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Home My WebLink AboutContract 27250C:ITY S�C�i�TA��Y �� CONTRAC� NO . �_ _ r4pplication �i�IT�� H�RL I F;Cr4R� IIVSUI�ANC� COIV��R41� Fiari#ord, Conn��i�u� Policyhalder — City of Fort Worth Address — 10a0 Thrackmorton 5treet Fart Worth, Texas 78102 The Policyholder applies for a policy of excess risk insurance for the �mplayse Ber�efit Plan. AfFiliafed organfzations under the common control of fne i'alicyholder may be included. The Policyholder will have to request in writing that they be included. The Employees of affiliafed �rganizakions will be included under the Employee Benefit Plan according to fhe rules of the Plan. 7he term "Palicyholder" will mean the Policyholder named above. It will also mean any affiliated organization the Policyholder has included under the policy. The Policyholder will represent any affiliated organizations �nder the policy. The Policyhalder will take any required ac�ions for them. The Company will act merely as a provider of excess risk insurance in accordance with the terms and conditions of this palicy. The Company does not have any fiduciary responsibility under this policy with respect io the Employee Bene�t plan. The Campany does not assume any ohligatian to perform any of the functions nor to provide any of the reports which are required by the Employee Retirement Income Security Act of �974, as amended from fime to time. The Company identifiss the poliey as Policy Number GA-707316AL. The Policyholder has approved it and accepts its terrns. The poljcy will take effect an October �, 2D01. Pre�nium payrnents are requirec! as described in ihe policy. Any earlier application for the poEicy is repiaced by t�is application. Dated at Fort Worth, Texas /�o�lew.��r �� 20 0l Wi#ness:_�� GG74�1 �? - I_ �_��l'� Contr�at Authori�a�.ion _ . �� r%�-�_ � �� City nf Fort Worth �y �� Official Title �� '� . �� 1 ' �,��'� �' r' � �TTESi�I� �� U�� `� �� o � �i�b� �. � �. � �. . - � - .- -- -_� Ur��te� ��alt��re ��sur�nce Co�pa�y 450 COL.UMBUS BOULEVARD 1-�ARTFORD, CONNECTiCUT A STOCK COMPANY {Hereinafter cailed the Company) Policyholder -- City of Fort Worth Policy Number —GA-701316AL. EfFective Date — October 1, 2001 State or other Jurisdiction of lssue — Texas The Company agrees to pay the benefits of this policy. The details of the benefits are shown or� the pages which follow. These pages form a part of the policy. Premiums The Policyholder has a{�plied for this policy and understands that it must pay the required �remium to the company to get th� insurance and keep it in force. The Premium Due Date 9s fhe firsk day of each caiendar month. When This Policy Will Take �ffect This policy will take effec# at the Poficyholder's address on the Effective �ate abave, its date of issue. All periods of time that apply to this policy are deerrtied to begin and end at 12:01 A.M. at the Policyfi�older's address. The Company witnesses that this poli is x � its date ' ue Hartfard, Connecticut. � Policy Regist`rar ��e�� d--�—/t � Secretary President and CEO Non-Participating Excess Risk Insurance Which can be Discontinuecf by the Company as Described in the Policy THIS lS NOT A POLICY OF WORKERS' COMPENSATION INSURANCE. THE POLICYHOLC}ER DO�S NOT BECOME A SUBSCRIBER TO TW� WORK�RS' COMPENSATION SYSTEM BY PURCNASI�'G TH15 pOLICY, AND I� THE POLICYHOLDER IS A NON-SUBSCRIB�R, THE POLICYHOLDER LOSES i"HOSE BENEFITS WHICH WOULD 07HFRWISE ACCRUE UNDER THE WORKERS' COMP�NSATION LAWS. TH� POLICYHOLUER MUST COMPLY WI7H THE WORKERS' COMP�NSATIO{� LAW AS IT PERTAINS TD NON�UBSCRIBERS AND YH� REQUIRED NOTIFICATIONS 7NAT MUST B� F1LEp AND POS�ED. 7his policy is not in lieu of and does not aff�ct any requirement for coverage by Workers' Compensation. GC-7400A, GC-6835, GC-74fl2-'IA, GG-7402-2A, GG7402-3A, GC-7402-4A, GC-7402-5A, GC-7402-6A, GC-7402-7A, GC-7402-8A, GG7402-9A Table �f Con�en�� Part1-Schedule ................................................... 2 Part 2 Definitions .................................................. 4 Park 3 - Aggregate Excess Risk B�nefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Part 4 - Indi�idual Excess Risk Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Par� 5 - Policy Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Part � - MEscellaneous Provisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Part 7 - Claim Provisio�s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Part 8 - General Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1 � � ��d ��C��Q� � �9� �C��"�� ' �� 1 Ua �� I�q Y.