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NOTIFICATION OF RENEWAL <br /> Policyholder: Indian River County SYMETRA . <br /> Policy Number: 16 =010204 =00 F I N A N C I A L <br /> Third Party Administrator: Blue Cross <br /> Please complete the appropriate section ( s ) below : <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> - - - - - - - - - - - <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> - - - - - - - - - - - <br /> RENEWAL TERMS : The above account has renewed effective Oct 1 , 2005 on the following terms : <br /> Specific : Contract : 12/ 12 Paid / 15 15/ 12 Paid Other: 12/ 15 <br /> Deductible Level - $200 , 000 Individual Advantage Deductible : $ 54 , 000 <br /> Lifetime Maximum : $ 1 , 000 , 000 <br /> Renewal Specific Rates : Single : Family : Composite : $ 14 . 03 <br /> Terminal Liability Coverage : Yes _ No _xx ( Note : Only available if purchased at policy inception ) <br /> Aggregate : Contract : 12/ 12 15/ 12 Paid Other : 12/15 <br /> Renewal Aggregate Factors : Single : Family : Composite : $ 665 . 46 <br /> Aggregate Premium : $ 1 . 80 Lifetime Maximum : $ 1 , 000 , 000 <br /> Monthly Aggregate Accounting : Yes or No Rate : <br /> Terminal Liability Coverage : Yes No ( if yes , specify terminal liability factors below ) <br /> Terminal Liability Factors : Single : Family : <br /> Managed Care Network(s ) : Blue Cross <br /> Changes ( Formal signed amendment required ) & Additional Provisions : <br /> Plan AdministratorsSOX <br /> nature : <br /> S . Lowther , Chairman <br /> Date : 10 / 4 / 05 <br /> Agent ' s Signature . <br /> ti, uo� Date : 3 3/ /0&03x" <br /> This form needs to be completed and returned to SAFECO no later than 15 days following the <br /> renewal effective date . Please forward to : <br /> Symetra Financial <br /> Attn : Mary Hewitt APPROVED AS TO FORM <br /> SU CI <br /> Mary. hewitt@symetra . com AND LEGAL <br /> FAX : ( 678 ) 728 = 1567 BY &X <br /> WILLIAM K . DEBRAAL <br /> ASSISTANT COUNTY ATTORNEY <br /> Symetra Life Insurance Company • Group Division • 3740 Davinci Court Suite 350 • Norcross, GA 30092 • www. symetra . com <br /> Phone: 678-728- 1549 FAX: 678-728- 1567 Toll Free : 800-746-6246 <br />