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, . '� <br /> ZURiCH <br /> ZURICH AMERICAN INSURANCE COMPANY <br /> Schaumburg,III. <br /> STOP LOSS POLICY <br /> SCHEDULE <br /> POLICYHOLDER: City of Decatur, IL <br /> Item 1 Employer Policy Number: 3 6-3 6-512 R <br /> Name of Employer: <br /> City of Decatur, IL <br /> 1 Gary K. Anderson Plaza <br /> Decatur, IL 62523 <br /> Item 2 Employer Effective Date: November 1, 2 0 04 <br /> Coverage Year From 11/01/0 4 > 12:00 A.M. Standard Time at the Address in Item 1, <br /> through 10�31�0 5 , 11:59 P.M. Standard Time. <br /> Premium Due Date: ls`of the month <br /> Individual Reporting: N/A , <br /> (a) Amount: $ during 12 months prior to the Employer Effective Date <br /> (b) Confinement in a hospital or similar insUtution: days prior to the Employer Effective Date <br /> (c) Compliance Date: must be within of the Employer Effective Date <br /> Claim Check Clearance Period: Two weeks from date of check issuance. <br /> Item 3 INDIVIDUAL STOP LOSS <br /> (a)Individual Stop Loss Amount per Covered Person for the Coverage Year $ 1, a o o, o 0 0 <br /> (b)Reimbursement Factor: i o o % <br /> Individual Deductible Amount $ 2 0 0, o 0 0 <br /> (c)Premium Rates Payable for the Coverage Year: <br /> Number of Initial Covered Units 6 g� <br /> Rates Per Unit Premium Mode <br /> 206 Single 11.07 Monthl� <br /> 481 Family 29_38 <br /> (d)Run-in Maximum: None <br /> (e) Minimum Premium: 14 7, 710 <br /> Item 4 AGGREGATE STOP LOSS <br /> (a) Monthly Aggregate DeducUble Factors <br /> Monthly Aggregate Initial Number of Covered Units <br /> Deductible Factor <br /> Single 548.59 206 <br /> Family 1,292_04 481 <br /> Initial Monthly Aggregate Deductible: 7 3 4,4 81 <br /> Initial Annual Aggregate Deductible: 8, 813, 7 6 9 <br /> (b) Minimum Annual Aggregate Deductible means: 1) If the Coverage is in force for the full coverage Year, an <br /> amount equal to i o o % of the Initial Aggregate Deductible Amount shown in the Schedule; and 2) If the <br /> Coverage does not continue in force for the full Coverage Year, the Minimum Annual Aggregate Deductible <br /> Amount means the greater of: <br /> a. the sum of the Monthly Aggregate Deductible amounts; <br /> b. 12 times the Monthly Aggregate Deductible for the third month during the Coverage Year;or <br /> c. an amount equal to i o o %of the Initial Annual Aggregate Deductible Amount shown in the Schedule. <br /> U-SL-D-100-A CW(1/97) Page 3 of 12 <br />