HomeMy WebLinkAboutGREATWEST - CONTRACT - RFP - P832 BENEFITS (2)Great - West
LIFE & ANNUITY INSURANCE COMPANY
8505 East Orchard Road
Greenwood Village, CO 80111
August 25, 2003
City of Fort Collins
215 North Mason, 2°d Floor
P.O. Box 580
Fort Collins, CO 80522-0580
Gentlemen:
Re: Excess Loss Insurance Policy No. 259613
The purpose of this Letter is to set out the terms of an Agreement between Great -West
Life & Annuity Insurance Company (Great -West) and the City of Fort Collins (the City)
whereby, subject to all other terms and conditions set out below, Great -West agrees to
modify the terms of the Excess Loss Insurance Policy by:
• Deleting Section G5 under the Article — Termination of Policy and replacing with the
following:
If one Party has materially breached this Contract (the 'Breaching Party") and the
other Party (the "Nonbreaching Party') desires to terminate this Contract, the
Nonbreaching Party shall give the Breaching Party specific written notice of the
nature of the breach. The Breaching Party shall have 30 days to cure such breach.
If the breach remains uncured 30 days following the notice of breach, this
Contract shall terminate as of the end of such 30-day cure period. This Section
shall not apply to immediate breaches.
• Deleting Section B under the Article -Premium Provisions and replacing with the
following:
GRACE PERIOD: A Grace Period of 31 days from the due date will be allowed for
the payment of each premium after the first premium payment. During the Grace
Period, the coverage will remain in effect provided that the premium is paid before
the end of the Grace Period. If the Policyholder does not pay the premium during the
Grace Period, the Service Contractor will suspend plan operations for a period not to
exceed twenty-four (24) hours, during which time the Client shall make full payment
of premium due. If payment is not received by the end of this twenty-four (24) hour
period, this Policy will terminate without further notice retroactively to the date for
which premiums were last paid.
1. to the extent not limited further under Section 2 immediately below, are limited to expenses incurred
by a Covered Person, which are'
a. included in the class or classes of Covered Benefits; and
b. covered under the terms of the Plan, taking into account all of the exclusions and limitations
of the Plan; and
C. incurred:
i. duringthe Expense Incurral Period or during the Run -In Expense Incurral Period, if
applicable; and
ii. prior to the date this Policy en s; and
d. paid during the Expense Payment Period, shown in the Schedule.
Covered Benefits do not include: 1) any amount that is excluded from coverage under this Policy
pursuant to Article - Limitations and Exclusions of Coverage; or 2) with respect.to any Policy Year,
any amount'that qualifies as Covered Benefits for any previous Policy Year. '
COVERED PERSON
means a person who is in a class or classes of persons included under Your Excess Loss Insurance Policy
who is enrolled for coverage and meets the eligibility requirements set forth under the Plan.
EXPENSE INCURRAL PERIOD
As shown in the Schedule, means the period of time during which an expense covered under Your Plan
must be incurred by a Covered Person to count as a Covered Benefit under this Policy. If specified in the
Schedule to be applicable to Your Policy, covered expenses incurred during the Run-Ih Expense Incurral
Period may also be counted as Covered benefits under the Policy.
In no event shall the Expense Incurral Period extend beyond the date the Policy ends.
Unless specifically stated otherwise, an expense is considered incurred on the date the service, treatment
or supply is provided to a Covered Person.
EXPENSE PAYMENT PERIOD
As shown in the Schedule, means the period of time during which the Plan must actually make payment for
expenses covered under Your Plan in order to count as a Covered Benefit under this Policy.
Unless specifically stated otherwise, an expense is considered paid on the date a check or draft of the
Company is issued for payment.
PLAN .
means the self -funded employee health benefit plan or plans established and maintained by You and
approved by You and the Company for purposes of this Excess Loss Insurance Policy. If so approved by
the Company, the term "Plan" shall, during the period immediately prior to the date on which the self -
funded plan as described in the first sentence is approved by both parties, mean either:
I
1. a draft Summary Plan Description(s), or a Brief Outline of Plan Benefit Design(s), or a copy(ies) of
Your plan's prior benefit booklets or certificates (with modifications, if any, as so specified),
whichever You have designated with the Company's acceptance to be Your self -funded Plan; or
2. magnetic or computer -readable records of plan's information maintained by the Company, which are
used by the Company as a source of information to provide claim payment and other administrative
services to the Policyholder's Plan.
