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6. Premium (select one): <br /> ❑ Annual Premium (Due on the first day of the Policy Period): $ <br /> The following applies if the answer to item 6.5. is "Yes" (Individual Stop Loss Coverage includes coverage of <br /> Run-Off Paid Claims): In the event of termination at the end of a Policy Period, an additional premium <br /> amount equal to 20% of the Annual Premium will due within 10 calendar days of receipt of the 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 /> $56.35 for each Coverage Unit <br /> ,� <br /> The following applies if the answer to item B.5. 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 211 Individual Coverage Units and 391 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 "Policynolder." <br /> � <br />, Bruce E.Williams `-- <br />' Sales Representative Signature of Authorized Purchaser <br /> Jim Paton �� S-`-� ���' '-'��" �Qr <br /> Name of Underwriter Title of Authorized Purchaser <br /> Date <br /> INTERNAL USE ONLY Date Application approved by Underwriting: <br /> Name of Underwriter: <br /> GA-10-4.1 HCSC Rev. 4/07 II <br />