� �1 �a�i 1 A S�hedule �oliCy �eriod Codered: October 1, 2Q01 to January 1, 2003 Policy Anniversary: January 1 Administrator: United HealthCare Insuranc� Campany The Administrator has been appointed by the Pol9cyhold�r to provide cla{m and other administrative services in connection with the Employee Beneft Plan. Any specified Benefi� Leve4, �actar or Attachment Point applies only to ihe Policy Perind shown above. 1f the Policy is continued beyond the specified Policy Period, the Company will redetermine these figures and issue a new Sc�edule. INDIViDUAL EXC�SS RISK BENEFIT 1. Individuaf Excess RislC B�nefit Level: $200,Qa0 per Covered Person per Policy Period. • Includes the following benefits under the Plan: Medical Benefits Mental Health Benefits Pregnancy Benefits Family Planning Benefits Preventive Health Care Benefits �. Reimbursement Factor: 100% 3. Type of {ndividual Excess Risk Benefit: Ineurred in � 5 months and Paid in 15 months (15115} � 4. Indi�idual Excess Risk Premium: $7.86 per Emplayee per month �' AGGREGATE �XCESS RISK �ENEFIT 1, Aggregate iillonthly Factar: $394.93 Per Employee enrolled in the Select EPO (Low) � $400.12 Per �mployee enrolled in the Sel�:ct EPO (High) J $436.13 Per �mployee enrolied in the Options PF'0 with Differential 4 $572.18 Per Employee enrolled in the Optians PPO without �ifFerential � Includes the foliowing benefits under the Plan: Med9cal Benefits Mental Health Benefits Pregnancy Benefits Family Planning Benefits 2 Preventive Health Care Benefits Manag�d Pharmacy Benefits 2. Reimbursement Facior: 100% 3. Maximum �ligible Benefits per lndividual: $20b,000 � 4. Minimum Annual Aggregate Attachment Point: 95% of the Manthly Aggregate Attachment Point for tfi�e first month af the Policy Period times 15, rsgardless of the durakion of the Palicy Period. 5. Type of Aggregate �xcess Risk �enefif: Eligible Benefiks which are: Incurred in 15 months and Paid in 15 months (15115} 6. Aggregate �xcess Ris�C Premium: $.91 per �mployee per month � 3 �art � o �e�iniiien� /�ccumulafied �aid Claims The total amaunt of Piar� Bene#iks that have been paid at any specified point in time during a Policy Period. Annual Aggregafe a4tfiachment �oin� The sum of the number of Em�loyees times khe carresponding Aggregate Monthly Factor applied each montF� of a Poficy Period. ChecEc The instrument of payment issued pursuant to the Administrative Ser�ices Agreement wh�fher such instrument is a draft or check. Covered �erson • An Eligible �mployee. • An Eli�ible Dependent. A�y persan required to be disclosed but not disclosed by the Policyholder on the Siflp Loss Disclosure Statement will not be considered a Cavered Persan under the Plan far the purposes of this poiicy. Eligi�le Benefits Paid for Late �ntrants may not be reimbursable under this policy. See t�e section titled "l.ate Entrant Undenrvriting Requirements" uncker General Limi�ations. �ligible �ene�its TF�ose benefits listed in Schedule thak the Polieyholder must pay under the terms of the Employee B�;nefit Plan to a Covered Person or to any other person or provEder of services and svpplies given to the Cavered Person for the kreatment ofi an injury or sickness. �ligible �ependenf A person who meets ail nf the following: • The persan is a dependent of an Eligible Employee as defined by the Plan. • An Eligible Employee has enrolled far coverage far the person under the Plan, i# required to do sa. "�ligibl� Dependent" inciudes any dependent whose coverage is being continued in compliance wit1� the provisions of the Consolidated Omnibus Budget Reconciliatian Act of 1985 (COBRA) and regulations implementing COBF2A. �ligible �mployee An Emplayee af the Policyhalder who meets all of the following� • The Employ�e is eligible for coverage under the Plan. "Eligible Empiayee" includes any Em�aloyee wh4se caverage is being continued in compliance with the provisions of fhe Consalidated OmNbus Budget Reconcaliation Act of 1985 (COBRA) an� regulations implementing CQBRA. "Eligible Emplayee" includes a�'etired employee as defined in the Plan. 4 I�mployee �ene�it Plan (alsa called fhe Plar�) The welfare benefits the PoGcyholder agrees to }arovide Employees and their eligible De�endents under a plan of benefits which has been ap�rowed by the Company. The Plan and any amendments to the Plan