POLICY MONTH
means a calendar month during a Policy Year.
POLICY YEAR
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means the Policy Period which is a period beginning on the Effective Date or the most current Renewal
Date of the Policy and consisting of 12' consecutive Policy Months. The first Policy Year may contain any
number of Policy Months as shown in the Schedule. For purposes of this Policy, the Policyholder's Final
Active Policy Year will end on the date the Policy ends, even if this results in a Policy Year consisting of
less than 12 Policy Months.
REIMBURSABLE SPECIFIC LOSSES
means the total Covered Benefits paid under the Plan with respect to each Covered Person less any
applicable Specific Deductible Amount as shown in the Schedule.
SCHEDULE '
means the Schedule of Excess Loss Insurance coverage included and specified under Article —Schedule of
Excess Loss Insurance as applicable to You, or such Schedule as amended or supplemented by the
Renewal Schedule of Excess Loss Insurance issued specifically to You, or any Amendments thereto,
showing the category, coverage basis, feature and applicable rates, factors and points of Your Excess Loss
Insurance coverage under the Policy.
YOU, YOUR, POLICYHOLDER or POLICYHOLDER'S
means the Policyholder whose name is shown in the Application.
NEL-DEF(04-00)
ARTICLE - SPECIFIC EXCESS LOSS INSURANCE
The provisions under this Article apply to You only if You are insured for the Specific Excess Loss Insurance as
indicated in the Schedule or added by an amendment. '
While the Policyholder's Specific Excess Loss Insurance remains in effect, the Company will pay to the
Policyholder, subject to the terms, conditions and limitations of the Policy, the Specific Excess Loss Insurance
reimbursement due, if any, pursuant to Article -Claims Provisions.
NEL-SPEC(04-00)
ARTICLE - LIMITATIONS & EXCLUSIONS OF COVERAGE
A. This Policy is solely between the Company and the Policyholder, and shall not create any rights or legal
relationship between the Company and any Covered Person or agent, assignee or beneficiary thereof. The
Company's sole liability hereunder is to the Policyholder, subject to the terms, conditions and limitations of
this Policy.
B. `, Expenses incurred for or in connection with the following, as reasonably determined by the Company, will
not be considered Covered Benefits under this Policy and the Company shall not be liable to reimburse the
Policyholder or any person for any such expenses:
1. For expenses incurred while the Plan's coverage is not in force with respect to the Covered Person.
2. For expenses which are not covered, or are in excess of the amount payable, under the terms and
provisions of the Plan.
3. For expenses to the extent the Policyholder or Plan receives any payment or receives a reduction in
charges because of a claims reduction negotiation program, a coordination of benefits provision in
the Plan or any right of recovery or subrogation.
4. For or in connection with procedures, drugs or treatment methods that are deemed Experimental,
Investigational or Unproven, as defined in the Plan, except to the extent agreed to otherwise in
Page 7
writing in advance by the Company.
5.
For any liability or obligations assumed by the Policyholder under any contract or service agreement
other than the Plan.
6.
For cost of the administration of claims payments or expense of litigation with individual claimants,
service or professional providers relating or unrelating to benefits under the Plan including, but not
limited to, costs of defense and liability for punitive or, exemplary or extracontractual damages.,
7.
For liabilities, expenses, losses or fineslIwhich are based upon noncompliance or violation of any
court judgment or order, any federal or State statute, rule, or regulation.
8.
For premium or surcharge taxes, other assessments, or similar payment obligations regardless of
what their title is and regardless of who or what entity the designated payee is, as levied by any
local, state or other governmental unit against the Plan, Policyholder or Company, unless the,
Company has agreed in writing in advance to cover such specific payment.
9.
For expenses or losses that were caused by a wrongful, criminal or tortuous act of any person or
entity and for which the Policyholder or Plan released such person or entity from its legal liability
without just compensation to the Plan. (Comment - An example would be as follows: A covered
employee was hit by a car driven by the client's truck driver in the course of his work. Not wanting
the company's liability insurance premium to increase, the client decides not to submit a truck
driver's liability claim, but has the injured employee's medical bills paid by the group health plan
instead.)
10.
