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<br />APPLICA T10NISCHEDULE . EXCESS LOSS REINSURANCE <br /> <br />I...AMAR. LIFE INSURANCE COMP A.'N PO &It uc lKbln. Miuisslppi 3920S or <br />AMERICAN NATIONAL INSURANCE COMPANY OacMoodyP:ca OaZ'lUfon. Tau 7mc <br />~ by Amc:ncAlIlu1nnc>c ~) <br /> <br />COMPANY City of San Mar-CDS <br /> <br />PROPOSED DATE: <br /> <br />ADDRESS 630 Eo Hop1<i ns <br /> <br />CITY San Marcos <br /> <br />STATE TX <br /> <br />TREATY EFFECTIVE DATE 8/1/99 <br />TREATYEXPIRATlONDATE 8/l/00 <br />ZIP CODE: 78666 <br /> <br />Tlus Applicaoon Wlll se~e as !be ScbeduJe for !be Treaty providin; the t.e:ms ~ 3pprtMd by the ~..ei:1SUm <br />Application is m::Ilde for a Tn:aty prov1c1ina rC!ISU!'IIla as spcafiec1 UM:raae is oaly applicable to the ca1egory <br />for wbicll a n:u::uoon amount 1.$ shown. a.tlO su:tl rctentioc1 amount is appIic3ble only to the Trt.aty Year If the <br />Treaty is r=cwed, the n=tc:utioc &.OlOUDU for Sllbscqucot Treary Yras will be dc:tcnnined aJ&.DDilly by ~ <br />~i1lM'U. and. DeW ApplicatioolSchcduJc will be~. Ifno re1ie:nt1on aJ'IK'lClnl U shosm. CIC:IYenp is DOt <br />pfC'V1dcd for \..bat CltcgtIry. <br /> <br />(A) SPECIFIC EXCESS COVERAGE - MEDICAL ONI.. Y <br />(1) Specific ~Q'l Amount per Covered Person <br />for the TJUty Year $40,000 <br />(2) R.cUnbu.rscmcm Factor PestaIt of paymeulS in excess <br />o{thc Spcci& ~ t\moo:J( 100 % <br />(3) Speaficd Amwa.l Maximum Amount peT <br />CoYered Person $ 960, 000 <br />(4) Treaty Pa.yment Basis <br />Inc:um:d oa or afta die cBi:c:t:ive date of 1he T fat)' Y car and Paid <br />within the Treaty Y car. <br />lnc:uttcd W1tbin the Trazy Y car aod Paid wi1hin d:lc Treaty Year <br />Plus _ DlOI1tb" foUowtna tbc apinltion date of the Treaty Year <br />Paid W1thm the Treaty Y car. <br />X Paid within the Treaty Year. Claims are Iim.iu:d to those iocurrcd <br />2- months pnor to tbe Treaty E~ Date and to <br />$ per Covered Pe:l'Som <br />(S) Pn::mium Rates Pzyab{c for 1be Treaty Year x Mootb.Iy Annually <br /> <br />Singie <br />Family <br />COmposite <br /> <br />Covered Unit <br />$24.03 <br />$50.39 <br />$ <br /> <br />Number of Umts <br />231 <br />189 <br /> <br />(B) AGGllEGA TE EXCESS COVERAGE <br />( 1 ) Coveraaes of the Ba:refit P1an to be lDcluded: <br />X Medical Dem.aJ Wcddy Disability Indemnity Vision <br />X Prescriptioo ~Pa1d) Card $en.,~ (included in medical If ~'n on proposal) <br />Through <br /> <br />(Name O[~ Coctps:r{) <br /> <br />Ocher <br />