HomeMy WebLinkAboutRFP - P902 BENEFITS (2)Administrative Services
Purchasing Division
CITY OF FORT COLLINS
City of Fort Collins
ADDENDUM No. 5
SPECIFICATIONS AND CONTRACT DOCUMENTS
Description of Bid: P902 Benefits
OPENING DATE: September 5, 2003 2:00 p.m.(Our Clock)
To all prospective bidders under the specifications and contract documents described above, the
following changes are hereby made.
OPENING DATE CHANGE:
FROM: August 29, 2003 2:00 p.m.(Our Clock)
TO: September 5, 2003 2:00 p.m.(Our Clock)
RECEIPT OF THIS ADDENDUM MUST BE ACKNOWLEDGED BY A WRITTEN STATEMENT
ENCLOSED WITH THE BID/QUOTE STATING THAT THIS ADDENDUM HAS BEEN RECEIVED.
215 North Mason Street • 2nd Floor • P.O. Box 580 • Fort Collins, CO 80522-0580 • (970) 221-6775 • FAX (970) 221-6707
ADC50 Enrollee and Dependents List 29/JUL/2003
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage 090 Voluntary AD6D
Group 006516 0099 CITY OF FORT COLLINS
Cert Nc. Dep Name Effective Status Birthday Be. Rel a;.i on
03/01/2003 A 07/10/1914 M
01/01/1999 A 06/04/2953 M
01/01/1996 A 12/04/1954 M
01101/1996 A 12/04/1946 M
01101/1996 A ositsil960 M
08/01/2002 A 09/29/1957 M
03101/1991 A 07/11/L930 M
06/01/2000 A 02/20/1972 F
12101IL997 A 03/22/1971 n
01/01/1999 A 11/21/1941 F
01/01/1996 A 02/19/1969 M
01/01/1996 A 12/10/1954 M
09/01/2002 A 12/18/1957 F
01/01/1996 A 12/08/1951 M
10/01/2001 A 10/19/1972 M
01/01/2996 A 12120/1967 F
01/01/1996 A 07/06/1952 M
01101i2000 A 04/21/1965 M
01/01/1996 A 12/21/1946 M
09/01/1999 A 10/21/1963 F
DI/01/2002 A 90/22/1972 F
01/01/1997 A 12/21/1966 M
01/01/1996 A 12/02/1949 M
04/Cl/1997 A 06/13/1967 M
06/01/2002 A 10/05/1962 9
01/01/1996 A 09/08/1964 F
01101/1997 A 06/17/1935 F
06/01/2003 A 09/11/1317 F
DIJ01/1996 A 05/09J1956 M
10/01/2002 A 10/27/1956 M
01/01/1996 A 09l1i111965 M
01/01/1996 A 06/22/1952 M
0101/1996 A 10/13/1964 M
01/01/1996 A 09/23/1970 M
01/01/1996 A 06/19/1969 M
02/01/1996 ➢. 09/11/1960 M
12/01/2002 A 02/15/1954 M
01/01/1996 A 12/07/1957 M
01101/200L A 06/08/1976 F
01/01/1995 A 04J05/1950 M
01/01/1996 A 12/20/1953 M
03/01/1996 A 06116/1963 M
08/01/2001 A 02/00/1966 F
02/01/2001 A 09/28/1950 M
01/01/1996 A 12/02/1951 M
Fags 2
Terminated Class
E-type
03
F
03
F
03
F
03
F
D3
F
03
s
03
F
03
F
03
5
03
F
03
3
03
S
03
F
03
F
03
S
03
F
03
F
03
F
03
F
03
S
03
5
03
S
03
F
03
S
03
F
03
F
03
F
03
F
03
03
S
03
6
03
F
03
9
03
S
03
F
03
F
03
F
03
F
03
5
al
F
03
F
01
F
03
s
03
5
03
F
Volume
15C,000-00
50,000.00
30, 000.00
40,000,00
130,000.00
150.000.00
140,000.00
150,600.00
150,000.00
150,000.00
150,000.00
150,000.00
100.000.00
100,000.00
90,000.00
$0,000-00
150,900.to
150, 000.00
a 0. 000.DO
50, a 00.00
150,000.00
so, 000.00
150,000.00
150, 0 Do.00
100.000.00
150,000.00
s0,000.00
50,000.00
100,003.00
50,000.00
80,000,00
120, 000. 00
100,000.00
30,000.00
40, 000.00
100, 000.60
100,000,00
150.000.00
100,000.00
100, 000.Ou
100,030.00
L00,000.00
150,000.00
10, 000.00
100,000.00
3DC50 Enrollee and Dependents List 29/JUL/2D03
.._-----`-------------------------
Company 004 Anthem Life Ina. rants Company
Country 01 United States
Coverage: 090 Voluntary AP6C
.,coup 006513-0099 CITY OF FORT COLLINS
Cart No, Pep Name Effective Status Birthday Sex Relation
12/01/2000 A 07/06/1950 M
O1/01/1996 A 12/1D/1953 M
02/01/2002 A OS/e9/1958 M
01/01/1997 A l2/30/1948 M
01/01/1996 A 02/23/1974 M
01,101/1996 A 12/19/1954 M
O1/C1/1996 A 12/09/1954 M
O1/C1/1996 A 12/18/1966 M
O1/01/1996 A ll/09/1952 F
12/01/2002 A 10/21/1969 F
08/01/2002 A 09/06/1975 M
10/01/2000 A 02/01/1967 M
01/01/1996 A 05/16/1971 M
10/01/2002 A 00/10/1979 M
05/01/2002 A 11/24/1952 F
01/01/1996 A 12/31/1964 M
01/01/1956 A 09/13/1949 M
O1/01/1990 A 12/17/1941 F
01/01/1996 A 07/14/1960 M
.: 02/0111996 A 12/27/1947 F
05/01/2D03 A 11/02/1965 F
05/01/2002 A 10/29/1964 M
O7/01/1997 A 06/25/1970 M
01/01/1990 A 12/03/1954 M
01/01/1996 A 12/23/1959 M
03/01/2001 A 08/09/1959 F
02/01/1996 A 07/25/1965 M
02/01/1996 A 02/20/1967 M
O1/D1/1996 A 11/21/19SI M
05/01/1999 A 05/20/1965 F
O1/01/1997 A 12/18/1968 M
O1/01/1997 A 04/16/1946 M
O1/01/1996 A 12/16/1946 M
D1101/1996 A 12/11/1948 F
12/01/199, A l2/18/1952 M
O1/01/1996 A 12/25/1951 F
03/01/1959 A 00/22/1957 F
O1/01/1996 A 00/18/1942 M
09/01/1996 A 03/31/1962 F
01/01/1997 A 03/06/1957 M
09/01/1999 A 04/21/1910 M
C2/01/2002 A O1/22!1970 F
C1/01/1999 A 12/21/1958 M
O1/01/1996 A 08/02/1971 F
01/01/1999 A 08/14/1944 M
Page 3
Terminated Class E-type
03
F
03
F
03
F
03
F
03
S
03
F
03
F
03
F
03
F
03
03
F
03
F
03
S
03
S
03
F
DS
F
03
S
03
F
03
F
03
F
03
F
03
F
03
03
F
03
F
03
F
03
F
03
S
03
F
03
S
03
03
S
03
F
03
S
03
P
03
5
03
F
03
F
03
F
03
S
03
F
03
S
03
F
03
S
03
F
Volume
1501000.00
50,000.00
50,000.00
100,000.00
50,000,00
100,000.00
150,OOO.00
100,000.00
150.000.00
100,000.DO
150,000.00
100,000.00
150,000.00
10, 000.00
100. 000,00
l OD,0O0.00
5D,o00.00
130,000.Do
120, coo.00
40, 000.00
40,000.00
1001000.00
70,000.00
15D,D0o.00
30,000.00
100. 000.00
70,000.00
100,000.00
150,000.00
150,000.D0
100,000.00
50,000.00
110,000.00
50,000.DO
50,000.00
100.000.00
90,000.00
20,000,00
So,000.00
100,000.Oo
150, 000.00
30,000.00
30, 000.00
SO,000.OD
30,000.03
DC50 Enrollee and Dependents List 29/JUL/20D3 Paa6 4
-----------------------------
Company : 004 Anthem Life Ine0rance Company
Couctry : 01 United States
Cove age: 090 Voluntary AD&D
0065:8-O099 CITY OF FORT COLLINS
'3ffeccive
stacus
Bitt Adey
Sex Relation
Te[minated Class
E-type
Volume
2/01/1998
A
12/29/1959
N
03
F
153,000.00
1/01/1996
A
12/23/1953
M
O3
F
100,000.00
1/01/2000
A
O8/13/1947
F
03
5
110,000.00
1/01/2001
A
04/22/1954
M
03
F
150,000.00
9/01/1999
A
01/14/1961
F
03
F
40,000.00
1/01/1996
A
12/25/1942
M
03
F
100.000.00
141 13,060,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003 Page 5
-----------------------------
._-------- ______.___
Company : 004 Anthem Life IneuCanes Company
Country 01 United States
Corera0e. 113 Volurtary Life - Employee
—6518 0099 CITY OF FORT COLLINS
fteot,o
StaLVa N_rthday
Sex Relation
Terminated Class
E.type
Volume
%O1/1993
A
12/il/1959
F
03
N
100,000.00
/01/1992
A
12/19/1956
M
O3
N
300,000.00
1/01/1956
A
02/_4/1959
M
e3
T
70.000.09
:/01/2003
A
OB/:31'1972
F
03
N
10u,000.00
2/01/2001
A
03/19/1960
M
03
N
150, 000.00
l/O1/.999
A
O4/1^/1947
F
03
N
10,000.00
4/O1/1992
A
12/09/1943
M
03
N
30,000.00
1/01/2002
A
11/23/1955
M
03
T
30, 000.00
1/01/2003
A
05/28/1973
F
- 03
N
200,000.00
1/01/2000
A
12/06/1964
M
03
N
300,ODO.00
6/01/1992
A
12/27/: 964
M
03
N
300,000.00
5/01/1992
A
12/06/1952
M
03
N
130,000.00
6/01/1992
A
12/24/1949
M
03
N
170,00D.00
4/01/1992
A
12/03/1957
F
03
N
100,000-Do
,7/01/1996
A
05/u5/196$
M
03
N
250,000.00
�S/D1/1992
A
12/06/1944
M
03
N
100,000.00
l7/01/2002
A
02/O7/1965
M
03
N
350.000.00
)4/01J1992
A
12/11/1941
F
03
N
50.000.00
14/01/1992
A
12/15/1946
N
03
N
30,000,00
11/01/1995
A
04/11/1966
N
03
N
70.000.00
33/01/1994
A
12/15/1954
M
03
T
200,000.00
04/01/1192
A
12/15/1942
M
03
N
40.000.00
D4/01/1994
A
02/24/1951
M
32
N
30,000.00
.4/01/1992
A
12/28/1950
M
03
N
80.000.0D
06/OL/1998
A
10/03/1951
M
33
N
200,000.00
-06/01/1998
A
11/10/1958
M
03
N
300,000.00
12/O1/2002
A
09/13/19i2
M
03
N
330,000.00
04/01/1992
A
12/01/1947
F
03
N
120,000.00
02/01/2001
A
08/19/1949
F
03
N
50.300.00
04/01/1992
A
11/23/1359
M
03
N
160,000.00
02/01/1997
A
06/15/1964
F
03
N
40,000.00
04/01/2000
A
01/18/1963
M
03
N
30,000.00
01/01IL995
A
10i31/1951
M
03
N
60,000.00
06/01/L192
A
12/29i1954
M
03
N
200,000.00
02/01/1993
A
12/06/1950
M
03
T
70,000.00
02/O1/1996
A
06/2 i/1964
M
03
N
200,000.90
01/01/1994
A
04/20/1961
F
03
N
300.000.00
02/01/1993
A
03/15/1950
M
03
N
300,000.00
04/01/1998
A
04/08/1966
N
03
N
300.000.00
04/01/1999
A
04/06/1972
F
o3
N
250,000.00
04/01/1932
A
03/23/1964
F
03
N
160,000.00
O8/011199a
A
05/27/1973
F
03
N
200.000.00
06/01/1992
A
12/31/2954
M
03
N
L00,000.00
04/01/L996
A
03101/1957
M
03
N
300.000.00
04/01/1992
A
121/04/1948
F
03
N
30.000. 00
Enr011ee and Dependents List 29/SUL/2003 Page 6
..--__.__.................
.___--_____ ____-.._--
Company : 004 Anthem Life Inaurante Company
country 01 united states
Co �e rage: 110 Voluntary Life - Employee
CITY OF FORT COLLINS
£(festive
Status airthday
Sex Relation
TerminaLed Class
E - type
VUl ume
^'/01/1952
/01/1992
A
A
122/13/1559
12/29/1950
P
F
03
N
(O,C00 00
/D1/1993
A
12/29/1949
M
03
T
30,000.00
/01/2001
A
06/O7/1957
M
03
T
70.000.00
/O1/1992
A
12/1S/1964
F
03
N
30, 000'00
i/01/1992
A
12/08/1954
F
03
N
100,000-00
I/0111992
A
12/27/1955
M
O3
N
1501000.00
3/01/2000
A
12/15/1947
M
03
N
30,000.00
2/01/1992
A
13/22/1956
M
03
N
300.90O.00
9/01/1993
A
12/18/1959
F
03
N
30,000.0C
4/01/1992
A
12/24/1952
F
03
N
501000.00
4/01/2992
A
12/29/1547
M
03
N
100,000.00
4/01/1992
A
12/08/1965
N
03
N
250,000.00
4/01/1992
A
12/30/1951
M
03
N
100,000.00
5 /O1/1993
A
12/16/1961
M
03
N
150,ODO.00
4/01/1992
A
12/26/1958
F
03
N
200.000.00
1/01/1992
A
12/11/1947
M
03
N
140.000,C0
4/01/1992
A
12/20/1945
M
93
N
30,000.00
.1/01/1996
A
O6/22/1958
F
03
N
30,000.00
+4/01/1992
A
12/13/1958
M
03
N
100.000.00
-1/01/1994
A
01/05/19E3
M
03
N
200,000.00
Ii/DS/1995
A
01/08/1966
F
03
N
50,000.O0
13/01/1999
A
04/25/1962
F
03
N
30, 000 00
18/01/1992
A
12/15/1962
F
03
T
1001000.00
11/02/1994
A
12/06/1966
M
03
N
100,300. 00
34/O3/1992
A
12/08/1942
M
03
N
100,000.00
04/0:/1992
A
12/10/1964
F
03
N
30,000.00
04101/1992
A
12/13/1967
F
03
N
30,00C.00
04/01/2000
A
01/30/1959
M
03
N
100, 000.00
04/01/1992
A
12/17/1952
M
Ul
N
30,000,00
03/01/1994
A
12/01/196C
M
f3
N
30,OGJ.GU
O1/01/1994
A
07/29/1969
14
C3
N
IIt, 000.00
02/01/1996
A
12/23/1965
F
03
N
ISO. DOO.CO
06/01/1992
A
12/10/1966
M
03
N
30, 000.00
03/92/1997
A
04/04/1957
M
03
N
300,000.30
05/01/1992
A
12/31/1960
M
03
N
110,000 JO
O1/01/1994
A
07/23/1961
F
03
N
100. D00 .00
O1/O1 /2001
A
12/11/1951
M
03
N
100,000.00
05/01/1991
A
O7/18/1955
M
03
N
80,000.00
04/01/1999
A
08/31/1968
M
03
N
200,000.00
05/01/1992
A
12/21/1943
F
03
N
150,000.00
03/01/2003
A
10/11/1965
M
03
N
30,000,00
04/01/1992
A
12/OS/1961
N
03
N
300,000.00
15/01/1992
A
12/13/1950
M
03
N
100,000.00
lB/01/1998
A
09/02/1912
M
03
N
30,000 .00
03
N
1D0,000.00
1
ADC50 Enrollee and DeDendenne List 29/JUL/2003 Page 0
----------- _-----------------
Company C04 Anthem Life Insurance company
Country C1 United States
Coverage: 110 Voluntary Life - EW10yee
CITY OF FORT COLLINS
Effective
Status.
Birthday
Sex Relation
Termi mated Class
E-type
Volume
"/01/2000
A
06/21/1956
M.
03
N
250,000.00
/01/1992
A
12/02/1952
M
O3
N
100,000.00
/0--/1992
A
12/27/1947
M
03
N
50,000.00
/O1/1992
A
12/23/1962
F
03
N
1001000.00
./01/1992
A
12/03/1948
M
03
N
150,000.00
1/01/1992
A
12/13/1952
F
03
N
12D,000.00
:/01/2002
A
02/2S/1918
M
03
N
1C0,000.00
1/01/1994
A
10/07/1960
F
03
N
1001ODO.D0
8/O1/2993
A
12/26/1955
F
03
N
1001000.00
6/01/2994
A
D3/06/1952
M
03
N
100,000,00
7/01/1999
A
08/07/1961
m
03
N
230,000.00
2/01/1993
A
12/12/1947
F
03
N
20,000.00
1/01/1992
A
12/26/1955
F
03
N
30.000.00
1/D1/1995
A
01/0?/1966
m
03
T
30.000.00
7/01/200C
A
04/19/1970
m
03
N
30,000.00
3/01/2002
A
04/02/1961
F
03
T
50,000.00
9/01/2C01
A
05/28/1963
F
03
N
150,000.00
6/01/1992
A
12/07/1957
m
C3
N
300,OOD.00
16/01/1992
A
12/04/1946
m
03
N
300,000.00
�9/01/3998
A
12/29/1964
F
03
N
60,000.00
14/01/1992
A
12/17/1947
F
03
N
100.000.00
13/01/1931
A
O1/31/L947
F
03
N
30,000.00
)4/01/1999
A
O1/26/1965
F
03
N
100,000.00
)5/01/1995
A
12/31/1957
F
03
N
250,000.00
:IB/01/1998
A
11/16/1955
F
03
N
70.000,00
34/01/1992
A
12/26/1961
m
03
N
300,000.00
3/0 L/2002
A
10/08/1963
F
03
N
300,000,00
05/01/2001
A
01/29/1965
m
03
N
200,000,00
04/01/1992
A
12/08/1954
m
03
N
30.000.00
04/01/1992
A
12/16/1955
m
03
N
200,000.00
08/01/1992
A
12/27/1967
F
03
N
30,000.00
02/01/1997
A
06/28/:963
m
03
T
40,000.00
06/01/1992
A
12/24/-957
M
03
N
300.000.00
12/01/1993
A
12/05/194?
