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4. Individual Stop Loss Provisions <br /> a. Individual Stop Loss Deductible: $200,000 <br /> Applies per Covered Person for the Employer Group's Current Policy Period. <br /> b. Aggregating Specific Deductible(if applicable):$ <br /> c. Lasered Individuals with Individual Stop Loss Deductible(if applicable): <br /> Individual identifier,alternate Individual Stop Loss Deductible: <br /> d. Lasered Individuals excluded from Stop Loss Coverage(if applicable): <br /> Individual identifier: <br /> e. If a run-in contract (24112, 18112, or 15112 coverage period) is purchased, per item 2. above, run-in <br /> claims are covered with a maximum liability of: $ per Covered Person. <br /> 5. Terminal Liability Option (TLO)(does not apply to Employer Groups with 12115, 12!18, or 12/24 contracts): <br /> ❑Yes ® No <br /> The following applies if the answer to item above is"Yes"(Terminal Liability Option): <br /> Must be elected at Policy inception or renewal. Premium cost is calculated by taking the average enrollment for <br /> the last two months of the Current Policy Period multiplied by three times pre-termination Individual Stop Loss <br /> rate(s). Premium is due at the time of termination, payable by lump sum within 10 days of receipt of bill. Claims <br /> will accumulate and be combined under one Individual Stop Loss Deductible specified in item B.4.a above for the <br /> Current Policy Period and Terminal Period.The Settlement for the Final Accounting Period will be described in the <br /> section of the Policy entitled SETTLEMENTS. <br /> 6. Individual Stop Loss Premium <br /> Monthly Individual Stop Loss Premium shall be equal to the amounts obtained by multiplying the <br /> number of Covered Employees for a particular Month by: <br /> $268.11 Composite;or <br /> $ for each Single Coverage Unit <br /> $ for each Family Coverage Unit <br /> C. The rates shown in this Application reflect a volume-based discount in an amount up to 3%of the Individual Stop- <br /> Loss Premium for the Policy Period. If ancillary coverage(BlueCare Dental, Basic Life, Short-Terra Disability, Long-Term <br /> Disability, Accident, Critical Illness and/or Vision product(s)), the election of which triggered the volume-based discount, <br /> lapses during the Policy Period, the Company reserves the right to remove the discount on the Individual Stop-Loss <br /> Premium. In such event, the Individual Stop Loss Premium will revert to the non-discounted amount, following sixty (60) <br /> days'prior notice to the Employer Group/Policyholder. <br /> D. Aggregate Stop Loss Coverage: Yes® No❑ <br /> If yes, complete Items 1. through 5. Below: <br /> 1. New Coverage ❑ Renewal of Existing Coverage <br /> 2. Stop Loss Coverage during the current Policy Period <br /> ❑ Choosea.n1em <br /> Coverage for Claims incurred from to and Claims paid from to <br /> 2 <br /> IL SL-APP Rev.3.21 <br /> A Division of Health Care Service Corporation,a Mutual Legal Reserve Company <br /> an Independent Licensee of the Blue Cross and Blue Shield Association <br />