For expenses or claims paid by any person,or entity other than the Company, unless the Company
has agreed in writing in advance to cover such specific payment. '
11. With respect to Specific Excess Loss Insurance, for expenses incurred for third party vendor
prescription drug coverage; for dental, vision, or weekly indemnity (short term disability) coverage;
for health conversion charges; for health care surcharges imposed by or authorized by any local,
state or federal authority; and for capitation or provider bonus payments.
NEL-EX(04-00)
ARTICLE - TERMINATION OF POLICY
The Policy and all coverages hereunder will terminate upon the earliest of the following dates.
A. Except as provided under the Grace Period Section under Article - Premium Provisions, at the end of any
period for which the last premium is paid.
B. The date the Policy ends.
• I
C. The date of termination of the Plan.
D. The date of cancellation of the administrative services agreement between the Policyholder and the
Company.
E. If any state or other jurisdiction enacts a law which prohibits the continuance of this Policy, or the existing law
is interpreted to so prohibit the continuance of this Policy, as reasonably determined by the Company, the
Policy shall terminate automatically as to such time or jurisdiction on the effective date of such law or
interpretation.
F. The Policyholder may terminate this Policy at any time by giving written notice to the Company at least 30
days in advance of such date.
Page 8
G. The Company may terminate this Policy:
1. On any Expiration Date of the Policy, by giving written notice to the Policyholder at least 60 days prior to
such date;
2. Immediately upon written notice to the Policyholder in the event the'Policyholder files a petition for
bankruptcy or for voluntary reorganization for the benefit of creditors, or is the subject of an involuntary
petition ,for bankruptcy. However, such termination will not relieve the Company from its liability existing
prior to the date of termination; I
3. Immediately upon written notice to the Policyholder of the discovery of the Policyholder's material
misrepresentation which .affects the insurability of the risk;
4. Retroactively to the Policy Effective Date or the latest Renewal Date as applicable, upon written ndtice to
the Policyholder, if it is discovered that the Policy was obtained or was renewed through fraudulent
statements, omissions or concealment of facts material to the acceptance of the risk assumed by the
Company;
5. Immediately and without notice upon failure of the Policyholder to comply with any material term of this
Policy; and
6. Immediately and without notice upon Company's receipt of information that the Policyholder has,failed to
fund its Bank Account established to pay benefits under its Plan or if the Company has had any checks
issued for benefit payments which have been returned for non -sufficient funds. This provision shall
survive the termination of this Policy. ,
Af this Policy terminates for any reason, the Policyholder shall remain liable for any unpaid amounts that have
accrued under this Policy including amounts accrued during the grace period.
NEL-TP(04-00)
ARTICLE -PREMIUM PROVISIONS
A. PREMIUM DUE DATE AND PAYMENT: The first premium is due on the Effective Date of this Policy.
Future premiums are due on the first day of each Policy Month. All premiums shall be paid in U.S. currency
to the Company at its Administrative Office in Greenwood Village, Colorado. Premiums are not considered
paid until the full premium payment is received by the Company.
B. GRACE PERIOD: A Grace Period of 31 days from the due date will be allowed for the payment of each
premium after the first premium payment. During the Grace Period, the coverage will remain in effect
provided that the premium is paid before the end of the Grace Period. If the Policyholder does not pay the
premium during the Grace Period, this Policy will terminate without further notice retroactively to the date
for which premiums were last paid. i
C. COMPUTATION OF PREMIUMS: Monthly premium for each Categorized Coverage will be computed as
stated in the Schedule. Add all monthly premiums for all Categorized Coverages together, as applicable to
the Policyholder, to arrive at the total monthly premiums for the Policyholder.
D. PREMIUM REFUNDS: Any error or correction to any premium paid for the preceding Policy Year must be
reported to the Company promptly. The premiums will be adjusted retroactively to reflect changes in
insurance amounts. For a decrease in, or termination of insurance, a credit will be given only for the 2-
month period prior to receipt of such notice. No premium refunds will be owed or made to the Policyholder
or any person if an error or a correction in paid premium is failed to be reported to the Company within this
time limit.
