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. , 4 <br /> ; ► <br /> �� (� BlueCross BlueS <br /> � v of Illinois <br /> An Independart Lica�see ofthe <br /> Blue Cross and Blue Shield Assoc:iation <br /> APPLICATION FOR STOP LOSS COVERAGE <br /> (ASO Accounts Only) <br /> Employer Group Name: City of Decatur Employees <br /> Employer Group Address: #1 Gary K.Anderson Plaza <br /> Decatur IL 62523-1196 <br /> Employer Group Number(s): 992844- 0100 <br /> Effective Date of Policy: 11-1-00 <br /> Aggregate Stop Loss Coverage: � Yes ❑ No <br />� If yes, complete items 1 through 9 below. <br /> 1. ❑ New Coverage � Renewal of Existing Coverage <br /> 2. Stop Loss Coverage Period: <br /> From 11-1-00 to 10-31-01 <br /> 3. Aggregate Stop Loss Coverage shall apply to: <br /> � Medical Claims ❑ Vision Claims ❑ Dental Claims(Pre-Dent) <br /> � Outpatient Prescription Drug Claims ❑ <br /> 4. Average Claim Value: $7,426.89 (per employee). Includes Claim Administrator's Provider Access Fee <br /> ���€��►x�F-�1��ew� <br /> 5. Attachment Point: 125% of the Average Claim Value. <br /> 6. Aggregate Stop Loss Limit Claim Value: $9,283.61 <br /> (equals the Average Claim Value multiplied by the Attachment Point) <br /> 7. Aggregate Stop Loss Coverage Limit: <br /> The Aggregate Stop Loss Coverage Limit shall equal the average number of employees during the Stop Loss <br /> Coverage Period multiplied by the Aggregate Stop Loss Limit Claim Value. <br /> 8. Annual Premium <br /> (Due on the Effective Date of Policy): $8,857.19 <br /> 9. The annual premium is based upon a current membership of 58 Individual Coverage Units and 32 Family Coverage <br /> Units. <br /> Individual Stop Loss Coverage: � Yes ❑ No <br /> If yes, complete items 1 through 6 below. <br /> 1. ❑ New Coverage � Renewal of Existing Coverage <br /> 2. Stop Loss Coverage Period: <br /> From 11-1-00 to 10-31-01 <br />