Policy Endorsement #2
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POLICY ENDORSEMENT NO.2
FOR GROUP #90396
Attached to and forming a part of the Agreement To Provide Dental Care Benefits between
the City of Salina (group #90396) and Delta Dental Plan of Kansas, Inc.,
It is agreed and understood that effective with the February 1, 2004 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.
AND,
Section I, Number 1.7 shall read:
II. PREVENTIVE:
Provides for the following:
Prophylaxis (c1eanings), once each six (6) months.
Topical Fluoride once each six (6) months for dependent children under age nineteen (19).
Space Maintainers for dependent children under age fourteen (14) and only for premature loss
of primary molars.
Sealants - once per lifetime for dependent children under age fifteen (15) when applied only
to permanent molars with no caries (decay) or restorations on the occlusal surface and with the
occlusal surface intact.
By
nwVe. iliil
Delta Dental Plan of Kansas, Inc.
Date: December 1, 2003