Policy Endorsement #4
,.
~
..-...-..----
POLICY ENDORSEMENT NO.4
FOR GROUP #90396
Attached to and forming a part ofthe Agreement To Provide Dental Care Benefits between City of Salina
(group #90396) and Delta Dental of Kansas, Inc.,
It is agreed and understood that effective with the February 1,2006 thru January 31, 2007 Renewal:
Section VIII, Number 8.3 shall read:
In consideration for the services provided hereunder, the Employer agrees to pay Plan a service fee as follows: Three Dollars
($3.00) per employee. Said fee shall be calculated and paid monthly.
It is agreed and understood that effective with the February 1,2008 Renewal:
Section VIII, Number 8.3 shall read:
In consideration for the services provided hereunder, the Employer agrees to pay Plan a service fee as follows: Three Dollars and
Twenty Five Cents ($3.25) per employee. Said fee shall be calculated and paid monthly.
Please initial the box next to your preferred option, sign below, and return one copy of the policy endorsement
in the enclosed, self-addressed envelope or fax to 316/462-3329 by January 1,2006.
.J A5o tJ It..Ê!B 8 £" I C I7Y m ¡; R.
Printed Name
~tl~
ßÍgnature
-.J' ()...n 11 n n 'J 23, 2nD 10
Date
Agent's Name
~ ß ctZ,Q
Delta Dental of Kansas, Inc.