HomeMy WebLinkAboutES10-045 - Amendment - #7 - LifeWise Assurance Company - Stop Loss Insurance Policy - 01/01/2016 , ,a t rt
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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: LifeWise Assurance Company
Vendor Number: 37413
JD Edwards Number
Contract Number: G-- ON
This is assigned by City Clerk's Office
Project Name: Schedule of Coverage Amendment
Description: ❑ Interlocal Agreement ❑ Change Order X Amendment ❑ Contract
❑ Other:
Contract Effective Date: 01/01/2016 Termination Date: 12/31/2016
Contract Renewal Notice (Days): N/A
Number of days required notice for termination or renewal or amendment
Contract Manager: Becky Fowler Department: HR-Benefits
Contract Amount: $476 495
Approval Authority: ❑ Department Director X Mayor X City Council kL �E
Detail: (i.e. address, location, parcel number, tax id, etc.):
As of: 08/27/14
AMENDMENT NO. 07
This amendment becomes a part of Stop Loss Policy No. WA-518212-9999 issued to City of Kent, the
Policyholder.
It is stipulated and agreed that:
Effective January 1, 2016:
The following section is replaced.
Section 1, Schedule of Coverage.
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
Ale-
S,uzet£e Cooke
,l Michael L. Krutt
President
Date'of Signature
Instructions: 1. Sign and return original to us.
2. Retain copy with your policy.
SLIP WA AMD (09-08) Amendment
SECTION 1
SCHEDULE OF COVERAGE LifeWse
Policyholder: City of Kent
WA-518212-9999 Assurance Company
POLICY PERIOD: January 1, 2016 through December 31, 2016
COVERAGE PROVIDED (Provided if checked):
1.1 ® AGGREGATE STOP LOSS
Attachment Level: ❑ 120% ❑ 125% ® Other: 200%
Aggregate Expense Incurral Period: From January 1, 2010 through December 31, 2016
Aggregate Expense Payment Period: From January 1, 2016 through December 31, 2016
A. Covered Benefits: ® Medical ® Rx ❑ Dental ❑ Vision
B. Aggregate Deductible (Composite):
Composite Units Medical/Rx
Aggregate Monthly Factor $2,316.00
C. Minimum Annual Aggregate Deductible: Greater of:
$18,787,812 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, 2010 through December 31, 2016
Specific Expense Payment Period: From January 1, 2016 through December 31, 2016
A. Covered Benefits: ® Medical ® Rx ❑ Dental ❑ Vision
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: $58.48"
1.3 ❑ TERMINAL LIABILITY PROTECTION
Number of months:
'A 50% Specific Stop Loss rate cap applies at 1/1/2017 renewal. This assumes no change in Specific
Stop Loss Deductible and/or contract.
SLP WA (10-10) 2 Schedule of Coverage
REQUEST FOR MAYOR'S SIGNATURE
® l" Print on Cherry-Colored Paper
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Routing Information:
(ALL REQUESTS MUST FIRST BE ROUTED THROUGH THE LAW DEPARTMENT)
Approved by Director
Originator: Becky Fowler Phone (Originator): X5290
Date sent:3anuary 7, 2016 Date Required: January 11, 2016
Return Signed Document to: Becky Fowler Contract Termination Date: 12/31/2016
VENDOR NAME: Date Finance Notified: i C
LifeWise Assurance Com an (Only required on contracts 1 2/08/2015
p y 20 000 and over or on an Grant
DATE OF COUNCIL APPROVAL: 12/08/2015 Date Risk Manager Notified: 12/08/2015
(Required on Non-City Standard Contracts/Agreements)
Has this Document been Specifically Account Number: 56301440.1739.64640
Authorized in the Budget? a YES ()
Brief Explanation of Document:
LifeWise Assurance Company 2016 stop loss amendment for the City's self-insured
medical plans.
All Contracts Must Be Routed Through The Law Department
(This area to be completed by the Law Department) Fl
Received:
Approval of Law Dept.:
Law Dept. Comments: `
Date Forwarded to Mayor: 77
Shaded Areas To Be Completed By Administration Staff
Received:
Recommendations and Comments:
Disposition: t h ,
Date Returned:
Ke 1 7 V
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