Laserfiche WebLink
�1V/ LLlvY a��a a .vv ann � �v v� � vvv� au.�� .��.....�.��..�� �"'�.� .�,." ' <br /> r , �� <br /> ZURI��i <br /> ZURICN AMERICAN INSURANCE COMPANY <br /> �,III. <br /> STOP LOSS POLICY <br /> ��HEIIU�E <br /> POLICYHOLbER; City o€ Decatur, IL <br /> Itcm I Employer P-oliry iVnmbcr; 36-36-512R <br /> Name of Employez: <br /> CYty of Decatur. IL <br /> 1 Gary 1C. Anderson Plaza <br /> Becatur. II; 62523 <br /> item 2 Employer Effective Date� November 1. 2004 <br /> Cwera e Year From <br /> g �1,LQ1LQt�, 12:00 A.M.Standard Time at the Address in Item 1, <br /> throu h 11:59 P,M. Scan <br /> g 14i3i�n5 , dard Time. <br /> Premium Due D"ate: 1`rof the month <br /> Individnal Rcporting�N/A <br /> (a) Amount; � during 12 months griar to the Employer Effective Date <br /> (b) Confinement in a hospital or similar institution: days prior to the Empioyer Effective Date <br /> (c) Comptiance�ate� must be within`w of the Employer Effcctive Date <br /> Claim Check Clearance Period: 'Irvo weeks from date of check issuancc. <br /> Item 3 INDIVIDUAL STOP LOSS <br /> (a)Inctividuat Stog Loss Amount per Cwered Person for thc Coverage Year $_ 1,son_nnn <br /> (b)Reimbursement Factor: �n�_% ' <br /> Individual IJeducti6le Amount $ 200 � <br /> (c)i'semium Rates Payable for the Cwerage Year: <br /> Nurtlber oftnitial CoverediTnits ti 5� ��, <br /> Rates Per Unit Premium Mode � <br /> 138 Single _.�l,QZ Monthl^ <br /> �f Family �9_38 <br /> (d)Run-in Maximum� None <br /> (e) MinimumFrcmium: 149.66T <br /> Item 4 AGGREGATE STOP LO�S <br /> (a) Mondily Aggregate beductibte Fat�eots <br /> Monthly Aggregate Initial Number of Covered U�its <br /> Deductihle F�tor <br /> Single 5�R_59 l�g <br /> Fam�Zy _1.292.�4,� <br /> Initial Monthly Aggregate Deducuble: 7�q,gL4 <br /> Initial Annual Aggregate Deductible� g�g)��768 <br /> {b) Mintmum Annua]Aggregau Dcductible means: 1)If the Coverage i�in foLca fQc the fi�lLcon�eragcXea�a� <br /> amount equal to 1 nn %of ihe Initial Aggregaie Deduct�ihle A�no� shown in thc Schedule; and 2}If rti@ <br /> Coverage does not continue in force for the full Coverage Year�t�e I�tinimum AnnuaLAggcegat�iledueiible <br /> Amou�st means thc greater of� <br /> a. the sum of the Monthly A�gregatc Deductible amounts; <br /> b. 12 dmes the Monthty Aggregate Deductiblc for the thirdmonW_during the Coverage Y¢ar;or <br /> c. an amonnteqvat t6 1 fl0 a/o of the tnitial annual Aggregate Deductible Amount shown in the Sched�}1e. <br /> U-SL-D-100.A CW(1/97) PaQa 3 of i2 <br />