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7. AGGREGATE EXCESS LOSS INSURANCE: <br />a. Benefits Covered: <br />91 Medical O Dental ❑ Vision <br />JP Prescription Drugs ❑ Weekly Disability Income ❑ 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 Rx Drugs (Other) <br />Single <br />Family <br />Composite $428.06 NA _ Included <br />d. JALIC's percentage payable (Excess of the Aggregate Deductible): 100 <br />e. Maximum Aggregate Benefit payable by JALIC: $ 11000,000.00 <br />f. Aggregate Monthly Premium Rate (per Employee per month): $ 1.78 <br />g. Payment Mode: Monthly <br />8. OTHER BENEFITS: <br />a. Monthly Cumulative Accommodation Yes O No a Premium: $ <br />b. Medical Conversion' Yes O No O: Premium Per Employee Per Month: $ <br />c. Terminal Liability Yes ❑ No a Initial Premium: $ <br />Election Premium: $ _ <br />d. ❑ Other <br />*not available in 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 />DATEDAT Indian River County the 12th day of Septembiilr , 02000 <br />1 represent that each of 4hr a4oye statements and answers are correct and true to the best of my knowledge and belief. <br />APPLICANT: Indian River',Gounty <br />BY:L�-t1� <br />Fran' B., Adams <br />TITLE: Chaitman <br />AGENT'S NAW(PRINT)t:•Boyd Max Branham <br />AGENT'S SIGNATURE: Fl, LICENSE NO.: 5 TIx I <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 />