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♦ lU/LL/Vy fAt 1J.VJ rnn � �v o� � o�v.. .....� . � . ��•.���-..--- -.... ' z--- <br /> Proposed Emptoyer{�tame� city of Decatur, TL <br /> Employer Policy Namber� 36-36-512R <br /> Requested Coverage Year: 11�01/04 - 10��1��5 <br /> C1rtiCr. Zwrich American Ins�zrance -Company <br /> The following conditions hereby attach to and �orm part of the application for Stop Loss Coverage <br /> with Zurich American Insurance Company: <br /> 1�eEired EE�g�oy�e�s are covered if eligibYe �iy definition under the terms of the Employeg <br /> Benefit Plan. Disabled Persons are covered xf eligible by definitio� under the terms of <br /> t�e Emp�oye�$e�f'rt Pk�: If- t}r� enrotYm�nt dtops below 48� Iives, tfie group wi�� b�e <br /> subject to review. Monthly Aggregate Deductible Factors are subject to adjustment based <br /> an m���2}� e��iffis art� errro��merrt to the- �tiv� dat�e. *I�IcohoZlsu�stance aiiu�e. <br /> benefi.t is paid according to the terms of the pIan Document. City of Decatur i.s aware <br /> �hat t�e es��aet rs �e��ng on a- t2/�2- bas'rs arn} tit�re- is a possi�irity that tFier� <br /> will be a gap i.n coverage due to the terms o� this contract. <br /> YQ/22�Q4 I5:4U:4 <br />