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11 ~l8 - D <br /> Ao i <br /> 0 •3� f�� <br /> r aS A F E CO - FOR OFFICE USE ONLY <br /> SAFECO Policy #: <br /> SAFECO Life Insurance Company IMPACT Case #: <br /> 5069 -154th Place N . E . Lincoln Policy #: <br /> Redmond , Washington 98052 Revision ? []Yes Eff. Date : <br /> PRELIMINARY EXCESS LOSS INSURANCE APPLICATION <br /> A. Applicant <br /> Legal Name of Applicant : Indian River County <br /> Business Address : 1840 25th . Street Vero Beach , FL 32960 <br /> Street City State Zip <br /> Applicant is a : ❑ Sole Proprietor ❑ Partnership ❑ Corporation ❑ Union <br /> ❑ Other: Municipality <br /> Associated Companies ( List if Associated Companies are to be covered . Attach a separate sheet if <br /> necessary . ) <br /> See Exhibit A <br /> Legal Name City State Zip # of employees <br /> Legal Name City State Zip # of employees <br /> Enrollment (at the beginning of the Policy Period ) : <br /> Composite : 1548 <br /> B . Effective Date of Coverage : 10/01 /2003 Policy Period : from 10/01 /2003 to 09/30/2004 <br /> ( No insurance is effective unless and until approved by SAFECO ) <br /> C . Individual Excess Loss Insurance ❑✓ Yes ❑ No <br /> 1 . Individual Deductible : (Select one ) <br /> ❑$ 200 . 000 per Covered Unit (separate deductible applies for the employee and each covered dependent) <br /> E:]$ .per Covered Family Unit (one deductible for the employee and all covered dependents ) <br /> 2 . Excess Loss Alternate Reimbursement Endorsement applicable? ❑ Yes ® No <br /> 3 . Eligible Covered Expenses <br /> ❑ Medical excluding all Prescription Drugs <br /> 0 Medical including Prescription Drugs defined as ONE of the following : <br /> ® Rx Card and Mail Order ❑ Rx Card Only ❑ Rx Mail Order Only OR <br /> ❑ Rx as part of Medical Plan subject to a Deductible and Coinsurance <br /> ❑ Other <br /> 4 . SAFECO 's Reimbursement Percentage : (Select one ) <br /> a . 100 % of Covered Expenses in excess of the Individual Deductible ; or <br /> b . % of the first $ of Covered Expenses in excess of the Individual Deductible , <br /> and % thereafter ; or <br /> c . % of Covered Expenses in excess of the Individual Deductible that are incurred at the <br /> Applicant medical facility or any affiliated or subsidiary medical facilities of the Applicant ; <br /> and % of all other Covered Expenses in excess of the Individual Deductible ; or <br /> d . % of Covered Expenses that are incurred at the Applicant medical facility or any affiliated <br /> or subsidiary medical facilities of the Applicant ; % of all other Covered Expenses will apply <br /> toward the Individual Deductible . <br /> LG 1320 10/02 1 8 A registered trademark of SAFECO Corporation <br />