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-- � B1ueCross B1ueShield <br /> ��� <br /> of Illi�aoi.s <br /> � � <br /> An Independent Licensee of rhe <br /> Bluc Cross and Blue Shield Associadon � <br /> APPLICATION FOR STOP LOSS COVERAGE <br /> (ASO Accounts Oniy) <br /> Employer Group Name: city of Decatur <br /> Employer Group Address: #1 civic Center P1aza <br /> I�ecatur. IL 62523 <br /> Employer Group Number(s): PQ68s6 section oloo <br /> Effective Date of Policy: il�oi/9� to 10/31/98 <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 ii�oi�97 to io/31/g8 <br /> 3. Aggregate Stop Loss Caverage shall apply to: <br /> � Medical Claims ❑ Vision Claims ❑ Dental Claims (Pre-Dent) <br /> � Outpatient Prescription Drug Claims ❑ <br /> 4. Average Claim Value: $ 5,043.23 (per employee) <br /> � Includes Claim Administrator's Provider Access Fee <br /> ❑ Excludes Claim Administrator's Provider Access Fee <br /> 5. Attachment Point: �-25 % of the Average Claim Value <br /> 6. Aggregate Stop Loss Limit Claim Value: $ ti,�n4_04 <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 <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): $ 4,099 <br /> 9. The annual premium is based upon a current membership of 26 Individual Coverage <br /> Units and �13 Family 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 li/ol/9� to ].0/31/98 <br /> (continued on reserve side) <br /> GA-10-4. HCSC 12/96 <br />