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E. CHANGES IN RATES: The Company reserves the right to change any premium rates and to propose
changes to the Specific Deductible Amount(s) on any of the following dates:
On the date when the terms of this Policy are changed;
2. On the second Anniversary Date of the Policy (however, any such change whjch represents an
increase in rates or Specific Deductible Amount(s), will not become effective until after the'date
which is 60 days after the Company has given written notice to the Policyholder informing the,
Policyholder about the increase);
3. On the effective date of any change to the Plan having material effects on benefits provided under
the Plan;
4. On the first day of a Policy Month following a change in Policyholder's primary business or in
Policyholders geographical location;
5. On the date the Policyholder adds or deletes subsidiary or affiliated companies or divisions with the
Company's approval;
6. On the first day of a Policy Month following a change in the number of Covered Persons under the
Plan if such change exceeds 10% in any Policy Month or 25% over any period of three consecutive
Policy Months; and
7. On any date that the Policyholder requests the addition of a Covered Person who should have been
included as a Covered Person earlier, such change to be retroactive to the date the Covered Person
should have been included; provided, however, that Company reserves the right to consider that
such Covered Person shall be included under this Policy no earlier than 60 days prior to the
Policyholder's request to add the person(s).
The effective date of the change in factors will be the effective date of the event in 1, 2, 3, 4, 5, 6, or 7
above, that causes such change, except that no increase will take effect before 60 days after the date
written notice of such increase is given to the Policyholder by the Company.
NEL-TP(04-00)
ARTICLE - CLAIMS PROVISIONS
A. PAYMENT OF CLAIMS: Contingent upon the Company's receipt of the Policyholder's timely submitted
notice and satisfactory proof of claim, the Company will thereafter pay to the Policyholder any Excess Loss
Insurance reimbursement due within a reasonable time, but not to exceed 30 working days.
B. ADJUDICATION OF CLAIMS: The Company shall have no obligation under this Policy for the settlement or
adjustment of claims filed by Covered Persons under the Policyholder's Plan. The Policyholder shall
always have the final right to determine the availability or extent of benefits payable under its Plan and the
Company shall always have the final right to determine the availability and extent of coverage to the
Policyholder under this Policy.
C. AUDITS: The Company or its authorized representative shall have the right to inspect and audit all records
and procedures of the Policyholder and to require, upon request, proofs of records satisfactory to the
Company that payment has been made to the Covered Person or the provider of such services or benefits
which are the basis for any claim by the Policyholder under this Policy.
D. RECOVERY OF OVERPAYMENT: If the Company reimbursed You more than it should have, the
Company has the right to recover the excess amount directly from you. If the Company reimbursed You
less than it should have, You have the right to recover the shortage from the Company.
The provisions in this Section D. shall survive beyond the termination of this Policy.
Page 10
E. INSOLVENCY: In the event of the insolvency or bankruptcy of the Policyholder, all reimbursements made
or becoming due after the effective date of this Policy shall be payable by the Company on the basis of the
amount of liability of the Plan under the terms and conditions of this Policy as finally determined in the
liquidation or receivership proceeding without diminution because of the insolvency or bankruptcy of the
Policyholder. Such amount shall be paid directly to the Policyholder or its liquidators, receiver, or other
statutory successor. The Company shall be discharged from its obligations under this Policy to the extent
of such payments.
Nothing in this Section shall increase the Company's liability beyond that which would have existed had the
Policyholder not become insolvent or bankrup`.
I NEL-TP(04-00)
ARTICLE - MISCELLANEOUS PROVISIONS
A. ENTIRE CONTRACT: This Policy together with the Policyholder's applications and the Policyholder's Plan,
a 'copy of which is on file with the Company, and any Riders, Renewal Schedules and amendments
attached hereto, constitute the entire contract regarding the Excess Loss Insurance between the parties.
In the event of a conflict between the provisions of the Plan and the provisions of this Policy, the latter shall
prevail. The Company has relied upon the underwriting information provided by the Policyholder or its
authorized representative in the issuance of this Policy and the Policyholder represents such information as
accurate. Should subsequent information become known which, if known prior to the issuance of Zhis
Policy, would affect the rate(s), deductible(s), or terms and conditions for coverage hereunder, the
Company shall have the right to revise the rate(s), deductible(s), or terms or conditions as of the effective
date of issuance of this Policy or, at the option of the Company as of the next premium due date, by
providing written notice to the Policyholder.
B. DATA REQUIRED: The Policyholder shall maintain adequate records regarding administration of the Plan
covered under this Excess Loss Insurance Policy. The Policyholder must maintain records of all Covered
Persons under the Plan during the period the Policy is in effect and for a period of five years after the end
of the Policy. Upon request by the Company, the Policyholder shall make available to the Company any
such records and information deemed necessary for the Company's administration of this Excess Loss
Insurance Policy. The Company may periodically examine any of the Policyholder's records relating to the
coverage under this Policy and any claims filed under the Plan, and as a result of any examination of the
Policyholder's records shall be entitled to readjust premiums, deductibles, or reimbursements paid as may
be necessary to reflect the true intent of this Policy. This provision shall survive the termination of this
Policy.
