HomeMy WebLinkAboutContract 46035 APPLICATION FOR GROUP INSURANCE
un um® Unum Life Insurance Company of America
2211 Congress Street• Portland, Maine 04122
CITY SECR;ETARV
CONTRACT NO. l' Jj
Name of Applicant City of Fort Worth
Address: 1000 Throckmorton Street
(Street)
Fort Worth,TX 76102
(City) (State) (Zip)
applies to the Unum Life Insurance Company of America,for:
❑ Group Life Benefits ❑ Group Short Term Disability Benefits
❑ Group Accidental Death and Dismemberment Benefits ❑ Group Worksite Short Term Disability Benefits
❑ Group Critical Illness Benefits 4 Group Long Term Disability Benefits
❑ Group Cancer Benefits ❑ Group Long Term Care Benefits
❑ Group Accident Benefits
Is there any group life insurance plan in force or being applied for on some or all employees? ❑Yes ❑No
If yes,complete the following or list the prior carriers:
Employee Class Maximum Amounts Name of Carrier Effective Dates(mmiddyyyy) Termination Dates(mmidpm)
If the Insurance Company approves this application,a policy will be issued.The applicant agrees that acceptance of the policy will be an approval of the
policy terms.The policy specifications will be made a part of the policy along with a copy of this form.
Signed at Fort Worth,TX City of Fort Worth
(City and State) (Applicant)
on O 1 6A By: cu'_a��
(mm/dd") (Signature and Title)
Broker Name: 6ruce, Vqv Broker Signature:
(Please Print) a, eStde
m 3� 7 01/01/2015
C-)
SS#/Tax ID#(last 4 digits): 17 I Policy Effective Date:
m (mm/dd/yyyy)
rn
o APPROVED AS 0 Fiji vt eni%)LEGALITY:
OFFICIAL RECORD
�4* CITY SECRETARY
FT. WORTH TX <C®°R�°0® "Assistan (ty Ar,.. ., : .D�vts
8 I 70
Unum is a registered trademark and marketing brand of U an its uril iaries.
� * Attested byk"2'�
AE-1080
QO
�� OOOaoo°°��� .,
TEXQ'
ys , City Secretary
CITY SECRETAW
• • • CONTRACT NO. 0 1202 Z
unum GROUP MASTER APPLICATION COMPENSATION
DISCLOSURE INSERT
Your insurance or benefits advisor can offer you advice and guidance as you select the policy and provider most
appropriate for your needs. At Unum we recognize the important role these professionals play in the sale of our products
and services and offer them a variety of compensation programs. Your advisor can provide you with information about
these programs as well as those available from other providers. We support disclosure of broker compensation so that
customers can make an informed buying decision.
Brokers may be eligible to receive Base Commissions and Supplemental Commissions from Unum.
Unless you have agreed in writing to compensate the broker differently, Unum provides Base Commissions to all brokers
in connection with the sale of an insurance policy. Base Commissions are a fixed percentage of the policy premium, and
may include a one time, first year,flat amount for each policy sold. Base Commissions are paid by Unum to the broker(s)
on your policy. In some circumstances, broker(s)may be eligible to receive commissions on your policy even after a
broker of record change has occurred.
A broker may also qualify for Supplemental Commissions paid by Unum. For group insurance products, Supplemental
Commissions may be paid as a fixed percentage of total eligible group insurance premiums.The Supplemental
Commission rate depends on the total dollar amount of all eligible premiums or number of group policies that the broker
had in force with Unum in the prior calendar year.
• For New Sales premiums, the Supplemental Commission rate may range from 0% to 5.00% of total premiums
paid. For certain group products, an additional 0%to 11.00% Supplemental Commission may be paid; and an
additional flat amount per application may be paid for using our laptop enrollment system.
• For Renewal premiums,the Supplemental Commission rate may range from 0%to 2.00% of total premium paid.
Supplemental Commissions may be calculated differently for other insurance products. The premium you pay is not
impacted whether or not your broker receives Supplemental Commissions.
If you would like additional information about the range of compensation programs our company offers for your group
insurance policy or any other Unum insurance product, you can find more details at www.unum.com. Should you have
other questions not addressed by the website, including the Supplemental Commission percentage applicable to your
broker, or if you want to speak to us directly about broker compensation, please call (866) 822-0716 (outside the US, call
(423)294-0001).
Policyholder Representative Signature:
(must be an officer of the company)
Print Policyholder Representative Name: �S4 n A ►'L -
OFFICIAL RECORD
Date: O c S I Aet CITY-SECRETARY
FT. WORTH,TX
M
Unum Use Only
C-) Policy No:
Z
M Policyholder Name:
0
Field Office Contact Name
Field Office Contact Number
N
e-mail to BCS: BCSSCAMAI@unum.com
Unum is providing this notice on behalf of the following insuring companies: nce Company of America,First Unum Life Insurance
Company(NY),Provident Life and Accident Insurance Company and Pr iffe;-0"'h$y Insurance Company(NY).
