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•IU/LL/U9 Ylll 1J:UO tMA I !V t/l1 t7JOG iGAv �-�-� VVI�JVV1AlL� an�a•a w�....v <br /> hem 4 AGGREGAT,E"STOP�,OSS, Continued <br /> (c) The Montlily Aggregate Deductihlc is determined monthly using the Monthiy ,qgg�ga1e <br /> Deductibl�Factors SFiown in 4(a) and�nuItiplied by the number of Covered Uni2s during each monrh, <br /> or pari therco�',on a prorated basis. <br /> (d3 �m�ai Aggregate ffeductible Amount means ihe grCater of thc Minimum Annpal Aggrcgate <br /> Deductible or 12 times the Monthiy Aggregate Deductible for the ninth month during the CQyezage <br /> ��arCrthe-sum of the Ntonthly Aggregate Deductibles during ihe coverage Year. <br /> (e) The Per Person Aggregate Maxim�un shall not exceed S 200,OQO <br /> f$ Reimb�semenfFacWr: I()0-�/0 <br /> (g) Ovexall Company Limit of�.iability-Maximum of $ 1,000,000 <br /> (1i) Premium Rates Payable for thc Coverage Year <br /> Number of Covercd Monthly Rate Pcr Premium Mode Deposit Prcmium Minimum pnnual <br /> Units Employec ASgreBate grEmit�m <br /> 652 6.34 Monthly 4,133-68 49�604 <br /> (i) Run-in Maximum: None <br /> Item 5 Speclf'ic Poliry CIaim Basis: Claims Incurred 11/Ol/04 thro <br /> h 10/31/05 <br /> � <br /> P-a�d �y t�ie Insured 11/O1/04 through 10/31/05 ' <br /> Covera��Includes: Medieal <br /> Aggrcgate Policq et�m Ba&is: Claims Incurred 11/Ol/04 through 10/31/OS I <br /> �x� by- rn� z�a irroi�� z��� ��r�r�os <br /> CoveragcI�rctudes� Medical <br /> Run-in PPriofi Spea`fic 0 Aggtegate 0 months prior 4o the Empioyer�ffective bate. <br /> Run-out Period� Sp�cific� Aggregate�_months after the ez�d of the Coverage Year. <br /> �tem 6 Serious Loss Notice: Notify the Company wiihin 30 days of the date clairos reach 85% of ihe <br /> A�regate-Eknnnat Deductib�te Amount and tre fi8te tfie rlaims for one individual reaches 50%af tlac <br /> Individual Stop Loss Amount and/or any cltim whici► one has reason to beli�ve as determined by a <br /> speei�ie�tagnosis aac}for progno,siswh�h woutd cxceed-t�ie Individual-�op Loss Amount per Covere� <br /> Person for Coverage Year. <br /> Item 7 Spec�ed�xcluded Charges: None <br /> Itcm 8 Minimum Participation Number 489 employeea <br /> Item 9 Amendatory Endorsement(s)executed simultaneously herewith: <br /> Itcm 10 ClairttsAdminisirator: Consociate Group <br /> Item 11 Associated Companies of the Employer: <br /> Item 12 Drug and Alcohol Conditio�as: The maximum eligible reimbnrsement for drug and alcohol con�tiens <br /> exccss of the Individual Smp �.oss Amount per Covered person for the Covezage Year is <br /> S � ° •,or the Current benc�t maximum under the Employee Bcnefit Plan,wliichever is 1€sa, <br /> This is a Ptoposed 5chediite-of eoverage, �cne�s and limits of liabiliiy far mediCal stop loss insurance, which is effective uptil <br /> .I2/�l/D4 The Coverng�is svbject to Definitions,Conditions,Limits, Exclusion�eu►d any other Policy ptovisions,wltich <br /> ate cantained iathaPotiEc}� ILtlsue_artan�inset►sisfeneies�m�rbignities-betrovearthe PraposerYgch�iul8 ru�d-Ehe�oliey,tfe�oI'ir� <br /> will govern. Tht Company restxves the tigltE tv ct��e the Progas�fi$�h��dute if t$e underwriting inFonnation on wMch thi�Proposed <br /> Schedule is based is not accwate or if after Ehe issuance uftbis Pzopa�sed rhrrin}n�e�_��g�_�����_����� <br /> the Cottlpuny. <br /> Signature of Authorized Person: <br /> Printe N nc of Authorizcd Person_ N�q <br /> Title: i�t�C�-C.�� Signed at L on <br /> Witness: (Licensed-Resident Agent,where required) <br /> U-SL-D-100-A CW(1/97) Pege 4 a(12 <br />