HomeMy WebLinkAboutRFP - P902 BENEFITSCitv 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
D:50 Enrollee and Dependents List 29/JUL/2CO3 page 4
.... ------------------- __________
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 090 Vol Mary AD6O
orOup 1 006sla-OC99 CITY OF FOR: COLLINS
'Sffectiv.
Status
Eitt hday
Sex Relation
Terminated Class
E-type
Volume
2%O1/1998
A
12/29/1959
M
O3
F
150,000.00
1/01/1996
A
12/23/1953
x
03
F
100,000.00
1/01/2000
A
O8123/1947
F
03
5
110, 000.0a
1/01/2001
A
0,12211954
X
01
F
150,000.00
9/01J1999
A
O1/14/1961
F
03
F
40,000.00
1/O1/1996
A
12/2S/1947
M
03
F
100,000.00
141
13,060,900.00
ADC50 Enrollee and Dependents List 29/JUL/2003 Page 15
___________ _-
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 110 Voluntary Life - Employee
Group 006SIS-0099 CITY OF FORT COLLINS
rorr No. Den Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
04/01/1992
A
12/20/1956
M
03
T
30,000.00
04/01/1992
A
12/26/1956
M
03
N
200,000.00
02/01/1993
A
12/26/1950
M
03
N
100,000.00
09/01/1996
A
03/31/1962
F
03
N
200,000.00
04/01/1992
A
12/09/1964
M
03
N
300,000.00
O8/01/2001
A
06/06/1970
M
03
N
300,000.00
04/01/1992
A
12/27/1961
F
03
N
180,000.00
04/01/1997
A
03/06/1957
M
03
N
100,000.00
04/01/1992
A
12/16/1946
M
03
N
100,000.00
05/01/1992
A
12/09/1948
M
03
N
40,000.00
03/01/1997
A
06/27/1945
M
03
N
50,000.00
° 07/01/2000
A
10/12/1973
F
03
N
300,000.00
07/01/1992
A
O1/30/1949
M
03
N
100,000.00
04/01/1992
A
05/19/1950
M
03
N
100,000.00
10/01/1998
A
08/03/1975
F
03
N
300,000.00
04/01/1992
A
12/22/1952
M
03
N
120,000.00
04/01/1992
A
09/30/1946
M
03
N
50,000.00
01/01/1995
A
03/26/1957
F
03
N
30,000.00
O1/01/2000
A
08/21/1959
F
03
N
30,000.00
02/01/1993
A
12/29/1955
M
03
T
200,000.00
04/01/1993
A
12/20/1948
M
03
N
100,000.00
10/01/1999
A
04/21/1970
M
03
N
300,000.00
01/01/2001
A
06/15/1962
F
03
N
100,000.00
O1/01/1994
A
06/08/1964
M
03
N
100,000.00
02/01/2002
A
O1/22/1970
F
03
N
30,000.00
07/01/1997
A
03/23/1967
F
03
N
50,000.00
O1/01/1999
A
05/21/1967
M
03
N
250,000.00
05/01/1992
A
12/21/1955
F
03
N
30,000.00
04/01/1992
A
12/27/1958
M
03
N
150,000.00
03/01/2000
A
08/02/1943
F
03
N
60,000.00
05/01/2000
A
04/26/1969
M
03
N
150,000.00
03/01/2002
A
02/11/1960
M
03
N
170,000.00
03/01/1996
A
12/07/1952
F
03
T
30,000.00
09/01/2001
A
05/01/1957
M
03
N
200,000.00
09/01/2002
A
02/10/1958
M
03
N
300,000.00
O1/01/1999
A
08/14/1944
M
03
N
30,000.00
04/01/1992
A
12/07/1956
M
03
N
300,000.00
O1/01/1994
A
06/23/1959
F
03
T
200,000.00
03/01/2002
A
09/03/1958
F
03
N
200,000.00
09/01/1992
A
12/23/1960
M
03
N
100,000.00
O1/01/2003
A
12/05/1950
F
03
N
140,000.00
04/01/1992
A
07/26/1950
M
03
N
300,000.00
04/01/1992
A
12/27/1949
F
03
N
30,000.00
O8/01/1992
A
12/08/1954
F
03
N
100,000.00
06/01/1992
A
12/29/1959
M
03
N
300,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 110 Voluntary Life - Employee
Group 006SIS-0099 CITY OF FORT COLLINS
ncn Name Effective Status Birthday Sex Relation
04/01/1992 A 12/23/1953 M
04/01/1992 A 12/15/1957 F
04/01/1992 A 12/09/1949 M
07/01/2002 A 05/10/1977 F
04/01/1992 A 12/21/1951 M
04/01/1992 A 12/05/1947 M
06/01/1992 A 12/28/1951 M
09/01/2000 A 04/28/1973 M
04/01/1992 A 04/22/1954 M
01/01/1996 A 02/17/1970 M
04/01/1992 A 12/08/1956 M
' 01/01/2001 A 02/22/1976 F
10/01/1995 A 06/15/1957 M
12/01/1997 A 01/14/1961 F
01/01/1995 A 10/12/1955 F
03/01/1995 A 07/14/1953 M
02/01/2003 A 10/15/1980 M
04/01/1992 A 12/09/1951 F
04/01/1992 A 12/25/1947 M
04/01/1996 A 09/22/1944 M
05/01/1992 A 12/31/1951 M
04/01/1992 A 12/09/1959 M
04/01/1997 A 04/29/1970 M
04/01/1992 A 12/15/1949 M
04/01/1992 A 12/20/1962 M
Page 16
Terminated Class
E-type
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
T
519
Volume
100,000.00
30,000.00
80,000.00
100,000.00
80,000.00
60,000.00
100,000.00
50,000.00
150, 000.00
100,000.00
80,000.00
200,000.00
200,000.00
80,000.00
50,000.00
180,000.00
50,000.00
100,000.00
150,000.00
100, 000.00
40,000.00
50,000.00
100,000.00
60, 000.00
100,000.00
67,240,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 112 Voluntary Life - Spouse
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name Effective Status Birthday Sex Relation
04/01/1992 A 12/19/1956 M
04/01/1992 A 06/21/1961 F SPOUSE
01/01/1999 A 04/17/1947 F
01/01/1999 A 05/05/1938 M SPOUSE
02/01/2003 A 08/20/1973 F
02/01/2003 A 09/29/1971 M SPOUSE
01/01/2003 A 05/28/1973 F
01/01/2003 A 07/10/1974 M SPOUSE
07/01/2000 A 12/06/1964 M
07/01/2000 A 05/09/1964 F SPOUSE
04/01/1992 A 12/27/1964 M
• 04/01/1992 A 12/16/1965 F SPOUSE
04/01/1992 A 12/24/1949 M
04/01/1992 A 08/01/1955 F SPOUSE
07/01/1996 A 05/05/1965 M
07/01/1996 A 05/14/1967 F SPOUSE
10/01/1998 A 12/06/1944 M
10/01/1998 A 06/02/1945 F SPOUSE
04/01/1992 A 12/11/1941 F
04/01/1992 A 05/09/1936 M SPOUSE
04/01/1992 A 12/15/1946 M
04/01/1992 A 10/03/1947 F SPOUSE
04/01/1992 A 12/15/1942 M
04/01/1992 A 01/15/1942 F SPOUSE
04/01/1992 A 01/01/1980 M
04/01/1992 A 04/22/1955 F SPOUSE
04/01/1992 A 12/28/1950 M
04/01/1992 A 09/30/1949 F SPOUSE
06/01/1998 A 10/03/1951 M
06/01/1998 A 09/25/1954 F SPOUSE
06/01/1998 A 11/10/1958 M
06/01/1998 A 12/27/1965 F SPOUSE
04/01/2000 A 01/18/1963 M
04/01/2000 A 03/23/1962 F SPOUSE
02/01/1999 A 12/06/1950 M
02/01/1999 A 02/21/1950 F SPOUSE
01/01/2002 A 03/23/1964 F
01/01/2002 A 05/27/1959 M SPOUSE
08/01/1998 A 05/27/1973 F
08/01/1998 A 02/22/1965 M SPOUSE
08/01/2002 A 12/13/1959 F
08/01/2002 A 12/30/1957 M SPOUSE
04/01/1992 A 12/27/1955 M
04/01/1992 A 12/09/1952 F SPOUSE
04/01/1992 A 12/27/1956 M
04/01/1992 A 07/24/1956 F SPOUSE
Page 17
Terminated Class
E-type
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
T
03
N
03
N
03
N
03
N
volume
300,000.00
10,000.00
300,000.00
200,000.00
10,000.00
200,000.00
150, 000.00
190,000.00
100, 000.00
50, 000.00
30,000.00
30,000.00
10, 000.00
10, 000.00
100,000.00
130, 000.00
30,000.00
30,000.00
100,000.00
10,000.00
200,000.00
50,000.00
10,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 112 Voluntary Life - Spouse
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name Effective Status Birthday Sex Relation
09/01/1993 A 12/18/1959 F
09/01/1993 A 02/11/1955 M SPOUSE
04/01/1992 A 12/24/1952 F
04/01/1992 A 09/30/1950 M SPOUSE
07/01/2003 A 03/16/1974 F
07/01/2003 A 10/11/1969 M SPOUSE
04/01/1992 A 12/29/1947 M
04/01/1992 A 11/20/1954 F SPOUSE
04/01/1992 A 12/08/1965 M
04/01/1992 A 05/14/1966 F SPOUSE
04/01/1997 A 12/30/1951 M
' 04/01/1997 A 08/31/1954 F SPOUSE
04/01/1992 A 12/20/1945 M
04/01/1992 A 08/15/1949 F SPOUSE
04/01/1992 A O1/01/1980 M
04/01/1992 A 05/11/1944 F SPOUSE
06/01/1998 A O1/01/1980 F
06/01/1998 A 03/27/1955 M SPOUSE
11/01/1994 A 07/05/1963 M
11/01/1994 A 07/28/1962 F SPOUSE
10/01/1992 A O1/01/1980 F
10/01/1992 A 10/31/1941 M SPOUSE
O8/01/1992 A 12/15/1962 F
08/01/1992 A 05/24/1961 M SPOUSE
02/01/1994 A 12/06/1966 M
02/01/1994 A 09/13/1969 F SPOUSE
08/01/1994 A 12/13/1967 F
O8/01/1994 A 05/22/1965 M SPOUSE
09/01/1999 A 07/29/1969 M
O1/01/1994 A 09/02/1971 F SPOUSE
02/01/1996 A 12/23/1965 F
02/01/1996 A 05/29/1963 M SPOUSE
04/01/1992 A 12/10/1966 M
04/01/1992 A 04/17/1967 F SPOUSE
01/01/1995 A 04/04/1957 M
O1/01/1995 A 04/06/1960 F SPOUSE
05/01/1992 A 12/31/1960 M
05/01/1992 A 10/23/1962 F SPOUSE
O1/01/1998 A O1/01/1980 M
01/01/1998 A 07/31/1959 F SPOUSE
11/01/1994 A 01/01/1980 F
11/01/1994 A 08/07/1952 M SPOUSE
12/01/1999 A 04/25/1969 M
12/01/1999 A 09/08/1979 F SPOUSE
O1/01/1994 A 07/23/1961 F
O1/01/1994 A 05/31/1960 M SPOUSE
Page 18
Terminated Class
E-type
03
N
03
T
03
N
03
N
03
N
03
N
03
T
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
T
03
N
03
N
03
N
Volume
50, 000.00
50,000.00
100,000.00
10,000.00
100,000.00
100,000.00
10,000.00
10,000.00
10,000.00
30,000.00
20, 000.00
100,000.00
100,000.00
50, 000.00
150,000.00
10,000.00
100,000.00
110,000.00
100,000.00
50,000.00
100,000.00
100,000.00
100.000.00
ADC50 Enrollee and Dependents List 29/JUL/2003
------ ----------------------------- ___--_____-
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
06/01/1994 A 07/18/1955 M
06/01/1994 A 07/15/1959 F SPOUSE
06/01/2002 A 02/25/1976 M
06/01/2002 A 05/12/1978 F SPOUSE
04/01/1994 A 03/06/1952 M
04/01/1994 A O1/11/1949 F SPOUSE
07/01/1999 A 08/07/1961 M
07/01/1999 A 06/27/1962 F SPOUSE
04/01/1992 A 12/26/1955 F
04/01/1992 A 04/29/1948 M SPOUSE
09/01/2001 A 05/28/1963 F
09/01/2001 A 04/24/1963 M SPOUSE
04/01/1992 A 12/07/1957 M
04/01/1992 A 04/07/1960 F SPOUSE
04/01/1992 A 12/04/1946 M
04/01/1992 A 11/30/1941 F SPOUSE
10/01/1998 A 12/29/1964 F
10/01/1998 A 12/19/1958 M SPOUSE
O1/01/1994 A O1/01/1980 M
01/01/1994 A 09/21/1959 F SPOUSE
04/01/1992 A 12/17/1947 F
04/01/1992 A 07/10/1947 M SPOUSE
03/01/1997 A O1/31/1947 F
03/01/1997 A 08/29/1946 M SPOUSE
07/01/1995 A 01/01/1980 F
07/01/1995 A 11/16/1963 M SPOUSE
03/01/1999 A 01/26/1965 F
03/01/1999 A 11/23/1967 M SPOUSE
08/01/1998 A 11/16/1955 F
08/01/1998 A 04/24/1957 M SPOUSE
05/01/2001 A 03/29/1965 M
05/01/2001 A 04/07/1965 F SPOUSE
04/01/1992 A 12/08/1954 M
04/01/1992 A 08/04/1958 F SPOUSE
03/01/2002 A 04/21/1970 F
03/01/2002 A 03/13/1969 M SPOUSE
05/01/1997 A 06/28/1963 M
05/01/1997 A 07/18/1969 F SPOUSE
04/01/1992 A 12/24/1957 M
04/01/1992 A 05/12/1958 F SPOUSE
05/01/2002 A 08/03/1946 F
05/01/2002 A 11/13/1948 M SPOUSE
03/01/1995 A 07/06/1951 M
03/01/1995 A 09/17/1959 F SPOUSE
08/01/1992 A 12/14/1951 M
08/01/1992 A 11/25/1950 F SPOUSE
Page 19
Terminated Class E-type
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 T
03 N
03 N
03 N
03 N
03 N
03 T
03 N
03 N
03 N
03 T
03 N
Volume
50, 000.00
100,000.00
50, 000.00
100, 000.00
100, 000.00
100,000.00
150,000.00
30,000.00
100,000.00
100,000.00
100,000.00
10, 000.00
100, 000.00
100, 000.00
30, 000.00
100,000.00
10,000.00
100,000.00
20, 000.00
10, 000.00
80, 000.00
10,000.00
300,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 112 Voluntary Life - Spouse
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name Effective Status Birthday Sex Relation
02/01/1993 A 12/25/1952 F
02/01/1993 A 11/19/1951 M SPOUSE
02/01/1993 A O5/14/1949 M
02/01/1993 A 05/14/1949 F SPOUSE
06/01/1992 A 12/15/1953 M
06/01/1992 A 12/19/1954 F SPOUSE
O1/01/1996 A O110111980 M
O1/01/1996 A 02/16/1949 F SPOUSE
09/01/2001 A 09/07/1973 M
09/01/2001 A 03/25/1976 F SPOUSE
03/01/1997 A 06/19/1952 M
° 03/01/1997 A 08/22/1956 F SPOUSE
04/01/1992 A 12/07/1947 M
04/01/1992 A 11/20/1950 F SPOUSE
02/01/1998 A 12/24/1961 M
02/01/1998 A 05/16/1960 F SPOUSE
O1/01/1995 A 12/29/1949 M
O1/01/1995 A 10/10/1951 F SPOUSE
10/01/1999 A 08/29/1967 F
.. 03/01/1997 A 05/18/1953 M
03/01/1997 A 03/04/1951 F SPOUSE
04/21/1993 A 03/20/1958 F
04/01/1993 A 09/01/1958 M SPOUSE
06/01/1997 A 12/11/1965 M
06/01/1997 A 12/19/1966 F SPOUSE
04/01/1992 A 12/05/1951 M
04/01/1992 A 10/29/1959 F SPOUSE
O1/01/1994 A 09/12/1959 M
O1/01/1994 A 11/04/1960 F SPOUSE
04/01/1992 A 12/25/1956 M
04/01/1992 A 05/24/1957 F SPOUSE
04/01/2002 A 11/19/1960 M
04/01/2002 A 11/11/1961 F SPOUSE
04/01/1997 A 01/29/1957 M
04/01/1997 A 04/OS/1958 F SPOUSE
08/01/1995 A 08/20/1958 M
O8/01/1995 A 09/07/1962 F SPOUSE
07/01/2003 A 02/25/1955 M
07/01/2003 A 08/05/1955 F SPOUSE
OS/01/2003 A OB/02/1956 F
05/01/2003 A 08/05/1954 M SPOUSE
11/01/1993 A 12/13/1965 M
11/01/1993 A 04/12/1966 F SPOUSE
04/01/1992 A 12/16/1946 M
04/01/1992 A 10/04/1949 F SPOUSE
Page 20
Terminated Class
E-type
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
T
03
N
03
N
03
N
03
N
03
N
03
N'
03
N
03
N
03
N
03
N
03
N
03
N
Volume
50,000.00
50, 000.00
200,000.00
10, 000.00
50,000.00
100,000.00
50,000.00
100,000.00
80,000.00
150,000.00
100,000.00
300,000.00
150,000.00
100,000.00
150, 000.00
20,000.00
300,000.00
300,000.00
100,000.00
50,000.00
100,000.00
30,000.00
70,000.00
ADC50 Enrollee and Dependents List 29/JUL)2003
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 112 Voluntary Life - Spouse
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name Effective Status Birthday Sex Relation
11/01/1998 A 12/12/1956 F
11/01/1998 A 12/09/1950 M SPOUSE
05/01/1998 A 12/30/1955 F
OS/01/1998 A 11/19/1954 M SPOUSE
04/01/2003 A 07/10/1974 M
04/01/2003 A 11/23/1974 F SPOUSE
12/01/2000 A 07/06/1968 M
12/01/2000 A O8/24/1970 F SPOUSE
06/01/2001 A 12/01/1961 M
06/01/2001 A 02/07/1964 F SPOUSE
05/01/1992 A 12/25/1958 M
° 05/01/1992 A O1/12/1962 F SPOUSE
O6/01/1993 A 12/04/1954 M
06/01/1993 A 04/02/1956 F SPOUSE
04/01/1992 A 12/29/1954 F
04/01/1992 A 08/29/1944 M SPOUSE
06/01/1992 A 12/20/1960 F
06/01/1992 A 07/25/1947 M SPOUSE
04/01/1992 A 12/24/1959 M
:-+ 04/02/1992 A O1/25/196B F SPOUSE
04/01/1992 A O1/01/1980 M
04/01/1992 A 09/29/1954 F SPOUSE
O1/01/2003 A 09/20/1955 F
04/01/1992 A 04/14/1952 M SPOUSE
02/01/1999 A 06/04/1953 M
02/O1/1999 A 12/31/1953 F SPOUSE
04/01/1992 A O1/01/1980 F
04/01/1992 A 03/15/1947 M SPOUSE
06/01/1999 A 07/23/1954 F
06/01/1999 A 09/08/1948 M SPOUSE
11/01/1999 A 12/15/1949 F
04/01/1992 A 12)06/1949 M SPOUSE
04/01/1992 A 12/05/1954 F
04/01/1992 A 06/20/1951 M SPOUSE
O1/01/1994 A O1/01/1980 M
O1/01/1994 A 11/18/1951 F SPOUSE
04/01/1992 A 12/07/1963 M
04/01/1992 A 10/25/1965 F SPOUSE
04/01/1992 A 12/04/1954 M
04/01/1992 A 07/07/1955 F SPOUSE
04/01/1992 A 12/10/1963 M
04/01/1992 A O8/31/1963 F SPOUSE
04/01/1998 A 07/10/1945 M
04/01/1998 A 09/10/1951 F SPOUSE
04/01/1992 A O1/01/1980 M
04/01/1992 A 02/09/1959 F SPOUSE
Page 21
Terminated Class
E-type
03
N
03
N
03
N
03
N
03
N
03
N
03
T
03
N
03
N
03
N
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
10,000.00
130, 000.00
300,000.00
100, 000.00
250,000.00
180,000.00
30,000.00
60,000-00
100,000.00
150,000.00
90,000.00
200,000.00
50,000.00
10,000.00
100,000.00
10,000.00
10,000.00
70,000.00
80,000.00
50,000.00
100,000.00
40,000.00
60,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003
_____________________________
Company : 004 Anthem Life Insurance Company
Country : 01 United States
Coverage: 112 Voluntary Life - Spouse
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name Effective Status Birthday Sex Relation
02/01/1996 A 05/06/1960 M
02/01/1996 A 01/17/1967 F SPOUSE
09/01/1993 A 12/03/1964 M
09/01/1993 A 04/24/1965 F SPOUSE
02/01/1993 A 12/19/1948 M
02/01/1953 A 06/19/1953 F SPOUSE
12/01/2002 A 02/24/1970 M
12/01/2002 A 07/21/1971 F SPOUSE
03/01/1997 A 07/31/1970 M
03/01/1997 A 02/20/1972 F SPOUSE
04/01/1992 A 09/02/1955 M
04/01/1992 A 04/23/1958 F SPOUSE
02/01/1998 A 10/20/1969 M
02/01/1998 A 11/11/1969 F SPOUSE
04/01/1992 A 11/11/1965 F
04/01/1992 A 11/11/1965 F SPOUSE
02/01/1996 A 08/16/1961 M
02/01/1996 A 11/30/1963 F SPOUSE
03/01/1993 A 12/13/1961 M
03/01/1993 A 05/26/1965 F SPOUSE
04/01/1992 A 12/27/1947 M
04/01/1992 A 07/06/1948 F SPOUSE
04/01/1992 A 04/25/1946 M
04/01/1992 A 06/25/1953 F SPOUSE
10/01/2002 A 12/18/1957 F
10/01/2002 A 10/23/1957 M SPOUSE
03/01/1999 A 01/24/1968 M
03/01/1999 A 07/20/1971 F SPOUSE
04/01/1996 A 02/08/1950 F
04/01/1996 A 07/10/194S M SPOUSE
02/01/1993 A 12/30/1953 M
02/01/1993 A 05/06/1959 F SPOUSE
•• 04/01/1992 A 12/08/1951 M
04/01/1992 A 11/21/1954 F SPOUSE
04/01/1992 A 12/05/1951 M
04/01/1992 A 12/16/1957 F SPOUSE
O1/01/1997 A 11/06/1961 F
01/01/1997 A 09/14/1961 M SPOUSE
O1/01/1995 A 07/31/1950 M
O1/01/199S A 08/31/1953 F SPOUSE
12/01/2000 A 04/02/1961 M
12/01/2000 A O6/2311969 F SPOUSE
11/01/2001 A 10/19/1972 M
11/01/2001 A 05/14/1974 F SPOUSE
04/01/1999 A 09/14/1968 M
04/01/1999 A 04/08/1969 F SPOUSE
Page 22
Terminated Class
E-type
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
T
03
N
03
N
03
T
03
T
03
N
03
N
03
T
03
N
03
N
03
N
Volume
100,000.00
200,000.00
150, 000.00
250,000.00
10,000.00
70, 000.00
150, 000.00
10, 000.00
200,000.00
100,000.00
10,000.00
100,000.00
50, 000.00
300,000.00
10,000.00
60, 000.00
100, 000.00
200,000.00
250,000.00
50,000.00
10,000.00
300,000.00
250,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003
_____________________________
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 112 Voluntary Life - Spouse
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name Effective Status Birthday Sex Relation
04/01/1992 A 03/15/1954 M
04/01/1992 A 10/26/1958 F SPOUSE
05/01/1999 A 11/17/1950 F
05/01/1999 A O1/18/1950 M SPOUSE
02/01/1999 A 12/28/1967 F
02/01/1999 A 12/03/1967 M SPOUSE
02/01/1993 A 12/02/1944 M
02/01/1993 A 12/01/1945 F SPOUSE
04/01/1992 A 12/05/1954 M
04/01/1992 A 10/31/1956 F SPOUSE
02/01/1994 A 08/10/1947 M
02/01/1994 A 02/27/1946 F SPOUSE
06/01/1992 A 12/02/1958 M
06/01/1992 A 05/08/1964 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
04/01/1999 A 07/22/1977 F SPOUSE
02/01/1999 A O1/01/1980 M
02/01/1999 A 06/25/1956 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
06/01/2002 A 10/05/1962 F
06/01/2002 A 09/28/1960 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
O8/01/2000 A 10/20/1959 M SPOUSE
05/01/1999 A 06/26/1967 M
05/01/1999 A 04/05/1968 F SPOUSE
04/01/1992 A 12/22/1946 M
04/01/1992 A OB/15/1949 F SPOUSE
06/01/1992 A 09/06/1956 M
06/01/1992 A 03/06/1958 F SPOUSE
12/01/2002 A O1/09/1966 F
12/01/2002 A 06/26/1964 M SPOUSE
06/01/2003 A 09/11/1977 F
06/01/2003 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
03
N
03
T
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
T
03
N
03
N
03
N
03
N
03
N
03
N
03
T
03
N
Volume
50,000.00
10, 000.00
300,000.00
100, 000.00
100,000.00
120,000.00
10,000.00
300,000.00
150,000.00
100,000.00
200,000.00
80, 000.00
50,000.00
250,000.00
10,000.00
150, 000.00
150, 000.00
100, 000.00
50,000.00
200,000.00
50,000.00
50,000.00
250,000.00
Page 24
y9/ju1,/2003 __-_______
and Dependents List
Enrollee
assurance company
Anthem Lz fe 1.
Volume
class E-type 10,000.00
004
Company United States
mated
Term=
03 N
01
Country ' Life - Spouse
Sex Relation
30,000.00
112 Voluntary
Coverage' op c0't.LINS
F
EirthdaY M
Status 12/05/1941
F SPOUSE
Effective
03 N
200,000-0
CITY OF
A
p4/O1( 1442 01(09J1g42
M
03 N
006518-0099 Name
A
04101(1492 12/03(1957 F SPOUSE
150, 000.00
P
cert No. DeP
A 02)G6ii957
04/011,992 A M
09/17/191, SPOUSE
03 N
g4JC1S1992 F
08/01/ 1999 A 01118t1968
F
100,000'00
03 T
A 1963
08/O1/1955 12/24( M SPOUSE
50,400.00
A
01/01/1994 06/26/1963 F
1i
03 N -
0110111994 12/25/1969 M SPOUSE
fl fl
200,0.bb
01/01/199, 12/11/1969
M
03 15
01101/1996 05 /19/1959 F SPOUSE
300,000.00
A
03/01/1999 A 06/29/1963 F
03 N
03/01/1999 121211,952 M SPOUSE
300, p00.00
A oz106/1956 A M
06/01/1992
03 N
06/01/1992 oa/16/1971 F SPOUSE
100.000.D0
P.