wiA 6e described in writing. A copy will �e given to the Company. For Co�ered Persons who are residents of California, the Ernployee Benefit Plan wiH include the provisions of California Assembly Bill No. 1672 and California Senate Bill 578 applicable to preexisting conditions and late enrollee limitafians. Incurred A beneft is "incurred" on: • the date the se�vice or supp�y is provided, or • the date a purchase is made. Individual �xcess Ris� ��ne�it Level Shown in Schedule. The Indi�idual Excess Risk Benefit Level applies separaiely ta each Policy I�eriod and is determined annually by fhe Company. If the policy terminates during any Policy Period, the Indi�idual �xcess Risk Benefit Level wil{ be determ9ned as if the policy had remair�ed in effect for the entire I'olicy Period. Lafie �nfranfi Any EmpEay�e or dependent who: • does not enroll in the Employee Benefit Plan when first eligible, and • ohtains coverage under the Employee Benefit Plan after th�: individuak's initiaf eligibility period has ended. [i�on�hly �►ccumula�ed Cap The accumulated Monthly Aggregate Aktachment Points tfuring the Poiicy Period for which khe Manthly Accumulated Cap Benefit is being determined. I4�onthly ,° ggregafie �t�achment Po�n� The Aggregate Monkhly Factor times #he number of Covered Units for any single manth. �aid With respect ko the Individual �xcess Risk Benefit, an expense is "paid" on the date the Policyholder's Check far payment af a Plan benefit is issued by the Administrator ar wh�:n a credit of funds for payment of a Plan benefif has been debiked by the Policyholder`s bank accounk, With respect to f�e Aggregate Excsss Rislc �enefit, an expense is "paid" on the date the Palicyholder's Check for payment af a Plan beneft has heen �resented through the collecting bank and reported to the Administrator or when a credit of funds for payment of a Plan benefit has been debited by the Policyholder's bank account. 5 �lan �enefii�s On a �aid �asis The kotal amount of Eligible Bene#its that ar� Paid during t�e Policy Period. F�olicy �eriod Shown in Schedule. The Policy Period also means any fraction of the period if the policy terminates before the er�d of the period as stated in Schedufe. �ar� 3 - �ggrega�e �x�e�� I�isk ��n�fit The Company will pay any Aggr�gate Excess Risk Benefit to the Policyhold�r. The Corripany will da khis wikhin 30 days fram the date the Com�any receives all information required to deterrnine th� Benefi#. The Aggregate Excess Risk Benefit far any Policy Period is an amount equal to: �or tl�e first Policy Period, the amount of Eligible Benefits that are Incurre� during that Policy Period and Paid on account of alf Covered Persons during that Policy Period and for each period khereafter khe Eligibl� Benefits that are Paid on accaunt af aH Co�ered Persans during the Policy Period less The greater of: • The Annual Aggr�gate Attachment Point, or • 7he Minimum Annual AggregateAttachment 1�aint less Efigible Benefits which have been Paid on account of one or more Govered Persons in excess of the Maximum Eligible Benefi#s per Indi�idual shown in tfi�e 5chedule. les� Any Monthly Accumulated Ca� B�nefit whieh has been �aid by the Company, If, at the end of a Policy Periad, th� Aggregate Exeess Risk Benefit is zero, the Policyholder will reimburse the Company for the amount of any Monthly Accumulated Cap Benefits paid during the Policy Period. �he Aggregate Excess Risk Benefit for any Policy Period is subject to any maxim�m b�nefit or limitation stated in this policy. In addition ko tf�s right tn change the policy an any policy ,4nniversary, the Campany can change the Aggregate Monthly Factor used to determine the Aggregate Excess Risk Benefit: • On the effective date of any change in benefits under th� Employee 8enefit Plan. • Rekroactive to a policy Anniversary when tMe �ligible Benefits I'aid in the last two manths of the preceding Policy Period vary by more than 10% of the average manthly b�nefits Paid during the prior 10 months. • On the date there is a 10°/p or more change in the number of Employees during a Policy Period. IVlonfihly Accumulafied Gap �enefit The Company will psy a Monthly Accumulaied Cap Benefit to the Policyholder when the exc�ss of: Accumulated Paid Claims less any Indi�idual �xcess Risk Benefit less any Monfhly Accumulated Cap B�nefit paid during th� Policy Periad less the Monthly Accumulated Cap is greater than zero. 7 �ar� 4 - lndividual �xces� Ris� ��nefit The Company wiil pay any Individual Excess Risk Senefit ta the Policyholder. 