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' � Includes Claim Administrator's Provider Access Fee <br /> ' ❑ Excludes Claim Administrator's Provider Access Fee <br /> Attachment Factor: 125% of the Average Claim Value <br /> 5. Aggregate Attachment Claim Liability: <br /> Employ�r's Claim Liability for each Policy Period shall be the sum of the Monthly amounts obtained by <br /> multiplying the number of Individual and Family Coverage Units for each Month by the following factor: <br /> $ 959.79 for each Coverage Unit <br /> 6. Aggregate Stop Loss Coverage includes coverage of Run-Off Paid Claims: � Yes ❑ No <br /> Run-Off Attachment Claim Liability Factors: <br /> Employer's Run-Off Claim Liability shall be an amount equal to 15% of the annualized Employer Claim Liability <br /> based on the participation of the two calendar months immediately preceding termination. Settlement for the <br /> final accounting period will be described in the section of the Policy entitled SETTLEMENTS. <br /> 7. Aggregate Stop Loss Coverage: <br /> a. The amount of Paid Claims during the current Policy Period, less Individual (Specific) Stop Loss Claims, if <br /> any, that exceed the Point of Attachment. The Point of Attachment shall equal the sum of the Employer's <br /> Claim Liability amounts calculated Monthly as described in Item 5. above for the indicated Policy Period. <br /> However, for the indicated Policy Period the minimum Point of Attachment shall be $6,841,365.30. <br /> b. The following applies if the answer to item 6. above is"Yes-° (Aggregate Stop Loss Coverage includes <br /> coverage of Run-Off Paid Claims): <br /> In the event of termination at the end of a Policy Period, Aggregate Stop Loss Coverage shall equal the <br /> amount of Final Settlement Paid Claims that exceed the Final Settlement Point of Attachment. Final I <br /> Settlement Paid Claims shall equal the sum of the Paid Claims during the Final Policy Period and the Paid ! <br /> Claims during the Run-Off Period, less Individual (Specific) Stop Loss Claims, if any. The Final Settlement <br /> Point of Attachment shall equal the sum of the Employer's Claim Liability amount for the Final Policy Period <br /> and the Employer's Run-Off Claim Liability calculated as described in items 5. and 6. above. However, for <br /> the Final Settlement Period the minimum Point of Attachment shall be the minimum Point of Attachment in <br /> item 7.a. above increased by 15%. <br /> 8. Premium (Select one): <br /> � Annual Premium (Due on the first day of the Policy Period): $ 69,347.15. <br /> The following applies if the answer to item 6. above is"Yes-" (Aggregate 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 15% of the Annual Premium will be due within 10 calendar days of receipt of the <br /> billing. <br /> ❑ Monthly Premium shall be equal to the amounts obtained by multiplying the number of Individual and Family <br /> Coverage Units for a particular Month by: <br /> $ for each Coverage Unit <br /> The following applies if the answer to item 6. above is"Yes-" (Aggregate Stop Loss Coverage includes <br /> coverage of Run-Off Paid Claims): <br /> In the event of termination at the end of a Policy Period, an additional premium amount equal to 15% of the <br /> annualized Premium based on the participation of the two months immediately preceding termination will be <br /> due within 10 calendar days of receipt of the billing. <br /> 9. The premium is based upon a current membership of 236 Individual Coverage Units and 424 Family Coverage <br /> Units. <br /> B. Individual (Specific) Stop Loss Insurance: � Yes ❑ No <br /> If yes, complete items 1. through 6. below. <br /> 1. � New Coverage ❑ Renewal of Existing Coverage <br /> GA-10-4.1 HCSC Rev. 4/07 <br />