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L � <br /> � ;�� � BlueCross BlueShiel <br /> � of Illinois <br /> EXHIBIT TO. THE <br /> STOP LOSS COVERAGE POLICY <br /> (ASO Accounts Only) <br /> Employer Group Name: Citv of Decatur, Illinois <br /> Employer Group Address: #1 Garv K. Anderson Plaza <br /> City: Decatur State of Situs: IL Zip Code: 62523- <br /> 1196 <br /> Account Number: 022346 <br /> Employer Group Number(s): P22346, P22347, P22348, P22349, 022346 <br /> Effective Date of Policy 01/01/2008 <br /> Policy Period: These specifications are for the Policy Period commencing on 01/01/2008 and ending on 12/31/2008 <br /> The specifications below shall become effective on the first day of the Policy Period specified above and shall continue in <br /> full force and effect until the earliest of the following dates: (1) The last day of the Policy Period; (2) The date the Policy <br /> terminates; or(3) The date this Exhibit is superseded in whole or in part by a later executed Exhibit. <br /> A. Aggregate Stop Loss Insurance: � Yes ❑ No <br /> If yes, complete items 1. through 9. below. <br /> 1. � New Coverage ❑ Renewal of Existing Coverage <br /> 2. Stop Loss Coverage Period: <br /> � New Coverage (Select one from below): <br /> � Standard: Claims incurred and paid during the Policy Period. <br /> ❑ Standard with "Run-in" included: Claims incurred on or after and paid during the Policy <br /> Period. <br /> ❑ Renewal of Existing Coverage: <br /> Claims incurred on or after the original Effective Date of Policy and paid during the Policy Period. <br /> 3. Aggregate Stop Loss Insurance shall apply to: <br /> � Medical Claims ❑ Vision Claims <br /> � Outpatient Prescription Drug Claims ❑ Dental Claims <br /> 0 <br /> ❑ For Hospital Employer Groups only: Excludes /o of Home Hospital Medical claims <br /> ❑ Other (please specify): <br /> 4. Average Claim Value: 767.83 (per employee per month) <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 /> ��A-10-4.1 HCSC Rev. 4/07 <br />