HomeMy WebLinkAboutES10-045 - Amendment - #6 - LifeWise Assurance Company - Stop Loss Insurance Policy - 01/01/2015 i
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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. rt
Vendor Number:
JD Edwards Number
Contract Number: 1 ;
This is assigned by City Clerk's Office
Project Name V, Y + y-
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Description: ❑ Interlocal Agreement ❑ Change Order ❑Amendment ❑ Contract
❑ Other:
Contract Effective Date: ; ��i`i` Termination Date:
Contract Renewal Notice (Days):
Number of days required notice for termination or renewal or amendment
Contract Manager: i. r Department: "_ — < � <<ylC,
L, 1
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Contract Amount:
Approval Authority: ❑ Department Director ❑Mayor ❑City Council
Detail: (i.e. address, location, parcel number, tax id, etc.):
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AMENDMENT NO. 06
This amendment becomes a part of Stop Loss Policy No. WA-518212-9999 issued to City of Kent, the
Policyholder.
It is 9
stipulated and agreed that:
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Effective January 1, 2015:
The following page is replaced:
Policy Cover.
The following sections are replaced:
Section 1, Schedule of Coverage.
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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.
City of Kent LifeWise Assurance Company
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Sjj'ette Cooke (bate
�, Nlaj Michael L. Krutt
President
Instructions: Retain copy with your policy.
SLP WA AMD (09-08) Amendment
SECTION 1 IJFEWISE
SCHEDULE OF COVERAGE
Policyholder: City of Kent Life I Disability I Stop Loss
WA-518212-9999
POLICY PERIOD: January 1, 2015 through December 31, 2015
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, 2015
Aggregate Expense Payment Period: From January 1, 2015 through December 31, 2015
A. Covered Benefits: ® Medical ❑ Dental ❑ Vision
❑ Weekly Disability Income ® Prescription Drugs
B. Aggregate Deductible (Composite):
Composite Units Medical/Rx
Aggregate Monthly Factor $2,345.80
C. Minimum Annual Aggregate Deductible: Greater of:
$17,762,398 or 95% of the First Monthly Aggregate Deductible times 12.
D. Limit of Liability: We will reimburse 100% of eligible expenses you pay under your Plan in
excess of the deductible 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, 2015
Specific Expense Payment Period: From January 1, 2015 through December 31, 2015
A. Covered Benefits: ® Medical ❑ Dental ❑ Vision
❑ Weekly Disability Income ® Prescription Drugs
B. $200,000 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:
Annual Maximum: ❑ $ ® Unlimited
Lifetime Maximum: ❑ $ ® Unlimited
E. Specific Advanced Funding: ® Yes ❑ No
F. Monthly Premium Rate:
❑ Employee Only: $ Family Rate: $
® Composite: Employee & Dependent: $50.85
1.3 ❑ TERMINAL LIABILITY PROTECTION
Number of months:
SLIP WA (10-10) 2 Schedule of Coverage
REQUEST FOR MAYOR'S SIGNATURE
LGEIi�IT Please Fill in All Applicable Boxes
Reviewed by Director
Ori inator's Name *�> � � fr-z rA2 Dept/Div.i ��Extension: 3Ci
Date Sent: Date Required: - ib -ham
Return to t z, ,K r a CONTRACT TERMINATION DATE:
VENDOR: DATE OF COUNCIL APPROVAL:
ATTACH THE COUNCIL MOTION SHEET FOR THE MAYOR - if applicable
Brief Explanation of Document:
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All Contracts Must Be Routed Through The Law Department
(This area to be completed by the Law Department)
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Received:
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Approval of Law Dept.:
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Law Dept. Comments: _ M' i%iirk-r it
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Date Forwarded to Mayor:
Shaded Areas To Be Completed By Administration Staff
Received:
Recommendations and Comments:
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Disposition.
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Date Returned: