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<br />APPLICATION/SCHEDULE - EXCESS LOSS REINSURANCE <br /> <br />o AMERICAN NATIONAL INSURANCE COMPANY One Moody Plaza Galveston, Texas 77550 <br />(Determined by American Insurance Managers) <br /> <br />COMPANY: City of San Marcos <br /> <br />PROPOSED DATE: August 1, 2000 <br /> <br />ADDRESS: 630 East Hopkins <br /> <br />TREATY EFFECTIVE DATE: 8/1/00 <br /> <br />TREATY EXPIRATION DATE: 7/31/01 <br /> <br />CITY San Marcos <br /> <br />STATE: <br /> <br />TX <br /> <br />ZIP CODE: 78666 <br /> <br />This Application will serve as the Schedule for the Treaty providing the terms are approved by the Reinsurer. <br />Application is made for a Treaty providing reinsurance as specified Coverage is only applicable to the category for <br />which a retention amount is shown, and such retention amount is applicable only to the Treaty Year. If the Treaty is <br />renewed, the retention amounts for subsequent Treaty Years will be determined annually by the Reinsurer, and a <br />new Application/Schedule will be signed. If no retention amount is shown, coverage is not provided for that <br />category . <br /> <br />(A) SPECIFIC EXCESS COVERAGE - MEDICAL ONLY <br />(I) Specific Retention Amount per Covered Person for the Treaty Year $60,000 <br />(2) Reirnbursement Factor Percent of payments in excess <br />of the Specific Retention Amount 100% <br />(3) Specified Annual Maximum Amount <br />per Covered Person $940,000 <br />(4) Treaty Payment Basis <br />D Incurred on or after the effective date of the Treaty Year and Paid within the Treaty Year. <br />D Incurred within the Treaty Year and Paid within the Treaty Year Plus _ months <br />following the expiration date of the Treaty Year <br />o Paid within the Treaty Year. <br />X Paid within the Treaty Year. Claims are limited to those incurred 12 months prior to the <br />Treaty Effective Date and to $ per Covered Person <br />(5) Premium Rates Payable for the Treaty Year X Monthly 0 Annually <br /> <br />o Single <br />o Family <br />o Composite <br /> <br />Covered Unit <br />$25.58 <br />$57.99 <br />$ <br /> <br />Number of Units <br />249 <br />182 <br /> <br />(B) AGGREGATE EXCESS COVERAGE <br />(1) Coverages of the Benefit Plan to be Included: <br />X Medical 0 Dental 0 Weekly Disability Indemnity 0 Vision <br />X Prescription (Pre-Paid) Card Service (included in medical if shown on proposal) <br />Through <br /> <br />(Name of Service Company) <br /> <br />o Other <br />