LETTER OF CONTRACT ACCEPTANCE
PROVIDENT
LIfE AND ACCIDENT
INSURANCE COMPANY
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1 FOUNTAIN SQUARE
CHATTANOOGA TN 37402
November 1, 1996
Ms. Susan Highsmith
Human Resource Manager
City of Clearwater
100 South Myrtle
Clearwater, FL 34616
SUBJECT: LETTER OF CONTRACT ACCEPTANCE
As acceptance of the delivery and terms of this LTD Policy, the undersigned Policyholder and
Provident Life and Accident Insurance Company agree to the following:
1. The Policy is issued by Provident Life and Accident Insurance Company in accordance with
the terms of the Application for Group Long Term Disability Insurance;
2. The Policyholder agrees to pay the premiums due under the group insurance plan to the
Provident at its Home Office when due by the terms and conditions set forth in this Policy;
3. The Policyholder understands and agrees to be bound by the terms, provisions, conditions,
and limitations of the Policy and all lawful amendments thereto; and
4. Provident Life and Accident Insurance Company understands and agrees to be bound by
the terms, provisions, conditions, and limitations of the Policy and all lawful amendments
thereto.
Acceptance of the terms set forth above are hereby noted by the signatures below, with an
executed copy being returned by the Policyholder to Provident Life and Accident Insurance
Company in the enclosed self-addressed, postage-paid return envelope or by fax to the Group
Underwriting, Corporate Risk Management (423) 755-5003.
PROVIDENT LIFE AND ACCIDENT
INSURANCE COMPANY
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Vice President, Group Underwriting
Corporate Risk Management
November 1, 1996
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me of Policyholder
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