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.;ALI FORNIA DENTAL SERVICE GROUP APPLICATION NAME OF GROUP CITY OF REDWOOD CITY PhoneNo 369-6251 Address P. O. BOX 391: Redwood City: California 94064 Area Covered Personnel Contact for Eligibility. Mike Brock Title Director Phone No. 369-6251 Bank Reference Type of lndustry San [ViaLeD County Cit~ Governm~.nt Subsidiary Companies Port of Redwood Proposed Effective Dat. 2-]-7~ Term of Agreement 2-1-74 tO 2-1-76 Name end claims office address of Medical Carrier BLUE CROSS r Oakland - Em~ EMPLOYER CONTRIBUTION: Employee 100 % Dependents N/A % (If less than 100 employees, must be 100%) MONTHLY RATES: One Party $ Two Party $ Three Party+ $_ SC $ RETENTION:(if applicabl~ First Year i ~ % Second and subsequent years 1 ~ % CENSUS DATA: CURRENT COMPLETE. IF: A. Total Number of Employees 415 TAKEOVER: Name of previous carrier Equitable Life Assurance B. Total Number of Eligible Employees ~ Locs. I claims office Male 31/I Female (:,)0 RETENTION: Maximum number to be enrolled Minimum number to be enrolled ~ ~ 0 C. Distribution by Dependency Status One Party ~,0.~z___ VOLUNTARY DEPENDENTS: Two Party ] 01 Eligible Enroged Spouses Three Party+ 1 C~C} Children PROGRAM DESCRIPTION: [] U,C & R [] T of A [] Incentive [] SGP #__ [] Basic Co-Payment ~(~ % Prosthodontic Co-Payment ~O % [] Waiting Perlod~On~ months ~ Dental Accident 100% [] Deductible: $ S 0 [] Initial ~ Annual [] Patient [] Employee & Spouse Only [] Family Aggregate [~] Maximum $ I O CI ~) [] Orthodontics: Co-Payment ~ 0 % Maximum $ ~ 0 0 [] Waiting Period:None months (Minimum 50 Employees Required) [] Other Eligibiltyspocialconditions' E]~£~'h'~l~y nn n'~'hnHn'n'l"~r,,~ ~ ~n'~ ~1~h1,~ ,~e~e,~Aent ELIGIBILITY RULES: children; payment and benefits will cease at age 19 or a~e 25 if ~ull-time student [] Same as Health and Welfa~ Plan (Attach Copy) . . o¥ iii Present Employees, first of the month following eemC~cJcr~ o [; ~ of continuous ~p~-rnent~[ hours per week. [] Future Employees, first of the month following eotw~etio~ Pf 1 months of conth3uou~se~ploym~t at~ hours per week. [] Other ~j/~ lZ~ ~,_/L ~/ r'~ . Dependent Coverage: Spouse E~ Children to age ] ,~ Students to age ? '~ Specify Classes of Ineligible Employees: IT IS AGREED THAT A CURRENT ELIGIBILITY LIST WILL BE SUBMITTED TO CDS PRIOR TO THE TENTH OF EACH MONTH. NAME OF BROKER License No.