Unum is a registered trademark ancy marketing nd of Un Grou S;Kuringbs
A O APPROVED AS TO FORM AND LEGALITY
° r 1
1052-05(01/12)
o
a S8 Ci �* ,AssI ant City"racy JDEW 116 A FL y
� °^00030°°° ._._.� .�
�qS
• • • CITY SECR VARY
Vf'1UtY1 CONTRACT NO.
Amendment to Broker Contract
Effective Date of this Amendment:01/01/2015
Field Office Name:Houston Broker Name:Gallagher Benefit Services
Sales Rep Name:Aaron Shisler Broker Number:596718
Sales Rep Number:526573 Policy Split%: 100
Policyholder:City of Fort Worth Policy Number:631800
PART A—Broker/Company
1. The Company agrees to pay the Broker and the Broker agrees to accept the commissions determined from the
commission schedule below for the above named policy only.
Record the agreed to Group commission rates in each box as Opp licable
Product LTD STD Life AD&D GLTC GCI ER GCI EE as needed
Commission
Rate: Zero(Net)
Other
2. It is understood and agreed that all of the terms and provisions of the Commission Schedule for Brokers and
of the Broker Contract are incorporated herein by reference as if fully set forth in this amendment and that
such terms and provisions shall remain applicable to the parties to this amendment and to any compensation
payable hereunder. For GCI cases with a Benefit Administration component,this Amendment will terminate
and the commission schedule noted above will revert to the standard Base Commission Schedule in effect for
GCI when the case was sold,at the sole discretion of Unum,upon,termination of that component.
Broker/Consultant Signature: 1 Date:
Print Broker/Consultant Name: 2SIdUl
This Amendment to the Broker Contract shall be valid and binding on the Company as of the date it is received in
the Home Office of the Company, if not rejected by the Company in a written notice communicated in a
reasonable manner to the Broker within ten(10)business days of receipt of the Amendment.
PART B-Customer
I/We the policyholder,acknowledge that the commission rates noted above are agreed to for the coverages noted.
Policyholder Representative Signature: Date: I 1 aUI't
Print Policyholder Representative Name: _
(Officer of the company or appropriate decision-maker °°�� °°° IQ� -Paoyty AS T�ti Ulu+i AND LEGALITY
Unum is providing this no�t"ICe oh Nell T011b s °u y ompany of Ameri ,First Unum Ufs
Insurance Company(NY),Provident Lif and Accident insurance Corn vide nd Casualty Insurance Company(NY).
UNUM 13 A REGISTElED TRADEMARK AND MARKET G BRAND OF UNUM GRO SURING SUBSIDIARIES.
OFFICIAL RECORD
G-73985(04110) CITY SECRETARY Email properly completed form to: bcsscamai @unum.com
FT.WORTH,TX
CITY SECR1-1- '
CONTRACT NO.
�(�035' 1,
unuffy
Amendment to Broker Contract& Supplemental Commission Program
Effective Date of this Amendment:01101/2015
Field Office Name:Houston Broker Name:Gallagher Benefit S rvices
Sales Rep Name:Aaron Shisler Broker Number:596718 OFFICIAL RECORD
Sales Rep Number:526573 Policy Split%: 100 CITY SECRETARY
Policyholder:City of Fort Worth Policy Number:631800 FT. WnRTH,TX
Customer Compensation Disclosure Notice & Supplemental Commission Consent
Your broker or benefit consultant can offer you important advice and guidance as you select the policy and
provider most appropriate for your needs. At Unum we recognize the vital role these professionals play in the
sale of our products and services and offer them a variety of compensation programs. Your broker can provide
you with information about these programs as well as those available from other providers. We support
disclosure of broker compensation so that customers can make an informed buying decision.
If you would like additional information about the range of compensation programs our company offers,you can
find more details at www.unum.com. Should you have other questions not addressed by the website or if you
want to speak to us directly about broker compensation,please call 1-800-633-7491.
For those insurance policies where no Base Commissions are payable,Unum's compensation policy requires
customer approval for the broker to be eligible for Supplemental Commissions. A customer's decision in this
regard will not impact the premium rate charged for their policy.
Please mark the box and initial below if you,the customer,request/authorize that the policy noted above be
included in the Unum Supplemental Commission program. This election will remain in effect for the life of the
policy,unless a change is otherwise requested by the customer in writing.