F
03
N
30,000.00
04/01/1992
A
12/17/1956
M
03
T
30,000.00
04/01/1992
A
12/2?/1951
m
03
N
08/O1/1992
A
12/08/1960
m
03
N
30,000.00
05/01/2002
A
08/03/1946
F
03
10,000.00
03/01/1995
A
07/06/1951
m
N
20, 000.00
08/01/1992
A
12/14/1951
M
03
N
10,000.00
02/O1/1993
A
12/25/1952
P
03
N
300,000.00
04/01/1992
A
12/27/1942
F
O3
03
N
100,000.00
09/01/1997
A
09/26/1963
m
N
30, 000.00
02/01/1993
A
O0/28/1952
M
03
N
10C,000.00
02/01/1993
A
05/14/1949
M
03
03
N
N
SC100D-00
1D0,000.00
ADC50 Enrollee and Dependents List 29/TOL/2003 Page 8
.._.. __._._•--------- __----- ______
Company OC4 Anthem Life Insurance C_rtpany
Country 01 united states
Coverage: 110 voluntary Life - Employee
Group 0065:8-DO99 CITY OF PORT COLLINS
Cart No. Oep Name
Effective
status Birthday
Be. Relation
Terminated C-a9s
E-type
volume
07/D1/1992
A
12/15/1953
M
03
N
200,000.00
09/31/2001
A
09/07/1973
M
03
N
1001000.00
03/01/1997
A
06/19/1952
M
03
N
150,000.00
06/01/1992
A
12/21/1951
M
03
N
170.000.00
04/01/1992
A
12/13/1955
M
03
N
100, 000. OD
06/01/=992
A
12/11/1947
M
03
T
30.000.03
04/01/1992
A
12107/1947
M
03
N
150,OCO.DD
02/01/1994
A
03/26/1962
M
03
N
100,000.00
06/01;1992
A
12/24/1961
M
03
N
300.000.00
11/D1/1999
A
03/19/1948
M
03
N
100,000.00
04/01/1992
A
12/19/1951
P
03
N
30,000.00
04/01/1992
A
12/29/1949
M
03
N
250,000.00
10/01/1999
A
08/29/196,
F
03
N
250.000.00
10/01/1999
A
01/05/1949
M SPOUSE
01/01/1995
A
05/18/1953
M
03
T
40,000.00
03/01/1997
A
09/03/1944
M
03
N
100,000'00
07/01/1992
A
12/03/1954
M
03
N
30.000.00
02/01/1997
A
04/30/1970
M
03
N
240,000.00
01/01/1994
A
03/20/1958
F
03
N
1DO,000.00
04/01/1992
A
12/11/1965
M
03
N
150,000.00
02/01/1993
A
12/05/1951
M
03
N
200,000.00
04/01/1992
A
12/23/1952
M
03
T
50.000.00
01/01/1994
A
09/12/1959
M
03
N
250,000.00
03/01/1998
A
06/07/1957
M
03
N
300,003,00
03/01/1997
A
08/01/1943
M
03
N
60,000.00
10/01/,1999
A
07/29/1975
M
03
N
100,000,00
04/01/1592
A
12/24/1949
M
03
N
20,000.0c
04/01/1992
A
22/25/1956
M
03
N
2501000.00
03/01/1993
A
i0/D6/1958
Y
03
N
04/01/2002
A
11/19/1960
M
03
N
80,000.00
06/01/2002
A
05/04/1966
M
03
N
300,000.00
04/01/1997
A
01/29/1957
M
03
150, 000. 00
09/01/1995
A
08/20/1958
M
03
N
N
300,000.00
04/01/1992
A
02/25/1955
M
03
N
150,000.00
11/0:/1993
A
12/13/1965
M
03
N
10.000,00
50,000.00
D4/01/1992
A
12/16/1946
M
03
N
30,000.00
33/01/1995
.A
02/25/1952
M
03
N
140, Out.00
11/01/1998
A
12/12/1956
F
DS
N
30,000.00
06/01/1992
A
12/10/1941
M
03
Y
30.000.00
04/01/1992
A
12/06/195D
M
03
N
100,000,00
10/01/2000
A
05/10/1971
F
D3
N
300,000.00
02/01/2003
A
11/12/1964
M
03
N
100,000.00
05/01/1998
A
12/30/1955
F
03
N
120,000.00
09/01/1995
A
12/08/1960
F
03
N
170,000.00
D4/01/2003
A
07/10/1974
M
V3
N
300,000.00
ADC50 Enrollee and Dependents List 29/JVL/2003
Company 004 Arn,heM Life In.urance Company
Country a1 united states
Coverage: 110 voluntary Life - employe-
G",, : 106518 0099 CITY OF FORT COLLINS
Cart NO, Cap Name Effective Status Birthday Sex Sedation
12/O1/2000 A 07/06/1968 M
02/O1/1996 A 03/05/1957 _
05/01/1995 A 12/01/1961 M
05/01/1992 A 12/25/1958 M
06/01/1993 A 12/04/1954 M
04/02/1992 A 12/29/1954 F
04/0t/1992 A 12/20/1960 F
09/01/1997 A 05/11/1954 M
04/al/1992 A 12/24/1959 M
04/01/1992 A 12/21/1952 M
04/01/1992 A 12/12/1959 F
05/01/1992 A 09/20/1955 F
02/01/1999 A 06/04/1953 M
O1101/1,99 A 10/07/1958 F
04/01/1992 A 12/15/1949 F
04/01/1992 A 12/05/19SI F
01/01/1992 A 12/07/1963 M
06/01/1992 A 12/24/1959 F
04/01/19➢2 A 12/04/1954 M
' 04/01/1992 A 12/10/1961 M
05/01/1998 A 07/10/1545 M
01/01/1997 A 40/1011950 M
10/01/2002 A C4/30/1971 M
01/01/1996 A C5/06/1960 M
04/01/1992 A 12/06/1946 F
08/01/1993 A 12/031196. M
10/01/2002 A 09/29/1957 M
03/01/1993 A 12/19/1946 M
12/01/2002 A C2/2411970 M
09/01/1995 A 03/20/1970 M
04101/1990 A n7/31/1970 M
06/01/2000 A 02/20/1972 F
04/0111992 A 09/02/1955 M
07/01/1994 A=0/20/1969 M
02/01/_998 A 03!22/1971 M
02/01/1997 A '_1/1i/1965 Y
02/01/1996 A 08/16/"61 M
C4/01/1992 A 11/13/1961 M
02/01/1996 09/24/1958 F
04/01/1992 A 12/27/1947 M
01/01/1994 A 04/25/1946 M
04/01/1992 A 12/10/1954 M
10/01/2002 A 12/19/1951 F
03/01/2000 A 01/24/1968 M
05/01/1996 A 02/09/1950 F
page 9
Terminated Cla9f
C-Lyptl
4'ulum-
03
N
:no, noo.eo
03
N
100.000.00
03
N
100,000.00
03
N
180,000.00
03
N
30,000.00
O3
N
60.000.00
03
N
30,000.00
03
N
100,000.00
03
N
300,000.00
03
N
100,000.00
03
N
1901000.00
03
N
50,000.00
03
N
100,000.00
03
N
$0,000.Co
03
N
3001000.00
03
N
30,000.00
03
N
80,000.00
03
N
30,000,00
03
N
160,000,00
03
N
50,000.00
03
N
50,000.00
03
N
60.000.00
03
N
70,000.00
O3
N
100,000,00
03
N
30,000.00
03
N
300,000.00
03
N
150,000.00
03
N
150,000,00
03
N
300,000.00
03
N
200,000.00
03
N
200,000.00
03
N
30,000.00
03
N
200,300.00
03
N
300.000,00
C3
N
300, 000.00
C3
N
20, 000.00
03
N
200, 000.00
03
N
300,000 .00
03
N
50,000.00
03
N
10,000.00
03
N
100,000.00
03
N
30,000.00
03
N
501000.00
O1
N
300,000.00
03
N
70,000.00
ADC50 Enrollee and Dependents List 29/S L/2003 page 10
Company : 004 Anthem Life Insurance Company
Couctry : 01 United States
Cove rays: 110 Voluntary Life Employee
Group : 006518 0099 CITY OF FORT Co:L:NS
Pert No, Dep Name
Effective
Status
Birthday
Sex RelaLlon
Terminated .'lass
E-Lyps
Volume
02/0l/1993
A
12/30A553
M
03
T
100.OD0. Oo
06/01/1999
A
C9/26/L960
M
03
N
30,000.Gi
04/01/1992
A
12/08/1951
M
03
N
60,000.00
04/01/1992
A
12/05/1951
M
03
N
150,000,00
Di/O1/1997
A
11/06/1961
F
D3
N
250,000.00
03/01/1995
A
C.T/31/I950
M
03
N
300,000-00
12101/2000
A
04/02/1961
M
01
N
30,000.00
04/01/1592
A
12/13/1363
F
03
N
100,000.00
11/01/2001
A
10/19/1972
M
03
N
300,000.00
04/01/1999
A
09/14/1968
N
Ol
N
250,000.00
04101/1992
A
03/15/1954
M
03
N
1DO,000.00
' 04/01/1992
A
12/28/1967
F
03
N
300,000.00
02/01/1993
A
12/02/1944
M
03
N
SD0,000.00
06/01/1994
A
11/12/1956
M
03
N
100,000.00
C4/DL/1992
A
12/05/1954
M
03
A
150,000.00
01/01/1994
A
CB/30/1941
M
03
N
120,000.00
02/01/1996
A
C9/16/1953
F
03
N
30,000.00
06/01/1992
A
12/02/1958
M
03
N
300.000.00
08/01/1995
A
04/21/1965
M
03
N
300.000.0C
- 09/01/1992
A
12/21/1946
M
03
T
130,000.00
10/01/1999
A
1C/21%1961
F
03
N
!20,060.00
04/01/1952
A
12/17/1963
M
03
N
200,000.00
03/01/2002
A
00/22/1972
F
03
N
200,000.00
04/O1/1999
A
04/20/1920
N
03
N
300,000.00
04;01/1992
A
12/05/1949
F
33
N
30,000.00
02/01/1996
A
12/21/196G
M
D3
N
200,000,00
03/01/1999
A
03/06/197L
F
03
N
200,000.V0
04/01/1992
A
12/02/1949
N
03
N
100,OD0.00
01/01/1996
A
05/_3/1962
F
03
N
♦O,000.00
C3/D1jl997
A
01/21j1953
M
03/01/2002
A
09/22/1966
F
03
N
15C,000.00
05/01/2003
A
02/DB/1962
F
03
N
3C,OOC.00
04/01/2002
A
06/19;1975
M
03
N
250, 000.00
C4/01/1992
A
12/1311951
M
03
03
N
V
20,000A0
06/01/2002
A
10/05/1962
F
03
N
30,000.no
09/O1/1993
F
09/c8/1964
F
03
N
SO,OOD.00
02/01/1999
F
06/07/1958
M
03
N
150,000.00
01/01/1996
A
04/2.3/1974
F
03
N
200. 000.00
Od/01/2000
A
01/23/1960
F
50,000.00
01/01/I995
A
11/03/1945
M
of
03
T
150,000.00
06/01/2002
A
12/04/1958
M
03
N
100,000.00
08/01/1992
A
12/04/1955
M
N
210,000.00
05/01/1599
A
06j26/1961
M
03
N
200,000,00
04/01/1992
A
12/22/1946
M
03
N
300,000.00
06/01/1,92
A
09/06/1956
M
03
N
60,000.00
03
N
300,D00.00
uCSD Enrollee and Dependents List 29/SUL/2003 Page 11
.. ... -------------- ---------- -----
--- -------- ---- -----
Company D04 Anthem Life Insurance Company
Country 01 United States
Coverage: 110 voluntary Life - Employee
Group 006518-0059 CITY OF FORT COLLINS
Cert N0. Dep Name
Effeet:ve
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
03/01/2000
A
O1/09/1966
F
03
N
130,OOD.CO
06/01/2003
A
09/11/1977
F
03
T
100, 003.00
04/01/1992
A
OS/09/1956
M
03
N
250,DDD.CO
04/01/1992
A
12/05/1941
M
03
N
30,000.00
DI/D1/1994
A
10/31/1957
F
03
N
5D,000.00
04/01/1992
A
12/03/1957
M
03
N
30,000.00
01/01/1994
A
O1/15/1967
M
03
T
110,000.00
D1/01/1956
A
12/10/1949
M
03
N
60,000,00
11/01/2002
A
10/27/1956
M
03
N
40,000.00
03/01/1990
A
09/17/1965
M
03
N
300,000.00
04/01/1992
A
12/12/1956
F
D3
N
50.000.00
' 02/01/1993
A
12/29/1963
F
03
N
150,000.00
10/01/1992
A
12/25/1969
F
03
T
100,000.00
03/01/1999
A
05/19/1959
M
D3
N
100,000.00
06/01/1992
A
12/21/1952
F
33
T
200,000.00
01/01/1994
A
06/22/1952
M
03
N
110,000.D0
31/01/1999
A
08/18/1971
M
03
N
300,000.00
02/01JI997
A
03/11/1958
M
03
N
80,000.00
05/01/1992
A
12/12/1958
M
03
N
300,000.00
- 01/01/2001
A
10/13/1959
F
03
N
40,000.00
04/01/1992
A
12/19/1949
M
D3
N
50,000.00
03/01/20DO
A
09/23/1970
M
03
N
300,000,00
04/01/1992
A
12/25/1953
M
03
N
150,000.00
09/01/2000
A
06/26/1974
F
D3
N
300,000.00
06/01/2000
A
01/12/1973
M
33
N
300,000.00
:1/01/1993
A
12/05/1955
M
03
N
70,00D.00
04/01/1992
A
05/12/1963
F
03
N
200,000,00
04/01/1992
A
12/05/1944
M
03
T
30,000,00
09/01/1994
A
02/03/1950
M
03
N
200,000.
00
06/01/2002
A
03/06/1978
M
03
N
100,000.00
02/01/1993
A
12/21/1957
F
03
N
10,000.00
12/01/2000
A
06/30/1973
M
03
N
100. 000.00
04/01/1992
A
12/25/1952
F
03
N
100,000,00
12/01/2000
A
11/22/1965
F
03
N
150, 000.00
04/01/I992
A
12/20/1954
F
03
N
300,C00.00
04/O1/1992
A
12/24/1948
M
03
N
280,000,30
06/01/1998
A
04/22/1966
F
03
N
200,000.00
O1/01/1996
A
12/12/1951
F
03
N
30,000.00
04/01/1992
A
12/09/1961
F
03
N
30, 000.
00
04/01/1992
A
12/02/1957
M
03
N
250,000.00
04/01/1992
A
12/19/1959
F
03
N
120,D00.00
11/01/2000
A
05/21/1977
F
03
N
200,000.00
O1/01/1996
A
02/15/1954
M
03
N
140,000.00
04/01/1992
A
12/12/1959
M
03
N
100,000.00
01/01/1996
A
12/07/1957
M
03
T
100,000,00
GROUP LONG TEAM
DISABILITY CLAIMS SUKMARY
m
SUN LIFE ASSURANCE
COMPANY
OF CANADA
N
AS OF 91MAY2003
FOR THE PERIOD
OIJAN2002 TO
31MAY2003
m
CO
CERTIFICATE
DATE OF
DATE
EXPIRY JCir
NET MONTHLY
CLAIINS PAID
TOTAL
DISABLED
W
NUMBER CERTIFICATE NAME
BIRTH
DISABLED
DATE
BENEFIT BENEFIT
THIS PERIOD
CLAIMS PAID
LIFE RESERVE
r
---------------------------
---------
---------
---------
-----------
OPEN AND APPROVED
A
16FEB1954
19FE82003
16FEB2019 ✓11
3095.60
123.82
123.92
140492_00
28FEB1944
20NOV2002
28FESZDOB }'
703..31
4662.63
4662.63
26991.00
26,%Y19S9
OIOCT2OO2
26MAY2023 ZA
139B.25
7010.82
7040.82
63083.00
07JUL1953
IISEP200i
07.JUL2018 4
2350.23
41677.41
41677.41
184264.00
08JAN1939
13JAN2001
13OCT2D04/q
993.22
16904.74
26063.23
16335.DO
11SEP1950
22JAN2000
IISEP2015 7
1809.42
30743.14
67614.35
187212.00
09SEP1947
04SEP1999
OBSEP2012 /V
634.64
9055.11
43141.49
51224.00
OICCTIO52
O3FEB1999
OIOCT2017 A
1296.75
18728.73
S0306.70
13843T.00
IONOVIO56
22AUG19"
IOA10V2021 F
120B.16
22068.72
76968.49
170W4.00
14SEPi947
OTJUN1997
14SEP2012 F
2727.95
46375.93
190667.16
247392.00
r
..
TOTAL OPEN AND APPROVED
m
16206.57
197330.07
496636.i0
1251604.00
CLOSED
13AUG194i
20PpV2002
18FE82007 M
2509.48
4i82.44
4182.44
.00
n
OEMAR1950
21MV2001
ONMAR2015 M
1S10.24
23352.81
23382-81
14AUG1954
26NOV2000
28NOV2019 ;%
4837.79
25300,24
37346.76
.00
OO
C
D
27FEE11963
04JUN200D
27FE02020 f
1750.63
17564.65
42015.12
.00
24MAY1938
21MAY1907
24MAY2003/Af
767.74
03234.03
54456.21
.00
TOTAL CLOSED
8T95.116
83664.17
163385.34
.00
TOTAL
25102.43
290995.44
660021.44
1251504.00
PENDING NOT APPROVED
27A►Ri849
04APP2003
2.7APl10i4 %M
2.024.10
-00
.00
80623.00
O6JUN1933
12MAR2002
IOJUN2004 A
129.72
_00
.00
11035.00
......�• . a..wiow nu. mrrmuvtu
2163.82
.00
.00
91658.00
TOTAL PENDING
2153.82
.00
.00
91658.00
' TOTAL
W
W
27256-25
260995.14
660021.44
1343162.00
N
W
W
m
r
d
IU
EXPIRY DATE MAY BE EARLIER THAN
GATE SHOW DEPENDING ON CONTRACTUAL
LIMITATIONS
00�
.��
wBftWBy
Fib, Mneachisafts 0249 i
fe Flft~aRciBi'"
Son
LIr9 AssuFXW@ CM4MV
Of CO26 FS 6-
;`=
A➢C50 NYls011ee and 33ependeots List 19/JUL/2081 Page 12
Company : 004 Anthem Life Insurance Company
Country C1 United States
Loverag, L10 Voluntary Life - Employee
Graup : 00651E-0099 CITY OF PORT COLLINS
Cart No 0ep Name Effective Status Birthday Sex Relation Terminated Class 0-type Volume
01,101/2001 A 06/06/1976 F 03 100,000.00
04/O1/1992 A 12/20/1942 M 03 N 40,000.00
02/01/-993 A 12/03/1959 M 03 N 40,OOo.00
04/01/1912 A 12/31/1956 M 03 N 100,000,00
04/01/1992 A 12/20/1953 N, 03 N 100.000.00
08J01/1992 A 12/05/1554 M 03 N 180,000, Do
12/02/1999 A 07/25119SI F 03 N '10,000.00
04/01/1992 A 12/14/1949 F 03 N 40,000,00
02/01/1996 A 06/16/196) M 03 N 300,000.00
02/01/1998 A 03/09/1956 F 03 N 130,000.00
01/Oi/1995 A 10/06/1964 F 01 N 300,000.00
08/01/2003 A 07/08/1966 F 03 N 200,000,00
01/01/1992 A 12/13/1955 M 03 N 100,000.00
09/01/2001 A OR102/1968 M 03 N 30.000.00
04/01,11992 A 12/02/1951 M 03 N 150,000.00
06/01/1992 A 12/15/1952 M 03 If 250,000.00
04/01/1995 A C2/26/1961 N, 03 N 300,000.00
04/01/1992 A i2/23/1946 N 03 N 30,000.00
03/01/199, A O4/2911951 M 03 N 50,000 on
05/01/1996 A 09/10/1960 M 03 N 220,000. 00
02/01/2002 A 03/25/1955 F 03 N 80,000.0.
