HomeMy WebLinkAboutES10-045 - Amendment - #10 - LifeWise Assurance Company - Stop Loss Insurance Policy - 01/01/2019 Records Management
KENT Document
W A S HI N G T O N
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: 096
This is assigned by City Clerk's Office
Project Name: stow SUSS �MUVZu p
Description: ❑ Interlocal Agreement ❑ Change Order ® Amendment ❑ Contract
❑ Other: 63nL!2.try l o V-\t 4�I o
Contract Effective Date: 1/1/19 Termination Date: 12/31/2019
Contract Renewal Notice (Days):
Number of days required notice for termination or renewal or amendment
Contract Manager: Laura Horea Department: HR
Contract Amount: $761,000
Approval Authority: ❑ Director ❑ Mayor ® City Council 02/05/19 Meeting Date
Detail: (i.e. address, location, parcel number, tax id, etc.):
AMENDMENT NO. 10
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, 2019:
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
�Vk
� Michael L. Krutt
President
Date of Signature
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
City of Kent LifeWise
WA 518212-9999 Assurance Company
Effective 01-01-19
POLICY PERIOD: January 1, 2019 through December 31, 2019
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, 2019
Aggregate Expense Payment Period: From January 1, 2019 through December 31, 2019
A. Covered Benefits: ® Medical ® Rx ❑ Dental ❑ Vision
B. Monthly Factor:
Number of Employees Monthly Factor (Composite)
712 $2,870.28
C. Minimum annual aggregate deductible: The greater of.-
1. $24,523,712; 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, 2019
Specific Expense Payment Period: From January 1, 2019 through December 31, 2019
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: $ 92.01
1.3 ❑ TERMINAL LIABILITY PROTECTION
Number of months:
SLP WA (10-10) 2 Schedule of Coverage
REQUEST FOR MAYOR'S SIGNATURE
KENT Print on Cherry-Colored Paper
Routing Information:
(ALL REQUESTS MUST FIRST BE ROUTED THROUGH THE LAW DEPARTMENT)
Approved by Director
Originator: Laura Horea Phone (Originator): 253.856.5290
Date Sent: 3/22/19 Date Required: 3/29/19
Return Signed Document to: Laura Horea Contract Termination Date: 12/31/2019
VENDOR NAME: Date Finance Notified:
LifeWise (Only required on contracts September 2018
20 000 and over or on an Grant
DATE OF COUNCIL APPROVAL: 2/5/19 Date Risk Manager Notified:September 2018
(Required on Non-City Standard Contracts/Agreements)
Has this Document been Specificall Account Number:
Authorized in the Budget? • YES NO
Brief Explanation of Document:
LifeWise Amendment #10 - Stop Loss Insurance
Riec
MAR 22
K�NT jiA
Apr
All Contracts Must Be Routed Through The Law Department
(This area-to e c mpleted by the Law Department)
Received:
Approval of Law Dept.:
Law Dept. Comments: U4--
Date Forwarded to Mayor:
Shaded Areas To �4 4mpleted By Administration Staff
Received:
RECEIVED
Recommendations and Comments:
Disposition: 5 3 a
�'`��- � � City of Kent
Office of the Mayor
Date Returned:
l ivi orms ocument recessing\Request forMayor's Signature.doa