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10/22/04 FRI 15:05 FAX 770 977 9582 PERO 1�i CONSOCIATE TRAVI 1�002 <br /> • . ,��� , �r , <br /> , � <br /> ZURICH <br /> ZURICH AMERICAN INSURANCE COMPANY <br /> Schaumburg,III. <br /> REQUHST FOR STOP LOSS COVERAGE <br /> Thc undenigned Employer�quests Stop Loss coverage in connection witb its sel[funded cmployer Plan afBene�its. 'Fhe <br /> Company requires a Plan of Benefits summary describing thc nature and amount of all benefirs provided und�r such Plan. <br /> Proposed EmpJoyer Name� Ci ty of Decatur, IL <br /> Adclrress: � Gary K. Anderson Plaza <br /> Decatur, IL 62523 <br /> �hone� <br /> Nanue of Business: 9Ig9 General Govezximent, NEC <br /> 1-ist anp affttiates,subsidiaties or branches to 6e included unda tlus ptogram. (Referred to Associated C;ompa�ics���e <br /> Master Policy); <br /> RequcstedeoveragcYear- 11/Ol/04 - 10/32/05 <br /> Requested Claim Basis: Speci�ic: Incurred in 1 Months, Paid in 2 Months <br /> A88'regat�: Inctirred in I� Mont�is. Paid in �2 Months <br /> RequcstedPremiumiNode; Specific: Monthly Aggregate: Monthly <br /> Claims Admimstrator Consociate Gxoup <br /> Minimum Participation: L employees <br /> lndividual Stop Loss 6t1 Yes 0 No <br /> Aggregate Stop Loss �Yes ❑No I, <br /> THE UND�RSIGNED ENII�LOYER H�.R�BY AGREES'l�iAT� <br /> The undersigned represents that he or she has read the entire proposal, that the statcments in this Request and the I <br /> underwriting submissions are represEntations and not warraaties, and that hc or she undcrstands that the Stop Loss I <br /> Coverage is not effective until this Request is approved by the C pany. � <br /> Signature of Authorized PersQn; I <br /> Printcd Name of Authonaed Person: �v�'\,v� <br /> Tide�E� �d',v�.0�`'Z_._ <br /> Signed at�b`�� � On <br /> Witness: <br /> (Licensed Rcsident Agent,where required) <br /> The Initiatpremium shouTdbe payable to the Company. <br /> U-SL-108-A CW(3l9� <br /> Page 1 of 1 <br /> 10/22/04 15:40:45 <br />