HomeMy WebLinkAboutContract 45599EXCESS RISK APPLICATION
ReliaStar Life Insurance Company
("ReliaStar Lite")
Home Office: Minneapolis, Minnesota 55440
Plan Sponsor hereby applies for the Excess Risk Policy.
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Employee Benefits
PLAN INFORMATION
Name of Plan Sponsor (exact legal name) City of Fort Worth
Address (number and street) 1000 Throckmorton Street
City Fort Worth
r] Corporation Partnership
Nature of Plan Sponsor's Business
State TX
Sole Proprietorship Other (Specify) Public Entity
City Administration
Are subsidiaries, affiliates or other associated entities to be included?
If "Yes," give Names.
Relationship to Plan Sponsor
Please provide the number of individuals covered as noted below:
Eligible Individuals 6850
Enrolled Individuals 6850
Individuals Covered Elsewhere
The initial Contract Period is from April 1, 2014
Yes No
Covered Persons Only n/a
Covered Persons Only n/a
Covered Persons Only
ZIP 76102
SIC Code
Covered Persons with Dependents n/a
Covered Persons with Dependents n/a
Covered Persons with Dependents
through December 31, 2014
CLAIM ADMINISTRATOR INFORMATION (Claim Administrator for coverages checked below for the Employee Benefit Plan)
Name of Claim Administrator* (exact legal name of entity) Aetna Life Insurance Company
Address (number and street) 2777 North Stemmons Freeway, Ste 1300
City Dallas
*Claim Administrator must be approved by ReliaStar Life prior to acceptance of this Application
INDIVIDUAL EXCESS RISK
Individual Excess Risk: Yes No
Benefits To Be Covered: [VI Medical
Initial Coverage Period:
Incurred and Paid in 12 months
Incurred in 15 months and Paid in 12 months
Paid in 12 months
Other:
Other (Please specify) Prescription (Rx)
State TX
ZIP 75207
Incurred in 12 months and Paid in 15 months
�] Incurred in 12 months and Paid in 9
months *
*Per agreement between Sponsor and ReliaStar Life,
Coverage Period shall begin at 12:00 01 a.m. on 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)
Individual Excess Risk Deductible $ 1, 0 0 0, 000
Individuals subject to the Individual Adjusted Deductible as identified in the disclosure process n/a
per Individual
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.
Benefit Percentage 10 0 0
RL-SL-APP-2013 Page 1 of 2 - Incomplete without all pages. Order #160042 12/04/2012
INDIVIDUAL EXCESS RISK (Continued)
Maximum Individual Benefit:
Individual Excess Risk Lifetime Maximum: $ Unlimited
Other $
Optional Endorsements:
Individual Terminal Liability: 3 months 6 months
Individual Advanced Funding
Individual Gapless Renewal (Only available for 12/15 or 12/18)
Aggregating Individual Deductible: $
Plan Mirroring Coordination
Renewal Rate Cap
Other:
AGGREGATE EXCESS RISK
Aggregate Excess Risk. Yes k% No
Benefits To Be Covered: Medical [ j Vision
Initial Coverage Period:
Incurred and Paid in 12 months
Incurred in 15 months and Paid in 12 months
Paid in 12 months
Other:
Prescription Drugs
Individual Excess Risk Annual IVaximum: $ unlimited
Dental
Other (Specify)
(Individual Excess Risk must be elected)
n Incurred in 12 months and Paid in 15 months
Incurred in months and Paid in months
Aggregate Adjustment Corridor
Minimum Annual Aggregate Deductible: See Excess Risk Schedule
ReliaStar Life's Limit of Liability: $ per Coverage Period OFFICIAL RECORD .
Optional Endorsements: CITY SECRETARY'
Plan Mirroring Coordination E
no WORTH, TX
Aggregate Terminal Liability: 3 months 6 months (Individual Terminal Liability must also be elected)
Other:
Are retirees covered?
V Yes No
Are retirees age 65 and over covered? 71 Yes
No
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 law) is: n/a
This insurance is to be effective on April 1, 2014 at 12:01 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 $ 34,25 0 is attached. (The deposit is to equal the first premium.) The 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 Plan Sponsor Applicant.
ACKNOWLEDGEMENT & SIGNATURES
By signing this Application below and the Disclosure Agreement, the Plan Sponsor 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 Sponsor 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 ReliaStar 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 for; (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 ReliaStar Life, any policy issued by ReliaStar Life may be rescinded and/or any benefits that might other 4 • se sayable thereunder
maybe denied; and (iii) the Plan Sponsor Applicant has full read and understands this completed Application and the D'�
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Plan Sponsor Applicant City of Fort Worth
Name of Signer (Please Print.) susan Alanis
By
RL-SL-APP-201V
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4/2012
City of Fort Worth, Texas
Mayor and Council Communication
COUNCIL ACTION: Approved on 4/8/2014
DATE: Tuesday, April 08, 2014 REFERENCE NO.: **C-26750
LOG NAME: 14INGSTOPLOSS14
SUBJECT:
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)
RECOMMENDATION:
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 12/9 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 foi 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.
M/WBE OFFICE — A waiver of the goal for MBE/SBE subcontracting requirements was requested by the
Human Resources Department and approved by the M/WBE 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 Group Health Insurance Fund
FUND CENTERS:
TO Fund/Account/Centers
CERTIFICATIONS:
Submitted for City Manager's Office by:
:
Originating Department Head:
Additional Information Contact:
ATTACHMENTS
1. Fund Verification FE85.docx
2. Fund Verification.docx
3. Stop Loss Insurance.pdf
FROM Fund/Account/Centers
FL85 534840 0148520
FE85 534840 0148540
Susan Alanis (8180)
Brian Dickerson (7783)
Margaret Wise (8058)
$164.400.00
$41.100.00