7he Company will da this within 30 days from the date the Company receives all informatinn required ta determine the Benefit. The lndividual Excess Risk 6enefit for any ane Covered Person in any Policy Period is an amount equal to: For the first Poficy Periad, the amount of �ligible B�:nefits that a�e {ncurred during that Policy Period and Paid on account af khe Co�ered Person tiuring fhat Policy Period and for each period thereafter the amount of Eligibfe Benefits that are Paid on account af the Co�ered Person during the Policy Period less Ti�e Ind�vidual �xcess Risk Benefit Level. The Individual Excess Risk Benef9t a� account af any ane Co�ered Person is subject to any maximum benefit or lim�tation stat�d in the policy. In ad�ikion to the right to change the policy on a Palicy Anni�ersary, the Company can change the lndividual Excess Risk B�nefit leve{: • On the effective c�ate of any change in benefits unc�er the Employee Benefit Plan. • Retroactive to a Policy AnniWersary, when the �ligible Benefits Paid in the last twa months of the preceding Palicy Feriod �ary by more than 10°/d of the average monthly benefits Paid in the prior 10 months. • On the date there is a 10% or more change in the number of Employees during a Poficy Perind. 0 Part � � �olicy ierminati�n The policy and all of the benefits will end on the earliest af the following: • The end of any Grace F'eriod if any p�emium is not paid. • The date the Plan ends. • The date that fewer than 25 employees are covered under the Plan. • The last day of a PoEicy Period, if the P�licyholder has nat accepted the rates and terms offered by the Company fo� the following Palicy Periad. Tf�e Policyhold�r has 45 days from the PoEicy Anniversary date io accept such rates and terrns in writing. If the I'olicyholder pays premium during this �eriod, the premium wiil be used to purchase coverage an a pro rata basis, based on the new rates. The policy will end on the last day of the period for which pro rata premium is applied. • The daie the Policyholder fails to provide the funds required ko pay the Eligible Benefits under ihe Plan. • ihe date the Corr�pany determines that th� Policyholder is: • inso��ent, or • has filed for bankruptcy. • The date the ad�ninistrative ser�icas arrangement between th� Policyholder and the Administrator ends. • On any Policy Anni�ersary by tfi�e Company giving 30 ciays advance written notice #haf the �olicy will end. All insurance will end when #he policy ends. � Par� G m IVYis��llaneou� P'rovi�ion� �iabili4y The Campany's liability under this policy is limited to reimbursing the Palicyholder for certain payments the Policyhalder makes to Cowered Persons or providers for expenses cavered under the Plan. The Company is not liable fo� any c�sts the Policyhalder incurs because af contested claims under the Plan. The Company is not liable for punitive, exemplary or consequential damages tF�e Policyholder incurs with respect to the Plan. �'remium Rates The premiums are shown ir� the Schedule. ihe Company reserves the right to change the premium rates at any of fhe following times: • On the effective date of ar�y change in bene�ts under the Plan. • On the effecti�e date of any change in fiederal laws or state regulations which affecf the benefifs or amounts payable under this policy. The change in premium wili reflect the change in the Company's obligations under this paficy. • On the efFective date of a 1 d% ar more chang� in the number of Employees during a policy period. • On any Pre�nium �ue Date. However, the Company rriay not inc�ease the rates before either of the fallowing times: • December 31, 2002, or • twelve months after a previous increase in premium rates excepk for an increase due to a change in the number of ��nployees, a change in Plan or a change in f�deral laws or state regulations. Premium Computafion a�d Adjus�menfi The pr�mium due: • an t�e palicy's Effective Date, and • on each Premium Due Date is the sum of khe premiums for all insurance in force on that da#e, determined by the appropriate premium rates then in effect. The Com�any may change ihe way it �gures premiums if the Policyhalder agrees. Premiums Where ar�d How Payable The Policyholder will pay monkhly premiums in advance on ar before the Premium Due Date. Premiums are paid: • af the Nome Office, or • to an authorized agent of the Company. 