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Individual Stop Loss Coverage (continued) <br /> 4. Individual Stop Loss Limit $ I� 00 <br /> 5. Premium: �f Monthiy $ 3, `I5�-�v or$ SCs . d� (per employee) <br /> (select one) <br /> � Annual $ <br /> 6. The premium is ased on a current membership of � �`�- Individual Coverage units <br /> and 3� � 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 Corporation, a Mutual Legal Reserve Company(HCSC). Upon acceptance, <br /> HCSC shall issue a Stop Loss Coverage Policy to the Employ Group. <br /> � <br /> � �,.5��� -�l.l�' � �- � . <br /> Sales Representetrv �gnature of Authorized Purchaser <br /> �� <br /> City Manager <br /> Name ol Underwriter Title ol Authorized Purchaser <br /> September 22 , 1992 <br /> �ece <br /> GA-10-4.1 HCSC 4/91 <br /> (Back) <br />