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Minimum Annual Aggregate Deductible:$8,291,417 or 95%of the first Monthly Aggregate Deductible amount times 12, <br /> whichever is greater. <br /> Maximum Covered Expenses per Covered Person accumulating toward the Maximum Aggregate Benefit: $100,000 <br /> Monthly Aggregate Factors:$730.97 per subscriber <br /> Aggregate Excess Loss Premium:$4.99 per subscriber per month <br /> It is understood and agreed by the undersigned that: <br /> a. The statements,declarations and representations made in this Application,any request for proposal,the underwriting information <br /> provided by or on behalf of the undersigned and the Plan Document are the undersigned's representations; that any Policy is <br /> issued in reliance upon the truth of such statements,declarations,and representations;and that such statements,declarations,and <br /> representations will form a part of the Excess Loss Insurance Policy. Any inaccuracy in such information or failure to disclose <br /> any such information, including all claims or possible claims, paid or pending, or which the Employer should otherwise know <br /> about,if discovered later,can result in rejection of this Application,or can change the terms,conditions or premiums,or can void <br /> coverage. <br /> b. As a condition precedent to the approval of this Application, the undersigned shall furnish to the Company a copy of the <br /> executed Plan Document within 90 days after the date of this application describing the benefits provided by the Plan, which <br /> shall be kept on file in the office of the Company. If the Company does not receive the Plan Document within 90 days, the <br /> Company may refund all premium and the Application shall have been null and void when signed. No Excess Loss Insurance <br /> will be effective nor reimbursement made unless a Plan Document is received and accepted by the Company. <br /> C. The Company will evaluate the undersigned's risk, as requested by this application, the underwriting data received and <br /> represented by the Plan and may require adjustments of rates,factors,and/or special limitations. <br /> d. Any coverage resulting from this Application shall be subject to the terms and provisions of the Policy herein applied for. <br /> Coverage shall become effective on the date specified in this Application if all requirements of the Company, including the Plan <br /> Document and the underwriting requirements have been met and the required premiums paid. <br /> e. The receipt by the Company of the first month's premium and deposit of any check drawn in connection with this Application <br /> shall not constitute an acceptance of liability. In the event the Company does not approve this application, its sole obligation <br /> shall be to refund such sum to the undersigned. <br /> The undersigned has read the entire Application for Excess Loss Insurance and understands that the insurance requested <br /> herein is not in effect until this Application is approved and accepted by the Company. <br /> Full Legal Name of Applicant: <br /> V y` -,,-t <br /> Signature of A Sze er o / <br /> Print Na e: Title: <br /> Date: r <br /> YJ <br /> Signature of Agent or Broke <br /> Print Name of Agent or Broker: <br /> UHIAPP(12/01) <br />