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, • • 7. Extension of Coverage due to Temporary Layoff, Leave of Absence or Disabiliry: <br /> Temporary Layoff days <br /> Leave of Absence days <br /> Disabiliry days <br /> 8. Financial Arrangement: <br /> (a) ❑ New Administrative Services Only Account <br /> (b) ❑ Former HCSC insured group converting to Administrative Services Only Account <br /> If(b)is checked: ❑ Converting on "Paid Claims" basis <br /> ❑ Converting on "Incurred and Paid Claims" basis <br /> (c)Service Charge: <br /> � � •c'I�J %of Claim Payments <br /> ❑ Separate Service Charges as checked and completed below. <br /> ❑ Applicable to health Claims: <br /> %of Claim Payments OR$ per employee per month <br /> ❑ Applicable to dental Gaims: <br /> %of Claim Payments OR$ per employee per month <br /> ❑ Administration of the Medical Seroices Advisory Program: <br /> %of Claim Payments OR$ 1 . J�� per employee per month <br /> (d)T pe of Agreement: <br /> � Advance Payment(Complete item#9 below) <br /> �'Transfer Payment(Complete item#10 below) <br /> 9. Advance Payment Agreement Specifications: <br /> (a)Amount of Advance Payment Coverage Period of this Advance Payment: <br /> $ <br /> $ <br /> $ <br /> (b) Payment Period <br /> ❑ Monthly <br /> ❑ Quarterly <br /> ❑ <br /> (c)Claim Settlement Period <br /> ❑ Monthly <br /> ❑❑ (�uarterly <br /> (d)Term of Agreement ❑ one year ❑ years <br /> (e) Number of Advance Payments required after termination of agreement: <br /> (fl Final Settlement to be made month(s)after termination of agreement. <br /> 10. Transfer Payment Agreement Specifications: <br /> (a) Method of Transfer Payment <br /> �Wire Transfer <br /> ❑ Draft <br /> ❑ Other: <br /> GA-10-4 HCSC Rev.3/92 PaoP 2 <br />