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