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: : <br /> BlueCross BlueShieid <br /> . . . <br /> � <br /> of Illinois <br /> EXHIBIT TO THE <br /> STOP LOSS COVERAGE POLICY <br /> (ASO Accounts Only) <br /> Employer Group Name: Citv of Decatur <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 <br /> Effective Date of Policy 1/1/2016 <br /> Policy Period: These specifications are for the Policy Period commencing on 1/1/2016 and ending on 12/31/2016 <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 terminates; or(3)The date this Exhibit is superseded in whole or in part by a later executed Exhibit.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 /> "Run-in" includes claims paid by Policyholder's prior claim administrator: Yes ❑ No ❑ <br /> If yes, such claims must be reported by the Policyholder to the Company(Blue Cross and Blue <br /> Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve <br /> Company)within 12 months of the Effective Date of Policy and paid by the Policyholder's prior <br /> claim administrator within 6 months after the Effective Date of Policy. , <br /> � Renewal of Existing Coverage: i <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 I <br /> � Outpatient Prescription Drug Claims ❑ Dental Claims I� <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 /> GA-10-4.1 HCSC Rev.4/07 <br />