10 The Policyhalder will be given a receipt signed by the President or a Secretary and cour�tersigned by an authorized agent of the Company. Grace Period Th�s section applies anly to premiums due after the Effective Dake of the policy. There is a 31-day grace periad during which the policy will remain in force if premiur�s are nok paid by a Premium Due Date. The Policyholder must pay premiums for the fime the policy stays in force. ff writken notice to end the policy is given by the �olicyholder �efore t�e end of the 31 days, an adjustment of the premium will be made. Renewal �rivilege The Policyhalder may renew fhis policy on �ach Palicy Anniversary date. The renewal is subject to: • The provisians af the policy. • The terms offered �y khe Company. �a�a Required The Policyholder will: - Keep adequate records. These records must be acceptable ta the Company for insurance purposes. • Provide any informatian the Company needs fo.administer khe policy. The Company can i�spect and audit the Policyholder's records of the following: • The insurance under the policy. • Any claims filed under the Employee Benefit Pian. The Company can do this at any reasonable time: • While the po{icy is in force. • puring the 6-year period aft�r the pol9cy ends. Clerical �rror A clerical error made by the Policyholder ar the Corr�pany will not: • Invalidate any caverage okherwise validly in force. • Continue any co�erage which has validly ended. �n�ire Contrac� and Stafiemen�s ido4 lNarranfiies This policy is governec� by the laws of the State or other Jurisdiction of Issue. The entire contract between ihe parties is made up of: • This palicy. • The Policyl�older's applica#ion, which is attached. UnEess there is fraud, all statements made 6y the Policyholder will be considered statements af fact and not guaraniees. . 11 No s#atement will be used in defense of a claim under the policy unless it is contained in the written signed applicatian. Changes Only the Presider�t, a Vice President, or the Secretary of the Company is autharized to: • Alter this policy. • Waive any of the Company's rights or requirements. Any change ia this policy is nat valid unless it is dor�e in writing and attachecE ko this policy. No agent has the authoriky ta; • Change this policy. • Waive any of its provisions. �mendments fio fihe I�olicy This policy can be amended in writing at any time if the Company and the Policyholder agree to the amendment. �amendmen�s �o �he Plan The Campany must be given notice of any amandment to the Plan at least 31 days before the efFecti�e date of the ame�dment. The notic� musf be given in writing at the Company's Nome Office. If the Company does not rec�ive 31 days ad�ance writ�en notice of any arrtiendment, the Company will be liable to pay benefits under this policy as if the Plar� had not been amended. Right of �ecoverylSubrogafiion If the Policyholci�r recovers: • damages, • expenses, or • benefits feom a third party, the recovered amount cannot b� used to meet a deductible amaunt or attachment point. The Company vuill nof reimburse the reco�ered amount. !f the Company reimburses the Policyholder for all or part of a particular payment and the Policyhalder r�ca�ers that payment from a third party, fhe Policyholder must repay the Gompany the reimbursed amaunt. If the policy is no# in force on fhe date the Policyholder recovers the payment, the Policyholder must still reimburse the Company. The amouni of the repayment may be reduced by khe amount of the Policyholder's teasonable and neeessary expenses ta obtain the recovery. The Policyholder agrees �o prosecute any and all val�d claims it may have against a third pariy involving ihe �ayment of benefits under the Plan. TF�� Policyholder �qrees to reimburse the Company for any payments the Gompany has made or is liable to make under the policy from any amount the Policyhalder recavers either directly or indirectly from such a claim. If the Policyholder does nof prosecufe a valid claim against a third parky and the Company becomes liable under the terms of this policy, the Company will �e subrogat�d io all rights of �he Poiicyholder. 92 The amount recovered by the Company will be used to: • Reimburse the Company for any amounts the Co�pany paid under the Individual, Family or Aggregate Risk �enef{ts of this policy. • Pay the callection expenses. Any remaining amount will be paid to th� Policyholder. This pravision applies even after the policy ends. 13 P�r� l � Claim �r�vision� Nofiice o� Claim The Policyhalcier authorizes the Administrakor to file claims on its behalf under this policy. 