i1i01(1999 07 /30/1913 M
A
03 N
01/1999 03j11f 1958 SPOUSE
11i P
30,000.00
p
04(O1{1997 02/12/1959 M
03 N
pgf01/1997 A 12J1211958 F SPOUSE
100 000.00
02fD1f 1553 A 08/26/1960 F
03 N
02/01/1993 10/13/1959 M SPOUSE
A
100,000.00
0110112001 A p7/14/1963 M
03 N
01/01/2001 A 09/23/1g70 F SPOUSE
100,000.00
03/01/2000 A 09/09/1915 M
03 N
1/25/1953
A F SPOUSE
03/0112000 2
20,000.00
04J01/1992 A 04/18/1956 M
03 N
p4/01/1992 12/05/1955 F SPOUSE
A
100,000.00
04/01/199' 05/31(1953
A F
03 N
041011,99,
A 01/01/1980 M SPOUSE
7,00,000-00
04/01)1992 A 11/09l1951 F
03 N
0410111992 A 05/12/1963 ?A SPOUSE
100.000 .00
04101/1992 04J2011951 M
A
03 N
D/1950
F SPOUSE
04ffll0992
A 2J03
150 OOO.00
09/01/1994 02/0911966
09/0111994 03/06/1978 SPOUSE
p3 N
2D ,Db0 .DO
A
06/01/2002 Oa/1211984
F
03 14
06(01(2002 A 12(12/1957 M SPOUSE
80,000.00
10/01/1995 A 05/20/1957
03 N
10/01/1995 A 1210911961 M SPOUSE
200,000.00
04/01/199' P. 11/01/1958
F
p3 N
p 4fOli1g92 lZ11 9/1954 M SPOUSE
120,000 .00
A
041011,992 08/17/1957 F
A
03 N
197
04101/1992 A OSi21f M SPOUSE
11/0112000 A 09/14/1974 M
11/01/2000 02115/1954 F SPOUSE
A
p2J01f199'7 04/03(1957
A
02/01/199"
A 50 Enrollee and ➢ependent& List 39/J 12003 Fege 5
--__.------------------------- ------- '"-
Company : 004 Anthem Life Insurance Company
Country 01 United States
Coverage: it0 volvntary Life - Employee
1A518 0099 CITY OF FORT COLLINS
lteutive
Status
Birthday
Sex Relation
Terminated Class
E-type
Y'I'me
/01/1993
A
12/'.1/1959
F
03
N
100,000,00
/01/1992
A
12/I9yi956
M
03
N
300.000.00
!01/3996
A
01/1i/1959
M
03
S
70.000, 00
01,01/2003
A
08::3/1972
F
03
N
300, 000.00
1101(2001
A
03119/1960
M
03
N
150,000.00
1/O1/1999
A
04/17/1941
F
03
N
10,000.00
4/01/1992
A
12/D9/1943
M
03
N
30,000.00
1/01/2002
A
11/23/1955
M
03
T
30, ODD .00
1/01/2003
A
05/28/1973
F
03
N
20O.000.00
7/01/2000
A
12/06/1964
M
03
N
300,ODO.00
6/01/1992
A
12/27/1964
M
03
N
300,000.00
5/01/1992
A
12/06/i952
M
03
N
130,000.00
6/01/1992
A
12/2411949
M
03
N
110,000.00
4/01/199;
A
12/03/1957
F
03
N
100,000.00
,7/01/1996
A
05/05/1965
M
03
N
250,060.00
�5/01/1992
A
12/06/1944
M
03
N
100,000.00
17/01/2002
A
02/07/L965
M
03
N
150.000.00
14/O1/1992
A
12/11(1941
F
01
N
50,000.00
14/01/1992
A
12/15/2946
N
03
N
30,000,00
)1/91/1995
A
04/11/1966
M
03
N
70,000, 00
33/01/1994
A
12/15/1954
M
03
T
200,000.00
04/01/1992
A
12/15/1942
M
03
N
40,000.00
04/01/1991
A
02/24/1951
M
O3
N
30,000.00
04/O1/1992
A
12/28/1950
M
33
N
80,000.OD
06/01/1998
A
10/03/1951
M
03
N
200,000.00
•DQW1998
A
11/10/1958
M
03
N
300.000.00
'2101/2002
A
09113/19D2
M
03
N
300,000.00
04/01/1992
A
12/01/1947
P
03
N
120,00"0
02/01/2001
A
08i19/1949
F
03
N
50,000.00
04/01/1992
A
11/23/1959
M
03
N
160,000.00
)210111991
A
06f1511964
F
03
N
AO.000.00
04/O1/2080
A
O1/19/1961
M
03
N
30,OOD.00
01/01/1995
A
10/31/1951
M
03
N
60,000.00
06/01/1992
A
12/25/1954
M
03
N
200,000.00
02/D3/1993
A
12/06/1950
M
03
T
021,0111996
A
O6/27/1964
M
03
N
200.000.00
01/01/1994
A
04/20/1961
F
03
N
300,000.00
O2/O1/1993
A
.,/35/1950
M
03
N
300,000.00
04/01/1998
A
04j08/1966
M
03
N
300.000.00
04/01/1999
A
04/06/1972
F
03
N
250,000.00
04/01/1992
A
03/23/1964
F
03
N
160,000.00
00/01/1998
A
05/2"1/1573
F
03
N
200.000.00
06/01/1952
A
12/31/1954
M
03
N
100,000.00
04/41/1996
A
03101/1951
M
03
N
300.00O.00
04/01/1992
A
12/04/194E
F
03
N
30.000.00
ADC50 Enrollee and Dependents List 29/JUL/2003
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 112 Voluntary Life - Spouse
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name Effective Status Birthday Sex Relation
04/01/1992 A 12/20/1942 M
04/01/1992 A 01/18/1943 F SPOUSE
02/01/1993 A 12/07/1959 M
02/01/1993 A 10/25/1959 F SPOUSE
04/01/1992 A 12/31/1956 M
04/01/1992 A 04/02/1962 F SPOUSE
04/01/1992 A 12/20/1953 M
04/01/1992 A 10/06/1941 F SPOUSE
02/01/1998 A 03/09/1956 F
02/01/1998 A 02/22/1952 M SPOUSE
04/01/1992 A 12/13/1955 M
04/01/1992 A 06/15/1957 F SPOUSE
09/01/2001 A 08/07/1968 M
09/01/2001 A 09/20/1959 F SPOUSE
01/01/1995 A 02/26/1961 M
01/01/1995 A 04/02/1964 F SPOUSE
04/01/1992 A 12/23/1946 M
04/01/1992 A 09/25/1946 F SPOUSE
03/01/1994 A 04/29/1963 M
.. 03/01/1994 A 04/29/1963 F SPOUSE
02/01/1996 A 09/10/1966 M
02/01/1996 A 12/09/1966 F SPOUSE
04/01/1996 A 03/29/19SS F
04/01/1996 A 09/17/1947 M SPOUSE
04/01/1995 A 07/23/1947 M
04/01/1995 A 10/04/1949 F SPOUSE
04/01/1992 A 12/10/1953 M
04/01/1992 A 11/04/1953 F SPOUSE
04/01/2002 A 05/09/1958 M
04/01/2002 A 09/16/1958 F SPOUSE
02/01/1994 A 12/28/1965 M
02/01/1994 A 02/04/1964 F SPOUSE
., 10/01/1996 A 04/20/1959 F
10/01/1996 A 04/20/1959 M SPOUSE
01/01/1996 A 12/19/1959 M
01/01/1996 A 09/04/1964 F SPOUSE
04/01/1996 A 06/24/1945 M
04/01/1996 A 07/30/1944 F SPOUSE
04/01/1992 A 12/29/1958 M
04/01/1992 A 01/21/1958 F SPOUSE
04/01/1992 A 12/27/1956 F
04/01/1992 A 07/07/1956 M SPOUSE
11/01/1995 A 10/07/1970 M
11/01/1995 A 09/06/1972 F SPOUSE
02/01/2003 A 06/10/1967 M
02/01/2003 A 10/26/1966 F SPOUSE
Page 25
Terminated Class E-type
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 T
03 N
03 N
03 N
03 N
03 N
03 N
03 T
03 N
03 N
Volume
20,000.00
30,000.00
50,000.00
50,000.00
150,000.00
100, 000.00
300,000.00
100,000.00
10,000.00
50, 000.00
100,000.00
50, 000.00
50,000.00
60,000.00
10,000.00
80,000.00
10,000.00
80,000.00
50,000.00
50,000.00
10, 000.00
30,000.00
100, 000.00
ADC50 Enrollee and Dependents List 29/JUL/2003
_____________________________
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
04/01/1992 A 12/09/1954 M
04/01/1992 A 02/10/1953 F SPOUSE
04/01/1992 A 12/29/1945 M
04/01/1992 A O1/22/1947 F SPOUSE
O1/01/1999 A 10/04/1949 M
01/01/1999 A 03/16/1964 F SPOUSE
11/01/2001 A 07/17/1953 F
11/01/2001 A 11/26/1954 M SPOUSE
06/01/1992 A 12/18/1966 M
06/01/1992 A 05/16/1967 F SPOUSE
09/01/1999 A 12/09/1958 F
09/01/1999 A 07/17/1949 M SPOUSE
04/01/1992 A 12/26/1951 M
04/01/1992 A 09/26/1951 F SPOUSE
O1/01/1999 A O1/01/1980 M
01/01/1999 A 07/09/1965 F SPOUSE
04/01/1992 A 12/08/1952 F
04/01/1992 A 07/26/1955 M SPOUSE
O1/01/2003 A 10/21/1969 F
01/01/2003 A 07/20/1963 M SPOUSE
04/01/1992 A 12/19/1950 M
04/01/1992 A 04/13/1951 F SPOUSE
11/01/1996 A 09/06/1970 M
11/01/1996 A 02/26/1971 F SPOUSE
04/01/1992 A 12/14/1959 M
04/01/1992 A 03/02/1963 F SPOUSE
04/01/1992 A 08/20/1945 M
04/01/1992 A 03/16/1950 F SPOUSE
O1/01/1994 A 06/11/1957 F
O1/01/1994 A 04/23/1949 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
04/01/1992 A 12/31/1964 M
04/01/1992 A 10/02/1964 F SPOUSE
02/01/1996 A 09/13/1949 M
02/01/1996 A 02/06/1953 F SPOUSE
08/01/1992 A 12/30/1952 M
08/01/1992 A 11/22/1960 F SPOUSE
04/01/1992 A 12/02/1950 M
04/01/1992 A 10/04/1951 F SPOUSE
04/01/1992 A 12/11/1962 M
04/01/1992 A 12/29/1959 F SPOUSE
04/01/1992 A 12/19/1947 M
04/01/1992 A 07/19/1950 F SPOUSE
Page 26
Terminated Class E-type
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 T
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 T
03 N
03 N
03 T
Volume
150,000.00
10, 000.00
100, 000.00
10, 000.00
50,000.00
90,000.00
100,000.00
50,000.00
10,000.00
100,000.00
30, 000.00
250,000.00
10,000.00
50,000.00
50,000.00
150, 000.00
50,000.00
100, 000.00
40,000.00
100,000.00
10,000.00
100,000.00
30,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003
Company : 004 Anthem Life Insurance Company
Country : 01 United States
Coverage: 112 Voluntary Life - Spouse
Group 006518-0099 CITY OF FORT COLLINS
Cert No- Dep Name Effective Status Birthday Sex Relation
O1/01/1994 A 12/04/19SS F
O1/01/1994 A 11/22/1955 M SPOUSE
06/01/1994 A 03/20/1949 M
02/01/1994 A 01/17/1956 F SPOUSE
07/01/1992 A 12/27/1947 F
07/01/1992 A 07/12/1945 M SPOUSE
05/01/2003 A 05/08/1968 M
05/01/2003 A 04/23/1969 F SPOUSE
07/01/2002 A 10/29/1964 M
07/01/2002 A 05/03/1967 F SPOUSE
O1/01/1998 A 04/04/1954 M
• 01/01/1998 A 11/16/1959 F SPOUSE
04/01/1992 A 12/26/1953 M
04/01/1992 A 09/11/1949 F SPOUSE
O1/01/1996 A 04/15/1949 F
01/01/1996 A 07/06/1949 M SPOUSE
04/01/1992 A 12/03/1954 M
04/01/1992 A 08/08/1967 F SPOUSE
02/01/1997 A 03/04/1948 M
02/01/1997 A 04/03/1948 F SPOUSE
04/01/1992 A 12/23/1959 M
04/01/1992 A 07/13/1956 F SPOUSE
O1/01/2001 A 08/09/1959 F
O1/01/2001 A 04/15/1955 M SPOUSE
01/01/1998 A 10/05/1968 F
01/01/1996 A 10/21/1972 M SPOUSE
04/01/1992 A 12/05/1957 F
04/01/1992 A 03/07/1954 M SPOUSE
04/01/1992 A 12/05/1952 M
04/01/1992 A 04/05/1952 F SPOUSE
04/01/1992 A 12/16/1960 M
04/01/1992 A 02/03/1959 F SPOUSE
02/01/1999 A 02/20/1967 M
02/01/1999 A 08/08/1966 F SPOUSE
10/01/1993 A 06/22/1951 M
10/01/1993 A 05/16/1954 F SPOUSE
O8/01/2002 A 10/23/1969 M
08/01/2002 A 06/27/1972 F SPOUSE
02/01/2003 A 11/30/1967 F
02/01/2003 A 04/06/1969 M SPOUSE
05/01/2002 A 10/14/1951 F
05/01/2002 A 11/11/1939 M SPOUSE
04/01/1992 A 12/18/1968 M
04/01/1992 A 05/20/1967 F SPOUSE
04/01/1992 A 12/22/1964 M
04/01/1992 A 02/04/1961 F SPOUSE
Page 27
Terminated Class E-type
03 N
03 N
03 T
03 N
03 N
03 N
03 T
03 N
03 N
03 T
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 N
03 T
03 N
03 N
03 N
03 N
Volume
100, 000.00
50,000.00
30,000.00
120,000.00
100,000.00
50,000.00
50,000.00
30,000.00
150,000.00
10,000.00
60,000.00
30,000.00
200,000.00
100,000.00
10, 000.00
150,000.00
100, 000.00
150, 000.00
150,000.00
300,000.00
50,000.00
150, 000.00
300,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003
Company 004 Anthem Life Insurance Company
Country : 01 United States
Coverage: 112 Voluntary Life - Spouse
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name Effective Status Birthday Sex Relation
05/01/1997 A 04/16/1948 M
05/01/1997 A 10/23/1949 F SPOUSE
04/01/1992 A O1/01/1980 M
04/01/1992 A 03/07/1953 F SPOUSE
04/01/1992 A O1/01/1980 M
04/01/1992 A 06/09/1953 F SPOUSE
04/01/1992 A O110111980 M
04/01/1992 A 07/20/1950 F SPOUSE
O1/01/1995 A 12/18/1952 M
O1/01/1995 A 05/29/1953 F SPOUSE
10/01/2002 A 07/12/1970 M
10/01/2002 A 06/19/1975 F SPOUSE
04/01/1992 A 12/13/1954 M
04/01/1992 A O1/12/1958 F SPOUSE
05/01/1999 A 08/11/1959 F
OS/01/1999 A 11/04/1964 M SPOUSE
06/01/2000 A 06/25/1960 M
06/01/2000 A 06/07/1961 F SPOUSE
04/01/1992 A 12/20/1956 M
04/01/1992 A 03/06/1963 F SPOUSE
04/01/1992 A 12/26/1956 M
04/01/1992 A 03/11/1958 F SPOUSE
02/01/1993 A 12/26/1950 M
02/01/1993 A O1/18/1951 F SPOUSE
O1/01/1994 A O1/01/1980 F
O1/01/1994 A 08/28/1947 M SPOUSE
04/01/1992 A 12/09/1964 M
04/01/1992 A 06/14/1959 F SPOUSE
08/01/2001 A 06/06/1970 M
08/01/2001 A 01/29/1976 F SPOUSE
04/01/1992 A 12/27/1961 F
04/01/1992 A 01/09/1960 M SPOUSE
05/01/1997 A 05/19/1950 M
05/01/1997 A 11/15/1954 F SPOUSE
O1/01/2001 A 08/03/1975 F
05/01/1997 A 03/26/1957 F
OS/01/1997 A O1/22/1954 M SPOUSE
01/01/2000 A 08/21/1959 F
O1/01/2000 A 11/17/1956 M SPOUSE
02/01/1993 A 12/29/1955 M
02/01/1993 A 10/11/1955 F SPOUSE
10/01/1999 A 04/21/1970 M
O1/01/1994 A 06/08/1964 M
O1/01/1994 A O1/08/1967 F SPOUSE
O1/01/1999 A 05/21/1967 M
O1/01/1999 A 12/26/1958 F SPOUSE
Page 28
Terminated Class
E-type
03
N
03
N
03
T
03
T
03
N
03
N
03
N
03
T
03
N
03
N
03
N
03
N
03
T
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
T
03
N
03
N
Volume
30,000.00
40, 000.00
50,000.00
50,000.00
150,000.00
100,000.00
100, 000.00
100,000.00
100,000.00
10,000.00
70,000.00
50,000.00
10,000.00
100,000.00
300,000.00
180, 000.00
100,000.00
200,000.00
100,000.00
40,000.00
200,000.00
100,000.00
50,000.00
100.000.00
ADC50 Enrollee and Dependents List 29/JUL/2003
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 112 Voluntary Life - Spouse
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name Effective Status Birthday Sex Relation
05/01/1992 A 12/21/1955 F
05/01/1992 A 09/16/1961 M SPOUSE
05/01/2000 A 04/26/1969 M
05/01/2000 A 05/31/1971 F SPOUSE
03/01/2002 A 02/11/1960 M
03/01/2002 A 10/25/1956 F SPOUSE
11/01/1995 A 12/07/1952 F
11/01/1995 A 10/13/1940 M SPOUSE
O1/01/1999 A O8/14/1944 M
O1/01/1999 A 02/27/1950 F SPOUSE
08/01/1998 A 12/07/1956 M
08/01/1998 A 12/25/1969 F SPOUSE
05/01/1998 A 12/23/1960 M
05/01/1998 A 06/25/1956 F SPOUSE
04/01/1993 A 12/08/1954 F
04/01/1993 A 11/14/1946 M SPOUSE
06/01/1992 A 12/29/1959 M
06/01/1992 A 10/07/1963 F SPOUSE
04/01/1992 A 12/23/1953 M
„�. 04/01/1992 A 06/18/1951 F SPOUSE
04/01/1992 A 12/28/1951 M
04/01/1992 A 07/06/1951 F SPOUSE
03/01/2001 A 04/22/1954 M
03/01/2001 A 10/22/1959 F SPOUSE
O1/01/2001 A 02/17/1970 M
O1/01/2001 A 06/14/1973 F SPOUSE
04/01/1992 A 12/08/1956 M
04/01/1992 A 02/13/1956 F SPOUSE
02/01/1998 A 10/12/1955 F
02/01/1998 A 11/20/1946 M SPOUSE
O1/01/1995 A 07/14/1953 M
01/01/1995 A 12/05/1955 F SPOUSE
04/01/1992 A 12/25/1947 M
04/01/1992 A O1/15/1956 F SPOUSE
04/01/1992 A 12/31/1951 M
04/01/1992 A 11/03/1954 F SPOUSE
04/01/1992 A 12/15/1949 M
04/01/1992 A 07/20/1951 F SPOUSE
04/01/1992 A 12/20/1962 M
04/01/1992 A 06/28/1962 F SPOUSE
Page 29
Terminated Class
E-type
03
N
03
N
03
N
03
T
03
N
03
N
03
N
03
N
03
T
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
N
03
T
297
Volume
80,000.00
100, 000.00
100, 000.00
70,000.00
10,000.00
30,000, 00
100,000.00
100, 000.00
100,000.00
10,000.00
100,000.00
150,000.00
90, 000.00
50, 000.00
50,000.00
150, 000.00
150, 000.00
40,000.00
50,000.00
50,000.00
28,500,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003 Page 30
___________ __________
Company : 004
Country : 01
Coverage: 113
Group : 006518-0099
Anthem Life Insurance Company
United States
Voluntary Life - Child
CITY OF FORT COLLINS
Cert No. Dep Name Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
10/01/1993
A
12/19/1956
M
1B
1
5,000.00
03/01/1997
A
02/14/1959
M
1B
1
5,000.00
02/01/2003
A
08/20/1973
F
1B
1
5,000.00
10/01/1993
A
12/06/1952
M
1B
1
5,000.00
10/01/1993
A
12/24/1949
M
1B
1
5,000.00
10/01/1993
A
12/03/1957
F
1B
1
5, 000.00
10/01/1993
A
12/11/1941
F
in
1
5,000.00
O1/01/1995
A
04/11/1966
M
In
1
5,000.00
04/01/1994
A
02/24/1951
M
In
1
5,000.00
10/01/1993
A
12/28/1950
M
1B
1
5,000.00
06/01/1998
A
10/03/1951
M
1B
1
5,000.00
10/01/1993
A
11/23/1959
M
1B
1
5,000.00
10/01/1993
A
12/29/1954
M
1B
1
5,000.00
10/01/1993
A
12/06/1950
M
1B
1
5,000.00
01/01/1994
A
07/15/1960
M
1B
1
5,000.00
04/01/2000
A
04/08/1966
M
1B
1
5,000.00
10/01/1993
A
03/23/1964
F
1B
1
5,000.00
08/01/1998
A
05/27/1973
F
1B
1
5,000.00
10/01/1993
A
12/27/1956
M
1B
1
5,000.00
10/01/1993
A
12/24/1952
F
1B
1
5,000.00
10/01/1993
A
12/16/1961
M
1B
1
5,000.00
10/01/1993
A
12/20/1945
M
1B
1
5,000.00
10/01/1993
A
12/13/19SB
M
in
1
5,000.00
11/01/1994
A
07/05/1963
M
1B
1
5,000.00
01/01/1994
A
12/06/1966
M
1B
1
5,000.00
10/01/1993
A
12/08/1962
M
1B
1
5,000.00
05/01/2002
A
12/13/1967
F
1B
1
5,000.00
12/01/1998
A
07/29/1969
M
in
1
5,000.00
02/01/1996
A
04/04/1957
M
1B
1
5,000.00
02/01/1994
A
12/31/1960
M
1B
1
5,000.00
11/01/1994
A
01/01/1980
F
1B
1
5,000.00
01/01/1994
A
07/23/1961
F
1B
1
5,000.00
05/01/1994
A
07/18/1955
M
1B
1
5,000.00
04/01/1996
A
12/03/1948
M
1B
1
5,000,00
04/01/1994
A
03/06/1952
M
1B
1
5,000.00
10/01/1993
A
12/12/1947
F
1B
1
5,000.00
03/01/2002
A
04/02/1961
F
1B
1
5,000.00
10/01/1993
A
12/07/1957
M
1B
1
5,000.00
10/01/1993
A
12/04/1946
M
1B
1
5,000.00
10/01/1993
A
12/17/1947
F
1B
1
5,000.00
07/01/1995
A
O1/01/1980
F
1B
1
5,000.00
10/01/1993
A
12/08/1954
M
1B
1
5,000.00
10/01/1993
A
12/27/1967
F
1B
1
5,000.00
02/01/1997
A
06/28/1963
M
1B
1
5,000.00
10/01/1993
A
12/17/1956
M -
In
1
5,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003 Page 31
---------------------------------------------- _---------
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 113 Voluntary Life - Child
Group 006516-0099 CITY OF FORT COLLINS
Cert No. Dep Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
03/01/1995
A
07/06/1951
M
IB
1
5,000.00
10/01/1993
A
12/14/1951
M
1B
1
5,000.00
10/01/1993
A
12/25/1952
F
113
1
5,000.00
02/01/1994
A
08/28/1952
M
1B
1
5,000.00
10/01/1993
A
05/14/1949
M
1B
1
5, 000.00
10/01/1993
A
12/15/1953
M
1B
1
5,000.00
09/01/2001
A
09/07/1973
M
1B
1
5,000.00
03/01/1997
A
06/19/1952
M
1B
1
5,000.00
10/01/1993
A
12/13/1955
M
1B
1
5,000.00
10/01/1993
A
12/07/1947
M
1B
1
5,000.00
02/01/1994
A
03/28/1962
M
1B
1
5,000.00
05/01/1997
A
05/18/1953
M
1B
1
5,000.00
O1/01/1994
A
03/20/1958
F
1B
1
5,000.00
06/01/1997
A
12/11/1965
M
1B
1
5,000.00
10/01/1993
A
12/05/19SI
M
1B
1
5,000.00
03/01/1996
A
09/12/1959
M
1B
1
5,000.00
10/01/1993
A
12/25/1956
M
1B
1
5,000.00
04/01/2002
A
11/19/1960
M
1B
1
5,000.00
08/01/1995
A
08/20/1958
M
1B
1
5,000.00
10/01/1993
A
02/25/1955
M
1B
1
5,000.00
10/01/1993
A
12/06/1950
M
1B
1
5, 000.00
04/01/2003
A
07/10/1974
M
1B
1
5,000.00
12/01/2000
A
07/06/1968
M
1B
1
5,000.00
03/01/1997
A
12/25/1958
M
1B
1
5,000.00
10/01/1997
A
12/24/1959
M
1B
1
5,000.00
10/01/1993
A
12/21/1952
M
1B
1
5,000.00
10/01/1993
A
O1/01/1980
M
1B
1
5,000.00
02/01/1999
A
06/04/1953
M
1B
1
5,000.00
10/01/1993
A
O1/01/1980
F
1B
1
5,000.00
10/01/1993
A
12/05/1954
F
1B
1
5,000.00
10/01/1993
A
12/07/1963
M
1B
1
5,000.00
10/01/1993
A
12/04/1954
M
1B
1
5,000.00
01/01/1996
A
05/06/1960
M
1B
1
5,000.00
10/01/1993
A
12/19/1948
M
1B
1
5,000.00
06/01/2000
A
02/20/1972
F
1B
1
5,000.00
03/01/2001
A
09/02/1955
M
1B
1
5,000.00
02/01/1998
A
10/20/1969
M
1B
1
5,000.00
03/01/1996
A
11/11/1965
F
1B
1
5,000.00
10/01/1993
A
12/13/1961
M
1B
1
5,000.00
02/01/1996
A
09/24/1958
F
1B
1
5,000.00
10/01/2002
A
12/18/1957
F
1B
1
5,000.00
10/01/1993
A
12/30/1953
M
1B
1
5,000.00
O1/01/1997
A
11/06/1961
F
1B
1
5,000.00
03/01/1995
A
07/31/1950
M
1B
1
5,000.00
11/01/2001
A
10/19/1972
M
1B
1
5,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003 Page 32
-----------------------------
Company : 004 Anthem Life Insurance Company
Country : 01 United States
Coverage: 113 Voluntary Life - Child
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
03/01/1999
A
12/28/1967
F
1B
1
5,000.00
10/01/1993
A
12/05/1954
M
1B
1
5,000.00
03/01/1999
A
04/21/1965
M
1B
1
5,000-00
10/01/1993
A
12/21/1946
M
113
1
5,000.00
10/01/1993
A
12/17/1963
M
1B
1
5,000.00
12/01/2002
A
12/21/1966
M
1B
1
5,000.00
10/01/1993
A
12/02/1949
M
1B
1
5,000.00
07/01/1996
A
05/13/1962
F
1B
1
5,000.00
10/01/1993
A
12/13/1951
M
18
1
5,000.00
06/01/2002
A
10/05/1962
F
1B
1
5,000.00
05/01/1999
A
06/26/1967
M
1B
1
5,000.00
10/01/1993
A
12/22/1946
M
1S
1
5,000-00
10/01/1993
A
09/06/1956
M
1B
1
5,000.00
•
03/01/2000
A
O1/09/1966
F
1B
1
5,000.00
06/01/2003
A
09/11/1977
F
1B
1
5,000.00
10/01/1993
A
05/09/1956
M
1B
1
5,000.00
10/01/1993
A
12/03/1957
M
1S
1
5,000.00
10/01/1993
A
12/29/1963
F
1B
1
5,000.00
02/01/1997
A
03/11/1958
M
1B
1
5,000.00
-
10/01/1993
A
12/25/1953
M
1B
1
5,000.00
09/01/1994
A
02/03/1950
M
1S
1
5, 000.00
10/01/1993
A
12/21/1957
F
1B
1
5,000-00
10/01/1993
A
12/25/1952
F
1B
1
5,000.00
10/01/1993
A
12/24/1948
M
IB
1
5,000.00
06/01/1998
A
04/22/1966
F
1B
1
5,000.00
10/01/1993
A
12/19/1959
F
1S
1
5,000.00
11/01/2000
A
05/21/1977
F
1B
1
5,000.00
O1/01/2003
A
02/15/1954
M
1B
1
5,000.00
10/01/1993
A
12/07/1959
M
1B
1
5,000.00
10/01/1993
A
12/31/1556
M
1B
1
5,000.00
10/01/1993
A
12/20/1953
M
1B
1
5,000.00
10/01/1993
A
12/14/1949
F
1B
1
5,000.00
•
02/01/1996
A
06/16/1963
M
1B
1
5,000.00
02/01/1998
A
03/09/1956
F
1B
1
5,000.00
10/01/1993
A
12/13/1955
M
1B
1
5,000.00
09/01/2001
A
O8/07/1968
M
1B
1
5,000.00
10/01/1993
A
12/02/1951
M
1B
1
5,000.00
10/01/1993
A
12/23/1946
M
1B
1
5,000.00
03/01/1994
A
04/29/1963
M
1B
1
5,000.00
05/01/1996
A
09/10/1968
M
1B
1
5,000-00
04/01/1995
A
07/23/1947
M
1B
1
5,000-00
10/01/1993
A
12/10/1953
M
1B
1
5,000.00
10/01/1993
A
12/14/1961
M
1B
1
5,000.00
O1/01/1994
A
12/28/1965
M
1B
1
5,000.00
10/01/1993
A
12/30/1948
M
1B
1
5,000.00
ADC50 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
Cert 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
5,000.00
10/01/1993
A
12/19/1954
M
1B
1
5,000-00
10/01/1993
A
12/29/1958
M
1B
1
5,000.00
02/01/2003
A
06/10/1967
M
1S
1
5,000.00
10/01/1993
A
12/09/1954
M
1B
1
5,000.00
02/01/1995
A
07/24/1964
F
1B
1
5,000.00
11/01/2001
A
07/17/1953
F
1B
1
5,000.00
10/01/1993
A
12/26/1951
M
1B
1
5,000.00
10/01/1993
A
12/08/1952
F
1B
1
5,000.00
10/01/1993
A
12/06/1959
M
1B
1
5,000.00
10/01/1993
A
12/11/1958
F
1S
1
5,000.00
10/01/1993
A
12/14/1959
M
1B
1
5,000.00
10/01/1993
A
O8/20/1945
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
1B
1
5,000.00
10/01/1993
A
12/31/1964
M
1S
1
5,000.00
10/01/1993
A
12/17/1957
M
1B
1
5,000.00
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
5,000.00
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
10/01/1993
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
1B
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
1S
1
5,000.00
10/01/1993
A
12/13/1944
M
113
1
5,000.00
10/01/1993
A
06/22/1951
M
1B
1
5,000.00
04/01/2002
A
10/14/1951
F
1B
1
5,000.00
10/01/1993
A
12/16/1946
M
1B
1
5,000.00
10/01/1993
A
12/11/1948
F
1B
1
5,000.00
10/01/1993
A
01/01/1980
M
1B
1
5,000.00
02/01/1995
A
10/31/1963
M
1S
1
5,000-00
O1/01/1995
A
12/18/1952
M
1B
1
5,000.00
10/01/1993
A
12/23/1953
M
1B
1
5,000.00
10/01/1993
A
12/11/1954
M
1B
1
5,000.00
04/01/1994
A
12/09/1954
M
1B
1
5,000.00
10/01/1993
A
12/03/1961
F
1B
1
5,000.00
10/01/1993
A
12/13/1954
M
1B
1
5,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003 Page 34
------
----------- ----------
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 113 Voluntary Life - Child
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
10/01/1993
A
12/04/1956
M
1B
1
5,000.00
10/01/1993
A
12/20/1956
M
1B
1
5,000.00
10/01/1993
A
12/26/1956
M
1B
1
5,000.00
10/01/1993
A
12/26/1950
M
1B
1
5,000.00
08/01/2001
A
06/06/1970
M
1B
1
5,000.00
04/01/1997
A
03/06/1957
M
1B
1
5,000.00
02/01/1994
A
12/16/1946
M
1B
1
5,000.00
10/01/1993
A
O1/30/1949
M
1B
1
5,000.00
10/01/1993
A
05/19/1950
M
1B
1
5,000.00
10/01/1993
A
12/22/1952
M
1B
1
5,000.00
O1/01/1995
A
03/26/1957
F
1B
1
5,000.00
10/01/1993
A
12/29/1955
M
1B
1
5,000.00
10/01/1993
A
12/20/1948
M
1B
1
5,000.00
O1/01/2001
A
06/15/1962
F
1B
1
5,000.00
O1/01/1994
A
06/08/1964
M
1B
1
5, 000.00
10/01/1993
A
12/21/19SS
F
1B
1
5,000.00
O1/01/1995
A
12/27/1958
M
1B
1
5,000.00
05/01/2000
A
04/26/1969
M
1B
1
5,000.00
03/01/2002
A
02/11/1960
M
1B
1
5,000.00
,.r 09/01/2001
A
OS/01/1957
M
1B
1
5, 000.00
09/01/2002
A
02/10/1958
M
1B
1
5,000.00
10/01/1993
A
12/07/1956
M
1B
1
5,000.00
04/01/1996
A
06/23/1959
F
1B
1
5,000.00
10/01/1993
A
12/08/1954
F
1B
1
5,000.00
03/01/1996
A
12/29/1959
M
1B
1
5,000.00
10/01/1993
A
12/15/1957
F
1B
1
5,000.00
10/01/1993
A
12/09/1949
M
1B
1
5,000.00
10/01/1993
A
12/28/1951
M
1B
1
5,000.00
10/01/1993
A
04/22/1954
M
1B
1
5,000.00
01/01/2001
A
02/17/1970
M
1B
1
5,000.00
10/01/1993
A
12/08/1956
M
1B
1
5,000.00
03/01/1995
A
07/14/1953
M
1B
1-
5,000.00
10/01/1993
A
12/25/1947
M
1B
1
5,000.00
10/01/1993
A
12/31/1951
M
1B
1
5,000.00
10/01/1993
A
12/20/1962
M
1B
1
5.000.00
215 1,075,000.Q0
1172 109,875,000.00
Enrollee and Dependents List 29/dUL/2003 Page 6
-
----------------- " -'-----.---------------- -_.
Company 004 AOthem Life Insurance Company
Court ry : 01 United State.
Coverage: 1n0 'Voluntary Life - Emp.oyee
CI-Y OF FORT COLLINS
Effect ve Status Birthday Sex Relation Terminated Class E-type 'Volume
—/01/1992 A 12/l±/1959 F O3 N 40,000 00
/01/1992 A 12/29/1950 F 03 T 30,000.00
/01/1991 A 12/2911949 M 03 T 10,000.00
/01/2001 A 06/07/1957 M. 03 N 30, Do. 00
/01/1992 A 12/1S11964 F 03 N 100,000.00
;/0--/1992 A 12/08/1954 F 03 N 150.000.00
1/01/1992 A 12/27/1955 M 03 N 30,000.00
))ul/2000 A 12/15/1917 M 03 N 100,000.0c
t/01/1992 A 12/27/1956 M 03 N 30,onO.00
9/01/1993 A 11/18/1959 F DJ N SO,000.00
4/01/1992 A 12/24/1952 F 03 N 100,000.00
4/01/1992 A 12/29/1947 M 03 N 250,000.00
4)01/1992 A 1210812965 M 03 N 100,000.00
4/01/1992 A 12/30/:95- M 03 N ISO, 0DO.00
5/01/1992 A 12/16/1961 M 03 N 200,0c0.00
4/01/1992 A 12/26/1959 F 03 N 140,000.CD
I/O1/1992 A 12/11/1947 M 23 N 10,000.00
4/O1/1993 A 12/20/1945 M 03 N 30,000.OD
.110111996 A 06/22/1958 P 03 N 100, 000.00
WOVI992 A 12/13/1950 M 03 N 200,000.00
-1/01/199, A 07/05/1963 M 03 N 50, 000.90
)1/01/1995 A 01/08/1966 F OJ N 30,000,00
)3/01/1999 A 04/25/1962 F 03 T 1001000.0(
)8/01/1992 A 12/15/1962 F 03 N 100,300.00
11/51/1994 A 1210611966 M 03 N 100,000.0D
34/01/1992 A 12/00/1962 M 033 N 30,000.00
04/01/1992 A 12/10/1964 F 03 N 30,ODO 00
04/0=/l992 A :2/]J/1951 F 03 N 100,000..a
04/0:/2000 A 01/10/1959 M OJ N 30,000,00
0410111 P92 A 12i17/1952 M 03 N 30, 000.0.
03/01/1994 A 12/01/1960 M 03 N 170,"0, 00
01/01/1994 A 01/29/1969 M 03 N 150,000.00
02/01/1996 A 12/23/1965 F 03 N MOCO 00
06/01/1992 S 12/10/1966 M 03 N 300,000.Do
03101/1997 A 04/04/1957 M 03 N 110,000, 00
05/01/1992 A 12/31/1960 ,31 03 N 100.000,00
01/01/1994 A 07/23,11961 F 03 N IOV,000.00
01/01/2001 A 12/11/1951 M B3 N SO,D00.00
05/01/199, A 07/18/1955 M 03 N 200,OOC.00
04/01/1999 A 08/31/1960 M 03 N 150.000.00
05/01/1992 A 12/21/1943 F 03 N 30, 000.Do
03/01/2003 A IO/11/1965 M al N 30B,BDo.00
04/01/1992 A 12/05/1961 M 03 N 100,000,00
)5/01/1992 A 12/131195C M 03 N 39,000.00
18/01/1996 A 09/02/1912 M 01 N 300,000 .00
COMPARISON OF PLANS FOR CITY OF FORT COLLINS
C,0MPRF14F.N9IVF. VR RAgIC - PI.ANr nU'cfr-NI Vnr2 VV an inn')
COVERAGE
DELTA Preferred Option #1857
DELTA Preferred Option #1858
COMPREHENSIVE PLAN
BASIC PLAN
Provider Selection
The patient may select a DPO, Delta Participating or a Non-
The patient may select a DPO, Delta Participating or a
Participating provider. A DPO Dentist* must be used to
Non -Participating provider. A DPO Dentist* must be
receive the higher benefits. A patient who uses any other
used to receive the higher benefits. A patient who uses
provider will receive benefits at the lower percentage and may
any other provider will receive benefits at the lower
incur greater out-of-pocket expenses.
percentage and may incur greater out-of-pocket
expenses.
Annual Maximum
$1,500.00 per person
$400.00 per person
*DPO
*DPO PROVIDER
NON-DPO PROVIDER
*DPO PROVIDER
NON-DPO PROVIDER
Diagnostic (X-rays, oral examinations)
in red)
(printed in black)
(printed in red)
(printed in black)
100%
80%
80%
60%
Preventive (Cleanings, Fluoride)
100%
80%
80%
60%
Deductible
$25.00 per person per
$25.00 per person per
$25.00 per person per
$25.00 per person per
calendar year; $50.00 per
calendar year; $50.00 per
calendar year; $50.00 per
calendar year; $50.00 per
family per calendar year.
family per calendar year.
family per calendar year.
family per calendar year.
Deductible does not apply to
Deductible does not apply
Diagnostic & Preventive or
to Diagnostic & Preventive
Orthodontics Services.
Services.
Restorative (Fillings, Stainless steel crowns)
80%
60%
60%
50%
Endodontics (Root canal therapy)
80%
60%
60%
50%
Periodontics (Treatment of the gums)
80%
60%
60%
50%
Oral Surgery (Extractions)
80%
60%
60%
50%
Crown and Bridge
60%
50%
N/A
N/A
Pros thodontics (dentures, partials)
60%
50%
N/A
N/A
* Orthodontics: $1,500.00 Lifetime Maximum
50% (Dependents to age 19 or
50% (Dependents to age 19
N/A
N/A
per eligible dependent children) to age 19 or 25
to age 25 if a full-time
or to age 25 if a full-time
if a full-time student.
student)
student)
* Thn hanerit r... n .. f1.11...d.... a:- *-.._----.. _ enni
the oeneut for ongoing Urthodontic treatment is 50% of the remaining Orthodontic fee balance up to $1,500.
The balance for the remaining Orthodontic fee will be determined as of January 1, 2002.
This is a briefJcscriptiou of your deutal phut and is subject to tine terms of the Contract between Doha Denial Plan and vour eroun. Additional information including plan exclusions and Iiniiiatiuns are found in and governed by the
Consultants and Actuaries:
The Segal Company
DELTA IS NOW ONLINE
You can obtain a list of dentists in your area or verify
if your dentist is a participating member with Delta.
Visit Delta's website at:
www.dettadental.com
d DELTA DENTAL'
Delta Dental Plan of Colorado
Stanford Place III
4582 South Ulster Street
Suite 800
Denver, Colorado 80237
(303) 741-9300
Customer Service:
(303) 741-9305 or (800) 610-0201
GROUP DENTAL PLAN
for
CITY OF FORT COLLINS
(BASIC)
DPO PROGRAM
GROUP NUMBER - 1858
EFFECTIVE - JANUARY 1, 1997
d DELTA DENTAL'
Delta Dental Plan of Colorado
300 8/98
Please complete an Identification Card with your
name and Social Security Number. This is presented to
you for your convenience when making dental visits.
Another card has been included for your spouse. How-
ever, this should be completed with YOUR name and
Social Security Number.
(Please cut on dotted lines)
r--------------------------------------------
I I
I I
4582 South Ulster Street I
d DELTA DENTAL• Denver, Colorado 80237
I Delta Dental Plan of Colorado (303) 741-9300 I
I Customer Service: (303) 741-9305 or (800) 610-0201 1
DPO IDENTIFICATION CARD
CITY OF FORT COLLINS
1 (BASIC)
j NAME GROUP NBUMBER. j
I I
I I
j EMPLOYEE NAME EMPLOYEE SOC. SEC. NO. j
I CURRENT ELIGIBILITY SUBJECT TO DETERMINATION BY DDPC I
I I
I I
d DELTA DENTAL• 4582 South Ulster Street
Denver, Colorado 80237
Delta Dental Plan of Colorado (303) 741-9300
Customer Service: (303) 741-9305 or (800) 610-0201 j
DPO IDENTIFICATION CARD
CITY OF FORT COLLINS
(BASIC)
1858
NAME GROUP NUMBER.
I I
I EMPLOYEE NAME EMPLOYEE SOC. SEC. NO. I
I CURRENT EUGIBIUTY SUBJECT TO DETERMINATION BY DDPC I
notify the employer in writing within thirty-one (31) days of the birth or
placement in order to add the child to the COBRA coverage. A child born,
adopted or placed for adoption and enrolled as indicated will have the same
COBRA rights as any other dependents covered by the plan before the event
that triggered COBRA coverage.
A person's continued coverage elected under the Contract will terminate
at the and of the month in which any of the following events first occurs:
1. The allowable number of months of continued coverage (i.e.18, 29 or 36
months) expires.
2. The Contract terminates.
3. Fees are not paid for the person as required.
4. The person becomes enrolled for dental benefits under another group
dental plan (as an employee or otherwise).
5. The person becomes entitled to Medicare.
Once continued coverage terminates, It cannot be reinstated.
INTRODUCTION
YOUR DENTAL PROGRAM
We are pleased to introduce you to your new dental program. If you
choose the Basic plan, you may not select the Comprehensive plan fortwo (2)
years. If you are waiving dental coverage altogether, you may only enroll in the
Basic plan at a later date.
ELIGIBILITY
All eligible employees and their dependents who enroll shall be covered
on the effective date. All new eligible employees will become effective on the
first day of the month following thirty (30) days of employment.
Your dependents who are covered are your lawful spouse and your
unmarried children until the end of the month towhichthey attain nineteen (19)
years of age or any unmarried children, nineteen (19) years of age until the end
of the month to which they attain twenty-five (25) years who attend an
educational institution on a full-time basis and depend upon you for support.
This includes any stepchild, foster child or legally adopted child who lives with
the employee in a regular parent -child relationship.
Dependent children who are unable to gain employment because of
permanent physical or mental impairment that commenced prior to reaching
age nineteen (19) will be continued as eligible dependents for dental benefits
provided proof of such handicap or incapacity is submitted within thirty-one
(31) days after it is requested by Delta
Dependents in active military service are not covered.
"Dependent" also means any child for whom the employee or spouse is
responsible for medical or other health care benefits under a Qualified Medical
Child Support Order.
ENROLLMENT OF DEPENDENTS
a. You must select the same level of dependent coverage as chosen for
medical coverage.
b. Newly acquired dependents who are enrolled in the medical plan
provided by this employer must be enrolled within thirty-one (31) days of
acquisition. Newborn children must be enrolled within thirty-one (31)
days of birth.
c. Any eligible dependents that suffer involuntary loss of coverage through
another source will be allowed to enroll with satisfactory proof of coverage
loss. Such dependents must be enrolled within thirty-one (31) days of loss
of coverage and must also be enrolled in the medical plan provided by this
employer.
12.
TERMINATION OF COVERAGE
Coverage of enrolled eligible employees will terminate on the earliest date
of the following:
a. The last day of the month that eligibility is terminated in accordance with
the eligibility rules of the Contract, unless the eligible employee elects
continued coverage under the COBRA provisions.
b. The last day of the month for which premium has been paid.
c. The day the Master Contract is terminated.
Coverage for enrolled eligible dependents will terminate.on the earliest of
the following:
a. The day the enrolled eligible employee's coverage under which they are
covered terminates in accordance with the above.
b. The last day of the month for which premium for dependent coverage has
been paid.
c. The last day of the month during which the enrolled eligible dependent
ceasesto be eligible in accordance with the eligibility rules ofthe Contract
unless continued coverage is elected by or on behalf of any dependent
under the COBRA provisions.
HOW TO USE THE DELTA DENTAL PLAN
You may visit any dentist of your choice. If your dentist is a participating
member of Delta Dental Plan, the claim form for benefits will be filed by your
dentist. The patient should complete the top or patient section of the claim
form and sign the form to indicate that he/she authorizes release of the
information to Delta.
If you are treated by a Delta Preferred Option (DPO) Network dentist
(printed in red), you will receive the highest benefits available on this plan.
Delta makes payment directly to the dentist and sends an Explanation of
Benefits to the employee indicating how much the dentist has been paid and
the amount which the employee is responsiblefor paying. If there is an amount
not chargeable to the patient, that is shown on the Explanation of Benefits as
well. Delta Preferred Option Dentists provide services at a reduced fee which
means that your co -payment based on that fee will be less.
Both Delta Preferred Option Dentists and Delta Premier Participating
Dentists have agreed to collect only the portion of your charges for which you
are ultimately responsible (i.e., deductible and coinsurance). You will not be
charged the entire fee at the time services are rendered unless the service you
receive is not covered by your plan.
If you are treated by a Delta Premier Participating Network dentist
(printed in black) locally or nationwide you will receive the benefits indicated
for Premier Participating dentists.
Eligible dependents losing coverage due to any of the following
Oualtfying Events may elect to continue coverage for thirty-six (36)
months following the month in which the event occurs:
• An eligible employee's death;
• A divorce or legal separation from an eligible employee;
• A dependent child's ceasing to qualify as an eligible dependent under
this Program; or
• An eligible employee's entitlement to Medicare benefits.
Anyone who has elected continued coverage and becomes covered
under another plan may continue coverage if the plan contains a pre-existing
condition limitation. Coverage will be continued until the earlier of: the
expiration of the pre-existing condition limitation of the new plan or the
expiration of the original continuation period. The new plan must count the
months for which you have had prior creditable coverage for the pre-existing
condition. It is the employee's or dependent's responsibility to consult with
their new plan administrator to determine if this provision applies in their case.
