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<br />2) Limit of Liability: 100% of payments made by Employer in excess of the Annual Aggregate Attachment <br />Point to a maximum of $2,000,000. <br /> <br />3) Coverage Form: <br />l' ] Standard <br />[ ] Advanced Funding Option <br /> <br />4) Supplementary Coverages: <br />Yes No <br />[X] Dental <br />[Xl Prescription Drug Plan <br />[X] Weekly Income-Maximum per Policy Year: $5,200 per covered employee <br />[X] Other <br /> <br />6. $ 6,213.36 accompanies this Application as the initial premium deposit based on the fmal number of 326 Employees <br />of which 217 have Dependent Units. This deposit does not bind coverage. <br /> <br />7. Requested Effective Date <br /> <br />02 / 01 / 9S <br /> <br />8. Requested Endorsements <br /> <br />NIA <br /> <br />9. The Employer appoints HEALTHCARE BENEFITS, INC. <br />to act as its Designated Third-Party Administrator ("TPA"). <br /> <br />10. The Employer agrees and understands that the TP A is its agent and attorney-in-fact, and is not the agent of the Company or <br />its Underwriting Manager. The Employer authorizes the TPA to act on its behalf for purposes of the coverage applied for. <br />The Employer further agrees and understands that the Company may pay a commission to the TPA or a licensed insurance <br />broker or agent for placing this coverage. <br /> <br />II. THE EMPLOYER HAS READ THE FOREGOING AND UNDERSTANDS AND AGREES WITH THE TERMS AND <br />CONDITIONS OF THE COVERAGE APPLIED FOR. THE EMPLOYER REPRESENTS THAT IT HAS FORMED ITS <br />EMPLOYEE BENEFIT PLAN IN COMPLIANCE WITH AND IN RELIANCE ON THE APPLICABLE PROVISIONS <br />OF THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974, AS AMENDED. THE EMPLOYER <br />FURTHER REPRESENTS THAT ASSETS OF ITS EMPLOYEE BENEFIT PLAN WILL NOT BE USED TO <br />PURCHASE THE COVERAGE APPLIED FOR. THE EMPLOYER AGREES THAT THE STATEMENTS IN THIS <br />APPLICATION OR IN ANY MATERIALS SUBMITIED WITH THIS APPLICATION OR ATIACHED TO IT ARE <br />REPRESENTATIONS OF THE EMPLOYER AND SHALL BE DEEMED MATERIAL TO ACCEPTANCE OF THE <br />RISK BY THE COMPANY AND THAT THIS POLICY IS ISSUED BY THE COMPANY IN RELIANCE ON THE <br />TRUTH AND ACCURACY OF SUCH REPRESENTATIONS. <br /> <br />Signed at <br /> <br />Paris, Texas <br />(City, State) <br /> <br />, the 18thday of <br /> <br />January <br /> <br />,1995 <br /> <br />Witness <br /> <br />Lisa Wright <br />(Print or Type Name) <br /> <br />Wt1 } (A !JUr <br /> <br />Slgnat e <br /> <br />Employer: <br /> <br />CITY OF PARIS <br /> <br />By: <br /> <br />h.c-0~ <br /> <br />Signature <br /> <br />Title: Director of Finance <br /> <br />THIS APPLICATION DOES NOT BIND COVERAGE. Upon approval of the application, the Policy evidencing that the <br />coverage is in force will be issued by the Company through its Underwriting Manager, US Benefits, Inc. Coverage will <br />commence on the Effective Date set forth in the Policy. <br /> <br />USB lOOOEP 1/92 <br /> <br />Page 2 of2 <br />