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IndividuaS'Stop Loss Coverage (continued) <br /> ,3. Individu�! 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 <br /> includes Claim Administrator Provider Access Fee. <br /> 5. Premium (select one): <br /> � Monthly: $ each month or$6.39 per employee each month. <br /> ❑ Annual: $ <br /> 6. The premium is based upon a current membership of 122 Individual Coverage Units and 383 Family Coverage Units. <br /> Additional Provisions: <br /> The undersigned person represents that he/she is authorized and responsible for purchasing stop loss coverage on behalf <br /> of the Empfoyer Group. It is understood that the actual terms and conditions of coverage are those contained in the Stop <br /> Loss Coverage Policy into which this Application for Stop Loss Coverage shall be incorporated at the time of acceptance <br /> by Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC). Upon acceptance, HCSC shall issue a <br /> Stop Loss Coverage Policy to the Employer Group. <br /> Richard Rappenecker <br /> Sales Representative Signature of Authorized Purchaser <br /> Name of Underwriter Title of Authorized Purchaser <br /> Date <br /> GA-10-4.1 HCSC 12/96(Online Version) <br />