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<br />THE CONTINENTAL INSURANCE COMPANY <br />(a stock company) <br />Administrative Offices: <br />180 Maiden Lane <br />New York, NY 10038 <br />APPLICATION FOR EXCESS REIMBURSEMENT POLICY <br />A CLAIMS REIMBURSEMENT POLICY <br /> <br />1. Full legal name of Insured (Employer, YOU) <br />CITY OF PARIS <br /> <br />(As I t will appear in the Pohcy) <br />135 SE 1st PARIS <br />(Street) (City) <br />CITY GOVERNMENT <br /> <br />TEXAS <br />(State) <br /> <br />75460 <br />(ZIp) <br /> <br />Principal Office <br /> <br />2. <br /> <br />Nature of Business <br /> <br />3. If this Policy is to cover the Employer's liability for employee benefit plans of subsidiary or affiliated companies (companies <br />under common control through stock ownership, contract, or otherwise), attach the legal names and addresses of such <br />companies and the nature of their business. <br /> <br />4. A. If presently self-insured, full name of Employer's Employee Benefit Plan: <br /> <br />CITY OF PARIS <br />B. If presently insured: <br /> <br />Insurer: <br /> <br />Policy #: <br /> <br />Description of such plan(s) as currently amended must be attached to this Application. If the Plan Document has not <br />been adopted, an Employer Interim Adoption Agreement must be completed and attached to this Application. <br /> <br />5. COVERAGES REQUESTED <br /> <br />A. SPECIFIC EXCESS INSURANCE <br /> <br />I) Attachment Point: $ 50,000 <br />IX 1 Individual [ 1 Family <br /> <br />2) Limit of Liability: 100% of payments made by Employer in excess of the Attachment Point. <br /> <br />3) Reimbursable Lifetime Maximum: $ 950.000.00 <br /> <br />4) <br /> <br />Coverage Form: <br />[ 1 Incurred in 12 Months <br />and paid within 12 Months <br />Incurred in 12 Months <br />and paid within IS Months <br />1 Incurred in 12 Months <br />[ 1 Paid within 12 Months/_ day run-in <br />[Xl Other: PA Tn <br /> <br />5) <br /> <br />Extension'of Coverage: <br />X <br />[ 1 Yes [ 1 No <br />If yes, <br />[ 1 Up to 6 months <br />[ 1 6 to 12 months <br /> <br />B. AGGREGATE EXCESS INSURANCE (A V AILABLE ONLY WITH SPECIFIC) <br /> <br />I) Monthly Factor: $ 269.40 <br />on the first month's actual enrollment. <br /> <br />. Minimum Annual Aggregate Attachment Point will be based <br /> <br />USB JOOOEP 1/92 <br /> <br />Page 1 of 2 <br />