7he Palicyhalder autharizes the Com�any to pay b�nefits to the Administrator for deposit into khe bank accounk maintained by the Policyf�oader for the funding of Employee benefits under the Plan. Paymenfi o� Claims The Company has the sole authority ko dete�mine if benefits are payable under this policy. �egal poc4ion The Po�icyholder may not sue on a clairri befare 60 days after written proof of loss has been given to the Com}�any. 7he Poiicyholder may not sue after 3 years from the time writter� proof of loss is required. iVoiice o� �epp�al T�e Policyholder will notify the Company of any: • objection, • notice of I�gal action, or • complaint on a claim processed by the Policyhalder or the Administrator if it is expected that a benefit will be paid �nder this policy. 14 ��r� � � C�eneral �imi��ion� Any benefits Paid hy the Policyholder for expenses incurred by an Employee ar Dependent hefore the date of coverage uncier this policy will not he used to satisfy: • any Individual or Family Excess Risk Benefit Level, or • any Annual Aggregate Attachrnent Point. The Company will not reimburse the Policyholder for payments made under the Plan in connection with the follawing: • Injury or sickness contributed ko by: • Committing a felony. • Trying to commit a felony. • �ngaging in an illegal accupatian. • lnjury or sickness resulting from war declared or undeclared, or internatianal armed cat�flict. • Injury or sickness for which the covered Employee or Dependent receives payment under: • Workers' Compensatian or a simifar law, or • the Occupational Disease Law. • Injury or sickness for which tha covered Errmployee ar Dependent would recei�e payment under a workers' compensation act or similar law, except for the fact thai the person is not co�ered under a workers' comp�nsation act or similar law. This exclusian only applies to persons that can elect, or could ha�e e�ected for them, covErage under a warkers' compensation act or similar law. • Charges in excess of the Plan's Reasonable Charge standards. • Services or supplies which are not Medically I�ecessary, as determined by t1�e Plan. •[7rugs, treatment, services or supplies which are considered in�estigatinnal because: • They do not meet generally accepted standards of inedical practice in the United States. • They are cansidered investigational by the Food and Drug Administratian. This inc[udes any related confinement, treatment, ser�ices or supplies. • Expenses which can be paid under another group healkh bene#it program, a government or tax-supported program (other than Medicare or M�dicaid} ar a No-Fault Automobile Insurance Law. This includes amau�rts which can be recovered through the Caordination of Benefits ar nonduplication o# benefits provisions of the Plan. • Expenses resulting from: • Any extra or noncontractual damages incurr�d by khe Palicyholder. • Legal fees and expenses for the defense of a claim under the Plan. This includes, but is nat limited to, compensatory, exemplary and punitive damages. • Fines or statutory penalties resuiting from: - an act, - omission, or 15 - course of canduct committed by th� Policyholder or for which the Policyhalder is responsible under the Plan. • Expenses nok otherwise payable under the Plan for which the Palicyholder assumes responsibility unrler a contract or agreement other than the Plan. This limitation does not apply if the Campany agrees to include those expenses as reimbursable expenses. • Benefits �aid under the Plan on behalf of any Covered Psrson named in the Schedule or bene�ts paid for a Covered Person named in the Schedule that exceed khe Benefit Level stated in fhe Scheciule for that Couered Person. The coverage under this policy will end if: • The Policyholder willfully hides or misrepresents a�y fact relating �o th� Plan ar th9s palicy. • The Poficyholder is invalved ih any case of fraud relafing to the Plan or this policy. A Lafe �ntrant will be subject to Late �ntrant underwriking requirements. Eligible Ben�fits Paid far a Late Entrant are naf reimbursable under this policy unless the Gompany gives written appraval. The writ#en apprawa! will state the effective date af eoverage under the Plan for the purposes of this policy. The Company has tf�e right to deny or limit co�erage with respect ta a Late Entrant. 