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^ r <br /> SAFE <br /> SAFECO Life Insurance Company <br /> 5069454th Place N . E . <br /> Redmond , Washington 98052 <br /> EXCESS LOSS SCHEDULE OF BENEFITS <br /> A. Participating Employer: Indian River County Board of County Commissioners <br /> Policy Number: 16-010204-00 <br /> Effective Date of Coverage : October 1 , 2003 <br /> Participating Employer Anniversary Date : October 1st of each year beginning in 2004 <br /> Premium Due Date : Premium is due on the Effective Date of Coverage and the first of each month <br /> beginning with November 1 , 2003 <br /> Enrollment (at the beginning of the Policy Period) : <br /> Composite 1 . 548 <br /> B . This Schedule of Benefits applies to the Policy Period : from 10-01 -2003 to 10-01 -2004 <br /> C . Individual Excess Loss Insurance OYes ❑ No <br /> 1 . Individual Deductible per Covered Unit $ 200 , 000 <br /> 2 , Alternate Individual Deductibles applicable ? <br /> ❑ Yes (See Excess Loss Alternate Reimbursement Endorsement) 0 No <br /> 3 , Covered Expenses <br /> ❑ Medical excluding all Prescription Drugs <br /> FVI Medical including Prescription Drugs defined as ONE of the following : <br /> 0 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 <br /> 100 % of Covered Expenses in excess of the Individual Deductible . <br /> 5 , Individual Lifetime Reimbursement Maximum : <br /> $ 1 900U00 per Covered Unit <br /> 6 , Premium Rates <br /> Covered Units <br /> Composite $ 11 . 86 <br /> DP <br /> LGC 8802 03/02 1 of 3 0 A registered trademark d SAFECO Corporation <br />