If an eligible employee becomes entitled to Medicare before the expira-
tion of eighteen (18) months then any of his dependents will be entitled to
continuation of coverage foratotal of thirty-six (36) months fromthe date of the
original Qualifying Event.
Anyone who is entitled to elect continued coverage based on more than
one Qualifying Event shall be limited to continued coverage for a total of
thirty-six (36) months following the date of the first Qualifying Event.
You or your dependent must notify your employer within sixty (60) days
after a divorce or legal separation, or if a dependent child loses eligibility.
Otherwise, the option of continued coverage based on one of these events will
be lost.
Once aware of a Qualifying Event, the employer will notify affected
persons about their right to elect continued coverage. This notice will include
the amount of monthly fees the employer will charge them for continued
coverage as permitted by law. Persons desiring continued coverage must
advise the employer within sixty (60) days after receiving such notice, or within
sixty (60) days after losing coverage due to the Qualifying Event, whichever is
later. You or your dependent will then have forty-five (45) days to pay the initial
installment of fees which shall include fees for all months since the Qualifying
Event.
Continued coverage shall bathe same asfor eligible employees and their
dependents. If coverage is modified for eligible employees and their depend-
ents, it shall also be modified in the same manner for persons with continued
coverage and an appropriate adjustment in fees may be made by the
employer.
After COBRA coverage begins, the employee may add a newborn child,
an adopted child or a child who has been placed with the employee for
adoption and for whom you have financial responsibility. The employee must
11.
2.
WHEN TO USE YOUR DENTAL CARE PLAN
Routine dental care is the best way to maintain
Your oral health. Start at
Your earliest convenience and repeat your check_
ups at least annually,
WENDED COVERAGE
If eligibility is lost, Delta Will
started pnorto the date of termi ll Pay f r e services
a thatwerecoverage
sixty (60) days andP authorized and
removable applies only to single covered servicethat notexceed
us
laboratory prosthodontic appliances crowns,
ry processed restorations Jackets, are fixed or
or other
(60) days after termination of coyerade ere installed or seated Within sixty
Orthodontic Services, if included l this , This provision
program. does not apply to
NOTICE OF RIGHT
TO COBRA COVERAGE
Underthe Consolidated O 1985, as amended b Omnibus Budget Reconciliation
the
Health Insurancep yCongressin1986and1969andfurthe amended by
Who would lose aportability and Accountability) of
coverageunder theirem rs sponsored
eligible
(which includes dental employer s 9 Parsons
entitled to elect plan coverage) due to certain sQua group health plan continued coverage at their own expense.
in „ Eligible employees and dependent.ty g Events are
the followin losin
eighteen I a) Qualifying Events ma g Coverage due to either of
( ) months foflowin y elect t° continue
An eligible employee's 9 the month In which Coverage for
p(oyee's termination of employmentthe event occurs:
misconduct); or (other than for gross
An eligible employee's reduction in
mum required to be eligible under the work hours to less than an
Any eligible employee or de a contract. Y mini-
afion coverage who is disabled Mini -
Pendent who is eligible for C
Security disability and determined to be eligible for continu-
reduction of hours benefits at the time of termination of e
may elect to Soul
dependents for up to an additional elevencf j erage for the rnplOYment or
(18) month extension allowed for the initial ) months following Ives and their
applies if the eligible employeeQuali In 9 the eighteen
disabled within si °r dependent is t Event. This right also
hours. xty (60) days after termination of emtotally and permanently
The employee or dependent must not' p1oYment or reduction of
Social Security disability tY determination within the employer in writing of the
and before the end ofthe initial eighteen My (60) days
Period. Thee of the date it is
(30) days mployeeordependentmustatsonofi8)monthCOBRgcoVefage
Administration that heethe date m any final determination
rmination b Ployerwithin thirty
employee or dependent is no ion the Social Security
longer disabled.
10.
Should you elect to receive treatment from a
With Delta as either a DPO or a Premier Partici
Patin dentist who has not enrolled
9 Dentist), you Will be fully responsiblePaling Dentist i.e.
to the dentist. Delta will reimburse forfilin ( a non-Panent
Dentist. You You for the services ofa� nondforpayment
Deltab mayObtainac(aimform from Your HumanResour
ces Y calling the number o anon -Participating
ack c
basis of the lower level of benefits a d the over. You will be re'mbu�ceorfrom
the country for the covered services prevailinged on the
ing Dentist, 0 fees within his/her area of
YOU do risk additional out of receive, By going to a Non-P
If you anticipate extensive dental servicesPocket costs, articipat-
your dentist must submit the treatment 1Which isactuallydone. Predeterminationofbenefitss Deltallows both ie exceed$4�•�,
plan to Delta forreviewbeforeanywork
to know exactly what is covered and what
additional charge for having You and yourdentlst
Delta will not be obit g a Predetermination
Plan ttnlf pay. There
months to willer e d claims sub
done. is no
Obligated to pay claims submitted more than fifteen (15
If the ate the service was Provided.
Patient or emPloyee encounters an )
drffere O or' Possible excessive charges,
ofaDPOorPartici Y Problems relative to fee
should call the Participating Dentist to quality of care or refusal on the part
cooperate with the program, the e
Colorado, ustomer Service Representative at Delta Dental Plan of
employe
BENEFIT PAYMENT
PREFERRED OPTION DENTIST
Patients who choose
Preferred Option Ne a DPO dentist receive
to practice, h1'oM dentist the highest level of benefits.
has met the criteria for the Deltain rPreferred O
Delta Premier Participating) is a dentist who is licensed
Delta to Dentist who has signed a s Option Program, is a
Participate in the DPO program•
pecia! agreement with
PREMIER PARTICIPATING DENTIST
Premier Part'-cipatin
licensed to practice g Dentist (printed in
Over and who has signedblack), means a de 100,Op0 or 2 out of g anagreementwithDe dentist who is
Dentists. Under the terms of as signed
nationwide lta Dental Plan.
gating Dentists agree to render ig ntala a eetmoent with Premier Participating
requirequirements established b Delta, Premier Partici-
ementsiesta Eligible patients according to
Y the Board of Trustees of Delta Dental Plan.
Submit claim forms for their ea to:
• Accept direct payment from Patients.
at
the portion of the treatment Delta; they may only urge the Is
deductible and/or any coinsurance. not covered b Patient for
File a listingY the plan, i.e., the
of their usual fees, on a confidential basis, P
based upon the Participating Dentist's usual,
able fee as filed with and acceptedpa r will be
b c+.rstomary and reason.
Delta.
3.
NON -PARTICIPATING DENTIST (NOT IN DIRECTORY)
Non -Participating Dentists have not signed participating agreements or
filed fees. If a non -Participating Dentist is chosen, the patient may experience
additional costs out of pocket. The benefit is based on the prevailing fees of
Premier Participating Dentists.
The patient will also be fully responsible forthe dentist's entire fee and for
filing the claim with Delta.
BENEFIT PERCENTAGES
DIAGNOSTIC AND PREVENTIVE SERVICES
80% of a Preferred Option Dentist's allowable fee or
60% of a Premier Participating Dentist's usual, customary and reasonable fee.
BASIC SERVICES
60% of a Preferred Option Dentist's allowable fee or
50% of a Premier Participating Dentist's usual, customary and reasonable fee.
MAXIMUM BENEFIT
Each eligible employee and each eligible dependent may receive up to
$400.00 of covered dental benefits in each calendar year for Diagnostic,
Preventive, and Basic Services.
DEDUCTIBLE
DEDUCTIBLE APPLIES*
BASIC PLAN
DPO Network Dentist
Non-DPO Network Dentist
(type of service}
(printed in red)
(printed in black)
Diagnostic and Preventive
Basic
The patient is responsible forthe first $25.00 of dental charges
each calendar year, with a limit of $50.00 per family.
x. Any payable expense under any other group or individual plan, medical
or dental plan, whether claimed or not.
y. Charges for failure to keep a scheduled visit with your Dentist.
z. Charges for Orthodontics are not covered expenses.
aa. Charges for Special Restorative are not covered expenses.
bb. Charges for Prosthodontics are not covered expenses.
COORDINATION OF BENEFITS
a. If an eligible person is entitled to coverage under two or more plans, then
the benefits of the Contract shall be coordinated with other plan benefits.
"PLAN" means any plan providing dental care benefits under group,
blanket or franchise coverage; or service type plans or other group pre -paid
plans; or coverage under any governmental plan or required by law; or
"No -Fault" motor vehicle insurance.
b. Order of Benefit Determination if the other coverage is provided by a
dental insurance policy or prepaid dental care program:
1. The policy or program covering the patient as an employee shall be
primary over the policy or program covering the patient as a
dependent;
2. For dependent children's expenses the order of benefit determina-
tion shall be as follows:
a. The policy of the parent whose birthday (excluding year of
birth) occurs earlier irft a year shall be primary, or;
b. If the parents are separated or divorced, the policy of the
parent who is ordered by court decree to take financial
responsibility for dental expenses shall be primary, or;
c. The policy of the parent with custody is primary and if said
parent has remarried, the step -parent's plan is secondary
and the plan of the parent without custody pays third.
3. If the above rules do not establish an order of benefit determination,
the plan that has covered the person for the longer period of time
shall be primary with the following exception:
The plan covering the person as a laid -off or retired employee or
dependent of such person, shall be determined after the benefits
of any other plan covering the person or employee.
4. Any group plan that does not contain a coordination of benefits
provision is automatically primary.
If this plan is primary as provided above, this plan shall provide benefits
without regard to benefits provided by any other plan. If this plan is secondary,
this plan will provide benefits which together with the other plan(s) will not
exceed 100% of the covered dental expense or this plan's maximum benefit,
whichever is less.
4. s.
I. Habit appliances, night guards, occlusal guards, athletic mouth guards
and gnathological (jaw function) services, bite registration or analysis, or
any related services (except as covered under this plan).
g. Pre -medication, analgesia, hypnosis or any other patient management
services.
h. Charges for prescription drugs.
I. Experimental procedures, or any procedures other than those covered
services for which the prognosis is good. Any procedures done in
anticipation of future need (except covered preventive services).
j. Hospital costs and any additional fees charged by the dentist or hospital
for hospital services, visits, or charges for use of any facility.
k. Anesthesia other than general anesthesia, intravenous sedation or anal-
gesia administered in connection with covered oral surgery services as
provided for in the Contract.
I. Extraoral grafts (grafting of tissues or other substances from outside the
mouth to or into oral tissues), augmentations or implants and/or any
associated appliances. Removal of implants or any services associated
therewith.
m. Services for the treatment of any disturbances of thetemporomandibular
joint Qawjoint), facial pain, orany related conditions, including any related
diagnostic, preventive or interceptive services. Myofunctional therapy or
speech therapy.
n. Services not performed in accordance with the laws of the state of
Colorado, services performed by any person other than a person
authorized by license to perform such services, or services performed to
treat any condition, other than an oral or dental disease, malformation,
abnormality or condition.
o. Oral hygiene instructions or dietary instructions.
p. Completion of forms, providing diagnostic information or records, or
duplication of x-rays or other records.
q. Replacement of lost, stolen or damaged appliances.
r. Preparation for placement or replacement, removal or repair, or any other
procedure related in any way to any procedure or service not included in
covered service. Any services not specifically included as covered.
s. Services for which payment is prohibited by any law of the jurisdiction in
which the eligible person resides at the time the expenses are incurred.
t. Services for which charges would not have been made if this coverage
had not existed, except for services as provided under Medicaid.
U. Services for which legal payment obligations have been reduced due to
a professional or courtesy discount, or for services by a relative as the
provider.
v. Services which result from an act of declared or undeclared war or armed
aggression.
w. Services which result, whetherthe insured person is sane or insane, from
an intentionally self-inflicted injury or sickness.
COVERED DENTAL SERVICES
*This booklet is not a contract. The summary information In this
booklet is intended to describe in general terms the main features of the
program and does not constitute a contract. The specific terms and
conditions governing the coverage are set forth in the Contract between
Delta and your group and constitutes the basis on which claims will be
paid.
I. DIAGNOSTIC, PREVENTIVE AND ADJUNCTIVE SERVICES
Diagnostic - Provides the necessary procedures to assist the dentist in
evaluatingthe conditions existing and the dental care required as provided for
in the Contract. Covered Diagnostic Services include:
Oral Examination - to include initial, periodic or emergency
Dental X-Rays - to include complete (full mouth) series, single x-rays, or
bitewings
Preventive - Provides the necessary procedures ortechniques to prevent
the occurrence of dental abnormalities or disease as provided for in the
Contract. Covered Preventive Services include:
Dental Cleaning - to include removal of all deposits and/or stains, and
polishing as a single complete service
Adjunctive - Services including emergency treatment performed as a
temporary measure to relieve pain as provided for in the Contract.
LIMITATIONS ON DIAGNOSTIC, PREVENTIVE AND
ADJUNCTIVE BENEFITS
a. Complete mouth x-rays are a benefit only once in sixty (60) months,
unless special need exists.
b, Bitewing x-rays are a benefit only once in a twelve (12) month period and
are not a benefit in addition to a complete series.
c. Cleanings and oral examinations are a benefit only twice in a twelve (12)
month period.
d. Topical fluoride application is a benef it only to children through age fifteen
(15), and is a benefit only once in a twelve (12) month period.
e. Benefit for examination will not be made when performed in conjunction
with any covered Adjunctive Service.
f. Benefit for covered diagnostic services may be applied toward the cost of
special diagnostic services or techniques and the patient shall be
responsible for the portion of the dentist's fee in excess of the Delta
allowance.
8. 5.
gSP ace maintainer is a benefit only for premature loss of deciduous (baby)
teeth for children through age thirteen (13).
h. Sealant Benefits include the application of sealants only to permanent
molar teeth with the occlusal surfaces intact, no caries (decay), and with
no restorations.
I. Separate benefit shall not be made for any preparation or conditioning of
the tooth or any other procedure associated with sealant application.
j. Sealant Benefits do not include any repair or replacement of a sealant on
any tooth within three (3) years of its application. Such repair or replace-
ment is considered included in the fee for the initial placement of the
sealant.
k. Sealants area benefit onlyfor eligible dependent children through the age
of fourteen (14).
if. BASIC SERVICES
Restorative - Provides the necessary procedures to restore the teeth
other than special restorative. Covered Basic Restorative Services include
Amalgam, Silicate and Resin Restorations.
Endodontics - Includes the necessary procedures for pulpal and root
canal therapy as provided for in the Contract.
Oral Surgery - Extractions and certain other surgical services and
associated covered anesthesia as provided for in the Contract.
Periodontics -Services for treatment of gums and bone supporting teeth
as provided for in the Contract.
LIMITATIONS ON BASIC SERVICES
a. Benefits for the same covered basic restorative service shall not be
provided more than once in any twelve (12) month period.
b. Allowance for amalgam on posterior (back) teeth or intraorally cured
(placed and hardened completely in the mouth) resin or plastic restora-
tions (fillings) on anterior (front) teeth may be made toward the cost of
more expensive procedures or materials selected, and the patient shall
be responsible for the portion of the dentist's fee in excess of the Delta
allowance.
c. Covered surgical periodontic services area benefit only once in athirty-six
(36) month period and covered adjunctive perodonti services are a
benefit only once in a twenty-four (24) month period, unless evidence of
special need is provided to Delta.
d. Pulpotomy, Pulpectomy is a benefit only for deciduous (baby) teeth.
e. Benefits for non surgical periodontal procedures which include any
component of prophylaxis are limited to those provided under the
limitation of Diagnostic and Preventive Services.
I. No benefit shall be provided for any procedures performed on teeth
retained in relation to an overdenture.
GENERAL LIMITATIONS - ALL SERVICES
a. If an eligible person selects a service that is not provided for under the
terms of the Contract or specialized techniques rather than standard
services, Delta will pay the applicable percentage of the fee for the least
costly commonly performed covered service and the patient is responsi-
ble for the remainder of the dentist's fee.
b. Veneers, facings, or any other cosmetic services posterior to the first
molar are considered cosmetic and are not a benefit.
c. Pre- and post -operative procedures are considered part of any covered
service and are not benefits.
d. Local anesthesia is considered a component of any procedure in which it
is used.
e. Allowance for any covered service started but not completed shall be
limited to the amount determined by Delta.
f. A temporary dental service will be considered an integral part of a
complete dental service rather than a separate service, and separate
payment shall not be made for a temporary service unless otherwise
included as a covered service on the Contract.
g. Allowance for assistant surgeon when determined by Delta to be a
covered benefit shall not exceed 20% of the surgeon's fee for the same
covered service.
EXCLUSIONS
THE FOLLOWING SERVICES ARE NOT BENEFITS:
a. Services for injuries or conditionswhich are compensable underWorker's
Compensation, employer's liability laws, no-fault auto insurance, or
services which are provided to the eligible person by any federal or state
government agency or are provided without costto the eligible person by
any municipality, county or other political sub -division, or any services for
which the eligible person would have no obligation to pay in absence of
this coverage, except as such exclusion may be prohibited by law, such
as Medicaid.
b. Any covered service started during any period when the person was not
eligible for such service under the Contract.
c. Services for treatment of congenital (present at birth) or developmental
(following birth) malformations, except intraoral dental services for treat-
ment of a condition which is related to or developed as a result of cleft lip
and/or cleft palate, unless otherwise included as a covered service of the
Contract.
d. Services for cosmetic reasons.
e. Services for restoring tooth structure lost from wear or for any services
related to protecting, altering, correcting, stabilizing, rebuilding or main-
taining teeth due to improper alignment, occlusion or contour or for
splinting or stabilization of teeth.
7.
6.
Visit Delta's website at:
www.deltadentalco.com
You can search for a dentist, download a claim form or
access other personal account information.
t� DELTA DENTAL
Delta Dental Plan of Colorado
Stanford Place III
4582 South Ulster Street
Suite 800
Denver, Colorado 80237
(303) 741-9300
Customer Service:
(303) 741-9305 or(800) 610-0201
GROUP DENTAL PLAN
for
CITY OF FORT COLLINS
(COMPREHENSIVE)
DPO PROGRAM
GROUP NUMBER - 1857
EFFECTIVE - January 1, 1997
REVISED - January 1, 2002
d DELTA DENTAL
Delta Dental Plan of Colorado
2,000
01102
ADCSO Enrollee and Dependents LisC 29/J /2003 Page 9
Company C04 Anthem Life Insurance Company
Country C1 United States
Coverage: 110 Voluntary Life - Employee
CITY OF PORT COLLINS
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
^^/01/2000
A
06/21/1556
M
03
N
250,000.00
/01/1992
A
12/02/1952
M
03
N
100,000.00
/01/1992
A
12/27/1947
M
03
N
501000.00
/01(1992
A
12/23/1962
F
03
N
1001000.00
,/01/1992
A
12/03/194S
M
03
N
150,000.00
1/01/1992
A
12/13/1952
F
01
N
120,000.00
i/01/2002
A
02/25/1978
M
03
N
100,000 .00
1/01/1994
A
10/0)/1960
F
03
N
IOC,ODO.00
B/01/1993
A
12/26/1955
P
03
N
300,000.00
6/01/1994
A
03/06/1952
M
03
N
100,000,00
71011IS99
A
09/0I/1961
M
03
N
210,300.00
2/01/1993
A
12/12/1947
F
03
N
20,000.00
4/01/1992
A
12/26/1955
F
03
N
30,000.00
1/01/1995
A
02/00/1966
M
03
T
30,000.00
0/01/200C
A
04/19/1970
M
03
N
30,000.00
3/01/2002
A
04/02/1961
F
03
T
50.000.00
9/01/2001
A
05/28/1963
t'
03
N
150,000.00
6/O1/1992
A
1210711957
M
03
N
300,000.00
16/01/1992
A
12/04/1946
M
03
N
300,000.00
19/01/1998
A
12/29/1964
F
03
N
60.000.00
14/01/2992
A
12/17/1947
F
03
N
100,000,00
33/01/1937
A
01/31/1947
F
03
N
30,0D0.00
34/01/1999
A
O1/2611965
F
03
N
100,000.00
)5/01/1995
A
12/31/1957
F
03
N
250,000.00
:,a/01/3998
A
11/16/1955
F
03
N
10,D00.00
)4/C1/1992
A
12/26/1961
M
03
N
300,000 00
11/01/2002
A
10!0a/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
O6/28/1963
M
03
T
40.000.00
06/01/1992
A
,2/24/_957
M
03
N
300.000.00
12/01/1993
A
12/05/1941
F
0)
N
30,000.00
04/01/1992
A
12/-2/1956
M
03
T
30,000.00
04/01/1952
A
12/27/1951
M
03
N
30,000.00
08/01/1993
A
12/08/1960
M
03
N
10,000.00
05/01/2002
A
08/03/1946
F
03
N
20,000.00
03/01/1995
A
07/06/1951
M
O3
N
10,000.00
08/01/1992
A
12/14/19SI
M
03
N
300,000.OD
02/01/1993
A
12/25/1952
F
03
N
100.000.0c
04/01/1992
A
12/27/1942
F
03
N
3D,000.00
09/01/1992
A
56/26/1961
M
01
N
100,C00.00
02/01/1993
A
08/28/1952
M
03
N
50,000.00
02/01/1993
A
05/14/1949
M
03
N
100.000.00
Please complete an Identification Card with your name
and Social Security Number. This is presented to you for
your convenience when making dental visits. Anothercard
has been included for your spouse. However, this should
be completed with YOUR name and Social Security
Number.
(Please cut on dotted lines)
r--------------------------------------I
I �
I 1
d DELTA DENTAL '
1 P.O. Box 173503 I
I Denver, Colorado 80217-3803 1
I Delta Dental Plan of Colorado (303) 741-9300
Customer Service: (303) 741-9305 or (800) 610-0201
I I
DPO IDENTIFICATION CARD
I I
CITY OF FORT COLLINS
(COMPREHENSIVE) 1857
NAME GROUPNUMBER
I �
I I
I EMPLOYEE NAME EMPLOYEE SOC. SEC. NO.
1 CURRENT ELIGIBILITY SUBJECT TO DETERMINATION BY DDPC
1
---------------------------------------
I I
I I
dP.O. Box 173803
DELTA DENTAL I
I
Denver, Colorado 80217-3803
I Delta Dental Plan of Colorado (303) 741-9300 1
' Customer Service: (303) 741-9305 or (800) 610-0201 1 I 1
I
1 DPO IDENTIFICATION CARD
I I
CITY OF FORT COLLINS
(COMPREHENSIVE) 1857
NAME GROUPNUMBER
I �
I I
1 EMPLOYEE NAME EMPLOYEESOC. SEC.NO. '
1 CURRENT EUGIBILITY SUBJECT TO DETERMINATION BY DDPC-------------------------------
'
I
INTRODUCTION
YOUR DENTAL PROGRAM
We are pleased to introduce you to your new dental program. If you choose
the Basic plan, you may not select the Comprehensive plan for two (2) years. If
you are waiving dental coverage altogether, you may only enroll in the Basic plan
at a later date.
ELIGIBILITY
All eligible employees and theirdependents who enroll shall be covered on the
effective date. All new eligible employees will become effective on the first day of
the month following thirty (30) days of employment.
Your dependents who are covered are your lawful spouse and your unmarried
children until the end of the month to which they attain nineteen (19) years of age
or any unmarried children, nineteen (19) years of age until the end of the month to
which they attain twenty-five (25) years who attend an educational institution on a
full-time basis and depend upon you for support. This includes any stepchild,
foster child or legally adopted child who lives with the employee in a regular
parent -child relationship.
Dependent children who are unable to gain employment because of perma-
nent physical or mental impairment that commenced prior to reaching age
nineteen (19) will be continued as eligible dependents for dental benefits provided
proof of such handicap or incapacity is submitted within thirty-one (31) days after
it is requested by Delta.
Dependents in active military service are not covered.
"Dependent' also means any child for whom the employee or spouse is
responsible for medical or other health care benefits under a Qualified Medical
Child Support Order.
ENROLLMENT OF DEPENDENTS
a. Newly acquired dependents who are enrolled in the medical plan provided
by this employer must be enrolled within thirty-one (31) days of acquisition.
Newborn children must be enrolled within thirty-one (31) days of birth.
b. Any eligible dependents that suffer involuntary loss of coverage through
another source will be allowed to enroll with satisfactory proof of coverage
loss. Such dependents must be enrolled within thirty-one (31) days of loss of
coverage and must also be enrolled in the medical plan provided by this
employer.
TERMINATION OF COVERAGE
Coverage of enrolled eligible employees will terminate on the earliest date of
the following:
a. The last day of the month that eligibility is terminated in accordance with the
eligibility rules of the Contract, unlessthe eligible employee elects continued
coverage under the COBRA provisions.
b. The last day of the month for which premium has been paid.
c. The day the Master Contract is terminated.
Coverage for enrolled eligible dependents will terminate on the earliest of the
following:
a. The day the enrolled eligible employee's coverage under which they are
covered terminates in accordance with the above.
b. The last day of the month for which premium for dependent coverage has
been paid.
c. The last day of the month during which the enrolled eligible dependent
ceases to be eligible in accordance with the eligibility rules of the Contract
unless continued coverage is elected byoron behalf ofany dependent under
the COBRA provisions.
HOW TO USE THE DELTA DENTAL PLAN
You may visit any dentist of your choice. If your dentist is a participating
member of Delta Dental Plan, the claim form for benefits will be filed by your
dentist. The patient should complete the top or patient section of the claim form
and sign the form to indicate that he/she authorizes release of the information to
Delta.
If you are treated by a DeltaPreferred Option (DPO) Network dentist
(printed in red), you will receive the highest benefits available on this plan. Delta
makes payment directly to the dentist and sends an Explanation of Benefits to the
employee indicating how much the dentist has been paid and the amount which
the employee is responsible for paying. If there is an amount not chargeable to
the patient, that is shown on the Explanation of Benefits as well. DeltaPreferred
Option Dentists provide services at a reduced fee which means that your
co -payment based on that fee will be less.
Both DeltaPreferred Option Dentists and DeltaPremier Participating Dentists
have agreed to collect only the portion ofyourcharges for which you are ultimately
responsible (i.e., deductible and coinsurance). You will not be charged the entire
fee atthetime services are rendered unlessthe serviceyou receive is notcovered
by your plan.
If you are treated by DeltaPremierParticipating Network dentist (printed
in black) locally or nationwide you will receive the benefits indicated for
Participating dentists.
prior creditable coverage for the pre-existing condition. It is the employee's or
dependent's responsibility to consult with their new plan administrator to deter-
mine if this provision applies in their case.
If an eligible employee becomes entitled to Medicare before the expiration of
eighteen (18) months then anyof his dependents will be entitled to continuation of
coverage for a total of thirty-six (36) months from the date of the original Qualifying
Event.
Anyone who is entitled to elect continued coverage based on more than one
Qualifying Event shall be limited to continued coverage for a total of thirty-six (36)
months following the date of the first Qualifying Event.
You or your dependent must notify your employerwithin sixty (60) days after a
divorce or legal separation, or if a dependent child loses eligibility. Otherwise, the
option of continued coverage based on one of these events will be lost.
Once aware of a Qualifying Event, the employer will notify affected persons
about their right to elect continued coverage. This notice will include the amount
of monthly fees the employer will charge them for continued coverage as
permitted by law. Persons desiring continued coverage must advise the employer
within sixty (60) days after receiving such notice, or within sixty (60) days after
losing coverage due to the Qualifying Event, whichever is later. You or your
dependent will then have forty-five (45) days to pay the initial installment of fees
which shall include fees for all months since the Qualifying Event.
Continued coverage shall be the same as for eligible employees and their
dependents. If coverage is modified for eligible employees and their dependents,
it shall also be modified in the same manner for persons with continued coverage
and an appropriate adjustment in fees may be made by the employer.
After COBRA coverage begins, the employee may add a newborn child, an
adopted child or a child who has been placed with the employee for adoption and
for whom you have financial responsibility. The employee must notify the
employer in writing within thirty-one (31) days of the birth or placement in order to
add the child to the COBRA coverage. A child bom, adopted or placed for
adoption and enrolled as indicated will have the same COBRA rights as any other
dependents covered by the plan before the event that triggered COBRA
coverage.
A person's continued coverage elected underthe Contract will terminate at the
end of the month in which any of the following events first occurs:
1. The allowable number of months of continued coverage (i.e. 18, 29 or 36
months) expires.
2. The Contract terminates.
3. Fees are not paid forthe person as required.
4. The person becomes enrolled for dental benefits under another group dental
plan (as an employee or otherwise).
5. The person becomes entitled to Medicare.
Once continued coverage terminates, it cannot be reinstated.
15.
NOTICE OF RIGHT
TO COBRA COVERAGE
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) of
1985, as amended by Congress in 1986 and 1989 and further amended by the
Health Insurance Portability and Accountability Act of 1996, eligible persons who
would lose coverage under their employer sponsored group health plan (which
includes dental plan coverage) due to certain "Qualifying Events" are entitled to
elect continued coverage at their own expense.
Eligible employees and dependents losing coverage due to either ofthe
following Qualifying Events may elect to continue coverage for eighteen
(18) months following the month in which the event occurs:
. An eligible employee's termination of employment (other than for gross
misconduct); or
. An eligible employee's reduction in work hours to less than any minimum
required to be eligible under the contract.
Any eligible employee or dependent who is eligible for COBRA continuation
coverage who is disabled and determined to be eligible for Social Security
disability benefits at the time of termination of employment or reduction of hours
may elect to extend coverage for themselves and their dependents for up to an
additional eleven (11) months following the eighteen (18) month extension
allowed for the initial Qualifying Event. This right also applies if the eligible
employee or dependent is totally and permanently disabled within sixty (60) days
after termination of employment or reduction of hours. The employee or
dependent must notify the employer in writing of the Social Security disability
determination within sixty (60) days of the date it is issued, and before the end of
the initial eighteen (18) month COBRA coverage period. The employee or
dependent must also notify the employer within thirty (30) days of the date of any
final determination by the Social Security Administration that the employee or
dependent is no longer disabled.
Eligible dependents losing coverage due to any of the following Qualify-
ing Events may elect to continue coverage for thirty-six (36) months
following the month in which the event occurs:
. An eligible employee's death;
. A divorce or legal separation from an eligible employee;
. A dependent child's ceasing to qualify as an eligible dependent under this
Program; or
. An eligible employee's entitlement to Medicare benefits.
Anyone who has elected continued coverage and becomes covered under
another plan may continue coverage if the plan contains a pre-existing condition
limitation. Coverage will be continued until the earlier of: the expiration of the
pre-existing condition limitation of the new plan or the expiration of the original
continuation period. The new plan must count the months for which you have had
Should you elect to receive treatment from a dentist who has not enrolled with
Delta as either DPO or Premier Participating Dentist (i.e., a Non -Participating
Dentist), you will be fully responsible for filing your claim and for payment to the
dentist. Delta will reimburse you for the services of a Non -Participating Dentist.
You may obtain a claim form from your Human Resources office or from Delta by
calling the number on the back cover. You will be reimbursed on the basis of the
lower level of benefits and the prevailing fees within his/her area of the country for
the covered services you receive. By going to a Non -Participating Dentist, you do
risk additional out of pocket costs. If you anticipate extensive dental services
which would exceed $400.00, yourdentist must submit the treatment plan to Delta
for review before any work is actually done. Predetermination of benefits allows
both you and your dentist to know exactly what is covered and what your plan will
pay. There is no additional charge for having a predetermination done.
Delta will not be obligated to pay claims submitted more than fifteen (15)
months after the date the service was provided.
If the patient or employee encounters any problems relative to fee differences,
possible excessive charges or refusal on the part ofa DPO or Participating Dentist
to cooperate with the program, the employee should call the Customer Service
Representative at Delta Dental Plan of Colorado.
14. 3.
BENEFIT PAYMENT
PREFERRED OPTION DENTIST
Patients who choose a DPO dentist receive the highest level of benefits.
Preferred Option Network dentist (printed in red), is a dentist who is licensed to
practice, has met the criteria for the DeltaPreferred Option program, is a Delta
Participating Dentistwho has signed a special agreementwith Delta to participate
in the DPO program.
PARTICIPATING DENTIST
Participating Dentist (printed in black), means a dentist who is licensed to
practice and who has signed an agreement with Delta Dental Plan. Over 90% of
Colorado dentists, and 2 out of 3 dentists nationwide are Participating Dentists.
Underthe terms of a signed agreement with Delta, Participating Dentists agree to
render dental care to Eligible patients according to requirements established by
the Board of Trustees of Delta Dental Plan. Participating Dentists agree to:
Submit claim forms for their patients.
. Accept direct payment from Delta; they may only charge the patient for the
portion of the treatment that is not covered by the plan, i.e., the deductible
and/or any coinsurance.
. File a listing of their usual fees, on a confidential basis. Payment will be
based upon the Participating Dentist's usual, customary and reasonable
fee as filed with and accepted by Delta.
NON -PARTICIPATING DENTIST (NOT IN DIRECTORY)
Non -Participating dentists have not signed participating agreements or filed
fees. If a non -participating dentist is chosen, the patient may experience
additional costs out of pocket. The benefit is based on the average fees of
participating dentists.
The patient will also be fully responsible forthe dentist's entire fee and forfiling
the claim with Delta.
INTERL APPEAL OF CLAIMS
Questions concerning the action taken on a claim can be directed to the
Customer Service Department for clarification. If the explanation is not accept-
able, you may appeal the determination by writing to the Dental Director of Delta
Dental within one hundred and eighty (180) days after receiving a written denial.
Any written communication should include documents or records in support of
your claim. Delta may submit the matter to the Executive Committee of the Board
of Trustees for review.
EXTERNAL APPEAL OF CLAIMS (only available on qualified claims)
In addition to the Internal Appeal procedures, covered persons have certain
rights under Colorado Division of Insurance Regulation 4-2-21. You may request
an Independent External Review of a claim when the above Internal Appeal
procedures result in a final denial AND that final denial is based on one of the
following reasons:
. medical necessity;
. effectiveness;
. efficiency;
. experimental; or
. investigational.
When a claim qualifies for External Review, Delta will mail you a notice that
explains your right to request an Independent External Review of the denied
claim. In addition to the notice, you will receive the required forms for submitting
your request.
EXTENDED COVERAGE
If eligibility is lost, Delta will pay for services thatwere preauthorized and started
prior to the date of termination. The extended coverage will not exceed sixty (60)
days and applies only to single covered services that are fixed or removable
prosthodontic appliances, crowns, jackets, cast, fused or other laboratory
processed restorations and were installed or seated within sixty (60) days after
termination of coverage. This provision does not apply to Orthodontic Services, if
included in this program.
13.
COORDINATION OF BENEFITS
a. If an eligible person is entitled to coverage under two or more plans, then the
benefits of the Contract shall be coordinated with other plan benefits.
"PLAN" means any plan providing dental care benefits undergroup, blanket or
franchise coverage; or service type plans or other group pre -paid plans; or
coverage under any governmental plan or required by law; or "No -Fault" motor
vehicle insurance.
b. Order of Benefit Determination if the other coverage is provided by a dental
insurance policy or prepaid dental care program:
1. The policy or program covering the patient as an employee shall be
primary over the policy or program covering the patient as a depend-
ent;
2. For dependent children's expenses the order of benefit determination
shall be as follows:
a. The policy of the parent whose birthday (excluding year of birth)
occurs earlier in a year shall be primary, or;
b. If the parents are separated or divorced, the policy of the parent
who is ordered by court decree to take financial responsibility
for dental expenses shall be primary, or;
c. The policy of the parent with custody is primary and if said parent
has remarried, the step -parent's plan is secondary and the plan
of the parent without custody pays third.
3. If the above rules do not establish an order of benefit determination,
the plan that has covered the person for the longer period of time shall
be primary with the following exception:
The plan covering the person as a laid -off or retired employee or
dependent of such person, shall be determined after the benefits of
any other plan covering the person or employee.
4. Any group plan that does not contain a coordination of benefits
provision is automatically primary.
If this plan is primaryas provided above, this plan shall provide benefits without
regard to benefits provided by any other plan. If this plan is secondary, this plan
will provide benefits which together with the other plan(s) will not exceed 100% of
the covered dental expense or this plan's maximum benefit, whichever is less.
WHEN TO USE YOUR DENTAL CARE PLAN
Routine dental care is the best way to maintain your oral health. Start at your
earliest convenience and repeat your check-ups at least annually.
BENEFIT PERCENTAGES
DIAGNOSTIC AND PREVENTIVE SERVICES
100% of a Preferred Option Dentist's allowable fee or
80% of a Participating or Non -Participating Dentist's usual, customary and
reasonable fee.
BASIC SERVICES
80% of a Preferred Option Dentist's allowable fee or
60% of a Participating Dentist's usual, customary and reasonable fee.
MAJOR SERVICES
60% of a Preferred Option Dentist's allowable fee or
50% of a Participating Dentist's usual, customary and reasonable fee.
ORTHODONTIC SERVICES
50% of a Preferred Option Dentist's allowable fee or
50% of a Participating Dentist's usual, customary and reasonable fee.
MAXIMUM BENEFIT
Each eligible employee and each eligible dependent may receive up to
$1,500.00 of covered dental benefits in each calendar year for Diagnostic,
Preventive, Basic and Major Services. Each eligible dependent child may receive
up to $1,500.00 per lifetime for Orthodontic Services.