04/O1)1955 A 07/23/1941 M 03 N 50.000.00
02/01/1999 A 10/05/1953 M 02 N 200,000.00
04/01i1992 A 12/10/1953 M 03 N 250,000.00
a4/al/2002 A a5/09/1958 M 03 T 100,000.00
01/01/2000 A 01/21/1911 F 03 N 1501000,00
34/01/1992 A 12j14/1961 M 03 N 120,000 .00
04/01/1992 A 12/23/1965 F 03 N 110,000.00
04/01/1992 A 12/05/1948 M Oi N 60,0o0.00
O ij ol)1992 a 12/2a/1965 M 03 N 17010MOO
04/01/1992 A 12/30/1948 M 03 N 20, 000.0G
00/O1/20OI A 11/16/1956 M 03 N 150,000 .00
02/01/1997 A 04/20/1959 F 03 N 30, 000.00
05/01/1999 A 04/27/1951 M 03 T 30,000.00
WOS/1992 A L211911959 M C3 N 180 Ono .30
C210111999 A 02/23/1974 M 03 N 300,000.On
04/01/1992 A 12/25/1953 M 03 N 100, 000,00
0001J1996 A 06124/1945 M 03 N 300,000.0C
02/01/1993 A 12119/195, M 03 x 200,000.00
34/01/1992 A 12/29/1958 M 03 T 140,000.00
a3/O1/:99F A 07/06/1966 t' 03 T 20, 000.00
04/01/1992 A 12/27/1956 F 03 T 30,000.00
MEMO06/01/1996 A 08/19/1971 M 03 N 220,000.00
0110111995 A 06/10/1955 M 03 N 501000.00
05/01/2003 A 12/29/1967 F 03 N
AlIC50 Enrollee and Dependents List 29/TNL/2003 page 13
Company : 004 Anthem Life Insurance Companv
Country D1 united States
Pout[... 110 voluntary Lifn Employee
Group : 00651E-0099 CITY OF FORT COLLINS
Cart No Dep Name
Effective
SLalus
Birthday
r
n Relation
'N
Ter0unetsd Class
E-type
um
Vole
11/01/1995
A
10/07/1970
03
N
30,C.00.00
03/01/3003
A
06/16/1967
N
D3
N
100, 000.00
04/01/2003
A
D8/06/1911
N
03
T
200,000.00
O7/01/1992
A
12/09/1954
N
03
N
2DO,000.00
02/01/199S
A
D7/24/1964
F
03
N
50,000.00
02/01/2000
A
10/01/1949
N
03
N
50,000.00
11/01/2001
A
07/11/1952
F
03
N
100.000.00
06/01/1992
A
12/19/1966
N
03
N
100,000.00
11/01/1993
A
12/09/1956
F
03
N
150,000.00
04/01/1992
A
22/26/1951
N
03
N
100,000.00
05/Ol/1999
A
O1/01/1980
N
03
N
300,000.D0
04/01/1992
A
12/08/1952
F
03
T
30,000.00
08/01/1992
A
12/06/1959
N
03
N
200,000.00
O6/01/1992
A
12/19/1950
N
03
N
200,000.00
O6/01/1995
A
09/06/1970
N
03
N
200,000.00
04J0111992
A
12/11/1956
F
03
N
30,000.00
_2/01/2000
A
02/01/1967
M
03
N
130,000.00
04/01/1992
A
12/14/1959
N
03
N
30.000.00
01/01/1992
A
08/20/1945
N
03
N
50.000.00
O1/011,1994
A
06/11/1957
F
03
N
501COD.00
04/01/1993
A
12/06/1959
N
03
N
300,000.00
04/01/1992
A
12/18/1952
N
03
N
30,000.00
04/01/1992
A
12/31/1964
N
C3
N
100,000.00
O1/01/1997
A
09/13/1949
N
C3
N
501C00.00
04/01/1992
A
12/17/1957
N
03
N
301C0o.00
08/01/1992
A
12/30/1952
M
03
N
160.000.00
04/01/1992
A
12/02/1950
N
03
N
30,000.00
04/01/1992
A
12/11/1962
N
03
N
120,000.00
04/01/1992
A
12/12/1955
F
03
N
100,000.0C
04/01/1992
A
12/25/1958
N
03
N
200,000-OC
OS/01/1992
A
12/19/1911
N
03
N
190,000.Oo
02/01/1999
A
06/20/1964
F
03
N
140,000.00
O1/02/1997
A
11/21/1960
N
03
N
50,000.00
04/01/1992
A
12/04/1955
F
03
N
300,000.00
11/01/1954
A
03/20/1949
N
03
N
70,000.00
11/01/1993
A
12/17/1941
F
03
N
1O0,000.00
04/01/1992
A
12/20/194]
F
03
N
10,000.00
05/01/2003
A
05/08/1968
N
03
N
120,000.00
03/01/1995
A
05/28/1968
M
03
N
100,000.0.
04/01/1992
A
12/17/1956
F
03
N
30,000.00
O7/01/2002
A
10/29/1964
M
01
N
200,000.00
02/01/1998
A
04/04/1954
N
03
N
100,000.00
04/01/1992
A
12/26/i953
N
03
N
300,000.00
02/01/1993
A
12/21/1955
F
03
N
200.000.00
O4/01;1992
A
06/01/1963
F
03
N
120,000.00
ZC50 enrollee and De p------a fiat 29/Sw/2303
Company 004 Anthem Life Insurance Company
CCYnt [V 01 United States
Coverages 110 voluntary Life - Employee
Croup 006518-0099 CIT`! OF FORT COLLINS
nrn Name EEfectiv¢ Status Birthday Sex Relation
04/01/1992 A 12/21/1963 M
04/01/1992 A 12/03/1954 M
02/01/1997 A 03/04/1948 M
04/01/1992 A 12/24/1940 M
04/01/1992 A 12/23i1959 M
04/01/1992 A O9/09/1959 F
11/01/1995 A 10/05/1968 F
O810IY2000 A 04/22/19$1 F
05/01/1994 A 11/28/1966 F
05/01/1992 A 12/09/195, M
O5/01/1992 A 12/05119SI F
30/01/1995 A 02/14/1959 M
04/01/1992 A 12/15/1961 M
04/01/1992 A 12/OS/1952 M
04/01/1992 A 12/16/1960 M
02/01/1996 A 02/20/1967 M
10/01/1992 A 12/13/944 M
01/01/1994 A 06/2211951 M
10/02/1992 A 10/23/1969 M
10/01/2002 A 10/18/1965 F
02/01/2003 A 11/30/1967 F
D4/01/2002 A 10/14/1951 F
06/D1/1992 A 12/19/1968 M
04/01/1992 A 12/22/1964 M
03/C1/2000 A 10/10/1967 F
02/G1/1997 A D4/16/1948 M
04/01/1992 A 12/16/1946 M
OS/01/1992 A 12/11/1948 F
05/01/1999 A 11/11/196A M
O1/01/1994 A 10/31/1963 M
01/01/1995 A 12/18/1952 M
04/01/1992 A 12/25/195i F
04/01/1992 A 12/28/1949 M.
04/01/1992 A 12/21/1953 M.
10/01/2002 A 07/12/1970 M
04/01/1992 A 12/11/1954 M
09/31/1999 A 02i22/1957 F
04/01/1992 A 12/09/1954 M
03/01/1993 A 12/11!1955 M
03/01/1993 A 12/03/1961 F
06/01/2002 A 06/03/1957 F
04/01/1992 A _2/13/1954 M
05/01/1999 A 00/11/1359 F
06/01/2000 A 06/25/1960 M
04/01/1992 A 12/04/19se M
sage 14
Terminated Class
E type
volume
03
T
200.000.00
03
N
150,000.00
03
N
100,000,00
03
N
100,000.00
03
N
30.000.00
03
N
60,000.00
03
N
200,000.00
03
N
30,000.00
03
N
100,000.00
03
N
100,ODO.00
D3
N
30,0DO.00
03
N
30,000.00
03
N
30,000.00
03
N
60,000.00
03
N
100,000.00
03
N
100,000.00
03
N
100,000.00
03
N
200,000-00
03
N
250,000.00
03
N
20010Do.00
03
N
300.000.00
03
N
100,000.00
03
N
300,000.00
03
N
80,000. 00
03
N
150,000 00
03
N
50,000.00
03
N
30,000.00
03
N
2001000.G0
O3
N
300,000.00
03
N
1001000.00
03
N
1501000.00
03
N
300, 000.00
D3
N
150,000.00
03
N
120.000.00
03
N
100,000.00
03
M
80,000.90
03
N
120,000.00
03
N
100,000.00
03
N
303,000.00
03
N
300,000.00
O3
N
40,000.00
03
N
30,000.00
03
N
100,000.00
03
N
300,000.00
03
N
180,000.00
ADC50 enrollee and Dependents List 29/0111,/2003
Company 004 Anthem Life Insurance Company
Country OL United States
Coverage- 110 Voluntary Life - Fmployee
C.: oup 006518 -0059 CITY OF FORT COLLINS
^� +c. Den Name Effective Statue Birthday Sex Relation
04/01/1992 A 12/20/1956 M
04/O1/1992 A 12/26/1956 M
02/O1/1993 A 12/26/1950 M
09/01/1996 A 03/31/1962 P
04/01/1992 A 12/09/1964 M
O9/01/2001 A 06/O6/1910 M
04/01/1992 A 12/27/1961 F
U4/01/1590 A 03/06/1957 M
04/01/1992 A 12/16/1941 M
OS/O1/1992 A 12/09/1949 M
03/01/1997 A 06/27/1945 M
O7/0112000 A 30/12/1913 F
07/01/1952 A C1/30/1949 M
04/01/1992 A OS/19/1950 M
LO/O1/1996 A 08/03/1915 F
O4/01/1991 A 12/22i1952 M
04/01/1992 A 09/30/1946 M
01/011/1995 A 03/26/1957 F
O1101/2000 A 08/21/1959 P
02/01/1993 A 12/29/1953 M
04/01/1993 A 12/20/1948 M
10/01/1999 A 04/21/1970 M
01/01/2001 A 06/15/1962 F
01/01/1994 A 06/08/1964 M
02/01/2002 A 01/22/1970 F
e7/01/1997 A 03/23/1967 F
O1/01/1999 A O5/21/1967 M
05/01/1992 A 12/21/19SS F
04/01/1992 A 12/21/1958 M
03/01/2000 A O./02/19.3 F
05/01/2000 A 04/26/1969 M
03/01/2002 A 02/:1/1960 M
03/C1/1996 A 12/07/1952 F
09/C1/2001 A 05/OI/195T M
09/C1/2002 A 02/10/1956 M
01/C1/1999 A 08/14/1944 .N
04/01/1992 A 12/07/1956 M
01/01/1994 A 06/a3/1955 F
03/01/2002 A O9/03/1950 F
091O1/1992 A 12/23/196n M
01/01/2003 A 12/05/1950 F
04/vl/1992 A 07/26/1950 M
04/51/1992 A 12/27/1945 F
08/O1/1992 A 12i06/1954 F
O6/01/1992 A 12/29/1953 M
page is
Terminated Class
E-type
0)
T
03
N
03
N
03
N
O3
N
03
N
03
N
03
N
01
N
03
1
03
N
03
N
03
N
03
N
0)
N
03
N
C3
N
C3
N
C3
N
03
1
03
N
03
N
03
N
03
N
03
N
01
N
03
N
03
N
03
N
03
N
03
N
"
N
0)
T
O3
N
03
N
03
N
03
N
03
T
03
N
C)
N
N
11)
N
03
N
01
N
O3
N
Volume
30,000 00
200,000.00
100.000.00
200.000.00
300.000.00
300,000.00
180.000,00
100,000,00
300,000.00
40. 000.00
50, DD0.00
300.000.00
100,09t.00
100.000 00
300,000.Co
120,000.00
50,000.0D
30, 000,00
30,000.00
200,D00. 00
100,003.00
300,000.0D
100,000.00
100.000.00
30,100.00
50,000.00
250,000.00
30.000. 00
L50,000.00
60,O00.00
1501000.00
130,000.00
30,000.00
200,DDC.00
300.000.V0
30, OOC .00
3001.00,00
200,000.00
200,000.00
l00.000.00
140,000.00
300.000. 00
30.000.00
100,000 00
300,000.00
WCSG Enrollaa and ➢epeuients List 29/J /2093 F." :6
Company 004 Anthem Life Insurance Company
Country : O1 United State.
Coverage: 110 VO'Untary Life - Employee
Grcup 006518-0099 CITY OF PORT COLLINS
Ir nor: Name
Effective
Statue
Birthday
Sex Relation
Terminated Claaa
E-type
Volume
04/01/1992
A
12/23/1953
M
03
N
1001000.00
04/01/1992
A
12/15/1957
F
03
N
30,OCO.00
C4/01/1992
A
12/09/1949
M
03
N
80, DOD .00
C]/0112002
A
05/lf/197O
F
03
N
100, DOD .DO
04/01/1992
A
12/21/1952
M
03
N
80, 000.00
04/01/1992
A
''2/05/1941
M
Ol
N
60, 000.00
06/01/3992
A
12/2R/1951
M
03
N
100,000.00
09/01/2000
A
04/28/1971
M
03
N
so, 000.OG
04/01i1991
A
04/22/1954
M
03
N
150,000.00
01/01/1996
A
02/11/1970
M
03
N
100,000.O0
04/01/1992
A
12/OS/1956
M
03
N
00.000.00
O1/01/2001
A
02/22/1976
F
03
N
200.000.00
10/01/1995
A
06/15/1957
M
03
N
200. 0" .00
12/01/1997
A
O1/14/1961
F
03
N
901000.00
O1/01/1995
A
10/12/1955
F
03
N
50,000.DO
03/01/1995
A
07/14/1953
M
D3
N
1801000.00
02/01/2003
A
20/15/1980
M
03
N
50,000.00
04/01/1992
A
12/09/1951
F
03
N
100,000.00
04/01/1992
A
12/25/1947
M
03
N
150.000.00
04/011_996
A
C9/22/1944
M
03
N
100, 000.00
OS/011:992
A
12/31/1951
M
03
N
40.000.00
04/01/1992
A
12/09/1959
M
03
N
501000. OC
04/01/199i
A
04/29/1970
M
O3
N
100,000.O0
04/01/1992
A
12/15/1949
M
03
N
60, DOD DO
04/01/1992
A
11/20/1962
M
O3
T
100, 000.00
519
67,240,000.00
ADC90
Enrollee and Dependents
LLat
29/S13L/2003
Page 1J
Company
004
Anthem Life Insurance Ccmpany
Count',
01
United States
Coverage:
112
Voluntary Life Spouse
Croup OC6SI8-0099
CITY OF FORT COLLINS
Cart
No. pep Name
Effective
Status
Birthday
Sex
Relation
Terminated Class
E-type
Volume
04/01/1992
A
12/19/19se
M
03
N
300,00C.00
04/01/1992
A
06/21/1961
F
SPOUSE
01/01/1999
A
04/17/199i
P
03
N
10,000.00
O1101/1999
A
05/05/1936
M
SPOUSE
02/01/2003
A
08/20/,1973
_
03
N
300,030.00
02/01/2003
A
03/29/19a1
M
SPOUSE
0:/01/2003
A
05/26/1913
03
N
200,000.00
0:/01/2003
A
07/1C/1914
M
SPOUSE
O7/O1/2000
A
12/06/196.
M
O3
N
10,000.00
07/O2/2000
A
05/09/1964
F
SPOUSE
04/01/1992
A
12/21/19"
M
03
N
20C.000.00
• 04/01/1992
A
12/16/1965
F
SPOUSE
04/01/1992
A
12/24/1949
M
03
N
1501000.CO
04/01/1992
A
08/01/1955
F
SPOUSE
07/01/1996
A
05/05/1965
M
03
N
1901000.00
07/01/1996
A
05/14/1967
F
SPOUSE
10/01/1990
A
12/06/1944
M
03
N
100,0U0.U0
10/01/1996
A
06/02/1945
F
SPOUSE
04/O1/1992
A
12/11/19.1
P
O3
N
se,000.00
04/01/1992
A
05/09111916
M
SPOUSE
04/01/1992
A
12/15/1946
M
O3
N
30,000.00
04/01/1992
A
10/03/1947
P
SPOUSE
04/01/1992
A
12/15/1942
M
03
N
30,000.OU
04"01/1992
A
O1/15/1942
F
SPOUSE
04/01/1992
A
01/01/19E0
M
03
N
10.000.00
04/01/1992
A
04/22/1955
F
SPOUSE
04/01/1992
A
12/28/1950
M
03
N
10,000.00
04/01/1992
A
09/30/1949
F
SPOUSE
06/01/1998
A
10/03/1951
M
03
N
100,000.00
06/01/2998
A
09/25/1954
F
SPOUSE
06/01/1998
A
11/10/1958
M
03
N
130,000,00
06/01/1998
A
12/2a/1965
F
SPOUSE
04/01/2000
A
01/IR/1963
M
03
N
30,000.00
04/01/2000
A
O3/23/1962
F
SPOUSE
02/01/1999
R
22/06/1950
M
03
N
30,000,00
02/01/1999
A
02/21/1950
F
SPOUSE
01/01/20C2
A
03/23/1964
F
O3
T
i001 000.00
O1%O1120C2
A
OS/27/1959
M
SPOUSE
00!01/1990
A
05/27/1913
F
03
N
10,000.00
08/01/1998
A
02/22/1965
M
SPOUSE
00/01/2002
A
12/13/1959
F
03
N
200,000.00
OB/0112002
A
12/30/19S7
M
SPOUSE
04/01/1992
A
12/27/1955
M
03
N
50,000.00
04/01/1991
A
12/09/1952
F
SPOUSE
04/01/1992
A
12/27/1956
M
03
N
10,000.00
04/01/1992
A
07/24/1956
P
SPOUSE
ADC50 Enrollee and Dependent. List 29/nL/2003 Page 18
----------- ---------------
Company - 004 Anthem Life Insurance Company
country : 01 United States
Coverage: 112 voluntary Life - Spouse
Group : 006518-0099 CITY OF FORT COLLINS
Cart NO. Dep Name
Effective
Status
Birthday
Sex
Relation
Terminated Class
E-type
vo-ume
09/Cl/1993
A
12/18/1959
F
OS
N
50,000.00
09/01/,1993
A
02/11/1955
M
SPOUSE
04/01/1992
A
12/24/1952
F
03
T
50,000
00
04/01/1992
A
09/30/1950
M
SPOUSE
07/01/2003
A
D3/16/1574
F
01
N
100,000.00
07/01/2003
A
10/11/1969
M
SPOUSE
04/01/1992
A
12/29/1947
M
03
N
10,000.00
04/01/1992
A
11/2D/1954
F
SPOUSE
04/01/1992
A
12/08/1965
M
03
N
100,000.00
04/01/1992
A
05/14/1566
F
SPOUSE
04/DS/1997
A
12/30/1951
M
03
N
100, 00a.