16 THIS RIDER WILL BE ATTACHED TO AND FORM A PART OF TH� POLiCY SMOWN B�LOW. IT IS ISSUE� BY Unit�d HealthCare lnsurance Company, Hartford, Connecticut T� THE POLICYHOLDER SHOWN BELOW. Policyholder— Ciky of Fart Worth Policy Numh�r —GA-701316AL Effective Date of Rider — October 7, 2QQ'[ 7he terms of the policy in effect on the date shown abave are amended as described below to conform to the requirements of Texas for excess risk insurance policies. 2. 3 4. The Policyholder understands the liability assumed und�r the portion of the �mployee Benefit Plan which he is seff-insuring and further understands that he is exempted from Article 1.14-1 of the Texas Insurance Code oniy if a qualified employee benefits plan has been filed and meets ihe requirements of ERISA. The Policyholder may obtain information or make a eomplaint by calling the 8QQ numbers shown in the IMPORTANT NOTICE form which is included with the policy. In Claim Pro�isions, khe sectfon titled "Notice vf Claim" is changed to read as follows: Notice of Claim The Policyhalder will give the Company written notice af claim within 90 days or as soon khereafter as reasonably possible. Saiisfactory proof of loss should be given no later than 1 year after the date writtan noiice of claim is required. In Miscellaneous Pravisions, the following language is added to the section "Entire Contract and S�ateme�ts not Warranties": After two years frorn the effecti�e date af this policy, no misstatemenks made by the Policyholder in the application for this palicy, ather than frauduler�t misstaternents, will be used to void the policy or deny a clairn for loss incurred after the expiratian af such two-year period. This rider will nat affect any of the terms, pro�isions or conditions of the policy except as stated above. This �ider will kake effect on the Effective Date shown abo�e. Dated at Hartford, Connecticuf on the Effective Date shown above. Unit�d HealthCare Insurance Company �--��[ � President and C�EO �iY�, �'..� �'`' L ' Policy Registrar City of Fort Worth BY � ' �� Official 7itle �15��• f�� '� r Rider Na. 1 to GA-7013�6AL GC-7403TX �� 7 114APORTANT NOTICE To obtain information or make a complaint, you may call the Gampany's tnll-fr�� numb�r at: 'I -500-842-D841 You may contack the Texas Department of Insurance ta obtain infarmatio� on companies, ca��rages, rights or complaints at: 1-8D0-252-3439 You may write the Texas Department of Insurance P.O. Box 149104 Austin, TX 78714-9104 FAX # (512) 475-1771 �:��Ti1111��i[�7��;llull��.��'� Should you have a dispute concerning your premium or about a claim, you should contaet the Company first. If the dispute is not resol�ed, you may contact the Texas Department af Insurance. AT7'ACH TH15 NOTICE 70 YOUR POLiCY: This notice is �or infarmatio� only and does not become a part or condition of the attached documer�t. AVISO IMPORTANTE Para obtener informacion o para someter una queja, usted puede Ilamar gratis a� numero de kelafono de la Compania al: 1-80Q-842»0841 Puede comunicarse con el Departamento de Seguros de Texas para obtener informacion acerca de cornpanias, coberturas, derechos o quejas al: 1-800-�52-3439 Puede escribir al pepartamento de Seguros de Texas F'.O. Bax 149104 Austin, TX 78714-9104 FAX # (512) 475-177'f �ISPUTAS 50BRE PR�MAS O R�CL,AMOS: Si tiene una disputa cancerniente a su prirna o a un reclamo, debe comunicarse con la Com�ania primero. Si no se resuelve la �isputa, puede entonces comtanicarse eon el departamento (TDI}. UNA �ST� AVISO A SU POLIZA: Este avisa es solo para proposito de informacion y no se convierte en parte o candicion del documento adjunko. �r'�j� o�' �'o�� o��l�, ��rcr.� �� i� �o��o� f�AT� ��EF�REr�CE�rv�nr,L�r� i_c�� r�n�tr rAG� 4}� 7J��1 �-� �� 15��]UP ` � of � s�_ir.a��: r AW�If�D �� f�T�tACT �QI� 1�C�V��I�I�Tf��TIC��V �� R�LII� �N1ED�I�AL �3�N�F�T� ANQ PL�R�I-IA�� Of� riI�E�I�M� A1�1Ck fiti�C�f��C�AT� MEDI��L �T�P-I�� IN�1��2P�N�� TQ ��JITF.[�H�I��T�I�AR� G�I�UR�N�E ��N�I�AE�Y �ND � NiODIf I�A�'I�N �F �LA� a��r��l ��ofv�MEfv�r�Tl or�: 1� is rcco��r��nc��d tf��l 4k7e �iiy C;��a7c�l: �, �u�x7ori�e C�r� �i�� hAartiagc� f� cnt�r into a cortfra�t wifh L�r�ikedHeal�hc�re lr�su��t�ce �om��ty t�� admir�i�l��iion of 1he �ity's self-I�ur��ed gro�p e��dical h�,��fl# �rograr�r ��e�c:f�acl�r�� OBF��►} �ff�ckive �c�o�ee 1, �0� �, for an in�l��l 1��m�e�CF� p�rlod wEth �wa �dditional 1�-mnnth exts�siorrs at �nit �ricii�� fo� th� first perio� fisie� bolo+r�; ar�d �. AutY�orize rx�vdifi�ati�r� �� t1�� urrer�t p�ar� ��slg€� �or ]�IMC�-t�rp� ��r��Flts tn �r��rea�e �;o4payments �nd �o-I�sur�nc��_ C�l��.l��i�h3: l'fxe �ily's con��ac! Fo� +��oup medicai cov��agc far il� �m�lo�ees, M��tire�s, an� t�eir �li�ible dep��den�s �xpi��s ��t�n�b��r :3�. 