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Lf H <br /> Sun Life Assurance Company of Canada OCT Sun `�. ,;2r' '��14 <br /> I <br /> Application for Stop-Loss Insurance � �ica1' <br /> ' 1 Plan sponsor information <br /> Full legal name of plan sponsor Policy number(office use only) <br /> Indian River County Board of County Comissioners <br /> Street address Policy effective date <br /> 1801 27th Street _ 10/1/2014 <br /> City State i Zip code <br /> Vero Beach FL 32960 <br /> '2 Subsidiaries, affiliates, divisions and locations <br /> Please list all Subsidiaries, affiliates,divisions and locations to be covered under this policy: <br /> subsidiaries, affiliates, <br /> divisions, and locations 1 Indian River County Clerk of the Court <br /> to be covered under the 2. Indian River County Property Appraiser <br /> Stop-Loss policy. — <br /> 3 Indian River County Tax Collector <br /> 4 Indian River County Sheriffs Office <br /> 5 Indian River County Supervisor of Elections <br /> 6• <br /> 7 <br /> `3 Requested coverage <br /> Please select the ® Specific benefit <br /> coverages for which Specific benefit deductible <br /> you are applying. P ® Individual <br /> $ 275,000 ❑ Family <br /> Aggregating specific deductible (if applicable) <br /> $ 148,750 <br /> Specific benefit annual maximum eligible expenses <br /> $ UNLIMITED <br /> Specific benefit lifetime maximum eligible expenses OR ® No maximum <br /> N Aggregate benefit <br /> Aggregate benefit maximum Aggregate benefit maximum eligible expenses per covered person` <br /> $ 1,000,000 $ 275,000 <br /> * Individual or family option applies to all selected coverages <br /> Domiciliary State-Michigan <br /> XGR/2989 • Stop-Loss Application Page 1 of 4 <br />