HomeMy WebLinkAbout2004-232 IAL
SA , CO Life Insurance Company D4 * z 3 z.
NOTIFICATION OF RENEWAL
Policyholder Name : Indian River Countv Anniversary Date : 10/01 /2004
Policy Number: 16-010204-00
Please complete the appropriate section(s) below:
EXCESS DOSS : The above account has renewed on the following terms:
Individual : Contract : E] 12/ 12 ❑ 15/ 12 ❑Paid ❑Paid/ 15 ® Other(specify) : 12/ 15
Deductible Level: $200, 000 Individual Advantage Deductible: $50,000
Coverage Includes : ® Medical ® Prescription Drugs
$ 1 , 000 , 000 Maximum Lifetime Reimbursement per person
Individual Rates : Employee : Dependent :
Single : Family:
Other: $ 12. 97
Tiered: Employee : Employee + 1 : Employee + Spouse :
Employee + Child: Family:
Terminal Liability Coverage : [] Yes ® No Conversion : ❑ Yes ® No Rate :
Aggregate : Contract: ❑ 12/ 12 ❑ 15/ 12 ❑ Paid ® Other(specify) 12 / 15 —
Coverage Includes : 2 Medical ® Prescription Drugs ❑ Dental ❑ Vision ❑ STD ❑ Other:
Aggregate Factors : Employee : Dependent :
Single : Family:
Other: $665 . 46
Tiered : Employee : Employee + 1 : Employee + Spouse:
Employee + Child: Family:
Aggregate Terminal Liability Factors : Employee : Dependent:
Single : Family:
❑ Monthly
Aggregate Premium: $ 1 . 80 OAmm#;
Monthly Aggregate Accommodati9p: C sX-�jNl, o 17 000 , 000 Maximum Aggregate reimbursement
Policyholder Signa'W ; ` <', -� --( Date : 10 - 12 - 2004
Nrotipe a : , , Ginn , Chairman
This form needs to be completed and returned to the SAl?ECO sales office no later than 15 days following the
renewal effective date.
Attach any plan changes or revisions to this form. Any changes to the Excess Loss coverage requires a formal
signed amendment which must be received no later than 30 days following the renewal effective date otherwise
the plan changes and any reduction in pricing will not take effect.
S A F E C0 "