-D

Choice Plus and PPO Plans

All pharmacy plans are available with allEnterprise medical plans.

PHARMACY PLANS

PRODUCT K4 H9 2V G4 S8

Tier 1 Copay† $10 $10 $10 $10 $10

Tier 2 Copay† $25 $30 $35 $30 $30

Tier 3 Copay† $40 $50 $60 $50 $50

Deductible (per covered person) $0 $0 $0 $100 $250

† The participant will pay the lesser of the applicableminimum copayment or the Network Pharmacy’sU&C charge. In certain documents Tier 1 wasreferred to as “generics”; Tier 2 was referred to as“preferred brands” or “brand name on the PDL”;and Tier 3 was referred to as “non-preferredbrands,” “not on the PDL,” or “brand name not onthe PDL.” These changes in descriptive terms donot affect your benefit coverage.

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Enterprise Series

NationalSmall Business Group

Multi-Site One Source ExpressiPlan Health Savings Account High-Deductible Health PlansUnitedHealthcare is pleased to offer the latest solution in benefit programdesign, flexibility, and savings for small businesses (2-50 subscribers). OuriPlan Health Savings Account (HSA) is offered with high-deductible medicalplans, which provides an opportunity to save money and help employersmeet their employees’ demand for choice and control.

The iPlan HSA fromUnitedHealthcare — providing the benefits, strategies, resources and financial incentives to drive consumer-minded thinking into the everydayhealth care decisions.

DEDUCTIBLEIN / OUT


COINSURANCEIN / OUT*

IN-NETWORK MAXIMUM CONTRIBUTION** TO HSA ACCOUNT

PLAN CODE

OFFICEVISIT

URGENTCARE ER

CHOICEPLUS PPOSINGLE FAMILY

$1,100 / $2,200 $1,100 / $4,400 100%* / 80% 100%* 100% 100% $1,100 $2,200 HD-B LD-B$1,100 / $2,200 $2,200 / $4,400 80%* / 60% 80%* 80% 80% $1,100 $2,200 HD-C LD-C$2,000 / $4,000 $2,000 / $8,000 100%* / 80% 100%* 100% 100% $2,000 $4,000 HD-D LD-D$2,000 / $4,000 $4,000 / $8,000 80%* / 60% 80%* 80% 80% $2,000 $4,000 HD-E LD-E$2,850 / $5,000 $2,850 / $10,000 100%* / 80% 100%* 100% 100% $2,600 $5,150 HD-F LD-F$2,850 / $5,000 $5,000 / $10,000 80%* / 60% 80%* 80% 80% $2,600 $5,150 HD-G LD-G$2,850 / $5,000 $5,000 / $10,000 80% / 60% 80% 80% 80% $2,600 $5,150 HD-H LD-H$3,500 / $7,500 $3,500 / $10,000 100%* / 80% 100%* 100% 100% $2,600 $5,150 HD-I LD-I$3,500 / $7,500 $5,000 / $10,000 80%* / 60% 80%* 80% 80% $2,600 $5,150 HD-J LD-J$3,500 / $7,500 $5,000 / $10,000 80% / 60% 80% 80% 80% $2,600 $5,150 HD-K LD-K$5,000 / $7,500 $5,000 / $10,000 100%* / 80% 100%* 100% 100% $2,600 $5,150 HD-L LD-L$5,000 / $7,500 $5,000 / $10,000 100% / 80% 100%* 100% 100% $2,600 $5,150 HD-M LD-M

Notes

* Preventive coverage at 100%. Not subject to deductible. No coverage out-of-network.

** Estimates are based on the 2004 IRS-mandated maximum HSA contributions, and these maximums are subject to change by Cost of Living Adjustments (COLA) in 2005. Enrollees are responsible for determining their maximum HSA contribution, including taking intoaccount spousal high-deductible health plan/HSA coverage and contributions.

The Rx plan offered with the plans above is $10/30/50. Rx applies to the medical deductible and out-of-pocket maximum.

All services, except preventive when covered at 100%, apply to the deductible. The deductible applies to the out-of-pocket maximum.

The family deductible and out-of-pocket maximum are non-embedded, meaning no individualin the family has satisfied the deductible or out-of-pocket maximum until the entire familyamount has been satisfied.

The family deductible is 2x individual.

