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02c00 (o � 6y <br /> NOTIFICATION OF RENEWAL ( /' / SYMi T RA°° <br /> FINANCIAL <br /> Policyholder Name : _Indian River County Policy Number: 16-010204-00 <br /> Anniversary Date : _10-01 -2046 <br /> Please complete the appropriate section (s) below : <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> - - - - - <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> - - - - - <br /> Excess Loss : The above account has renewed on the following terms : <br /> Individual : Contract: 12/ 12 Paid Other: 12/15 <br /> Deductible Level : $200 , 000 .00 Individual Advantage Deductible : $549000 .00 <br /> Coverage Includes : X Medical X_ Prescription Drugs <br /> Lifetime Maximum : _$ 1 ,000 ,000 . 00 <br /> Renewal Individual Rates : Single : ; Family: _Composite $ 14.03 <br /> Terminal Liability Coverage : Yes _; No _X_ (Note: Only available if purchased at policy inception) <br /> Aggregate : Contract: 12/ 12 Paid Other: _12/15 <br /> Coverage Includes : _X_ Medical _X_ Prescription Drugs Other <br /> Renewal Aggregate Factors : Single : Family : Composite : $731 . 77 <br /> Aggregate Premium : $ 1 . 80_ Lifetime Maximum : _$ 1 ,000 ,000 . 00 <br /> Monthly Aggregate Accounting : Yes _X_ No Rate : <br /> Terminal Liability Coverage : Yes ; No _X_ (if yes , specify terminal liability factors below) <br /> Terminal Liability Factors : Single : Family: <br /> Managed Care Network(s ) <br /> BlueCross <br /> Plan--Administrators S1 ature : <br /> � , � rn nh�� rtn�l Date <br /> Ag Sig tan ure: vL Date : 7 - ! 7 - zod� <br /> Please forward to : <br /> Symetra Financial APPROVED AS TO FO <br /> Attn : Mary Hewitt AND LEGALS, FF 1 IN Y. <br /> Mary. hewitt@symetra .com <br /> FAX : (678) 728-1567 By <br /> WILLIAM K . D B AAL <br /> ASSISTANT COUNTY ATTORNEY <br /> Symetra Life Insurance Company • Group Division • 3740 Davinci Court Suite 350 • Norcross, GA 30092 • vnw✓.symetra.com <br /> Phone: 678-728-1549 FAX 678-728-1567 Toll Free: 800-746-6246 <br />