Oc
04/01/1997
A
08/31/1951
F
SPOUSE
04/01/1992
A
12/20/1945
M
03
-
10,000.00
04/01/1992
A
08/15/1949
F
SPOUSE
04/01/1992
A
01/01/1980
M
03
N
10,000.00
04/01/1992
A
05/11/1944
F
SPOUSE
C6/01/1996
A
01/01/1980
F
01
N
10,000.00
CV01/1998
A
03/27/1955
M
SPOUSE
11/01/1994
A
07/05/1963
M
Ul
N
30,000.00
11/0_/1994
A
D7/28/1962
P
SPOUSE
10/01/1992
A
01/01/1980
P
03
N
20,000.00
10/01/1992
A
10/31/1941
M
SPOUSE
08/01/1992
A
12/15/1962
F
03
N
1DO, 000.
00
O8/01/1992
A
05/24/1961
M
SPOUSE
02/01/1994
A
12/06/1966
M
03
N
100,000.Do
02/01/1994
A
09/13/1969
F
SPOUSE
Oe/01/1994
A
12/13/1967
F
03
N
50,000.00
08/01/1994
A
05/22/1965
M.
SPOUSE
09/01/1999
A
07/29/1969
M
03
N
150,000.00
01/01/199♦
A
09/02/1971
P
SPOUSE
02/01/1996
A
12/23/1965
F
03
N
10,00D.00
02/01/1996
A
05/29/1963
M
SPOUSE
04/01/1992
A
12/10/1966
M
03
N
100,000,00
04/01/1992
A
04/17/1967
P
SPOUSE
01/DI/1995
A
04/04/1957
M
03
N
110,000.00
01/01/1995
A
04/06/1960
F
SPOUSE
05/O1/1992
A
12/31/1960
M
03
N
10a, 000.00
05/01/1992
A
10/23/1962
F
SPOUSE
01/01/1998
A
O1/01/1980
M
03
T
50.000.00
01/01/1998
A
07/31/1959
F
SPOUSE
11/01/199,
A
01/01/19BO
F
03
N
100,000.00
11/01/1994
A
08/07/1952
M
SPOUSE
12/01/1999
A
04/25/1969
M
03
N
1001000.00
12/01/1999
A
09/0B/1979
F
SPOUSE
01/01/1994
A
07/23/1961
F
03
N
100,000.
00
01/01/1994
A
05/31/1960
M
SPOUSE
DC'-0 Enrollee and Dependent. L19t 29/JUL/2003 Pe9e 19
____ .
Company 004 Anthem Life loauranne Company
COuntry 01 United Staten
Coverage: 112 Voluntary Life - Spou9e
Group - 006516-0099 CITY OF FORT COLLINS
Cert N., Dep Name
Effective
StaLua
Birthday
Sex
Ael at ion
Terminated Claae
E-type
Volume
06/01/1994
A
01/18/1955
M
03
N
SD,600.2D
06/01/1994
A
OVISi I959
F
SPOUSE
06/01/2002
A
02/25/1976
M
03
N
100,000.0o
06/01/2002
A
05/12/1978
F
SPOUSE
D4/0111994
A
03/06/1952
M
03
N
50,000.00
04/01/1994
A
01/11/1949
P
.SPOUSE
07/01/1999
A
OU/07/1961
M
03
N
100,000.00
01/01/1999
A
06/27/1962
F
SPOUSE
04/01/1992
A
12/26/1355
F
03
N
100,900.00
04/01/1992
A
04/29/19.8
M
SPOUSE
09/01/2001
A
05128,1963
F
03
N
100,000.00
09/01/2001
A
01/24/1963
M
SPOUSE
04/0-/1992
A
12/O7/1957
M
O3
N
150,000.DO
04/01/1992
A
04/O7119GO
F
SPOUSE
04/01/1992
A
12/04/1946
M
C3
N
30.000.00
04/01/1992
A
11/30/1941
F
SPOUSE
10/01/199a.
A
12/29/1964
F
03
N
100,000.00
1 D/O1/1998
A
12/19/1958
M
SPOUSE
01/01/199.
A
O1/01/1980
M
03
N
100,000.00
01/01/1994
A
09/21/1959
F
SPOUSE
04/01/1992
A
12/11/1947
F
03
N
100,00D.00
04/O1/1992
A
O7/10/1947
M
SPOUSE
O1/0111997
A
01/31/1941
F
03
T
101000.DO
03/01/1997
A
08/25/1946
M
SPOUSE
O7/01/1995
A
O1/01/1960
F
03
N
1D0,000.00
07/01/1995
A
11/16/1963
M
SPOUSE
03/01/1999
A
01/26/1965
F
03
N
100,000.00
03/01/1999
A
11/23/1967
M
SPOUSE
06/OS/1999
A
11/16/1955
F
03
V
30,00D.OD
08/01/1998
A
04/24/1957
M
SPOUSE
05/01/2002
A
03/29/1965
M
el
N
100, 000.D0
05/01/2001
A
04/07/1965
P
SPOUSE
04/O1/1992
A
12/08/1954
M
01
N
10,000.00
04/01/1992
A
08/04/1958
F
SPOUSE
03!01/2002
A
04/21/1310
F
C3
T
100,000.00
03/D1/2002
A
03/:3/1969
N
SPOUSE
05/01/1991
A
C6,28/1963
N.
03
N
20,000.00
05/01/199,
A
57/18/1969
F
SPOUSE
04/O1/1992
A
12/24/1957
M
Oi
N
10,00"0
04/01/1992
A
05!12/1950
F
SPOUSE
OS/01/2002
A
O8/03/1946
F
03
N
80,000.00
05/01/2002
A
11/13/1948
M
SPOUSE
03/01/199S
A
07/06119SI
M
03
T
10,000.00
O3/01/1995
A
09/17/1959
F
SPOUSE
08/01/1992
A
12/14/1951
M
33
N
300,000.00
08/01/1992
A
11/25/1950
SPOUSE
MC50 Enrollee and Dependents List 29/J /2003 Page 20
-------------------------------------------------------
Company , 004 Anthem Life Insurance Company
Country : 01 United States
Coverage: 112 Voluntary Life - Spouse
Group 0965i8 0099 CITY OF FORT COLLINS
Cert No, Uep Name
Effective
Status
Birthday
Sex
Relation
Termrcated Class
E-type
'Jolume
02/01/1993
A
12/25/1952
F
03
N
50,000.00
02/01/1993
A
11/19/1951
N
SPOUSE
02/01/1993
A
06/14/1949
N
03
N
50.000,00
02/01/1993
A
OS/14/1949
F
SPOUSE
06/01/1992
A
12/15/1953
N
03
N
200,000.00
06/01/1992
A
12/19/195.
F
SPOUSE
01/01/1996
A
01/01/1980
M
03
N
10,000.00
01/01/1996
A
02/16/1949
F
SPOUSE
09/01/2001
A
09/07/1973
N
03
N
50,000.00
09/01/2001
A
01/25/1976
F
SPOUSE
03/01/1997
A
06/19/19S2
- M
03
N
100,000.00
03/01/1997
A
08/22/1956
F
SPOUSE
0410111992
A
12/07/1947
M
03
N
50,000.00
04/01/1992
A
11/20/1950
F
SPOUSE
02/01/1998
A
12/24/1961
N
03
N
100,000.00
02/Cl/1999
A
95/16/196C
F
SPOUSE
01/01/1995
A
12/29/1949
N
03
N
80,000.00
O1/O1/199S
A
10/10/1951
F
SPOUSE
10/02/1999
A
08/29/196]
F
03
N
150,000.00
03/01/1997
A
05/16/1953
N
03
T
100,000.00
03/01/1997
A
03/04/1951
F
SPOUSE
04/21/1993
A
03/20/1958
F
C3
N
300,000.00
04/01/2993
A
09/01/1958
N
SPOUSE
06/01/1997
A
12/11/1965
N
03
N
150,000.00
06/02/1997
A
12/19/1966
F
SPOUSE
04/02/1992
A
12/OS/1951
N
03
N
100,0J0.00
04/01/1992
A
10/29/1959
a
SPOUSE
01/01/1994
A
09/12/1959
N
03
N
150,050.00
01/01/1994
A
i1/04/1960
F
SPOUSE
04/01/1992
A
12/25/1956
M
C3
N
20,000.00
04/01/1992
A
05/24/1957
F
SPOUSE
04/01/2002
A
11/19/1960
N
C3
N
300,000.00
04/0:/2002
A
11/13i3961
F
SPOUSE
04/0:/lYY"/
A
U1/29/195`
N
C3
N
300,000.00
04/01!199,
A
04/05/1959
P
SPOUSE
08/01/1995
A
08/2U/l95Y
N
03
N
100, 000. 00
OB/01/1995
A
09/07/1962
F
SPOUSE
07/01/2003
A
02/2511955
N
03
N
50,000.00
07/01/2003
A
08/05/1955
F
SPOUSE
OS/01/2003
A
08/02/1956
F
03
N
100,000.00
OS/O1/2003
A
08/05/1954
N
SPOUSE
11/01/1993
A
12/13/1965
N
01
N
30.000.00
11/01/1993
A
04/12/1966
F
SPOUSE
04/01/1992
A
12/16/1946
N
03
N
7U,000.00
04/01/1992
A
10/04/1949
F
SPOUSE
aocs0 Enrollee and Dependents List
Company 00a Anthem Life insurance Company
Countzy 01 united States
Coverage: 112 voluntary Life Spouse
GT.o , - 006518-0099 CITY OF FORT COLLINS
29/.IUL/2003
C,: NO. Den Name Effective Status Birthday
11/01/1998 A 12/12/1956
11/01,11998 A 12/09/.950
OS/01/1990 A 12/10/19SS
05/01/,1990 A 11/19/:954
04/01/22003 A 01110/197e
04/01/2003 A 11/23/1974
12/01/2000 A 07/06/1968
12/01/2000 A 08/24/1970
06/01/2001 A 12/01/1961
06/O1/2001 A 02/07/1964
05/01/1992 A 12/25/1958
' OS/C1/1992 A 01/12/1962
O6/C1/1993 A 12/01/1954
06/Cl/1993 A D4/02/1956
04/01/1992 A 12/29/1954
04/01/1992 A 0812911944
06/01/1992 A 12/20/1960
06/01/1992 A 07/25/1947
04/01/1992 A 12/24/1959
- 04/01/1992 A 01/25/1968
04/01/1992 A 01/01/1980
04/01/1992 A 09/29/195a
01/01/2003 A 09/20/1995
04/01/1992 A 04/24/1952
02/01/1999 A 06/04/1993
02/01/1999 A 12/31/1953
04/01/1992 A O1/C1/1980
04/01/1992 A U3/15/1947
06/01/1999 A 07/23/1954
06/01/1999 A 03/06/1948
':1/01/1993 A 12/,15/1919
D4/O1,/1992 A 12i06/1919
04/01/1592 A 12/D5/1954
C4/01/1992 A 06/2C/1951
C1/01/1994 A 01/01/1980
01/01/1994 A 11/16/1951
04/01/1992 A 12/07/1961
04/O1/1992 A 10/25/1965
04/O1/1992 A 12/04/1954
04/01/1992 A 07/07/1955
04/01!1992 A 12/10/1963
01/01/1992 A 06/31/1963
04/01/1998 A 01/10/1945
04/01/1998 A 09/10/1951
04/Oij1992 A 01/01/1980
04/01!1992 A 02/i9/1959
Relation
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
Page 21
r,minatod Class
E-type
03
N
03
N
03
N
03
N
03
N
03
N
03
T
03
N
03
e
03
Y
03
T
03
N
03
N
03
T
03
N
03
T
03
N
03
N
03
N
03
N
03
N
03
N
03
T
Volume
IO,000 *e
130.000 OD
300.000.00
100, 000.0D
250, 000.00
180. 000. 00
30. 000, 00
60,000, 00
100,000.00
1501000. 00
90,000.00
200,000.00
so, 000.00
10, 00c .00
30D,"c 00
10.000.us
10,000.05
90,000.C2
Bo.D00.Dc
50,000.00
100,000.00
40, 000 00
60.000.00
City of Fort Collins
Administrative Services
Purchasing Division
CITY OF FORT COLLINS
ADDENDUM No. 4
SPECIFICATIONS AND CONTRACT DOCUMENTS
Description of Bid P902 Benefits
OPENING DATE: 2:00 PM (Our Clock) August 29, 2003
To all prospective bidders under the specifications and contract documents described above, the
following changes are hereby made.
QUESTION: Can the Long Term Disability Claims Summary be shown by gender?
ANSWER: See Attached
RECEIPT OF THIS ADDENDUM MUST BE ACKNOWLEDGED BY A WRITTEN STATEMENT
ENCLOSED WITH THE BID/QUOTE STATING THAT THIS ADDENDUM HAS BEEN RECEIVED.
215 North Mason Street • 2nd Floor • P.O. Box 580 • Fort Collins, CO 80522-0580 • (970) 221-6775 • FAX (970) 221-6707
ADr50
Croup
Enrollee and Dependents
List
29/SUL/2003
--------
page 22
Company 004 Anthem Life :Oaurance Company
Z.oOt,y 01 United Staff.
..cvr ra ge: 112 Voluntary L.Cc Spouse
OC6518-0099 CITY OF FORT COLLINS
Cart No. Oep Name
Effective
Status
Birthday
Be.
Relation
Terminated Class
E-type
Volume
02/01/1996
A
05/06/1960
M
03
.1
10C,000.00
02/01/199.
A
01/17/1567
F
SPOUSE
09/01/1993
A
12/03/1964
M
03
N
20C,000.00
09/01/1993
A
04/24/1965
P
SPOUSE
02/01/1993
A
12/19/1948
M
C3
N
150,000.no
02/01/1993
A
06/19/1953
P
SPOUSE
12/01/2002
A
02/24/1970
M
03
N
250,000.00
12/01/2002
A
07/21/1971
F
SPOUSE
03/01/1997
A
07/31/1970
M
03
N
10. 000.00
03/01/1597
A
02,12011972
F
SPOUSE
04/01/1992
A
09/02/1955 -
M
03
N
70,000,00
' OVOI11992
A
04/23/1958
F
SPOUSE
02/01/1998
A
10/20/1969
M
01
N
L50.000.00
02/01/1998
A
1_/11/1969
F
SPOUSE
04/01/1992
A
1'_/11/1965
F
03
N
L0,000.on
04/01/1992
A
li/11/1965
F
SPOUSE
02/01/1996
A
00/16/1961
H
03
N
2CO3 000.00
02/01/1996
A
11/30!1963
F
SPOUSE
03/01/1993
A
12/13/1961
M
03
N
100,000.00
-
03/01/1993
A
05/26/1965
F
SPOUSE
04/01/1992
A
12/21/1947
M
03
N
10,00C.00
04/01/1992
A
00/06/1949
F
SPOUSE
01/01/1992
A
04/25/1946
M
03
N
109,00C .00
04/31/199i
A
06/25/1953
F
SPOUSE
10/01/2002
A
12/10/195'1
F
33
T
$0,00010.
10/011,2002
A
10/23/1957
M
SPOUSE
C3/01/1999
A
Ul/24/1968
M
23
N
300,000 00
03/01/1999
A
.1/20/1911
F
SPOUSE
-
04/01/1999
A
02/08/1950
F
O3
N
10,000.00
04/O1/1996
A
07/10/1945
M
SPOUSE
02/01/1993
A
12130/1953
M
03
T
63,000,00
02/C1/1993
A
05/06/1959
F
SPOUSE
04/01/1992
A
12/08/1951
M
03
T
LOO.000.00
04!O1/399i
A
11/21/1954
P
SPOUSE
04/01/1992
A
l2/05i1951
M
03
Y
20D.000 00
04/01/1992
A
12/16/1957
P
SPOUSE
01/01/1597
A
11/06/1961
P
03
N
25D,000 03
01/01/1997
A
09/14/1961
M
SPOUSE
O1/OL/1995
T
07/11/1950
M
03
T
Sc,C00 00
O1/O1/1995
A
00/31/1953
F
SPOUSE
12/01/]000
A
04/U2/1961
M
C3
N
10,000.00
12/01/2000
A
06/23/1969
F
SPOUSE
11/01/2001
A
10/19/1972
M
C3
N
300, C 00.00
11/01/2D01
A
05/14/1974
t'
SPOUSE
04/01/1999
A
09/14/1969
M
03
N
250,000,00
04/01/1999
n
04/C8/1959
F
SPOUSE
ADC50 Enrollee and Dependents List 29/UUL/2003
..... ----------------------------- ------.----
Company : 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 112 Voluntary Life - Spouse
Group O0651B-0099 CITY OF FORT COLLINS
Cart No. Dep Name Effective Status Birthday Sex Relation
04/01/1992 A 03/15/1951 M
04/01/1992 A 10/26/1958 F SPOUSE
05/01/1999 A 11/17/1950 F
05/01/1999 A O1118/1950 M SPOUSE
02/01/1999 A 12/20/1967 F
02/01/1999 A 12/03/1967 M SPOUSE
D2/01/1993 A 12/02/1944 M
02/01/1993 A 12/01/1945 F SPOUSE
04/01/1992 A 12/05/1954 M
04/01/1952 A 10/31/1956 F .SPOUSE
02/01/1994 A 08/1D/1940 M
02/01/1994 A 02/27/1946 F SPOUSE
D6/01/1992 A 12/02/1958 M
06/01/1992 A 05/08/2964 F SPOUSE
09/01/2003 A 04/21/1965 M
09/01/2003 A 02/02/1966 F SPOUSE
04/01/1992 A 12/17/1963 M
04/01/1992 A 04/26/1965 F SPOUSE
04/01/1999 A 04/28/1970 M
04/01JI999 A 07/22/1977 F SPOUSE
02/01/1999 A 01/01/1980 M
02/01/1999 A D6/25/1956 F SPOUSE
04/01/1992 A 12/02/1949 M
04/01/1992 A OS/20/1950 F SPOUSE
04/01/1992 A O1/21/1953 M
04/01/1992 A 09/24/1952 F SPOUSE
05/01/2003 A 02/08/1962 F
05/01/2003 A 06/21/1960 M SPOUSE
O6/01/2002 A 30/OS/1962 F
06/01i2002 A 09/29/1960 M SPOUSE
09/01/1993 A 09/08/1964 F
09/01/1993 A 04/06/1965 M SPOUSE
08/01/2000 A 07/23/1960 F
08/01/2000 A 10/20/1959 M SPOUSE
D5/01/1999 A 06/26/1967 M
D5/01/1999 A 04/05/1568 F SPOUSE
04/01/1992 A 12/22/1946 M
04/01/1992 A 08/15/1949 F SPOUSE
06/01/1992 A 09/06/1956 M
06/01/1992 A 03/06/1956 F SPOUSE
12/01/2002 A O1/09/1966 F
12/01/2002 A O6/26/1964 M SPOUSE
06/01/2003 A 09/11/1977 F
06/01/2002 A 04/04/1977 M SPOUSE
04/01/2000 A 05/09/1956 M
04/01/2000 A 06/04/1961 F SPOUSE
Page 23
Terminated Class
E-type
Volume
03
N
50,000.00
03
T
SO, 000.30
03
N
300,000.00
03
N
100,000,00
03
N
100,000.00
03
N
_20.000.Oc
03
N
10,000.00
03
N
300,000,00
03
N
150,000.00
03
N
100,000.00
03
N
2DO,000.00
03
N
80, 000.00
03
N
5C,000-00
03
N
250,000.00
03
T
10,000.00
03
N
150,000'00
03
N
150,CDO.00
03
N
100,000.O0
03
N
50,000.00
03
N
200,000,30
03
N
50,000.00
03
T
$0,000 00
03
N
250,080.00
A0050
Enrollee and Dependents
___ _------- ______
List
--- _
29/aUL/2003
-.._------
Page 24
---- _--- ..