Available in select markets. State mandates apply.

Small Business National Plans

A strategic, long-term solution to health care cost management.

DUAL OPTIONPACKAGE

DEDUCTIBLEIN / OUT


COINSURANCEIN / OUT

OFFICEVISIT

URGENTCARE ER PLAN

PACKAGE 1$250 / $500 $1,500 / $3,000 90% / 70%

$20 $50 $100US-A

$1,100 / $2,200 $1,100 / $4,400 100% / 80% HD-B

PACKAGE 2$1,000 / $2,000 $1,000 / $5,000 100% / 80%

$20 $50 $75AN-A

$1,100 / $2,200 $1,100 / $4,400 100% / 80% HD-B

PACKAGE 3$500 / $1,000 $2,000 / $4,000 80% / 60%

$20 $50 $100US-D

$1,100 / $2,200 $1,100 / $4,400 100% / 80% HD-B

PACKAGE 4$1,000 / $2,000 $2,500 / $5,000 80% / 60%

$20 $50 $100US-F

$1,100 / $2,200 $2,200 / $4,400 80% / 60% HD-C

PACKAGE 5$500 / $1,000 $2,000 / $4,000 90% / 70%

$20 $50 $100US-C

$2,000 / $4,000 $2,000 / $8,000 100% / 80% HD-D

PACKAGE 6$1,000 / $2,000 $2,500 / $5,000 80% / 60%

$20 $50 $100US-F

$2,000 / $4,000 $2,000 / $2,000 100% / 80% HD-D

PACKAGE 7$1,000 / $2,000 $2,500 / $5,000 80% / 60%

$20 $50 $100US-F

$2,000 / $4,000 $4,000 / $8,000 80% / 60% HD-E

PACKAGE 8$1,500 / $3,000 $3,500 / $7,000 80% / 60%

$25 $75 $125US-J

$2,000 / $4,000 $4,000 / $8,000 80% / 60% HD-E

PACKAGE 9$1,000 / $2,000 $1,000 / $5,000 100% / 80%

$0 $0 $0AN-B

$2,850 / $5,000 $2,850 / $10,000 100% / 80% HD-F

PACKAGE 10$1,500 / $1,500 $3,500 / $3,500 80% / 80%

$25 $75 $125US-J

$2,850 / $2,850 $2,850 / $2,850 100% / 100% HD-F

National Small Business Dual Option Plan Package Examples

© 2005 United HealthCare Services, Inc.

Insurance coverage provided by or through: United HealthCare Insurance Company100-4611 8/05

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ArizonaSmall Business Group

PPO PLANS

DEDUCTIBLE

SINGLE / FAMILY

NETWORK COINSURANCE NON-NETWORK COINSURANCE

ANNUAL MAX

LIFETIME MAX

ORTHO

BENEFIT

PLAN

NAMEPREVENTIVE BASIC MAJOR ORTHODONTIA PREVENTIVE BASIC MAJOR ORTHODONTIA

$50 / $150 100% 80% 50% N/A 100% 80% 50% N/A $1,000 N/A P1211$50 / $150 100% 50% 50% N/A N/A N/A N/A N/A $1,500 N/A PIN60#

$50 / $150 100% 50% 50% 50% N/A N/A N/A 50% $1,500 $1,000 PIN06#†

390-3010 7/05© 2005 United HealthCare Services, Inc.

These benefit grids are intended only to highlight plan bene-fits and should not be relied upon to fully determine cover-age. These plans may not cover all health care expenses.This policy has exclusions, limitations and terms underwhich the policy may be continued in force or discontinued.For costs and complete details of the coverage, contact yourbroker or UnitedHealthcare.

