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� ' <br /> ' '� Monthly Pr�mium shall be equal to the amounts obtained by multiplying the number of Individual and Family <br /> ' Coverage Units for a particular Month by: <br /> $31.04 for each Coverage Unit <br /> The following applies if the answer to item B.S. above is"Yes" (Individual Stop Loss Coverage includes <br /> coverage of Run-Off Paid Claims): In the event of termination at the end of a Policy Period, an additional <br /> premium amount equal to 20%of the annualized Premium based on the participation of the two months <br /> immediately preceding termination will be due within 10 calendar days of receipt of the billing. <br /> 7. The premium is based upon a current membership of 248 Individual Coverage Units and 403 Family <br /> Coverage Units. <br /> Additional Provisions: <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 /> Exhibit and the Stop Loss Coverage Policy into which this Exhibit shall be incorporated at the time of acceptance by Blue <br /> 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 Exhibit and issuance of the Stop Loss Coverage Policy, the Employer Group shall be referred to as the"Policyholder." <br /> _, <br /> Penny Dunlevy -�-!',;- � <br /> Sales Representative Sign re of Authorize urchaser <br /> Carl Charvat City Ma ager <br /> Name of Underwriter Title of Authorized Purchaser <br /> December 14 , 2010 <br /> Dat <br /> AT S : , <br /> � <br /> INTERNAL USE ONLY Date Application approved by Underwriting: � <br /> Name of Underwriter: <br /> GA-10-4.1 HCSC Rev. 4/07 <br />