WISCONSIN PHYSICIANS SERVICE INSURANCE CORPORATION
WISCONSIN PHYSICIANS SERVICE INSURANCE CORPORATION
APPLICATION FOR STOP LOSS INSURANCE
The employer hereby applies for stop loss insurance coverage pursuant to the terms of this application.
Employer: State of Wisconsin
Address: 801 Badger Road, Madison, Wisconsin 53707
Nature of Business: Government
Effective Date: January 1, 2009_
SPECIFIC COVERAGE
Specific Deductible: $350,000.00 _______________ Lasers (if any): ___________________________________
Aggregating Specific Deductible: _X_ No ____ Yes If yes, $
Covered Benefits: _X__ Medical ___ Copay Prescription Legend Drugs ___ Vision ___ Dental
Covered Units: Applies to any group certified by the ETF as being covered under the Wisconsin Public Employers Employee Group Health Insurance Program: __X_ Single __X_ Family ___ Limited Family __X_ Retirees Under Age 65 _X__ COBRA
Benefit Claims Basis: __ 12/12 __ 15/12 __ 12/15 __ 18/12 __ 12/18 Other: 12/24
Monthly Rates: Employee/Single: __________ Dependent/Family: __________ Composite: Single: $25.19 Family: $62.97__________
Run-In Period: _Not Applicable_______________________________ Run-In Percentage: _Not Applicable_______
AGGREGATE COVERAGE
Monthly Aggregate Attachment Point: _ Single: $1,041.84 Family: $2,604.60________________
Covered Benefits: X _ Medical ___ Copay Prescription Legend Drugs ___ Vision ___ Dental
Covered Units: Applies to any group certified by the ETF as being covered under the Wisconsin Public Employers Employee Group Health Insurance Program: __X_ Single __X_ Family ___ Limited Family __X_ Retirees Under Age 65 _X__ COBRA
Benefit Claims Basis: __ 12/12 __ 15/12 __ 12/15 __ 18/12 __ 12/18 Other: 12/24 _
Monthly Rates: Employee/Single: __________ Dependent/Family: __________ Composite: $17.14 _______
Run-In Period: Not Applicable _ Run-In Percentage: Not Applicable___
Maximum Coverage Period Aggregate Benefit Amount: Not Applicable_____
Minimum Coverage Period Attachment Point: Not Applicable______________
If all outstanding requirements are not met within 90 days of the effective date, coverage may be rescinded and all collected premiums returned to the policyholder.
Conditions precedent to the binding of coverage under this application:
Approval of signed master plan document, approval of administrative services agreement between WPS and the policyholder, claims experience to effective date, approval of attending physician’s statements and/or updated information on any serious or on-going conditions, initial enrollment census and all other reinsurance underwriting contingencies.
Employer _________________________________________ Date ______________________________
By: ______________________________________________ Employer Identification # ____________________
Officer Authorized to Bind Employer
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