HomeMy WebLinkAbout2003-314B 11 ~l8 - D
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SAFECO Policy #:
SAFECO Life Insurance Company IMPACT Case #:
5069 -154th Place N . E . Lincoln Policy #:
Redmond , Washington 98052 Revision ? []Yes Eff. Date :
PRELIMINARY EXCESS LOSS INSURANCE APPLICATION
A. Applicant
Legal Name of Applicant : Indian River County
Business Address : 1840 25th . Street Vero Beach , FL 32960
Street City State Zip
Applicant is a : ❑ Sole Proprietor ❑ Partnership ❑ Corporation ❑ Union
❑ Other: Municipality
Associated Companies ( List if Associated Companies are to be covered . Attach a separate sheet if
necessary . )
See Exhibit A
Legal Name City State Zip # of employees
Legal Name City State Zip # of employees
Enrollment (at the beginning of the Policy Period ) :
Composite : 1548
B . Effective Date of Coverage : 10/01 /2003 Policy Period : from 10/01 /2003 to 09/30/2004
( No insurance is effective unless and until approved by SAFECO )
C . Individual Excess Loss Insurance ❑✓ Yes ❑ No
1 . Individual Deductible : (Select one )
❑$ 200 . 000 per Covered Unit (separate deductible applies for the employee and each covered dependent)
E:]$ .per Covered Family Unit (one deductible for the employee and all covered dependents )
2 . Excess Loss Alternate Reimbursement Endorsement applicable? ❑ Yes ® No
3 . Eligible Covered Expenses
❑ Medical excluding all Prescription Drugs
0 Medical including Prescription Drugs defined as ONE of the following :
® Rx Card and Mail Order ❑ Rx Card Only ❑ Rx Mail Order Only OR
❑ Rx as part of Medical Plan subject to a Deductible and Coinsurance
❑ Other
4 . SAFECO 's Reimbursement Percentage : (Select one )
a . 100 % of Covered Expenses in excess of the Individual Deductible ; or
b . % of the first $ of Covered Expenses in excess of the Individual Deductible ,
and % thereafter ; or
c . % of Covered Expenses in excess of the Individual Deductible that are incurred at the
Applicant medical facility or any affiliated or subsidiary medical facilities of the Applicant ;
and % of all other Covered Expenses in excess of the Individual Deductible ; or
d . % of Covered Expenses that are incurred at the Applicant medical facility or any affiliated
or subsidiary medical facilities of the Applicant ; % of all other Covered Expenses will apply
toward the Individual Deductible .
LG 1320 10/02 1 8 A registered trademark of SAFECO Corporation
5 . Individual Lifetime Reimbursement Maximum $ 1 , 000 , 000 . 00
(Select one ) ❑ per Covered Unit ❑ per Covered Family Unit
6 . Premium Rates
Covered Units
Composite $ 11 . 86
7 . Reimbursement Option :
Covered expenses incurred on or after the Policy Effective Date and paid during the Policy Period
with :
Run -in Period of months Run - in Limit $
Run -out Period of 3 months Run -out Limit $
8 . Individual Excess Loss Terminal Provision (Available at initial policy issue only ) ❑ Yes ❑✓ No
Terminal Run -out Period : months
9 . Individual Excess Loss Advantage Provision ✓❑ Yes No
Individual Advantage Deductible $ 50 , 000 . 00
10 . Individual Advantage Deductible applies toward the Aggregate Attachment Point? ❑ Yes R] No
11 . Individual Excess Loss Transplant Provision ❑ Yes ❑✓ No
D . Aggregate Excess Loss Insurance 0 Yes ❑ No
1 . Eligible Covered Expenses
❑ Medical excluding all Prescription Drugs
❑✓ Medical including Prescription Drugs defined as ONE of the following :
0 Rx Card and Mail Order ❑ Rx Card Only ❑ Rx Mail Order Only OR
❑ Rx as part of Medical Plan subject to a Deductible and Coinsurance
❑ Short Term Disability
❑ Dental
❑ Vision
❑ Other
2 . Aggregate Attachment Point will be set by SAFECO .
3 . SAFECO 's Reimbursement Percentage : (Select one )
a . 100 % of Covered Expenses in excess of the Aggregate Attachment Point ; or
b . % of the first $ of Covered Expenses in excess of the Aggregate Attachment Point ,
and % thereafter; or
C . % of Covered Expenses in excess of the Aggregate Attachment Point that are incurred at the
Applicant medical facility or any affiliated or subsidiary medical facilities of the Applicant ;
and % of all other Covered Expenses in excess of the Aggregate Attachment Point ; or
d . % of Covered Expenses that are incurred at the Applicant medical facility or any affiliated or
subsidiary medical facilities of the Applicant ; and % of all other Covered Expenses will apply to
the Aggregate Attachment Point ,
LG 1320 10/02 2
4 . Aggregate Reimbursement Maximum $ 1 , 000 , 000 . . per Policy Period
5 . Monthly Aggregate Accommodation Provision applicable ? ❑ Yes ❑✓ No
Monthly Aggregate Accommodation premium $
Paid : E] annually in advance ❑ per employee per month [] monthly
6 . Reimbursement Option :
Covered expenses incurred on or after the Policy Effective Date and paid during the Policy Period
with :
Run -in Period of months Run - in Limit $
Run -out Period of 3 months Run -out Limit $
7 . Minimum Aggregate Attachment Point :
a . 95 % of the first Monthly Aggregate Attachment Point x 12 ; or
b . $
8 . Monthly Aggregate Attachment Factors
Covered Units
Employee $665 . 46
9 . Aggregate Excess Loss Terminal Provision ❑ Yes ZNo
a . Terminal Run -out Period : months
b . Terminal Factors
Covered Units
10 . Aggregate Excess Loss premium $ 1 . 80
Paid : ❑ annually in advance ✓❑ per employee per month ❑ monthly
E . Medical Conversion Privilege (Available at initial policy issue only) ❑ Yes ✓❑ No
a . $ per conversion
b . $ monthly rate per employee
LG 1320 10/02 3
Any person who knowingly , with intent to defraud any insurance company or other person , files
an
application of insurance containing any materially false information or conceals for the purpose
of
misleading , information concerning any fact material thereto commits a fraudulent insurance act , which is
a crime .
Deposit of $ 0 . 00 is enclosed to apply to the first premium payment under the Policy , if issued .
Signed at : Date : November 18 , 2003
Applicant : Indi . n River Couqky Board of County Commissioners
flAngal Name )
Signed bKenneth R . Macht , Chairman
jr (Officer's Name and Title )
Agency Name : Ch 0tkrNiE
Agent's Signature : .
CLVA�
PROVED :
A - 8cA QA
07
04 C,7-; C my AdIninistrator
APPAO As YO FORM
AN L SUFFtCIE
By
ARIAN E . FELL
A ISTANT COUNTY ATTORNEY
LG 1320 10/02 4
f
Exhibit A
M1
Divisions to be Covered
Board of County Commissioners
Sheriff' s Department
Property Appraisers
Clerk of the Courts
Tax Collectors
Supervisor of Elections