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. .. ,. <br /> . �.: <br /> � • BlueCross BlueShield <br /> � of Illinois <br /> `n Independent Licensee of the <br /> lue Cross and Blue Shield Association <br /> APPLICATION FOR STOP LOSS COVERAGE <br /> (ASO Accounts Only) <br /> Employer Group Name: City of Decatur <br /> Employer Group Address: #1 Gary K Anderson Plaza <br /> Decatur I L 62523 <br /> Employer Group Number(s): 992844 section 0100 <br /> Effective Date of Policy: 11-1-98 to 10-31-99 <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 11-1-98 to 10-31-99 <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: $6,173.14 (per employee). Includes Claim Administrator's Provider Access Fee <br /> 5. Attachment Point: 125% of the Average Claim Value. <br /> 6. Aggregate Stop Loss Limit Claim Value: $7,716.43 <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 82 Individual Coverage Units and 54 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 11-1-98 to 10-31-99 <br /> GA-10-4.1 HCSC 12/96(Online Version) <br />