DEDUCTIBLE
DEDUCTIBLE APPLIES*
COMPREHENSIVE
PLAN
(type of service)
DPO Network Dentist
(printed in red(printed
Non-DPONetwork Dentist
in black
Diagnostic and Preventive
Basic
Major
Orthodontic
The patient is responsible for the first $25,00 of dental charges
each calendar year, with a limit of $50.00 per family.
12. 5.
COVERED DENTAL SERVICES
This booklet is not a contract. The summary information in this booklet
is intended to describe in general terms the main features of the program
and does not constitute a contract. The specific terms and conditions
governing the coverage are setforth inthe Contractbetween Delta andyour
group and constitutes the basis on which claims will be paid.
I. DIAGNOSTIC, PREVENTIVE AND ADJUNCTIVE SERVICES
Diagnostic - Provides the necessary procedures to assist the dentist in
evaluating the conditions existing and the dental care required as provided for in
the Contract. Covered Diagnostic Services include:
Oral Examination - to include initial, periodic or emergency
Dental X-Rays - to include complete (full mouth) series, single x-rays, or
bitewings
Preventive- Provides the necessary procedures ortechniquesto preventthe
occurrence of dental abnormalities or disease as provided for in the Contract.
Covered Preventive Services include:
Dental Cleaning - to include removal of all deposits and/or stains, and
polishing as a single complete service
Adjunctive- Services including emergency treatment performed as a tempo-
rary measure to relieve pain as provided for in the Contract.
LIMITATIONS ON DIAGNOSTIC, PREVENTIVE AND
ADJUNCTIVE BENEFITS
a. Complete mouth x-rays are a benefit only once in sixty (60) months, unless
special need exists.
b. Bitewing x-rays are a benefit only once in a twelve (12) month period and are
not a benefit in addition to a complete series.
c. Cleanings and oral examinations are a benefit only twice in a twelve (12)
month period.
d. Topical fluoride application is a benefit only to children through age fifteen
(15), and is a benefit only once in a twelve (12) month period.
e. Benefitfor examination will not be made when performed in conjunction with
any covered Adjunctive Service.
f. Benefit for covered diagnostic services may be applied toward the cost of
special diagnostic services or techniques and the patient shall be responsi-
ble for the portion of the dentist's fee in excess of the Delta allowance.
g. Space maintainer is a benefit only for premature loss of deciduous (baby)
teeth for children through age thirteen (13).
h. Sealant Benefits include the application of sealants only to permanent molar
g. Pre -medication, analgesia, hypnosis or any other pa Cent management
services.
h. Charges for prescription drugs.
i. Experimental procedures, or any procedures other than those covered
services forwhich the prognosis is good. Any procedures done in anticipation
of future need (except covered preventive services).
j. Hospital costs and any additional fees charged by the dentist or hospital for
hospital services, visits, or charges for use of any facility.
k. Anesthesia other than general anesthesia, intravenous sedation or analge-
sia administered in connection with covered oral surgery services as
provided for in the Contract.
I. Extraoral grafts (grafting of tissues or other substances from outside the
mouth to or into oral tissues), augmentations or implants and/or any
associated appliances. Removal of implants or any services associated
therewith.
m. Services for the treatment of any disturbances of the temporomandibular
joint Qaw joint), facial pain, or any related conditions, including any related
diagnostic, preventive or interceptive services.
n. Services not performed in accordance with the laws of the state of Colorado,
services performed by any person other than a person authorized by license
to perform such services, or services performed to treat any condition, other
than an oral or dental disease, malformation, abnormality or condition.
o. Oral hygiene instructions or dietary instructions.
p. Completion of forms, providing diagnostic information or records, or duplica-
tion of x-rays or other records.
q. Replacement of lost, stolen or damaged appliances.
r. Preparation for placement or replacement, removal or repair, or any other
procedure related in any way to any procedure or service not included in
covered service. Any services not specifically included as covered.
s. Servicesforwhich payment is prohibited byanylawof thejurisdiction in which
the eligible person resides at the time the expenses are incurred.
t. Services for which charges would not have been made if this coverage had
not existed, except for services as provided under Medicaid.
u. Services for which legal payment obligations have been reduced due to a
professional or courtesy discount, orforservices by a relative asthe provider.
v. Services which result from an act of declared or undeclared war or armed
aggression.
w. Services which result, whetherthe insured person is sane or insane, from an
intentionally self-inflicted injury or sickness.
x. Charges for failure to keep a scheduled visit with your Dentist.
y. Any payable expense under any other group or individual plan, medical or
dental plan, whether claimed or not.
6. 11.
GENERAL LIMITATIONS - ALL SERVICES
a. If an eligible person selects a service that is not provided for underthe terms
of the Contract or specialized techniques rather than standard services,
Delta will pay the applicable percentage of the fee for the least costly
commonly performed covered service and the patient is responsible for the
remainder of the dentist's fee.
b. Veneers, facings, or any other cosmetic services posterior to the first molar
are considered cosmetic and are not a benefit.
c. Pre- and post -operative procedures are considered part of any covered
service and are not benefits.
d. Local anesthesia is considered a component of any procedure in which it is
used.
e. Allowance for any covered service started but not completed shall be limited
to the amount determined by Delta.
f. A temporary dental service will be considered an integral part of a complete
dental service ratherthan a separate service, and separate payment shall
not be made for a temporary service unless otherwise included as a covered
service on the Contract.
g. Allowance for assistant surgeon when determined by Delta to be a covered
benefit shall not exceed 20% of the surgeon's fee for the same covered
service.
EXCLUSIONS
THE FOLLOWING SERVICES ARE NOT BENEFITS:
a. Services for injuries or conditions which are compensable under Worker's
Compensation, employer's liability laws, no-faultauto insurance, or services
which are provided to the eligible person by any federal or state government
agencyorare provided withoutcostto theeligible person by any municipality,
county or other political sub -division, or any services for which the eligible
person would have no obligation to pay in absence of this coverage, except
as such exclusion may be prohibited by law, such as Medicaid.
b. Any covered service started during any period when the person was not
eligible for such service under the Contract.
c. Services for treatment of congenital (present at birth) or developmental
(following birth) malformations, except intraoral dental services for treatment
of a condition which is related to or developed as a result of cleft lip and/orcleft
palate, unless otherwise included as a covered service of the Contract.
d. Services for cosmetic reasons.
e. Servicesfor restoring tooth structure lostfrom wearorforany services related
to protecting, altering, correcting, stabilizing, rebuilding or maintaining teeth
due to improper alignment, occlusion or contour or for splinting or stabiliza-
tion of teeth.
f. Habit appliances, night guards, occlusal guards, athletic mouth guards and
gnathological Ijaw function) services, bite registration or analysis, or any
related services (except as covered under this plan).
teeth with the occlusal surfaces intact, no caries (decay), and with no
restorations.
i. Separate benefit shall not be made for any preparation or conditioning of the
tooth or any other procedure associated with sealant application.
j. Sealant Benefits do not include any repairor replacementof a sealant on any
tooth within three (3) years of its application. Such repair or replacement is
considered included in the fee for the initial placement of the sealant.
k. Sealants are a benefit only for eligible dependent children through the age of
fourteen (14).
II. BASIC SERVICES
Restorative - Provides the necessary procedures to restore the teeth other
than special restorative. Covered Basic Restorative Services include Amalgam,
Silicate and Resin Restorations.
Endodontics - Includes the necessary procedures for pulpal and root canal
therapy as provided for in the Contract.
Oral Surgery- Extractions and certain othersurgical services and associated
covered anesthesia as provided for in the Contract.
Periodontics - Services for treatment of gums and bone supporting teeth as
provided for in the Contract.
LIMITATIONS ON BASIC SERVICES
a. Benefits forthe same covered basic restorative service shall not be provided
more than once in any twelve (12) month period.
b. Allowance for amalgam on posterior (back) teeth or intraorally cured (placed
and hardened completely in the mouth) resin or plastic restorations (fillings)
on anterior (front) teeth may be made toward the cost of more expensive
procedures or materials selected, and the patientshall be responsible for the
portion of the dentist's fee in excess of the Delta allowance.
c. Covered surgical periodontic services are a benefit only once in a thirty-six
(36) month period and covered adjunctive periodontic services are a benefit
onlyonce in a twenty-four (24) month period, unless evidence of special need
is provided to Delta.
d. Pulpotomy, Pulpectomy is a benefit only for deciduous (baby) teeth.
e. Benefits for non surgical periodontal procedures which include any compo-
nent of prophylaxis are limited to those provided under the limitation of
Diagnostic and Preventive Services.
f. No benefit shall be provided for any procedures performed on teeth retained
in relation to an overdenture.
10.
Ill. MAJOR SERVICES
Special Restorative - Crowns, jackets, cast, fused or other laboratory
processed restorations for teeth which cannot be restored with amalgam on
posterior teeth or resin/plastic on anterior teeth as provided for in the Contract.
LIMITATIONS ON SPECIAL RESTORATIVE BENEFITS
a. If more than one restoration is used to restore a tooth, benefit will not exceed
the covered amount fora single covered service.
b. Special restorative services are a benefit only once in sixty (60) months for
procedures involving the same teeth.
c. Special restorative services are not a benefit for children under age twelve
(12).
d. No benefit shall be provided for any procedures performed on teeth retained
in relation to an overdenture.
Prosthodontics - Services for construction or repair of fixed bridges, remov-
able partial and complete dentures to replace completely extracted or missing
natural permanent teeth as provided for in the Contract.
LIMITATIONS ON PROSTHODONTIC BENEFITS
a. Replacement of an existing prosthetic appliance is a benefit once insixty (60)
months and only if the appliance is unsatisfactory and cannot be made
satisfactory.
b. A covered prosthodontic appliance is a benefit only after sixty (60) months
has elapsed for any payment of covered special restorative benefit for the
same tooth.
c. Delta will pay the allowed percentage of the dentist's fee for a standard cast
base metal and/or acrylic partial denture or a standard complete denture, up
to a maximum fee allowance for a standard denture. The patient is
responsible for the portion of the dentist's fee in excess of the Delta
allowance.
d. Removable temporary partial dentures are a benefit only when anteriorteeth
are missing. An allowance limited to the covered amount for a removable
appliance may be made toward the cost of the other procedures performed.
The patient is responsible for the portion of the dentist's fee in excess of the
Delta allowance.
e. Benefit based on the cost of a covered complete or partial denture may be
made toward the cost of implants and appliances constructed in association
therewith. If benefit is made for such an appliance, benefit will not be made
for any replacement within sixty (60) months thereafter.
f. Fixed bridges and/or cast metal framework partial dentures are not a benefit
for persons underage sixteen (16).
g. Fixed and removable Prosthodontic appliances are not a benefit in the same
arch except in cases of special need as determined by Delta. Any allowance
made will be limited to the cost of a removable appliance.
h. Overdenture appliance benefits will be limited to the allowance fora standard
appliance.
i. Benefit for reline or rebase of a prosthodontic appliance will be made only
once in any thirty-six (36) month period. Reline or rebase of a prosthodontic
appliance at the time of insertion and/or within six (6) months following
insertion is considered a component of the appliance and a separate
payment will not be made.
IV. ORTHODONTIC SERVICES
Provides the procedures associated with the orthodontic movement of the
teeth into proper alignment, position and occlusion. Only dependent children
under age nineteen (19) and dependent students underage twenty-five (25)
are eligible for Orthodontic benefits.
LIMITATIONS ON ORTHODONTIC BENEFITS
a. Replacement or repair of appliances is not a benefit.
b. Orthodontic care provided in the treatment of periodontal cases or cases
involving treatment or repositioning of the temporomandibularjointorrelated
conditions is not a covered service.
c. The obligation of Delta to make periodic payments for an Orthodontic
treatment plan shall cease upon termination oftreatmentfor any reason prior
to completion of the case.
d. The obligation of Delta to make periodic payments for an Orthodontic
treatmentplan begun priortothe eligibility date ofthe patientshallcommence
with the first payment due following the patient's eligibility date. The above
mentioned maximum amount payablewill apply fullyto this and subsequent
payments.
e. The obligation of Delta to make periodic payments for an Orthodontic
treatment plan shall cease upon termination of the covered person's
eligibility.
f. Delta's obligation to make periodic payments for Orthodontics shall termi-
nate at the end of the month during which the eligible dependent child(ren)
reaches age nineteen (19)orage twenty-five (25) if a full-time student.
g. Extended coverage provisions do not apply to Orthodontic services.
8. 9,
City of Fort Collins - Long Term Care
During open enrollment, this year only, all employees are offered
different plan options on a MODIFIED GUARANTEED ISSUE basis.
The Plans are:
Portable,
Discounted 10% as an employee, up to 25% if you cover your spouse.
Available to family members as frilly underwritten applicants.
Three Plan Options
A. 100% Nursing Facility, 75% Assisted Living, 50% Home Health Care
60 day Elimination Period, $60 Daily Benefit, 4 Year Benefit Period
B. 100% Nursing Facility, 100% Assisted Living, 100% Home Health Care
60 day Elimination Period, $120 Daily Benefit, 6 Year Benefit Period
C. 100% Nursing Facility, 100%0 Assisted Living, 100% Home Health Care
30 day Elimination Period, $150 Daily Benefit, Lifetime Benefit Period
There are riders available to control inflation and payment period.
Get ALL the information you may want at:
Itcwo rksite.comdiohnson
Choose Group Enrollment
User ID fort
Password collins
Take 10 minutes to go through LTC Education.
Then choose Benefit Info to check out your 3 plan choices and RATES.
Want a family member to look at the plan, email them from the site.
Review Definitions, Enroll, Schedule Appointments.
Everything you need or need to know is right there.
Don't wait, click that mouse.
Don't have computer access, leave me a message at X 1050.
ApC50 Enrollee and Dependent. list 29/JM/2003 Page e
-----------------------------
_.___'----_ ....__
Company 004 Anthem Life insurance c_mpany
Country 01 united state.
Coverage: 110 voluntary Life - Employee
group JD6516-0099 CITY OF PORT COLLINS
Cert No. Dep Name
Effective
status
Birthday
Be. Relation
Terminated Class
E-type
volume
01/02/1992
A
12/15/1953
M
03
N
200,000.00
09/01/2001
A
09/07/1973
M
03/01/1997
A
06/19/1952
M
03
N
100.000.00
06/01/1992
A
12/2'_/1951
M
03
N
150.000.00
04/01/1992
A
12/13/1955
M
03
T3
170,000.00
06/01/1992
A
12/17/1947
M
03
N
100,000.OD
04/01/1992
A
12/07/1947
M
03
03
T
N
3D.000.00
02/02/1994
A
33/28/1962
M
03
150, 000.00
06/01/1992
A
12/24/1961
M
03
N
N
100. 000.OD
11/02/1999
A
03/19/1948
M
03
N
300,000.00
04/01/1992
A
12/19/1951
F
03
100,000.00
04/01/1992
A
12/29/1949
M
N
30,000.00
10/01/1999
A
08/29/296,
F
03
N
250,000.00
10/01/1999
A
01/05/1949
M SPOUSE
03
N
250,000.00
01/01/1995
A
05/18/1953
M
03
T
03/01/1997
A
09/03/1944
M
40,000.00
O7/01/1992
A
12/03/1954
M
03
N
SDO,000.00
02/01/1997
A
01/30/1970
M
03
N
30.000.00
O1/01/1994
A
03/20/1958
F
03
N
240,000.00
04/01/1992
A
12/11/1565
M
03
N
100,000.00
02/01/1993
A
12/05/1951
M
03
N
150,000.00
04/01/1992
A
12/23/1952
M
03
03
N
T
200,000.00
O1/01/1994
A
09/12/1959
M
03
N
50,000.D0
03/01/1998
A
O6/07/1957
M
250,OOD.00
01/01/199,
A
O8/01/2943
M
03
N
3001OOD.00
10/01/1999
A
07/29/1975
M
03
N
60,000.00
04/01/1992
A
12/24/1949
M
03
03
N
N
100.000-00
04/01/1992
A
12/25/1956
n
03
N
20,000.00
02/01/1993
A
10/06/1958
M
250,000.Oc
04/01/2002
A
ll/19/1960
M
03
03
N
N
80,000.00
06/01/2002
A
05/04/1966
M
JJ
N
30C,ODO.00
04/01/1997
A
01/29/1957
M
03
I50, 000.00
09/03/1995
A
08/20/1958
M
N
300,000.00
04/O:i1992
A
02/25/1955
M
03
N
150,000.00
11/01/1993
A
12/13;1965
M
03
N
10,000,00
34/01/1992
A
12/16/1946
M
03
N
50, 000.OD
33/01/1995
.A
02/25;1952
M
03
N
30,000.00
11/O1/l998
A
12/12/1956
F
03
N
140. 00C.00
06/01/1992
A
12/30/1941
M
03
03
N
30,000.00
04/01/1992
A
12/06/1950
M
N
30,000.00
10/01/2000
A
05/10/1971
F
03
N
100.000.OD
02/01/2003
A
11/12/1964
M
03
N
300,000.00
OS/01/1998
A
12/30/1955
F
03
N
100,000,00
D9/01/1995
A
12/08/1960
F
03
N
120,000.00
04/01/2003
A
07/10/1974
M
03
N
110,000.00
03
N
300,000.OD
ADC50 Enrollee and Dependents List 29/1VL/20D3
------------ _---- . _.__"..___-
Company : 004 Anthem Life Insurance Company
Country : 01 united states
Coverage: 110 volun b,ry Life - Employee
G loop : CO 6518-0099 CITY OF FORT COLLINS
Cert NO. Dep NaTe Effective Status Birthday Be. Nelatlon
" 12/01/2000 A 07/06/1968 N
021Cl/1996 A 09/05/1957 F
05/01/1995 A 12/01/1961 M
05/tIA992 A 12/2511959 N
06/01/1993 A 1./04/1954 N
00/0111991 A 12/29/1954
04/01/1992 A 12/20/1960 F
09/01/1991 A 05/il/1954 N
04/01/1992 A L2/24/1959 N
04/01/1992 A 12/21/1952 n
04/01/1992 A 12/12/1959 F
' 05/01/1992 A 09/20/1955
02/01/1999 A C6/04/1953 N
O1/01/1999 A 10/07/1958 F
04/01/1992 A 12/15/1949 F
04/01/1992 A 12/05/1954 F
01/01/1592 A 12/07/1963 N
06/01/1992 A 12/24/1959 F
04/01/1992 A 12/04/1554 N
04/01/1992 A 22/10/1963 N
05/01/1999 A 07/20/l945 N
01/01/1997 A 10/10/1950 N
10/01/2002 A C4/30/1971 ]n
GL/01/1996 A CS/06/1960 M
04/01/1992 A 12"W1946 F
08/01/1993 A 12/03/1564 N
10/01/2002 A C91291195 "1 N
03/01/1993 A 12/29/1948 N
12/01/2002 A 02/241197C N
09/01/1995 A 03/20/1970 N
04/01/1997 A 07/31/1970 m
06/0112000 A 02/20/1972 F
04/01i-992 A 09/02/1955 N
07/01/1994 A :0/20/1969 N
02/01/19" A 03/22/1971 M
02/01/1997 A 11/1]/19 E.5 F
02/01/1996 A 06/16/196. N
04/01/1992 A 12/13/1961 N
O S/04/1996 A 09/241L958 F
04/01/1992 A 12/27/194Y N
01/01/1994 A 04/25/1946 N
E4101/1992 A 12/1C/1954 N
10/01/2002 A 12/18/1957 F
C30112000 A 01/21/1966 N
05/02/1996 A 02/08/1950 F
Page 9
Term_nace0 Class
E-type
vu tome
03
N
100,000.00
03
N
100.000 .00
03
N
100,000.00
03
N
120,000.00
03
N
30,000.00
03
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
190,000,09
03
N
SO,000.00
03
N
100,000.00
03
N
50,000.00
03
N
100,000.00
03
N
30,000,00
03
N
SD,000.00
03
N
30,000.00
03
N
16D,000.00
03
N
50,OD0 00
03
N
50,000.00
03
N
60,000.00
03
N
70,000.00
03
N
100,000, to
03
N
30,000.00
03
N
300,000.00
03
N
150,000.00
03
N
150,000.00
G3
N
300,000.00
03
N
200,000.00
03
N
200,000.00
03
N
30,000.00
G3
N
200,000.00
03
N
300,DD0.00
C3
N
300,000,00
C3
N
20,000.00
03
N
200,000.00
03
N
300,000.00
03
N
$0,000.00
03
N
40,000.00
03
N
100,000.00
03
N
30,000.00
03
N
50,000.00
03
N
100,000.00
03
N
70,000.00
ADC50 Enrollee and Dependent. Li.t
Company - 004 Anthem Life Insurance Company
C..n, : 01 United Stare.
Coverage: 110 Volun_ary Life - Employee
GrovB : 006518-0099 CtTY OF FORT COLL!NS
291TIIL/2003 Page le
Cerr No. Dep N... Effective Status Birthday
...__._._ 02/01/1993 A l2/30/L953
O6/01/1999 A 09/28/1960
04/01/1992 A 12/09/1951
04/01/1992 A 12/OS/1951
D1101/1997 A 11/06/1961
13/01il99i A 07/31/2950
12/01/2000 A 04/02/1961
01/01/1992 A 12/13/1963
11/01/2001 A 10/19/1972
04/01/1999 A 09/14i196B
04/01/1992 A 03YIS11954
04/01/1992 A 12/28/1967
02/01/1993 A 12/02/1944
O6/01/1994 A 11/12/1956
24/01/1992 A 12/05/1954
01/01/1994 A 08/10/1947
01/01/1996 A 09/18/1953
06/01/1992 A 12/02/1958
O8/01/1995 A 04/21/1965
0B/01/1992 A 12/21/1946
10/01/3999 A 10/21/1963
04/01/1992 A 12/1,11963
O3/01/2002 A O8/12/1912.
04/U1/1999 A 04/28/1910
04/01/1992 A 12/,05/1949
02/01/1999 A 12/21/1966
03/91/1999 A 08/06/1971
04/D1/1992 A 12/02/1919
07/01/1996 A 05/:3/1962
03/01/1997 A 01/21%L953
03/01/2002 A 09/22/1966
05/01/2003 A 02/Da/1962
04/01/2002 A 06/l9/1975
04/01/1992 A 12/13,.9hl
O6/01/2002 A 10/05/1962
09/01/1993 A 09/08/1964
92/01/1999 A O6/01/1958
O1/01/1996 A 04/21/19'4
OB/O1!2000 A O7/23/196U
01/O1/1995 A 11/01/1945
06/01/2002 A 12/04/1958
08/01/1992 A 12/04/1955
05/01/1999 A 06/26/1567
04/01/1992 A 12/22/1946
06/01/1992 A 09/06/1956
Relation Terminated .'lase
3-t11e
Volume
03
T
1.0'.00. 00
03
N
30,000.30
03
N
60,000.00
03
N
150,000.00
03
N
250,000.00
03
N
100,000.03
03
N
3D,000.00
03
N
100,000.00
03
N
300,000.00
03
A
250,000,00
03
N
3DO,000.00
03
N
300,000,00
03
N
200,000.00
03
N
300,000.00
01
N
150,000A0
03
N
120.000.00
03
N
30,000.00
03
N
300.000.UC
03
N
300.000.0C
03
T
130,000.0C
03
6
120,000.00
03
N
200,000.00
03
N
200.000.00
03
N
300,000.00
23
N
30,000.00
33
N
200,000,00
31
N
200,000.00
93
N
100,000.00
03
x
40,000.00
01
N
15C.000.00
03
N
30.000.00
03
N
250,300.00
03
N
20,20D.00
O3
Y
30.000.00
03
14
50,090.0D
03
Y
1501000.00
03
N
200,000.00
03
N
50,000.00
03
T
150,000.00
03
14
100,000.00
03
N
210,000.O0
03
N
200,000.00
03
N
300,000.00
03
N
60,000.00
03
N
300,000.00
DC50 Enrollee and Dependents List 29/UUL/2003 Page 11
..... -------------------------.---
-----------------.
Company 004 Anthem Life Insurance Company
Country 02 United States
Coverage: 110 voluntary Life - Employee
Croup OOSS38-0099 CITY OF FORT COLLINS
Cert No. Dep Name
Effective
status
Birthday
Sex Relation
Terminated Class
E-type
Volume
03/01/2000
A
01/09/1966
F
03
N
130.DOD.00
06/01/2003
A
09/11/1977
F
03
T
100, 000.00
04/01/1992
A
05/09/1956
M
03
N
250,000.OD
04/01/1992
A
12/05/1941
M
03
N
30.00D.00
O1/01/1994
A
30/31/1952
F
03
N
50,OO1.00
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.D0
D1101/1996
A
12/10/1949
M
03
N
60,ODO.00
11/01/2002
A
10/27/1956
M
03
N
40.000.00
03/01/1998
A
09/17/1965
M
03
N
300,000.00
04/01/1592
A
12/12/1956
F
D3
N
50,000.00
' 02/01/1993
A
12/29/1963
F
03
N
150,000.00
30/01/1992
A
12/25/1969
F
03
T
1001000.00
03/01/1999
A
C5/19/1959
M
03
N
100,000.00
O6/OL/1992
A
12/21/1952
F
93
T
200,000.00
O2/O1/1994
A
06/22/1952
M
33
N
110,000.00
11/01/1999
A
08/18/1971
M
03
N
300,000.00
02/01/1997
A
03/12/1958
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
12/18/1949
M
03
N
50.000.00
03/01/2000
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
P
D3
N
300,000.00
O6/01/2000
A
01/12/1973
M
03
N
300,000.00
11/01/1993
A
12/05/1955
M
03
N
70, 000.00
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
O3
N
200,000.00
06/01/2002
A
03/D6/1909
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
11/22/196,
F
03
N
150,000.00
04/01/1952
A
12/20/1954
F
03
N
300,000.00
04/01/1992
A
12/24/1940
M
03
N
280,000,00
O6;e1/1998
A
04/22/1966
F
03
N
200,000.00
01/01/1996
A
12/12/1957
F
03
N
30,OOD.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
120,000.00
11/01/2.000
A
05/21/1977
F
03
N
20D,000.D0
01/01/1996
A
C2/15/1954
M
03
N
140,000.00
04/O1/1992
A
12/12/1959
M
03
N
100,000.00
O1/01/1996
A
12/07/1951
M
03
T
100,000.00
ADC50
Enrollee and Dependents List
Company : .04 Anthem Life Insurance Company
countay - 01 United state.
Coverage: 110 Voluntary Life - Employee
Group C06518-0099 CITY OF PORT COLLINS
Cart No pop Name
'effective
01/01/2001
04/01/1992
02/01/1993
04/01/1992
04/01/1992
08/01/1992
12/01/1999
04/01/1992
02/01/1996
02/01/1998
01/01/199S
08/01/2003
04!01/1992
09/01/2.01
04/011,1992
06/01/1992
04/01/1995
04/01/1992
03/01/1994
OS/01/1996
02/01/2002
04/91/1995
03/01/1998
04/0:/1992
04/01/2002
01/01/1003
34/O1/1992
04/01/1992
04/01/1992
0./01/:992
04/0l/1992
O'/01/2001
02/01/1997
05/01/1999
09/C1i1992
C2/Oi/1999
01/01/1992
09/01/199C
02/01/1993
04/01/1992
03/O1/:99Y
04/01/1992
06/01/1996
01/01/1995
05/01/2003
R9/JUL/2001
Statu. Birthday
A 06/08/1976
A 12/20/1942
A 12/07/1959
A 12/31/1956
A 12/23/1953
A 12/05/195,
A 07/25/1951
A 12/14/1949
A 06/16/1963
A 03/09/1956
A 30/06/:964
A 07/08/1966
A 12/13/1955
A 08/07/1968
A 12/02/1951
A 12/15/1952
A C2/26/1961
A 12/23/1946
n J4/29/1963
A 09/10/1368
A 03/29/1955
A 07/23/1947
A 10/05/1953
A 12/30/1953
A 05/09/1958
A 01/21/1971
A 12/14/1961
A 12/23/1965
A 12/05/1948
a 12j26/1965
A 12/30JI948
A 11/16/1958
A 04/20/1959
a 04/27/1951
A 12/19/1959
A 02/23/1971
A 12/25/1953
A 06/24/1945
A 11/1911954
A 12/29/1950
A 07/06/196,
A 12/27/1956
A 06/19/1971
A 06/10/1955
A 22/29/1967
S.z
F
M
M
M
M
M
F
P
M
P
F
F
M
M
M
M
N.
M
M
M
F
M
M
M
M
F
M
F
M
M
M
M
F
M
M
M
M
Page 12
Relation Terminated Class E-type Volume
03 T 100.000-00
03 N 40,000.00
03 N 40,000.00
03 N 100, 000.00
03 N 100,000.00
03 N 180,000.30
03 N 70,000.00
03 N 40,000,00
03 N 300,000.00
03 N 130,000.00
03 N 300,000.00
03 N 200,000.00
03 N 100,000.00
03 N 30,000.00
01 N 150,000.00
03 N 250,000.00
03 N 300,000.00
03 N 30.000.00
03 N WOOL .00
03 N 220,000.00
03 N 00,000.00
03 N 50.000.00
03 N 290,000.00
03 N 250,000.00
03 T 100,000.00
03 N 150,000,00
03 N 120,000.00
03 N 110,000 00
03 N 60,000.00
03 N 170, 000.00
03 N 20,000.cc
03 N 150,000.00
03 N 3C,OCO.CO
03 T 30,000.00
C3 N 180,000.00
03 N 300,000.n0
03 N 100, 000. 00
03 N 100,000.0C
03 N Y00,000. 00
03 T 140,000.00
03 T 20, 000. 00
03 T 30.000,00
03 M 220,000.00
03 M 50,000.00
03 N IQO.jj, ,• -�:
ti,p'; ray
z' a ,
A0050 Enrollee and Dependents List 29/JUL/2003
.._...---------------
Company 004 Anthem Life Insurance Company
Country 01 united States
Covera•3e 110 Voluntary I.ifn Employee
Group 00651E-0099 CITY OF FORT COLLINS
Cart No. Dep Name Effective SLaLu6 Birthday Sex Relation
11/01/1995 A 10/07/1910 M
02/01/2003 A 05/1t/1961 M
04/01/2003 A D8/06/1971 M
07/01/1992 I. 12/09/1954 M
02/01/1995 A 07/24/1964 F
02/03/2000 A 10/04/1949 M
11/01/2001 A O7/17/1953 F
06/01/1992 A 12/18/1966 M
11/01/1993 A 12/09/1958 F
D4/01/1992 A 12/26/1951 M
OS/01/1999 A 01/01/1980 - M
04/01/1992 A 12/06/1952 F
O8/01/1992 A 12/06/1959 M
06/01/1992 A 12/19/1950 M
O6/01/1553 A D9/06/1310 M
04/01/1992 A 12/11/1956 F
12/01/2000 A 02/01/1967 M
04/01/1992 A 12/14/1959 M
04/01/1992 A 08/20/1945 M
O1/01/1994 A 06/11/1957 F
04/01!1993 A 12/06/1959 M
04/01/1992 A 12/18/1952 M
04/01/1992 A 12/31/1964 M
01/01/1997 A 09/13/1949 M
04/01/1992 A 12/17!15S7 M
O8/01/1992 A 12/30/1952 M
04/O1/1992 A 12/02/1950 M
0410IY1992 A 12/11/1962 M
04/01/1992 A 12/12/1955
04/01/1992 A 12/25/195B M
05/01/1992 A 12/19/1947 M
02/01/1999 A 06/20/1964 F
O1/01/1990 A 11/21/1960 M
04/01/1992 A 12/04/1955 F
11/01/1994 A 03/20/1949 M
11/01/1993 A 12/17/1941 F
04/01/1992 A 12/27, 1947 F
05/01/2003 A 05/06/1968 M
03/01/1995 A 05/28/1968 M
04/01/1992 A 12/17/1956 F
O7/01/2002 A 10/29/1964 M
02/01/1990 A 04/04/1954 M
04/01/1992 A 12/26/1953 M
02/01/1993 A 12/21/1955 F
04/01!1992 A 06/01/1961 F
Paga 13
T.Imlaited Class
E-type
Volume
Ol
N
30,000.00
D3
N
tDo.000.00
D3
T
200,OOD.00
03
N
2DO,000.00
03
N
50, 000.00
03
N
50,000.00
03
N
100,000.00
03
N
100,000.00
03
N
150,000.00
03
N
100,000.00
03
N
300,000.00
03
T
30,000.00
03
N
200,000.00
01
N
200,000.90
03
N
200.000.00
03
N
30.000.00
03
N
100,000.00
03
N
30, 000.00
03
N
50.000.00
03
N
90,COO.00
03
N
300,000.00
03
N
30,000.00
O3
N
100,000-00
03
N
50,000.00
03
N
30,0OO.DO
03
N
360,OOD.00
03
N
30,000.00
03
N
120,000.00
03
N
100,000.00
03
N
200,003.00
03
N
160,000.00
03
N
140,000.00
03
N
50,000.00
03
N
300,000.00
03
N
70,000.00
03
N
300,000.00
03
N
10,090.00
03
N
120,000.00
03
N
100,000.00
03
N
30,900.00
03
N
200,000.00
03
N
300,000.00
03
N
300,000.OD
D3
N
200,000.00
03
N
120,000.00
CERTIFICATE
N1IYBER--- CERTIFICATE NAME
OPEN AM APPROVED
TOTAL PENDING
TOTAL
.-r
11I Iii.t
UlliV
We Flimadal"
CITY OF FORT COLLINS
GROUP POLICY 96544
y
GROUP LONG TERM DISABILITY CLAIMS SUNRARV
m
SUN LIFE ASSURANCE COMPANY OF CANADA
AS OF 90MAY2003
N
FOR THE PERIOD CIJM2002 TO 3114AY2003
DATE OF
DATE
EXPIRY NET MONTHLY
CLAIMS PAID
TOTAL
DISABLED
BIRTH
DISABLED
DATE BENEFIT
THIS PERIOD
CLAII4S PAID
LIFE RESERVE
r
'--- ----
--------
--------- -----------
--------- -
-----------
------------
r
16FEB1954
19FE82003
16FE92019 M
3095.60
123.82
123.82
140492.00
`0
2aFEBta44
2ONDV2002
29FE82009 F
703.31
4662.93
4652.43
26" 1.00
26MAYfa58
OIOCT2002
26MAY2023 M
1398.25
1090.92
1010.82
83023.00
07JUL 053
115EP200t
07JUL2019 M
2350.22
41677.41
41677.41
184264.00
OGJANS939
13JAN20DI
130CT2004 M
993.22
16804.74
20063.23
16335.00
I1SEP19Sp
22JAN2000
IISEP200 F
1809,42
30743.14
6761A.35
147212.00
ONEP1947
04SEP1999
OSSEP2082 M
04.44
9055,11
43141,49
'51224.00
0HICT1952
03FEB19B9
ClOCT2017 M
1296.75
18724.75
50306.70
130437.00
10KOV1956
22AUG1986
10-VOU2011 F
1290.16
220".72
75969.49
176094.00
14SEP1947
OTJlRJ1997
14SEP2012 F
2727.95
4637S.83
190167.14
247392.00
f
m
16306.67
197330.87
496636.10
1254604.00
!�
13AUG1041
2QNOV2002
ISFE82007 M
2900.46
4182.44
4192.44
09MAR1950
21MOV2001
00MAR2015 M
1810.24
23392.81
23342.81
.00
$
14AUG1994
24NOV2000
28NOV201S F
4637.79
25300.24
37346.76
.00
,OO
D
27FESIS43
04JUM200D
27FE82028 F
1750.63
07524.65
42016.12
24MAY1928
21MAYIS97
2414AY2003 M
797.74
13234.03
50450.21
.00
.00
9791.66
53664.17
163385.34
.00
25102.43
250995.14
660021.44
1251504.00
27A/RIS49
04APP2003
27APR2014 M
2024.10
-00
.00
00623.00
06JUNS939
12MAR2009
40JUN2004 M
129.72
-00
.00
11035.00
2153.82
.00
.00
91656.00
2153.82
.00
.00
91659.00
27256.25
260995.14
660021.44
1343162.00
N
10
W
m
r
N
EXPIRY DATE MAY BE EARLIER THAN GATE SHOWN DEPENDING ON CONTRACTUAL LIMITATIONS
8
W6"W@Y Wb. MEB9achusa t6 02481
Sdm Life Aaannnce CowpN1Y of Cma" 1a a -
- - 111ar9i11p o1 9A1.1jun.lila.FMYnd+i arum--qC- pjwgWG1
DCSD Enrollee and Dependents List 29/JM/2DO3
Company : 004 Anthem Life Insurance Company
Ccuntry 01 united state.
Coverage: -in Voluntary Life - Employee
Group - 00651E -0099 CITY OF FORT COT LINS
non Name Effective Status Birthday .Sex Relation
04/01/1992 A 12/21/1963 M
04/01/1992 A l2J03/l DS4 M
02/01/1997 A 03/04/1948 M
04/01/1992 A 12/24/1940 M
04/01/1992 A 12/23/1959 M
04/Dl/1992 A 08/D9/1959 F
11/01/1995 A 10/05/1968 F
00/01/2000 A 04/22/1951 F
05/01/1994 A 11/28/1966 P
OE/01/1992 A 12/09/1954 M.
