Laserfiche WebLink
. <br /> �� <br /> ZURICH <br /> ZURICH AMERICAN INSURANCE COMPANY <br /> Schaumburg,III. <br /> REQUEST FOR STOP LOSS COVERAGE <br /> The undersigned Employer requests Stop Loss coverage in connection with its self-funded employer Plan of Benefits. The <br /> Company requires a Plan of Benefits summary describing the nature and amount of all benefits provided under such Plan. <br /> Proposed Employer Name: City of Decatur, zL � <br /> Address: 1 Gary K. Anderson Plaza <br /> Decatur, IL 62523 <br /> Phone: <br /> Nature of Business: 9199 General Government, NEC <br /> List any affiliates, subsidiaries or branches to be included under this program. (Referred to Associated Companies in the <br /> Master Policy): <br /> Requested Coverage Year: 11/01/0 4 - 10/31/0 5 <br /> RequestedClaimBasis: Specific: Incurred in 12 Months, Paid in 12 Months <br /> Aggregate: Incurred in 12 Months, Paid in 12 Months <br /> Requested Premium Mode: Specif ic: Monthly Aggregate: Monthly <br /> Claims Administrator: Consociate Group <br /> Minimum Participation: s� s employees <br /> Individual Stop Loss �Yes ❑No <br /> Aggregate Stop Loss �Yes ❑No <br /> TI�UNDERSIGNED EMPLOYER HEREBY AGREES THAT: <br /> The undersigned represents that he or she has read the entire proposal, that the statements in this Request and the <br /> underwriting submissions are representations and not wananties, and that he or she understands that the Stop Loss <br /> Coverage is not effective until this Request is approved by the Com <br /> Signature of Authorized Person: <br /> Printed Name of Authorized Person: ���.�e G,q��nn�v� <br /> Title: (�1� 1( ' 1 �N�CG f'✓l._ <br /> Signed at �e.Cd't� n-- , �t��t�c�i S on '�.-��j, l , 2�� <br /> Witness: ��� �- <br /> �� <br /> (Licensed Resident Agent,where required) <br /> The Initial premium should be payable to the Company. <br /> U-SL-106-A CW(3/97) <br /> Page 1 of 1 <br /> O1/24/05 14:18:33 <br />