All Plans■ Available Stand-Alone■ Freedom to See Any Dentist■ Multi-Site Capabilities■ Deductible Waived for Preventive Services■ Waiting Period Waived & Deductible Credit for

Take-Over Groups■ Streamlined, Online Administration through

Employer eServices®

Voluntary Plans■ Only 2 Enrollees Required■ Orthodontia Available to Groups of 10+

Eligibles and 8 Enrollees■ Periodontics/Endodontics/Oral Surgery

Covered as Major■ No Participation Percentages Required■ Non-network PPO Claims Reimbursed at MAC,

Indemnity at 85%Employer Sponsored Plans■ 50% Employer Contribution Required for

Employee Premium■ 75% Participation of all eligible employees, not

less than 50% after waivers■ Periodontics/Endodontics/Oral Surgery Covered

as Basic Services■ 85th Percentile UCR Reimbursement Non-Network■ Orthodontia Available to Groups of 10+ Eligibles

and 8 Enrollees

Top Selling Voluntary Plans

Top Selling Employer Sponsored Plans

UnitedHealthcare Dental■ Industry Leading Customer Service*■ 98% Enrollee Satisfaction Rating**■ Plan Designs to Fit Every Group

* From 9/03 service report compared to LIMRA’s statistical information

** From 6/03 member satisfaction survey*** Deductible applies

† Plan covers both adult and child ortho# In-Network Only plans are not available in all

areas. Benefits are for in-network only exceptfor ortho and emergency coverage which isboth in and out of of network. X-rays andlabs are covered at 50%.

Shaded plans have no waiting periods regardlessof previous coverage

INDEMNITY PLANS

DEDUCTIBLE

SINGLE / FAMILY

COINSURANCE

ANNUAL MAX

LIFETIME MAX

ORTHO BENEFIT

PLAN

NAMEPREVENTIVE BASIC MAJOR ORTHODONTIA

$50 / $150 100% 80% 50% N/A $1,000 N/A I0675

INDEMNITY PLANS

DEDUCTIBLE

SINGLE / FAMILY

COINSURANCE

ANNUAL MAX

LIFETIME MAX

ORTHO BENEFIT

PLAN

NAMEPREVENTIVE BASIC MAJOR ORTHODONTIA

$0 / $0 100% 50% 50% N/A $700 N/A I0026$25 / $75 100% 80% 50% N/A $1,500 N/A I0011

$50 / $150 100% 80% 50% N/A $1,000 N/A I0007PPO PLANS

DEDUCTIBLE

SINGLE / FAMILY

NETWORK COINSURANCE NON-NETWORK COINSURANCE

ANNUAL MAX

LIFETIME MAX

ORTHO

BENEFIT

PLAN

NAMEPREVENTIVE BASIC MAJOR ORTHODONTIA PREVENTIVE BASIC MAJOR ORTHODONTIA

$50 / $150 100% 80% 50% N/A 80% 60% 50% N/A $1,000 N/A P0060$50 / $150 100% 80% 50% N/A 80% 60% 50% N/A $1,000 N/A P0123$50 / $150 100% 80% 50% 50% 80% 60% 50% 50% $1,000 $1,000 P0124$50 / $150 100%*** 80% 50% N/A 80%*** 60% 50% N/A $1,500/$1,000 OON N/A P0002$50 / $150 100% 80% 50% N/A 100% 80% 50% N/A $1,500 N/A P0019$50 / $150 100% 80% 50% N/A 80% 60% 50% N/A $1,500/$1,000 OON N/A P0042$50 / $150 100% 80% 50% N/A 100% 80% 50% N/A $1,500 N/A P0095$50 / $150 100% 50% 50% N/A N/A N/A N/A N/A $1,500 N/A PIN50#

$50 / $150 100% 80% 50% N/A 90% 70% 50% N/A $1,500 N/A P0102$50 / $150 100%*** 80% 50% 50% 80%*** 60% 50% 50% $1,500/$1,000 OON $1,000 P0003$50 / $150 100% 80% 50% 50% 80% 60% 50% 50% $1,500/$1,000 OON $1,000 P0038$50 / $150 100% 50% 50% 50% N/A N/A N/A 50% $1,500 $1,000 PIN05#†

$50 / $150 100% 80% 50% 50% 100% 80% 50% 50% $1,500 $1,500 P0096$50 / $150 100% 80% 50% 50% 90% 70% 50% 50% $1,500 $1,500 P0103$50 / $150 100% 80% 50% 50% 80% 60% 50% 50% $1,500/$1,000 OON $1,000 P2225

UnitedHealthcare Dental®

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These benefit grids are intended only to highlight plan benefits and should not be relied upon to fully determine coverage. Please refer to theactual Policy/Certificate of Coverage issued for complete benefit information. These plans may not cover all health care expenses. This policyhas exclusions, limitations and terms under which the policy may be continued in force or discontinued. For costs and complete details of thecoverage, contact your broker or UnitedHealthcare.

