R2010-233 AUTHORIZING AGREEMENT - Laserfiche WebLink

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� 2. 'Stop Loss Coverage Period: II ' ❑ New Coverage(Select one from below): !I ❑ Standard: Claims incurred and paid during the Policy Period. 'I ❑ Standard with "Run-in" included: Claims incurred on or after and paid during the Policy Period. I "Run-in" includes claims paid by Policyholder's prior claim administrator: Yes ❑ No ❑ If yes, such claims must be reported by the Policyholder to the Company (Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company)within 12 months of the Effective Date of Policy and paid by the Policyholder's prior claim administrator within 6 months after the Effective Date of Policy. � Renewal of Existing Coverage: Claims incurred on or after the original Effective Date of Policy and paid during the Policy Period. 3. Individual (Specific) Stop Loss Insurance shall apply to: � Medical Claims ❑Vision Claims � Outpatient Prescription Drug Claims ❑ Dental Claims ❑ For Hospital Employer Groups only: Excludes % of Home Hospital Medical claims ❑ Other(please specify): 4. Individual (Specific) Stop Loss Coverage a. Individual Stop Loss Coverage equals the amount of Paid Claims for a Covered Person during the current Policy Period in excess of the Point of Attachment of$200,000 per Covered Person. Such amount shall apply for the Policy Period. , Point of Attachment � Includes Claim Administrator's Provider Access Fee ❑ Excludes Claim Administrator's Provider Access Fee b. Employer's Claim Liability equals the sum of Paid Claims for a Covered Person during the Policy Period up to the Point of Attachment specified in 4.a. above. 5. Individual Stop Loss Coverage includes coverage of Run-Off Paid Claims: � Yes ❑ No The following applies if the answer to item 5. above is"Yes" (Individual Stop Loss Coverage includes coverage of Run-Off Paid Claims): a. In the event of termination at the end of the Policy Period, Individual Stop Loss Coverage shall equal the amount of Final Settlement Paid Claims that exceed the Point of Attachment specified in 4.a. above. Final Settlement Paid Claims shall equal the sum of Paid Claims for a Covered Person during the Final Policy Period and the Run-Off Period. b. In the event of termination at the end of the Policy Period, Employer's Final Settlement Claim Liability equals the sum of Paid Claims for a Covered Person during the Final Policy Period and Run-Off Period up to the Point of Attachment specified in Item 4.a. above. Settlement for the final accounting period will be described in the section of the Policy entitled SETTLEMENTS. 6. Premium (select one): ❑ Annual Premium (Due on the first day of the Policy Period): $ The following applies if the answer to item 6.5. is"Yes" (Individual Stop Loss Coverage includes coverage of Run-Off Paid Claims): In the event of termination at the end of a Policy Period, an additional premium amount equal to 20% of the Annual Premium will due within 10 calendar days of receipt of the billing. GA-10-4.1 HCSC Rev.4/07