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• � Blue G�+oss � <br /> � ' � Blue Shield ` - <br /> ot Illinois •L' <br /> � a <br /> APPLICATION FOR STOP LOSS COVERAGE <br /> (For use by ASO Accounts) <br /> Employer Group Name �._:� <br /> Employer Group Address � � � ���� ,� <br /> ��c-c��.� � l��?5�� <br /> Employer Group Number q9 � �`��{ <br /> Effective Date of Policy I I- I-`��2 I <br /> Aggregate Stop Loss Coverage (gl Yes O No I�, <br /> !f yes, complete items i through 9 be/ow. ' <br /> 1. ❑ New Coverage � Renewal of Existing Coverage <br /> 2. Stop Loss Coverage Period: <br /> From � �- l- �1 a to I O-3 1-9 � '� <br /> 3. Aggregate Stop Loss Coverage shall apply to: - l <br /> � Medical Claims ❑ Vision Claims <br /> ❑ Dental Claims(Pre-Dent) ❑ Outpatient Prescription Drug Claims ❑ <br /> 4. Average Claim Value: $ `�,��b- 3 3 (per employee) , <br /> 5. Attachment Point: I d 5 % of the Average Claim Value <br /> 6. Aggregate Stop Loss Limit Claim Value: $ S. v3�1.°I 1 ' <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. I <br /> 8. Annual Premium ' <br /> (Due on the Effective Date of Policy) $ 1 � 383- d� <br /> 9. The annual premium is based on a current membership of � ��- Individual Coverage units <br /> and _ 38`� Family Coverage units. <br /> Individual Stop Loss Coverage �Yes ❑ No <br /> If yes, complete items 1 through 6 below. <br /> 1. O New Coverage L�Renewal of Existing Coverage <br /> 2. Stop Loss Coverage Period: <br /> From 1 I - I - 1 a �o I 0 -�1 -`�3 <br /> 3. Individual Stop Loss Coverage shall apply to: <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 /> �F.,._.� <br />