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HomeMy WebLinkAboutContract 45014 (2)Allstate.. Benefits Scott Shapard Higginbotham 500 W. 13trh Street Fort Worth, Texas 76102 October 3, 2013 Scott, MIN ,ta y Darin Reeser GBA Vice President National Accounts South Central Territory Please consider this acknowledgment of the City of Fort Worth's request to add the following to their application for Group Insurance with Allstate Benefits: "Signed signature pages may be transmitted by facsimile or email, and any such signature shall have the same legal effect as an original signature." Best regards, Darin Reeser ZU'I5RECEIVED DU 1l 8 American Heritage Life Insurance Company 4920 Westway Park Blvd. Suite 120 Houston TX 77041 dreeicaallstate.com Office 713-744-8310 Cell 281-460-5855 AMERICAN HERITAGE LIFE INSURANCE COMPANY (AHL) Jacksonville, Florida GROUP ACCOUNT INFORMATION 1. Proposed Policyholder A. Name City of Fort Worth (Legal Name) C. Fed. I.D. No. 75-6000528 D. Type of Business Municipality For Home Office use only Group/Account No. Master Account No Effective Date B. SIC code E. Years in Business N/A F. Address 1000 Throckmorton Street Fort Worth TX 76102 Tarrant (Street) (City) (State) (Zip) (County) (P.O. Box, If any) (City) G. Contact Person(s): 1. Responsible Officer & Title Susan Alanis - Assistant City Manager 2. Administrative Contact Maria Gray 3. Administrative Contact Email H. Affiliated Companies to be included in coverage: Name Location (Street, City, State, Zip) (State) (Zip) (County) Phone:( 817) 392-8180 Phone:( 817 )392-7787 Fax:( 817 ) 392-8869 Number of Employees Wholly -owned Subsidiary of Policyholder? YES NO* ■ *If the "affiliate" is not owned by the Policyholder, please describe the relationship under Item IV, "Comments" I• Requested Effective Date for Plan year01/01/2014 to .First Payroll Deduction Date 01/03/2014 CI ■ Will this replace similar group coverage? j2Yes ■ No If yes: Termination date of similar plan 12/31/2013 Name of similar insurer AFLAC and Allstate individual plans (attach copy of Certificate or SPD) K. Is the Policyholder discontinuing a previous voluntary insurance program9 r4 Yes ❑ No If yes, name of prior insurer and product types AFI AC and Allstate individual arcident cancer critical illness life hospital indet L. Will the AHL insurance be part of an Employee Welfare Benefit Plan (ERISA)? ❑Yes 0 No If yes, should AHL include a Summary Plan Description (SPD) in the Certificates of Coverage? ❑Yes ❑ No If yes, complete the following as it appears on the most recent Form 5500 or AS IT WILL APPEAR on the first form 5500 for a new plan. ERISA Plan No. Plan Year: From through each year Plan Nam° If no, th3 SPD will bo the Policyholder's rocronc biiity: M. All Group Plans underwritten by AHL with the exception of Disability and Life are subject to COBRA. AHL offers and pays for administration of its COBRA plans through COBRAGuard with the exception of The Major Medical Complement. If you want to utilize COBRAGuard please complete the COBRAGuard User Service Order Form, ABJ13007. IL Proposed Insureds A. Eligible Employees. 1. Total number of employees eligible for coverage• 6.200 2. Eligible Employees are (check all that apply) ❑ Full-time employees who work 25 or more hours per week. ❑ Full-time employees who work 30 or more hours per week. © Regular part-time employees who work 20 or more hours per week. ❑ Full-time employees who work 20 or more hours per week. ❑ Other (explain): • 3. Describe any class of employees to be excluded Temporary and Contract Employees B. Eligible Association / Union Members (applies to Cancer/Specified Disease, Accident, SHOP, Indemnity Medical, Critical Illness, Vision, Universal Life, and Disability (GVDI)) 1. Total number of members eligible for coverage: • 2. Eligible Members are (check all that apply) Full-time members who work 25 or more hours per week. ❑ Full-time members who work 30 or more hours per week. Page 1 of 3 (2/12) ■ ABJ4040 3 II. Proposed Insureds (continued) Regular