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• N`' -e -e 61t-0 - /0 <br />AIPPEMNIMIMPI <br />-��-J.)'.) <br />-F <br />The Company's Legal Name <br />Indian River County Board of County Commissioners <br />(Include punctuation and any abbreviations that apply) <br />Mailing Address: 1840 25th Street Vero Beach, FL 32960 <br />Effective Date: 10-1-2000 <br />Employer Tax I.D.#: 59-6000674 <br />Type of Organization: 0 Employer <br />0 Corporation a Government Segment <br />O Trust 0 Association O Partnership <br />O Sub -Chapter S Corporation❑ Other <br />Q Divisions: <br />0 Subsidiaries: <br />O Affiliates: <br />Mums <br />See Attached <br />Address (City/State/Zip) <br />• <br />Please confirm sold rates: LTD <br />STD <br />T, 1 1 1 1% , S¢ 1 <br />Life AD&D, <br />Dental <br />Dep. Life <br />45.3611 <br />}naa}u:mx <br />Billing Correspondent: <br />Name' See Attached Listing <br />Phone Number: <br />Fax Number: <br />Claim Correspondent Of different): <br />Name' See Attached Listing <br />Phone Number: <br />Fax Number: <br />Decision -maker for the company's employee benefits: <br />BASIC MONTHLY EARNINGS: 0 Salary Only <br />0 Salary, Commissions & Bonuses* 0 W-2 w/Bonuses* <br />Board of County Commissioners <br />O Salary & Commissions <br />O W-2 without Bonuses <br />❑ Salary & Bonuses* <br />O Other (please specify) <br />4164 <br />,,`: <br />fj/,G/, <br />t: <br />AMMOINIMMIla <br />tf� sfV <br />ittNe <br />