Company 004
Anthem Life Insu [ante Company
Country 91
United States
Coverage: 112
voluntary Life Spouse
006518 0099
CITY CF FORT COLLINS
Cart
No. Uep Name
Effective
SCaLun
Birthday
Sex
Relation
Terminated Class
E-type
Volume
04/D1/1992
A
12/05/_941
M
03
N
10,000,00
C4/01/1992
A
01/09/,942
F
SPOUSE
04/01/1992
P.
12/03/1957
M
03
N
30.000.00
04/01/1992
A
02/06/L957
F
SPOUSE
O8/01,/1999
A
09/17/1965
M
03
N
200.000.00
06/01/1999
A
O1/1811960
F
SPOUSE
O1/01/1994
A
12/29/1963
F
03
N
150.000.00
O1/D1/1994
A
06/26/1963
M
SPOUSE
0110111996
A
12/25/1969
F
03
T
100,000. 00
01/01/1996
A
S2/11/1969
M
SPOUSE
03/01/1999
A
OS/19/1959
M
D3
N
50,000.00
'
03/01/1999
A
06/29/1963
F
SPOUSE
O6101/1992
A
!]/21/1952
F
93
N
200,000.00
06/01/1992
A
02/06/1956
M
SPOUSE
11/01/1999
A
08/18/1971
M
03
N
3D0,000.00
11/01/1999
A
D7/30/1973
F
SPOUSE
04/01/1997
A
D3/11/1958
M
O3
N
300,OOC.00
04/0111991
A
32/12/1959
F
SPOUSE
02/01/1993
A
_2/12/1958
M
03
N
160,000.00
02/01/1993
A
36/26/1960
F
SPOUSE
O1/O1/1001
A
10/13/1959
F
03
U
30,000.00
O1/01/2001
n
37/14/1961
M
SPOUSE
03/01/2000
A
09/23/197D
M
03
N
100,000.00
03/01/2000
A
09/09/1975
F
SPOUSE
D4/01/1992
A
12/25/1953
M
03
N
100,000.00
D4/01/1992
A
04;16/1956
F
SPOUSE
04/01/1992
A
12/05/1955
M
03
N
100.000 00
04/U1/1992
A
05/31/1953
F
SPOUSE
-
04/01/1992
A
O1/01/1980
F
03
N
20,000.00
04/01/1992
A
11/09/1951
M
SPOUSE
04/01/1992
A
05/12/1963
F
03
N
100,000.00
04/01/1992
A
04/20/1951
M
SPOUSE
09/01/1994
A
02/03/1950
M
03
N
200,000.CC
09/01/1994
A
02/09/1966
F
SPOUSE
06/01/2002
A
03/O6/1908
N
03
N
1C01000.00
06/01/2002
A
04/12/1980
F
SPOUSE
10/01/1995
A
12/12/1957
F
03
N
150,D00.00
10/01/2995
A
05/20/1959
M
SPOUSE
04/01/1992
A
12/D9/1961
F
03
N
20,O00.nn
04/O1/1992
A
11/01/1958
M
SPOUSE
04/01/;992
A
12/19/1959
F
03
N
8C.000.00
04/01/:992
A
00/17/1957
M
SPOUSE
11/01/2000
A
O5/21/1971
F
03
N
200,OD0.00
11/01/2000
A
09/14/1974
M
SPOUSE
02/01/1997
A
C2/15/1954
M
03
N
123,000.00
02/01/1997
A
04/03/1957
F
SPOUSE
ADC50 Enrollee and Dependents List 29/dUL/2003
Company 004 Anthem Life Insurance CoMany
..Sono rY 01 Un ted States
Covera(]e: 112 Voluntary Life - Spouse.
Group - 006510-0099 CITY OF FORT COLLINS
Cart No. Dep Name Effective Status Birthday sex Relation
04/01/1992 A 12/20/1942 N
24/01/1992 A 01/19/1943 F SPOUSE
021D1/I993 A 12/07/1959 N
02/01/1993 A 10/25/1939 F SPOUSE
04/01/1992 A 12/31/1956 M
04/01/1992 A 04/02/1962 P SPOUSE
D4/01/1992 A 12/20/1953 N
04/01/1992 A 101,06/1941 F SPOUSE
02/01/1990 A 03/09/1956 F
02/01/2958 A 02/22/1552 N SPOUSE
04/01/1992 A 12/13/1955 N
04/01/1992 A 06/15/1957 F SPOUSE
09/01/2001 A 03/07/1568 N
09/01/2001 A 09/20/1959 F SPOUSE
O1101/1995 A 02/26/1961 N
O1/01/1995 A 04/02/1964 F SPOUSE
04/01/1992 A 12/23/7946 N
94/01/1992 A 09/25/1946 F SPOUSE
O3/01/1994 A 04/29/1963 M
03/02/1994 A 04/29/1963 F SPOUSE.
02/01/1996 A 09/10/1969 M
02/01/1996 A 12/09/1966 F SPOUSE
04/01/1996 A O3/29/1955 F
04/01/1996 A 09/17/1947 N SPOUSE
04/01/1995 h 07/23/1947 M
04/01/1995 A 10/04/1949 F SPOUSE
04/01/1992 A 12/10/1953 N
04/01/1992 A 11/04/1953 F SPOUSE
04/01/2002 A 05/09/1950 N
04/01/2002 A 09/16/1958 F SPOUSE
02/01/1994 A 12/28/196S N
02/01/1994 A 02/04/1964 F SPOUSE
10/01/1996 A 04/20/1959 F
10/01/-.96 A 04/70/1959 N SPOUSE
01/01/1990 A 12/19/1959 N
0l/41i1996 A 09/04/1964 F SPOUSE
04/01/1996 w C6/24/1945 N
04/01/L996 A 17/301194. F SPOUSE
04i01/1992 A 12/29/1955 M
04/01/1992 A 01/21/1956 F SPOUSE
04/01/1992 A 12/2l/1956 F
04/D1/1992 A O7/07/1956 M SPOUSE
ll/D1/1995 A 10/00/1970 N
11/01/1995 A 09/06/L972 F SPOUSE
02/01/2003 A 06/1]/196'1 N
02/D1/2003 A 10/26/196s P SPOUSE
Peg. 25
Terminated Class
E-type
Volume
01
N
20,000.00
03
N
30,000 00
03
N
50,000 00
C3
N
5.1000,00
03
N
350,000.00
03
N
100,000 .00
03
N
300,000.Go
03
N
100,000.00
O3
N
10,000.00
03
N
so, coo .00
03
N
100,000.00
03
N
501000.00
03
N
SO,OCO.00
03
T
60,000.00
03
N
1C, 000.00
03
N
80,000 00
03
N
10,000.OD
03
N
80.000.00
03
N
5D,000.00
C3
N
50,000.CO
03
T
10.000,00
03
N
30.000.00
03
N
300,000.00
ADC`.0 Enrollee and Dependents List 29/.NL/2003
------------------------
Ccmpany : 004 Anthem Life insurance Company
Country 01 United States
Coverage. 112 Voluntary L-_fe - Spouse
Croup 006519 0099 CITY OF FORT COLLINS
Ce [[ N. Dal+ Name Effective sta:ue Birthday Sex Relation
04/01/1992 A 12/09/1954 M
04/O1/1992 A 02!10/1953 F SPOUSE
04/01/1992 A L2/29/1945 M
041O1/1992 A O1/22/1947 F SPOUSE
01/01/1993 A 10/04/1949 M
01/O1/1999 A 03/16/196, F SPOUSE
11/01/2001 A O7/11/1953 F
11/01/2001 A 11/26/1954 M SPOUSE
06/01/1992 A 12119/1966 M
C610111992 A 05/16/1967 F SPOUSE
09/01/,1999 A 12/09/1958 F
09101/19:9 A 07/17/1949 M SPOUSE
04/01/192 A 12/26/1951 M
04/01/1992 A 09/26/1951 F SPOUSE
O1/01/1999 A 01/01/1960 M
O1/01/1999 A 07/09/1965 F SPOUSE
04/0111992 A 12/08/1952 F
04/01/1992 A 01!26/1955 M SPOUSE
O1101/2001 A 13/21/1969 F
O1101/2003 A 07/23/1963 M SPOUSE
04/01/1932 A 12/19/1950 M
04/01/1992 A 0411311951 7 SPOUSE
11/01/1,96 .4 09!06/1970 M
11/01/1996 A 02/26i1371 SPOUSE
04/01/1992 A 12/11/1959 M
04/0l/199z A 03/02/1963 F SPOUSE
04/01/1992 A O5/2011945 N.
04/01/1992 A 03/16/1950 F SPOUSE
O2/01/1994 A 06/11/155, F
01/01/1994 A 04/23/1149 M SPOUSE
02/01/1993 A 12/06/1959 M
02/01/1993 A 12/01/1960 F SPOUSE
04/01/1992 A 12/18/1952 M
04/01/1992 A 10/14/1948 F SPOUSE
04/01/1993 1 12/31/1964 M
04/01/1992 A-_0/02/1964 P SPOUSE
02/0:/1996 A 09/13/1949 M
02101/1996 A 32/36/1953 F SPOUSE
Od/01/1992 A 12/20/1952 M
OB/C1/1392 A 11/22/1960 F SPOUSE
04/01/1992 A 12/02/3950 M
C4/01/1992 A 10/04/1951 F SPOUSE
04/01/1992 A 12/11/1962 M
04/01/1992 A 12/29/1959 P SPOUSE
04/01/1992 A 12/19/1947 M
04/01/1992 A 07/19/1950 P SPOUSE
Page 26
Terminated Claas
E-type
03
N
03
N
O3
N
03
N
03
N
03
N
03
N
03
N
03
r
03
N
O3
N
03
N
03
N
03
N
01
N
03
N
03
N
03
N
03
N
03
T
03
N
O3
N
03
T
Volume
150, 000.00
10,OVU.UU
100,000.00
10, oon .0c
so, coo.0c
90, 000 .00
100, 000.00
50,000 00
10,000.00
100,000 00
3J,OOo 00
2 SC, ono.00
la,nco.co
so, 000.00
'_O, C30 00
150,000, 00
so, 000.co
200,000.OD
40, OOC.00
: oo,0on.00
101000.00
100,000.00
30,O00.to
ADC50 Enrollee and Dependents List 29/UUL12003 Page 20
...__ ------------ _________________
Company : 004 Anthem Life Insurance Company
Country : Cl United Stater
Coverage: 112 Voluntary Life - Spouse
l:rnnp 006518-0191 CITY OF FORT COLLINS
Cert NO, Oep Name
Effective
Statue
S,r1hda1
Sex
Relation
Tetminated Class
E-type
Vol.ne.
D1i01/1994
A
12/0411955
F
03
N
100,000.00
01/01/1994
A
11/22/1955
M
SFUUSE
06/01/1594
A
03/20/1949
M
03
N
50,OOD.CO
D2/01/1994
A
01/17/1956
F
SPOUSE
07/01/1992
A
12/27/1947
F
03
T
30,000.00
07/01/1992
A
CV! 2/1945
M
SPOUSE
05/01/2003
A
05/08/1968
M
03
N
120.000,00
05/01/2003
A
04/23/1969
F
SPOUSE
O'1/01/2002
A
10/29/1964
M
03
N
100.000.OD
O7/01/2002
A
DS/03/1967
F
SPOUSE
01/01/1998
A
04/04/1954
M
03
N
50,000.00
01/01/1998
A
11/16/1959
F
SPOUSE
04/01/1992
A
12/26/1953
M
03
T
50,000.00
04/01/1992
A
09/11/1949
F
SPOUSE
O1/01/1996
A
04/15/1949
F
03
N
30,000.00
01/01/1996
A
01/06/1949
M
SPOUSE
04/01/1992
A
12/03/1954
M
03
N
150,000
a
04/01/1992
A
08/O8/1967
P
SPOUSE
02/01/1997
A
03/04/1948
M
O3
T
10, 000.Ot
02/01/1997
A
04/03/194B
P
SPOUSE
C4/01/1992
A
12/23/1959
M
03
N
60, 000.00
04/01/1992
A
07/13/1956
F
SPOUSE
C1/01/2001
A
06/09/1959
F
03
N
30,000.00
01/01/2001
A
04/15/1955
M
SPOUSE
01/01/199B
A
10/05/1968
F
03
N
20C,000.00
O1/D1/1998
A
10/21/19'12
M
SPOUSE
04/01/1992
A
12/05/1957
F
03
N
100,000,00
04101/1992
A
03/07/1954
M
SPOUSE
01/01/1592
A
_2/05/1952
M
03
M
10,000,00
04/01/1992
A
04/05/1952
F
SPOUSE
04/01/1992
A
12/16/1960
M
O3
N
150.000.00
04/01/1992
A
02/03/1959
F
SPOUSE
02;01/1999
A
02/20/1967
M
03
N
100, 060.G0
02/01/1999
4
08/O8/1966
F
SPOUSE
10/01/1993
A
06/22/1951
M
03
N
150.000.00
10/01/1993
A
DS/16/1954
P
SPOUSE
08/01/20D2
A
10/23/1969
M
03
T
1501OO5.00
O6/0112002
A
06/27/1972
F
SPOUSE
02/01/2003
A
11/30/---967
F
o3
12
300,000.00
02/01/2003
A
34/06/1969
M.
SPOUSE
05/01/2002
A
10/14/1951
F
03
N
50,000.00
05/01/2002
A
1:/11/1939
M
SPOUSE
04/01/1992
A
12/1B/1968
M
03
N
04/01/1992
A
05/20/1967
F
SPOUSE
150,000.
00
04/01/1992
A
12/22/1964
M
03
N
300,000.00
04/01/1992
A
02/04/1961
F
SPOUSE
XC50 Enrollee and Dependent, Liet 29/JUL/2003 Page 28
-----------------------------
Company 004 Anthem Life :n,urance Company
Country 01 United Stdtee
Coverage: 112 voluntary Life - Spou,e
Group 00651E 0099 CITY OF FORT COLLINS
Cert No. Dep Name
Effective
Status Birthday
Sex
Relation
Terminated Class
E-type
Volume
05/01/1997
A
D4/26/1948
M
03
N
30,000.00
05/01/1997
A
10/23/1949
F
SPOUSE
04/01/1992
A
O1101/1990
M
03
N
40,000.00
04/01/1992
A
03/07/1953
F
SPOUSE
04/01/1992
A
01/01/1980
M
03
T
50,000.00
04/01/1992
A
06/09/1953
F
SPOUSE
04/01/1992
A
01/01/1980
M
03
T
50,000.00
04/O1/1992
A
07/20/1950
F
SPOUSE
01/01/1995
A
12/18/1952
M
03
N
150, 000.
00
01/01/1995
A
05/29/1953
F
SPOUSE
10/01/2002
A
00/12/1970
M
03
N
10/01/2002
A
06/19/1975
F
SPOUSE
100,000.00
04/01/1992
A
12/13/1954
M
03
N
I00,C00.00
04/01/1992
A
O1/12/1958
F
SPOUSE
05/01/,1999
A
O8/11/1959
F
03
T
100,000.00
05/01/1999
A
11/04/1964
M
SPOUSE
06/01/2003
A
O6125/1960
M
03
N
100,000.03
D6/01/2000
A
e6/0T/1961
F
SPOUSE
04/01/1992
A
12/20/1956
M
03
N
30,00C.00
,. D4/01/1992
A
03/06/1963
F
SPOUSE
04/01/1992
A
12/26/19SG
M
03
N
D4/01/1992
A
03/11/1958
F
SPOUSE
70.000.00
02/01/1993
A
12/26/1950
M
03
N
02/01/1993
A
O1/18/1951
F
SPOUSE
50,000.00
D1/01/1994
A
01/01/1980
F
03
T
10,000.00
01/01/1994
A
08/28/194,
M
SPOUSE
04/O1/1992
A
12/09/1964
M
C3
N
100,000.00
04/01/1992
A
06/14/1959
F
SPOUSE
O8/01/2001
A
06/06/1970
M
C3
N
06/01/2001
A
01/29/1976
F
SPOUSE
300,000,00
04/01/1992
A
12/27/1961
F
C3
04/01/1992
A
01/09/1960
M
SPOUSE
N
160,000.Ca
OS/01/1992
A
05/19/1950
M
03
N
05/01/1991
A
11/15/1954
F
SPOUSE
100,000.00
01/01/2001
A
O8/03/1975
F
03
N
05/01/1997
A
03/26/1957
F
20D,000.00
05/0111991
A
O1/22/1954
M
SPOUSE
03
N
100,000.00
O1/01/2000
A
O8/21/1959
F
03
N
01/0I/2000
A
11/17/1956
M
SPOUSE
40,000.50
02/01/1993
A
12/29/1955
M
D3
N
02/01i1993
A
10/11/1955
F
SPOUSE
200,000.00
10/01/1999
A
04/21/1970
M
03
T
01/01/1994
A
06/08/1964
M
300,000.00
01/01/1994
A
O1/08/1960
F
SPOUSE
03
N
50,000
00
01/01/1999
A
05/21/1967
M
03
N
01/01/1999
A
12/26/1958
F
SPOUSE
1D0,000-00
A0050 Enrollee and Oependent9 Liet 291JUL/2003 Page 2)
------ ----- --------- ----------- ----------- -.__--____
company _ 004 Anthem Life Insurance COmpacv
country , 01 United 9cacee
Coverage: 112 voluntary Life - Spouse
Group . 006518-OC99 CITY OF FORT COLLINS
Cert NO. Oep Name
Effective
Status
Birthday
Sex
Relation
Terminated Class
E-type
Volume
05/01/1992
A
12/21/1955
F
03
N
e0,000.Ot
05/01/1992
A
09/16/1961
M
SPOUSE
05/01/2COO
A
04/26/1965
M
O3
N
_00,000.O0
05/01/2000
A
05/31/1971
F
SPOUSE
03/01/2002
A
O2/11/1960
M
03
N
100,000.00
03/01/2002.
