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� B1ueCross B1ueShield <br /> ��� <br /> � of Illinois <br /> An Independent Licensee of the <br /> 31ue 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 IL 62523 <br /> Employer Group Number(s): P06859 section 0100 <br /> Effective Date of Policy: 11-1-98 <br /> Aggregate Stop Loss Covera e: Yes No <br /> 9 � ❑ <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 ❑ Dentat Claims (Pre-Dent) <br /> � Outpatient Prescription Drug Claims ❑ <br /> +. Average Claim Value: $5,144.28 (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: $6,430.35 <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): $32,888.81 <br /> 9. The annual premium is based upon a current membership of 122 Individual Coverage Units and 383 Famify <br /> Coverage 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 />