Laserfiche WebLink
� � , <br /> Ini�ivittual Stop Loss Coverage(continued) <br /> 3. Individual Stop Loss Coverage shall appiy to: I� <br /> � Medical Claims � Vision Claims ❑ Dental Claims(Pre-Dent) ' <br /> � Outpatient Prescription Drug Claims ❑ , <br /> 4. Individual Stop Loss Limit: $200,000.00 �', <br /> InGudes Claim Administrator Provider Access Fee. ' <br /> 5. Premium (select one): <br /> ❑ Monthly: $ each month or$1 Q.86 pe�employee each month. <br /> ❑ Annual: $ <br /> 6. The premium is based upon a current membership of 58 Individual Coverage Units and 32 Family Coverage Units. <br /> Additional Provisions: <br /> The undersigned person represents that he/she is authorized and responsible for purchasing stop loss coverage on I' <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 /> shalt issue a Stop Loss Coverage Policy to the Employer Group. <br /> Penny Dunlevy, Account Representativ� <br /> Sales Representative Signature of A orized ur ser <br /> Name of Underwriter Title of Authorized Purchaser <br /> Date <br />