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, _ <br /> Individual Stop Loss Coverage (continuedj <br /> 4. Individual Stop Loss Limit $ 100.000.00 <br /> 5. Premium: � Monthly $ 15.15 or$ (per employee) <br /> (select one) <br /> ❑ Annual $ <br /> 6. The pre�um is based on a current membership of 41 Individual Coverage units <br /> and Family Coverage units. <br /> Additional Provisions: <br /> The undersigned person represents that he/she is authorized and responsible for purchasing stop loss coverage <br /> on behalf of the Employer Group. It is understood that the actual terms and conditions of coverage are those <br /> contained in the Stop Loss Coverage Policy into which this Application shall be incorporated at the time of <br /> acceptance by Health Care Service Co�poration, a Mutual Legal Reserve Company(HCSC). Upon acceptance, <br /> HCSC shall issue a Stop Loss Coverage Policy to the Employ roup. <br /> David Underkoffler <br /> Sales Representativa Si ature of thorized Purchaser <br /> City Manager <br /> Name of Undetwnter Title at Authorized Purchase� <br /> 10/22/96 <br /> Date <br /> GA-10-4.1 HCSC 4/91 <br /> (Back) <br />