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Federal Racketeer Influenced and Corrupt Organizations Act. Any false statements made herein may be reported to state <br /> and federal tax and regulatory authorities as is appropriate. <br /> The undersigned person represents that he/she is authorized and responsible for purchasing Stop Loss Coverage on behalf <br /> of the Employer Group. it is understood that the actual terms and conditions of coverage are those contained in this <br /> Application and the Stop Loss Coverage Policy into which this Application shall be incorporated at the time of acceptance <br /> by Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation,a Mutual Legal Reserve Company <br /> ("HCSC"). Upon acceptance, HCSC shall issue a Stop Loss Coverage Policy to the Employer Group. Upon acceptance of <br /> this Application and issuance of the Stop Loss Coverage Policy, the Employer Group shall be referred to as the <br /> "Policyholder". <br /> Crystal Schuring <br /> Sales Representative Signature of Authorized Purchaser <br /> Title of Authorized Purchaser <br /> Date <br /> 5 <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 />