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<br />5) Supplementary Coverages: <br />Yes No <br />[ ] [X] Dental <br />[ ] [X] Prescription Drug Plan <br />[ ] [X] Weekly Income-Maximum per Policy Year: $5,200 per covered employee <br />[ ] [X] Other <br /> <br />6) <br /> <br />Rates (pER MONTH): Per Employee $ <br /> <br />2.50 <br /> <br />Annual Minimum and Deposit Premium $ <br /> <br />C. OTHER PROVISIONS/FORMS ATIACHED: <br />Endorsement No.7 Manuscript Change (Claims Adv) <br /> <br />This renewal of the above captioned Policy is issued by US as of the Renewal Effective Date, but is not valid unless <br />countersigned by OUR duly authorized representative. The renewal will be effective upon acceptance by the Employer and <br />payment of the required premium. <br /> <br />/11(4t t ~ <br /> <br />, . <br />Martin D. Haber <br />Secretary <br /> <br />~"- G? r:...""<<b <br /> <br />hn P. Masc tte <br />Chairman <br /> <br />Issued at Costa Mesa, California on February 14. 1996 <br /> <br />Auth~ <br /> <br />THE EMPLOYER UNDERSTANDS AND AGREES TO THE TERMS AND CONDITIONS OF THE RENEWAL. THE <br />EMPLOYER AGREES THAT STATEMENTS IN ANY MATERIALS SUBMITTED TO THE COMPANY TO INDUCE <br />IT TO ISSUE THIS RENEWAL ARE REPRESENTATIONS OF THE EMPLOYER AND SHALL BE DEEMED <br />MATERIAL TO ACCEPTANCE OF THE RISK BY THE COMPANY AND THAT THIS RENEWAL IS ISSUED BY <br />THE COMPANY IN RELIANCE ON THE TRUTH AND ACCURACY OF SUCH REPRESENTATIONS. <br /> <br />Dated at Paris, Texas <br />(city,state) <br /> <br />h 8th <br />, t e <br /> <br />day of April <br /> <br />,19.2.L <br /> <br />Witness: Lisa Wright <br />(Print or Type Name) <br /> <br />Employer: City Of Paris. Paris. Texas <br /> <br />By: <br /> <br />Signature Eric S. Clifford <br /> <br />Title: <br /> <br />Mayor <br /> <br />Signature <br /> <br />ATTEST: <br /> <br />APPROVED AS TO FORM: <br /> <br />Mattie Cunningham, City Clerk <br /> <br />T. K. Haynes, City Attorney <br /> <br />USB IOOOOEPR 1/92 <br /> <br />Page 2 of 2 IOI~""'1' <br />