05/01/1992 A 12/05/1957 F
10/01/1995 A 02/14/1959 M
04/01/1992 A 12/15/1961 M
04/01/1992 A 12/05/1952 M
04/01/1992 A 12/16/1960 M
02/01/1996 A 02/20/1967 M
10/01/1992 A 12/13/1944 M
01/01/1994 A 06/22/1951 M
10/01/1992 A 1D/23/1969 M
10/01/2D02 A 13/18/1965 F
02/01/2003 A 11/30/1967 F
04/01/2002 A 10/14/1951 F
04/01/1.992 A 12/18/1968 M
04/01/1992 A 12/22/1964 M
03/01/200C A 10/10/1967 F
02/01/1997 A 04/16/194e M
04/01/1992 A 12/16/1946 M
D5/01/1992 A 12/11/1948 F
35/01/1999 A 11/11/196A M
01/01/1994 A 10/31i1963 M
01/01/1995 A 12/:B/1952 M
04/01/1992 A 12/25/195, 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 12/12/1954 M
09/31/1999 A 01,23/1957 F
04/01/1992 A 12/09/1934 M
03/01/1993 A 12/11/1955 M
03/01/1993 A 12/03;1961 F
06/01/2002 A 06/031,1957 F
04/01/1992 A 12/1311954 M
05/01/1999 A 08/11/1959 .
06/01/2000 A 06/25/1960 M
04/01/_992 A 12/04/1956 M
Pagc 14
Terminated Class
E type
volume
03
T
200,000.00
03
N
1501000.00
03
N
1001000.00
03
x
100,000.00
03
N
30,000.00
03
N
60,000.00
03
N
200,003.00
03
N
30,000.00
03
N
100,000.00
03
N
100,ODO.00
01
x
30,ODO.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
200,0n0-00
03
N
300.000.00
03
N
100,000,00
03
N
300,000,00
03
N
e0,C00.00
03
N
150,000.00
03
N
50, 000.00
03
N
30, 000.00
03
N
2001000.00
03
N
300,000.00
03
N
100.000.00
03
N
150.000.00
03
N
100,000.00
03
N
150,000.00
03
N
120,000.00
03
N
100,00C.DO
03
N
80,000.00
03
N
120,000.00
03
N
10D.000.00
O3
N
300,000.00
C3
N
300.000.00
03
N
40,000.00
03
N
301000.00
03
N
1DO,090.00
O3
N
300,000.00
03
N
180,000.00
ADC50
Enrollee and Dependence
List
29/JUL/2003
Page is
Company
: D04 Anthem Life Insurance Company
Country
: 01 United States
Coverage:
110 Voluntary Life - Employee
Group _ 006518
-0099 CITY OF FORT COLLINS
on. Uec Name
Effective
9tatua
Birthday
Sex
Termina:ed Class
E-type
Volume
04/01/1992
A
12/2011195ti
M
01
T
30,000.00
04/01/1992
A
12/26/:956
N
03
N
200,000.00
02/01/1993
A
12/26/1950
M
03
N
100.000.00
09/01/1996
A
C3/31/:962
F
03
N
200.000,00
04/01/1992
A
12/09/1964
N
O1
N
300.000.00
O3/01/2001
A
09/06/1970
M
03
N
300,000.00
04/01/1992
A
11/27/1961
F
03
N
180,000.00
04/01/1991
A
02/06/1951,
n
03
N
100,000.00
04/01/1992
A
12/16/1946
M
0]
N
100,000.00
05/01/1992
A
12/09/1948
M
03
N
40.000.00
O31011199,
A
06/27/1945
M
03
N
So,D00 00
' 07/01/2001
A
10;12/1973
F
03
N
300,000.00
C1/01/:932
A
01/30/1949
N
03
N
100,000.00
04/01/1992
A
05/19/1950
M
O3
N
100,000 00
10/01/1998
A
89/03i1915
F
03
N
300,000.00
04/01/1992
A
12/22/1952
M
03
N
120,000.00
34/01/1992
A
09/30/1946
M
03
N
50,OOD.00
01/01/1995
A
03/26/1957
F
03
N
30,000.V0
01/01/2000
A
00/21/1959
F
03
N
30,000,00
..
02/01/1993
A
12/29/1955
N
03
T
200,000.00
04/0:/1993
A
12/20/1918
M
03
N
300,000.00
10/01/1999
A
04/21/1970
M
03
N
300,000.00
O1/01/2001
A
06/15/1962
F
03
N
100,000.OD
01/01/1994
A
06/08/1964
M
03
N
100,000.00
O2/01/2002
A
01/22/1970
F
03
N
30.000.00
07/01/1991
A
03/23/1961
F
03
N
50,OCD.00
01/01/1999
A
05/21/1967
M
03
N
250,003.00
05/01/1992
A
12/21/1955
F
03
N
301000.00
O1/01/1992
A
12/27/1956
4
33
N
150,000.00
03/01/2000
A
00/02/1943
F
03
N
60,000.00
05/01/2000
A
04/26/1969
M
03
N
150,000.00
03/01/2002
A
02/ii/1960
M
03
N
110,000.OD
03/01/1996
A
12/01/1952
F
03
T
30.000,00
09/C1/2001
A
05/C1/1951
N
03
N
200,00C.00
09/01/2002
A
02/10/1956
M
C3
N
3001000.00
01/01/1999
A
08/14/1944
N
C3
N
30,000,00
04/01/1992
A
12/07/1956
Y
03
N
300,000.00
O1/C1/1994
A
06/43/1952
F
03
T
200.000.80
03/01/2002
A
09/03/1958
F
03
N
200,000. 00
09/91/1992
A
12/23/1960
M
03
N
100,000 00
O1/01/2003
A
12/05/1950
F
03
N
140,000.00
04i01/1992
A
01/26/191n
4
03
N
300,000.00
04/01/1992
A
12/20/1995
F
03
N
30,000.00
08/01/1992
A
12/08/1954
F
03
N
100,000 00
06/01/1992
A
12/29/1959
M
03
N
300.000.00
n Csc
____..
Enrollee and Dependents
..... ....-------
List
29/JUL/2001
.- _--- _---
Page 16
-- -------
Company : 004
Anthem Life Insurance Company
Country : 01
United State.
Coverage: 110
voluntary Life - employee
Group 006518-OC99
CITY OF PORT COLLINS
nn., :lame
Effective
Status
Birthday
sex Relation
Terminated Class
E-type
volume
04/01/1992
A
12/23/1953
M
03
N
1001000.c0
04/01/1992
A
12/15/1952
F
03
N
30,000.00
04/01/1992
A
12/09/1949
M
03
N
80,000.00
07/01/2002
A
05/10/1971
F
03
N
100,000.00
04/01/1992
A
12/23il9S1
M
03
N
80,000.00
04/01/1992
A
12/05/1941
M
03
N
60.000.00
06/O1/1992
A
'2128/1951
M
01
N
100,000.00
09/O1/2000
A
04/28/1973
M
03
N
50,000.00
04/01/1992
A
04/22119S4
M
03
N
150,000.00
01/01/1996
A
02/17/1970
M
Ol
N
100,000.00
04/01/1992
A
12/06/1956
M
03
N
80,000.00
01/01/2001
A
02/22il976
F
03
N
200.000.00
10/01/1995
A
06/15/1957
M
03
N
200,000.00
12/01/1997
A
01/14/1961
T
03
N
00,000.00
01/01/1995
A
10/12/1955
F
03
N
50,000.00
03/01/1995
A
07/14/1953
M
03
N
180,000.00
02/01/2003
A
10/15/1980
M
03
N
50,000.00
04/01/1992
A
12/09/1951
F
01
N
100,000.00
04/01/1992
A
12/25JI947
M
03
N
150,000.00
04/01/1996
A
09/22/1944
M
Ol
N
100,000.00
05/01/1992
A
12/31/19SI
M
03
N
40.000.00
04/01/1992
A
12/09/1959
M
03
N
50,000.00
04/01/1997
A
04/29i191U
M
Ol
N
100,000.00
04/01/1992
A
12/15/1949
M
03
N
60,000.00
04/01/1592
A
12/,20/1962
M
03
T
100,000.00
519
67,240,000.00
ADC 50 Enrollee and Dependent. List 29/JUL/2003 Page 17
----- ______
Company 004 Anthem Life I..uranne Company
Country 01 United Staten
Coverage: 112 Voluntary Life Sp0u.e
Group OOf518-0099 CITY OF FORT COLLINS
Cart No. Dep Name
Effective
Status
Birthday
Sex
Relation
Terminated Class
E-type
volume
04/01/1992
A
12/19/1956
M
03
N
300,OCO.o0
04/01/1992
w
06/21/1961
F
SPOUSE
O1/01/1999
A
04/11/194-1
F
03
N
10,000,00
O110111999
A
OS/CS/1938
M
SPOUSE
02/01/2003
A
08/30/1923
F
Ol
N
3C0,000.00
02/01/2003
A
D9/29/1921
M
SPOUSE
01/01/2002
h
05/2P/1923
F
D3
N
200, 030.00
01/01/2003
A
01/1C/1974
M
SPOUSE
07/01/2000
A
12/06/1964
M
03
N
10,000.00
07/01/2000
A
05/09/1964
P
SPOUSE
04/01/1992
A
12/3l/1964
M
03
N
20C1000.00
04/01/1992
A
12/16/1965
F
SPOUSE
04/01/1992
A
12/24/11949
M
03
N
150, Can CO
04/01/1992
A
08/01/2955
F
SPOUSE
07/01/1996
A
05/05/1965
M
03
N
190,000,00
07/01/1996
A
O5/14/1967
F
SPOUSE
10/01/1998
A
12/06/1944
M
03
N
100, 000.00
10/01/1999
A
06/02/1945
F
SPOUSE
04/01/1992
A
12/11/1911
F
03
N
50.000.00
04/01/1992
A
05/39/1936
M
SPOUSE
04/.1/1992
A
12/15/1946
M
03
N
30.000.00
04101/1992
A
10/03/1947
F
SPOUSE
04/01/1992
A
12/13/1942
M
03
N
30.000.00
04/01/1992
A
^.1/35/1942
F
SPOUSE
04/01/1992
A
G1/01/1980
M
03
N
10.000. 00
04/01/1992
A
34/22/1955
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
'-0/03/1951
M
03
N
100,000.00
06/01/1996
A
09/25/1954
F
SPOUSE
06/01/1998
A
11/10/1958
M
03
N
130,000.00
06/01/1998
A
12/23/1965
F
SPOUSE
04/01/2000
A
01/IA/1963
M
03
N
30.0OD.00
04/01/2000
A
03/23/1961
F
SPOUSE
02/01/1999
A
12/06/1950
M
03
N
30,COO.00
02/01/1999
A
02/,21/1950
P
SPOUSE
O1/01/2002
A
03/23/1964
F
03
T
100.000.OD
O1/01/20C2
A
05/27/1959
M
SPOUSE
00!01/1998
A
D5/27/1913
F
03
N
ID,C00.00
08/01/1998
A
D2/22/1965
M
SPOUSE
08/01/2.02
A
12/13/1959
F
03
N
200,00D-00
O8/O1/2002
A
12/30/1957
M
SPOUSE
O4/01/1991
A
12/27/1955
M
03
N
50, COD.00
04/01/1992
A
12/09/1952
F
SPOUSE
04/01/1992
A
12/27/1956
M
03
N
1D,COD.00
04/01/1992
A
07/24/1956
F
SPOUSE
ADC50 Enrollee and Dependent. List 29/.3UL/2003 Page 18
Company : 004 Anthem Life Insurance Company
Country 01 United State.
Coverage: 112 Voluntary Life - Spouse
Group : 006510-0099 CITY OF FORT COLLINS
Cert No. Dep Name
Effective
Status
Birthday
Sex
Relation
Terminated Class
E-type
Vclume
09/01/1993
A
12/18/1959
F
D3
N
50.000.00
09/01/1993
A
02/11/1955
M
SPOUSE
U4/01/1992
A
12/24/1952
F
D3
T
50,000,00
04/01/1992
A
09/30/1950
M
SPOUSE
01/01/2003
A
03/16/1974
F
03
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
04/0111992
A
11/20/1954
F
SPOUSE
04/01/1992
A
12/0a/1965
M
03
N
1001000.00
04/01/1992
A
05/14/1966
F
SPOUSE
04/01/1997
A
12/30/19SI
M
03
N
100,000.06
' 34/01/1997
A
08/31/1954
F
SPOUSE
04/01/1992
A
12/20/1945
M
03
T
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
06/01/1996
A
01/01/1980
F
03
N
10,000.00
06/01/1998
A
03/27/1955
M
SPOUSE
11/01/1994
A.
07/DS/1963
M
03
N
30,000 .00
-" 11/01/1994
A
07/26/1962
F
SPOUSE
10/01/1992
A
01/01/1960
F
03
N
20,000.00
10/01/1992
A
10/31/1941
M
SPOUSE
08/01/1992
A
12/15/1962
F
03
N
100,000.00
OB/01/1992
A
05/24/1961
M
SPOUSE
02/01/1994
A
12/06/196E
M
OS
N
1001000.UO
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.to
01/01/1994
A
09/02/1971
P
SPOUSE
02/01/1996
A
22/23/1965
F
03
N
10,000.00
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
F
SPOUSE
01/01/,1995
A
04/04/1957
M
C3
N
110.D00.00
01/01/1995
A
04/C6/1960
F
SPOUSE
05/01/,1992
A
12/31/1960
M
03
N
100,000, 00
05/01/1992
A
10/33/1962
F
SPOUSE
D1/01/1998
A
01/01/1980
M
03
T
$0,000_no
01/01/1998
A
07/31/1959
F
SPOUSE
11/01/1994
A
01/01/1980
F
03
N
100,000.00
11/01/1994
A
08/07/1952
M
SPOUSE
12/01/1399
A
04/25/1969
M
03
N
100,000,00
12/01/1999
A
09/00/1979
F
SPOUSE
01/01/1994
A
07/23/1961
F
03
N
100.000 .00
01/01/1994
A
05!31/1960
M
SPOUSE
DCSO Enrollee and Dependents List 29/JUL/2003 Page 19
Compact' 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 112 Voluntary Life - Spouse
Group - 00651S-0099 CITY OF FORT COLLINS
Cent N, Dep Name
Effective
Statue
Birthday
Sei
Relation
Ter mina red Class
E-type
Vclume
06/01/1994
A
07/18/1955
M
O1
N
50,000.00
06/01/199,
A
01/IS/1959
F
SPOUSE
06/02/2002
A
02/25/1978
H
03
N
100,000.00
06/01/2002
A
OS/i2/1978
P
SPOUSE
04/01/1994
A
03/06/1952
N
03
N
50.000.00
04/01/1991
A
Gi/il/1949
F
SPOUSE
J7/01/1999
A
08/07/1961
M
Dl
N
100,000.00
37/01/1999
A
06/27/1962
P
SPOUSE
04/01/1992
A
12/26/i955
F
01
N
100,000.00
04/01/1992
A
04/29/1946
H
SPOUSE
09/01/2001
A
05/28/1963
F
03
N
100,000.00
09,101/2001
A
04/24/1963
H
SPOUSE
0410_11992
A
12/07/1957
M
03
N
150,000.00
04/01/1992
A
04/07/1960
F
SPOUSE
04/01/1992
A
12/04/1946
H
03
N
30,000.0.
04/02/1992
A
11/30/1941
F
SPOUSE
10/01/199B.
A
12/29/1964
F
03
N
100,000.00
10/01/1996
A
12/9/1958
H
SPOUSE
01/01/1994
A
01/01/1990
M.
03
N
100,000.00
01/01/1994
A
09/21/1959
F
SPOUSE
04/01/1992
A
12/12/194t
F
03
N
100,000.00
04/01/1992
A
07/10/194,
H
SPOUSE
01/01/1997
A
01/31/1947
F
03
T
10,000.00
03/01/1997
A
08/29/1946
N
SPOUSE
07/01/1995
A
01/01/1980
F
03
N
100,00D.00
07/01/1995
A
11/16/1963
H
SPOUSE
03/01/1999
A
Dl/26/1965
F
03
N
100,000.00
03/01/199R
A
11/23/1967
N
SPOUSE
08/01/1996
A
11/16/1955
F
03
N
30,000.00
08/01/1998
A
0./24/1957
M
SPOUSE
05/01/2001
A
03/29/1965
H
03
N
100,000.00
05/01/2001
A
04/07/1965
P
SPOUSE
04/01/1992
A
12/06/1994
M
03
N
10,000.00
04/01/2992
A
08/04/1958
F
SPOUSE
03/01/2002
A
04/21/190
P
03
T
1001000.00
03/01/2002
A
03/13/1969
M.
SPOUSE
05/01/199,
h
C6:28/1963
N
03
N
20,000.00
05/01/1997
A
07/18/1969
F
SPOUSE
01/01/1992
A
12/2.4/195]
H
03
N
10,000.00
01/01/1992
A
0S/12/1959
F
SPOUSE
05/01/2002
A
OB/C3/1946
P
03
N
80, 000.00
05/01/2OD2
A
11/13/1948
H
SPOUSE
03/01/1995
A
07/C6/1951
H
03
T
10,000.00
C3/01/1995
A
09/17/1959
F
SPOUSE
08/01/1992
A
12/14/1951
M
03
N
300,000.00
08/01/1992
A
31/25!1950
F
SPOUSE
Mcso Enrollee and Dependent. List 29/JM/2003
_____________________________
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 112 Voluntary Life - Spouse
Group 00651a-0099 CITY OF FORT COLLINS
Cerc No. Dep Name Effective Status Birthday Be. Relation
02/01/1993 A 12/25/1952 F
02/01/1993 A 11/19/1951 M SPOUSE
02/01/1993 A 05/14/1949 M
02/01/1993 A 05/14/1949 F SPOUSE
06/01/1992 A 12/15/1953 M
06/01/1992 A 32/19/1954 F SPOUSE
01/01/1996 A 01/D1/1990 M
01/01/1996 A 02/16/1949 F SPOUSE
09/01/2001 A 09/07/1973 M.
09/01/2001 A 03/2S/1976 F S➢OUSE
03/01/1997 A 06/19/1952 - M
03/01/1997 A 08/22/1956 P SPOUSE
04/01/1992 A 12/07/1947 M
U4/01/1992 A 11/20/1950 F SPOUSE
02/01/1998 A 12/24/1961 M
02/01/1999 A 3S/16/1960 P SPOUSE
01/01/1995 A 12/29/1949 M
01/02/1995 A LO/10/1951 P SPOUSE
30/01/1999 A 08/29/196] F
03/01/1997 A DS/18/1953 M
03/0211991. A 03/04/1951 P SPOUSE
04/21/1993 A O3/20/1959 F
04/01/1993 A 09/01/1958 M SPOUSE
06/01/1997 A 12/11/1965 M
06/01/1997 A 12/19/1966 F SPOUSE
04/01/1992 A 12/0S/1951 M
04/01/1992 A 10/29/1959 F SPOUSE
01/01/1994 A 09/12/1959 M
01/01/1994 A 11/04/1943 P SPOUSE
04/01/1992 A-2/25/1956 M
04/01/1992 A 05/24/195: F SPOUSE
04/01/2OC2 A 11/19/1960 M
04/01/20C2 A 11/11/1961 F SPOUSE
04/0--/1997 A 01/29/195' M
04/01!1991 q U4/01/195. P '➢OILS:
08/01/1995 A O6/2U/195H M
OB/01/1995 A 09/07/1962 F SPOUSE
07/01/2003 A 02/25/1955 M
07/01/2003 A 08/05/1955 F SPOUSE
05/01/2003 A 08/02/1956 P
05/01/2001 A 08/05/1954 M SPOUSE
11/01/1993 A 12/13/1965 M
11/01/1993 A 04/12/1966 F SPOUSE
04/01/1992 A 12/16/1946 M
04/01/1992 A 10/04/1949 F SPOUSE
Page 20
Terminated Class
E-type
Volume
03
N
50,000.00
03
N
50.000,00
03
N
200.000.00
03
N
10,000.00
03
N
50,000.00
03
N
100,000.00
03
N
50,000.00
03
N
100,000.00
03
N
80,000.00
03
N
150,00D.00
03
T
100,OOD.00
C3
N
300,000.00
03
N
150,000.00
C3
N
100,000.00
03
N
150,050.00
C3
N
20,000.00
03
N
300,000.00
03
N
300,000.00
C3
N
100,000.00
C3
N
50,000.00
03
N
100,000.00
C3
N
30,000.00
03
N
70,000.00
>OCsn Enrollee and Dependents List 10/1UL/2003
Company 004 Mthem Life Insurance Company
Country 01 United Scares
Co--,.: 112 voluntary Life SPOLLSe
U—up D06518-DO" CITY OF FORT COLLINS
Cert No. Den Name Effective Status Birthday $ex Soled..
11/Cl/1998 A 12!12/195f F
11/01/1998 A 12/09/1950 M SPOUSE
OS/01/1998 A 12/3D/1955 F
05/01/1998 A 11/19/19S4 M SPOUSE
04/01/2003 A 07/10/1974 M.
04/01/2003 A 11/23/1974 F SPOUSE
12/01/2000 A 07/06/1968 N
12/al/200D A 08/24/1970 F SPOUSE
06/01/2001 A 12/01/1961 M
06/01/2001 A 02/01/1961 P SPOUSE
05/01/1992 A 12/25/1958 - M
OS/Cl/1992 A 01/12/1962 F SPOUSE
06/01/1993 A 12/04/1954 N
06/91/1993 A 04/02/1956 F SPOUSE
04/01/1992 A 12/29/1554 F
04/01/1992 A 08/29/1944 M SPOUSE
06/01/1992 A 12/20/1960 P
06/01/1992 A 07/25/1947 N SPOUSE
04/01/1992 A 12/24/1959 M
04/01/1992 A 01/25/1968 a SPOUSE
04/01/1992 A D1/01/1980 M
01/01/1992 A 09/29/195a P SPOUSE
01/01/2003 A 09/,20/1555 F
04/01/1992 A 04/14/1952 M SPOUSE
02/01/1999 A 06/04/1953 M
C2/01/1999 A 12/31/1953 P SPOUSE
04/01/1992 A 01/01/1,80 P
04/O1/1992 A 03/15/1941 N SPOUSE
C6/D1/1999 A 07/21/1954 P
26/01/1993 A Oi!ge!1948 M SPOUSE
1=/01/1993 A 12/15/1949 F
04/01/1992 A 12106/1949 N SPOUSE
04/01/199, A 12/OS/1954 F
04/01/1992 A 06/20/1951 N SPOUSE
C1/O3/1994 A 01/01/1980 M
Oi/01!1994 A I1/1B/1951 P SPOUSE
04/01/1992 A 12/C7/1963 N
04/01/1992 F 10/25/1965 F SPOUSE
04/01/1992 A 12/04/1954 M
04/01/1992 A 071'07/1955 F SPOUSE
04/02/1992 A 12/10/1963 M
04/01/1992 A 08/31/1963 P SPOUSE
04/01/1995 A 07/10/1945 N
04/01/1998 A 09/30/I951 P SPOUSE
04/01/1992 A 01/0,11980 M
04/01/1392 A 02/09/1959 F SPOUSE
Page 21
Tennlnatcd Class
E-type
03
N
03
N
03
N
03
N
03
N
03
N
03
T
03
N
03
N
03
N
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
10,n00 C.,
130.000. 00
300.000.30
100, 000, 0C
250,00a.nn
100, DOC.00
30,000-00
60,000.00
100,000.00
150,000. 00
90.000.00
200,000.00
50,000. 00
10, 300.00
100.000-00
10,000.00
10,000.03
70, 000.CD
80.000, 00
50, 000.00
100,000.00
40,000.00
60,000.00
AOCSC
Group
Enrollee and Dependents
List
29/.IUL/2003
page 22
Company 004
Anthem Life in aursnce Company
..cur. , 01
United Statea
. c�erage: 112
;olun[ary Life Spousa
OC6518-0099
CITY OF PORT COLLINS
Cart
No. Oep Name
Effective
Status
Birthday
Sex
Relation
Terminated Class
E-type
volume
02/01/1996
A
05/06/1960
M
03
N
ini,090.00
02/01i1996
A
01/11/191,
P
SPOUSE
C9/01/1992
A
12/03/1964
M
03
:!
200,000.0C
09/01/1993
A
04/24/1965
P
SPOUSE
02/01/1993
A
12/19/1949
M
C3
N
150,000 .00
02/01/1993
A
06/19/1953
F
SPOUSE
12/01/2002
A
02/24/1970
M
03
N
250,000.00
12 /41/2002
A
07/21/1971
P
SPOUSE
03/D1/1997
A
01/31/2970
M
01
N
10,000.00
03/01/1997
A
02/20/1972
F
SPOUSE
04/01/1992
A
09/02/1955
M
03
N
10,000.D0
• 04/01/1992
A
04/23/195a
F
SPOUSE
02/02/1990
A
1D120/1969
M
03
N
150,000.00
D2/01/1990
A
1_/1111969
F
SPOUSE
04/01/1992
A
1''/11/1965
F
01
N
10,000. C.O
04/01/1992
A
11/11/1965
F
SPOUSE
02/01/1996
A
08/16/1961
M
O3
N
2-",000.co
02/01/1996
A
11/30/1963
F
SPOUSE
03/01/1993
A
12/13/1961
M
O3
N
100.300.00
03/01/1993
A
0,1/2611965
F
SPOUSE
04/01/1992
A
12/27/1947
M
03
N
10.000,00
04/01/1992
A
07,'06/1948
8'
SPOUSE
C4101/1992
A
04/25/1946
M
03
N
100,000,00
OVD1/1992
A
06/25/1953
F
SPOUSE
10/D1/2002
A
12/10/1957
F
03
T
50,00C.00
10/01/2002
A
10/21/1957
M
SPOUSE
03/01/1959
A
'1/29/1968
M
03
N
303,000,00
03/01/1999
A
07/20/1971
F
SPOUSE
04/01/1996
A
02/08/1950
F
!I1
N
10,C00.0o
04/C1/1996
A
01/30/1945
M
SPOUSE
02/01;1993
A
12/30/1953
M
03
T
6>,090.00
02/C1/1993
A
05/06/1959
F
SPOUSE
04/01/1992
I.
12/OS/1951
M
03
1'
100,000.DO
04/01/199i
A
11/21/1954
P
SPOUSE
14/01/1992
A
12/05/1951
M
O3
N
205,000.0]
04/01/1992
A
12/16/1957
P
SPOUSE
01/01/iwl
A
11/06/1962
F
03
N
250,000 02
01/01/:997
A
09/14/1961
Y
SPOUSE
D1/O1/1995
n
0]/31/1950
M
O3
T
So,C00.90
O1/O1/1995
A
O9/31/1953
F
SPOUSE
12/01/2t0O
A
04/./4961
M
03
N
10, 000 00
12/D1/2000
A
06/23/1969
F
SPOUSE
11/01/2001
A
10/19/1972
M
03
N
300,C00 00
11/01/2D01
A
05/14/191.
k-
SPOUSE
04/01/1999
A
09/14/1966
M
03
N
250,000 00
04/01/1999
A
04/CS/1959
F
SPOUSE
AD [s0 Enrollee and Dependents List 29/JUL/2003 Page 23
_____________________________
Company D04 Anthem Life Insurance Company
Country 01 United States
Coverage: 112 Voluntary Life - Spouse
Group 006518-0099 CITY OF FORT COLLINS
,it No. Oep Name
Effective
Status
Birthday
Sex
Relation
Terminated Class
E-type
Volume
04/01/1992
A
03/15/1954
M
03
N
50,000.00
04/01/1992
A
10/26/1958
P
SPOUSE
05/01/1999
A
11/17/1950
F
03
T
10,000.30
05/01/1999
A
01/10/1950
M
SPOUSE
02/01/1999
A
12/28/1967
F
03
N
300.000.00
02/01/1999
A
12/03/1967
M
SPOUSE
02/01/1993
A
12/02/1944
M
03
N
IDO,000.00
02/01/1993
A
12/01/1945
F
SPOUSE
04/01/1992
A
12/05/1954
M
03
N
100,000.00
04/01/1992
A
10/31/1956
F
.SPOUSE
02/01/1994
A
OB/30/1947
M
03
N
120, DOD. OC
• 02/01/1994
A
02/27/1946
F
SPOUSE
06/01/1992
A
12/01/195H
M
03
N
10,000.00
06/01/1992
A
05/08/1964
F
SPOUSE
09/01/2 D03
A
04/21/1965
M
03
N
100,000.00
09/01/2DO3
A
02/02/1966
P
SPOUSE
04/O1/1992
A
12/17/1563
M
03
N
1so, 000.00
04/01/1992
A
04/26/1965
P
SPOUSE
04/01/1999
A
04/28/197C
M
03
N
100, 000.00
D4/01/1999
A
07/22/1979
F
SPOUSE
02/01/1999
A
01/01/1980
M
03
N
200,000.00
02/01/1999
A
06/25/1956
F
SPOUSE
04/01/1992
A
12/02/1949
M
03
N
80,000.00
04/01/1952
A
05/2D/1950
F
SPOUSE
04/01/1992
A
01/21/1953
M
03
N
5C, 000.00
04/01/1992
A
09/24/1952
F
SPOUSE
05/01/2003
A
02/08/1962
F
03
N
250,000.00
05/03/2003
A
06/21/2960
M
SPOUSE
06/01/2002
A
10/05/1962
F
03
T
Ia. DOD .00
06/01/2002
A
09/28/1960
M
SPOUSE
09/01/1993
A
09/08/1964
F
03
N
1501000.00
09/01/1993
A
04/06/1965
M
SPOUSE
08/01/2000
A
07/23/1960
F
03
N
150, 000. OC
OB/01/2000
A
10/20/1959
M
SPOUSE
05/01/1999
A
06/26/1967
M
03
N
130,000.00
US/01/1999
A.
04/05/1968
F
SPOUSE
04/01/1992
A
12/22/1946
M
03
N
50,000.00
04/31/1992
A
08/15/1949
F
SPOUSE
06/01/1992
A
09/06/1956
M
03
N
200,000.DO
06/01/1992
A
03/06/1958
F
SPOUSE
12/01/2002
A
01/09/1966
F
03
N
50,000.00
12/01/2002
A
06/26/1964
M
SPOUSE
06/01/2003
A
09/11/1977
P
03
T
50,000'00
06/01/2003
A
04/04/1977
M
SPOUSE
04/D1/2000
A
05/09/1956
M
03
N
250,DOD.00
04/01/2000
A
06/04/1961
P
SPOUSE
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.
213 North Mason Street • 2nd Floor • P.O. Box 580 • Fort Collins, CO 80522-0580 9 (970) 221-6775 • FAX (970) 221-6707
ADC50
"c"
Enrollee and Dependents
List
29/]UL/2003
Paye 24
Company w 004 Anthem Life Insurance Company
Country 01 United S[af.ec
Coverage: 112 voluntary Life Sy0u¢e
006518 0099 CTTV CF FORT COLLINS
Cart No. Dep Name
Effective
Stalu.s
Birthday
Sex
Relation
Terminated Class
E-type
Volume
04/O1/1992
A
12/05/1943
M
03
N
10,000.06
04/01/1992
A
01/09/942
F
SPOUSE
04/01/1992
P.
12/03/1957
M
O3
N
30,000.08
04/01/1992
A
02/06/1957
F
SPOUSE
O8/01/1999
A
09/17/1965
M
03
N
200,000.00
OB/O1/1999
A
O1/1811966
F
SPOUSE
01/02/1994
A
12/29/1963
F
03
N
150,000 00
Ol/D1/1994
A
06/26/1963
M
SPOUSE
O1/01/1996
A
12/25/1969
F
03
T
100,000,00
01/01/1996
A
12/11/1969
M
SPOUSE
03/01/1999
A
05/19/1959
M
03
N
50,000.00
'
03/01/1999
A
06/29/1963
F
SPOUSE
06/01/1992
A
13/21/1952
F
O3
N
200,000.00
06/01/1992
A
02/06/1956
M
SPOUSE
11/01/1999
A
O8/18/1911
M
03
N
100.00C.00
11/01/1999
A
01/30/1973
F
SPOUSE
04/01/1997
A
03/11/1950
M
03
N
300,000.00
04/01/1997
A
02/12/1959
-
SPOUSE
02/01/1993
A
12/12/1958
M
03
N
100,000.OD
02/01/2993
A
JB/26/1966
F
SPOUSE
O1/01/2031
A
10/13/1959
F
03
N
30,000.00
01/01/20]1
A
02/14/1961
M
SPOUSE
O3/01/2000
A
CS/23/1970
M
03
N
100,000.00
03/01/2000
A
05/09/1975
F
SPOUSE
04/O1/1992
A
12/25/1953
M
03
N
100,000.00
0.101/1992
A
09/19/1956
F
SPOUSE
04/01/1997
A
12/05/1955
M
03
N
100,000.00
04/01/1997
A
05/31/1953
F
SPOUSE
-
04/O1/1992
A
01/01/190C
F
03
N
20,000.00
04/0111992
A
11/09/195i
M
SPOUSE
04/01/1992
A
05/12/3963
F
03
N
100,000.00
04/01/1992
A
04/20/1951
M
SPOUSE
09/01/1994
A
02/03/1950
M
C3
N
200,000. 0c
09/01/1954
A
02/09/1966
P
SPOUSE
06/01/2002
A
03/06/19^8
M
03
N
06/01/2002
A
04/12/19RO
F
SPOUSE
100,000.Go
13/01/1995
A
12/12/1957
F
03
N
30/01/1995
A
05/20/1957
M
SPOUSE
150,000.00
04/01/1992
A
12/09/1961
F
03
N
04101/1992
A
11/01/1958
M
SPOUSE
20,000.00
04/01/1992
A
12/19/1959
F
01
N
04/01/1992
A
08/17/19S7
M
SPOUSE
801000.U0
11/01/2000
A
05/21/192I
F
03
11/01/2000
A
09/14/1974
M
SPOUSE
N
200.000.00
02/D1/1997
A
O2/1S/1954
M
03
02/01/1997
A
04/03/1957
P
SPOUSE
N
12 J. 000.00
AUC50
Orcup
Enrollee and Dependents
List
29/JUL/2003
Page 25
company
004 A,nthen Life :naurance Company
Counary
01 United Staces
coverage:
112 voluntary Life - Spouse
006S18
-0399 CITY OR FORT COLLINS
Corr No. pep Name
Effective
a'tatus
Birthday
Sex
Relation
Terminated Class
E-type
Volume
0-101/1992
A
13/20/1942
M
03
N
20,000,00
34/01/1992
A
O1/19/1943
P
SPOUSE
021,0111993
A
12/07/1959
M
03
N
30,000 00
02/01/1993
A
101,25/1959
F
SPOUSE
04/01/1992
A
12/31/1956
M
03
N
50,000.00
04/01/1992
A
04/02/1962
F
SPOJSE
D4/01/1992
A
12/20/1953
M
03
N
501000,00
04/01/1992
A
10/06/1941
F
SPOUSE
02/01/1998
A
03/09/1956
P
03
N
150, 000.00
02/01/199e
A
02/22/1952
M
SPOUSE
04/01/1952
A
12/13/1955
M
03
N
100, coo .00
34/01/1992
A
06/15/1957
F
SPOUSE
09/01/2001
A
03/07/1568
M
03
N
300,000.co
09/01/2001
A
09/20/1959
F
SPOUSE
01/01/1995
A
02/26/1961
M
03
N
100,000.co
01/01/1995
A
04/02/1964
F
SPOUSE
04/01/1992
A
12/23/1g46
M
03
N
10,000.00
04/02/1992
A
09/25/1946
F
SPOUSE
03;61/1994
A
04/29/1963
M
03
N
50,000.00
03/01/1994
A
04/29/1963
F
SPOUSE.
