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<br /> -. - - -. - - ~ . .. . .-- L~~d~ ~unlclpal League (QOO2 <br /> 104 <br /> Attachment to Resolution Page 1 of 3 <br /> ~ lliSURllNcr CI::MP.~ (MIJI'IJAL) <br /> A;plicatic:n far Excess L:::I5s Insuran=e ~~ <br /> AJ;plicatian is Í"...e-~ æè.e to Trustmark L'1St.1I'arX:S ("~ny ~""bJal) ("~ny' ) <br /> for ~ ~ t.e am Sfa:::i£ i c Ða:::ess r.oss ~ . 'Ihis Af:p li cation must œ <br /> ~':X:""'1.l:ed ani ~ by the Cœpany or its autborized represe.!'Itative prior to <br /> any CC1 ¡ t... d. ct l:ei..n;r in exi.sten:::e. <br /> ~. fu.l.l Legal Na:rœ. of .Employer (.i1.fPlicant] TXL GROUP BENEFITS RISK POOL CT'T'Y OF SAN M.l\RC <br /> 2. Key Person at Emp 1 cry er TERRY HALE EXECUTIVE DIRECTOR <br /> 3. Address 1821 RUTHERFORD LANE SUITE 300 <br /> 4. City AUSTIN TEXlIS 78754-5~51 <br /> S. SU1:sidiary or affiliated ~es (~'::Jr1ies urder ~¡.;u u..Ju~l t.J.u-cugh <br /> sb:x:k a.JnerShip, ccnt:t:act or other..rise) are to œ include:1, list legal names <br /> arx1 aèdresses of such <Y'n1['a1Íes. <br /> 6 . Other I.cca.ticr.s <br /> 7. Nature of Employer' 5 Busir.ess CHAPTER 172 RISK POOL <br /> 8. ( ) Q...u:. p.i "- d. ti en ( )?arb:rship ( ) Propriet.o.rsbip <br /> ( ) Ot..~ <br /> 9. Has the Emplcyer e'Ær volurrt:arily a~lied far relief in the EaI1kruptcy C:::urt? <br /> ( ) Yes (XX) No If yes, e..'q;Üa.ì.J. <br /> ~O.:Enter ti'..e tull naIæ of YaII: Employee Benefit Plan <br /> - CITY OF SAN l'A.ARCOS <br /> , <br /> NaIœ ar:d address of EIrployer's 'Ihi.rd Part:y Admi.T1.ist:rator <br /> TML GROUP -BENEFITS RIS:o( POOL 1821 RUTHERE'ORD LANE !f300 AUSTIN TEXAS 7R7<;4-S151 <br /> 12. Pl.~IJ5.E'd Effective cate AUGUST L 1997 <br /> 1.3. Total Eligi:.ole Employees 384 SINGLE Est. L'1Ít.liù. EnrollIr.errt384 STNc'LE'/?08 DEI' <br /> ~4. r>ep:::sit PrEmium. ~ 9078.72 <br /> 1.5. 'Rt" i ti.nq h;ent or Brd<.er of Emp 1 eyer « <br /> SS No . or Tax ID <br /> J!i.Ul. e:s.:::; <br /> ~6. Where is the CDrrt:ract an::i ot.ber Carresp::¡rrlen to œ ìIE.Íled to? <br /> 1821 Qn'T'~F"R't:'('I.¡:H'I r ~~J';:' ~1T!TS: JOg AUSTIN TEXAS 73754-5151 <br /> ~7. Name oJ: DR an::l¡or PRJ T~ GROUP BENEFITS RISK POOL <br /> ~8- ~ s:.:1-il-J'I!TY CPITCNS <br /> A.. ~ ~ te ExI::ess I..css ( XX ) Yes ( ) No <br /> Benefit Perio:i: Eligible Ezjjplaye:r: T £"'!S.'5E'5 frcm Plan e;q::ense. <br /> In:::uz:rej f:r:an 5/1/97 thraJgh 7/31/98 , ar:d <br /> Paid fran 8/1/97 thraJgh 7/31/98 . <br /> If:;s.c;es In::::I.Irred prior to t."le Effect..ive Date will ba limited to the aIIX:tmt <br /> re..i:mb.Jrsable as set f œ:t'1 in t.'1.e Sch=-1t 1 J e of Dcr:8ss Less. <br /> SIr J. 09 3 / APP-Nr <br />