Contract - Madison National Life Insurance Company - 12/4/2025 Madison National
Life Insurance Company
RATE CONFIRMATION
1. Policyholder: City of Round Rock
2. Group Number: 25660
3. Insurance Product: Long Term Disability
4. Rate Coverage Period: January 1, 2026—December 31, 2027
Long Term Disability
Premium Rates:
Current Rates Renewal Rates
Coverage Rate per$100 of covered payroll Rate per$100 of covered payroll
per month per month
Long Term
Disabilit $0.140 $0.196
ACKNOWLEDGEMENT BY AUTHORIZED REPRESENTATIVE OF POLICYHOLDER
This document confirms that the rates stated above are the agreed upon rates for the specified policy numbers.
These rates will be charged for coverage amounts effective during the Rate Coverage Period listed above.
By Date (Z
Title
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