02/01/1996
A
09/10/1965
M
93
N
100,000.00
02/01/1936
A
12/09/1966
F
SPOUSE
04/01/1996
A
03/29/1955
F
03
N
50.000,00
04/01/1996
A
09/17/1947
M
SPOUSE
04/D1/1995
A
07/23/1947
M
03
N
50,000.00
04/01/1995
A
10/04/1949
F
SPOUSE
04/O1/1992
A
12/10/1953
M
03
T
60,000.00
04/01/1992
A
11/04/1953
F
SPOUSE
04/01/2002
A
05/09/1958
M
03
N
10,000 An
04/01/2002
A
09/16/1958
P
SPOUSE
02/01/_994
A
12/26/1965
M
03
N
80,000.00
02/01/_994
A
02/04/1964
F
SPOUSE
10/01/1996
A
04/20/1959
F
03
N
10,000.00
30/01/1996
A
04/20/1959
M
SPOUSE
01/01/1996
A
12/19/1959
M
03
N
80,000.00
01/01/1996
A
C9/04/1964
F
SPOUSE
04/01/1996
w
C6/24/1945
M
03
N
SD,000.00
01/01/1996
A
C7/36/1344
F
SPOUSE
04/C1/1992
A
12/29/1958
M
63
N
04/C1/1992
A
01/21/1956
F
SPOUSE
59,000.CO
D4/01/1992
A
12/27/1956
F
03
T
10.000.00
04/01/1992
A
01/01/1956
M
SPOUSE
11/O1/1995
A
10/07/197C
M
03
N
30.000. of
11/81/1995
A
09/06/1972
F
SPOUSE
02/01/2003
A
06/10/1961
N
03
N
02/81/2003
A
10/26/1966
F
SPOUSE
100,000 00
A0050 Enrollee and Deoendenta List 29/,IUL/2003
--------------------------
Company 004 Anthem Life Insurance Company
Country 01 united states
Coverage. 112 Voluntary Life - Spouse
Croup 006518 0099 CITY OF FORT COLLINS
Csrf U. D.F some Effective Status Birthday Sex Relat)On
04/01/1992 A 12/09/1954 M
04/O1/1992 A 02/10/1953 P SPOUSE
04/01/1992 A 12/29/1945 M
04/01/1992 A O1/22/1947 F SPOUSE
91/01/1999 A 1C/04/1949 M
01/01/1999 A 03/16/1964 P SPOUSE
11/01/2001 A. 07/17/1953 F
11/01/2001 .4 11/26/1954 M SPOUSE
06/01/1992 A 12/18/1966 M
06/01/1992 A O5/16/1567 F SPOUSE
09/01,11999 A 12/09/1958 F
09/01/1999 A 07/17/1949 M SPOUSE
04/O1/1992 A 12/26/1951 M
01/01/1992 A 09/26/1951 F SPOUSE
01/01/1999 A O1/01/1980 M
01/01/1959 A O7/0911965 F SPOUSE
04/01/1992 A 12/00/1952 F
04/01/1992 A 07/26/1955 M SPOUSE
01/O1/2003 A 10121/1969 F
O1,02/2003 A O7j20/1963 M SPOUSE
O4/01/1992 A 12/19/1550 M
04/01/1992 A O4/13/1951 F SPOUSE
11/01/1996 .4 09/06/1970 M
11/01/1,96 A 02/26/1971 F SPOUSE
04/01/1992 A 12/14/1959 M
04/O1/1992 A 03/02/1963 F SPOUSE
04/01/1992 A O8/20/1945 M
04/01/1992 A 03/16/1950 F SPOUSE
01/01/1994 A 05/11/1352 F
01/01/1994 A 04/23/1949 M SPOUSE
02/01/1993 A 12/C6/1959 M
02/01/1993 A 12/01/196C P SPOUSE
04/01/1992 A 12/18/1952 M
04/01/1992 A 30/il/194e F SPOUSE
04/02/1992 A 12/31/1964 M
04/Oi/1992 A 10/02/1964 F SPOUSE
02/0:/1996 A 09/13/1949 M
02/01/1996 A 02/06/195) F SPOUSE
O8/01/3992 A 12/30/1952 M
O8/O1/i392 A 11/22/1960 F SPOUSE
04/01/1992 A 12/02/1950 M
04/01/1992 A 10/04/1951 F SPOUSE
C4/01/1992 A 12/11/1962 M
C4/01/1992 A 12/29/1919 P SPOUSE
04/01/1992 A 12/19/19.7 M
04/01/1992 A 07/19/1950 P SPOUSE
Page 26
Terminated Class
E-type
03
N
01
N
03
N
O3
N
03
N
03
N
03
N
03
N
03
T
O3
N
O3
N
03
N
03
N
03
N
03
N
03
N
C3
N
03
N
03
N
03
T
03
N
03
N
03
T
Volume
150,000.00
10.000.00
1n0,00o.00
IO,OOC .00
so, 000.00
90,000.00
100, 000.00
s0, 000.00
LO, 000.00
100,000, so
30, 000.00
250,000.00
10, 000.co
so. 000.00
50.000 00
1501000.00
50,000.00
100,000.00
40, OOC.00
100, 000.00
10, 000, so
103,030.00
30,O00.IS
ADC50 Enrollee and Dependents List
-----------------------------
Company : 004 Anthem Life Insurance Company
Country : C1 United States
coverage: 112 voluntary Life - Snoufle
Ornun :if,6CIN-0099 _ITY OF PORT COLLINS
29/JUL/2003
Cert No. Den P.1e Effective Status Birthday
01/01/1994 A 12iO4/1955
01/01/1994 A 11122119SS
06/01/1994 A 03/20/1949
02/01/1994 A C1/17/1956
07/O1/1992 A 12/27/1947
07/01/1992 A C7/12/1945
D5/01/2003 A OSj Oaj1958
05/01/2001 A 04/23/1969
07/01/2002 A 10/2911964
O7/01/2002 A 05/03/1967
01/01/1990 A 04/04/1954
O1/01/1998 A 11/16/1959
04/01/1992 A 12/26/1953
04/01/1992 A 09/11/1949
O1/01/1996 A 04/15/1949
C1101/1996 A O,/06/1949
04/O1/1992 A 12/03/1954
01/01/1992 A 00/00/1967
02/01/1997 A 03/04/1 P48
02/01/1997 A 04/03/1948
04/01/1992 A 12121/1959
04/01/1992 A 07/13/1956
01101/200i A O61,0911959
01/01/2001 A 04/15/1955
01/01/1998 A 10/05/1960
01/O1/1998 A 10/21/1972
04/01/1992 A 12/05/1957
04/01/1992 A 03/07/1954
04/01/1992 A _2/05/1952
O4/Di/1992 A 04/OSjL952
04/01/1992 A 12/16/1960
04/01/1992 A 02/03/1959
021101/1999 A 02/20/1967
0 ci /1999 A 08/08/1966
1U/O1/1993 h 06/22/1931
10/01/1993 A 05/16/1954
09/01120D2 A 10/23/19"
06/01/2002 A 06/37/1902
02/01/2003 A 11/30/196O
02/01/2003 A 04/06/1969
05/01/2DO2 A 10/14/1991
05101/2002 h llj11/1939
04/01/1992 A 12/18/1968
04/01/1992 A O5130(1967
04/01/2992 A 12;22/1964
04/01/1992 A 02/04/1961
Relation
SFOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
SPOUSE
Page 27
Term -,Oared Class
E-type
03
N
03
N
03
T
03
N
03
N
O3
N
03
T
03
N
03
N
03
T
03
N
03
N
03
N
03
N
C3
N
03
N
03
N
03
N
03
T
03
.
03
N
03
N
03
N
iolum
100,000.00
50, OOO.CO
10,000,00
12D, 000 .00
100, OOD.00
so, 000.00
so, ODD.00
30,000.00
150,000.00
10,000-On
60, 000.00
30,000 .On
20c,cao.00
100,000,00
10,030.00
ISD,000.no
100, oco .00
150,000,00
150,303.ca
300,D00.00
50,000.00
'_50,000.00
303,000'00
MC50 Enrollee and Dependents List 29/SUL/2003 Page 28
----------------------------- ----------- -.__..----
Company 004 Anthem Life 2nsurance Company
Country al United Staten
Coverage: 112 Voluntary Life - Spocse
Group 006518-0099 CITY OF FORT COLLINS
Cert No. pep Name
Effective
Status
Birthday
Sex
Relation
Terminated Class
E-type
Volume
05/01/1997
A
04/16/1948
M
03
N
30,000.a0
05/01/1997
A
10/23/1949
F
SPOUSE
04/01/1992
A
01/01/1990
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
D4/01/1992
A
06/09/1953
F
SPOUSE
04/01/1992
A
01/01/1980
M
03
T
$0,000.00
D4/01/1992
A
01/20/195D
F
SPOUSE
01/01/1995
A
12/18/1952
M
03
N
15D,000.00
01/01/1995
A
05/29/1953
F
SPOUSE
10/01/2002
A
01/12/1970
M
03
N
100,C00.00
10/01/2UO2
A
06/19/1975
F
SPOUSE
04/01/1992
A
32/13/1954
M
03
N
100,C00.OD
04/01/1992
A
01/12/1958
F
SPOUSE
05/01/1999
A
08/11/1959
F
03
T
100,000.00
05/01/1999
A
11/04/1964
M
SPOUSE
06/01/2000
A
06/25/1960
M
03
N
100, 000.
OD
06/01/2000
A
06/07/1961
F
SPOUSE
04/01/1992
A
12/20/1956
M
03
N
10,00C
00
04/01/1992
A
03/06/1963
F
SPOUSE
04/01/1992
A
12/26/1956
M
03
N
70,000.00
04/01/1992
A
03/11/1958
F
SPOUSE
02/01/1993
A
12,126/1950
M
03
N
50,000.00
02/01/1993
A
01/18/1931
F
SPOUSE
01/01/1994
A
01/01/1930
F
03
T
10,000.00
01/01/1994
A
08/26/1947
M
SPOUSE
04/01/1992
A
12/09/1964
M
C3
N
100,000.00
04/01/1992
A
06,114/1959
F
SPOUSE
08/01/2001
A
06/06/1970
M
C3
N
300,000
.00
09/01/2001
A
01/29/1976
F
SPOUSE
01/01/1992
A
12/27/1961
F
C3
N
160,000.00
04/01/1992
A
01/09/1960
M
SPOUSE
OS/D1/1997
A
05/19/1950
M
03
N
100, 000.
00
OS/01/1997
A
11/15/1954
F
SPOUSE
01/01/2001
A
08/03/1975
F
03
N
200,000,00
05/01/1997
A
03/26/1951
F
03
N
100,000,00
05/01/1997
A
01/22/1954
M
SPOUSE
01/01/2000
A
08/21/1959
F
D3
N
40,000.00
01/01/2000
A
11/17/1956
M
SPOUSE
02/01/1993
A
12/29/1955
M
D3
N
200,000.]0
02/01/,1993
A
10/11/1955
F
SPOUSE
10/01/1999
A
C4/21/1970
M
03
T
100,000.00
01/01/1994
A
06/08/1964
M
03
N
50, 000 .00
01/01/1994
A
01/08/1967
P
SPOUSE
01/01/1999
A
05/21/196-
M
03
N
100, 000AD
03i01/1999
A
12/26/1950
P
SPOUSE
ADC50 Enrollee and Dependents List 29/]UL/2003 Paye 29
Company 004 Anthem Life Insurance Company
Country 01 Ud-tea States
Coverage: 11-1 Voluntary Life - Spouse
Group 00651E-2093 CITY OF FORT COLLINS
Cart No. Lop Marne
Effective
Status
Birthday
Be.
Relation
Terminated Class
E-type
volume
05/01/1992
A
12/21/1955
F
03
N
60.00U.0C
05/01/2992
A
09/16/1961
M
SPOUSE
05/01/2CCO
A
04/26/1969
M
03
N
100,
O00.00
05/01%2000
A
05/31/1971
F
SPOUSE
03/01/2002
A
02/11/1960
M
03
N
100.000.
J0
03/01/2002
A
10/25/1956
F
SPOUSE
11/01/1995
A
12/O7/1952
F
03
T
70.000.00
11/01/1995
A
10/13/1940
M
SPOUSE
01/01/1999
A
OB/14/1944
M
03
N
10.000.00
O1/02/1999
A
02/21/1950
F
SPOUSE
OB/01/1998
A
12/01/1956
M
03
N
30,000.
00
OB/01/1998
A
12/25/1969
F
SPOUSE
05/01/1998
A
12/23/1960
M
03
N
100,000.00
05/01/1998
A
06/25/1956
F
SPOUSE
D4/01/1993
A
12/08/1954
F
03
N
100,000.00
04/01/1333
A
11/14/1946
M
SPOUSE
06/O1/1992
A
12/29/1959
M
u3
T
100.000.OD
06/01/1992
A
10/O7/1963
F
SPOUSE
34/01/1992
A
12/23/1953
M
03
N
10.000
00
04/01/2992
A
06/28/1951
F
SPOUSE
O4/01/1992
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
15 D,OOJ.OG
03/01/2001
A
10/22/1959
F
SPOUSE
01/01/2001
A
02/L7/1910
M
03
N
90.000.00
O1/01/2001
A
06/14/1973
F
SPOUSE
04/02/1992
A
12/08/1956
M
03
N
50,000.00
04/01/1992
A
02/13/1956
F
SPOUSE
02/01/1998
A
10/12/1955
F
03
N
50,00C.00
02/01/1995
A
11/20/1946
M
SPOUSE
O1/01/1995
A
27/14/1953
M
03
N
150,000
OD
01/01/1995
A
12/05/1955
F
SPOUSE
04/01/1992
A
12/25/1947
M
03
N
15D,000.00
O4/01/1992
A
O1/15/1956
P
SPOUSE
04/01/1992
A
12/31/1951
M
O3
N
40,003.00
C4/01/1992
A
11/03/1954
F
SPOUSE
04/01/1992
A
12/15/1949
M
O3
N
50.000.00
O4/01/1992
A
O7/20/1951
F
SPOUSE
04/01/1992
A
12/20/1962
M
03
T
50,000.00
04/01/1992
A
06/28/1962
F
SPOUSE
299 28,500,000.00
ADCSO Enrollee and Dependents List 29/dUL/2003
..__.--------------------------- -- ---- ------
Company 004 Anthem Life Insurance Companv
Country 01 United States
Coverage: 113 Voluntary Life - Child
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name Effective Status Birthday Be. 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
O1/01/1995 A 04/11/2966 M
04/01/1994 A 02/24/1951 M
10/01/1993 A 12/28/1950 M
06/01/1998 A 10/03/1951 M
10/01/1993 A 11/23/1559 M
10/01/1993 A 12/29/1954 M
10/01/1993 A 12/06/1950 M
01/01/1994 A 07/15/1960 M
04/01/2000 A 04/08/1966 M
10/01/1993 A 03/23/1964 P
08/01/1998 A 05/27/1973 P
10/01/1993 A 12/27/1956 M
10/01/1993 A 12/24/1952 F
10/01/1993 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
12/01/1958 A 07/29/1969 M
02/01/1996 A 04/04/1957 M
02/01/1994 A 12/31/1960 M
11/O1/1994 A O1/01/1980 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 12/07/1957 M
10/01/1993 A 12/04/1946 M
10/01/1993 A 12/17/1947 F
07/01/1995 A O110111980 F
10/D1/1993 A 12/08/1954 M
10/01/1993 A 12/27/1967 F
02/01/1997 A 06/28/1963 M
10/01/1993 A 12/17/19SG M
Page 30
Terminated Class
E-type
1B
1
1B
1
1B
1
1B
1
1B
1
1B
1
1B
1
1B
1
1B
1
1B
1
1B
1
1B
1
iB
1
1B
1
1B
1
1B
1
1B
1
lE
1
1B
1
1B
1
lB
I
1E
1
1B
1
1B
1
1B
1
3E
1
1E
1
1B
1
19
1
3E
1
1n
18
L
1B
1
is
1
1B
1
18
1
18
1
1B
1
1B
1
1B
1
1B
-
SB
1
18
1
1B
1
18
1
Volume
5,000.00
5,000.00
5,000.00
5,000.00
5,000.00
51000.00
S, DOD. 00
5,000.00
5,000.00
5,000.00
5.000.00
5,000.00
5,000.00
5,000.00
S,O00.00
51000.00
5,000.00
S. OOD.00
5,000.00
5,000.00
5,000.00
5,000.00
5,000.00
5, 000.00
5,000.00
5,000.00
5,000.00
5,000.00
5,000.00
5,000.00
5,000.00
5,000.00
5,000.00
5, 000.00
5,000.00
5,000.00
5,000.00
5,000.00
51000.00
5,000.00
5,000.00
S, OOO.DO
5,000,00
5,000.00
51000.00
ADC50
Enrollee and Dependents List
--------------------- ________
Company 004 Anthem Life Insurance
Country 01 Company
United States
Coverage: 113 voluntary Life - Child
Group 006516.0099 CITY OF FORT COLLINS
Cart No. ❑ep Name
29/-IM/2003 Page 31
Effective
03/01/1995
Status Birthday
Sex Relation
Terminated Class E-type
A
07/06/1951
M
10/01/1953
A
12/14/2951
M
is 1
10/01/1993
A
12/25/1952
P
is 1
02/01/1994
A
08/29/1952
M
10 1
10/01/1993
A
05/14/1949
M
1B 1
10/O1/1993
A
12/15/1951
M
1B 1
09/01/2001
A
09/07/1973
M
Is 1
03/01/1997
A
06/19/1952
M
is 1
10/01/1993
A
12/13/19SS
M
15 1
10/01/2993
A
12/07/1947
M
Is 1
02/01/1994
A
03/26/1962
M
is 1
05/01/1997
A
DS/1B/1953
M
13 1
01/01/1994
A
01/20/1958
P
13 1
06/0I/1997
A
12/11/1965
M
is 1
10/01/1993
A
12/05/19SI
M
1B 1
03/01/1996
A
09/12/1959
M
in 1
10/01/1993
A
12/25/19$6
M
1B 1
04/01/2002
A
11/19/1960
M
is 1
08/01/1995
A
08/20/1958
M
1B 1
10/01/3993
A
02/25/1955
M
1B 1
10/01/1993
A
12/06/1950
k
is I
04/01/2D03
A
07/10/1974
M
is 1
12/01/2000
A
07/06/1968
M
is 1
03/02/2997
A
12/25/1956
M
is 1
30/01/1997
A
12/24/1959
M
1s 1
10/01/1993
A
12/21/1952
M
1B 1
10/01/1993
A
01/01/1980
M
1s 1
02/01/1999
A
06/04/1953
M
1B 1
10/01/1993
A
01/01/1980
P
Is 1
10/01/1993
A
12/05/1954
P
1B 1
10/01/1993
A
12/07/1963
M
is 1
10/01/1993
A
12/04/1954
M
1B 1
01/01/1996
A
05/06/1960
M
1B 1
10/02/1993
A
12/19/1946
M
Is 1
06/01/2000
A
02/20/1972
F
is 1
03/01/2001
A
09/02/1955
M
1B 1
02/01/199B
A
10/20/1969
M
1s 1
03/01/1996
A
11/11/1965
F
13 1
10/03/1993
A
12/13/1961
M
1s 1
02/01;1996
A
09/24/2958
F
1B 1
10/01/2002
A
12/18/1957
F
1B 1
10/01/1993
A
12/30/1953
M
is 1
01/01/1997
A
11/06/1961
F
1B 1
03/02/1995
A
07/31/19SO
M
1s 1
11/01/2001
A
10/19/1972
M
11) 1
18 1
xDC50 Enrollee and Dependence List
Company 004 Anthem Life Insurance Company
Coun_ry : 01 United States
Coverage: 113 Voluntary Life - Child
Croup : 006516 0699 CITY OF PORT COLLINS
29/SVL/2003
Cert N, Dep Name Effective SLa-un Birthday
03/O112999 A 12/29,'1997
10/01/1991 A 12/05/2954
03/01/,1999 A 04/21/1965
10/01/1993 A 12/21/1946
10/01/1993 A 121'1711963
12/01/2002 A 12/21/1966
SD/01/1993 A 12/02/1949
07/01/199. A 05/13/1962
30/D1/1993 A 12/13/1951
06/01/2002 A 10/05/1962
05/01/1999 A 06126i1961
-0/01/1993 A 12/22/1946
=0/Ol/199J A 09/06/1956
03/01/2000 A 01/09/1969
06/01/2003 A 09/11/1977
1./01/1993 A 05/Y9/1956
10/O1/1993 A 12/03/1957
10/01/1_993 A 12/29/1963
02/01/_991 A 03/11/1958
30/01/_993 A 12/21/1953
09/e1/:994 A 02/O3/1950
10/01/_991 A 12/21/1957
I0/01/_993 A 12/25/1962
10/01/'-"I F 12/24/1948
06/O1/1998 A 01/22/1966
10/D1/:993 A 12/19/1955
11/01/2000 x 05/21/1977
01/01/2003 A 02/15/1954
10/01i1993 F 12/07/1959
10/01/1991 A 11/31/1956
10/01/1993 A 12/20/1953
10/01/1593 A 12/14/1949
02/01%1996 A O6/16/L963
32/O1/199s A 03/09/1956
10/01/1993 A 12/13/1955
09/01/2001 A 08/O7/1968
30101/1993 A 12/02/1951
10/01/1993 A 12/23/1946
03/01/1994 A 04/29/1963
05/01/1996 A 09/10/1968
04/01/1995 A O7/23/1947
10/01/1993 A 12/10/1953
30/ol!1993 A 12/14/1961
01/01/1994 A 12/28/1965
101OS/1993 A 12/3D/1940
Page 32
Relation Terminated Class
£-type
Volume
IS
I
5,000.0c
IS
1
5,000,00
1B
1
5,000.00
LB
L
5,000.00
1B
1
5,000,00
1B
1
5,000.00
1B
1
5.000.so
IB
1
5,000,00
LB
I
5,000.00
is
I
51000.00
16
1
5,0V0.00
1B
1
51000.00
1B
1
51000 O0
IS
1
5,000,00
1B
1
51000.00
IS
1
5,000.00
IB
1
5,000.00
IS
1
5,000.00
IS
1
51000.00
IB
1
5,000-00
IS
1
5.000 9e
LB
1
51000.00
is
I
S,oan 00
1B
1
S,OD0 .00
IS
1
5,000.00
12
1
5,000.00
1B
1
5,000,00
IN
1
51000.00
Is
1
$1000.00
is
1
5,000.00
1B
1
5,000.00
1B
1
S, 000. OC
1B
1
5, 000.00
IS
1
5, 000.00
1B
1
5, 000.00
is
1
5,000.Oo
IS
1
S, Of 0.00
1s
1
5.000.00
3B
1
51 00 D.00
Ss
1
51000.so
1B
1
51000,00
is
1
S. 000.00
1s
1
5, 000.00
1B
1
51 000.00
1B
5, V00.00
�C5D 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
1D/01/1993
A
12!25/1953
M
1B
3
5,000.0D
09/01/1996
A
06/24/1945
M
18
1
5,000.00
10/01/1993
A
12/19/1954
M
1B
1
5,000.00
10/01/1993
A
12/29/19SB
M
1B
1
5,000.00
02/01/2003
A
06/10/1967
M
18
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
30
1
5,000.00
11/01/2001
A
07/17/1953
F
1B
1
5,000.00
10/01/1993
A
12/26/1951
M
1B
1
5,000.00
10/01/1993
A
12/08/1952
F
1B
1
5,000.00
10/01/1993
A
12/06/1959
M
13
1
5,000.00
10/01/1993
A
12/11/1956
F
36
1
5.000.00
10/01/1993
A
12/14/1959
M
1B
1
5,000.00
'0/01/1993
A
05/20/1945
M
1B
1
5,000.00
10/01/1993
A
12/D6/1959
M
18
1
5,000.00
10/01/1993
A
12/16/1952
M
1B
1
5,000.00
10/01/1993
A
12/31/1964
M
1B
1
5,000.00
10/01/1993
A
12/17/1957
M
1B
1
5,000.00
1D/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
10/01/1953
A
12/19/1947
M
1B
1
5,000,00
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
10/01/1993
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
1B
1
5,000.00
10/01/1993
A
12/23/1959
M
10
1
51000.00
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
_
5,o00.00
10/01/1993
A
12/13/1944
M
16
1
51000.00
10/01/1993
A
06/22/1951
M
in
1
5,000-00
04/01/2002
A
10/14/1951
F
1B
1
5,000.00
10/01/1993
A
12/16/1946
M
1B
1
5,000.00
10/01/1993
A
12/11/1948
F
1B
1
5,000.00
10/01/1993
A
01/01/1980
M
1B
1
5,000,00
02/01/1995
A
10/31/1963
M
1B
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
5,000.00
10/01/1993
A
12/11/1954
M
1B
1
5,000.00
04/01/1994
A
12/09/1954
M
1B
1
5,000.00
10/01/1993
A
12/03/2961
F
1B
1
5,000. 00
10/01/1993
A
12/13/1954
M
1B
1
5,000. 00
QUESTION: LTD CLAIMS VS. PAID PREMIUM
ANSWER:
Year Beg(nning Year Ending
Paid Premium
Paid Claims
Disabled Life Res.
1-Jan-01 31-Dec-01
$
304,638.00
$
129,627.00
$ 201,519.00
1-Jan-02 31-Dec-02
$
337,186.00
$
149,692.00
$ 215,612.00
1-Jan-03 1-Aug-03 $
275,412.00
$
102,676.00
$ 340,061.00
T OTAL __. _ .__ __..
._
1 67 362.00
_$
536 138 00
$ 1 133,092, 00
QUESTION:
Voluntary Life and AD&D VS.
Paid Premium
ANSWER:
toes wtao Rsport
14:10 Friday, Auguat 15, 2003 ,
Casa(a) - City
of Fort CollLu ('0085181)
Billing Unit(a) -
('All Billing Units
Selected')
OOVera9e COdo(s)
- ('All 00VOMpes Selected')
By Incurred Dates:
Jan 1, 2001 thru Jul $1, 2003
%0P
Coverage
Reserves
Total
o Code
Earned
Paid
Open C1Ns
18NR
Incurred Loss
e Description Period
Premium
Claims
Reserves
Reserves
Claims Ratio
a Vol Life 01/01/2001 to 12131/2001
166,203.82
0.00
0.00
0.00
D.00 0%
01/01/2002 to 12/31/2002
155,714.00
O.00
0.00
0.00
0.00 0%
.~L 0110112003 to 07131/2DO3
01,567.40
30,094.93
0.00
15,697.27
45,782.20 SO%
Vol Life
413,565.22
3D,084.93
0.00
16,4*7.27
45,192.90 11%
Vol LSfelChild 01/01/2001 to 12/9112DOI
4,372.99
5,017.04
0100
0.00
51017.08 its%
01101120D2 to 12/3112002
4,412.00
O.DO
0100
0.00
9.00 0%
01101/2003 to 0713112003
2,522.50
0.00
0.00
439.43
432.43 17%
Vol L1ts/Child
11,307.46
5,017.98
0.00
439.43
5,460.41 46%
VADLD 01/0112001 to 12/31/2001
8.127.66
0.00
0.00
0.00
8.00 D%
0/10112002 to 12/3112002
8,105.81
0.00
0.00
0.00
0.00 p4
01/0112003 to 0713112ODS
415OW82
0.00
0.00
0.00
0.00 0%
VADBD
21,152.18
0.00
0.00
0.00
0-DO 0%
Billing Fee 01/0112001 to 12/3112001
745.00
0.00
0.00
0.00
0.00 0%
01/01/2002 to 12/31/2002
804.60
0.00
0.00
0.00
0.00 0%
01/01/2003 to 07/31/2003
405.00
0.00
D.DO
0.00
0.00 0%
Billing Fee
2,004.60
0.00
0.60
O.00
0.00 0%
448,061149
cac_=35,112.01
0100
�c 16,129.70 -'--'51,242.61
'=call%
Grp and Vol Litt tsm is "tinted at 104, of annual promise.
AD9D AM VADID 18191 Is Hare to be 0.
Short Taro Disability ISM is astinted at 6% of sdnwl prosion.
,', Long Ten Disability 101111 is estLrted at 968 of 7 oonthe of preales.
ADC50
Enrollee and Dependents List
-----------------------------
Company 004 Anthem Life Insurance Company
Country _ 01 United States
Coverage: 113 Voluntary Life - Child
Group 006518-0099 CITY OF FORT COLLINS
Cert No. ➢ep Name
29/JVL/2003
Effective Status Birthday Sex Relation
10/01/1993 A 12/04/1956 M
30/01/1993 A 12/20/1956 M
10/01/1993 - A 12/26/1956 M
30/01/1993 A 12/26/1950 M
O8/01/2001 A 06/06/1970 M
04/01/1991 A 03/06/1957 M
02/01/1994 A 12/16/1946 M
10/01/1993 A 01/30/1949 M
10/01/1993 A 05/19/1950 M
10/01/1993 A 12/22/1952 M
01/01/1995 A 03/26/1957 F
10/01/1993 A 12/29/1955 M
10/01/1993 A 12/20/1948 M
O1/01/2001 A 06/15/1962 F
O1/01/1994 A 06/08/1964 M
10/01/1993 A 12/21/195S F
O1/01/1995 A 12/27/1958 M
05/01/2000 A 04/26/1969 M
03/01/2002 A 02/11/1960 M
09/01/2001 A 05/01/1957 M
09/01/2D02 A 02/10/1950 M
10/01/1993 A 12/07/1956 M
04/01/1996 A 06/23/1959 F
10/01/1993 A 12/OB/1954 F
03/01/1996 A 12/29/1959 M
10/01/1993 A 12/15/1957 F
10/01/1993 A 12/09/1949 M
10/01/1993 A 12/2a/1951 M
10/01/1993 A 04/22/1954 M
01/01/2001 A 02/17/1910 M
1D/01/1993 A 12/08/1956 M
03/01/1995 A 07/14/1953 M
10/01/1993 A 12/25/1947 M
10/01/1993 A 12/31/1951 M
IO/Ol/1993 A 12/20/1962 M
Page 34
Terminated Class
E-type
Volume
1B
1
51000.00
1B
1
5,000.00
38
1
5,000.00
1B
1
51000.00
1B
1
5,000.OD
1B
1
5,000.00
IB
1
5,000.00
1B
1
5,000.00
1B
1
51000.00
1B
1
5,D00.00
1B
1
S,D00.00
1B
1
5,000.00
1B
1
5,000.00
1B
1
5,000.00
IB
1
51000.00
1B
1
5,0D0.00
1B
1
51000.00
1B
1
51000.00
1B
1
5,000.
00
IF
1
5,000.00
18
1
5,000,00
1B
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
IB
1
5,000.00
1B
I
5,00D.00
3B
1
5.000.00
1B
1
5,000.00
1B
1
5,000.00
1B
1
5,000.00
215 1 075, 00a.DD
1172 10�00.00
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 e 2nd Floor e P.O. Box 580 e Fort Collins, CO 80522-0580 e (970) 221-6775 e FAX (970) 221-6707
EE-1 X
STATEMENT OF PREMIUMS DUE
EMPLOYEE LIFE STEP RATE BANDS
1X ANNUAL SALARY
Policy No. 985" Policyholder Name CITY OF FORT COLLINS
Premium Due Date: 8/1/2003 Billing Group No. N/A
# of EE's
Covered
Volume of
Insurance
Ago Rate
Bands
Rate Per
$1,000
Current Mo.
Premium
Adjustmt
+
Adjustmt
Premium
Due
21
898.278
0-29
0.10
89.83
89.83
26
1,372,287
30-34
0.12
164.67
164.67
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
1.007.87
1,007,87
63
2,039,618
50-54
0.66
1,910.761
1 910.75
23
1,273,130
55-59
1.02
1.298.59
1,298.59
8
361.782
50-64
1 1.45
524.58
524.58
1
41,134
65-89
2.00
82.27
1
82.27
O
O
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
Folic #: 98544
1 Policyholder Name:
CITY OF FORT COLLINS
Prerrlum Due Date, 81112003
jBilling Group No,
NIA
Plan
Coverage
# of EE's
Covered
Voluane of
Insurance
Rate
Current Mo
Premium
Adjustmt
(+)
Adjustmi
(•}
Premium
Due
Employee
Life
10,000
148
1,480,000
0.200
296.00
296,00
1X Salary
1,296
66,536,608
0.200
13,307.12
13,307.1
'10,000
148
1,480,0001
0.04
59.20
5920
Employee
ABD
1XSala
1,296
66,535,608
0.04
2,661.42
2661.42
Add'11X
177
91384968
0.04
376.40
375,40
Add'12X
81
8,218,360
0.04
328.73
328.73
Add'I 3XI
106
14,982,802
0.04
599.31
599.31
Dependent
5,000
47
NIA
0.50
23.50
23.60
Child
10,000
337
NIA
1.00
337,00
337.00
Optional
Employee
Life
1XSalary
240
12,523348
Attached
5,763.12
6,753.1
2X Sala
111
11,078 218
Attached
3,759.94
3,759 .
3X Sala
125
17,953 044
Attached
4,208.21
4,208 .
U to 125,000
1
19,000
12.3
12.
Up to 125,000
1
30,000
30.60
30.
10,000
144
1,440 000
Attached
669.80
669.
Optional
25000
72
1,800000
Attached
765.00
765. '
Spouse
Life
50,000
63
3,150 000
Attached
1071.50
1,071,
75000
20
1,500,000
Attached
361.60
361.
100,0001
16
1,600,000
Attached
330,00
Lon Term Disabilily
1 1,072 1
4,353,825
0.790
1 34,395.21
34,395.21
69�98
Adminish .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
AGE
SIO-OW
s20.00u
SIG -OOP
S4AQW
S50,004
560.000
00000
S80.0➢4
S90.909
1100- 4
au0.00n
simAOu
st30Q40
S140.90u
u500M
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
6.00
35 - 39
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
4.50
S.00
5.50
6.00
6.50
7.00
730
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
1120
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
4.00
C00
840
IOAO
12.00
14.00
16.00
19.00
20.00
22.00
24.00
26.00
Z8.00
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
53.20
57.00
60 - 64
4.90
9.80
14.70
19.60
24.50
29AO
34.30
39.20
44.10
49.00
53.90
58.80
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
58.00
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
178.80
208,60
238.40
268.20
29840
327.80
337.60
387.40
417.20
447.00
ATTAINED
AMOUNTS
OF INSURANCE
AGE 1160,000
1170 000
5180 000
2190 000
S200-OM
S210.000
S220MO
1211000
5290,000
S22M
S260,000
S270.000
MO ON
S290 000
S300 ODD
Less than 35
6.40
6.80
7.20
7.60
8.00
3.40
8.90
9.20
9.60
10.00
10.40
1010
11.20
11.60
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
MOO
40 - 44
12,80
13.60
14.40
15.20
16.00
16.80
17.60
19.40
19.20
20.00
20.80
21.60
22.40
23.20
24.00
45-49
20.90
22.10
23.40
24.70
26.00
27.30
29,60
29.90
31.20
3250
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
48.00
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
78A0
93.30
88.20
93.10
99.00
102.90
107.80
112.70
117.60
122.50
127AO
13230
13710
142.10
147.00
65 - 69
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
249.00
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
476.90
506.60
536.40
566.20
596.00
625.90
655,60
68SAO
715.20
745.00
774.80
804.60
834.40
864.20
894.00
09/12/02 $1.50 fiat 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
S I n 000
520.000
530.000
S40.000
150 000
5610W
t10 000
S90 000
520.000 1100.000
5110
W
tM 000
S130-000 S140.000
S150 000
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
6.00
35 - 39
0.50
1.00
1.50
2.DO
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
L.60
2.40
3.20
4.00
440
5k0
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
7.90
9.10
10.40
11.70
13.00
14.30
15.60
16.90
18.20
19.50
50 - 54
2.OD
4.00
6.00
8.00
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
3D.40
34.20
39.00
41.80
45.60
49.40
53.20
57.OD
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
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
7D - 74
14.50
29.00
43.50
58.00
72.50
87.00
101.50
116.00
130.50
145.00
159.50
174.00
188.50
203.00
217.50
75 - 79
29,8D
59.60
89.40
119.20
149.00
178.90
208.60
238.40
268.20
298.D0
327.80
357.60
387.40
417.20
447.00
ATTAINED
AMOUNTS
OF INSURANCE
AM
1150 000
5110.400
I1t0.000
1140.400
1200ADO
$210.000
S220MO
1230MO
S240AN
S250.900
S260.000
5220-000
$280 000
S240A40
$300.090
Less than 35
6.40
6.80
7.20
7.60
8.00
8.40
8.80
9.20
9.60
10.00
10.40
10.80
11.20
11.60
12.00
35 - 39
8.00
8.50
9.00
9.50
10.D0
10.50
11.00
11.50
12.00
12.50
13.00
13.50
14.00
14.50
15.00
40 - 44
12.90
13.60
14.40
15.20
16.00
16.90
17.60
18.40
19.20
20.00
20.90
21.60
22.40
23.20
24.00
46 - 49
20.90
22.10
23.40
24.70
26.00
27.30
29.60
29.90
31.20
32.50
33.80
35.10
36AO
37.70
39.00
50 - 54
32.00
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
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
83.30
$8.20
93.10
98.00
102.90
107.80
112.70
117.60
122.50
127.40
132.30
137.20
142.10
147.00
65 - 69
132.80
141,10
149.40
157.70
166.00
174.30
192.60
190.90
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
$04.60
834.40
864.20
894.00
09/12/02 $1.50 flat rate covers all children for $5,000
CITY OF FORT COLLINS
VOLUNTARY ACCIDENTAL DEATH AND DISMEMRF.ttMVINT ueTIWc
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
I40,000
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.
• MedicalIy 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.
REQUEST FOR PROPOSAL
CITY OF FORT COLLINS
Proposal Number
P902
Benefits
OPENING DATE: 2:00 p.m. (our clock), August 29, 2003
City of Fort Collins, RFP 2003
QUESTION: Basic Life AD&D Claims vs. Paid Premium
ANSWER:
City of Ft Collins 98544 - Claims vs. Premium
January 2001
- August 2003
ors®owed !
Basic Life
Opt Life
Basic AD&D
Opt AD&D DeP Life
02/01/01
34,000
34,000
34,000
34,000 ;
06/27/01
25,000
- --
12/31 /01
09/10/02
41,000
123,000
41,000
123,000
11 /22/02
................
03/26/03
03/27/03
=
04/27/03
__
— ---
04/30/03
—
..............
10,000
05/20/03
35,000
138,000
- - — —
--
05/22/03
46,000
91,000
06/09/03
181,000
386,000 75,000 157,000
10,000
Basic Life Opt Life Basic AD&D Opt AD&D Dep Life
Premium Jan
......
01 - Aug 03 i 355,050 470,976 1�15,868 ? 11,359
Waiver
17,000
10,000
32,000
...........................
34,000
35,000
Closed
Closed
Open
Closed
Closed
REQUEST FOR PROPOSAL
CITY OF FORT COLLINS
Proposal Number P902 - Benefits
The City of Fort Collins is seeking proposals from qualified firms for certain employee benefit
plans.
Written proposals, six (6) copies, will be received at The City's Purchasing Division, 215 North
Mason Street, 2"d Floor, Fort Collins, Colorado 80524. Proposals will be received before 2:00
p.m. (our clock), August 29, 2003. Reference Proposal No. P902. If delivered, they are to be
sent to 215 North Mason Street, 2"d Floor, Fort Collins, Colorado 80504. If mailed, the address
is P.O. Box 580, Fort Collins, Colorado 80522-0580.
