The URL can be used to link to this page

Home My WebLink AboutContract 45599 CITY SEC' COMTRA EXCESS RISK APPLICATION lx ii ii ReliaStar Life Insurance Company "I eliaStar Life" Home Office: Minneapolis, Minnesota 515440 Plan Sponsor hereby applies for the Excess Risk Policy. y t l 1J III, l 111 � ��1�//��%/��r✓rl��//��/1//%��!��i��/��/��%%��/� ��1��1�✓��/��/�� 11//11�!rT/l/l�/��i�'��1��y1�11'l��l�/�r)�� /��Jl,��llJ��!/l�/��J R�"1�1�+1+�1�J1�1�1�U�G�IIIIIJ��1�J��IJ�J�1�11�1%�11r1�1�11�1�"�/"��r��lrr��1�ll1 11.lUla>'�Jt�1u�J��1��1�11�v�eu�J��I��J��lJ�1 PLAN INFORMATION Name of Plan Sponsor(exact legal name) C'�t � c� Fort orth Address number and street) 10010 Throc rmrton Street City Fort Worth State TX ZIP 76102 [1{Corporation E!Partnership F]Sole Proprietorship V1 Other(Specify) Pu 1.i c Ent i ty Nature of Plan Sponsor's Business City Administration SIC Code Are subsidiaries,affiliates or other associated entities to be included Yes No If"Yes,"give Names. Relationship to Plan Sponsor Please provide the number of individuals covered'as noted below: Eligible Individuals 6850 Covered Persons only n/a Covered Persons with Dependents n/a Enrolled Individuals 6850 Covered Persons only n/a Covered Persons with Dependents n/a Individuals Covered Elsewhere Covered Persons only Covered Persons with Dependents The initial Contract Period is from Apri 1 1 2 0 14 through December 31, 2 0 .4 rte? E11111m,M CLAIM ADMINISTRATOR INFORMATION' Cam Administrator for coverages checked below for the Employee Benefit Plan) Name of Claim Administrator* (exact legal name of entity Aetna Life Insurance Company 1 i r Address "bomber and street, 2777 North St8mmons Freeway, Ste 1300 City Dallas State TX ZIP 752;07 *Claim Administrator most be approved by Behest r Life prior to acceptance of this Application INDIVIDUAL EXCESS RISK t Individual Excess Risk: Yes F-1 No Benefits To Be(Covered; Medical other(Please specify) Prescription (Rx) 1 Initial Coverage Period: Incurred and Paid An 12 months Incurred in 12 months and Paid in 15 months F-]Incurred in 15 months and Paid in 12 months Incurred in �2 months and Paid in months n Paid in 112 months E]Other; *Per agreement between Sponsor and Re . .aStar Life, Coverage Period shall begin at 12:00:01 a.m. an 1/1/2014 and end at 11:59:59 p.m. on 12/31/2014 (12 months) with premiums paid between 4/1 and 12/31/2014 (9 months) J J Individual Excess Risk Deductible 1 0 0 0 0 0 0 per Individual Individuals subject to the Individual Adjusted Deductible as identified in the disclosure process n/a Claims for Individuals subject to the Individual ,adjusted Deductible that exceed the Individual Excess Risk Deductible amount are excluded under any Aggregate Excess Risk Insurance. J Benefit Percentage 10 0 ww" .. ., � � RL- L--APP-:2013 Page 1 of 2-Incomplete without all pages. Order#160042 12/0412012 i l I r r I, ! r r ( I I 7 D G 11 )l l J �1 /lr'1�711 �lrrrr,��r�r��rl��i�art�r�i�r"��ur�r�r��l��r��r��i INDIVIDUAL EXCESS RISK (Continued) Maximum Individual Benefit: Individual Excess Risk Lifetime.Maximum.: unlimited Inlld:ivid'ual Excess Risk Annual Ma imlum; unlimited Other Optional Endorsements. Individual Terminal Liability: n 3 months E]6 months ]Individual Advanced Funding Individual Capless Renewal(Only available for 12,115 or 12/18) [�Aggregating Individual Deductible: (Individual Excess Risk must be elected) Plan Mirroring Coordination E]Renewal Rate Cap other: I y ,qny ItiY �i I ��.. i�(1��111l�l�IX�CJ.ri ar��fl'dl�llll�^Id�l'llf klG /&4'illYle!