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� � B1ueCross B1ueShield <br /> i�i <br /> of Illinois <br /> � � <br /> An Independent Liccnsee of che <br /> Bluc Cross and Bluc Shield Association <br /> APPLICATION FOR STOP LOSS COVERAGE <br /> (ASO Accounts Only) <br /> Empioyer Group Name: city o� Decatur <br /> Employer Group Address: #�. ciVic Center Plaza <br /> Decatur, IL 62523 <br /> Empioyer Group Number(s): 992s44 section o100. <br /> Effective Date of Policy: Zl/o.1/9� to io�3i/9s <br /> Aggregate Sto�� 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/O1/97 to 10/31/98 <br /> 3. Aggregate Stop Loss Coverage shall apply to: <br /> � Medicai Claims ❑ Vision Ciaims ❑ Dental Claims (Pre-Dent) <br /> � Outpatient Prescription Drug Claims ❑ <br /> 4. Average Claim Value: $ 5,683.�2 (per employee) <br /> � Includes Claim Administrator's Provider Access Fee <br /> ❑ Excludes Claim Administrator's Provider Access Fee <br />� 5. Attachment Point: 125 % of the Average Claim Value <br /> 6. Aggregate Stop Loss Limit Claim Value: $_ �,�04.55 <br /> (equdls 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 ti�e average number of employees during the ' <br /> Stop Loss Coverage Period multiplied by the Aggregate Stop Loss Limit Claim Value. <br /> 8. Annual Premium ' <br /> (Due on the Effective Date of Policy): $ 23,230 ' � <br /> 9. The annual premium is based upon a current membership of Zco�� Individual Coverage � <br /> Units and _ •2,�� Family Coverage Units. <br /> lndividual Stop Loss Coverage: 0 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 _ �.�ioi/9� to il/ol/9s <br /> (continued on reserve side) <br /> GA-10-4.1 HCSC 1?J96 <br />