R2010-233 AUTHORIZING AGREEMENT - Laserfiche WebLink

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� " �� BlueCross BlueShiel � � of Illinois EXHIBIT TO THE STOP LOSS COVERAGE POLICY (ASO Accounts Only) Employer Group Name: City of Decatur, Illinois Employer Group Address: #1 Garv K. Anderson Plaza City: Decatur State of Situs: IL Zip Code: 62523- 1196 Account Number: 022346 Employer Group Number(s): P22346, P22347. P22348, P22349 Effective Date of Policy 1/1/2011 Policy Period: These specifications are for the Policy Period commencing on 1/1/2011 and ending on 12/31/2011 The specifications below shall become effective on the first day of the Policy Period specified above and shall continue in full force and effect until the earliest of the following dates: (1)The last day of the Policy Period; (2) The date the Policy terminates; or(3)The date this Exhibit is superseded in whole or in part by a later executed Exhibit. A. Aggregate Stop Loss Insurance: � Yes ❑ No If yes, complete items 1. through 9. below. 1. ❑ New Coverage � Renewal of Existing Coverage 2. Stop Loss Coverage Period: ❑ New Coverage (Select one from below): ' ❑ Standard: Claims incurred and paid during the Policy Period. ❑ Standard with "Run-in" included: Claims incurred on or after and paid during the Policy Period. � Renewal of Existing Coverage: Claims incurred on or after the original Effective Date of Policy and paid during the Policy Period. 3. Aggregate Stop Loss Insurance shall apply to: � Medical Claims ❑Vision Claims � Outpatient Prescription Drug Claims ❑ Dental Claims ❑ For Hospital Employer Groups only: Excludes °/o of Home Hospital Medical claims ❑ Other(please specify): 4. Average Claim Value: 929.70 (per employee per month) A Diwsion of Health Care Service Corporation,a Mutual Legal Reserve Company an Independent Licensee of the Blue Cross and Blue Shield Association GA-10-4.1 HCSC Rev.4/07