2015-393-E HR - UnitedHealthCare (UHC) for UHC Application for Excess Loss Insurance Policy $1,265,095

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DocuSign Envelope ID: EE765B38-37EF-4402-B4E9-8B82F98E2EE8 Company may refund all premium and the Application shall have been null and void when signed. No Excess Loss Insurance will be effective nor reimbursement made unless a Plan Document is received and accepted by the Company. C. The Company will evaluate the undersigned's risk, as requested by this application, the underwriting data received and represented by the Plan and may require adjustments of rates,factors,and/or special limitations. d. Any coverage resulting from this Application shall be subject to the terms and provisions of the Policy herein applied for. Coverage shall become effective on the date specified in this Application if all requirements of the Company,including the Plan Document and the underwriting requirements have been met and the required premiums paid. e. The receipt by the Company of the first month's premium and deposit of any check drawn in connection with this Application shall not constitute an acceptance of liability. In the event the Company does not approve this application, its sole obligation shall be to refund such sum to the undersigned. The undersigned has read the entire Application for Excess Loss Insurance and understands that the insurance requested herein is not in effect until this Application is approved and accepted by the Company. Full Legal Name of Applicant: Bonnie Hammersley DocuSigned by: Signature of Authorized Person: �jOV�,l�t't- ( mmvsb )637994B755E477... Print Name: Bonnie Hammersley Title: County Manager Date: 8/5/2015 Signature of Agent or Broker: DocuSigned by: vac 6A B71 B11 . Printed Name of Agent or Broker: Eric Black License No. FRAUD WARNING NOTICES: (Please review notice that applies in your state) For applicants in Arkansas and Louisiana: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance,is guilty of a crime and may be subject to fines and confinement in prison. For applicants in Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment,fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds, shall be reported to the Colorado division of insurance within the Department of Regulatory Agencies. For applicants in District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the application. UHIAPP(12/01)