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40 0 Wghmark Llfe Insurance Compam ' Client services, FIS. 20515 `ffIGH"Kr Highmad We Insurance Compam of Ness fork Request For Group P.O. Box 1840 Highmark Casualer Insurance Company LIFE &CASUALTY GROUP Highmark Services lompany Insurance Amendment Hertford CT 06144.1848 %-x,77-` 9 Policyholder Name: Indian River County Group Policy Number: 908398 9 9 — 1 q$ As an authorized representative of the Policyholder, Coverage(s): Retiree Life Insurance 1. 1 request that Highmark Life amend the above Group Policy to make the following change(s): FROM: T0: Retiree Life $10,000 Retiree Life $20,000 (retirees retiring on or after 10/1/99) There are no changes to the Retiree Life rates as a result to this amendment request effective 10/1/99. 2. 1 request that the amendment become effective on October 1, 1999 NOTE: The requested effective date must be a current or future date. 3. I understand that the amendment will not become effective unless approved and issued by Highmark Life. I request that the amendment be approved by Highmark Life subject to Highmark Life's usual underwriting requirements, including, if applicable, Evidence Of Insurability or a Pre -Existing Condition limitation. 4. I understand that additional information may be required before the amendment can be approved. If the requested change is based on a union negotiated benefit, a copy of the new Collective Bargaining Agreement is attached. 5. I understand that if a rate change is required, then the new rate must be agreed to by the Policyholder before the amendment will be approved and issued by Highmark Life. [Note: if a new rate has already been provided, it should be shown on the reverse side of this form.) 6 1 ram,pct that tha a _ Pn lm m :f _pprcYea b Hig ;rrk Li°^,' -G ;ssucd iu thtr N6iiky iwiguagc cusiomariiy used by Highmark Life. 7. I understand that any increase in Insurance for a Member who does not meet the Active Work Requirement oil the scheduled effective date of the amendment will be deferred until the first day after the Member completes one full day of Active Work. 8. I request that the amendment, if approved and issued by Highmark Life, become effective by its terms without any further acceptance by the Policyholder, and that a copy of this Request for Group Insurance Amendment form be attached to and made part of the amendment. _ Signed By Title: Chairman Date: 07-2 7-9S enne Macht For Highmark Life Use Only Name of Highmark Life employee who prepared form: HM3408 See Reverse Side