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<br />STANDARD SECURITY LIFE INSlJRANCE COMPANY OF NEW YORK <br />(a New York Sfod[Life aDd Health Innrance Compuy) <br /> <br />Home Office: <br />485 Madison Avenue <br />New York, New York 10022 <br />112-355-4141 <br /> <br />POUCYNUMBER: BOSSL-2004-320 <br /> <br />POUCYBOLDER: City of La Porte <br />POLICY PERIOD: O41OlJ04 - 03131/05 <br /> <br />EFFECTIVE DATE: 04101104 <br /> <br />EXl'JRAnON DATE: 03/31/05 <br /> <br />ANNIVERSARY DATE: 04101105, and on the same day each year after. <br /> <br />PREMlUM DUE DATE: First day of the montll, and on the same day each month.. <br /> <br />STATE OF DELIVERY: Texas <br /> <br />This Policy is a legal confract. We issue it in consideration of (1) Your Application, (2) Your Disclosure <br />StatP.l11l'Ut, and (3) Your payment of pl'p.minmR when due. This Policy, Your Application, Your Disclosure <br />Statement, and a copy oftbe Plan form the entire agreement between Us. <br /> <br />. In issuing this Policy, We have relied upon the infOIJDation (mcluding, without limitation, infoxmation in <br />the Disclosure StatemeJrt, Your Application, and the Plan) provided to Us by: (1) You, (2) Your <br />Administrator, and (3) Your agent or broker. We have also relied on this information being both cmnplete <br />and accurate. If the information was incomplete or incorrect, We shall have the immP.diate right (1) to. <br />modify the Policy to reflect the complete or COD'CCt informatiOD, or (2) to tP.nn1nAte tQe Policy upon <br />written notice. <br /> <br />We agree to D:.ake payments in accordance with.the provisions oftbis Policy. <br /> <br />In this Policy, "Yonll and "Your" refer to the Policyholder, and "We", "Us", and "QmJ' refer to Standard <br />~ Life Insunmce Coinpany of New Yorlc. <br /> <br />This Policy is issued and governed by the laws of the state of delivery as indicated above. <br /> <br />Signed for Standard Secmity Life Jnsor.mce Company of New Yorlc as of the Effective Date. <br /> <br />~? <br /> <br />Rachel Lipari <br />President <br /> <br />G--r~ <br />David Kettig <br />Secretary <br /> <br />EXCESS LOSS INSURANCE POUCY <br />Non-Participating <br /> <br />SL-2001 <br /> <br />1 <br /> <br />(6101) <br />