part-time members who work 20 or more hours per week. Full-time members who work 20 or more hours per week. ❑ Other(explain): 3. Describe any class of members to be excluded: New -Hire Waiting Period is 1 month days after hire date. New -Hire Enrollment Period includes the 31 days following the New -Hire Waiting Period. Coverage for New Hires begins 9 D. Eligible Individuals in the Waiting Period on the policy effective date will: m Complete Waiting Period - or - ■ Be eligible immediately. C. ■ the Next Day. E. Annual Enrollment Period is: ❑ The Calendar Month before the Policy Anniversary Date - or - ® Other (explain) Usually October each year (Only applicable to Heritage Choice Dental, Disability (GVD-4000) and Term Life) F. Individuals first eligible after the policy effective date may enroll (Applies to AHL Products ONLY): ❑ within 31 days of eligibility - or - ® only at the next Annual Enrollment Period G. Rehired Employees: More than 31 days after termination considered a new employee? IJ Yes ❑ No If No, explain* III. Billing Information ❑ Credit Union Account: Complete Credit Union Account Set -Up Form ABJ445. Billing Contact Person: Anthony Rousseau Billing Address (Street & Number): City: Telephone: 817-392-8338 State: Zip: Fax. Email. If billing/premium payment will be processed through a third party, indicate whether third party is: ® The account's own service provider (example: payroll service company). A third party administrator of AHL (example: AHL agent). Requires TPA contract with AHL. Name of third party ■ Billing Options (Check only one.) Billing Frequency Monthly Monthly Every 4 Weeks (28 days) Every 4 Weeks (28 days) Deductions Per Year 12 monthly 24 semi-monthly 52 weekly 26 bi-weekly Bills Per Year 12 12 13 13 IV. Comments ITEM # ADDITIONAL INFORMATION III City will continue current billing process with Allstate. The City sends a file based on deductions for each billing period. ABJ4040-3 Page 2 of 3 (2/12) V. Employer Agreement A. Electronic Acceptance of American Heritage Life Insurance Company Products By checking the "Yes" box below, you agree to electronic delivery of the certificate of insurance and its accompanying notices ("the Certificates"). If electronically delivered, insureds will be provided instructions on how to receive their Certificate via the following address: www.allstatebenefits.com/mvbenefits. To electronically receive their Certificate, insureds will need a personal computer with Internet access and appropriate browser software, and Adobe Acrobat Reade Insureds must also consent to receive their Certificate electronically, which is valid as long as they are covered by the policy. At any time, they may withdraw their consent for any reason and receive a paper copy of their Certificate, free of charge, by calling, toll -free: 1-800-521-3535; or by writing to: Customer Care Center, American Heritage Life Insurance Company, 1776 American Heritage Life Drive, Jacksonville, Florida, 32224. [J YES, I agree to have insureds receive their Certificate electronically via the Internet. NO, I prefer for insureds to receive paper copies of their Certificate. B. Additional Services May we contact your employees to offer them: a) The Good HandssM Roadside Assistance Plan? Yes P2 No b) A no obligation auto insurance quote? ■ Yes J No C. Effective Date If issued, the coverage selected as indicated on the attached addendum(s) will become effective on the date stated in the Pol- icy(ies). The Policy(ies) issued and any amendments, riders, and/or endorsements thereto, along with the application, will constitute the entire contract. D. Acceptance of Voluntary Insurance This is to advise American Heritage Life Insurance Company (AHL) that we will process AHL's Insurance Program for the ben- efit of our employees. For each employee who executes a payroll deduction request, we will withhold the amount authorized. We will forward this money either: (i) directly to AHL upon notice of the premium due from each employee, or (ii) to the credit union if named below. We may, upon written notice to AHL and to our employees, discontinue our participation in AHL's Insurance Program. In such event, the continued payment of premiums will be a matter directly between each employee and AHL We assume no responsibility for forwarding premiums from anyone other than current employees. We understand that AHL does not disclose personal information about our employees to companies or organizations not affil- iated with AHL that would use the information to market their own products and services. However, AHL may share with us per- sonal information about our employees, and other persons, in order to carry out the purpose of AHL's Insurance Program. Personal Information includes all personally identifiable health information and other information about a person that: • a person provides to AHL to obtain insurance, • results from an insurance transaction, or • is otherwise obtained in connection with providing insurance. We agree not to disclose or use this personal information except as necessary for our participation in AHL's Insurance Program. We may be provided access to this information in electronic form and are responsible for limiting this access to those neces- sary for our participation. Authonzed Officer Printed . Namn Date Signed (v, �. LJ 1 AGENT OF RECORD # SERVICING AGENT # 9PEBO ADDITIONAL AGENT # Susan Alanis . Authorized Officer Signature Pik-k C C-c ciake Mfr'450 AS Tb fetkek tatik tt‘i AGENT NAME SIGNATURE AOR SALES CHANNEL (check one): Higginbotham Insurance Agency cle R 7 Scott Shapard Allstate (EA/EFS) ■ Independent Agent ABJ4040-3 tn.L vr�%I`""- OrPC ei(tecjiA-404.-A • Def.tS cMcEl.fry i•scssT C UPI DATE ikeng6RNE1 /6 V/ /OAS 4,..3 r4 Accident** (GVAP1) © Section 125 Base Units- 1/2 Benefit Enhancement Rider Units• 1/1 Optional Disability Riders for Employees Off the Job Accident On and Off the Job Accident -] Off the Job Accident and Sickness On and Off the Job Accident and Sickness ■ Units Units U nits U nits (Employer and Association / Union Groups) Optional Disability Riders for Insured Spouse* On and Off the Job Accident Units ❑ On and Off the Job Accident and Sickness Units * Available only with Individual & Spouse or Family coverage when Insured Spouse has worked 25 hours per week for 3 consecutive months. ■ Strike/Layoff Riders: (Only one Rider may be selected.) 0 Continuation During Strike or Layoff Rider ■ Premium Refund Upon Layoff Rider (Not available on Section 125 plans) Policyholder contributes $ Policyholder contributes $ * 4 tiers except in CO, WA and WV. o r 0 % of each Employee's/Member's Total Monthly Premium. o r 0 % of each Dependent's Unit Total Monthly Premium. ❑ Accident* (GVAP2) ❑ Section 125 (Employer and Association / Union Groups) Base Units- Benefit Enhancement Rider Units- Outpatient Physician's Rider Units Strike/Layoff Riders: (Only one Rider may be selected.) ❑ Continuation During Strike or Layoff Rider ❑ Premium Refund Upon Layoff Rider (Not available on Section 125 plans) Policyholder contributes $ Policyholder contributes $ or % of each Employee's/Member's Total Monthly Premium or % of each Dependent's Unit Total Monthly Premium. * In South Dakota, all employees/members must be covered by Workers' Compensation. If Workers' Compensation is not available, you must elect GVAP1. ❑ Cancer/Specified Disease P2 Check one: ■ PLAN 1 ■ (GVCP2) PLAN 2 BENEFITS (Select Units) Hospital Benefits Radiation/Chemotherapy Benefits Surgery/Related Benefits Miscellaneous Benefits Pohcyholder contributes $ Policyholder contributes $ ■ ❑ Section 125 (Employer Groups Only) PLAN 3 UNITS OPTIONAL BENEFITS (Select Units) ❑ Initial Diagnosis ❑ Intensive Care ❑ Cancer Screening 1 or % of each Employee's Total Monthly Premium. or % of each Dependent's Unit Total Monthly Premium Cancer/Specified Disease (GVCP3) ❑ 2-Tier (EE Only or Family) BENEFITS (Select Units) Hospital Benefits Radiation/Chemotherapy Benefits Surgery/Related Benefits Miscellaneous Benefits P2 UNITS Section 125 (Employer and Association / Union Groups) 4-Tier (EE Only, EE + Spouse, EE + Child(ren), or Family) UNITS OPTIONAL BENEFITS (Select Units) 2/2 Initial Diagnosis Intensive Care Wellness Strike/Layoff Riders: (Only one Rider may be selected.) ■ ■ Ell UNITS 0/5 0/4 4/4 Continuation During Strike or Layoff Rider ❑ Premium Refund Upon Layoff Rider (Not available on Section 125 plans) Policyholder contributes $ or Policyholder contributes $ or % of each Employee's/Member's Total Monthly Premium. 