HomeMy WebLinkAboutES10-045 - Amendment - #3 - LifeWise Assurance Company - Stop Loss Insurance Policy - 01/01/2012 �a?3
Records Ma emena__
O
KENT
W.s„,„GTo„ Document
CONTRACT COVER SHEET
This is to be completed by the Contract Manager prior to submission
to City Clerks Office. All portions are to be completed.
If you have questions, please contact City Clerk's Office.
Vendor Name: Lk Ft-( I y
Vendor Number: _ 3 71-113
JD Edwards Number
Contract Number: 1E
This is assigned by City Clerk's Office
Project Name: t t=f Ot 5!:, S7VP LOSS pdoqt -c /yLi-M"r'
Description: ❑ Interlocal Agreement ❑ Change Order 19 Amendment ❑ Contract
❑ Other:
Contract Effective Date: — -apla Termination Date: 101-31-a0lZ
Contract Renewal Notice (Days):
Number of days required notice for termination or renewal or amendment
Contract Manager-z JVDepartment: �S
Detail: (i.e. address, location, parcel number, tax id, etc.):
S,Publlc\RecordsManagement\Forms\ContractCover\adcc7832 1 11/08
AMENDMENT NO. 03
This amendment becomes a part of Stop Loss Policy No WA-518212-9999 issued to City of Kent, the
Policyholder.
z
It is stipulated and agreed that:
Effective January 1, 2012:
The following sections are replaced
Section 1, Schedule of Coverage, and
Section 2, Definitions. +,
All other terms and conditions of the contract remain unchanged This amendment is signed for us at
Mountlake Terrace, Washington on the policy amendment effective date
LifeWise Assurance Company
I
Michael Wozny
President
Instructions: Retain copy with your policy.
SLP WA AMD (09-08) Amendment
L
SECTION 1
SCHEDULE OF COVERAGE
Policyholder: City of Kent LJFEWISE
WA-618212-9999
Life I Disability I Stop Loss
POLICY PERIOD January 1, 2012 through December 31, 2012
COVERAGE PROVIDED (Provided if checked):
1.1 ® AGGREGATE STOP LOSS
Attachment Level ❑ 120% ❑ 125% ® Other: 200%
Aggregate Expense Incurral Period From January 1, 2009 through December 31, 2012
Aggregate Expense Payment Period From January 1, 2012 through December 31, 2012
A Covered Benefits ® Medical ❑ Dental ❑ Vision
❑ Weekly Disability Income ® Prescription Drugs
B Aggregate Deductible (Composite)
Composite Units Medical/Rx
Aggregate Monthly Factor $2,302 27
C Minimum Annual Aggregate Deductible- Greater of
$24,284,344 or 95% of the First Monthly Aggregate Deductible times 12
D. Limit of Liability- 100% of eligible expenses you pay under your Plan, in excess of the
deductible, will be reimbursed to a maximum of$1,000,000
E. Claim Review is ® end of Policy Period ❑ Monthly with $ threshold.
F Monthly Premium Rate (Composite Units)- $0 01 per Employee
1.2 ® SPECIFIC STOP LOSS
Specific Expense Incurral Period From January 1, 2009 through December 31, 2012
Specific Expense Payment Period, From January 1, 2012 through December 31, 2012
A Covered Benefits ® Medical ❑ Dental ❑ Vision
❑ Weekly Disability Income ® Prescription Drugs
B $175,000 Individual Specific Deductible per person
C $N/A Aggregating Specific Deductible per contract year
D Limit of Liability We will reimburse 100% of eligible expenses you pay under your Plan in
excess of the deductible The maximum we will reimburse you per person
Annually ® $1,825,000 ❑ Unlimited
Lifetime ❑ $ ® Unlimited
E Specific Advanced Funding, ® Yes ❑ No
F Monthly Premium Rate:
❑ Employee Only $ Family Rate- $
® Composite Employee & Dependent $49 61
1.3 ❑ TERMINAL LIABILITY PROTECTION
❑ Yes ® No If yes, number of months•
SLP WA (10-10) 2 Schedule of Coverage
SECTION 2
DEFINITIONS
Effective 01-01-12
The following definitions apply unless otherwise required by the context With the exception of "we",
"us", "our', "you" and "yours", these definitions are capitalized throughout the policy
2.1 Administrator means the third party administrator selected by you to perform certain functions
for your Plan The term "administrator" as used in the Policy does not refer to the Plan
administrator used in the Employee Retirement Income Security Act of 1974, unless you have ;
specifically appointed the administrator as such. We are not the Administrator We must
approve the third party administrator selected by you
22 Aggregate Attachment Point is equal to the greater of.
A The sum of the Monthly Aggregate Attachment Points for the Policy Period shown in the
Schedule, or
B the Minimum Aggregate Attachment Point shown in the Schedule.
23 Annual Maximum is the maximum amount of eligible expenses you pay under your Plan, in
excess of the deductible, per Policy Period, that we will reimburse as stated on the Schedule.
The Annual Maximum will be reset each Policy Period.
24 Covered Benefits means those services and/or supplies received or obtained by a Covered
Person that are covered by the Plan and Incurred during the Expense Incurral Period as stated in
the Schedule
2.5 Covered Person means an employee or his or her dependent or a Leoff 1 retiree or his or her
dependent that are enrolled in the Plan during the Expense Incurral Period
26 Expense Incurral Period means the period of time as stated in the Schedule for which a
Covered Person may Incur Covered Benefits under the Plan. In the event that the Policy
terminates prior to the end of the Policy Period stated in the Schedule, the Expense Incurral
Period is modified, separately for Aggregate and Specific, to end on that date rather than at the
end of the Policy Period
2.7 Expense Payment Period means the period of time stated in the Schedule for which you may
pay for Covered Benefits under the Plan In the event that the policy terminates prior to the end
of the Policy Period stated in the Schedule, the Expense Payment Period is modified, separately
for Aggregate and Specific, to end on that date rather than at the end of the Policy Period plus
the length of time, if any, between the end of the Expense Incurral Period stated in the Schedule
and the end of the Expense Payment Period stated in the Schedule
2.8 Incur or Incurred means the date on which Covered Benefits was received and/or obtained by a
Covered Person under your Plan
2.9 Initial Effective Date means the date specified in the Schedule when the Policy first becomes
effective
210 Pay or Paid means the date your check or draft for payment of Covered Benefits is issued and
mailed or electronically deposited directly to the payee, within the policy period, and that the
account upon which the payment is drawn contains sufficient funds to permit the check or draft to
be honored
SLP WA (10-10) 3 Definitions
SECTION 2
DEFINITIONS
(Continued)
Effective 01-01-12
211 Plan means the employee benefit plan you have adopted in writing to provide benefits to your
employees and their dependents, if applicable
2.12 Policy means this policy, any amendments to this policy, the policyholder application, Plan, and
Schedule
2.13 Policy Period means the period of time that this Policy is effective as stated in the Schedule.
214 Schedule means the Schedule of Coverage that is part of your Policy.
215 We, us and our means LifeWise Assurance Company
216 You and your means the Policyholder.
SLP WA (10-10) 4 Definitions