C. 'CLERICAL ERROR: Clerical error whether by the Policyholder or by the Company in keeping any records
pertaining to the coverage will not invalidate coverage otherwise validly in force nor continue coverage
otherwise validly terminated, but no such error shall expand the Company's obligations under this Policy.
D. NOTICE: All notices and communications required under the terms of this Policy shall be given in writing
by one party addressed to the other.
I
1. Notices to the Company, to the following address, or other address as the Company may from time to
time specify to the Policyholder in a written notice:
Great -West Life & Annuity Insurance Company
Executive Office — National Accounts — 9T1
8505 East Orchard Road
Greenwood Village, Colorado 80111
2. Notices to the Policyholder, to the Policyholder's address specified in the Application for Group
Coverage or other address as the Policyholder may from time to time specify to the Company in a
written notice.
Page 11
E. HOLD HARMLESS: It is understood that the only parties to this Policy are the Company and the
Policyholder. No express or implied interest or rights are created under this Policy for any other persons or
entities, whether they are the Policyholder's employees, former employees, providers, their dependents,
heirs or assignees; and no third -party beneficiary status is conferred upon such persons or entities.
Based on the above understanding, except for a claim, demand or lawsuit arising out of either party's
tortuous or wrongful act committed directly against either party's employees or their dependents, neither
party shall have any liability under this Policy, and each party agrees to hold the other harmless and•to
indemnify the other party against any and all such loss, damage, and expense including court costs and
attorney's fees, resulting from or arising out of Maims, demands,, or lawsuits brought against either party by
such employees, their dependents, heirs or ass gnees, and to claims for paid claim or surcharge taxes by
any local, state or other governmental unit or other assessments (except for taxes on insurance premiums
received under this Policy'as described in Article - Premium Provisions made against the Company by any
governmental unit.
F. AMENDMENT TO THE PLAN: The Plan shall not be amended while this Policy is in force without the prior
written consent of the Company. Notice of any amendment to the Plan must be given to the Company in
writing at least 30 days prior to the effective date of the amendment. No change in benefits payable under
the Plan or any amendment to the Plan will be binding on the Company until such change or amendment is
approved in writing by'the Company. In the event that such advance written notice is not received by the
Company in accordance with this provision, the' Company's reimbursement liability will be limited to the
Plan provisions in effect prior to the change or amendment. The Company may, in its sole discretion and at
the written request of the Policyholder, approve a Plan amendment retroactively to the date requepted by
the Policyholder, but the Company shall have no obligation to do so.
G. CONFORMITY WITH THE LAW: If any provision of this Policy at time of issue is contrary to any law to
which it is subject, that,provision is changed to meet the law's minimum requirements.
H. LEGAL ACTION: No action at law or in equity shall be brought to recover on this Policy prior to the
expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of
the Policy. No such action shall be brought after the expiration of three years after the time written proof of
loss is required to be furnished.
I. AMENDMENTS TO THE POLICY: Only the President, a Vice President; the Secretary or an Assistant
Secretary of the Company have the authority to alter this Policy, or to waive any of the Company's rights or
requirements and then only in writing. No such alteration to this Policy shall be valid unless amended on or
attached to this Policy. Notwithstanding anything in this Policy to the contrary, Company reserves the right
to amend the Policy at any time on 90 days advance written notice, such amendment to be effective at the
expiration of said 90 days.
J. OFFSET: The Company shall be entitled to offset payments due to the Policyholder under this Policy
against premiums due and unpaid by the Policyholder.to the Company.
K. ASSIGNMENT: Any assignments of this Policy or of any rights hereunder shall be void and of no force or
effect. ,
L. NOT WORKERS' COMPENSATION: The coverage provided under this Policy applies only to benefits
under Your Plan of benefits for non -occupational accidents or illnesses. It is not the intent of this Policy to
provide benefits or coverage under any Plan in lieu of Worker's Compensation Insurance.