(V%��V�d��dff(r)�ff�r�f!„��Idllk7dfx!�I�I��V!J��I�J4X;,V��rt��1��11 (V r, AGGREGATE EGA►T'E EXCESS RISK Aggregate Excess Risk. []Yes W]No Benefits To Be Covered: E]Medical []"vision Prescription Drugs Dental ❑!other ��ec�.�' Initial Coverage Period. E]Incurred and Paid in 12 months ]]Incurred in 12 months and Paid in 15 months Incurred in 15 months and Paid in 12 months []Incurred in months and Paid in months E]Paid in 12 months Other: Aggregate Adjustment Corridor °, rU'NSItlXMWINUM4mIINnugIN'IrvIiNWNlrv9 vygIUNU UUIU Iinirnurn Annual Aggregate Deductible:see Excess Risk Schedule i mur'nuuwrrumnti vwanmmaNrv;mu.^uwNl,.rewuwmuunuummmpm�mlorovou Reliastar Life"s Limit of Liability.- per Coverage Period OFFICIAL RECORD Optional Endorsements: r � i ��r Plan Mirroring Coordination „ ,,�:� WORTH, I Aggregate Terminal Liability: E] months 0 6 months(Individual Terminal Liability rust also be e1ec � ) TX �7N,dxl, �INxrIINN,�r�l»r�IrYIIrIII�,I�IIINYINN��Y, INe ,, F]Other: I , I Are retirees covered? VYes N:o Are retirees age 65 and over covered? , Yes 0 No I�Yd w`(+d�l�l!J!�f?�I�IG1(�IIIId? �'I��+f71r77N�a1X191�X�1�'f+�1 11�I�C�iY'!16W1�9�''�JJJ�1�!Y��i 111�l��"uY711�+I�'UMEN=INI�91171=f7k�111J1wuV�i7�lllr��1Y61,afaiifll�r x.71 I)�izl�"l�Vi�Ir"�'l�lili,�Ilr�rJIG117ff7J�kIPX�"Y��7��7�'��P !��1 I P I 1 ?I � o I u c ICI a I Attached to and incorporated in this Application is a copy of the Employee Benefit Plan that relates to the Excess Risk Policy being applied for.. The Producer/Agent of Record (provided he/she is duly licensed as required by lave)is n/a This insurance is Ito:be effective,on April 1, 2014 at 1 2;01 a.m. standard Time at the Plan sponsor's place of� business, provided that the first premium is paid in full and that the Disclosure Agreement and this�Application are accepted by Reliastar Life, An advance deposit of 3 412 5 0 is attached.(The deposit is to equal the first premium.)Thee deposit will be applied toward payment of the premiums on the insurance requested if the application is accepted by Reliastar Life.If not accepted,the deposit will be refunded to the Flan sponsor Applicant. III MNIM MENEMEMEMEEM,MI ACKNOWLEDGEMENT & SIGNATURES By signing this Application below and the Disclosure Agreement,the Plan Sponsolr Applicant represents that all statements,,answers and information made above in this application and in the Disclosure Agreement are complete and true to the best of its knowledge and belief. Plan splonsolr Applicant further acknowledges and agrees i)that such statements,answers and information in this Application and in the Disclosure Agreement,together with a copy of the Employee Benefit Plan and other information attached to this application or furnished to Relliastar Life,are,submitted by the Plan sponsor Applicant as an inducement to,and will be relied upon,Reliastar Life, in underwriting this risk and determining whether to accept this application and issue the Excess Risk Policy being applied folr;(ii)if such statements,answers and information is/are incomplete or untrue,and such incompleteness or falsity is material to the risk to be insured by Rel'iatar Life,any policy issued by Reliastar Life may be rescinded and/or any benefits that might other e ayable thereunder may be deniedll;and(iii)the Plan Sponsor Applicant has fully read and understands this completed Application and the t. Plan sponsor Applicant city of Fort Werth. 