0 % of each Dependent's Unit Total Monthly Premium. 0 Addendum 1 • Mayo Services Option (Available with GVCIP1, GVCIP2, GC13) Please select which Critical Illness Product you would like to add the Mayo Services option to: GVCIP1 ■ GVCIP2 ■ GCIP3 ■ ■ r: Critical Illness (GVCIP1) Basic Benefit Amount $ Enhanced Benefit Amount $ ❑ 2nd Evaluation Benefit Rider OPTIONAL BENEFITS Critical Illness Cancer Option Recurrence Option • 0 Section 125 (Employer and Association / Union Groups) Check one: ❑ My Lifeline ■ New Generation OPTIONAL BENEFITS (Select Units) UNITS ❑ Wellness Option Policyholder contributes $ or % of each Employee's/Member's Total Monthly Premium. Policyholder contributes or % of each Dependent's Unit Total Monthly Premium. Critical Illness (GVCIP2) ❑ Section 125 (Employer and Association / Union Groups) Basic Benefit Amount $ 15,000/$30,000 Enhanced Benefit Amount $ ❑ Waive Preexisting Condition Exclusion (Subject to Home Office Approval) ❑ 2nd Evaluation Benefit Rider OPTIONAL BENEFITS Cancer Critical Illness Benefit Second Event Initial Critical Illness Benefit ❑ Supplemental Critical Illness I (with Occupational HIV) [I Supplemental Critical Illness II (without Occupational HIV) ❑ Increasing Critical Illness Benefit Units: [� Wellness Benefit Units: 4/4 Strike/Layoff Riders: (Only one Rider may be selected.) ❑ Continuation During Strike or Layoff Rider 0 Premium Refund Upon Layoff Rider (Not available on Section 125 plans) P2 P2 ❑ Waive Portability (Subject to Home Office Approval) Policyholder contributes $ or 0 % of each Employee's/Member's Total Monthly Premium. Policyholder contributes $ or 0 % of each Dependent's Unit Total Monthly Premium. ❑ Critical Illness (GCIP3) (Employer Paid) (Employer and Association / Union Groups) Basic Benefit Amount $ Enhanced Benefit Amount $ ❑ 2nd Evaluation Benefit Rider OPTIONAL BENEFITS Cancer Critical Illness Benefit 0 Second Event Critical Illness Benefit Supplemental Critical Illness I (with Occupational HIV) Supplemental Critical Illness 11 (without Occupational HIV) Wellness Benefit Units: • ■ ■ Heritage Choice Dental Plan Check one: ■ PLAN 1 Policyholder contributes $ Policyholder contributes $ Addendum 2 ❑ PLAN 2 or or ❑ Section 125 PLAN 3 ■ ■ (Employer Groups Only) PLAN 4 ■ PLAN 5 % of each Employee s Total Monthly Premium. % of each Dependent's Unit Total Monthly Premium. Group Voluntary Disability Income (GVDI) (Non -Occupational Coverage [off the job only]) Check one: ■ My Lifeline ■ My Generation ❑ Section 125 (Employer and Association / Union Groups) 1. Monthly Benefit Amount: Insured may choose amounts in $100 units, subject to the following: • Minimum monthly benefit is $400. • Maximum monthly benefit is ❑ $3,000; -or- ■ $ (insert maximum from proposal, if it is not $3,000) Insured's maximum monthly benefit may not exceed 60% of his/her Monthly Earnings, as defined in the policy 2. Monthly Earnings do not include: commissions, overtime, bonuses, or other extra compensation, unless specifically requested. (If included, they will be averaged for the 12 month period just prior to the date of disability.) ■ Request the following be included: 3. Select your Elimination Period and Monthly Benefit Combinations: Elimination Period: 0 Days Injury/ 7 Days Sickness 7 Days Injury / 7 Days Sickness 14 Days Injury / 14 Days Sickness 30 Days Injury / 30 Days Sickness *90 Days Injury / 90 Days Sickness *180 Days Injury / 180 Days Sickness *N/A for My Generation 4. Optional Portability Benefit ❑ Yes Benefit Period 3 months N/A N/A 6 months ■ ■ ■ N/A N/A 12 months 24 months ❑ ❑ ❑ ❑ ❑ ❑ ■ ■ N/A ■ No (N/A for My Generation) (If blank, portability will not be included.) 