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� • � � . • <br /> C•roup Number(s): g,�2844 <br /> _... <br /> ' � %of ADP Savings: 5� % <br /> 4 <br /> � ❑ $Per Employee per Month $ <br /> Group Number(s): Po6856 <br /> � nx %of ADP Savings: 25 <br /> � ;. % I <br /> ❑ $Per Employee per Month $ ' <br /> _ � , <br /> Payment Method: �Transfer Payment ❑ Post Payment <br /> ; If Transfer Payment: <br /> Method of Transfer Payment: �Wire Transfer ❑Draft ❑Electronic Fund Transfer ❑Other: <br />� Payment Period: ❑Daily �Weekly ❑Bi-Weekly ❑Montt��y ❑Other: <br /> � <br /> Ciaim Settlements: OMonthly ❑Quarterly ❑Other: <br /> �.. <br /> I Term of Agreement: �One Year ❑ Years <br /> ' Jumber of Transfer Payments required after termination: (applicab/e to TransferPaymentMethod only) <br /> Final Settlement: Final SE:ttlement to be made 6 month(s) after termination of agreement <br /> i}#UMAN ORGAN TRANSPLANT COVERAGE ' <br /> 1. � All human organ transplants will be self-insured by the Employer up to any applicable stop loss limit(s). <br /> 2. ❑ Special Human Organ Transplant Coverage—selected organ�will be fuliy insured by Health Care Service Cor- <br /> poration,a Mutual Legal Reserve Company("HCSC"). (A separate Application for Special Human Organ Trans- <br /> planfs Coverage musf be carr,plefed.) <br /> OTHER PROVISIONS: <br /> �. Reimbursement Provision: �Yes O No If yes: <br /> �l It is understood and agreed that in the event HCSC makes a recovery on a third-party liability claim, HCSC will <br /> retain 15%of the net recovery after attorneys'fees, if any, have been paid. <br /> ❑ It is understood and agreed that in the event HCSC makes a recovery on a third-party liability claim, HCSC wili <br /> retain % of the net recovery after attorneys'fees, if any, have been paid. <br /> 2. Conversion Privilege: � Yes �No lf yes, conversion fee: $ 6,Q0o per conversion. <br /> 3. Stop Loss Coverage purchased: �Yes ❑No (If yes,complete a separate Application for Stop Loss Coverage) <br /> �. Fort Dearborn Life Insurance purchased: X�Yes ❑No (If yes, complete separate application) <br /> �. Medical 3ervices Advisory Program (MSA)/ <br /> Individual Benefits Management Program (IBMP) purchased: � Yes ❑No <br /> I/yes: The undersigr�-�d representative authorizes provision of a/ternative benefits forservices rendered to Cod�ered Persons in <br /> accordance w�th the provisic:�s o/the Administrafive Services Agreement and the P/an Document. <br /> �;A-10-4 HCSC Rev.6/96 page 3 <br />