NEL-TP(04-00)
Page 12
• Deleting Section E under the Article — Miscellaneous Provisions and replacing with
the following:
HOLD HARMLESS: It is understood that the only parties to this Policy are the
Company and the Policyholder. No express or implied interest or rights are created
under this Policy, and to the extent permitted by law, including the Charter of the City
of Fort Collins, the policyholder agrees to hold harmless for any other persons or
entities, whether they are the Policyholder's employees, former employees, providers,
their dependents, heirs or assignees; and no third -party beneficiary status is conferred
upon such persons or entities.
Based on the above understanding, except for a claim, demand or lawsuit arising out
of either party's tortious or wrongful act committed directly against either party's
employees or their dependents, neither party shall have any liability under this Policy,
and each party agrees to hold the other harmless and to indemnify the other party
against any and all such loss, damage, and expense including court costs and
attorney's fees, resulting from or arising out of claims, demands, or lawsuits brought
against either party by such employees, their dependents, heirs or assignees, and to
claims for paid claim or surcharge taxes by any local, state or other governmental unit
or other assessments (except for taxes on insurance premiums received under this
Policy as described in Article - Premium Provisions made against the Company by
any governmental unit. Nothing herein shall act as a waiver of rights or protections
under the Colorado Governmental Immunity Act.
1. Effective Date
This Agreement is effective as of January 1, 2003.
2. Definitions
The definition of all terms used herein is hereby deemed to have the same meaning as
those defined in the Excess Loss Insurance Policy.
Dated at Greenwood Village, Colorado this -Aday of 2003.
GREAT -WEST LIFE & ANNUITY INSURANCE COMPANY
woo
Senior Vice President President
General Counsel and Secretary
For the Actuary 67
The terms of this Agreement are accepted by the City of Fort Collins this day of
SF
WrW,nfft�Z 2003.
CITY OF FORT COLLINS
BY: � 69-��
TITLE:
THE CITY ORT COLLINS, COLORADO
By:
John PFischbach
City Manager
By:
VameB. O'Neill II, CPPO, FNIGP
Direhassiing & Risk Management
DATE: / J
A TEST:
•'City Clerk
? AP OVaD AS TO FORM:
AS&SWfant d4 Att rney
PSA 05/01
GREAT -WEST LIFE & ANNUITY INSURANCE COMPANY
Executive Office:
8505 East Orchard Road
Greenwood Village, Colorado 80111
303-737-3000
APPLICATION FOR EXCESS LOSS INSURANCE
EXCESS LOS$ INSURANCE POLICY
City of Fort Collins hereby applies to Great -West Life & Annuity Insurance Company for Excess Loss Insurance
Policy No. 259613 in the form attached hereto. The Policy has been approved and its terms accepted by the
Applicant.
Dated at P9Dy1?,V COL,L:K;u5 C%�' this / 7 dayof--Q5 `�O&e22003.
City, State Day Month
THE CITY A FORT COLLINS, COLORADO
By: -h—
John F. Fischbach
City Manager
By: "en&jj e—
(
Jqdnes B. O'Neill II, CPPO, FNIGP
Dire off Purchasing & Risk Management
DATE: [ 7 b 3
TTEST:
�City ;�i�rk
APPROV D AS TO FORM:
•Assistant City Attorney
Page 1
Great -west ute''& Annuity insurance t pOMPany
Executive Office:
850, East Orchard Road
Greenwood Village, Colorado 80111'
303-737-3000
EXCESS LOSS INSURANCE POLICY°
Great -West Life & Annuity Insurance Company ("Company") issues this Excess Loss Insurance Policy number
259613 to CITY OF FORT COLLINS ("Policyholder" and/or "You") and thereby agrees to pay the benefits to the
Policyholder, pursuant to provisions and conditions of the Excess Loss Insurance Policy contained and specified
herein, upon receipt of satisfactory proof of loss.
The consideration for coverage under this Policy is the Policyholder's application and the payment of the required
premium as it becomes due.
The effective date of this Policy is January 1, 2003. All Policy and Agreement periods begin and end at 12:01
a.m. standard time at the Company's Executive office.
This Policy is delivered in the State of Colorado and is governed by its laws.
The provisions and conditions of the pages and Riders, if any, that follow will form a part of this Policy as fully as if
recorded in detail above the signature placed on this Policy's cover page.
The Company has executed this Policy at its Executive office on August 25, 2003.