5. Remove Mental/Nervous Disorder Exclusion ❑ Yes ■ No (If blank, Mental/Nervous exclusion remains.) 6. OPTIONAL. RIDERS' ❑ Doula/FMLA Rider ■ On the Job Accident Disability Rider ❑ Increasing Benefit Period Rider ❑ Survivor/Accident Rider Premium Refund Upon Layoff Rider (Not available on Section 125 plans) ■ 7. Policyholder contributes $ ❑ Group Universal Life • Plans or % of each Employee's Total Monthly Premium. (Employer and Association / Union Groups) Available Riders: Optional Required Declined Total Disability Waiver of Premium (Employee Coverage Only) Total Disability Payor Waiver of Premium (Spouse Coverage Only) Level Term Accelerated Death Benefit for Terminal Illness Future Purchase Option Children's Term Other Insured Person (Spouse) Term Accidental Death Benefit Accelerated Death Benefit for Long Term Care Long Term Care with Extension of Benefits Continuation of Coverage During a Strike or Layoff Policyholder contributes $ Policyholder contributes $ Addendum 3 ■ 0 0 0 ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ or % of each Employee's/Member's Total Monthly Premium. or % of each Dependent's Unit Total Monthly Premium. ❑ Indemnity Medical (Composite Rated -Hospital Indemnity) ❑ Section Check one: For all states, except CO and FL, plans 1 - 8 are available. ❑ PLAN 1 ❑ PLAN 2 ■ PLAN 3 ❑ PLAN 4 ❑ PLAN 5 ❑ PLAN 6 ❑ Life Insurance Rider: ■ Employee: $20,000 Dependent: $10,000 125 (Employer and Association / Union Groups) For CO and FL, plans 3 -10 are available PLAN 7 ❑ PLAN 8 ■ PLAN 9 ❑ PLAN 10 ■ Life amounts are 75% of the amounts selected for Insured Persons who are ages 65-69 and 50% for those who are age 70 and over. Short Term Disability Rider: • Non Occupational Coverage (off the job only) • Elimination Period: 7 Days Accident / 7 Days Sickness • Monthly Benefit: $650 • Maximum Payment Duration: 3 months 0 Catalyst Rx Plan ■ Catalyst Rx Plus Plan (Only one Rx Plan may be selected per plan.) (Underwritten by Fidelity Security Life Insurance Company, Kansas City, MO 64111) Policyholder contributes $ or % of each Employee's/Member's Total Monthly Premium. Policyholder contributes $ or % of each Dependent's Unit Total Monthly Premium. Long Term Disability (24-Hour Coverage with offset for Workers' Comp.) 1. Monthly Benefit Amount: ❑ Insureds may choose amounts in $100 units, subject to the following: • Minimum monthly benefit is $400. • Maximum monthly benefit is $6,000; -or- ❑ $ (insert maximum from proposal, if it is not $6,000) (Maximum monthly benefit may not exceed 60% of Monthly Earnings); - or- Insured's monthly benefit will be 60% of his/her Monthly Earnings, not to exceed: ❑ $6,000. -or- ❑ $ • ■ ■ ■ Section 125 (Employer Groups Only) ▪ or ❑ lnsured's monthly benefit will be 50% of his/her Monthly Earnings, not to exceed $ . (Please attach a copy of the proposal.) 2. Monthly Earnings do not include: commissions, overtime, bonuses, or other extra compensation, unless specifically requested. (If included, they will be averaged for the 12 month period just prior to the date of disability.) ❑ Request the following also be included: 3. Elimination Period: (Applicable to Disabilities due to both Accident and Sickness) E 90 Days ■ 180 Days ❑ 365 Days 4. Benefit Duration will be• ❑ To Normal Social Security Retirement Age* ❑ 2 Years* ❑ 5 Years* *Modified benefit duration may apply to disabilities beginning on or after age 60. 