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Proposed Employer Name: city of Decatur, IL <br /> Employer Policy Number: 3 6-3 6-s i a R <br /> Requested Coverage Year: ii/oi/o4 - io/3i/os � <br /> CaiilBi: Zurich American Insurance Company <br /> The following conditions hereby attach to and form part of the application for Stop Loss Coverage <br /> with Zurich American Insurance Company: <br /> Retired Employees are covered if eligible by definition under the terms of the Employee <br /> Benefit Plan. Disabled Persons are covered if eligible by definition under the terms of <br /> the Employee Benefit Plan. If the enrollment drops below 515 lives, the group will be <br /> subject to review. Monthly Aggregate Deductible Factors are subject to adjustment based <br /> on monthly claims and enrollment to the effective date. *Alcohol/substance abuse <br /> benefit is paid according to the terms of the Plan Document. City of Decatur is aware <br /> that the contract is renewing on a 12/12 basis and there is a possibility that there <br /> will be a gap in coverage due to the terms of this contract. <br /> O1/24/05 14 :18:3 I <br />