A
10/25/1956
F
SPOUSE
11/01/1995
n
12107/1952
F
03
T
70,000,00
11/01/1995
A
10/13/1940
M
SPOUSE
O1/01/1999
A
O8114/1544
M
01
N
10,
00C.00
01/01,1999
A
02/2T/"SO
F
SPOUSE
08/01/1998
A
12/07/1955
M
03
N
30,000.00
O8/01/1998
A
12/25/1969
F
SPOUSE
05/01/,1998
A
12/23/1960
M
03
N
100,000.00
O5/01/1,98
A
06/25/1956
F
SPOUSE
04/01/1993
A
12/08/1954
F
n3
N
100,000.00
04/01/1993
A
11/14/1946
M
SPOUSE
06/D1/1992
A
12/29/1969
M
01
T
300.000.00
06/D1/1992
A
1./07/1963
F
SPOUSE
04/01/1992
A
12/23/1953
M
03
N
10,000.00
04/01/1992
A
C6/15/1951
F
SPOUSE
01/01/1992
A
12/28/1951
M
03
N
100,000
00
04/01/1992
A
07/06/1951
F
SPOUSE
03/01/2001
A
04/22/1954
M
03
N
15U1
000.00
03/01/2001
A
10/22/1959
F
SPOUSE
01/O1/2001
A
02/17/1910
M
03
N
90.000.00
01/011,2001
A
06/14/1913
F
SPOUSE
04/01/1992
A
12/08/1956
M
03
N
50.000.00
O4/O1/1992
A
02/13/1956
F
SPOUSE
01/C1i1998
A
10/12/1955
F
03
N
SO,
00C.00
02/01/1996
A
11/20/1946
M
SPOUSE
O1/01/1995
A
)?/14/1953
M
03
N
ISO,
000.00
01/01/1995
A
12/05/1955
F
SPOUSE
04/01/1992
A
12/2S/1941
M
03
N
i50,000.00
04/01/1992
A
O1/15/1956
F
SPOUSE
04/01/1992
A
12/31/1951
M
03
N
40,000.00
04/01/1992
A
11/03/1954
F
SPOUSE
04/01/1992
A
12/15/1949
M
O3
N
SO,C00.00
04/O1/1992
A
07/20/1951
F
SPOUSE
04/91/1992
A
12/20/1962
M
03
T
501000.00
04/91/1992
A
O6/20/1962
F
SPOUSE
297
za,soD,ocD.Do
ADC50 Enrollee and Dependents List 29/d UL/2003
____________________________---------__
Company 004 Anthem Life Insurance Company
Country 01 Unitad States
Coverage: 113 Voluntary Life - child
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name Effective Status Birthday Sex Relation
10/01/1993 A 12/19/1956 M
03/01/1997 A 02/14/1959 M
02/01/2003 A 08/20/1973 F
10/01/1993 A 12/06/1952 M
10/01/1993 A 12/24/1949 M
10/01/1993 A 12/03/1957 F
10/01/1993 A 12/11/1941 F
01/01/1995 A 04/11/1966 M
04/01/1994 A 02/24/1951 M
10/01/1993 A 12/28/1950 M
O6/01/1998 A 10/03/1951 M
10/01/1993 A 11/23/1959 M
10/01/1991 A 12/29/1954 M
10/01/1993 A 12/06/1950 M
O1/0111994 A 07/15/1960 M
04/01/2000 A 04/08/1966 M
10/01/1993 A 03/23/1964 F
08/01/1998 A 05/27/1973 F
10/01/1993 A 12/27/1956 M
10/01/1993 A 12/24/1952 F
30/01/1993 A 12/16/1961 M
10/01/1993 A 12/20/1945 M
10/01/1993 A 12/13/1958 M
11/01/1994 A 07/05/1963 M
01/01/1994 A 12/06/1966 M
10/01/1993 A 12/08/1962 M
05/01/2002 A 12/13/1967 F
12/01/1998 A 07/29/1969 M
02/01/1996 A 04/04/1957 M
02/01/1994 A 12/3I/1960 M
11/01/1994 A 01/01/1980 F
O1/01/1994 A 07/23/1961 F
05/01/1994 A 07/18/1955 M
04/01/1996 A 12/03/1948 M
04/01/1994 A 03/06/1952 M
10/01/1993 A 12/12/1947 F
03/01/2002 A 04/02/1961 F
10/01/1993 A 12/07/1952 M
10/01/1993 A 12/04/1946 M
10/01/1993 A 12/17/1947 F
07/01/1995 A 01/01/1980 F
10/01/1993 A 12/08/1954 M
10/01/1993 A 12/27/1967 F
02/01/199- A 06/28/1963 M
10/01/1993 A 12/1]/1956 M
Page 30
Terminated Class
E-type
Volume
1B
1
51000.00
1B
1
5,000.00
1B
1
5,000.00
1B
1
5,000.00
1B
1
5,000.00
111
1
5,000.00
1B
1
5,000.00
15
1
5,000.00
IB
1
5,000.00
IS
1
5,000.00
1B
1
5.000.00
1B
1
51000.00
1B
1
51000.00
1B
1
5,000.00
IB
1
5,000.00
1B
1
5,000-00
1B
1
5,000-00
1B
1
5,000.00
is
1
5,000.00
1B
1
5,000.00
1B
1
5.000,00
1B
1
5.000.00
IB
1
5,000.00
1B
1
5,000.00
1B
1
5,000.00
1B
1
5,000.00
1B
1
51000.00
1B
1
5,000.00
15
1
5,000.00
1B
I
5,000.00
1B
1
5,000.00
35
1
5,000.00
1B
i
51 000.00
1B
1
5,000.00
LB
1
51000,00
1B
1
5,000.00
18
1
5,000.00
1B
1
51 000.00
1B
1
5,000.00
IB
1
5,000.00
16
1
51000.00
1B
1
5,000.00
113
1
5,000.00
1B
1
5,000.00
1B
1
5,000.00
ACC50
Group
Enrollee and Dependents List
.-- - -- --------------------
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 113 Voluntary Life - Child
D06518-0099 CITY OF FORT COLLINS
Cart No. Bep Name Effective Status Birthday Sex Relation
03/01/1995 A 07/06/1951 M
10/01/1993 A 12/14/1951 M
10/01/1993 A 12/25/1952 F
02/01/1994 A 08/20/1952 M
10/01/1993 A OS/14/1949 M
10/01/1993 A 12/15/1953 M
09/01/2001 A 09/07/1973 M
03/01/1997 A 06/19/1952 M
10/01/1993 A 12/13/19SS M
10/01/1993 A 12/07/1947 M
02/01/1994 A 03/26/1962 M
05/01/1997 A 05/18/1953 M
O1/01/1994 A 03/20/1950 F
06/O1/1997 A 12/11/1965 M
30/01/1993 A 12/05/1951 M
03/01/1996 A 09/12/1959 M
10/01/1993 A 12/25/1956 M
04/01/2002 A 11/19/1960 M
08/01/1995 A 08/20/1958 M
10/01/1993 A 02/25/1955 M
10/01/1993 A 12/06/195D M
04/01/2003 A 07/10/1974 M
12/01/2000 A 07/06/1968 M
03/01/1997 A 12/25/1958 M
10/01/1997 A 12/24/1959 M
10/01/1993 A 12/21/1952 M
10/01/1991 A O1/01/1980 M
02/01/1999 A 06/04/1953 M
10/01/1993 A 01/01/1900 F
10/01/1993 A 12/05/1954 F
10/01/1993 A 12/07/1963 M
10/01/1993 A 12/04/1954 M
O1/01/1996 A 05/06/1960 M
10/01/1993 A 12/19/194B M
06/01/2000 A 02/20/1972 F
03/01/2001 A D9/02/1955 M
02/01/1998 A 10/20/1969 M
03/01/1996 A 11/11/1965 F
10/01/1993 A 12/13/1961 M-
02/01/1996 A 09/24/1958 F
10/01/2002 A 12/18/1957 F
10/01/1993 A 12/30/1953 M
01/01/1997 A 11/06/1961 F
03/01/1995 A 07/31/1950 M
11/01/2001 A 10/19/1972 M
29/JNL/2003
Page 31
Terminated Class
E-type
1B
1
1B
1
1B
1
1B
1
18
1
18
1
IS
1
1B
1
18
1
13
1
1B
1
1B
1
1B
1
18
1
18
1
1B
1
1B
1
18
1
1B
1
1B
1
18
1
1B
1
1B
1
1B
1
1B
1
1B
1
1B
1
1B
1
1B
1
SB
I
1B
1
1B
1B
1
1B
1
1B
1
1B
1
1B
1
1B
1
1B
1
1B
1
1B
1
1B
1
1B
1
1B
1
1B
1
)PAGE 1
CITY OF FORT
COLLINS
GROUP POLICY
99544
GROUP LONG TERN DISABILITY
CLAIMS SUMMARY
SUN LIFE ASSURANCE COMPANY
OF CANADA
0.
AS OF 91MAY2003
FOR THE PERIOD OIJAN2002 TO
31MAY2003
CERTIFICATE
DATE OF
DATE
EXPIRY
NET MONTHLY
CLAIMS PAID
TOTAL
DISABLED
14WBER CERTIFICATE NAME
----------- ----------------
BIRTH
---------
DISABLED
DATE
BENEFIT
THIS PERIOD
CLAIMS PAID
LIFE RESERVE
OPEN AND APPROVED
-1-------
---------
-----------
----- -- -
-----------
------------
IBFE81954
19FE820O3
16FE92019
M
3095.00
123.62
123.82
140492.00
29FEB1844
2OMV20O2
28FE112009
F
703.31
4962.63
4662.43
2698 1. 00
26MAVISS8
01OCT2002
26MAY2023
M
1390.25
7010.02
7010.82
83063.00
O7JUL 053
IOSEP20O1
O7JUL2018
M
2350.23
41677.41
41677.41
184264.00
OGJAN1939
13JAN2001
ASOCT2004
M
003.22
15884.74
20060.23
16335.DO
IISEP19SO
22JAN200O
IISEP2015
F
1809.42
30743.14
67614.35
187212.00
095EP1947
O4SEP1990
O9SEP2012
M
a4.64
9055.11
80141.49
51224.O0
OICCTIO52
O3FEB1998
O10012017
M
1296.75
18724.75
50306.70
138437.00
10NOV0056
22AU61998
106VOV202t
F
1290.14
22068.72
75968.49
176084.00
14SEPS941
OTJM1997
14SEP2012
F
2727.95
46378.53
t90167.14
247392,00
16306.67
197330.97
496636.1O
1251504.00
13AUG1841
20MV2O02
ISFES2007
M
2509.44
4682.44
4182.44
.00
ORMAJ11950
21NOV2O01
OOMM2015
M
1910.24
23392.81
23382.81
.00
14ALJGIS14
24NOV2O00
28NOV2010
F
1937.79
253W1 24
37346.TG
.00
27FES1983
O4JU42O0D
27FE82029
F
1750.63
07564.45
42016.12
.00
24NAY1038
MIMAY1997
24MAY2O03
M
787.74
13234,03
56466.21
.90
8795.66
83664.t7
163386.34
.00
25102.43
290995.14
660071.44
1251504.00
27A►RSB49
OWN2008
27A1012014
M
2O24.10
-00
.00
80623.00
O5JUH1839
12MAR20O9
IOJUN2004
M
129.72
.00
.00
11135.00
2163.82
.00
.00
81656.00
TOTAL PENDING
2163.82
.00
.DO
51650.00
TOTAL
Ell
2
UT&
We Pimndai"
27256.7E 260995.14 6600121.44 1343162.00 N
W
EXPIRY DATE MAY BE EARLIER THAN DATE SHOWN DEPENDING ON CONTRACTUAL LIMITATIONS
Waloslay WNs. M69610lRJNi6 02481
Sti► Life Aaawmce Cow wW of Coale Is s•
_ .. - _ _ : _:. - -• _ :: --: :..- .. !R9!eilyu AI Brr;$rnL11� fAR41dM- 9rouo,g4 r����•
Al]C50 Enrollee and nepenBente Lie[
-----------------------------
Company 004 Anthem Life insurance Company
Country 01 11n11ed States
Core rage: 113 VOLuntary Life - Child
Gaoup 1 006518 0099 CITY OF FORT COLLrNS
29/JM/2301 Page 32
Cert No. rep Name Effective Sta=us Birthday 9
03/01/1999 A 12/29/1967
10/01/1993 A 12/05/1954
03/011,1999 A 04/21/1965
10/01/1993 A 12/21/1946
10/O1/1993 A 12/17/1963
L2/e1/2002 A 12/21/1966
Lo/01/1993 A 12/02/1949
07/O1/1996 A O5/13/1962
10/O1/1993 A 12/13/1951
06/01/2002 A 1C/05/1962
05/O1%1999 A OE/26/1967
10/01/1993 A 12/22/1946
1./01/1993 A 09/06/1956
0310112D00 A O1/09/1966
06/01%2003 A 09/11/1977
1010111993 A US/U 9/1956
10/01/1993 1. 12/03/1,67
10/01/1993 A 12/29/1963
02/01/199� A 03/11/19se
10/01/1993 A 12/25/1953
O9/01/1994 A 02/03/1950
10/01/1993 A 12/21/1957
10/01/1193 A 12/25/1952
10/01/1993 A 12/24/1948
06/01/1998 A 04/22/1566
10/01/1993 A 12/19/1959
11/01/2000 A 05/21i1977
O1/U1/2001 A 02/15/195i
10/01/1993 A 12/09/1959
10/01/1993 A 1213l/1956
10/01/1993 A 12/20/1953
10/01%1993 A 12/14/1949
02/0111996 A 06/16/1963
02/01/1998 A 03/09/1956
10/01/1993 A 12/13/1955
09/01/2001 A 00/07/1968
10/01/1993 A 12/02/1951
10/01/1993 A 12/23/1946
03/01/1994 A 04/29/1963
a5/01/1996 A 09/10/196R
04/01/1995 A 07/23/1947
10/01/1.93 A 12/10/1953
10/01/1993 A 12/14/1961
C1/O1/1994 A 12/28/1965
10,/01/1993 A 12130/1918
i elation
Terminatsd C:a95
E-_yps
V.I.
Fx
1B
1
5.000.00
M
LB
1
5,000 00
x
1B
1
5,000.00
M
1B
1
51000.00
A
1B
1
5,000 00
0
18
1
5,000.00
x
1B
1
S.0Do .00
F
1B
1
5,000 00
q
1H
1
6,000.D0
F
1B
1
91000.00
x
LB
1
S,OD0.00
M
1B
1
S,ODO.DO
B
1B
1
5,000,00
F
1E
1
5,000.00
F
10
1
51000.00
N
1B
1
5.000 00
M
1B
1
5,000 00
P
1B
1
51000.00
1
18
1
51000.00
N
1B
1
51000.UU
M
1B
1
5,000.00
F
1B
1
5.000.00
F
1B
1
5,000.00
n
is
1
5.0DD.DD
P
1B
1
51000.00
F
1B
1
51000.00
F
1B
1
5,000.00
4
1N
1
5,ODO.00
15
1
51000.00
x
1B
1
5,000,00
M
1B
1
5,000.00
F
1B
1
S,OOC.00
4
1B
1
5.000.CC
F
1B
1
5,000 00
1B
1
5,000.00
1B
1
5,000 an
x
16
1
5,000.00
4
1B
1
51 000 .00
x
LB
1
5,000.00
x
1B
1
5,000.00
x
1B
1
5.000 00
4
LB
1
5.000.00
x
1B
1
5,000.00
4
1B
1
5.000.00
4
LB
1
5.000 OU
IDC50 Enrollee and Dependents List 29/JUL/2003 page 33
----------- ----- _-_._
-----------------------------
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 113 Voluntary Life - Child
Group 006518-0099 CITY OF FORT COLLINS
Cart No. Dep Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
10/01/1993
A
12/25/1953
M
1B
1
5,000.00
09/01/1996
A
06/24/1945
M
1B
1
5,D00.00
10/01/1993
A
12/19/1954
M
1B
1
5,D00.00
10/01/1993
A
12/29/19SS
M
1B
1
$1000.00
02/01/2003
A
06/1D/1967
M
1B
1
5,000.00
10/01/1993
A
12/09/1954
M
1B
1
5,000.0C
02/01/1995
A
07/24/1964
F
1B
1
5.000.00
11/01/2001
A
07/17/1953
F
18
1
5.000.00
10/01/1993
A
12/26/1951
M
IB
1
5,000.00
10/01/1993
A
12/08/1952
F
1B
1
5100D.00
10/01/1993
A
12/06/1959
M
1B
1
5,000.00
10/D1/1993
A
12/11/1958
F
3B
1
5,00D.00
10/01/1993
A
12/14/1959
M
1B
1
5,000.00
-0/01/1993
A
08/20/1945
M
1B
1
5.000.00
10/01/1993
A
12/06/1959
M
1B
1
5,000,00
10/01/1993
A
12/18/1952
M
IS
1
5,000_00
10/01/1993
A
12/31/1964
M
IS
1
5.000.00
10/01/1993
A
12/17/1957
M
is
1
51000. 00
10/01/1993
A
12/30/1952
M
1B
1
5,000.00
., 10/01/1993
A
12/02/1950
M
1B
1
5,000.00
10/01/1993
A
12/19/1947
M
1B
1
51000,00
10/01/1993
A
12/04/1955
F
1B
1
5,000,00
06/01/1994
A
03/20/1949
M
1B
1
5,000.00
07/01/2002
A
10/29/1964
M
1B
1
5,000. 00
30/01/1993
A
12/26/1953
M
1B
1
5,000.00
10/01/1993
A
12/21/1963
M
1B
1
5,000.00
10/01/1993
A
12/03/1954
M
13
1
5,000.00
10/01/1993
A
12/23/1959
M
1B
1
5,000.00
10/01/1993
A
08/09/1959
F
1B
1
5,000.00
10/01/1993
A
12/05/1952
M
1B
1
5,000.00
10/01/1993
A
12/16/1960
M
1B
1
5,000.00
02/01/1996
A
02/20/1967
M
1B
1
5,000.00
10/01/1993
A
12/13/1944
M
1B
1
51000.00
10/01/1993
A
06/22/1951
M
18
1
5,000,00
04/01/2002
A
10/14/1951
F
1B
1
5,000.00
10/01/1991
A
12/16/1946
M
18
1
5,000.00
10/01/1993
A
12/11/1948
F
lE
1
5,000.00
10/01/1993
A
01/01/1980
M
1B
1
5,D00.D0
02/01/1595
A
10/31/1963
M
3B
1
5,000.00
01/01/1995
A
12/18/1952
M
1B
1
5,000.00
10/01/1993
A
12/23/1953
M
1B
1
51000, 00
10/01/1993
A
12/11/1954
M
1B
1
5,000.00
04/D1/1994
A
12/09/1954
M
1B
1
5,000.00
IO/D1/1993
A
12/03/1961
F
1B
1
5,000.00
10/01/1993
A
12/13/1954
M
1B
1
5,000.00
ADCSC
Enrollee and Dependents List
----------------------
Company : 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 113 Voluntary Life - Child
Group 00651B-0099 CITY OF FORT COLLINS
Cert No. Dep Name
29/JUL/2003
Ef Eective Status Birthday
10/01/1993 A 12/04/1956
10/01/1993 A 12/20/1956
IO/D1/1993 A 12/26/1956
10/01/1993 A 12/26/1950
08/01/2001 A 06/06/1970
04/01/1997 A 03/06/1957
02/D1/1994 A 12/16/1946
10/01/1993 A 01/30/1949
10/01/1993 A 05/19/1950
10/01/1993 A 12/22/1952
01/01/199S A 03/26/1957
10/01/1993 A 12/29/1955
10/01/1993 A 12/20/1948
01/01/2001 A 06/15/1962
01/01/1994 A 06/08/1964
10/01/1993 A 12/21/19SS
01/01/1995 A 12/27/1958
OS/D1/2000 A C4/26/1969
03/01/2002 A C2/11/1960
09/01/2001 A 05/01/1957
09/01/2002 A 02/10/1958
10/01/1993 A 12/07/1956
04/01/1996 A 06/23/1959
10/01/1993 A 12/08/1954
03/01/1996 A 12/29/1959
10/01/1993 A 12/15/1957
10/01/1993 A 12/09/1949
10/01/1993 A 12/2B/1951
10/01/1993 A 04/22/2954
01/01/2001 A 02/17/1970
10/01/1993 A 12/08/1956
03/01/1995 A 07/14/1953
10/01/1993 A 12/25/1947
1010111993 A 12/31/1951
10/01/1993 A 12/20/1962
Sex Relation
M
M
M
M
M
M
M.
