The URL can be used to link to this page

Home My WebLink AboutContract 45447 CITY SECRETARY q1 OFFICIAL RECORD awma Wig:em (;,Isry 11%RKTARY R DISCLOSURE AG E ij'�°�� „Nt F,t irw„l,,i v,rn turn ruvrraiwrire� Reliastar Life l'nsLuran e C mpan r, Minneapolis, VIN � A member of the ING famil y of companies t "Company") Your future.Made a Bier. Pollicy Effective'Date 0 o 1 2 o 14 11 w otV F 0 Plan sponsor lame 'The City of FL. WortJi Now= 11101 INSTRUCTIONS FOR COMPLETION' � Please provide the information described in the Disclosure Reports,Section,below and then have an authorized re resen . in sign the p p Disclosure Agreement below.The Company,shall use the information rovuded solel for the purpose of evaluating the rids � V p � � or renewed Excess Risk Insurance Policy("Policy"). Prior to submitting this Disclosure Agreement and Disclosure Reports to the Company, p eas e consult with your current Claim Administrator(s), Utilization Review Firm(s), Cease Management,and Pharmacy Benefits Ma:nager s (collectively, "'Claim Vendors"),and Plan Sponsor's Broker or other insurance advisor.The Disclosure Reports must be provided to the Company no earlier than go calendar days prior to the Policy's Effective Dates or renewal date,as applicable.should the Company require any,additional information, it w,ill notify the Plan sponsor and/or its designated representative,in waiting no later than 20 calendar days following receipt of the Disclosure Reports,Any fire quote is void unless accepted by the Plan Sponsor in writing within 35 days from the date quoted by the Company. DISCLOSURE REPORTS (Plan Sponsor squall'attach the following reports or data include claimant name, i y CD 9' diagnosis) hereinafter referred to as the (("Disclosure eports., •Any individual with paid claims that has exceeded 50%of the stop loss deductiblle during the applicable current policy year minirriUM g months)-, •Any individual'with denied and/or pended claims that has exceeded $25,000 during the applicable current policy year(mini(TI UFri of 9 months): •Any individual evaluated and/or listed for an organ,stem cell or borne marrow transpilantM •Any individual diagnosed with a condition,during the applicable current police year,represented by any of the IC ID-91 codes contained in the attached list rndivid�uall who is in case management during the a licable current policy year minimum of months). including claii��n amounts,as well as any. pp p y DISCLOSURE AGREEMENT The Plan sponsor submits this Disclosure Agreement and the attached Disclosure 'Reports to the Company to induce the Company to issue an Excess Risk Insurance Polio Policy )or to renew an existing Policy,The Plain Sponsor represents,� Company,to the best of its knowledge and belief,and after ("Policy") onsor re a eseu�nts to the tom making a diligent and good faith inquiry, that i all information contained in the Disclosure Reports its compete, true and materially correct ii prior to submitting this Disclosure Agreement and(Disclosure Reports to the Company,Pan sponsor reviewed and discussed sucl-iDisclosure Reports(together with all pre-certifications,case management notes,claim files,and pharmacy benefit management fides(grid motes)for both the current polio year and each year thereafter during which the Company provided excess insu.rrance coverage to Plan sponson-with its Claims Vendors,broker or other insurance advisor;(iii)it as reviewed this Disclosure staterrient and thy.attached Disclosure Reports with its Broker or other insurance advisor,and has fully read and uunderstanids this Disclosure Agreement; and iv as of the date of signing of this Disclosu re Agreement there are no known potential catastrophic claims other than those disclosed on the attached Disclosure Reports,The Plan sponsor Understands and agrees that; i the Company will rely on this Disclosure Agreement and the attached Disclosure Reports to i underwrite this risk,iii}determine whether or not to issue or renew)a Policy,and(iii)if tyre Company agrees to issue or renew a Policy,determine'the terms,conditions, limitations,and rates of our for such loo icy«The Plan Sponsor further understands and agrees that ii if such Disclosure 'Reports are incomplete or untrue,and such incompleteness or fallsity is material to the risk to be insured by the Company, any Policy issued or renewed by the Company may be rescinded,any benefits that might otherwise be payable thereurnc c.)r may be denied,and/or the premium rates deductibles,terms,conditions and limitations of the Policy may be revised by the Company;and,(ii)its