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11 <br />IV <br />J -1178-A (FL) 3/97 <br />_ = John Alden Life Insurance Company <br />Home office: Si. Louis Park, MN <br />Executive office: 7300 Corporate Center Drive, Miami, FL 33126-1223 <br />A Stock Company <br />1I APPLICATION FOR EXCESS LOSS INSURANCE <br />.tor <br />,etiaww <br />1. NAME OF APPLICANT: INDIAN RIVER COUNTY BOARD OF COUNTY CAMMI SSTONERS <br />ADDRESS: 1840 25th Street <br />(STREET) <br />Vero Beach Florida 32960 <br />(CITY) (STATE) (ZIP CODE) <br />2. NAMES AND ADDRESSES OF SUBSIDIARIES TO BE COVERED: <br />NO. OF <br />Board of NAME CITY, STATE, ZIP CODE EMPLOYEES <br />County Commissioners <br />Sheriff's Department <br />Prnperty AppraiRerR <br />Clerk of the Courts <br />Tax P.nllaetnr <br />Sunervisor of Elections <br />3. TOTAL EMPLOYEES AT ALL LOCATIONS: Est. 1280 Fl.. Est. 70 Retirees, Multiple States <br />4. NAME OF THIRD PARTY ADMINISTRATOR: BLUE CROSS & BLUE SHIELD <br />ADDRESS: 8400 N.W. 33rd Street <br />(STREET) <br />Miami Florida 33122 <br />(CITY) (STATE) (ZIP CODE) <br />5. PROPOSED EFFECTIVE DATE: October 1, 2000 <br />6. SPECIFIC EXCESS LOSS INSURANCE: <br />a. Benefits Covered: $1,000,000.00 <br />b. Benefit Period: <br />Eligible Expenses Incurred from 10/1/2000 through <br />9/30/2001 ;and <br />Eligible Expenses Paid from 10/1/2000 through <br />12/31/2001 <br />c. Specific Deductible (per Covered Person): $ 100, 000.00 <br />d. JALIC's percentage payable (Excess of the Specific Deductible): 100 <br />% <br />e. Maximum Specific Benefit payable by JALIC (per lifetime per <br />Covered Person, while the Policy is in force): $ 900, 000.00 <br />f. Monthly Premium Rate: <br />Single Rate: $ <br />Family Rate: $ <br />Composite Rate: $ 23.27 <br />J -1178-A (FL) 3/97 <br />