2001. A Rec��iesk ��r Inforr�aEaon w�s r�l�as�d �l��er�-�b�r �8, ��00, The F2ec��sk ��r Prc�posal was issued �anuar�+ ��, �UO'I, �nd ad�r�rt�s�d �n th� �omm�rcial R�cordor or� Jar��r�r �1 and ��L�ru�r� 7, �00� _ Sev�n pr�pos�l� w�r� re��iv�d, �r�d all w�� raspor�sive, �r� ��Eu�ilor� l��r� c�r�p�s�d af �iiy slaff, lhe �it�r's c�r��ultan� f�e grou� ben�iits, �€f�ctEve Pl�n i h�an�g��ner��, Gnc., ar�c� �iiy e�r��Eo�ee� a�d reE��e�s �� l�e pro�.�os�� sut�rx�r��e� t�y Ur�ktedH�all.hcare Ir�suran�� omp�n� �U��} as bes� m��:king th� �it�'� r��uieem�r�k� as riescribed in kl�e �valuatio� c�it�rr� by vt+Y�3ch �II praposals we�e eval+�al�d. TYr� pricing for ih� ir�iti�l 15�mo��th peri�rd ��tob��• 1 ��001, through D�c��nk�er 3�, ��, is �s follows: �� Adrr�ir�istrailor� of �e�neiits ; ��.78 ��er su��i��rr p�r m�n�h • ��4_�� p�r su�scfil#�c�r per �nonlh • $�8.9�J per su�scri��r per ar�anlh b� �t�p-foss ir�sur�nc� �5!'�� P�PNf} for EP� (P��f�} �or ou� af s�nrl�c� ar�a �arti�l��nts (P�PN1� �nr PP� ��ec�fic, �� C�,{l�� A��r�galc �t � �5°l� �f ��cp��i�d .�} �DB��1 ad��in��Er�kic�r� * In�i�a set-up fee + Er�rallrr��nt f�� (with q4,alif�ring �ver�i} � �nrc�karri�nt fee �wiiho�t ��aalllyar�r� �ver��} ■ Rc�ttuctue� �af��r ��tu�) * �nnu�� ac[r�ir�rslr�iion tee {s€,bje�� la adjustm�n�} i Dir��f biili�g f�� _�� er s��criE�er p�r month ��.9� ��r ��i��cri�er �� rn�r�kh $�,�}00 $11 per enrollment $�� p�� enrollm��t Bas�d �n �ar��laxil� �0 first yea,r, �1,�04 y��f� � �nd 3 $7 �er b�ll C}r�jr ��'f r��*� �o��`��t, �'ex�rs ��a� �� a�� ar��i��+��io� � L��ATL �r� ��F�J�� d�unn�Er� I��CS r��,�E i�GE �l17{Q1 �� a�RQUP 'I of � ��.�r =T �1V1��11�C} �F ��}iVTR�� F�1� �ID�+IIC�I^�TRATI��1 �F C�I��UI� iVi�D��W1_ ��fEF1T� A�1D PUf��I-il��C O� �PE�IFI� Af�D A��R��AT� �1�Df�AL �TC}P-L�� M�I�URA�If�� T� UNM�`E[7f�lEALTH��F�� I��lJR�1N�E ��N11�AEVY Ai��} �I+iDDlFIC�IT�C��I O� PL�1�1 p��l�{� � �E�OMMCNUAiIC�i�: Il Is rec�mm+�nd�d th�t [he �ity �oun�il: 1, ��hori,�� e �i!}r f�ar�ac��;r to er7ker i��ks� a c�ntract wEt�� U��edMealtE�care tn�urance �orr��an� F�� d��ni€�Istral�nr� of the �iiy's �elf-funded groti� m�dlc�l b��e�l# �?ro�ram {ir��€iacJa�� 8#��1� effe�li�r� ��lot��r 1 r ��'� , f�r ��7 in ikaal � ��m�r7lh �erioc� �r�rit� #wo a�ditRoi7�l � �-mon#h �x#�r�si�ns a� �nl� �ricir�c� for Ihe first periad �ist�d b�low; �r�d �, �#uEhari�e m��ifi�ation of l�e c�rr�nt g�an d��ign �ar F��-#yps b�r�e�lts ta �n�rea�e �o-�a�rn�rrt� �nr� Cp�iflSUf��rC��_ D1��l.l��l�i�: Tt�� it}�'s contraci for gr�up rn�dicaM �:�v�r�c�� fc�r its err7�rlay��s, ret�re�s, and t1��r eli�i��e dep�nclerkt� �x��r�� eptemb�r �0, �� , A F��r��i�si fnr 1,7in�-r��#ian wa� released �lov�m�ae ��, �Q�Q. Th� I�e�u�s# for Pr��osaa was is��.ied ,l�nu�r� ��}, ��1, ar�d a�#v��l��ed in th� �omm�rr,��l R��ord�r or� J�nuary �1 �nd �ebr�ar�r 7, ��Q� , S�v�n {�ro�os�ls w�re rece'rv�d, �nd al1 were re�por�si��, An ��r��uallo� l�am c�mpas�d of �Et�+ �#�f�, tY�e �ity's cor�s�r�lant �or group b�n�fits, Eff��tiv� Plan f�an��m�nt, I�c_, �Cl� �It�+ ��T�p��+�e9 �r�{i I`eEii`��S ra�� tl�� p�Op�S�I SU�r71ilket� b� Ur�kt�tfl-je�llt�rcar� Ins��r�rk�e C;om�ar�y {Ul�t�} as b��t r�rt��lFn� �h� ��I�'s rec��irernents as d�s�fll�ed irr tl�� valuaii�n critr:ri� by wt�»�� a!M prc�p�sals we�e �va€uat��, �-17� �ri��r�g iar tl�e initial � 5-�nonkh p��ior� ��kob�r 1, ��]�� r thr�a��h �7oc:emb�r 31. ��, i� as �ollows: a} Adr��ni�lea�i�r� of �ren�fit� • �3�.78 p�r su�scri��r ��r rnontE� {P�PN�) �or �F�Q +$�4,4� p�r su�scrlt��r per rrror�fh {P�PiV�) for ouk of �eruic� area p�rk€�ipar�ts * $�8_�!� p�r �ub��ik��r �� rr�or�lE� {P��f�j far �P� fi�� top-�oss in�ur�nce 1 ��'1 � * ��e�kfi�, �k ��[�O,�i}0 ' �9�f�=9�#� at 1 ��°1� of ��cpe�le�f �) ��SRA a�mw��is#ralion * Irtili�l set-u}� f�� ■ Enr��lr��ni fe� (w�th +��ia�ii�yirrc� �venE� • Enroll�r��n# fee (uv�El�oul �ual�f�rir�g �veni� * �t�s�fu�t�r� �af��r saluP} • l�n��al ��rriini�iratior� f�e� �s�bjer.t tn �dj�isl��t� • �ir��l blali�r� f�� 7.�� er subs�riber ��r �ont� $0_8� ��r �ub��ribef per m��kfi� $2�Q00 �'! 1 ��r ��rollmer�# �2� p�r ��rollrrte�# ��s�d on �ompiexity �0 �irst year, ��,0�� }r��r� 2 ��d 3 �7 per bi�l