All Plans

■ Available Stand-Alone■ Freedom to See Any Vision Care Provider■ Two Year Rate Guarantee■ Streamlined, Online Administration through

Employer eServices®

Voluntary Plans

■ Only 2 Enrollees Required■ No Participation Percentages Required

Employer Paid Plans

■ For stand-alone vision offering, 100%participation net of waivers required

■ If offered with medical, 75%participation net of waivers required

Voluntary PlansAll Spectera Vision Plans include: ■ Full coverage on an annual eye exam*■ Full coverage on eyeglasses and frames or

contact lenses* ■ Discounts on laser eye surgery■ National network of private practice and retail

chain providers

*Network Benefits: Frames: Other than copay, all covered-in-full frames are fully covered. Receivea $50 wholesale frame allowance (approximate retail value of $120-$150) atprivate practice providers, or a $130 allowance at retail chain providers forframes outside the covered-in-full selection.

Lenses for eyeglasses: Standard single vision, standard lined bifocal, standardlined trifocal, and standard Lenticular lenses are covered-in-full. Options suchas progressive lenses, polycarbonate lenses, tints, UV, and antireflectivecoating may be available at a discount.

Contact lenses (in lieu of eyeglasses): The fitting/evaluation fees, contactlenses from Spectera’s covered selection, and up to two follow-up visits arecovered-in-full. Spectera’s covered contact lenses may vary by provider. A$105 allowance is applied toward the fitting/evaluation fees and purchase ofcontact lenses outside the covered selection (materials copay does not apply).Toric, gas permeable, and bifocal contact lenses are examples of contactlenses that are outside of our covered contacts.

**Non-Network Benefits:Lenses (for eyeglasses): Receive up to $60 reimbursement for bifocal lenses,up to $80 reimbursement for trifocal lenses, and up to $80 reimbursement forLenticular lenses.

Don’t see what you’re looking for? Ask your UnitedHealthcare Sales Representative— we have many plan options!

Spectera® Vision

Plan CodeFrequency Network Copays Out-of-Network Reimbursement Schedule

(reimbursement up to the amount shown)

Exam Lenses Frames Exam Materials’ Exam Lenses** Frame Contact Lenses

V0005 12 12 12 $10 $10 $40 $40 $45 $105

V0006 12 12 12 $10 $25 $40 $40 $45 $105

V0007 12 12 24 $10 $10 $40 $40 $45 $105

V0008 12 12 24 $10 $25 $40 $40 $45 $105

100% Employer Paid (100% Participation)




V0001 12 12 12 $10 $10 $40 $40 $45 $105

V0002 12 12 12 $10 $25 $40 $40 $45 $105

V0003 12 12 24 $10 $10 $40 $40 $45 $105

V0004 12 12 24 $10 $25 $40 $40 $45 $105

Employer Paid 100% for Employees/0% for Dependents (buy-up plans)




V0009 12 12 12 $10 $10 $40 $40 $45 $105

V0010 12 12 12 $10 $25 $40 $40 $45 $105

V0011 12 12 24 $10 $10 $40 $40 $45 $105

V0012 12 12 24 $10 $25 $40 $40 $45 $105

M39711 5/06© 2006 United HealthCare Services, Inc.

For Groups 2-50

Spectera administers vision benefits underwritten by the following entities:Spectera, Inc., United HealthCare Insurance Company and United HealthCareInsurance Company of New York.

Spectera® Vision Plans (2-50)

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UnitedHealthcare PacifiCare AZ SG Predications 1-1-07V1.doc

UnitedHealthcare - PacifiCare New Business Proposal for Employers with 2-50 Eligible Employees

We are pleased to provide you with this rate quote and benefit summary. Please note that this quote is subject to the following conditions and assumptions.

1. All medical product proposals for UnitedHealthcare (UHC) and PacifiCare (PHS) are valid only for those employees and dependents that work or reside in the designated service area.

2. Insurance coverage is provided by or through United Healthcare Insurance Company and affiliates, except New York.

3. This rate quote is not an offer or a guarantee of coverage. Enrollment materials should be submitted at least 10 days prior to the effective date before a group will be considered for coverage. A group must be approved by underwriting no later than the 10th of the month and all required case installation documentation must be received by the 5th of the month in order to back date coverage to the 1st of the month. This group should not, under any circumstances, cancel their existing coverage until they have received approval from the UnitedHealthcare or PacifiCare Underwriting Department.