Questions regarding the scope of the project should be directed to Vincent Pascale, Benefits
Administrator and Project Manager for this RFP, (970) 221-6828.
Questions regarding proposal submittal or process should be directed to David Carey, C.P.M.,
Buyer, (970) 416-2191.
A copy of the Proposal may be obtained as follows:
1. Call the Purchasing Fax -line, 970-416-2033 and follow the verbal instruction to
request document #30902.
2. Download the Proposal/Bid from the Purchasing Webpage,
www.fcciov.com/purchasing.
3. Come by Purchasing at 215 North Mason St., 2nd floor, Fort Collins, and request
a copy of the Bid.
Sales prohibited/Conflict of Interest: No officer, employee, or member of City Council shall have
a financial interest in the sale to The City of any real or personal property, equipment, material,
supplies or services where such officer or employee exercises directly or indirectly any decision -
making authority concerning such sale or any supervisory authority over the services to be
rendered. This rule also applies to subcontracts with The City. Soliciting or accepting any gift,
gratuity, favor, entertainment, kickback or any items of monetary value from any person who
has or is seeking to do business with The City is prohibited.
Collusive or sham proposals: Any proposal deemed to be collusive or a sham proposal will be
rejected and reported to authorities as such. Your authorized signature of this proposal assures
that such proposal is genuine and is not a collusive or sham proposal.
The City reserves the right to reject any and all proposals and to waive any irregularities or
formalities.
Sincerely,
,James B. O'Neill II, CPPO, FNIGP
Director of Purchasing & Risk Management
City of Fort Collins, RFP 2003
2
Proposal Number P902 — Benefits
The City of Fort Collins is seeking proposals from qualified firms for the following employee
benefit plans:
• Basic Group Life and AD&D — fully insured and completely employer paid
• Supplemental Group Life and AD&D — fully insured and completely employee paid
• Voluntary Group Life and AD&D — fully insured, portable and completely employee paid
• Group Long Term Disability — fully insured and completely employer paid
• Dental (comprehensive and basic) TPA Services — self -funded with cost shared by employer
and employees
• Vision Care TPA Services — self -funded and completely employee paid
• Transplant Benefits — currently fully insured and completely employer paid
• Long Term Care — fully insured individual contracts and completely employee paid
Single as well as multiple plan providers are encouraged to respond. Proposals may be on one
or multiple plans.
Current plan descriptions are available upon request. Included with this RFP are: census data,
claims experience and questionnaires. For each plan in your response, please answer the
respective questionnaire in the format provided. Rates must be quoted net of broker or other
commissions, since The City does not pay commissions.
The City intends to replicate current plan provisions. Your answers must be responsive to the
current plan design and questions posed; otherwise, your organization may be deemed non-
responsive and disqualified from consideration. If you are unable to administer the plans as
written, you must specify clearly and specifically where your response deviates from current
plan design.
Section 1.0 Proposal Requirements
1.1 General Description
The City provides employee benefits to approximately 1,450 active employees and
approximately 40 retirees.
The City is requesting proposals to administer its group life, disability, dental, vision care,
transplant and long term care plans. Some plans are self -funded, while others are fully insured.
In addition, some plans are 100% employer paid, some share the cost between the employer
and the employee, and some are 100% employee paid.
Based on the proposals received, The City may select one carrier/administrator for all plans, or
separate carriers/administrators.
The City believes that an essential factor in managing the cost/service/quality balance is the
relationship with each of its business partners. The City will review the selected vendor(s) as an
active partner in assuring employee satisfaction.
City of Fort Collins, RFP 2003
3
1.2 Timetable
The following is a proposed timetable developed for this project. You will be notified of any
significant changes which might occur:
The City releases RFP to vendors
Written questions due to The City
Proposals due to The City
Finalist vendors notified
Onsite evaluations of finalists (if necessary)
Finalist negotiations (completed)
Selection of recommended vendors
Plan effective date
1.3 Proposal Submittals
August 7, 2003
August 20, 2003
August 29, 2003, 2:00 P.M. (our clock)
September 15, 2003
September 22, 2003
September 29, 2003
October 6, 2003
January 1, 2004
Your proposal must clearly indicate the name of the responding organization, as well as the
name, address and telephone number of the primary contact at your organization for this
proposal. Your proposal must include the contact name for local service and account
management whom the City can call directly.
Please submit your proposal no later than 2:00 p.m. (our clock) on August 29, 2003. Submit
six (6) copies of your proposal to:
Mr. James B. O'Neill II, CPPO, FNIGP
The City of Fort Collins
Purchasing Department
215 North Mason Street, 2nd Floor
Reference RFP P902
PO Box 580
Fort Collins, Colorado 80522-0580
Questions regarding this RFP are due to The City no later than August 20, 2003. A written
response to substantive questions will be provided to all proposers.
The City assumes no responsibility for liability for any costs you may incur in responding to this
RFP, including attending meetings, site visits or negotiations.
1.4 Deviations from RFP Specifications
All responses to this RFP must be prepared in accordance with the Proposal Requirements set
forth in Section IV of this RFP. The City reserves the right to refuse any proposal not
prepared according to the Proposal Requirements of Section 1.5.
The City retains the right to directly negotiate the finer points of your proposal that comply in
spirit with this RFP and that satisfy The City's objectives for effective, interactive and proactive
claims and (where applicable) network administration. The City shall not be bound to accept the
proposal with the lowest price. The RFP may be amended or revoked at any time prior to final
execution of an Agreement by The City.
City of Fort Collins, RFP 2003
4
Any deviations from this RFP must be clearly identified and explained in your proposal. These
deviations are to be delineated as instructed in the Proposal Requirements as set forth in
Section 1.5 of this RFP.
It is intended that you should conform to these specifications as much as possible. Do not
quote alternative plan designs unless absolutely necessary. Please quote the requested
financial arrangements only.
Your company will be bound to comply with the provisions set forth in this RFP unless any and
all deviations are explicitly stated in your proposal.
1.5 Proposal Instructions
Do not deviate from the requested formats. Provide your proposed rates and fees as specified
in this RFP.
The City is seeking an initial premium/administration cost that runs for at least 24 months
(January 1, 2004 — December 31, 2005). Please confirm the time period applicable to your
proposed rate/fee guarantees.
Quote all life, disability, long term care and transplant coverage on a fully insured non-
participating basis. Administrative services for dental and vision should be quoted for a self -
funded plan.
Define specifically what services are included in the fees your company has quoted.
Specify any charges for services that your company has not included in the fees quoted above,
including any start-up fees.
Adhere to the instructions in this section when organizing your proposal.
1.6 Proposal Requirements
Your response should be organized in the following sections:
Section I: Executive Summary
Section II: Proposal Compliance Letter (Signed by an authorized officer of your organization
signifying your proposal's complete adherence with the RFP specifications,
except as specifically noted in the appropriate sections)
Section III: Checklist of Items included with Proposal
Section IV: Plan Design Confirmation (Statement indicating your willingness to replicate
current plan provisions or indicating clearly deviations from current plan design)
Section V: Questionnaire Responses
Section VI: Performance Guarantees
Section VII: Financial Exhibits
Section VIII: Items Included with Proposal (As indicated on the Checklist included in Section
III. These items should be indexed in the order listed on the checklist, with a copy
of the index included in this section)
City of Fort Collins, RFP 2003
5
Section 2.0 Services to Be Provided
In addition to the plan provisions set forth in the attachments, The City has specific vendor
requirements needed to support its day-to-day operations.
2.1 Specific Requirements
• Account Management
The account executive and service representative(s) will deal directly with The City. This
environment requires the account management team to:
➢ Be able to devote the time necessary to the account, including being available for
frequent telephone and on -site consultations with The City. Proposers who are not
committed to serious account service will not receive serious consideration;
➢ Be extremely responsive;
➢ Be comprised of individuals with specialized knowledge of the proposing company's:
- Claims and Eligibility Systems
- Provider Networks (where applicable)
- Systems Reporting Capabilities
- Claims Adjudication Policies and Procedures
- Administrative Services Contract Wording
- Standard and Non -Standard Banking Arrangements
- Relationships with Third Parties
➢ Be thoroughly familiar with virtually all of the proposing company's functions that relate
directly or indirectly to the account.
➢ Act on behalf of The City in "cutting through red tape". This facet of account
management cannot be emphasized enough — the account management team must
be able to effectively advance the interests of The City through the vendor's corporate
structure.
• Enrollment/Eligibility
The City will provide initial enrollment forms on paper, but seeks to provide eligibility
updates electronically. The initial enrollment and updates will provided directly to the
selected vendor(s) by The City.
The selected vendor(s) will perform direct eligibility certification to providers and verify
coverage as a part of the claims management and adjudication process. A quarterly
reconciliation between payroll and eligibility will be required of the selected vendor(s).
• Fee Administration
All fee/premium statements will be self -billed by The City. The City will calculate the fees/
premiums payable on a monthly basis and will submit these fees directly to the selected
vendor(s).
• COBRA Administration
City of Fort Collins, RFP 2003
6
Where applicable, the COBRA Administration will be conducted by the chosen vendor(s)
and eligibility information will be provided by The City. Supportive services required by the
selected vendor(s) will be as follows:
➢ Accept information from The City on COBRA participants
➢ Send COBRA notifications to plan participants at termination
➢ Claims adjudication inquiries
➢ COBRA member service inquiries related to benefits and claims
• Customer Service
The selected vendor(s) must have as its primary focus on efficient and effective processing
of all inquiries. Satisfactory customer service will include prompt, courteous and accurate
responses to the City and employee inquiries regarding claim submissions, applicable
provider networks, plan design and provisions, etc. A toll free number should be available
for eligibility certification and claim submission inquiries.
• Financial Accounting
On a monthly basis, the selected vendor(s) must provide an accounting reconciliation of any
"central bank" accounts utilized.
The selected vendor(s) must provide a quarterly written report detailing all administrative
expenses charged outside the Administrative Services Agreement. The selected vendor(s)
must present a report detailing and justifying proposed fees for the coming year by
September 1st of the preceding year.
• Right to Audit
The selected vendor(s) must agree to allow The City, or its representative, the right to audit
all claims, applicable provider credentialing, financial data and other information relevant to
the City's account.
• Data and Management Information Reporting
The selected vendor(s) must provide monthly paid claim summaries and detailed claim
listings, preferably in Excel format. The vendor(s) must also provide its standard reporting
package. Ad hoc reports will periodically be requested. Enrollment, claims and
premium/fee information must be accurate and supplied in a timely manner upon request.
Please describe your online claim reporting and look -up capabilities that will be available to
The City.
• "No Loss/No Gain" for Covered Employees
It is critical that there will be no loss of coverage for any employees. Therefore it is required
that your proposal waives any "actively at work", "dependent confinement", or any other
rules that would prevent 100% continuity of coverage for any employees or dependents who
are currently covered under the plans.
City of Fort Collins, RFP 2003
Section 5.0 Evaluation
The Request for Proposal (RFP) is intended to assess which vendors have the ability to meet
The City's long-term goals and objectives as previously defined. The proposals will be evaluated
per the review and assessment criteria listed below.
5.1 Evaluation and Assessment of Proposal
An evaluation committee shall rank the interested firms based on their written proposals using
the ranking system set forth below. Firms shall be evaluated on the following criteria:
From 1 to 5, with 1 being a poor rating, 3 an average rating, and 5 an outstanding rating.
Recommended weighing factors for the criteria are listed adjacent to the qualification.
Weighting
Qualification
Standard
Factor
Does the proposal show an understanding of the City's
2.0
Scope of Proposal
objectives and results desired from the plan(s)?
Adherence to the services requested and described in
the RFP.
Do the personnel administering the plan(s) have the
needed skills and experience? Are sufficient people of
2.0
Assigned Personnel
the requisite skills assigned to the plan(s). Quality of
care and customer service.
Can the plan(s) be completed in the time frame
required? Can targeted effective date be met? Are
other qualified personnel available, if required, to
1.0
Availability
assist meeting the plan(s) schedule? Is the account
management team available to attend meetings as
required by the Project Manager?
Is the firm interested in providing the services
1.0
Motivation
requested in this RFP? Quality of responses to the
RFP's Questionnaire sections.
How competitive are the plan's costs, rate guarantees
2.0
Cost Financial
and where applicable, provider's contracts with area
Effectiveness
providers?
Experience managing similar plans of this type and
2.0
Benefit Management
scope. Thoroughness in selecting providers and
Capability
managing benefit plans. Actively seek to provide most
appropriate level of service?
Based on results of the written evaluation, The City will select finalists for consideration. Any or
all proposals may be rejected by The City. Finalists may be asked to make formal presentations
of their proposals, as well as to demonstrate their systems and procedures for administering
The City's plans. Site visits may take place at the finalists' home offices and/or the claims and
administrative facility/facilities that would provide service to The City.
City of Fort Collins, RFP 2003
8
5.2 Reference Evaluation (Too -ranked firms)
The Project Manager will check references using the following qualification and standard
criteria. The evaluation rankings will be labeled Satisfactory / Unsatisfactory.
a. Overall Performance - Would you hire this company again?
b. Timetable —Was the plan implementation completed within the specified time?
C. Customer Service - Was the company responsive to customer needs? Did the
company provide interactive and proactive claims and network administration?
Were problems solved quickly and effectively?
C. Premium/Administration Costs — Thoroughness in selecting providers and
managing plan costs. Actively seek to provide most appropriate level of service?
d. Knowledge - Did company personnel exhibit the knowledge and skills necessary
to efficiently carry on benefit provider operations?
Section 6.0 Proposal Acceptance:
All proposals shall remain subject to initial acceptance 90 days after the day of submittal.
Section 7.0 Agreement:
Proposer to provide sample plan agreement for review by the City.
Section 8.0 Proposal Process Information and Requirements
8.1 Intent
The intent of this RFP is to confirm key information about specific proposers, receive financial
proposals and (where applicable) identify network access compatibilities with The City's
employees. The following describes the anticipated proposal process, including confidentiality,
timing, expected response format and requirements for interaction regarding questions.
Please note that The City reserves the right to accept or reject any and all proposals, to
waive any technicalities or irregularities therein, to award contracts, or to withdraw this
request for proposal without awarding a contract. Your response to this RFP and any
subsequent correspondence related to this proposal process will be considered part of the
contract, if one is awarded to you. Under no circumstances are commissions related to The
City's benefits payable to anyone in conjunction with this request.
8.2 Confidentiality
All data included in this RFP, as well as any census data and attachments, are proprietary to
The City. It is for your exclusive use in preparing a proposal and must not be shared with any
other firm or used for any other purpose. The use of the City's name in any way as a potential
customer is strictly prohibited.
City of Fort Collins, RFP 2003
9
8.3 Miscellaneous
The City shall not infringe upon any intellectual property right of any vendor, but specifically
reserves the right to use any concept or methods contained in this proposal. Any desired
restrictions on the use of information contained in the proposal should be clearly stated.
Responses containing your proprietary data shall be safeguarded with the same degree of
protection as The City's own proprietary data. All such proprietary data contained in your
proposal must be clearly identified. Failure to respond due to the proprietary nature of data in
your response may be construed as non -responsive and could result in disqualification. The
City shall not be under any obligation to return any materials submitted in response to this RFP.
The City's contractual selection of a vendor is final. The methodology by which the proposals
are evaluated and vendors are selected is confidential and proprietary to The City.
The City expects to enter into a written Agreement (the "Agreement") with the chosen vendor
("Chosen Vendor") that shall incorporate this RFP into your proposal. The anticipated terms
and conditions of the Agreement are set forth in this RFP; however, The City may include
additional terms and conditions in the Agreement as deemed necessary.
Section 9.0 Proposal Checklist
The following information is requested as part of the proposal process. Please indicate your
included attachments by duplicating this checklist and marking the appropriate column (Yes or
No):
City of Fort Collins, RFP 2003
10
CHECKLIST OF ITEMS INCLUDED WITH PROPOSAL
Yes No Description of Item
Proposal for Group Life Insurance, AD&D and Supplemental Life
Proposal for Group Voluntary Life
Proposal for Voluntary Group Life and AD&D
Proposal for Group Long Term Disability
Proposal for Group Dental
Proposal for Vision Care
Proposal for Transplant Coverage
Proposal for Long Term Care
Signed Proposal Compliance Letter
Signed Plan Design Confirmation
Completed and Signed Questionnaire(s)
Dental Network Access Analysis (if applicable)
Vision Network Access Analysis (if applicable)
Copy of your EOB for Dental and/or Vision Services (if applicable)
Proposed Implementation Timeline for The City.
Audited Financial Statements and/or Department of Insurance
filings for the past two years (Only if requested by The City)
Provider "Report Cards" used to provide feedback on clinical and
non -clinical performance measures
Copy of your Policy Assuring Member Satisfaction
Samples of all Standard and Optional Reports you are proposing
to provide on an account specific basis
Copy of your Banking Services Agreement
Copy of your Customer Satisfaction Survey
Copy of your Administrative Services Agreement or Insurance
Contract that will be in effect January 1, 2004
Signature of Authorized Representative:
City of Fort Collins, RFP 2003
tt
QUESTION:
Is the premium history for Basic
Life available.
City
of Fort
Collins
98544
ANSWER:
—
Jonaary
2001 t„rw
a„D Wr 2001
January
20021„rODD„D«ember
200E
9A4k Aa,1m1n
LIFE EE 01JANJ1
L&a
Mama P,e "
Eak ro Wyr
LNA1
Vd.0 Fr vP
8a1�4 Ean6A January
200„_ „ 2D0�+
Liam vd1An9 PraAfun
1363
W,81O.346 E
9.148
UFE EE 01JAM2
1419
62 w7,487 $
lo.w
LIFE EE OU"a
1458
68125.54D d
13625
01FEW1
DIMAMI
I363
53,810,346 $
9,14E
D1FEW2
1419
62,W1,M7 E
1D.693
D1FE903
1466
68,1M..540 d
13825
D1APR11
1874
54,500,742 E
9,265
01MAM2
1421
64,040.911 S
ID,&97
DIMAM3
116E
9,96A,550 E
18591
01MAYD1
1363
law
%.662,476 S
9,293
01APRD2
1440
65,196 w4 $
11083
01APPM
145E
68,161285 E
13.M2
DiJU„D1
IS86
55, 187666 b
9.362
DIMAM
1449
65.757,95 S
11.179
01 MAY03
1♦61
68DM.M2 S
13,613
01JUW1
M,7M767 b
9.471
DIJUM2
1451
65,753,]96 d
11.176
D1JND3
1452
M.115624 S
13,623
DIA"I
law
1377
%,867408 E
55487,93D b
9.498
O1JULD2
1449
65731928 $
11,174
01JULD3
1I64
68267,M7 f
43,63f3
DISEP01
1381
M,764,478 $
9,433
9,480
01AJG02
DISEP02
1447
1461
66.788,' $
66.425.M b
11,184
11.92
010CT01
1393
W.268,218 d
9,566
MOM
1461
66,425,069 j
11992
Di NJVD1
14DO
W634,537 $
9.611
D1NOL92
14M
66.aD1,433 E
11.287
OIDECDI
Ux
5A534,537 b
9,611
D1DEM2
145E
66.391433 d
MW
TOTAL
E
112,906
TOTAL
E
133,129
TOTAL
i
96,362
LIFE DEPOIJAMI
365
S
aM
LIFE DEP D1JAW2
3W
b
WO
LIFE DO OUAN03
369
W
DIFE901
365
- b
335
01FE912
3W
- S
360
OIFEBD3
389
' S
6
D1MAM1
am-
M4
D1APM1
am
E
S38
DIAPRD2
am
- S
359
O'APRD3
997
f
01 MAYDI
372
- b
341
01MAM
3m
- S
361
D1MAW3
398
t
365
01JUM1
377
- b
346
DiJUWY2
3W
- b
362
D1JUM3
387
d
,6q
01JUID1
381
E
349
OIJLl02
ads01AUOD1
01JULD3
386
- S
W2
379
- d
347
011WGD2
387
- $
01SEPW
W3
- b
351
DISEPD2
384
- S
356
01OCT01
364
- E
352
D10CTD2
384
- $
358
DINJVDI
am
- t
Ma
01N 2
3M
- t
356
D1DEC01
386
- d
Ma
D1DEM2
3W
- b
356
TOTAL
$
4,136
TOTAL
E
4,311
TOTAL
i
2,551
OPT 01JAN01
676
37,558.010 E
11.526
OPT DIJAM2
742
44,159.�3 S
14.91
OPT 01JMW
WD
5D44592
17206
EE 01FE501
676
3].556,DID E
11,528
EE 01FEM
742
44, 159 w3 b
14,571
EE 01FE W3
600
W49592
17208
011VAM1
6W
39503.903 b
12.635
DIMAFD2
]W
45.710,W2 S
14.94
DIMAM3
Wt
51D22144
17313
D1APM1
696
M.740,297 E
12.682
01APRD2
7W
46332.951 $
15.053
D1APR03
W3
61616111
17,261
01MAY01
699
33976667 b
12.71D
01MAYD2
776
47 C69016 S
15,249
D1MAW3
7M
513D7733
17.162
01JUND1
712
40,8D2.946 $
12,882
DUUNU2
761
47.474.855 S
15.342
01JUM3
W3
515DOO76
17, 111
01JUID1
716
41,D97,941 E
12.972
DULL02
779
47428,594 b
15.312
OIJULD3
W2
51.469.D60
17.049
01AW01
714
40,990.962 b
12946
01AUG02
781
41,584,98 $
15,341
MOM
713
41,171,5W b
12.997
D15EPD2
782
47.W17W b
15,382
01OCTD1
723
41,39A 157 d
12.884
MCTD2
782
47Ml7W S
15.W2
01NDVD1
729
4t7271M b
13043
011J02
776
47,W2,753 E
15,342
D10EC01
729
41.72 ,IM b
13,043
D1DE002
778
47.592,753 S
15,342
TOTAL
$
151,698
TOTAL
E
191,778
TOTAL
$
120,302
AD&DEE01JAMD1
1669
77,I44.500 E
3.110
AD&D EE DIJAM2
1748
96.I65,7D6 $
3.471
AD&D EE DLAAW
1@2
1W,115.976 t
4,Dw
01FE901
01MAM1
1669
7,744,600 b
3,110
D1FE902
17M
M765.)D8 S
3.471
DVEW3
1&2
10D,118976 E
4D06
01APM1
1683
789M.711 E
3,156
0114AM2
1754
92,5174M d
3.771
011WAM3
1821
100,371,830 b
4,016
D19WYD1
%M
79264,653 $
3,170
01APRD2
1778
93 w3040 $
3,756
01APRD3
1823
100,947.243 $
4,D38
01JUNJ1
1699
17M
A,922,891 b
3.197
01MAY02
1794
95.068216 S
3,W2
DiMA`03
1818
10D.685.57D b
4027
01JUMI
W966.993 j
3.239
01JUND?
I
95,374,551 S
3,815
01JUM3
1819
ICO.M7,018 t
4D33
DIAM01
17M
81,276,424 b
3.251
O1JUL02
17N
95,M M7 b
3.816
DUUW3
1821
101,019./05 E
4,D42
V96
8D,877,419 b
3235
01AJGO2
17%
95.W9,324 b
3.822
01SEP01
1699
81,302,172 E
3.252
DISEP02
1812
96,M7,6M d
3.861
D10CTD1
1714
61.924,889 $
3.277
010CM2
1812
96527,60 $
awl
DINJVDI
1724
M.449.958 b
3,298
D1NJV02
Mi
96.161).M b
3,646
01DECD1
1724
32,448958 E
3.298
O1DECO2
1801
9616D 70 $
3,846
TOTAL
E
39,693
TOTAL
$
16,068
TOTAL
S
28,165
LTD 01JAM1
01FE901
1013
3MO 969 b
24838
LTD D1JAO2
10W
4,92, 1M b
27,47D
LTD DIJAND3
1077
4,362355 E
34p 3
0110AM1
1013
3.8W,959 d
24.8W
01FE002
10W
4,292.186 d
2747D
01FEW3
1D77
4.362.355 S
a4.6a
O1APM1
V14
via
3,892216 E
39D7628 b
24,910
DIMAM2
low
4 ,99 t
278D3
DIMAM3
ID76
4,356.501 E
34.416
DIMAYDI
V28
3.953.143 b
25DN
M.300
DIAPRD2
10W
4347,114 S
27.M2
DwR03
1077
4,368216 j
34A69
01JUM1
1D32
3.079.874 E
25.471
01MAYM
OULM@
I
10W
5.113.206 b
32,MS
01 MAY03
1D76
4.356,917 $
34.412
01JUID1
V37
3.9M.361 S
2867D
01JULD2
1079
4343.557 d
27.799
DiJUM13
1D77
4.WA994 d
34,397
DIA0001
A33
3,981.768 S
25,40
D1ALI 02
4,321,761 $
27,898
01JULD3
1076
4,355G81 S
34,4C6
VISEP01
TOM
401D758 E
25.669
DISEP02
1D75
1019
4.319.166 S
4,M%9 $
27843
27756
01OCT01
V42
4024,411 b
25756
010CT02
1D79
4,aW.5 S
27,756
DIMJVDI
V47
4046.280 E
26.896
D1NT02
1076
4,W9.545 $
277/3
01DEUI
1047
4.04628D $
26,696
D1DEOD2
1076
4.339 E45 $
27,]73
TOTAL
E
301,636
TOTAL
E
33T,189
TOTAL
i
211,026
Section 10.0 Questionnaires
Questionnaires for each plan appear below. Please respond to each plan for which you wish to
be considered.
10.1 Grouo Lona Term Disability (LTD
The City's fully -insured Group LTD Plan covers classified and non -classified employees who
work 20 or more hours per week. Uniformed police and fire employees are not eligible to
participate in this plan, but rather have separate coverage. Approximately 1,100 employees
are enrolled for LTD coverage. The current volume of coverage is approximately $4,355,200 in
monthly earnings. The current carrier has served The City since January 1, 1997, and has paid
$660,021.44 in total claims. The total disabled life reserve is $1,343,162.00.
The City pays 100% of premiums, and participation is mandatory for eligible employees. For
approved LTD claims, benefits are paid at 66 2/3% of base monthly salary, to a maximum
benefit of $4,500 per month. The plan provides for a 24-month own occupation disability, after
which benefits are continued if the claimant cannot work at any job for which he/she is
reasonably qualified on the basis of education, training and experience.
A copy of the current plan booklet is available upon request. It is expected that you will use this
booklet to duplicate exactly the current plan provisions. Deviations from current plan design
must be clearly stipulated as an addendum to the questionnaire. Please answer completely the
following questions.
A recent census and a list of benefit recipients are available upon request. Contact the
Purchasing Division at (970) 221-6775.
City of Fort Collins, RFP 2003
12
QUESTIONNAIRE
Group Long Term Disability
Please refer to plan booklet for current plan provisions.
1. Will you agree to cover without limitation all employees enrolled as of December 31, 2003?
2. Will you agree to replicate each of the current plan's provisions? If not, please list the
specific provisions you will not replicate, along with the reason you elect not to replicate the
provision(s). If you do not identify those specific provisions you cannot replicate and
you are selected as The City's group LTD vendor, you may be required to make the
necessary adjustments in order to achieve replication. Otherwise, your selection may
become void.
3. What is your fully insured premium rate for this coverage? Please express your premium
rate in terms of cents per $100 of base monthly salary. Premiums must be net of any
commissions or broker fees. If you are selected for multiple plans, will you offer discounted
premiums?
4. Include samples of claim payment reports, e.g., premiums vs. claims, etc.
5. Is there a toll -free number for employees to call with questions on plan provisions or claim
status? What is the average call waiting time?
6. What is the average length of time an employee waits for an inquiry to be answered fully?
7. What performance guarantees will you provide?
8. Specify clearly any conditions and circumstances that would be excluded from coverage.
9. Please refer to the checklist on page 10 for additional items to submit (e.g., audited financial
statements, etc.).
City of Fort Collins, RFP 2003
13
10.2 Group Life Insurance AD&D and Supplemental Life
The City's fully insured Group Life/AD&D/Supplemental Life Insurance Plan covers classified
and non -classified employees who work 20 or more hours per week. Uniformed police and fire
employees are eligible to participate in this plan. Basic coverage is mandatory for each eligible
employee, and is 100% paid by The City. No retiree life insurance is available, except through
individual conversion. Waiver of premium is required.
Eligible employees may elect basic coverage in the amounts of $10,000 or one -times annual
base salary. Basic AD&D coverage is equal to the basic life amount. Employees may also elect
additional life and AD&D coverage in amounts of one-, two- or three -times base annual salary.
Spousal coverage is available in $25,000 increments up to $100,000. Dependent child
coverage is available in amounts of $5,000 or $10,000.
The guaranteed Basic Maximum Benefit is $100,000. The guaranteed issue amount for Basic
and Optional Life is $125,000. The combined maximum benefit is $500,000. Benefits reduce
by 30% at age 65; 50% at age 70; 70% at age 75; and 80% at age 80.
A recent census and a listing showing coverage volumes are available upon request.
Contact the Purchasing Division at (970) 221-6775.
The following table indicates the coverage amounts in effect and the number of enrolled
persons:
Plan
Coverage
# Enrolled
volume ($)
Employee Life
$10,000
149
1,490,000
1-x salary
1,305
66,777,227
Employee AD&D
$10,000
149
1,490,000
1-x salary
1,305
66,777,227
Add'I 1-x
178
9,425, 543
Add'] 2-x
82
8,265,225
Add'I 3-x
107
15,091,410
Optional Employee
1-x salary
242
12,603,726
Life
2-x salary
113
11,197,150
3-x salary
128
18,059,185
Up to $125,000
1
19,000
Up to $125,000
1
30,000
Optional Spousal
$10,000
145
1,450,000
Life
$25,000
72
1,800,000
$50,000
64
3,200,000
$75,000
20
1,500,000
$100,000
16
1,600,000
"This level of coverage no longer available for new electors; however, this level of coverage
must be continued for those who are already enrolled.
City of Foil Collins, RFP 2003
14
10.3 Group Voluntary Life
In addition to basic and supplemental life insurance, employees may elect additional voluntary
life insurance coverage. This coverage is fully -insured and 100% employee paid. Applications
are subject to medical evidence. Smoker and non-smoker rates are in effect. A copy of the
current plan booklet is available upon request for specific plan provisions. Coverage is available
in $10,000 increments up to $300,000. Benefits must be portable. The following coverage
amounts are in effect.
Voluntary Life — Employee:
$67,240,000
Voluntary Life — Spousal:
28,500,000
Voluntary Life — Children:
1,000,075
Voluntary AD&D (Employees and Dependents)
13,000,060
QUESTIONNAIRE
Group Voluntary Life
Please refer to plan booklet for current plan provisions.
1. Do you agree to cover without limitation all employees/dependents enrolled on December
31, 2003?
2. Will you agree to replicate each of the current plan's provisions? If not, please list the
specific provisions you will not replicate, along with the reason you elect not to replicate the
provision(s). If you do not identify those specific provisions you cannot replicate and
you are selected as The City's voluntary life vendor, you may be required to make the
necessary adjustments in order to achieve replication. Otherwise, your selection may
become void.
3. What is your fully insured premium rate for this coverage? Please express your premium
quote in terms of cents per covered $1,000 of base annual salary. Premiums must be net of
any commissions or broker fees. If you are selected for multiple plans, will you offer
discounted premiums?
4. Include samples of claim payment reports, e.g., premiums vs. claims, etc.
5. Will you provide a toll free telephone number that employees can use to ask questions
about claims or plan provisions?
6. Please refer to the checklist on page 10 for additional items to submit (e.g., audited financial
statements, etc.).
City of Fort Collins, RFP 2003
16
QUESTIONNAIRE
Group Dental- Administrative Services Only (Cont.)
6. What percentage of your providers has limited their practice to current patients?
7. What is your organization's financial rating (e.g., Best & Co., S&P)?
8. Please describe your credentialing procedures.
9. What type of reimbursement/payment method(s) is used to reimburse participating
providers? Please provide a breakdown by method of review.
10. In addition to routine reimbursement and any withholding provisions, can your providers
increase the total reimbursement received from your plan, e.g., by provider incentive
programs? If so, please explain.
11. If provider discounts are used, state the basis of the agreement. Are discounts based on
provider charges or actual cost of service?
12. Is there a formal committee that sets quality assurance policy and review the outcome on a
regular basis?
13. Do you capture all utilization data?
14. What claims experience and utilization reports are available? If there is additional cost,
please specify.
15. Describe patient satisfaction surveys that you perform.
16. Do you have an agreement that prohibits providers from billing or collecting from patients
more than the designated coinsurance or co -payment in the plan design?
17. Please describe your method for calculating renewal rates.
18. Do you provide a toll -free number for employees to call with questions on claims, plan
provisions or requests for dentist referrals?
19. Do you provide a care line that employees can call with questions about proper levels of
care?
20. Will you perform pre-treatment estimates? If yes, what is your average turnaround time?
21. Will you provide COBRA services?
22. Please certify that you are in compliance with HIPAA privacy regulations, and include a copy
of your privacy statement or policy.
23. Please refer to the checklist on page 10 for additional items to submit (e.g., audited financial
statements, etc.).
City of Fort Collins, RFP 2003
18
10.5 Vision Care — Administrative Services Onl
The City makes available to eligible employees working 20 or more hours per week a Vision
Care Plan. Benefits are self -funded, and employees pay 100% of the cost.
Currently, 730 employees are enrolled for coverage. Enrollment distribution between tiers of
coverage is:
Individual: 263
w/child(ren): 70
w/spouse: 214
w/family: 183
A copy of the current plan booklet, census and claims experiences are available upon
request. Contact the Purchasing Division at (970) 221-6775.
QUESTIONNAIRE
Vision Care — Administrative Services Only
Please refer to plan booklet for current plan provisions.
1. Do you agree to provide services to all employees/dependents enrolled as of December 31,
2003?
2. Will you agree to replicate each of the current plan's provisions? If not, please list the
specific provisions you will not replicate, along with the reason you elect not to replicate the
provision(s). If you do not identify those specific provisions you cannot replicate and
you are selected as The City's vision services administrator, you may be required to
make the necessary adjustments in order to achieve replication. Otherwise, your
selection may become void.
3. What is your monthly administrative fee, expressed in terms of dollars per month per
employee?
4. For each geographic area in which you have a network applicable to employee population,
provide the following information:
• Geo-Access, using 2 vision providers in 10 miles; provide a map if available
• Most recent participating provider directory and summary of the number of participating
providers in each of the applicable areas (ophthalmologists, optometrists, opticians,
etc.). Also provide the website where provider information can be found.
5. For each network, describe the specific measures used by your organization to monitor
participating provider access. Provide the most recent corresponding statistics available for:
• provider to member ratios
• Average waiting period for an appointment
6. What percentage of your providers has limited their practice to current patients?
7. Please describe your credentialing procedures.
City of Fort Collins, RFP 2003
19
QUESTIONNAIRE
Vision Care — Administrative Services Only (Cont.)
8. What type of reimbursement/payment methods is used to reimburse participating providers?
Please provide a breakdown by method of review.
9. In addition to routine reimbursement and any withholding provisions, can your providers
increase the total reimbursement received from your plan, e.g., by provider incentive
programs? If so, please explain.
10. If provider discounts are used, state the basis of the agreement. Are discounts based on
provider charges or actual cost of service?
11. Is there a formal committee that sets quality assurance policy and review the outcome on a
regular basis?
12. Do you capture all utilization data?
13. What claims experience and utilization reports are available? If there is additional cost,
please specify.
14. Describe patient satisfaction surveys that you perform.
15. Do you have an agreement that prohibits providers from billing or collecting from patients
more than the designated coinsurance or co -payment in the plan design?
16. Please describe your method for calculating renewal rates.
17. Do you provide a toll -free number for employees to call with questions on claims, plan
provisions or requests for dentist referrals?
18. Do you provide a care line that employees can call with questions about proper levels of
care?
19. Will you provide COBRA services?
20. Please certify that you are in compliance with HIPAA privacy regulations, and include a copy
of your privacy statement or policy.
21. Please refer to the checklist on page 10 for additional items to submit (e.g., audited financial
statements, etc.).
22. What is your organization's financial rating (e.g., Best & Co., S&P)?
City of Fort Collins, RFP 2003
20
10.6 Transplant Coverage
Except for kidney and cornea transplants, which are covered by the City of Fort Collins Group
Health Plan, covered transplants are provided through a pooled trust. Individual group
experience is not available. The City pays 100% of premiums for this coverage. All employees
and dependents enrolled for coverage under The City of Fort Collins Group Health Plan are also
enrolled for this separate transplant coverage.
A health plan census is available upon request. Contact the Purchasing Division at (970)
221-6775.
QUESTIONNAIRE
Transplant Coverage
Please refer to plan booklet for current plan provisions.
1. Do you agree to provide services to all employees/dependents enrolled as of December 31,
2003?
2. Will you agree to replicate each of the current plan's provisions? If not, please list the
specific provisions you will not replicate, along with the reason you elect not to replicate the
provision(s). If you do not identify those specific provisions you cannot replicate and
you are selected as The City's vision services administrator, you may be required to
make the necessary adjustments in order to achieve replication. Otherwise, your
selection may become void.
3. What is your monthly administrative fee, expressed in terms of dollars per month per
employee?