144k I a 04 A 0 .............. Susan �l.a.ni Name of signei "Please Prin i AI V R ,' ,,, Lk, yw � die i tart City Man r L, `h � I' ......................................................................................1 ............... -FE:H�- FP-2 9 "'� w.................................................................................Page 2 f I� n� I� �th �III d� �16 11 4l"201 11 J �a 0000 wry 21 Mara CJAqkA%A&01ftAft__._ City of Fort Wtexas Mayor a ion COUNCIL ACTION: Approved on 4/8/2014 DATE: Tuesday,April 08, 2014 REFERENCE NO.: **C-26750 LOG-NAME: 141NGSTOPLOSS 14 SUJECT: Authorize Execution of Agreement with Reliastar Life Insurance Company in the Amount of$308,250.00 for Stop Loss Insurance for the City's Health Benefits Plan with an Effective Date of April 1, 2014(ALL COUNCIL DISTRICTS) RE MNIENDATIO : It is recommended that the City Council authorize execution of an Agreement with Reliastar Life Insurance Company in the amount of$308,250.00 for stop loss insurance for the City's health benefits plan with an effective date of April 1,2014. DISCUSSION: The purpose of this Mayor and Council Communication is to seek authorization to enter into a new Agreement with Reliastar Life Insurance Company, a member of the ING family of companies,for stop loss insurance coverage for the City' s health benefits program.. Effective April 1, 2014,Reliastar will begin providing specific stop loss coverage for the City's self—insured health plan. The Agreement is on a claims basis of 1219 which means that the Agreement will cover the claims incurred for the 2014 Plan Year, January 1, 2014—December 31, 2014, at the total cost for nine months premium. The specific stop loss coverage caps the City's liability for annual claims on a per member basis. The City pays for all claims for each participant up to a specified dollar amount with the stop loss insurance coverage paying for any claims beyond that the per--participant threshold. The threshold for coverage for 2013 was$750,000.00 per participant, and the total premium cost was $753,265.00. However, Staff recommends increasing the threshold to$1,000,000.00 based on historical claim data. By increasing the specific coverage level to$1,000,000.00,the City will realize a premium reduction of 59 percent compared to last year's total premium. The City will pay a monthly premium in the amount of$5.00 per active and Non--Medicare member to acquire stop loss coverage for individual claims in excess of$1,000,000.00 for a total premium amount of $308,250.00 for the year. The amount that will be paid from Fiscal Year 2014 funds is $205,500.00 for January through September 2014. MIwBE OFFICE—A waiver of the goal for MBEISBE subcontracting requirements was requested by the Human Resources Department and approved by the MIwBE Office, in accordance with the BDE Ordinance, because the purchase of goods or services from source(s) where subcontracting or supplier opportunities are negligible. FISCAL INFORMATION: The Financial Management Services Director certifies that funds are available in the current operating budget, as appropriated, of the Croup Health Insurance Fund. FUND CENTERS: TO Fund/Account/Centers FROM Fund/Account/Centers FE85 534840 0148520 $164,400.00 FE85 534840 0148540 $41,100.00 CERTIFICATIONS: Submitted for City Mana ees ffice by: Susan Alanis (8180) Originating Department Head: Brian Dickerson (7783) Additional Information Contact: Margaret Wise (8058) ATTA CUMENTI'S 1.Fund Verification FE85.docx 2. Fund Verification.docx 3. Stop Loss Insurance.pdf