YES As a customer,f DO consent to the inclusion of the policy noted above in the Unum Supplemental
Commission program.
Required Initials:
q f /An -
M i ,;i' /+.."`D LEGAI,IT�'' r
Broker/Consultant: Date: I
Policyholder Representative: Date: 10 s
,A For Florida Net of Commissions Policies Only: o°
rrn The undersigned Unum applicant/policyholder acknowledges providing compensation directly to the
named below in connection with any purchase of group insurance from one of the Unum insuring c nes. o�
rri
Required Initials/Sienature:
O� °0000000°°*
Broker/Consultant: Date: `c
Policyholder Representative: Date: City Se
N
O
Unum Sales Rep Signature: Date:
Unum Is providing this notice on behalf of the following insuring companies:Unum Life insurance Company of America,First Unum Life
Insurance Company(NY),Provident Life and Accident insurance Company and Provident Life and Casualty Insurance Company
UNUM tS A REGISTERED TRADEMARK AND MARKETING BRAND OF UNUM GROUP AND ITS INSURING SUBSIDIARIES.
G-73985(04/10) Email properly completed form to: bcsseamai @unum.com
M&C Review Page 1 of 2
Official site of the City of Fort Worth,Texas
TH
CITY COUNCIL AGENDA FoR�
COUNCIL ACTION: Approved on 7/22/2014
DATE: 7/22/2014 REFERENCE NO.: C-26886 LOG NAME: 14LTD
CODE: C TYPE: NON-CONSENT PUBLIC HEARING: NO
SUBJECT: Authorize Execution of a Contract with Unum Life Insurance Company of America for the
Administration of Voluntary Long-Term Disability Insurance with Participants Paying All
Premiums and No Financial Impact to the City (ALL COUNCIL DISTRICTS)
RECOMMENDATION:
It is recommended that the City Council authorize the execution of a contract with Unum Life
Insurance Company of America for the administration of voluntary long-term disability insurance with
participating employees paying all premiums and no financial impact to the City.
DISCUSSION:
The Human Resources Department(HRD) will use this Contract to provide City employees with
access to voluntary long-term disability insurance products. The City of Fort Worth currently
contracts with Standard Insurance to provide employees with access to this type of
insurance. Having worked with the same carrier for many years, HRD staff determined that it would
be in the best interest of City employees to go out to the market and give all providers an opportunity
to compete for the City's business to ensure the employees are getting the best overall policies and
price.
The City issued a Request for Proposals (RFP) on February 19, 2014. This RFP was advertised in
the Fort Worth Star-Telegram every Wednesday starting on February 19, 2014 through March 27,
2014. Fifty-nine vendors were solicited from the purchasing database; six responses were
received. The incumbent, Standard Insurance, did not respond to the RFP. The proposals were
thoroughly reviewed by an evaluation team consisting of staff from the following
departments: Transportation and Public Works, Fire, Water, Parks and Community Services and
Human Resources. The evaluation team was provided with resources and assistance by the City's
benefits consultant, Arthur J. Gallagher, and staff from the Purchasing Division.
The evaluation team ranked the proposals based on the following factors: technical proposals,
qualifications, adherence to terms and conditions of the RFP, financial stability, value-added services
and pricing competitiveness. Two finalists were selected and made presentations. Following the
presentations, the evaluation team determined that Unum Life Insurance Company of America
(Unum) provides the best overall solution to the City and significant premium savings to employees
who choose to purchase the benefit. Unum has agreed to provide a rate guarantee until December
31, 2017.
AGREEMENT TERMS - Upon City Council approval, the initial three-year term of this contract shall
begin on January 1, 2015 and expire on December 31, 2017.
RENEWAL OPTIONS - This contract may be renewed up to two additional one-year periods at the
City's sole discretion. This action does not require specific City Council approval.
M/WBE OFFICE -A waiver of the goal for MBE/SBE subcontracting was requested by the
Purchasing Division and approved by the M/WBE Office, in accordance with the BDE Ordinance,
because the purchase of goods or services is from sources where subcontracting or supplier
http://apps.cfwnet.org/council_packet/mc review.asp?ID=20033&councildate=7/22/2014 10/17/2014
M&C Review Page 2 of 2
opportunities are negligible.
FISCAL INFORMATION/CERTIFICATION:
The Financial Management Services Director certifies that this action has no material effect on City
funds.
TO Fund/Account/Centers FROM Fund/Account/Centers
Submitted for City Manager's Office by: Susan Alanis (8180)
Originating Department Head: Brian Dickerson (7783)
Additional Information Contact: Margaret Wise (8058)
ATTACHMENTS
http://apps.cfwnet.org/council_packet/mc review.asp?ID=20033&councildate=7/22/2014 10/17/2014