5. Policyholder contributes $ or % of each Employee's Total Monthly Premium. ❑ SHOP (Age Banded - Hospital Indemnity) Section 125 (Employer and Association / Union Groups) BENEFITS (Select Units) UNITS OPTIONAL BENEFITS (Select Units) UNITS Hospital Related ❑ Diagnostic/Wellness Option Surgery/Inpatient Physician ❑ Prescription Drug Option Outpatient Related Strike/Layoff Riders: (Only one Rider may be selected.) Continuation During Strike or Layoff Rider ❑ Premium Refund Upon Layoff Rider (Not available on Section 125 plans) Policyholder contributes $ Policyholder contributes $ or % of each Employee's/Member's Total Monthly Premium. or % of each Dependent's Unit Total Monthly Premium. BUY UP OPTIONS (Optional coverages Employees/Members may select) Life amounts are 75% of the amounts selected for Insured Persons who are ages 65-69 and 50% for those who are age 70 and over. ■ Life Insurance Rider UNITS Short Term Disability Rider: • Non -Occupational Coverage (off the job only) • Monthly Benefit: $650 ❑ Dental - Check one: ❑ PLAN 1 Policyholder contributes $ Policyholder contributes $ ■ • Elimination Period: 7 Days Accident / 7 Days Sickness • Maximum Payment Duration. 3 months PLAN 2 i-I PLAN 3 ■ PLAN 4 ❑ PLAN 5 or % of the Buy Up Option for each Employee's/Member's Total Monthly Premium. or % of the Buy Up Option for each Dependent's Unit Total Monthly Premium. Addendum 4 ❑ Short Term Disability* (GVD-4000) ❑ Section 125 (Employer Groups Only) (Non -Occupational Coverage [off the job only]) 1. Monthly Benefit Amount: ❑ Insured may choose amounts in $100 units, subject to the following: • Minimum monthly benefit is $400. • Maximum monthly benefit is $2,500; -or- ❑ $ (insert maximum from proposal, if it is not $2,500) Insured's maximum monthly benefit may not exceed 60% of his/her Monthly Earnings, as defined in the policy; - or - ❑ Insured's monthly benefit will be 60% of his/her Monthly Earnings, not to exceed: ❑ $2,500; -or-0 $ 2. Monthly Earnings do not include: commissions, overtime, bonuses, or other extra compensation, unless specifically requested. (If included, they will be averaged for the 12 month period just prior to the date of disability.) ❑ Request the following be included: 3. Elimination Period: 7 Days Accident / 7 Days Sickness 14 Days Accident / 14 Days Sickness ■ 4. Maximum Payment Duration: 5. Policyholder contributes $ ■ ■ or * Please attach proposal with sold rates in it. Term Life Insurance Include Accidental EMPLOYEE DESCRIPTIONS ❑ All Eligible Employees -or- • Other (describe): Policyholder contributes $ Policyholder contributes $ ❑ 30 Days Accident / 30 Days Sickness ❑ 0 Days Accident / 7 Days Sickness 3 Months ❑ 6 Months ❑ 12 Months ❑ 24 Months % of each Employee's Total Monthly Premium. ❑ Section 125 (Available for benefit amounts up to $50,000) Death & Dismemberment? ❑ Yes 0 No AMOUNTS OF LIFE INSURANCE Employee* The amount elected by the employee (must be in even multiples of $10,000), subject to a minimum amount of $10,000 and a maximum amount equal to the lesser of: (a) $500,000; or (b)5 times the Employee's Basic Annual Earnings. -or- 3 times the Employee's Basic Annual Earnings, subject to a minimum amount of $50,000 and a maximum amount of $500,000, -or- Other (describe): ■ ■ * Employees age 70 and older at time of enrollment are limited to a maximum life insurance amount of $20,000. Higher amounts may be available with evidence of insurability. Employee life insurance amounts will be automatically reduced to 65% of the original amount upon reaching age 70, to 50% upon reaching age 75, and to 35% upon reaching 80. Spouse ❑ The amount elected by the employee for his/her spouse (must be in even multiples of $10,000), subject to a minimum amount of $10,000 and a maximum amount equal to the lesser of: (a) $100,000; or (b) 50% of the amount of Voluntary Life Insurance in force on the Employee. - or- ❑ Other (describe): ■ All of the following: Plan A Plan B Plan C Plan D - or- Other (describe): Child(ren)** 1 year & Over $ 10,000 $ 7,500 $ 5,000 $ 2,500 14 days to 1 year $ 1,000 $ 750 $ 500 $ 250 ** Children less than 14 days old are not eligible. o r % of each Employee's Total Monthly Premium. o r % of each Dependent's Unit Total Monthly Premium. ❑ EyeMed Vision Care ❑ Section 125 (Employer and Association / Union Groups) Underwritten by Fidelity Security Life Insurance Company of Kansas City, MO Policyholder contributes $ Policyholder contributes Si or % of each Employee's/Member's Total Monthly Premium. or % of each Dependent's Unit Total Monthly Premium. Addendum 5 ■ The Major Medical Complement* (Fills gap left by insurance) ❑ Section 125 (Employer Groups Only) U nderwritten by Fidelity Security Life Insurance Company of Kansas City MO 1 Name of Group Major Medical Insurance Carrier: 2. Effective Date of Major Medical Plan: 3. Payroll Deductions are: ❑ Current (example: June premiums are deducted in May) -or- ■ in Arrears (example: June premiums are deducted in June) 4. Does the group account have Employees residing out of the account's situs state? ❑Yes ❑ No If yes, list states: Policyholder contributes $ Policyholder contributes $ Major Medical Plan Annual Enrollment Period or % of each Employee's Total Monthly Premium. or % of each Dependent's Unit Total Monthly Premium. to * Not available for groups sitused in CT, KS, MA, MN, MT, NH, NY, UT, and WA. ] Group PPO Dental Plan* ❑ Section 125 (Employer and Association / Union Groups) U nderwritten by Guardian Life Insurance Company of America (New York, NY) ALL ARKANSAS SITUSED GROUPS MUST COMPLETE FORM GG-011593AR. P lans: ■ Value Plan 1 ❑ Value Plan 2 ❑ Value Plan 3 ❑ Network Access Plan 1 ■ Network Access Plan 2 ❑ Network Access Plan 3 ❑ Check here for Orthodontia Benefits Open Enrollment Period *Open Enrollment is only available when a Section 125 is in place. From / to Transfer Date / / Domestic Partner Information: • Does the company offer coverage for Domestic Partners? ❑ Yes ❑ No • Does the company offer coverage for children of Domestic Partners? ❑ Yes ■ No Policyholder Contribution: Policyholder contributes % of each Employee's/Member's Total Monthly Premium. Policyholder contributes % of each Dependent's Unit Total Monthly Premium. Does policyholder have an employment location in TX? ■ Yes ❑ No Municipal employees covered? (Illinois sitused policy only) ❑ Yes ❑ No Delivery of Plan Materials Certificate Coveraae & Employer Rider: Group Dental PPO policy forms and certificates of coverage will be delivered to the Policyholder. The Policyholder is responsible for delivery of the certificate of coverage to enrolled employee. Delivery Method to the Policyholder: All States Except Texas — Ema I (Completed EDELPPODEN Form Required) Texas ONLY (Choose ONE): ❑ Email (Completed EDELPPODEN-TX Form Required) ❑ Postal Mail Electronic ID Cards: Employees access and print generic Group Dental PPO ID card directly online at www.GuardianAnytime.com. (Paper copies will not be provided.) The Policyholder will be emailed a notice with instructions to provide to enrolled employees. Georgia ONLY — Employees access and print member level Group Dental PPO ID cards directly online, at www GuardianAnytime.com. (Paper copies will not be provided.) The Policyholder will be emailed a notice with instructions to provide to enrolled employees. Takeover Grouos Only: 12 month waiting period for Maior and Orthodontia (if aDDlicablel applies to: (Choose ONE) ❑ Future Employees Only ❑ None (neither current or future employees) Current and Future Employees (Only available to groups with 100+ eligible employees) • Employer s immediate prior carrier eligibility report showing member effective date is required to provide coverage period credit to current employees. Credit applies to appropriate coverage category. (Prior carrier booklet required.) Deductible and annual maximum credit (100+ eligible employees required): ❑Yes ❑ No • (Available with employer's immediate prior carrier claim report.) Maximum Rollover Reward Credit (100+ eligible employees required): E Yes ❑ No • (Available with employer's prior carrier rollover report. Report must be within 3 months of this plan's effective date.) *Plans may vary by state. Addendum 6 ■ M&C Review DATE: 9/10/2013 CODE G SUBJECT: COUNCIL ACTION: Approved on 9/10/2013 REFERENCE NO.: TYPE: G-17993 NON - CONSENT Page 1 of 2 Official site of the City of Fort Worth, Texas FORT WORTI 1 LOG NAME: 14VOLBENALLST2014 PUBLIC HEARING: NO Authorize