HomeMy WebLinkAboutES10-045 - Amendment - #8 - LifeWise Assurance Company - Stop Loss Insurance Policy - 01/01/2017 W A6HINOTON e Document
VI
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
Vendor Number:
ID Edwards Number
Contract Number: ES10-045-005
This is assigned by City Clerk's Office
Project Name: 2017 Stop Loss Coverage with Premera
Description: ❑ Interlocal Agreement ❑ Change Order ❑ Amendment ❑ Contract
® Other: Amendment No 8
Contract Effective Date: 1/1/2017 Termination Date: 12/31/2017
Contract Renewal Notice (Days):
Number of days required notice for termination or renewal or amendment
Contract Manager: B. Fowler Department: HR
Contract Amount:
Approval Authority: ❑ Department Director ❑ Mayor ® City Council
Detail: (i.e. address, location, parcel number, tax id, etc.):
As of: 08/27/14
AMENDMENT NO. 08
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, 2017:
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 .,J LifeWise Assurance Company
suzette C'oj oke
Michael L. Krutt
President
Date of Si nature
Instructions: 1. Sign and return original to us.
2. Retain copy with your policy.
SLP WA AMD (09-08) Amendment
SECTION 1
SCHEDULE OF COVERAGE LifeWise
Policyholder: City of Kent l�
WA 618212.9999 Assurance Company
POLICY PERIOD: January 1, 2017 through December 31, 2017
Coverage 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, 2017
Aggregate Expense Payment Period: From January 1, 2017 through December 31, 2017
A. Covered Benefits: ® Medical ® Rx ❑ Dental ❑ Vision
B. Monthly Factor:
Number of Employees Monthly Factor(Composite)
698 $2,543.14
C. Minimum annual aggregate deductible: The greater of:
1. $21,301,341; or
2. 95% of the first monthly aggregate deductible times 12.
D. Annual aggregate deductible (Aggregate Attachment Point):
The greater of:
1. The sum of the monthly aggregate deductible amounts for each policy month in the
Policy Period; or
2. The minimum annual aggregate deductible.
Note: The annual aggregate deductible cannot be finalized until the monthly aggregate deductible
amounts are calculated for each policy month of the Policy Period.
E. 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.
F. Claim Review is ® end of Policy Period ❑ Monthly with $ threshold.
G. Monthly Premium Rate: $0.02 per Employee
1.2 ® SPECIFIC STOP LOSS
Specific Expense Incurral Period: From January 1, 2010 through December 31, 2017
Specific Expense Payment Period: From January 1, 2017 through December 31, 2017
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: $69.60*
1.3 ❑ TERMINAL LIABILITY PROTECTION
Number of months:
A 50% rate cap applies to the Specific Stop Loss coverage for the January 1, 2018 renewal, provided
there is no change in Specific Stop Loss Deductible and/or contract.
SLP WA (10-10) 2 Schedule of Coverage
REQUEST FOR MAYOR'S SIGNATURE
� T Print on Cherry-Colored Paper
Routing Information (ALL REQUESTS MUST FIRST BE ROUTED THROUGH THE LAW DEPART®rNT,
Approved by Di
Ori inator ��� s Phone (Originator): ),
Date Sent: - i Date Required:
Return Signed Document to _r1 Contract Termination Date:a p 7
VENDOR (NAME: Date Finance Notified:
.--- (Only required on contracts
10 000 and over or on any Grant
DATE OF COUNCIL APPROVAL: Date Risk Manager Notified:
(Required on Non-City Standard Contracts/Agreements)
Has this Document been Specifically Account Number:
Authorized in the Bud et? YES Q NO Z to t`_I SC; r � �v"
Brief Explanation of Document:
,
All Contracts Must Be Routed Through The Law Department
(This area to be fcori"i Ieted by the Law Department)
Received: f f
�pp aa L) 5 f
Law Dept. Comments:
Date Forwarded to Mayor:
Shaded Areas To Be Completed By Administration Staff
Received:
i
Recommendations and Comments.
V1 ,
Disposition: 2ol� J
Date Returned: