Document aBgrXRze1GJQeKBdeoKbzRKLe

' \ 0^4/ PLAINTIFF'S EXHIBIT \ - GBOOP ACCOGSSB DIVTSICB [ TO: ( ) Oroup Office *t.!?.TW*.9.,?XIW*0 ** L0UI1* *IANAPCUS ' 6d Actuarial Dixieion^Jroup Tbdexvrltlac Boreau { 1 Coaacrelal droop Disability Clalas Section ( ) droop Berlov ( ) droop Accents Division-Section................................... loceri ( ; Hr. Sotlor Secretary's OfflccrAddltlcn to coda #514.08.330.6 7BCM.X*..??..*!?.9PW!??..............................droop Accoonta Diriaioo taetlaB..f!^... BB: State Plans - T.D.B. Bevlsien Effective 1-1-53 - liatoiy Cards * UM cr KCZCZIOUSB: RAYKSTOS-MAMUTTAN, INCe The folloviac items la reference to T.D.S. ahoold be delated tram, the preaeat baele history card: BUf*UCMTARY HISTORY CARO fOR T.OJ. BENEFITS ATTACHED ( ) Certificate fora na*er { Aaoots aad doxatlea of beaeflta A|a 60 llaltatloa C ) Maternity beaeflta C j Sapplanaotary Aeeldeat aad Zoalth Benefits aad Doratlea of Benefits ( ) If Sapp. A A X Benefits are dlsccatlsaad aad a pacbated certificate is presently need reprint certificate for aev e^loyses. The follOTlac chaatss ahoold be aads on the present basic history card: (^ T.B3. droop XoAer jl) T.5.B. Policy fen 1 ( ) Sopplaaaatazy Accident ( ) Add.................. a ( ) Chanted froa. e .tof e e e e ( ( ) ) Add.................. Chanted Cron. tuPRiraw a to. tfTSSSO*' Kaalth sehadalo cheated to: 159Q6-4 f a-#-# e * aeeaeeeeee SH 1949 ReJ. 32/s'ft ' Coetrlboti S3U NO CHANBC > Renewal Date: "W- f? Master No.:___ g- r -i~7- C- i Name of Group: Revision' Renewal Industry:. nee last uj Disability <>* v t *. iO/'FaLVanJ Cov. Prem.Payable Inforce as of_ Actual At Manual f?S't J40rA/I0-fity7">o$Wn"+Trr-Zftl*/zf5>rVri71)"'/.- <.<rs/J/OB*tP'V *IO wg.il.-WT >fV ' ' yr__ ,** J> <7ay "'*y i I J 'JPtfr 'll" rMV f r // ,,/- ^ ^' ' ' ./6 Jlll-IUM _____ id"'flsUii. sTWfchl 7 VV277*l i- / --/.* <a. u-u/ sig7. y-u^.---- -/ja*7>.I- . 7^-a- "^ yit*.*. "?2v, Current Claim Renewal Rate Rate .\ /n,>i/J"//vf t/,se/i,.,it: J2L ' -/?/. -V- /<A*/S- -4>W *.<v J7^ ,1.21 a.<*V S 7 7' J2Z_ Yl-CrMs#n .331 } .0 --nrr ZS: .ZZ *7* ?o _jLS- JC2L^ Total Manual P.P., Volume Reduction___ $-Hosp.Surg.& Flat Mni . # Other Disabilities Disability coverages which qualify for more than Volume Reduction (Worksheet attached) 1 U^ltr.yv-tx ,S~ >kC^u</. ^oft/srs o j^ c/ ci>v' ^ J**. i jL<X\k ,,*. (tsMu . '> #vZe/fe*-< V .Vm4 *3av/J Lg Year's Div. Leas than 10^ at U Year Ending U Claim Rate (7) Max. Ben. (8) Avg. Ben. Present Rate Basis 19__ 19-22 19-21 19_S 19Xi * (,-h <f> $ ----- S3a_% / 73 V (1) Average U Claim Rate 6^ ^ (2) T U - ------- * (3) Actual /^j( 5 ) j for Ind. Exper ted J> (h) Net T ($ )* ---------------Gross (5) (2)X(3)X(h) > Cl.Rate for Ind. at U EC j-i Eg *-* u. Er _L * 'htrisi (6) Total J0_1> \v\^ t (9) Retirement 0 ~~ ft N.R. '''r. ___ / ' < ____ j> R. (10) Ins. Inforce as of * (11) Inforce Premium at U $ (12) Approx. Reserve Required $ ________________ _* s / / Calculated s. 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