4. Completed UHC or PHS employee applications including medical questions on all eligible employees and COBRA applicants of groups with 2–25 eligible employees and on all eligible employees in groups with no prior coverage. Groups with 26–50 eligible employees complete the group medical risk questionnaire found within the employer enrollment materials. Note: COBRA or state continuation enrollees are not counted when determining the total number of eligible employees.

5. The UHC Employer Application is completed and signed by the employer and broker when UHC plans are elected. The UHC employee applications are completed and signed by the employees when the employer elects UHC plans.

6. The PHS Employer Application is completed and signed by the employer and broker when PHS plans are elected. The PHS employee applications are completed and signed by the employees when the employer elects PHS plans.

7. Carrier Replacement –UnitedHealthcare Insurance Company, PacifiCare of Arizona or PacifiCare Life and Health Insurance Company will be the sole carrier(s) for medical benefits.

8. Rating structure is provided in 4 tiers; employee only, employee and spouse, employee and children or employee and family. UHC rates are age-banded for groups with 2 to 9 eligible employees and composite rated for groups of 10 or more eligible employees. PHS rates are composite rated for groups of 2 or more eligible employees.

9. If coverage is issued, these rates will be in effect for 12 months from the initial effective date of coverage, subject to the group policy provisions.

10. UnitedHealthcare and PacifiCare small group plans are subject to pre-existing condition limitations when permitted by law.

11. The rates in this quote are valid for the proposed effective date, but rates are subject to change if:

• Data for employees actually enrolled is different than the quoted employee data; • Any benefits are added or deleted; • Additional medical information is revealed on the individual employee health applications or individual underwriting

telephone interview(s); • The effective date is deferred; • Medical underwriting accepts coverage conditional to an additional percentage increase to the medical rates; • Change in base location or zip code; • Change in SIC code; • Change in number of eligible employees.

12. Minimum 75% participation of the total eligible employees, excluding valid waivers (spouse’s employer group plan, AHCCCS, tribal, or military insurance). A minimum of 50% of the total eligible employees must enroll in the plan, regardless of valid waivers.

13. Minimum employer contribution of 50% toward single premium.

14. Minimum enrollment of two (2) full-time employees for group coverage.

15. PHS SignaturePOS plans are offered to those who live or work in the Phoenix or Tucson Metro Area.

16. This proposal is for discussion purposes only and is not a guarantee of rates. Final rates are determined by Underwriting. Do not cancel current coverage until written approval from Underwriting is received.

of 21


Application Checklist:

Individual enrollment applications and medical questions completed and signed by all eligible employees (including those in their probationary period and those waiving coverage because they are continuing coverage under their former employer’s plan as a COBRA participant).

Waiver of Group Coverage form completed and signed by any eligible employee not selecting coverage (including those in their probationary period).

Group Application completed and signed by Employer and broker.

A copy of the current carrier’s most recent billing statement. If a terminated employee is listed on the most recent billing statement, a state continuation or COBRA application or waiver form must be completed on that former employee.

Binder Check made payable to the carrier for estimated first month total group premium. When UHC plans are elected, direct debit is available. To elect this payment method, submit a completed Direct Debit form (including a blank voided check), with the application. Binder checks for UHC plans are deposited upon receipt and a refund provided if coverage is not issued.

UHC or PHS proposal noting correct effective date of coverage.

Wage and Tax information

Quarterly Wage & Tax Report (QWR)* Submit a copy (all pages) of the most recent state Quarterly Wage and Tax Report (QWR). For churches, submit the most recent Quarterly IRS Form 941Form & current Payroll.

--Or--

Payroll Records* Groups of 6+ eligible employees may submit a current Payroll in lieu of a QWR. For groups of 2-5 eligible employees, a QWR is always required. A payroll is not acceptable in this size segment unless the company has not been in business long enough to file a QWR. Note: If a 2-week payroll statement is submitted, it must list the company name, reflect a current pay period and include a list of all employees indicating wages paid, withholdings and a grand total. Handwritten or estimated payroll, individual payroll/ pay stubs or W-2/W-3/W-4/W-9’s are not accepted.