Secretary President
Excess Loss Insurance Policy
(Non -Dividend Participation)
Cover Page
NEL-CP1(04-00)'
Page 2
CONTENTSTABLE OF
ARTICLES
Application for Excess Loss Insurance
Article - Schedule of Excess Loss Insurance
Article -'Definitions
Article - Specific Excess -Loss Insurance I
Article - Aggregate Excess-Losg Insurance
Article - Limitations & Exclusions of Coverage
Article - Termination of Policy
Article Premium Provisions
Article - Claim Provisions
Article - Miscellaneous Provisions
NEL-TOC(04-00)
u
Page 3
ARTICLE - SCHEDULE OF EXCESS LOSS INSURANCE
This Schedule is applicable only to the Excess Loss Insurance Policy issued to the Policyholder.
Each category, coverage basis, and optional feature of Excess Loss Insurance described herein and in each of
any attached Riders (hereafter, collectively referred to as "Categorized Coverage") applies'to the Policyholder
only when the appropriate selection of such Categorized Coverage is indicated by the Company in the
appropriate space provided.
A. Policyholder's and Plan's Information, PoI6's Important'Dates and Coverage Periods
1. Policy's Important Dates & Renewal Term:
'The Effective Date of this Policy: January 1, 2003
The Expiration Date of this Policy: 1-year term, subject to renewal
The Anniversary Date of this Policy: Each January 1 beginning in 2004
2. Policy Period and'Coverage Periods:
Policy Year:
First & Thereafter: Each January 1 beginning in 2003
Expense Incurral Period:
Specific:
For the period beginning January 1, 2003: The Policy Year
For the period beginning January 1, 2004: N/A
Aggregate: N/A
Expense Payment Period:
a. While the Policy is in effect:
Specific: The Policy Year
Aggregate: N/A
b . After the Policy ends for any reason except the Policyholder's insolvency or failure to pay premium
on time:
Specific: N/A
Aggregate: N/A
Run -In Expense Incurral Period:
Specific: Three calendar months preceding January 1, 2003
Aggregate: N/A
Maximum Amount for Run -In Claims:
Specific per Covered Person: N/A
Aggregate (exclude those excluded under Specific Run-in): N/A
B. SPECIFIC EXCESS LOSS INSURANCE
You are insured for the Specific Excess Loss Insurance as specified below:
1. Specific Deductible Amount:
Page 4
(a) $120,000 in Covered Benefits incurred by the same Covered Person (Individual
Deductible).
2. Covered, Benefits:
Medical (excluding outpatient prescription drugs)
C. AGGREGATE EXCESS LOSS INSURANCE NIA
D. PREMIUMS
Monthly premium for each Categorized Coverage is determined by multiplying the applicable premium rate
(expressed as a dollar amount) by the applicable number of the specified premium units covered under the
Plan on the first day of each Policy Month. (Comment: categorized Coverage is defined in the second line
under the 2"d paragraph under Article 1 — Schedule of Excess Loss. I had overlooked this myself when I first
read through this contract. As it is defined, can we leave as is?
If more than one type of premium unit is utilized, add all products of the multiplications for all identified types
of the premium unit together to arrive at the total monthly premium for such Categorized Coverage.
As used throughout the Premiums section of this Schedule, the term Covered Benefits includes only those
amounts that meet the definition of Covered Benefits of Article - Definitions but which are not reimbuIrsable by
the Company because, with respect to the Specific Excess Loss portion they do not exceed the applicable
Specific Deductible Amount or, with respect to the Aggregate Excess Loss portion, they do not exceed the
Cumulative Attachment Limit or the Annual Attachment Limit, whichever is applicable.
1. Specific Excess Loss Premium:
For the policy year beginning January 1, 2003:
Per PPO Employee Premium Rate $ 26.91
Per POS Employee Premium Rate $ 22.90
For the policy year beginning January 1, 2004:
Per PPO Employee Premium Rate $ 33.50
Per POS Employee Premium Rate $ 28.51
2. Aggregate Excess Loss Premium: N/A
E. BANKING OPTIONS: (identifies the frequency of your withdrawals from Your Bank Account for claims
payments)
Weekly with week delay
NEL-SP(04-00)
ARTICLE - DEFINITIONS
As used in this Policy and its attached Riders, unless the context specifically indicates otherwise, the following
terms shall have the following meanings:
COMPANY
means Great -West Life & Annuity Insurance Company.
COVERED BENEFITS
for purposes of Excess Loss Insurance coverage under this Policy:
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