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Blue G�+oss <br /> Blue Shield ` ' <br /> of Iilinois •�' <br /> o a <br /> APPLICATION FOR STOP LOSS COVERAGE <br /> (For use by ASO Accounts) <br /> Employer Group Name Ci ty of Decatur <br /> Employer Group Address �1 Ci vi c Center P1 aza <br /> Decatur IL 62523 <br /> Employer Group Number P06856 secti on O 100 <br /> Effective Date of Policy 11/Ol/96 <br /> Aggregate Stop Loss Coverage � Yes ❑ No <br /> If yes, complete items 1 through 9 be/ow. <br /> 1. ❑ New Coverage � Renewal of Existing Coverage <br /> 2. Stop Loss Coverage Period: <br /> From 11/O1/96 to 10!31/97 <br /> 3. Aggregate Stop Loss Coverage shall apply to: <br /> � Medical Claims ❑ Vision Claims <br /> ❑ Dental Claims(Pre-Dent) X❑ Outpatient Prescription Drug Claims ❑ I <br /> 4. Average Claim Value: $ 4249.05 (per employee) I� <br /> 5. Attachment Point: 125 0� of the Average Claim Value <br /> 6. Aggregate Stop Loss Limit Claim Value: $ 5311.31 <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 Stop <br /> Loss Coverage Period mutiplied by the Aggregated Stop Loss Limit Claim Value. <br /> 8. Annual Premium <br /> (Due on the Effective Date of Policy) $ 4490.00 <br /> ni <br /> 9. The annual premium is based on a current membership of Individual Coverage units <br /> and �3 Family Coverage units. <br /> Individual Stop Loss Coverage �] Yes ❑ No <br /> !f yes, complete items 1 through 6 be/ow. <br /> 1. ❑ New Coverage � Renewal of Existing Coverage <br /> 2. Stop Loss Coverage Period: <br /> From 11/10/96 to 10/31/97 <br /> 3. Individual Stop Loss Coverage shall apply ta: <br /> � Medical Claims ❑ Vision Claims <br /> ❑ Dental Claims � Outpatient Prescription Drug Claims ❑ <br /> (continued on reverse side) <br /> GA-10-4.1 HCSC 4/91 <br /> (Front) <br />