*Indicate the employment or eligibility status for each employee listed on any submitted QWR or payroll records with these abbreviations: A= any employee submitting an Application, W=Waiving, P/T = Part-Time, T=Terminated, S = Seasonal, WP=Waiting Period.

Proof of Ownership ~ In addition to the above wage and tax information, Proof of Ownership is required for all enrolling owners, officers or partners not listed on the submitted QWR or Current Payroll reports.

The following information is required for groups with 2 – 5 eligible employees and/or “owner only” groups: Corporations:

In business < 1 year: S-Corps & C-Corps: Articles of Incorporation, filed with the state listing all enrolling officers’ names

In business > 1 year: S-Corps: IRS Schedule K-1(Form 1120S) for all enrolling Owners/Partners

C-Corps: IRS Form 1120 (pages 1 & 2) which includes “Schedule E”

Partnership/LLP:

In business < 1 year: Partnership Agreement signed by all partners In business > 1 year: IRS Schedule K-1 (Form 1065) for all enrolling partners or Partnership Agreement signed

by all partners

LLC

In business <1 year: LLC Agreement signed by all managers/members/parties In business >1 year: LLC Agreement signed by all managers/members/parties or copies of appropriate tax returns

(follow the guidelines for an S-Corp, Partnership or Sole Proprietorship based on how the LLC was formed)

Sole Proprietorship

In business < 1 year: Business License In business > 1 year: IRS Schedule C (Form 1040)

Farms

IRS Schedule F (Form 1040) Note: Husband and Wife groups must provide documentation that they are full-time employees of the company. They need to provide supporting documentation showing they are either an owner, or an employee, and provide sufficient documentation based on their business entity. UnitedHealthcare and affiliates reserve the right to request: proof of ownership, additional payroll or supporting tax documentation on any submission.

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Arizona PacifiCare (PHS) Small Business (2-50) Plan Availability To obtain PHS medical plan rates for groups with 2-9 eligible employees, please contact an Arizona UHC Sales Executive.

Stand Alone: one plan available to all small groups, except for the PHS Indemnity*** Plan. ***This plan is subject to network availability and underwriting guidelines.

Dual Choice: Dual Choice Plans are available for groups with 10 or more eligible employees. The employer may select 2 UHC plans or 2 PHS plans but may not select a combination of UHC and PHS plans. One PHS SignatureValue (HMO) or one PHS SignaturePOS Open Access plan and one Signature Options PPO product combination is offered.

PHS HMO plans may not be offered alongside PHS POS plans. PHS HMO Plans $10/100% and $15/100% and SDHP and QHDHP plans are not available for Dual Choice.

A 6% rate load will be applied to all PacifiCare Dual Choice plan rates upon final Underwriting approval.

Product Description PHS

Plan Code PHS Product Type

PHS Stand Alone

PHS Dual Choice Plans

PHS SignatureValue HMO $10/100% A2-A HMO √

PHS SignatureValue HMO $15/100% A2-B HMO √

PHS SignatureValue HMO $10-$25/$150 A2-C HMO √ √

PHS SignatureValue HMO $15-$30/$250 A2-D HMO √ √

PHS SignatureValue HMO $15-$30/$350 A2-E HMO √ √

PHS SignatureValue HMO $20-$40/$500 A2-F HMO √ √

PHS SignatureValue HMO $25-$50/$750 A2-G HMO √ √

PHS SignaturePOS $10-$25/$100/80% A2-H POS √ √

PHS SignaturePOS $15-$30/$200/70% A2-I POS √ √

PHS SignaturePOS $20-$40/$300/60% A2-J POS √ √

PHS SignaturePOS $25-$50/$500/50% A2-K POS √ √

PHS SignatureOptions PPO $20-$40 OV/80%-60%/250 A2-L PPO √ √

PHS SignatureOptions PPO $20-$40 OV/80%-60%/500 A2-M PPO √ √

PHS SignatureOptions PPO $25-$50 OV/80%-60%/1000 A2-N PPO √ √

PHS SignatureOptions PPO $25-$50 OV/70%-50%/1500 A2-O PPO √ √

PHS SignatureOptions PPO 80%-60%/5000 A2-P PPO √ √

PHS Indemnity *** A2-Q Indemnity

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