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I ' . <br /> �• • � <br /> Iniiividual Stop Loss Coverage (continued) <br /> 3. Individuaf Stop Loss Coverage shall apply to: <br /> � Medical Claims � Vision Claims ❑ Dental Claims(Pre-Dent) <br /> � Outpatient Prescription Drug Claims ❑ <br /> 4. Individual Stop Loss Limit: $200,000.00 <br /> Includes Claim Administrator Provider Access Fee. <br /> 5. Premium (select one}: �, <br /> ❑ Monthly: $ each month or$6.81 per employee each month. I <br /> ❑ Annual: $ <br /> 6. The premium is based upon a current membership of 129 Individual Coverage Units and 433 Family Coverage <br /> Units. <br /> Additional Provisions: <br /> The undersigned person represents that he/she is authorized and responsible for purchasing stop loss coverage on <br /> behalf of the Employer Group. It is understood that the actual terms and conditions of coverage are those contained in <br /> the Stop Loss Coverage Policy into which this Application for Stop Loss Coverage shall be incorporated at the time of <br /> acceptance by Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC). Upon acceptance, HCSC <br /> shall issue a Stop Loss Coverage Policy to the Employer Group. <br /> Penny Dunlevy, Account Representati e��� <br /> � <br /> Sales Representative Signature of uthorized urchaser <br /> Name of Underwriter Title of Authorized Purchaser <br /> Date <br />