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IAL <br /> SA , CO Life Insurance Company D4 * z 3 z. <br /> NOTIFICATION OF RENEWAL <br /> Policyholder Name : Indian River Countv Anniversary Date : 10/01 /2004 <br /> Policy Number: 16-010204-00 <br /> Please complete the appropriate section(s) below: <br /> EXCESS DOSS : The above account has renewed on the following terms: <br /> Individual : Contract : E] 12/ 12 ❑ 15/ 12 ❑Paid ❑Paid/ 15 ® Other(specify) : 12/ 15 <br /> Deductible Level: $200, 000 Individual Advantage Deductible: $50,000 <br /> Coverage Includes : ® Medical ® Prescription Drugs <br /> $ 1 , 000 , 000 Maximum Lifetime Reimbursement per person <br /> Individual Rates : Employee : Dependent : <br /> Single : Family: <br /> Other: $ 12. 97 <br /> Tiered: Employee : Employee + 1 : Employee + Spouse : <br /> Employee + Child: Family: <br /> Terminal Liability Coverage : [] Yes ® No Conversion : ❑ Yes ® No Rate : <br /> Aggregate : Contract: ❑ 12/ 12 ❑ 15/ 12 ❑ Paid ® Other(specify) 12 / 15 — <br /> Coverage Includes : 2 Medical ® Prescription Drugs ❑ Dental ❑ Vision ❑ STD ❑ Other: <br /> Aggregate Factors : Employee : Dependent : <br /> Single : Family: <br /> Other: $665 . 46 <br /> Tiered : Employee : Employee + 1 : Employee + Spouse: <br /> Employee + Child: Family: <br /> Aggregate Terminal Liability Factors : Employee : Dependent: <br /> Single : Family: <br /> ❑ Monthly <br /> Aggregate Premium: $ 1 . 80 OAmm#; <br /> Monthly Aggregate Accommodati9p: C sX-�jNl, o 17 000 , 000 Maximum Aggregate reimbursement <br /> Policyholder Signa'W ; ` <', -� --( Date : 10 - 12 - 2004 <br /> Nrotipe a : , , Ginn , Chairman <br /> This form needs to be completed and returned to the SAl?ECO sales office no later than 15 days following the <br /> renewal effective date. <br /> Attach any plan changes or revisions to this form. Any changes to the Excess Loss coverage requires a formal <br /> signed amendment which must be received no later than 30 days following the renewal effective date otherwise <br /> the plan changes and any reduction in pricing will not take effect. <br /> S A F E C0 " <br />