HomeMy WebLinkAboutES10-045 - Amendment - #9 - LifeWise Assurance Company - Stop Loss Insurance Policy - 01/01/2018 %// is
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CONTRACT COVER SHEET
This is to be completed by the Contract Manager prior to submission
to the City Clerk's office. All portions are to be completed.
If you have questions, please contact the City Clerk's Office at 253-856-5725.
Vendor Name: LifeWise Assurance Company
Vendor Number:.
JD Edwards Number
Contract Number: )'o
This is assigned by City Clerk's Office
(Project Name: o) 5
Description: ® Interlocal Agreement 0 Change Order D Amendment 0 Contract
❑ Other: Jq VvVvl(At yU_A ',,f- -k 01
Contract Effective Date: 1/1/18 Termination Bate: 12/31/2018
Contract Renewal Notice (Days):
Number of days required notice for termination or renewai or amendment
Contract Manager: Laura Horea Department: HR
Contract Amount: $610,000
Approval Authority: F' Director Mayor 0 City Council 12/12Z17 Meeting gate
Detail: (i.e. address, location, parcel number, tax id, etc.):
AMENDMENT NO., 09
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, 2018:
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
Michael L. Krutt
President
Date ot 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 � LifeW i se
Policyholder: City of Kent
WA 618212-9999 Assurance Company
Effective 01-01-18
POLICY PERIOD: January 1, 2018 through December 31, 2018
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, 2018
Aggregate Expense Payment Period: From January 1, 2018 through December 31, 2018
A. Covered Benefits: ® Medical ® Rx ❑ Dental ❑ Vision
B. Monthly Factor:
Number of Employees Monthly Factor(Composite)
708 $2,971.54
C. Minimum annual aggregate deductible: The greater of:
1. $25,246,204; 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, 2018
Specific Expense Payment Period: From January 1, 2018 through December 31, 2018
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: $77.26
1.3 ❑ TERMINAL LIABILITY PROTECTION
Number of months:
SLP WA (10-10) 2 Schedule of Coverage
REQUEST FAIR MAYOR'S SIGNATURE
Pirint, on Cherry-Colored Paper
Z�KKNT
Routing Information:
(ALL REQUESTS MUST FIRST RE ROUTED THROUGH THE LAM/ DEPARTMENT)
Approved by Director
Originator: Laura Horea Rhone (Originator): 253.856.5290,
Date "gent: 2/21/1 Date Requiredl: 2/26/1
Return, Signed Document to: Laura, Horea Contract Termination Nate: 12/31/2018
VENDOR NAME: Nate Finance Notified:
Life' ise (only required on contracts 09/ 8/ 7
20 000 and over or on any Grant
DATE QE COUNCIL APPROVAL: 12/12/17 Date Rise Manager Notified:09/28/17
(Required on Non-City Standard Contracts A reements
Has this Document been Specificall Account Number:
Authorized in the Bud et' • YES NO
Brief Explanation of Document:
LifeWise contract - Stop Loss Insurance
All Contracts Must Be Routed Through The Law Department
(This area to be c feted by the Law Department)
Received:
Approval of Lai Dept.:
Lanni Dept. Comments:
date Eorw2 d dd to Ma or:
Shaded Areas To Be"Co44ted By Acfrninstratrcn trf ,,,
r
Received:
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Recommendation and Comments: : IJ
Disposition, qY0
mate Returned:
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