complete and accurate disclosure of known potential catastrophic clairns is a condition precedent to issuance or renewal) of the Policy. In the event the Disclosure Reports are not timely submitted to, and approved by,the Company within 45 days following the Effective Cate or renewal date of the Policy,the Company retains the unconditional right to deny any claim,adjust the rates or its underwriting tears,and/or rescind the Policy at any time,and such right shall not be irrnpaired as a resuilt of the Company's acceptance of premium, Pan sponsor verifies that to the best of its knowledge and belief, and after making a diligent and good faith inquiry, the Disclosure Reports herein and hereafter provided is(are)accurate and complete. .. Plan sponsor Signature By(Its Corporate Officer or OtherAuthorizied Representative) Title `�,�, �. �� . ,Date, RL-SL-DISCLOSE-201 3 Page 1 of 2-incomplete without all pages. Order-#1647211 2106/20112. ft(Tif ,%r A" Od VAf 4_ M16 IC D-9 CODES FOR DISCLOSURE NOTIFICATION Please list all Plan Participants who have been diagnosed with or treated for any of thle Codes listed under the fc Howing categories during the current Benefit Period, Neoplasms Diseases of thle Genitourinary System 140-239 Neoplasms, -594-584.9 Acute Renal Failure Endocrine, Nutritional, Metabolic, Immunity 585 Chronic Penal Failure 277,0 Cystic Fibrosis 586 Renal Failure, unspecified Diseases of the Blood and hood-Formling Organs Complications of Pregnancy,Childbirth, 284.9 A p llastic Anemia I" 05 651 Multiple Gestation 286-286.9 Coagulation Defects and/cur Hemophilia Diseases of the Musculloskelletal System and Connective Ti sue Diseases of the Nervous System and Sense Organs 13'0-730.9 Osteomyelitis and/or Periolstitis 344.0-344.09 Quadriplegia and c uadriparesis 730-730.10 Chronic Osteomyelitis 344.1 Paraplegia Congenital Anomalies. 348..0-348.9 Enceplalpathy 7472 Aortic Atresia/stensis Diseases of the Circulatory System 7 51.6 Piliary Atresia 410-410.9 Acute Myocardial Infarction 759-759,.9 Other and Unspecified Congenital Anomalies 411-411.89 Acu.ite and subacute Ischemic heart Disease Conditions Originating in the Perinatail Period 414.414.05 Coronary Atherosclerosis ASHI 765-765.1 Prematurity 4115-415.19 Acute Pulmonary Heart.Disease 769 Respiratory(Distress syndrome 416-416.9 Chronic Pulmonary Heart Disease 7 70. -770.9 Other Respiratory Conditions of Newborn rn 417.1 Aneurysm of Pulmonary Artery Injury and Polisoning 421-421.9 Acute and subacute End card'itis 800-804.9 Fracture of Skull 424-424.9 Valve Disorders 805-805.9 Fracture of"vertebral Column 425-425.9 Cardiomyopathy 806-806.9 Fracture of Vertebral Column with Spinal Cord Inji..iry 427-427.9 Cardiac Dysrhy°°thmias 828-828.1 (Multi le Fractures 428-428.9 Heart Failure, 853- 54.1 Intraucranial (injury 430!1 431' Subarachnoid Intracerebral Hemorrhage 8 g g.1 Internal Injury 434.9 Occlusion of cerebral Arteries 887-8873 Traumatic Amputation of Arm,and Hand 436 Acute Cerebrovascular Accident(C VA) 897-897.7 Traumatic Amputation of Leg 440-441.9 Atli erosdelrosis/Aortic Aneurysm 949-949.5 Burns Diseases of the Respiratory System 952-952.9 spinal Cord Injury 480-486 Pneuru nnia Complications peculiar to certain specified conditions 490-496 Chronic Obstructive Pulmonary Disease COPD,,etc. 23 Supervision of High Risk Pregnancy 515 Postinflarnmatory Pulmonary Fibrosis '42-V58.91 Transplants,etc. 5118-518.89 Pulmonary Collapse and/car Respiratory Failure Diseases of the Digestive Syster n 555-5155.9 Regional Enteritis Crhn's Disease) 560.0-560,91 Intestinall Obstruction 562.1 Diverticulitis of C011011 567-567.9 Perito rill itls 569.0-569.9 Other Disorders of Intestine 570-57 1.q-1 Liver Hiiseases and Cirrhosis 572.8 Other 5egtiela of Chronic Liver Disease 573-517 3.9 Other Liver Disorders 577-577.9 Pancreas Diseases 578-578.91 Gastrointestinal Hemorrhage L-SL-D I SlC I.OS l -2 013 Page 2 of 2-Incomplete vvithOLA all pages. Ord er#1 64721 12/06/2012 The Ct f Fort Worth Stop-Loss Comparison Summary ING Sun Life Aetna Proposed Effective Date 4/1/2014 4/1/2014 No Bid Policy year end date 12/31/2014 12/31/2014 Covered benefits, Me x Me Rx Annual maximum Unlimited' Unlimited Lifetime maximum Unlimited Unlimited Benefit percentage, 100% 100% Commission None None Plan Mirroring Coordination Included Included Claim Basis: 12/9 12/9 Specific Deductible $110,001000 $11000;000 Employee tier/live,s Employee Only 6497/$5 3338/$3.66 Employee& Family - 3159/$7.95 Estimated monthly premium $32,485 $3713,31 Estimated policy year premium $292 365 $335;980