Group Name:

Policy Eff Date:

# Single:

X

Single Factor: $

=

$

(1)

# Family:

X

Family Factor: $

=

$

(2)

Annual Attachment Point

=

$

(A)

Use annual counts times the factors to get (1) & (2), then sum (1) & (2) to get the actual annual attachment point (A).

MAP listed on the policy:

Minimum Attachment Point

=

$

(B)

Total Paid Claims (include run-in, if applicable)

$

(3)

Ineligible Claims

$

(4)

Specific Claims

$

(5)

Net Paid Claims = (3) - (4) - (5)

$

(6)

List the greater of (A) or (B) from table above

$

(7)

Aggregate Reimbursement Due (6) – (7)

$

(8)

SPECIFIC CLAIMANT

AMOUNT OVER SPECIFIC

$

$

$

$

$

Prepared by:

Date:

TPA Name:

TPA Address:

TPA Phone:

TPA Fax: