Laserfiche WebLink
1 <br />7. AGGREGATE EXCESS LOSS INSURANCE: <br />a. Benefits Covered: <br />gi Medical 0 Dental 0 Vision <br />j1 Prescription Drugs 0 Weekly Disability Income 0 Other <br />b. Benefit Period: <br />Eligible Expenses Incurred from 10/1/2000 through 9/30/2001 ; and <br />Eligible Expenses Paid from 10/1/2000 through 12/31/2001 . <br />c. Aggregate Monthly Factor(s): <br />Covered Units Medical Dental <br />Single <br />Family <br />Composite $428.06 NA Included <br />Rx Drugs (Other) <br />d. JALIC's percentage payable (Excess of the Aggregate Deductible): <br />e. Maximum Aggregate Benefit payable by JALIC: <br />f. Aggregate Monthly Premium Rate (per Employee per month): <br />g. Payment Mode: Monthly <br />8. OTHER BENEFITS: <br />a. Monthly Cumulative Accommodation Yes O No IY <br />b. Medical Conversion* Yes 0 No Q <br />c. Terminal Liability Yes 0 No a <br />100 g(, <br />$ 1,000.000.00 <br />$ 1.78 <br />• <br />Premium: $ <br />Premium Per Employee Per Month: $ <br />Initial Premium: $ <br />Election Premium: $ <br />d. 0 Other <br />*not avallabk la all states. <br />9. A DEPOSIT of $ Self Accounting — Renewal is enclosed to apply to the first payment under the policy, if issued. <br />Any person who knowingly and with intent to injure, defraud, or deceive any insurer, files a statement <br />of claim or an application containing any false, incomplete, or misleading information is guilty of a <br />felony of the third degree. <br />DATED AT Indian River County , the 19th day of September . !d(2000 <br />I represent that each of the above statements and answers are correct and true to the best of my knowledge and belief. <br />APPLICANT: Indian River County <br />BY: QAA.--� Cly <br />Fran B. Adams <br />TITLE Chairman <br />AGENT'S NAME (PRINT). Boyd Max Branham <br />AGENT'S SIGNATURE' U4 aOt4yyL� FL LICENSE NO.: 7 i s5 7 9 - <br />Please return the completed and signed application to: <br />Alden Risk Management Services <br />Self -Funded Markets <br />P.O. Box 025472 <br />Miami, Florida 33102-5472 <br />