MVP Health Care ViiP Rate Quote Table Grandfathered Plans May 2011

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					                                        ViiP Rate Quote Table Instructions
 If you need assistance calculating your rate, contact MVP’s ViiP Sales representative at 1-888-656-5698


1. Choose your deductible. Refer to the Quote Table provided. Determine what plan design based
   on deductible level you’d like to purchase and check the “Deductible Level” box at the bottom of
   the form. Note what column this is, you will use this in Step 3 (and 4-5, if applicable).
2. Determine your age on the Policy Effective Date. If your birthday falls between today and the
   Policy Effective Date, increase your age today by one year. Note this age in the Quote Table on
   the bottom of the page in the “Age” column on the “Subscriber” row.
3. Enter your monthly rate. Locate your age from Step 2 on the Quote Table. Match that column
   with your chosen deductible level. Enter this amount in the Quote Table on the bottom of the
   page on the “Subscriber” row of the column you chose in Step 1. If you are the only one covered
   on your policy, proceed to Step 6.
4. (If applicable) Enter your spouse’s/domestic partner’s monthly premium. Determine the age
   of your spouse or partner on the Policy Effective Date in the same way you determined yours in
   Step 1. Locate your spouse’s or domestic partner’s age on the Quote Table. Match that column
   with your chosen deductible level. Enter this amount in the Quote Table on the bottom of the
   page on the “Spouse/DomPar” row of the column you chose in Step 1.
5. (If applicable) Enter the monthly premium for your dependent(s). Each dependent child has
   the same rate. Locate the “Dependent Child” category on the Quote Table. Enter this amount in
   the Quote Table on the bottom of the page on the “Dependent” row of the column you chose in
   Step 1 for each dependent you wish to cover.
6. Add up your Total Monthly Rate. Total the sum of the rates noted in the column(s) for
   “Subscriber,” “Spouse/DomPar” (if applicable) and “Dependents” (if applicable). This is your
   total monthly premium.
7. Sign, date, and return with your ViiP enrollment materials. Sign this rate sheet, keep a copy for
   yourself, and return this rate sheet, completed enrollment form, and a check for the first month’s
   total monthly premium calculated in Step 6 and mail to the address below. This must be
   postmarked by the last day of the month in order for coverage to begin on the first of the
   following month. Premium rate quote change monthly. (If the application package is not
   postmarked by the last day of the month, you will need to make a request for a new ViiP Rate
   Quote Table.) Mail to:
8. MVP Health Care, EAS-VT Non-Group Indemnity, P.O. Box 2207, Schenectady, NY 12305.
                         ViiP Rate Quote Table                                POLICY EFFECTIVE DATE: May 1, 2011
                                                                 Grandfathered Plans
        If you need assistance calculating your rate, contact MVP's ViiP Sales representative at 1-888-656-5698.

  Deductible                    $3,500             $5,000                $10,000          $25,000            $100,000
 Age on Policy
                                                       Monthly Premium per Covered Adult
 Effective Date
Dependent Child                $114.03              $96.78                $77.35           $31.36              $8.48
   Under 30                    $243.27             $206.50               $165.01           $66.90              $18.09
      30                       $246.28             $209.04               $167.04           $67.74              $18.31
      31                       $249.33             $211.61               $169.11           $68.57              $18.54
      32                       $252.42             $214.24               $171.19           $69.43              $18.75
      33                       $255.53             $216.89               $173.30           $70.28              $18.98
      34                       $258.68             $219.58               $175.44           $71.15              $19.23
      35                       $261.88             $222.29               $177.62           $72.02              $19.47
      36                       $265.13             $225.05               $179.81           $72.92              $19.70
      37                       $268.39             $227.85               $182.04           $73.80              $19.95
      38                       $271.72             $230.67               $184.29           $74.72              $20.19
      39                       $275.08             $233.52               $186.57           $75.66              $20.42
      40                       $278.48             $236.41               $188.87           $76.58              $20.69
      41                       $281.92             $239.35               $191.21           $77.53              $20.95
      42                       $285.40             $242.31               $193.57           $78.50              $21.21
      43                       $288.92             $245.30               $195.97           $79.46              $21.46
      44                       $292.48             $248.33               $198.40           $80.45              $21.72
      45                       $296.11             $251.40               $200.84           $81.43              $22.00
      46                       $299.76             $254.50               $203.32           $82.43              $22.28
      47                       $303.47             $257.65               $205.84           $83.45              $22.54
      48                       $307.23             $260.83               $208.38           $84.48              $22.82
      49                       $311.03             $264.06               $210.97           $85.53              $23.10
      50                       $314.87             $267.32               $213.57           $86.58              $23.39
      51                       $318.77             $270.64               $216.21           $87.66              $23.69
      52                       $322.71             $273.98               $218.88           $88.75              $23.98
      53                       $326.71             $277.36               $221.57           $89.84              $24.26
      54                       $330.74             $280.79               $224.31           $90.94              $24.56
      55                       $334.83             $284.27               $227.08           $92.06              $24.87
      56                       $338.96             $287.79               $229.90           $93.21              $25.18
      57                       $343.14             $291.35               $232.74           $94.35              $25.49
      58                       $347.39             $294.94               $235.61           $95.52              $25.80
      59                       $351.67             $298.60               $238.53           $96.72              $26.13
      60                       $356.02             $302.29               $241.46           $97.90              $26.46
      61                       $360.43             $306.03               $244.45           $99.11              $26.79
      62                       $364.87             $309.82               $247.46          $100.32              $27.11
      63                       $364.87             $309.82               $247.46          $100.32              $27.11
     64+                       $364.87             $309.82               $247.46          $100.32              $27.11

  My Premium:                   $3,500             $5,000                $10,000          $25,000            $100,000
   Check Deductible Level
  My Premium:        AGE         RATE               RATE                  RATE              RATE                   RATE
   Subscriber
Spouse/DomPar
   Dependent
   Dependent
   Dependent
Total Monthly Rate


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