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. <br /> � . . . . • <br /> Group Number(s): 992s44 <br /> �%of ADP Savings: 50 % <br /> ❑ $Per Employee per Month $ <br /> Group Number(s): P06856 <br /> �%of ADP Savings: 25 0�0 <br /> ❑ $Per Employee per Month $ <br /> . . <br /> Payment Method: ❑ Transfer Payment ��ost Payment <br /> If Transfer Payment: <br /> Method of Transfer Payment: I�Vire Transfer ❑Draft ❑Electronic Fund Transfer ❑Other: <br /> Payment Period: ❑Daily �Weekly ❑Bi-Weekly ❑Monthly ❑Other: <br /> Claim Settlements: �Monthiy ❑Quarterly ❑Other: <br /> Term of Agreement: �One Year ❑ Years <br /> Number of Transfer Payments required after termination: (applicable to TransferPayment Method only) <br /> Final Settlement: Final Settlement to be made 6 month(s)after termination of agreement <br /> HUMAN 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 organs will be fully insured by Health Care Service Cor- <br /> poration,a Mutual Legal Reserve Company("HCSC").(A separate Application forSpecial Human Organ Trans- <br /> plants Coverage must be completed.) � <br /> OTHER PROVISIONS: <br /> 1. Reimbursement Provision: �] Yes � No !f yes: <br /> � 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 liabiliry claim, HCSC will <br /> retain %of the net recovery after attorneys'fees, if any, have been paid. <br /> 2. Conversion Privilege: �Yes ONo If yes, conversion fee: $ per conversion. <br /> 3. Stop Loss Coverage purchased: �Yes ❑No (If yes,complete a separate Application for Stop Loss Coverage) <br /> 4. Fort Dearborn Life Insurance purchased: �Yes ❑No (!f yes, complete separate application) <br /> 5. Medical Services Advisory Program (MSA)/ <br /> Individual Benefits Management Program (IBMP) purchased: � Yes ❑No <br /> If yes: The undersigned representative authorizes provision of alternative benefits for services rendered to Covered Persons in <br /> accordance with the provisions of the Administrative Seivices Agreemenf and the P/an Document.) <br /> GA-10-4 HCSC Rev.6/96 page 3 <br />