Agreement with American Heritage Life Insurance Company, a Subsidiary of Allstate Insurance Company, to Provide Employees with Access to Voluntary Insurance for Critical Care, Accidental and Cancer Coverage with Employees Paying All Premiums and No Financial Impact to the City (ALL COUNCIL DISTRICTS) bi RECOMMENDATION: It is recommended that the City Council authorize an Agreement with American Heritage Insurance Company, a subsidiary of Allstate Insurance Company, to provide employees with access to voluntary insurance for critical care, accidental and cancer insurance with no financial impact to the City. DISCUSSION: The purpose of this Mayor and Council Communication (M&C) is to approve an Agreement with American Heritage Life Insurance Company, a subsidiary of Allstate Insurance Company (Allstate), to provide City employees with access to voluntary, employee -paid insurance products. The City of Fort Worth currently contracts with Allstate and AFLAC to provide employees with access to voluntary accident, cancer and critical illness insurance with participating employees being responsible for their own premium costs. Both of those contracts expire on December 31, 2013 On March 6, 2013, a request for proposals (RFP) was issued and responses were required by April 4, 2013 The RFP was designed to solicit proposals for a provider of: 1) accident, 2) cancer and 3) critical illness insurance. Staff received 14 bids in response to the RFP. Higginbotham, the City's Voluntary Benefits Consultant, met with the voluntary benefits evaluation team and representatives from the Human Resources Department and the Purchasing Division to review the proposals and begin the evaluation process. Proposals were thoroughly evaluated by a committee comprised of representatives from the Equipment Services, Code Compliance, Finance, Police and Library departments. Proposals were scored taking into account the following factors: qualifications and experience, contract provisions, ongoing administration, enrollment process and cost/fee schedule. The Committee unanimously agreed that Allstate's proposal offers the best overall quality of service and pricing of the submissions. The proposed contract moves the City to a national account, which greatly improves the variety of offerings and services to employees at lower costs As an added benefit Allstate will provide guarantee issue on the three listed insurance products and is waiving pre-existing conditions for all AFLAC policyholders moving to Allstate. A total of 3,453 employees participate in voluntary benefits offerings with the two current providers representing the amount of $1,677,309.00 paid in premiums. The City processes the payroll deductions for participating employees and transfer of premiums to the insurance providers but does not contribute to the premium costs, which are the sole responsibility of those employees who elect to take advantage of access to this voluntary benefit. http://apps.cfwnet org/council_packethnc_review.asp?ID=18852&councildate=9/10/2013 10/21/2013 M&C Review Page 2 of 2 AGREEMENT TERMS - Upon City Council's approval, the Agreement will be effective on January 1, 2014 and will expire on December 31, 2017. RENEWAL OPTIONS - This contract is for three years and may be renewed for two, one-year periods at the City s option. This action does not require specific City Council approval. FISCAL INFORMATION/CERTIFICATION: The Financial Management Services Director certifies that the Financial Management Services Department, Accounting Section, will be responsible for payroll deductions and the Revenue Office will be responsible for transmittal of funds to Allstate under this Agreement. TO Fund/Account/Centers FROM Fund/Account/Centers Submitted for Citv Manager's Office bv: Susan Alanis (8180) Originating Department Head: Karen Marshall (7783) Additional Information Contact: Margaret Wise (8058) ATTACHMENTS http://apps.cfwnet.org/council_packet/mc review.asp?ID=18852&councildate=9/10/2013 10/21/2013