Laserfiche WebLink
SA F ECO " <br /> SAFECO Life Insurance Company <br /> 5069-154th Place N . E . <br /> Redmond , Washington 98052 <br /> PARTICIPATION AGREEMENT <br /> Policy Number: 16-010204-00 <br /> The Participating Employer: Indian River County Board of County Commissioners <br /> (Legal Name) <br /> has received a SAFECO contract which consists of: <br /> (a ) the SAFECO Excess Loss Policy, including any amendments or endorsements ; <br /> (b ) the Excess Loss Schedule of Benefits ; <br /> (c) the Employee Benefit Plan document, approved by SAFECO ; and <br /> (d ) the Disclosure Statement <br /> and has approved and accepted the terms of this contract . <br /> No reimbursement under this Policy will be paid until such time as this Participation Agreement <br /> has been executed and received by SAFECO . <br /> Any person who knowingly and with intent to injure , defraud , or deceive any insurer files a statement of <br /> claim or an application containing any false , incomplete , or misleading information is guilty of a felony of <br /> the third degree . <br /> Name : Thomas S . Lowther Title : Chairman <br /> (Please Print Name of Signatory) (Please Print) <br /> By: QL, s L <br /> (Signature of Participating Employer) <br /> Signed at: Vera NO On : February 1 , 2005 <br /> i ( Date) <br /> Witnes . `"" f 77 Title : DEPUTY CLERK <br /> re) (Please Print) <br /> Instructions to Parte ` tii yJoyer: (1 ) Sign and return original to SAFECO . <br /> (2) Retain copy with your Policy. <br /> APPROVED AS TO FOIA <br /> AND LEGAL SUFFI IE <br /> • PROVED : <br /> s <br /> WILLIAM K . DEBRAAL <br /> ASSISTANT COUNTY ATTORNEY C my Ad inistrator <br /> LGC 8821 (a) 10/02 8 A registered trademark of SAFECO Corporation <br />