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<br />A. AGGREGATE EXCESS LOSS INSURANCE <br />8. BENEFITS rOBE INCLUDED; Yes No <br /> <br />1. Medical............................................. m I:l <br /> <br />2. Dental............................................. D 0 <br /> <br />3. Weekly Income. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 0 0 <br /> <br />4. Vision.............................................. 0 0 <br /> <br />5. Prescription Drug Card. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. [3l1 0 <br /> <br />6. Other............................................... 0 0 <br /> <br />Description: <br />9. Maximmn Aggrcga~ Bendit . . . . . . . . . . . . . . . . . . . . . . . . . . $ 1 , 000 , 000 <br />10. Benefit percentage payable ... ... . .... ... __ . . .. __ __.... 100% <br /> <br />11. Policy BasislBcncfit Period (check one): <br /> <br />o Covered expalScs incuacd during the Policy year <br />and paid during the Policy~. <br />o Covered cxpCDSCS paid during the Policy year. <br />m Covered apenscs incurred within the J.. month <br />period prior to coverage effective date and paid during the Policy year. <br />o Cova-cd expCDKS incurred during the Policy year <br />and paid within _ months after the Policy year. <br /> <br />THE APPLICANT AGREES AND ACKNOWLEDGES THAT, DEPENDING UPON THE COVERAGE <br />SELEcrED AND THE TERMS OF ANY EXPIRING COVERAGE OR COVERAGE THE APPLICANT MAY <br />ELECf IN THE FUTURE, THE APPLICANT MAY EXPERIENCE LOSSES THAT ARE NOT COVERED <br />UNDER THE POLICY, WHEN ISSUED, OR UNDER ANY SUCH PRIOR OR SUBSEQUENT COVERAGE. <br /> <br />12. Annual aggregate prenUum. . . , ............... . . . . . . . . . ..... <br /> <br />$20,020.80 <br /> <br />13. Monthly aggregate prenpum per employee. . . . . . . . . . . . . . . <br /> <br />~4.30 <br /> <br />14. Aggregate monthly factors. . . . . . . . . . . . . __ . . . .. . . .. __.. Single: <br />Family: <br />Composite: 772. 7 3 <br /> <br />$3,597,831 <br /> <br />15. Minimum Attachment Point. . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> <br />B. SPECIFIC EXCESS LOSS INSURANCE <br />16. Deductible per covered person.. __ .. . . .. .. . . .. . .. .. . __ . $ 11 5 , 000 <br /> <br />17. Maximum specific benefit minus the deductible. . . . . . . . . .' . <br /> <br />$885,000 <br />100% <br /> <br />18. Benefitpercentagepayable....,.................... ... <br /> <br />19. Expense eligibility claim basis (check one): <br />[J Covered expenses incurred during &he Policy year <br /> <br />SL-2001-APP <br /> <br />2 <br /> <br />(6/01) <br />