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� • 8. The Enrollment Period d;.�ring which a� Eligible Person may apply for coverage if he did not ap Iy prior to <br /> his Eligibility Date or if he did not apply for Family Coverage when eligible to do so is: the �Uth day <br /> after eligibili#�y date • <br /> Such Person's Coverage Date or Family Coverage Date is: <br /> 9. Extension of Benefits Due to Temporary Layoff or Leave of Absence: ❑ 30 days Q �.SD—days <br /> 10. Financial Arrangement: <br /> (a) ❑ New Administrative Services Only Account <br /> [� Former HCSC insured group converting to Administrative Services Only Account <br /> (b)Service Charge: <br /> � 1.95 %of Claim Payments ' <br /> , � Separate Service Charges as checked and completed below. <br /> O Applicable to health Claims: <br /> %of Claim Payments OR$ per employee per month <br /> 0 Applicable to dental Claims: � � . <br /> %of Claim Payments OR$ per employee per month <br /> ❑ Administration of the PPO Program: <br /> a/o of Claim Payments OR$ per employee per month <br /> L�Administration of the Medical Senrices Advisory Program: <br /> %of Claim Payments OR$ 1•�� per employee per month - <br /> (c)Type of Agreement: <br /> O Advance Payment(Complete item#11 below) <br /> � Transfer Payment(Complete item#12 below) <br /> 11. 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 /> a <br /> (c)Claim Setttement Period <br /> O Monthly <br /> ❑ Quarterly <br /> ❑ <br /> (d}Term of Agreement � O 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 /> 12. Transfer Payment Agreement Specifications: <br /> (a) Method of Transfer Payment <br /> ❑ Wire Transfer <br /> CJ Draft <br /> ❑ Other: <br /> c;�-1�-n N�c�^�� , ,^A Page 2 of 4 <br /> I <br />