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<br /> <br />411S Madilllll Aw:Ilue <br />New YaJk, NY 10022 <br /> <br />APPUCATION FOR EXCESS LOSS lNSURANCE <br /> <br />I. Name of Applicant: <br /> <br />City of LaPorte <br /> <br />Address: LaPorte <br />(City) <br /> <br />TX <br />(State) <br /> <br />77571 <br />(Zip) <br /> <br />2. Inclustry/Business Type and Description: <br />Municipality <br /> <br />3. Name and Addresses of Subsidiaries to be covered: <br /> <br />Name Address (CityJ State. Zip) <br /> <br />4. Number of Employees at. all Locations listed above: Single: .l1..-8 <br />Composite: _ <br />Family: 2 60 <br />COBRA Continuc:cs: <br />Retirees; <br /> <br />S. NamcofAdministrator: Texas Municipal League <br /> <br />Address: Aust i n <br />(City) <br /> <br />TX <br />(State) <br /> <br />78754-5151 <br />(Zip) <br /> <br />6. Proposed Effective Date of the Policy: <br /> <br />April 1, 2002 <br /> <br />1. Benefit Description: <br />[Xl Medical [ ] Dental [ ] Weekly Income [] Vision <br /> <br />[x] Prescription Drugs [ ] <br /> <br />SL-2001-APP <br /> <br />1 <br /> <br />(6/01) <br />