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2000-268
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L] <br />• <br />C-1 <br />John Alden Life Insurance Company <br />Home office: Sl. I-ouis Park, MN <br />1 Executive ofOce: 7300 Corporate Center Drive, Miami, FL 33126.1223 <br />A Stock Company <br />APPLICATION FOR EXCESS LOSS INSURANCE <br />1. NAME OF APPLICANT: INDIAN RIVER COUNTY BOARD OF COUNTY COMMISSIONERS <br />ADDRESS: 1840 25th Street <br />(STREET) <br />Vero Beach Florida <br />32960 <br />(CITY) (STATE) <br />(ZIP CODE) <br />2. NAMES AND ADDRESSES OF SUBSIDIARIES TO BE COVERED: <br />NO. OF <br />Board of NAME CITY, STATE, ZIP CODE <br />EMPLOYEES <br />County Commissioners <br />Sheriff's Department <br />Prnnerty AnraiR ra <br />Clerk of the Courts <br />Tax Cnllentnr <br />Supervisor of Elections <br />3. TOTAL EMPLOYEES AT ALL LOCATIONS: Est. 1280 F1., 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 <br />33122 <br />(CITY) (STATE) <br />(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): $ <br />100, 000.00 <br />d. JALIC's percentage payable (Excess of the Specific Deductible): <br />100 <br />e. Maximum Specific Benefit payable by JALIC (per lifetime per <br />Covered Person, while the Policy is in force): $ <br />900, 000.00 <br />t. Monthly Premium Rate: <br />Single Rate: $ <br />Family Rate: $ <br />Composite Rate: $ <br />23.27 <br />J -1178-A (FL) 3197 <br />
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