HomeMy WebLinkAbout000183.tiff AMENDATORY RIDER
This Rider forms a part of the Aggregate Excess Risk Insurance Agreement
issued by HARTFORD ACCIDENT AND INDEMNITY COMPANY to:
WELD COUNTY
Rider Effective Date: January 1 , 1985
The Agreement is amended by the addition or deletion of the pages listed
below:
Page Numbers of Pages Added Page Numbers of Pages Deleted
ER - 6.0 Rev. Eff. 1 -1 -85 ER - 6.0
ER - 7.0 Rev. Eff. 1 -1 -85 ER - 7.0
In all other respects, the Agreement remains the same.
Signed by the Insurance Company on / lei ( 71 )64°A Ne
Date
eit
7170AA1.11%d 704.0.$0
ecretar Registrar
183
GR-11221 1524C
REIMBURSEMENT
We will reimburse the Employer for Plan Benefits Paid which exceed the
Annualized Deductible Amount.
In order to be applied against the Annualized Deductible Amount, Plan
Benefits must have been Paid:
a) while this Agreement is in force;
b) within the Agreement Year;
c) within 30 days of the Administrator's receipt of Proof of Loss;
and
d) within 120 days of the date on which the Covered Expense was
Incurred.
Reimbursement will not exceed:
a) the Reimbursement Percent; or
b) the Maximum Reimbursement Amount
shown in the Schedule.
GR-11259 ER - 7.0 Rev. Eff. 1 -1 -85 K72
ANNUALIZED DEDUCTIBLE AMOUNT
The Annualized Deductible Amount for an Agreement Year is calculated in
the following manner:
a) multiply the number of Eligible Employee Participants covered
under The Plan on the first day of each month within the
Agreement Year by the Excess Risk Insurance Determinant
Factor shown in the Schedule.
b) add the products of each month for the entire twelve months
in the Agreement Year.
The number of Eligible Employee Participants used in each monthly
calculation can never be less than 85% of the Reported Number of Eligible
Employee Participants shown in the Schedule.
GR-11259 ER - 6.0 Rev. Eff. 1 -1 -85 K62
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