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SAFECO " <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 o <br /> the third degree . <br /> Name : Thomas S . Lowther Title :_ Chairman <br /> ( Please Print Name of Signatory) (Please Print) <br /> By: ---�� 5. L <br /> (Signature of Participating Employer) <br /> Signed at : <br /> + On : FPhrliary 1 . 2nn5 <br /> e fq (Date) <br /> Witness . Title : DEPUTY CLERK <br /> (Please Print) <br /> 4 <br /> f� Yru ..PC�Aa <br /> Of <br /> Instructions toN , f �fiployer: (1 ) Sign and return original to SAFECO . <br /> (2) Retain copy with your Policy. <br /> ru d . <br /> JAPROVED . APPROVED AS T FO ` <br /> AL F y <br /> y Ad inistrator BY t <br /> WIL IAM K . DEBRAAL <br /> ASSISTANT COUNTY ATTORNEY <br />