M
M
M
F
M
M
F
M
F
M
M
M
M
M
M
F
F
M
F
M
M
M
M
M
M
M
M
M
Page 34
Terminated Claes
E-type
Volume
1B
1
5,000.00
1B
1
S,DOO.OD
IB
1
51000.00
1B
1
5,000.00
3B
1
5,000.00
1B
1
5.000.00
IB
I
5,000.00
1B
1
5,000.00
1B
1
51000.00
1B
1
5,OD0.00
1B
1
5.000.00
1B
1
S,DOO.00
1B
1
5,000.00
15
1
5,000.00
1B
1
51000.00
1B
1
5,000.00
1B
1
5,000.D0
1B
1
5,000.00
1B
1
S,OOD.00
1B
1
5,000.00
1B
1
S. 0DO. 00
1B
1
5,000.00
1B
1
5,000.00
is
1
5,000.00
SB
1
S,OOO.OD
1B
1
5,000.00
1B
1
5,000.00
1B
1
S,000.00
is
1
51000.00
1B
1
5,000.00
1B
1
51000.00
1B
1
5,000.00
IB
1
5,000.00
18
1
5,000.00
1B
1
5,000 .00
215 ,.! 11O�151000.QQ�_
1102 - �io9,gp5rpo 0.00
RECEIPT OF THIS ADDENDUM MUST BE ACKNOWLEDGED BY A WRITTEN STATEMENT
ENCLOSED WITH THE BID/QUOTE STATING THAT THIS ADDENDUM HAS BEEN RECEIVED.
City of Fort Collins
Administrative Services
Purchasing Division
CITY OF FORT COLLINS
ADDENDUM No. 1
SPECIFICATIONS AND CONTRACT DOCUMENTS
Description of Bid: P902 Benefits
OPENING DATE: August 29, 2003 2:00 P.M. (Our Clock)
To all prospective bidders under the specifications and contract documents described above,
the following changes are hereby made.
VISION
QUESTION: Does the city want to see fully insured rates in addition to ASO rates?
ANSWER: Yes
QUESTION: What tiering structure would you like in the rates?
ANSWER: 4-tier rate structure.
QUESTION: What are the current rates?
ANSWER: Current Monthly Rates:
Individual: $ 7.74
+child(ren): $13.35
+spouse: $14.52
+family: $23.18
Admin fee: $2.15/employee/month
QUESTION: Is or can the vision program be offered to the employees as a bundled product
with either their medical plan or the dental plan?
ANSWER: Yes. But also quote stand alone plan.
QUESTION: Should the quote be "net' or with commissions built into the quote?
ANSWER: Quote "net" of ALL commissions per RFP.
LTD/LIFE
QUESTION: Are claims loss runs from the past three years; broken down by month, including
paid out premium, and diagnosis available?
ANSWER: Life loss claims are available for 1997 forward, LTD Claims are available for
2002 forward. Claims are listed by approval date. Monthly breakdown,
diagnosis and paid out premium are not available.
QUESTION: What are the current rates and rate history?
ANSWER: The incumbent carrier has consistently provided 2-year rate guarantees.
Life: Basic: 2001 and 2002 = $.20/$1,000 covered annual salary
AD&D: 2001 and 2002 = $.04/$1,000 in covered salary
Basic: 2003 and 2004 = $.17/$1,000 covered annual salary
AD&D: 2003 and 2004 = $.04/$1,000 covered annual salary
LTD: 2001 and 2002: $.64/$100 covered monthly salary
2003 and 2004: $.79/$100 covered monthly salary
215 North Mason Street - 2nd Floor - P.O. Box 580 - Fort Collins, CO 80522-0580 - (970) 221-6775 - FAX (970) 221-6707
EE-1X
STATEMENT OF PREMIUMS DUE
EMPLOYEE LIFE STEP RATE BANDS
1X ANNUAL SALARY
Policy NO. 08544 Policyholder Name CITY OF FORT COLLINS
Premium Due Date: 8/1/2003 Billing Grou No. N/A
# of EE's
Covered
Volume of
Inaurance
Age Rate
Banda
Rate Per
$1,000
Current Mo.
Premium
Ad)ustmt
+
AdJustmt
Premium
Due
21
898,278
0-29
0.10
89.83
89.83
26
1 372 28]
30-34
0.12
164.67
184.87
27
1,348,033
35-39
0.15
202.20
202.20
37
1 889 408
40-44
0.25
472.35
472.36
44
2,399 680
45-49
0.42
1007.87
1.007,87
63
2 939 616
50-64
0.66
1,010.76
1.910.75
23
1,273,130
55-59
1.02
1.296.59
1 29g 59
8
351,782
60-54
1.45
924.58
524.58
1
41,134
65-69
2,00
82.27
82.27
0
0
70,
4.60
0.00
0.00
240
12.523 348
5,753.12
5,753.12
Page 1
SUN LIFE OF CANADA • STATEMENT OF PREMIUMS DUE
P011 #: 98544
Policyholder Name:
CITY OF FORT COLLINS
Prerrtum Due Date; 11111112003
jBilling Group No,
NIA
Plan
Coverage
# of EE's
Covered
Volume of
Insurance
Rate
Current Mo
Premium
Adjustmt
N
Adjustmt
(•j
Premium
Due
Employee
10,000
148
1,480,000
0,200
296.00
296.00
Life
1X Sallaq
1,296
66,536,606
0.200
13,307.12
13,307.12
10,000
148
1,480,0001
0,04
59.20
5920
Employee
1XSala
1,296
66,535,608
0,04
2661.42
2681.42
AD&D
Add'11X
177
9,384968
0.04
376.401
375,40
Add? 2X
81
8,218,360
0.04
32833
328,73
Addl 3XI
105
14,982,802
0.04
599.31
599.31
Dependent
5,0001
47
NIA
0.50
23.60
23,50
Child
10,000
337
NIA
1.00
337.00
337.00
Optional
Empbyee
Life
1XSala
240
12,523,348
Attached
5,763.12
2X Sala
111
11,078,218
Attached
3,769.94
3X Sab
125
17,953,044
Attached
4,208.21
142DR.
U to125,D00
1
19,000
12.35
Up to 125,D00
1
30,000
30.60
Optional
Spouse
10,000
144
1,440000
Attached
669.80
669.
25000
72
1,800000
Attached
765.00
765,
50,0
63
3,150 000
Attached
1071.50
1,0T1.
Life
75 000
20
1,500,000
Attached
361.501
361. 0
100,000
16
1,600,000
Attached
330.00
0
34,395.21
Lon Term DisaWity
1,072
4,353,825
0.790
34,395.21
�693
Administi,.dve Services
Purchasing Division
City of Fort Collins
CITY OF FORT COLLINS
ADDENDUM No. 2
P 902 Benefits
SPECIFICATIONS AND CONTRACT DOCUMENTS
Description of Bid: P 902 Benefits
OPENING DATE: August 29, 2003 2:00 P.M. (Our Clock)
To all prospective bidders under the specifications and contract documents described above,
the following changes are hereby made.
QUESTION: (Life) Are premium and claims for the last three years, split by Basic,
Supplemental and Voluntary available?
ANSWER: See Chart for Basic, Supplemental and AD&D. Voluntary has been
requested from the current provider.
QUESTION: (Life) How many police and fire employees are eligible for benefits?
ANSWER: There are 321 Police and Fire employees eligible for benefits.
QUESTION: (Supplemental Life)
Is the supplemental life premium employee paid?
ANSWER: Yes.
QUESTION: (Supplemental and Voluntary Life)
Can the supplemental and voluntary be combined into one plan?
ANSWER: The RFP requests separate supplemental and voluntary life plans.
QUESTION: (Life) What is the guarantee issue level for the Spouse?
ANSWER: ' $10,000
QUESTION: (Life) Are the 2004 renewal rates available?
ANSWER: Available in addendum #1.
QUESTION: (LTD) Why is this out to bid and how often is the City required to bid this
coverage?
ANSWER: Current agreements are expiring. Every 5 years.
215 North Mason Street • 2nd Floor • P.O. Box 580 • Fort Collins, CO 80522-0580 • (970) 221-6775 • FAX (970) 221-6707
QUESTION: (LTD) Can we meet with City Personnel to ask questions prior to the bid
deadline?
ANSWER: No. Please direct all questions and requests for information
through the Purchasing Division.
QUESTION: (LTD) Are Current rates and rate history from 5 years.
ANSWER: LTD Rates from 2001 forward are listed in addendum 1.
QUESTION: (All) Is it important to have as many lines of coverage with one carrier as
possible?
ANSWER: No, however the City of Fort Collins is open to suggestions.
QUESTION: (Supplemental Life)
Are the rates age banded and are the spouse rates the same?
ANSWER: Supplemental life spouse rates are based on the employee's age
and salary. The age bands are posted in Addendum 1.
QUESTION: (Life) Is the overall combined maximum $500k for the basic and supplemental
plans and $300k for the voluntary life plan?
ANSWER: $500K maximum applies only to the Basic and Supplemental
Plans. Voluntary Plan is separate with a maximum is $300K
QUESTION: (Life) Can employees participate in Basic, Supplemental and AD&D, or are
they required to choose one over the other?
ANSWER: Basic Life & Basic AD&D are mandatory. Supplemental Life and
Supplemental AD&D are optional.
QUESTION: (Life) Do you want to maintain all three plans?
ANSWER: Yes.
QUESTION: (Voluntary Life)
Do you have any experience for the voluntary life plan?
ANSWER: Waiting on information from the current provider.
QUESTION: (Voluntary Life)
What is the volume under the voluntary plan?
ANSWER: Information unavailable.
Question: (Voluntary Life)
Is the city interested in offering ONE voluntary plan instead of a
supplemental plan and a voluntary plan?
ANSWER: No, however the City of Fort Collins is open to suggestions.
RECEIPT OF THIS ADDENDUM MUST BE ACKNOWLEDGED BY A WRITTEN
STATEMENT ENCLOSED WITH THE BID/QUOTE STATING THAT THIS ADDENDUM HAS
BEEN RECEIVED.
VOLUNTARY GROUP TERM LIFE INSURANCE
NON-SMOKER MONTHLY RATES
CITY OF FORT COLLINS
ATTAINED
AMOUNTS
OF INSURANCE
AM
Sam
S20 000
530.000
540.000
S50 000
S50 000
170 000
S80.000
S90.480
S100
1110
Less than 35
0.40
0.80
1.20
1.60
2.00
2.40
2.80
3.20
3.60
000
4.00
ON
4.40
MOM
4.80
5130 040
5.20
S140 000
5.60
S350.900
6.00
35 - 39
0.50
1.00
1.50
2.D0
2.50
3.00
3.50
4.00
4.50
5.00
5.50
6.00
6.50
7.00
7.50
40 - 44
0.90
1.60
2.40
3.20
4.00
4.80
5.60
6.40
7.20
8.00
8.80
9.60
10.40
1110
12.00
45 - 49
1.30
2.60
3.90
5.20
6.50
7.80
9.10
10.40
11.70
13.00
14.30
15.60
16.90
18.20
19.50
50 - 54
2.00
C00
6.00
9.00
10.00
12.00
14.00
16.00
18.00
20.00
22.00
24.00
26.00
28.00
30.00
55 - 59
3.80
7.60
11.40
15.20
19.00
22.80
26.60
30.40
34.2D
38.00
41.90
45.60
49.40
53.20
57.00
60 - 64
4.90
9.80
14.70
19.60
24.50
29.40
34.30
39.20
44.10
49.00
53.90
58.90
63.70
68.60
73.50
65 - 69
8.30
16.60
24.90
33.20
41.50
49.80
58.10
66.40
74.70
83.00
91.30
99.60
107.90
116.20
124.50
70 - 74
14.50
29.00
43.50
59.00
72.50
87.00
101.50
116.00
130.50
145.00
159.50
174.00
188.50
203.00
217.50
75 - 79
29.80
59.60
89.40
119.20
149.00
179.80
208.60
238.40
268.20
298.00
327.80
357.60
387.40
417.20
447.00
ATTAINED
AMOUNTS
OF INSURANCE
AM
S160 000
S120 000
Sign 000
5140.00Il
5200.000
1210 000
S220.000
S230J140
S140-M
Less than 35
6.40
6.90
7.20
7.60
8.00
8.40
8.90
9.20
9.60
S750.004
10.00
S260 000
10.40
127B.000
10.80
S280,000
11.20
S240 0Q0
11.60
1100000
12.00
35 - 39
9.00
8.50
9.00
9.50
10.D0
10.50
11.D0
11,50
12.00
12.50
13.00
13.50
14.00
14.50
15.00
40 - 44
45 - 49
12.80
13.60
14.40
15.20
16.00
16.80
17.60
18.40
19.20
20.00
20.80
21.60
22.40
23.20
24.00
50 54
20.80
22.10
23.40
24.70
26.00
27.30
28.60
29.90
31.20
32.50
33.80
35.10
36.40
37.70
39.00
-
55 - 59
32.D0
34.00
36.00
38.00
40.00
42.00
44.00
46.00
48.00
50.00
52.00
54.00
56.00
58.00
60.00
60 - 64
60,80
64.60
68.40
72.20
76.00
79.80
83.60
87.40
91.20
95,00
98.80
102.60
106.40
110.20
114.00
65-69
78.40
83.30
88.20
93.10
98.00
102.90
107.8D
112.70
117.60
122.50
127.40
13230
137.20
142.10
147.00
70 74
132.80
141,10
149.40
157.70
166.00
174.30
182,60
190.90
199.20
207.50
215.80
224.10
232.40
240.70
249.D0
-
75 - 79
232.00
246.50
261.00
275.50
290.00
304.50
319.00
333.50
348.00
362.50
377.00
391.50
406.00
420.50
435.00
476.80
506.60
536.40
566.20
596.00
625.80
655.60
685.40
715.20
745.00
774.00
804.60
834.40
864.20
894.00
09/12/02 $1.50 flat rate covers all children for $5,000
VOLUNTARY GROUP TERM LIFE INSURANCE
NON-SMOKER MONTHLY RATES
CITY OF FORT COLLINS
ATTAINED
AMOUNTS
OF INSURANCE
AGE
110 00II
120.000
130AW
.40.000
S50.000
S60 400
S70.Mp
190006
S40,000
S100.000
1110 000
5120.000
S130 4a4
114➢ OW
Less than 35
0.40
0.80
1.20
1.60
2.00
2.40
2.80
3.20
3.60
4.00
4.40
4.80
5.20
5.60
S150 000
6.00
35 - 39
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
4.50
5.00
5.50
6.00
6.50
7.00
7.50
40 - 44
0.80
1.60
2.40
3.20
4.00
4.80
5.60
6.40
7.20
8.00
8.80
9.60
10.40
11.20
12.00
45 - 49
1.30
2.60
3.90
5.20
6.50
7.80
9.10
10.40
11.70
13.00
14.30
15.60
16.90
1820
19.50
50 - 54
2.00
4.00
6.00
8.00
10.00
12.00
14.00
16.00
18.0D
20.00
22.00
24.00
26.00
28.00
30.00
55 - 59
3.80
7.60
11.40
15.20
19.00
22.80
26.60
30.40
34.20
38.00
41.80
45.60
49.40
5320
57.00
60 - 64
4.90
9.80
14.70
19.60
24.50
29.40
34.30
39.20
44.10
49.00
53.90
58.80
63.70
69.60
73.50
65 - 69
8.30
16.60
24.90
33.20
41.50
49.80
58.10
66.40
74.70
83.00
91.30
99.60
107.90
116.20
124.50
70 - 74
14.50
29.00
43.50
58.D0
72.50
87.00
101.50
116.00
130.5D
145.00
159.5D
174.00
198.50
203.00
217.50
75 - 79
29.80
59.60
89.40
119.20
149.00
178.90
208.60
238.40
268.20
298.00
327.80
357.60
387.40
417.20
447.D0
ATTAINED
AMOUNTS
OF INSURANCE
AGE
1160-000
S170-000
S180 000
S149.000
S200.000
S210,000
S770,000
5230,00
S240 000
S750-000
S260-000
S270-000
MUM
S290,000
Less than 35
6.40
6.80
7.20
7.60
9.00
8.40
8.80
9.20
9.60
10.00
10.40
10.80
11.20
11.60
S300,000
12.00
35 - 39
8.00
8.50
9.00
9.50
10.00
10.50
11.00
11.50
12.00
12.50
13.00
13.50
14.00
14.50
13.00
40 - 44
12.90
13.60
14.40
15.20
16.00
16.80
17.60
18.40
19.20
20.00
20.80
21.60
22.40
23.20
24.00
45 - 49
20.80
22.10
23.40
24.70
26.00
27.30
28.60
29.90
31.20
32.50
33.80
35.10
36.40
37.70
39.00
50 - 54
32.00
34.00
36.00
39.00
40.00
42.00
44.00
46.00
48.DD
50.00
52.00
54.00
56.00
59.00
60.00
55 - 59
60.80
64.60
68.40
72.20
76.00
79.80
83.60
87.40
91.20
95.00
98.80
102.60
106.40
110.20
114.00
60 - 64
78.40
93.30
88.20
93.10
98.00
102.90
107.80
112.70
117.60
122.50
127.40
132.30
13720
142.10
147.00
65 - 69
132.80
141.10
149.40
157.70
166.00
174.30
182.60
190.9D
199.20
207.50
215.80
224.10
232.40
240,70
249.00
70 - 74
232.00
246.50
261.00
275.50
290.00
304.50
319.00
333.50
348.00
362.50
377.00
391.50
406.00
420.50
435.00
75 - 79
476.80
506.60
536.40
566.20
596.00
625.80
655.60
685.40
715.20
745.00
774.80
8D4.60
834.40
864.20
894.00
09/12/02
$1.50
flat rate
covers all children for $5,000
City of Fort Collins
Administrative Services
Purchasing Division
CITY OF FORT COLLINS
ADDENDUM No. 3
P 902 Benefits
SPECIFICATIONS AND CONTRACT DOCUMENTS
Description of Bid: P902 Benefits
OPENING DATE: August 29, 2003 2:00 p.m.
To all prospective bidders under the specifications and contract documents described above, the
following changes are hereby made.
This Agreement shall commence January 1, 2004, and shall continue in full force and effect until
December 31, 2004, unless sooner terminated. In addition, at the option of the City, the
Agreement may be extended for additional one (1) year periods not to exceed four (4) additional
one(1) year periods. Written notice of renewal shall be provided to the Service Provider and
mailed no later than ninety (90) days prior to contract end.
CURRENT RATES BASIC LIFE:
CORRECTION:
Life: Basic: 2001 and 2002 = $.17/$1,000 covered annual salary
Basic: 2003 and 2004 = $.20/$1,000 covered annual salary
QUESTION: Is the information listed in the census by employee name, and in alphabetical
order?
ANSWER: NO
QUESTION: Are Police and Fire employees eligible for both Life and LTD
ANSWER: Police and Fire employees are eligible for Life, not LTD. Disability coverage is
provided by an alternative program.
QUESTION: Under Optional employee life, why is there a category for up to $125,000?
ANSWER: The original Sun Life policy guaranteed $125K.
QUESTION: Are the 2X and 3X salary age bands the same as the 1X salary age banded
rates for the optional life? Are the rates the same regardless of which plan
design is chosen under the optional plan?
ANSWER: Yes -all rates are the same.
215 North Mason Street • 2nd Floor • P.O. Box 580 • Fort Collins, CO 80522-0580 • (970) 221-6775 • FAX (970) 221-6707
CITY OF FORT COLLINS
VOLUNTARY ACCIDENTAL DEATH AND DISMEMBERMENT RATES
Benefit Amount
Employee Only Plan
Family Plan
$10,000
$.43
$.57
20,000
.86
1.14
30,000
1.29
1.71
40,000
1.72
2.28
50,000
2.15
2.85
60,000
2.58
3.42
70,000
3.01
3.99
80,000
3.44
4.56
90,000
3.87
5.13
100,000
4.30
5.70
110,000
4.73
6.27
120,000
5.16
6.84
130,000
5.59
7.41
140,000
6.02
7.98
150,000
6.45
8.55
Coverage Included
Seat Belt Rider
Pays an additional 50% if the insured person perishes in an automobile accident and there is specific evidence to show the insured
wore a seat belt at the time of the accident.
Special Education Benefits Rider
Under the Family Plan, if the insured perishes as the result of a covered accident, each surviving dependent child who enrolls as a full-
time student in an accredited school of higher learning before age 23, the benefit pays an additional 2% of principal sum or $2,500
yearly, whichever is less, for a maximum of 4 years.
This benefit also pays for not more than one year and $3,000 of incurred expenses for the insured's surviving spouse who enrolls in
any accredited school for the purpose of retraining or refreshing skills needed for employment.
If there are no dependents who qualify for Special Education Benefits at the time of the accident, an additional $1,000 is paid to the
insured's beneficiary.
Travel Assistance, Emergency Evacuation Benefit and Repatriation Assistance
If the insured is traveling 100 miles or more from home, arrangements have been made through American International Assistance
Services for the following assistance:
• Travel Assistance
• Evacuation — if the insured becomes injured or seriously ill and adequate medical facilities are not available locally, we will make
arrangements for your emergency evacuation, under constant medical supervision, by whatever means necessary to a facility
capable of providing the necessary medical care.
• Medically Supervised Repatriation and Repatriation of Remains — when medically advisable to hospitalize the insured closer to
home, arrangements will be made for repatriation under medical supervision. If the insured should lose their life while traveling,
we will render assistance to obtain necessary clearance and arrange for return of the remains.
QUESTION: LTD CLAIMS VS. PAID PREMIUM
ANSWER:
ear beginning
1-Jan-01
1-Jan-02
1-Jan-03
OTAL
Year Ending Paid Premium
31-Dec-01 $ 304,638.00
31-Dec-02 $ 337,186.00
1-Aug-03 $ 276,412.00
QUESTION: Voluntary Life and AD&D VS. Paid Premium
ANSWER:
Paid Claims
$ 129,627.00
$ 149,692.00
$ 102,676.00
$ 536.138.00
Disabled Life Res.
$ 201,519.00
$ 215,512.00
$ 340,061.00
Loas anus Heport
Cases) • City of Fort Collins ('008518')
14:10 Friday, Aogu41 15, 2003 1
Billing Unit(4) -
('All Billing Units Selected')
Davarage Dodge)
- ('All COVOP2908 Selected')
By Incurred Dates:
Jan 1, 2001 th rd Jul 31, 2003
W Coverage
SOP
ti Cade
Description
Period
Earned
Roservas
Paid Open Claim
IBNI
Total
Ineurrod
Loae
o
d
Prenitm
Claims Reserves
Reserves
Claim
Ratio
Vol Life
01101/2001 to 12/31/2D01
150,203.82
0.00 0.00
D.00
.r„
01/01/2002 to 12/3112002
165,714.00
0.00 0.00
0.00
0.00
0%
01/01/2003 to 07 31 2003
/ !
91 ,687.40
30,09/.93 0.00
15,687,27
D'�
0%
45,792.20
Spy
Vol Life
413,565.22
30,094.93 0.00
16,697.27
45,702.20
11%
Vol Life/Child
01/01/2001 to 12/31l2001
4,372.91
5,017.98 0100
0.00
01/01/20D2 to 12131/2CO2
4,412.00
0.D0 0.00
51017.98
115%
01101/2003 to 07/31/2003
2,522.50
0.D0 0,00
0.00
0.00
0y
432.43
432.43
17%
Vol Life/Child
11,307.40
5,017.90 0.D0
432.43
5,460.41
ley
VADSD
01l0112D01 to 12/3l/2001
8.127.86
0.00 0.00
0.00
O1/0112002 to 12/31/20D2
Bliss 81
D.00 D.oD
o.OD
0.00
ovav2oo3 to 07131/2003
4,63e.92
000 0.00
o.00
A
0.00
0.00
016
vAD&D
21,152.19
0.00 0.00
0.00
a-D0
0%
Billing Fee
01/01/2001 to 12131/2001
745.00
0.D0 0.00
01/01/2002 to 12/3112002
804.60
0.00 0.00
0.00
0.00
0.00
0y
0110112OD3 to 07/3112M
485.00
0.00 0.00
0.00
0%
0.00
0.00
0%
Billing Foe
2,034.80
0.00 0.00
0.D0
0.00
0%
==�=448,060.49
635,112.91 ••"van-0100 'm16,129.70
61,242.41
�11%
Grp end Vol Lift I" is estiested at lot of nn0al praade•,
Y AD9D and VAUSD IBM is "Mud to be 0.
Short TOM Disability IBM is estisRad at 6% of Sonde, pnsie..
n Long Ten Disability IBM it satimted at an of 7 seethe of FrbdWM.
QUESTION: Basic Life AD&D Claims vs. Paid Premium
ANSWER:
City of Ft Collins 98544 - Claims vs.
Premium
January 2001
-August 2003
Dame Apos ed I
Basic Life
j Opt Life
Basic AD&D
_... _
Opt AD&D
Dep Life
Waiver
02/01/01
34,000
34,000
34,000
34,000
12/31/01
............ _ ..
17,000
09/10/02
41,000
123,000
41,000
123,000
11/22/02
_
-
--- _
10,000
03/26/03
32,000
.........
03/27/03
--
—_
.......................
34,000
04/27/03
...... ......_.._ A.__
e
35,000
04/30/03
10,000
05/20/03
35,000
138,000�
05/22/03
46,000
91,000
06/09/03
56,000
181,000
386,000
75,000
157,000 1
10,000
184,000
Basic Life
Opt Life
Basic AD&D
Opt AD&D
Dep Life
Premium Jan
-
01 - Aug 03 i
355,050
470,976
115,868
?
11,359
j MIA
Waiver
Status
Closed
Closed
Open
Closed
Closed
Open
993,000
953,253
QUESTION:
Is the premium history for Basic
Life available.
City of Fort
Collins --
98544
ANSWER:
January
2001 through
Dagam5ar 2001
January
2002 through
Dammber 2002
Janu
am 2003 to
rwah MY 2003
Beg Nk OAagRAYr
LMa
W..B Prenrum
ar�R A4nVlY7
LMas
Yclanoa Prangm
Be�mFt AkO6R1T
W.
Lives Wvna Pro7ii4m
LIFE EE 01JAhD1
M63
53810,346 E
9146
LIFE EE 01JAhD2
1419
62 W7487 b
11).643
LIFE EE 011
1456
68,12S540 $
13,625
01FEW1
M63
53,81D,346 S
9.148
Di FEB02
1419
6207.487 E
iD843
01FEW3
1458
68,125,540 d
MKS
014AP01
MI
54,6DO.742 b
9.265
DlM IR02
1421
64.040.911 b
10887
01 WARDS
1451
G..560 b
U.591
D1APFD1
1363
54862476 b
9293
01APRD2
1440
65,196 &10 $
11.083
01APW
1454
66161285 $
M.632
01MAY01
MM
55, 187666 b
9,382
OIMAY02
1449
66,757215 E
11.99
DIMAW3
1451
69,064.842 j
16613
01JUM1
M88
35708,767 b
9.471
01JI-ilW
1451
65763796 S
11.178
D1JUN13
1462
68,115.624 b
M623
01JUW1
1389
55,867498 $
9,4W
01JU1D2
1449
65.731,E26 S
11,174
01JULD3
1464
66,267,227 j
13,663
01A0001
1377
55,487.930 $
9,433
DUUG02
1447
65,781 b
11,164
01$EP01
1381
S5,764,478 b
9480
DISEP02
1461
66.426,060 S
11.292
01OCT01
MIM
55,268,216 E
9.566
011
1461
66,425,069 E
11,2a2
olh w1
1400
65,534,537 b
9.611
01NOV02
1454
66W1433 S
11.287
Di DEC01
14D0
5A539,537 S
9.611
01DEm2
1454
66,W 1433 S
11.397
TOTAL
6
112,906
TOTAL
S
133,129
TOTAL
E
%,362
LIFE DEP0IJANDI
365
- b
335
LIFE DPP DIJAI
am
- E
WD
LIFE DEP D1JAN03
W&I
- j
WS
D1FEW1
365
- d
335
01FEB02
3m
- d
36D
DiFEW3
WE,
- S
366
D1MAWI
365
S
335
DiIRAF02
am
- E
360
01 MAFD3
367
$
W4
DIAPFDI
am
d
338
DIAPRD2
SSG
- E
359
01APRW
W7
- E
364
01MAYO1
an
- d
341
OIMAYD2
am
- S
361
DIMAW3
368
- E
365
01JUN11
377
- d
346
01J1N4B
am
- S
X2
DiJUN93
367
- E
364
DIJUIDI
381
- E
349
01JUW2
386
- d
360
01JU4D3
Am
- $
362
01AIJI
379
- S
347
DlAJG02
357
- E
361
OISEPDI
383
- $
351
DISEP02
384
- j
358
01OCT01
384
- b
352
D10CT02
am
- S
am
DINOVDI
385
- b
353
01N W2
382
- $
W6
01DECD1
385
- E
353
D1DEm2
3@
- S
356
TOTAL
6
4,136
TOTAL
$
4.311
TOTAL
4
2,551
OPTL 01JAWI
676
37.556010 b
11.528
OPTL 01JAM
742
44.1626D3 $
4491
OPT DIJAND3
800
5AESS72
17,206
EE D1FEB01
676
37.556.010 S
11.626
EE DIFEB02
742
44, 159993 b
1491
EE 01FEIA93
8)0
5D495572
17208
0114AR01
6W
WSD39D3 S
12,635
01MAF02
76)
4571D.W2 b
14,874
01 MAFD3
Wt
51022144
17.313
01APF01
696
M 740 297 E
12682
DIAPRD2
765
46.332.951 $
15.069
01APRD3
W3
61616111
V251
01MAYD1
699
3396667 b
12.710
O1MAW2
776
47.069.D16 S
15.249
DIMAW3
799
51W7733
17, 162
DiJUAD1
712
40.802.946 b
12.882
01JUN)2
781
47,474855 S
15,342
ODUN)3
W3
515DD078
17.111
01JU1D1
716
41.D97.941 $
12972
01JU1D2
79
47428,594 b
15.312
01JULD3
W2
51.469.D6D
17.049
01A000I
714
40,9W.D52 b
12945
D1A1G02
781
47.584.96 b
15.341
D1SEP01
713
41, 1715W b
12.997
OISEPD2
782
47,WL738 E
15,382
D100TOI
723
41.3W.157 E
12,864
011
7@
47,8Q1,738 E
IS.W2
01N 1
729
41,727.165 d
13.043
01N]VD2
778
47%2,753 d
15.342
DIDEC01
729
41,727,165 E
13.043
01DE012
778
47592,753 S
15,342
TOTAL
6
151,699
TOTAL
6
181,779
TOTAL
i
120,302
AD&D EEOIJANJI
1669
7.744.W0 S
3,110
AMD EE 01JAN12
1748
86.765,708 S
3471
AMD EE OUM03
1522
100.115976 b
4.005
01FEB01
1669
7744SDO E
AVID
D1FE002
1746
86766 M6 b
3,471
01FEW3
1822
10D,116,975 $
4D06
DIMARGI
1683
78,903711 6
3,156
Di MAR02
1751
92,517.456 d
3,7D1
01 MAMS
1821
100,374,830 S
4015
01APFD1
1686
79254.65Z b
3,170
DIAPRO2
1778
91 $
3.766
01APW
1823
IM.947.243 S
4,038
DlIVAY01
16W
79.922891 E
3,197
0110AYD2
1794
95.058216 E
3W2
DIMAW3
1818
160.655,57D E
4027
CUU1,91
17M
W966.993 6
3.239
01JUM2
1860
9537451 S
3815
01JU6D3
1819
100.837DI8 j
4,D33
OIJUIDI
1708
81,276424 S
8,251
01JUW2
1797
95.398237 S
3,816
DIJU103
1@1
101,049,4D5 $
4042
DIAW01
1695
W 877,419 b
3235
OMCO2
1796
95.539,324 b
3,822
D15EP01
1699
813D2,172 b
3.252
01SEP02
1612
96,527,669 E
3.661
01OCT01
1714
81.924.889 E
3,277
011
1812
96.527658 S
3.861
01NOVD1
1724
82,446.958 E
3,296
DINCVD2
i3D1
W150470 $
3,816
D1DEC01
1724
82446,956 b
3,298
D1DEM2
16D1
96,150.70 $
3.846
TOTAL
6
39,593
TOTAL
$
45,068
TOTAL
i
28,165
LTD 01JANO1
1013
3.660.959 d
24838
LTD 01JAIW
low
4,M2186 d
27,470
LTD 01JMDS
1077
4,362.365 $
34 ASS
DIFEBDI
1D13
3SW 959 b
24836
D1FEBW
10W
4492186 S
27,470
D1FEED3
1077
4,362.355 S
34,463
01MARD1
V14
3.892216 E
W.910
01MAF02
IDW
4,M7.M $
27.503
Di"PW
INS
4.356,901 S
34.416
01APFDI
A13
3907,626 d
25.0D9
01APRD2
1DW
4,347114 $
27,822
DIAPRD3
1077
4.W3.216 b
M469
01MAYDI
1026
3.953.143 $
25.300
01MAY02
1081
5, 113216 $
32.725
01 MAW3
1076
4.355917 $
34442
DIJUMI
1D32
3,9791874 S
25.471
DiJUND2
low
4,343.557 E
27,799
01JU103
ID77
4,363.994 $
34,397
01JDID1
V37
39M 361 S
25.670
D1J=2
1079
4.327.761 S
27.®8
01JU1D3
WE
4.355.181 S
34.406
D1AUG01
V33
3.961.766 b
25.483
01AUG02
1D75
4.319.168 $
27.613
D1SEP01
1036
4010.758 E
25,669
01SEP02
ion
4.336,859 $
27756
010CTD1
1042
4024,411 b
25.755
010CT02
ion
4,336.859 S
27.766
)lINOW1
V47
4046280 S
258W
D1N 2
1D76
4,339.645 S
27.773
D1DEC01
M47
4,046,260 b
26.8W
DIDECJY2
1076
4.339.645 j
27,T73
TOTAL
E
304,636
TOTAL
f
337,180
TOTAL
i
241,026
QUESTION: VOLUNTARY LIFE AND AD&D VOLUMES PER PARTICIPANT
ANSWER:
A005D
Enrollee and Dependents List
-----------------------------
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 090 Voluntary AD=
Group : 006518 0099 CITY OF FORT COLLINS
Cert NO. Dep Name
29/JUL/2003 page 1
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
01/01/1996
A
02/12/1953
M
03
S
100,000.00
01/01/2001
A
03/19/1960
M
03
S
150,000.00
06/01/2000
A
12/36/1964
M
03
F
100,000.00
01/01/1996
A
06/08/1961
F
03
F
50,000.00
01/01/1996
A
12/06/1952
M
03
F
150,000.00
01/01/1998
A
12/11/1941
F
03
8
iCO.000. 00
01/01/199E
A
12/15/1942
M
03
F
100,000.00
31/O1/1996
A
12/3011942
F
03
S
20,000.00
02/01/2000
A
04/30/1970
M
03
S
60,000.00
cl/01/1996
A
06/26/1951
M
03
F
50,000.00
01/01/1996
A
12/06/1950
M
03
p
100,000.00
' 05/01/2002
A
05120/1972
F
03
S
40,000.00
01/01/1996
A
03/23/1964
F
03
F
20,DOO.00
09/01/1999
A
05/29/1973
F
03
F
50,OOD.00
01/01/1996
A
12/29/1949
M
03
S
100,000.DO
12/01/2000
A
06/07/1957
M
03
S
140,000.00
01/01/1996
A
12/15/1964
F
03
S
100,000.00
01/01/1996
A
12/27/19SS
M
02
F
50,000.00
01/01/1996
A
_2/27/1956
M
03
F
120,000.00
01/01/1996
A
07/29/1961
M
D3
F
40,000.00
01/01/1996
A
C4/04/3957
M
03
F
20,000.00
01/01/1997
A
12/31/1960
M
03
F
160,000.00
05/01/1999
A
D025/1969
H
03
5
100.000.00
01/01/1996
A
09/13/1954
M
01
F
100,000-00
01101/1996
A
O8/02/1968
F
03
S
50,000.00
05/01/1999
A
08/07/1961
M
03
F
100,000.00
08/01/2001
A
05/28/1962
F
03
F
300.000.00
01/01/1996
A
04/26/1947
M
03
F
100,000.00
01/01/1996
A
12/17/1947
F
03
F
80,000,00
03/01/1997
A
01/31/1947
F
03
F
60,000.00
01/01%1998
A
11/16/1955
F
03
F
70.000.00
02/01/1997
A
06/29/1963
M
03
F
150,000.00
01/01/1996
A
12/05/1947
F
03
F
150,000.00
01/01/1996
A
05/2D/1951
M
03
F
801000.00
01/01/1996
A
11/20/1953
M
C3
F
10010DO.00
O1/01/2002
A
08/03/1946
F
03
F
10,000.00
01/01/1996
A
12/14/1951
M
03
F
1SD,000.00
01/01/i996
A
12/2711942
F
03
5
60,D00.00
05/01/1997
A
09/26/1963
M
03
S
70,000.00
01/O1/1996
A
12/1711911
M
03
S
100,000.00
01/01/1996
A
03/19/1951
M
03
S
50,000.00
06/01f2000
A
09/01/1944
M
03
F
50,000.00
01/01/1996
A
03/20/1950
F
03
F
100,000.OU
01/01/i996
A
10/06/1958
M
03
S
100.000.00
12/01/2002
A
11/12/1964
M
03
S
100,000.00