4. For each geographic area in which you have a network applicable to employee population,
provide the following information:
5. Geo-Access, using 2 vision providers in 10 miles; provide a map if available
6. Most recent participating provider directory and summary of the number of participating
providers in each of the applicable areas (physicians, specialists, institutions, etc.). Also
provide the website where provider information can be found.
7. For each network, describe the specific measures used by your organization to monitor
participating provider access. Provide the most recent corresponding statistics available for:
8. Provider to member ratios
9. Average waiting period for an appointment
10. What percentage of your providers has limited their practice to current patients?
11. Please describe your credentialing procedures.
City of Fort Collins, RFP 2003
21
QUESTIONNAIRE
Transplant Coverage (Cont.)
12. What type of reimbursement/payment methods is used to reimburse participating providers?
Please provide a breakdown by method of review.
13. In addition to routine reimbursement and any withholding provisions, can your providers
increase the total reimbursement received from your plan, e.g., by provider incentive
programs? If so, please explain.
14. If provider discounts are used, state the basis of the agreement. Are discounts based on
provider charges or actual cost of service?
15. Is there a formal committee that sets quality assurance policy and review the outcome on a
regular basis?
16. Do you capture all utilization data?
17. What claims experience and utilization reports are available? If there is additional cost,
please specify.
18. Describe patient satisfaction surveys that you perform.
19. Do you have an agreement that prohibits providers from billing or collecting from patients
more than the designated coinsurance or co -payment in the plan design?
20. Please describe your method for calculating renewal rates.
21. Do you provide a toll -free number for employees to call with questions on claims, plan
provisions or requests for dentist referrals?
22. Do you provide a care line that employees can call with questions about proper levels of
care?
23. Will you provide COBRA services?
24. Please certify that you are in compliance with HIPAA privacy regulations, and include a copy
of your privacy statement or policy.
25. Please refer to the checklist on page 10 for additional items to submit (e.g., audited financial
statements, etc.).
26. What is your organization's financial rating (e.g., Best & Co., S&P)?
City of Fort Collins, RFP 2003
22
10.7 Long Term Care
The City offers employees the opportunity to enroll for long term care coverage. These plans
are individual contracts. Approximately 25 contracts are currently in force. Due to the nature of
these contracts, it is likely that they will remain in force with the current carriers.
QUESTIONNAIRE
Long Term Care
How long has your organization offered long term care coverage?
2. How many contracts do you have currently in force?
3. How many contracts have been cancelled in the past two years, and what has been the
primary cause of cancellations?
4. Besides employees, which family members are eligible for coverage?
5. How much in benefits has been paid by your organization during the past two years?
6. What is your organization's financial rating (e.g., Best & Co., S&Pp
7. What type(s) of contract(s) do you offer? Please provide samples of your contracts.
8. Please provide a side -by -side comparison of your various plan options.
9. How are benefits funded (e.g., with life insurance, other)?
10. Will you accommodate payroll deducted contributions? Will you permit a single annual
payment at a discounted rate?
11. Will you provide a toll free telephone number for employees to call with questions about
claims and plan provisions?
12. Please indicate the method used to calculate premiums. Do premiums remain stable
through the life of the contract?
13. Please refer to the checklist on page 10 for additional items to submit.
City of Fort Collins, RFP 2003
23
QUESTION: VOLUNTARY LIFE AND AD&D VOLUMES PER PARTICIPANT
ANSWER:
ADC50
Enrollee and Dependent, List
Company 004 Anthem Life Insurance Company
COYntry 01 United States
Coverage: 090 Voluntary AOwl
Oronp : 006518 0099 CITY OF FORT COLLINS
Cert No. Dep Name
29/SUL/2003 Page 1
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
O1/O1/1996
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
12/06/1964
M
03
F
100,000.00
01/01/1996
A
D8/08/1961
F
03
F
50, 000. 00
01/01/1996
A
12/06/1952
M
03
F
150,000.00
01/01/1995
A
L2/1111941
F
03
S
1001000,00
01/01/1996
A
12/15/1942
M
03
F
100,000.00
01/01/2996
A
12/3O/1942
F
03
S
20, 000.00
02/D3/2000
A
04/30/1970
M
03
S
60.000-00
01/01/1996
A
06/26/1952
M
03
F
50,000,00
01/01/1996
A
12/D6/1950
M
03
P
100,000.00
' 05/01/2002
A
05/20/1972
F
03
S
40,000.00
01/01/1996
A
03/23/1964
F
03
F
70,000.00
09/01/1959
A
05/27/1913
F
03
F
$0,000.00
01/01/1996
A
12/29/1949
M
03
S
100,000.00
12/01/2000
A
06/02/1951
M
03
S
140,000.00
01/01/1996
A
12/15/1964
F
03
S
100,000.00
01/01/1996
A
12/27/1955
M
03
F
50. 000.00
01/01/1996
A
12/27/1956
M
03
F
120,000.00
:- O1/U1/1996
A
0'1/39/1969
.4
03
F
40,000.00
01/01/1996
A
04/04/1957
M
03
F
20,000.00
O1/O1/1997
A
12/31/1960
M
03
F
1SO,000.00
OS/Oi/1999
A
04/25/1969
M
03
9
100,000.00
02/01/1996
A
09/131l954
M
03
F
100,000.00
01ID1/1996
A
08/02/1966
F
03
S
50.000.00
05/01/1999
A
08/07/2961
M
03
F
100,000.00
08/01/2001
A
05/28/1963
F
03
F
100,000.00
01/01/1096
A
04/26/1947
M
03
F
1601000.00
02/01/1996
A
22/17/1947
F
03
F
80,000.00
03/01/1997
A
01/31/1547
F
03
F
60,000.00
O1/01/1998
A
ll/16/1955
F
03
F
20,000.A10
02/02/1997
A
06/28/1963
M
03
F
150,000.00
01/01/1996
A
12/05/1947
F
03
F
150,000.00
01/01/1996
A
05/27/1951
M
03
F
80,000.00
01/01/1996
A
11/20/1953
M
03
F
100,000.00
01/01/2002
A
08/03/1946
F
03
F
10,000.00
01/01/1996
A
12/14/1951
M
03
F
150,000.00
01/01/1996
A
12/20/1942
F
03
S
60,000.00
05/01/1997
A
06/26/1563
M
03
S
"0,000.00
01/01/1996
A
12/11/194?
M
03
S
100,000.00
01/01/1996
A
03/19/1951
M
03
S
60,000.00
06/0112000
A
09/03/1944
M
03
F
50,000.00
O1/01/1996
A
03/20/1958
F
03
F
100,000.00
01/01/1996
A
10/06/1954
M
03
S
100.000.00
12/01/2002
A
11/12/1964
M
03
S
1001000.00
¢S rtn
]PAGE 1
CERTIFICATE
NUMBER CERTIFICATE NAME
----------------
.._.. .OPEN AND APPROVED
TOTAL PENDING
TOTAL
EIR
9
un
Life Financial'
CITY OF FORT COLLINS
GROUP POLICY 98544
C
r
GROUP LONG TERN DISABILITY CLAIMS SUMMARY
SUN LIFE ASSURANCE COMPANY
OF CANADA
rtmi
AS OF SIMAY2003
FOR THE PERIOD OIJAN2002 TO
31MAY 2003
rtgit
DATE OF
DATE
EXPIRY
MET MONTHLY
CLAIMS PAID
TOTAL
DISABLED
W
BIRTH
DISABLED
DATE
BENEFIT
THIS PERIOD
CLAIMS PAID
LIFE RESERVE
"---'---
---------
---------
-------" --
'-'--
-----___---
------------
AL
IGFE81954
IDFES2003
/6FE92019
3095.60
123.82
123.02
140491.00
0
26FEB1844
2ONDV2002
28FE82DOS
703.31
4662.63
*662.63
26981.00
26%AYI$58
OOOCT2002
26MAY2023
1390.25
7010.42
7010.02
83D63.00
071JUL1952
11SEP2001,
07JUL2010
2350.23
41677.41
41677.41
184264.00
08JAN1939
13JAN2001
13OCT2004
993.22
16094.74
20063.23
16335.00
11SEP1950
22JAN2000
11SEP2015
1808.42
30743.14
67614.35
107212.00
OBSEP1947
04SEP1999
09SEP2012
634.64
9055.11
30141.49
51224.00
W
OVOCT1952
03FEB19"
CIOCT2017
1298.75
18728.73
S0306.70
118437.00
10NOVI956
22ALM1998
IONOV2021
129e.t6
22068.72
76968.49
176064.00
14SEP W47
07JUN1997
14SEP2012
2727.8E
46375.83
100167.16
247392.00
m
16306.57
1973".97
496636.10
1251504.00
T
(Dl
13AUG1841
ZONOV2002
ISFES2007
2509.46
4182.44
4192.44
.00
Z
08MAR1950
21MOV2001
OMMAR2015
IS1D.24
23392,81
23382.01
14AUG1954
26NOV2000
28NOV201S
1837.79
25300.24
37346.76
.00
.00
t7
1)
21FESIOSS
04JUM2000
27FEB2029
1750.63
17564.65
42015.12
.00
24MAY1938
21MAY19R7
24MAY200
767.74
13234.03
64458.21
.00
8795.116
B3664.t7
163385.34
.00
25102.43
280995.14
660021.44
1251504.00
27A►RIS48
04APP2003
27APR2Ot4
2024.10
-00
.00
80623.00
06JUNW23
1114AR2009
IOJUN2004
129.72
.00
.00
11635.00
2153.82
.00
.00
6t65e.00
2163.62
.00
.00
61658.00
W
(9
W
27256-25
260995.14
660021.44
1343162.00
m
i0
W
m
A
fU
EXPIRY DATE MAY BE EARLIER THAN GATE SHOMN DEPENDING ON CONTRACTUAL LIMITATIONS
Welosley Hh, MnamalpisattB 02481
Sdn Life Asa6nne. Cw4mW of Cmade Is a•
1"W .al IoA - ernu0_e�f- r4w}y2ei4
- - PAGE 1
CITY OF FORT COLLINS
C
J �
GROUP POLICY NO, 98544 m
0)
FOR THE PERIOD OF 01 JAN 1997 TO 30 JUN 2003 N
m
GROUP LIFE CLAIMS SUMMARY W
SUN LIFE ASSURANCE COMPANY OF CANADA
BASIC OPTIONAL
CERTIFICATE CERTIFICATE GATE DATE DATE BASIC OPTIONAL ADND ADND Rl
NUMBER NAME NOTIFIED APPROVED CLOSED LIFE LEF£ AMOUNT AMOUNT M
DEATH CLAIMS
U)
12AUG1997 ISSEP1997 37,000 74.000 0 O S
17JAN2001 OIFES2001 34,OOD 34,000 34,000 34,000
04SEP2002 10SEP2002 41,000 123.000 41,000 123,000
CBMAY2003 22MAY2003 46,000 91,000 O 0 m
O1MAY2003 20MAY2003 35.000 138.000 O O
130CT199a Oa0EC1998 27,000 O 27,000 0
28NOV2000 27DEC20M 67,000 67,000 O O
26JUN2001 27JUM2001 25.000 0 0 0 D
OSJUN2000 279JUN2000 53,000 O O 0 D
13JAN1999 2aJAN1989 68,000 O 0 O t7
D
TOTAL EMPLOYEE
433,000 527,000 102,000 157,000
�1 OIAPR2003 SOAPR2003 10,000 O O 0
fOAUG2000 200 00 0.0O 0 O
17NAR2000 27HAR7NAR201
00 0.000 O O O
!/ IBMAY1998 iGMAY1998 10.000 O O O
yA �L'2 TOTAL DEPENDENT
NO %
m
C4
W
m , 0
N
1� K)
m
N
m �
l7
73 y, m
N
u� lg Wellesley Hills, Massachusetts-02481
)A[4jII1BI1Cia1"- Sun Life Asswaneo Company bS Canada is a
._
-'`PAGE 2
CITY OF FONT COLLINS
m GROUP POLICY NO. 98544
Q
FOR THE PERIOD OF 01 JAN 1997 TO 30 JUN 2003
OROUP LIFE CLAIMS SU14MARY
SUN LIFE ASSURANCE COMPANY OF CANADA
eASIC
OPTIONAL
CERTIFICATE CERTIFICATE DATE DATE DATE
BASIC
LIFE
OPTIONAL
LIFE
ADM
AMOUNT
ADHO
AMOUNT
NUMBER NAME NOTIFIED APPROVED CLOSED
WAIVER OF PREMIUM CLAIMS (ED8)
AS OF O JUN2003
03SEP1997 21DCTI8a7
22.400
44,800
O
0
0
OGNDVIsea ISNOVIMS
41.000
81.000
O
O
27FE82DOS OSJUN2003
66,000
O
0
O
O
22JAN2008 26MAR2003
32,000
O
0
0
16MM 1998 04NOV1998
74,000
0
TOTAL OPEN
225,400
125,800
O
O
OSJM2002 14MAR2002 27APP2003
35.000
1oa, 000
0
0
O.
10JUL2001 04NOV20D1 27MAR2003
04.000
34,000
0
0
OBNOV2001 04DEC2001 310ECIOOI
17,000
0
0
O
0
04JUN/99B I1SEP/99a 22NDV2002
10,000
O
TOTAL CLOSED
O
96,000
572,000
O
N
M
s
1
w
..,
iAn°�
fG� i al"
_
Wetesley FW1s," Massachusaft 02481
San Life Assormoo CWPOW 01 Canldr Is a
1
m
O
'rl
D
O
D
W
0
L4
W
W
m
r
A
IV
O1/03/02 -
THURSDAY
TIME 08:18
VISION SERVICE PLAN -
COLORADO
PEXPJ110/EXPB2331
PAGE
3
GROUP UTILIZATION REPORT
STATE:
CO
SUMMARY 2063997
FORT COLLINS COLORADO, CITY OF
2 GROUPS
REPORTING
PERIOD
NUMBER
GROSS
RETENTION
RETN
NET
CLAIMS
GAIN/LOSS
PLR
AVG CLAIMS
NBR
PAID
REV/
------------------------------------------------------------------------------------------------------------------------------------
COVERED
$
$
$
$
AMT
$
AMT
PAID
FREQ
MBR
1998
6,953
$88,523
$14,154
16
$74,369
$67,530
$6,839
91
$100.94
669
96
$12.73
1999
0
$0
$0
0
$0
$151
$151-
0
$7 .50
2
0
$.00
2000
0
$347-
$0
0
$347-
$0
$347-
0
$$.00
0
0
$.00
BAL.
12,002
$153,057
$24,529
16
$128,528
$122,249
$6,279
95
$101.45
1,205
100
$12.75
JAN
0
$0
$0
0
$0
$0
$0
0
$.00
0
0
$.00
FEB
p
$0
$0
0
$0
$0
$0
0
$.00
0
0
$•00
MAR
0
$0
$0
0
$0
$0
$0
0
$•00
0
0
$.00
APR
0
$0
$0
0
$p
$0
$0
0
$.00
0
0
$.00
MAY
0
$0
$0
0
$0
$0
$0
0
$.00
0
0
$.00
JUN
p
$0
$0
0
$0
$0
$0
0
$.00
0
0
$•00
JUL
0
$0
$0
0
$0
$0
$0
0
$.00
0
0
$.00
AUG
0
$0
$0
0
$0
$0
$0
0
$•00
0
0
$.00
SEP
0
$0
$0
0
$0
$0
$0
0
$.00
0
0
$.00
OCT
0
$0
$0
0
$0
$0
$0
0
$.00
0
0
$.00
NOV
p
$0
$0
0
$0
$0
$0
0
$.00
0
0
$
00
DEC
0
$0
$0
0
$0
$0
$0
0
$.00
0
0
$.00
LTM
0
$0
$0
0
$0
$0
$0
0
$.00
0
0
$.00
ADJ
0
$0
$0
0
$0
$0
$0
CUR CON
12,002
$153,404
$24,529
16
$128,875
$122,249
$6,626
95
$101.45
1,205
100
$12.78
YTD
0
$0
$0
0
$0
$0
$0
0
$.00
0
D
$.00
--------------------------------------
*MEMBERSHIP AVERAGES* I
----------------------
**********MEMBERS*********
- ---
*********SPOUSE*********
- -'
--
-
*********CHILD**********
-'------------'----
REV/
CLM
IND.
PNLI
PERIOD
CLM
#
AVG MBR
CLM
#
AVG
SP
CLM
#
AVG
CH
DPT
PERIOD MBR
-----------------------
AMT
RATE
PCTJ
AMT
CLMS
CLM PCT
AMT
CLMS
CLM
PCT
AMT
CLMS
CLM
PCT
PCT
1998
$12.73
$9.71 $11.55
96�
JAN
$0
0
$0
0
---$.
$.00
0
-_------� ---_
$0
0
--------_-
$.00
0
__
0
1999
$.00
$.00
$.00
251
FEB
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
2000
$.00
$.00
$.00
01
MAR
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
QTR1
$.00
$.00
$.00
01
APR
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
QTR2
$.00
$.00
$.00
01
MAY
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
QTR3
$.00
$.00
$.00
01
JUN
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
QTR4
$.00
$.00
$.00
01
JUL
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
LTM
$.00
$.00
$.00
01
AUG
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
CUR
$12.78
$10.19 $12.11
961
SEP
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
YTD
$.00
$.00
$.00
01
OCT
$0
p
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
1
NOV
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
1
1
DEC
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
_______________________________
TOT
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
*ASTERISK INDICATES ESTIMATES DUE TO NON OR PARTIAL PAYMENT 21,446
O1/03/02 -
THURSDAY
TIME 08:18
VISION SERVICE PLAN -
COLORADO
PEXPJ110/EXPB2331
PAGE
3
SUMMARY 2063997
GROUP
UTILIZATION REPORT
STATE: CO
FORT COLLINS COLORADO, CITY OF
2 GROUPS
REPORTING
PERIOD
_____________________________________________
NUMBER
GROSS
RETENTION
RETN
______________
NET
_____________________________________________________
CLAIMS
GAIN/LOSS
PLR AVG
CLAIMS
NBR
PAID
REV/
___________________________________________________________________________________________$___g
COVERED
$
$
g
$
AMT
________
AMT
____________________________
PAID FREQ
MBR
1998
0
$0
$0
0
$0
$0
$0
0
$.00
0
0
$.00
1999
7,439
$91,611
$16,297
18
$75,314
$75,314
$0
100
$86.97
866
116
$2.19
2000
8,071
$94,602
$17,351
18
$77,251
$77,251
$0
100
$94.09
821
102
$2.15
HAL.
15,510
$186,212
$33,647
18
$152,565
$152,565
$0
100
$90.44
1,687
109
$2.17
JAN
670
$10,225
$1,439
14
$8,786
$8,786
$0
100
$91.52
96
143
$2.15
FEB
689
$7,465
$1,480
20
$5,985
$5,985
$0
100
$92.08
65
94
$2.15
MAR
643
$7,733
$1,381
18
$6,352
$6,352
$0
100
$81.44
78
121
$2.15
APR
690
$6,705
$1,482
22
$5,223
$5,223
$0
100
$84.24
62
90
$2.15
MAY
688
$6,280
$1,478
24
$4,802
$4,802
$0
100
$87.31
55
80
$2.15
JUN
685
$6,363
$1,471
23
$4,892
$4,892
$0
100
$97.84
50
73
$2.15
JUL
708
$8,851
$1,521
17
$7,330
$7,330
$0
100
$99.05
74
105
$2.15
AUG
695
$7,948
$1,493
19
$6,455
$6,455
$0
100
$97.80
66
95
$2.15
SEP
691
$7,873
$1,489
19
$6,384
$6,384
$0
100
$95.28
67
97
$2.15
OCT
701
$8,587
$1,508
18
$7,079
$7,079
$0
100
$93.14
76
108
$2.15
NOV
700
$7,971
$1,504
19
$6,467
$6,467
$0
100
$96.52
67
96
$2.15
DEC
702 *
$7,348 *
$1,508
* 21*
$5,840
$5,840
$0
100
$84.64
69
98
$2.15
LTM
8,262 *
$93,349 *
$17,754
* 19*
$75,595
$75,595
$0
100
$91.63
825
100
$ 2.15
ADJ
0
$0
$0
0
$0
$0
$0
CUR CON
8,637 *
$97,001 *
$18,579
* 19*
$78,422
$78,422
$0
100
$92.04
852
99
$2.15
YTD
8,262 *
$93,349 *
$17,754
* 19*
$75,595
$75,595
$0
100
$91.63
825
100
$2.15
_________________-____________________________
*MEMBERSHIP AVERAGES*
REV/ CLM
**********MEMBERS*********
________________________________________________#
**x******SPOUSE*********
*********CHILD**********
_________
PERIOD MBR
IND.
AMT RATE
PNLI PERIOD
PCTJ
CLM
#
AVG MBR
CLM
#
AVG
SP
CLM
AVG
CH
DPT
______________________
______________________
AMT
CLMS
CLM PCT
______________________
AMT
CLMS
CLM
PCT
AMT
CLMS CLM
PCT
PCT
1998 $.00
$.00 $.00
01
JAN
$5,335
56
58
--
$1,302
- 18--$75.94----------$2,084
18
$76.58
19
----22
$2$879
$9-
22" $87
_ __
72
23
1999 $2.19
$10.12 $12.30
98
� FEB
$3, 804
38
100.10
$100.10 58
$1,302
17
$76.58
26
10
42
2000 $2.15
$9.57 $11.72
991
MAR
$3,103
37
$83.86 47
$1,938
23
$84.07
29
$1$885
18 $72.88
23
QTR1 $2.15
$10.55 $12.70
971
APR
$3,297
38
$86.76 61
$1, 041
13
$80.07
21
,312
$526
17 $BO
A S
18
53
QTR2 $2.15
$7.23 $9.38
981
MAY
$2,072
23
$90.08 42
$1,391
25
$88.16
45
$526
7
13
39
QTR3 $2.15
$9.63 $11.77
971
JUN
$2,390
25
$95.60 50
$1,391
14
$99.35
28
$1, 111
11 $101.00
101$75.00
58
QLTM4 $2.15
$9.22 $11.37
971
JUL
$3,940
36
$109.44 49
$1,916
19
$100.84
26
$1,474
19 $77.57
22
50
$2.15
$9.15 $11.30
971
AUG
$2,385
24
$99.37 36
$1,181
12
$98.41
18
$2,890
30 $96.33
26
51
CUR
CUR $2.15
$9.08 $11.22
971
SEP
$2,778
30
$92.60 45
$1,756
19
$92.42
28
$1,850
18 $102.77
45
64
YTD $2.15
$9,15 $11.30
971
OCT
$3,385
36
$94.02 47
$2,013
22
$91.50
29
$1,680
18 $93.33
27
55
NOV
$2,947
27
$109.14 40
$1,993
23
$86.65
34
$1,527
17 $89.82
24
25
53
60
DEC
$3,338
38
$87.84 55
$808
11
$73.45
16
$1,694
20 $84.70
29
45
_
TOT
$38,774
408
$95.03 49
$18,910
216
$87.55
26
$17,912
201 $89.11
24
51
*ASTERISK INDICATES ESTIMATES DUE TO NON OR PARTIAL PAYMENT
22,926
O1/03/02 - THURSDAY TIME 08:18
GROUP 2106603 CONTRACT NUMBER 2063997 C
CONTRACT TYPE S (12063997 0001 0001 )
INDUSTRY TYPE
VISION SERVICE PLAN - COLORADO
GROUP UTILIZATION REPORT
FORT COLLINS COLORADO, CITY OF
.CITY OF FT. COLLINS, COLORADO
CITY OF FT. COLLINS
PEXPJ110/EXPB2331 PAGE 1
STATE: CO
PERIOD
_____________________________________________________________________________________________________________________
NUMBER
GROSS
RETENTION
RETN
NET
CLAIMS
GAIN/LOSS
PLR AVG
CLAIMS
NBR PAID
REV/
------------------------------------------------------------------------------------------------------------------------------------
COVERED
$
$
%
$
AMT
$
%
AMT
PAID FREQ
MBR
1998
0
$0
$0
0
$0
$0
$0
0
$.00
0
0
$.00
1999
7,260
$90,089
$15,889
18
$74,200
$74,200
$0
100
$86.78
855
118
$2.19
2000
7,875
$92,471
$16,933
18
$75,538
$75,538
$0
100
$93.84
805
102
$2.15
BAL.
15,135
$182,560
$32,822
18
$149,738
$149,738
$0
100
$90.20
1,660
110
$2.17
JAN
664
$9,989
$1,427
14
$8,562
$8,562
$0
100
$91.09
94
142
$2.15
FEB
679
$7,444
$1,459
20
$5,985
$5,985
$0
100
$92.08
65
96
$2.15
MAR
632
$7,710
$1,358
18
$6,352
$6,352
$0
100
$81.44
78
123
$2.15
APR
672
$6,667
$1,444
22
$5,223
$5,223
$0
100
$84.24
62
92
$2.15
MAY
679
$6,079
$1,459
24
$4,620
$4,620
$0
100
$85.56
54
80
$2.15
JUN
673
$6,298
$1,446
23
$4,852
$4,852
$0
100
$99.02
49
73
$2.15
JUL
692
$8,817
$1,487
17
$7,330
$7,330
$0
100
$99.05
74
107
$2.15
AUG
682
$7,830
$1,466
19
$6,364
$6,364
$0
100
$97.91
65
95
$2.15
SEP
682
$7,809
$1,470
19
$6,339
$6,339
$0
100
$96.05
66
97
$2.16
OCT
689
$8,525
$1,483
17
$7,042
$7,042
- $0
100
$93.89
75
109
$2.15
NOV
691
$7,891
$1,485
19
$6,406
$6,406
$0
100
$97.06
66
96
$2.15
DEC
691 *
$7,325 *
$1,485
* 20*
$5,840
$5,840
$0
100
$84.64
69
100
$2.15
LTM
8,126 *
$92,384 *
$17,469
* 19*
$74,915
$74,915
$0
100
$91.70
817
101
$2.15
ADJ
0
$0
$0
0
$0
$0
$0
CUR CON
8,126 *
$92,384 *
$17,469
* 19*
$74,915
$74,915
$0
100
$91.70
817
101
$2.15
YTD
8,126 *
$92,384 *
$17,469
* 19*
$74,915
$74,915
$0
100
$91.70
817
101
$2.15
___________________�____________________MEMBERS______________________________________
*MEMBERSHIP AVERAGES*
*xx:**xxxx
xxxx**xxx
x++******SPOUSE*******••
_-___________
_____
•*******xCHILD*xx+******
____
_
REV/
CLM IND.
PNLI PERIOD
CLM
#
AVG MBR
CLM
#
AVG
SP
CLM
AVG
CH
DPT
PERIOD MBR
_________________
AMT RATE
______________________
PCTJ
AMT
________________________________________________________________________________________
CLMS
CLM PCT
AMT
CLMS
CLM
PCT
AMT
CLMS CLM
PCT
PCT
1998
$.00
$.00 $.00
01
JAN
$5,111
54
$94.64 57
$1,367
18
$75.94
19
$2,084
22 $94.72
23
43
1999
$2.19
$10.22 $12.40
981
FEB
$3,804
38
$100.10 58
$1,302
17
$76.58
26
$8792000
10 $72.88
15
$2.15
$9.59 $11.74
991
MAR
$3,103
37
$83.86 47
$1,938
23
$84.26
29
$1$885
18 $80.45
23
42
53
QTRI
$2.15
$10.58 $12.72
971
APR
$3,297
38
$86.76 61
$1,041
13
$80.07
21
,312
$526
17 $75.14
18
39
QTR2
$2.15
$7.26 $9.40
981
MAY
$1,890
22
$85.90 41
$2,204
25
$88.16
46
7
13
QTR3
$2.15
$9.74 $11.88
971
JUN
$2,349
24
$97.87 49
$1,391
14
$99.35
29
$1,474
101.00
11 $$77.57
22
59
51
QTR4
$2.15
$9.31 $11.46
971
JUL
$3,940
36
$109.44 49
$1,181
19
$$98.41
26
,111
$2,890
19 $96.33
26
51
LTM
$2.15
$9.22 $11.37
971
AUG
$2,293
23
$94.24 35
$1,756
12
$92.42
18
$1,850
30
46
65
CUR
$2.15
$9.22 $11.37
971
SEP
$2,733
29
$94.24 44
$2,013
19
$92.50
29
$1,680
102.77
18 $$93.33
27
56
YTD
$2.15
$9.22 $11.37
971
OCT
$3,348
35
$95.65 47
$2, 013
22
$91.50
29
$1,680
18 $93.33
24
NOV
$2,886
26
$111.00 39
$1,993
23
$86.65
35
$1,
17 $8.
26
53
61
DEC
$3,338
38
$87.84 55
$808
11
$73.45
16
$1,694 94
20 $84.70
29
45
TOT
$38,092
400
$95.23 49
_____________________________________________________________________________
$18,910
216
$87.55
26
$17,912
201 $89.11
25
51
*ASTERISK
INDICATES ESTIMATES DUE TO NON OR PARTIAL PAYMENT
22,924
O1/03/02 - THURSDAY TIME 08:18
GROUP 2106604 CONTRACT NUMBER 2063997 C
CONTRACT TYPE S (12063997 0002 0002 )
INDUSTRY TYPE
VISION SERVICE PLAN - COLORADO
GROUP UTILIZATION REPORT
FORT COLLINS COLORADO, CITY OF
CITY OF FORT COLLINS RETIREES
CITY OF FT. COLLINS
PEXPJ110/EXPB2331 PAGE 2
STATE: CO
_
PERIOD
_______________________________________
NUMBER
COVERED
GROSS
$
RETENTION
RETN
NET
CLAIMS
GAIN LOSS
PLR
AVG CLAIMS
NBR
PAID
REV
$
$
___________________________________________________________________________________
$
AMT
$
%
AMT
PAID
FREQ
MBR
1998
1999
0
179
$1,5
$0
22
$0
$408
0
27
$0
$1,114
$0
$1,114
$0
0
$.00
0
0
$.00
2000
196
$2
$418
20
$1,713
$1,713
$0
100
$101.27
11
61
$2.28
$0
100
$107.06
16
82
$2.13
BAL.
JAN
375
$3,652
$825
23
$2,827
$2,827
$0
100
$104.70
27
72
$ 2.20
FEB
6
10
$237
$21
$12
5
$225
$225
$0
100
$112.50
2
333
$2.00
MAR
11
$23
$21
$23
100
100
$0
$0
$0
0
$.00
0
0
$ 2.10
APR
18
$38
$38
100
$0
$0
$0
0
$.00
0
0
$2.11
MAY
9
$201
$19
9
$182
$182
$0
$0
0
100
0
0
$2.11
JUN
12
$66
$25
38
$41
$41
$0
100
2.00
$182.00
1
111
2.11
$2.08
JUL
16
$34
$34
100
$0
$0
$0
0
$41.00
1
83
$
AUG
13
$118
$27
23
$91
$91
$0
100
1.00
$91.00
0
0
$2.08
SEP
OCT
ONOVCT
g
12
$64
30
$45
$45
$0
100
$45.00
1
1
77
111
$2.08
$2.11
9
$62
$19
$25
40
24
$37
$37
$0
100
$37.00
1
83
$2.08
DEC
11
$23
$23
100
$61
$61
$0
100
$61.00
1
111
$2.11
$0
0
$.00
0
0
$2.09
LTM
ADJ
136
0
$967
$285
29
$682
$682
$0
100
$85.25
8
59
$ 2.10
$0
$0
0
$0
$0
$0
CUR CON
YTD
511
136
$4,619
$1,110
24
$3,509
$3,509
$0
100
$100.26
35
68
$967
$285
29
$682
$682
$0
100
$85.25
8
59
$2.10
_______________________
*MEMBERSHIP AVERAGES* I
REV/ CLM ZND. PNLI
___________________________________
PERIOD
**********MEMBERS
*********
____________________________
*********SPOUSE*********
*********CHILD**********__--
PERIOD
MBR
AMT RATE
PCTJ
CLM
A MT
#
AVG MBR
CLM
#
AVG
SP
CLM
#
AVG
CH
DPT
--------
------'
---------------------------------------
CLMS
CLM PCT
AMT
CLMS
CLM
PCT
AMT
CLMS
CLM
PCT
PCT
1998
$.00
$.00
$.00
0
JAN
$225
2
-------------------$0__--_-0-
$112.50 100
$0
-------------------------------
0
$.00
0
_______________
1999
$2.28
$6.22
$8.50
1001
FEB
$0
0
$.00 0
$0
0
$.00
0
0
2000
$2.13
$8.74
$10.87
1001
MAR
$0
0
$•00
$.00
0
$0
0
$.00
0
0
QTR1
$2.07
$8.32
$10.39
1001
APR
$0
0
0
$0
0
$.00
0
$0
0
$.00
0
0
QTR2
$2.10
$5.71
$7.80
1001
MAY
$182
1
$182.00 100
$0
$
$0
0
$.00
0
0
QTR3
$2.11
$3.59
$5.69
1001
JUN
$41
1
$41.00 100
$0
0
$00
0
$0
0
$.00
0
0
QTR4
$2.09
$3.06
$5.15
1001
JUL
$0
0
$.00 0
0
$.00
0
$0
0
$.00
0
0
LTM
$2.10
$5.01
$7.10
1001
AUG
$91
1
$ 100
$0
$0
0
$.00
0
$0
0
$.00
0
0
CUR
$2.17
$6.87
$9.03
1001
SEP
$45
1
$45.00
.00 100
$0
0
$.00
0
$0
0
$.00
0
0
YTD
$2.10
$5.01
$7.10
100l
OCT
$37
1
$37 .00 100
$0
0
$.00
0
$0
0
$.00
0
0
NOV
$61
1
$61.00 100
$0
0
0
$.00
$.00
0
0
$0
0
$.00
0
0
DEC
$0
0
$.00 0
$0
0
$.00
0
$0
0
$.00
0
0
$0
0
$.00
0
0
TOT
$682
8
$85.25 100
$0
0
$.00
_____________________________
-------
0
*ASTERISK INDICATES ESTIMATES DUE TO NON OR PARTIAL PAYMENT
22,925
V,®CLIENT U77LIZAT70NRF_PORT UTIL0001
FOR: PORT COLLINS COLORADO, CI7YOF
GROUP ID: 12063997 Summary
CONTRACTTYPE: ASP
GROUP TYPE: Individually Rated
PAGE: 1
RUN DATE;06/03/2003
NBR
GROSS
RETENTION
RETN
NET
CLAIM
GAIN/
PLR
AVG CLM
# CLMS
PAID
PEW
PERIOD
COVERED
$
$
%
$
$
LOSS $
%c
COST
PAID
FREQ
MBR
20M
0
$0
$0
0.0
$0
$0
$0
0
$D.00
0
0
$0.00
2001
a
$0
$0
0.0
$0
$0
$0
0
$0.00
0
0
$0.00
2002
8.651
$102,988
$18,625
19.1
$84,363
$84,363
$0
100
$99.48
848
98
$2.15
JUN
732
$7,796
$1,574
202
$6,222
$6,222
$0
100
$103.70
60
82
$2.15
JUL
720
$8,698
$1,548
17.8
$7,150
$7,150
$0
100
$108.33
66
92
$2.15
AUG
730
$8,205
$1,570
19.1
$6,635
$6.635
$0
100
$103.68
64
88
$2.15
SEP
718
$6,876
$1,563
22.7
$5,313
$5,313
$0
100
$102.18
52
72
$2.18
OCT
723
$8,511
$1,654
18.3
$6,956
$6,966
$0
100
$103.82
67
93
$2.15
NOV
736
$8,723
$1,580
18.1
$7,142
$7,142
$0
100
$103.51
69
94
$2.15
DEC
733
$9,722
$1,576
16.2
$8,146
$8,146
$0
100
$100.56
81
111
$2.15
JAN
754
$12,358
$1,621
13.1
$10,737
$10,737
$0
100
$106.30
101
134
$2.15
FEB
749
$8,421
$1,610
19.1
$6,811
$6,811
$0
100
$100.16
68
91
$2.15
MAR
752
$7,360
$1,617
22.0
$5,743
$5,743
$0
100
$110.44
52
69
$2.15
APR
714
$8,178
$1,542
18.8
$6,637
$6,637
$0
100
$93.48
71
99
$2.16
MAY
739
$7,978
$1,589
19.9
$6,390
$6,390
$0
100
$104.75
61
83
$2.15
LTM
8,799
$102,826
$18,944
18.4
$83,882
$83,882
$0
100
$103.30
812
92
$2,15
ADJ
0
$0
$0
0.0
$0
$0
$0
0
$0.00
0
0
$0.00
CC
3,706
$44,296
$7,979
18.0
$36,317
$36,317
$0
100
$102.88
353
95
$2.15
YTD
3,708
$44,296
$7,979
18.0
$36,317
$36,317
$0
100
$102.88
353
95
$2.15
�'•. `-
'::INEMBCRSHIP'RVERAU"ES: r'::::'
REV/
CLM
IND
PNL
PERIOD
MBR
$
RATE
%
2000
$0.00
$0.00
$0.00
0
2001
$0.00
$0.D0
$0.00
0
2D02
$2.15
$9.75
$11.90
98
Q1
$2.15 $10.33
$12.48
98
02
$2.15
$8.97
$11.12
97
Q3
$0.00
$0.00
$0.00
0
04
$0.00
$0.00
$0.00
0
LTM
$2.15
$9.53
$11.69
98
CC
$2.15
$9.79
$11.95
97
YTD
$2.15
$9.79
$11.95
97
EMlWO's:.:".,
CLMS
#
AVG
MBR
CLMS
#
AVG
SP
PERIOD
$
CLMS
COST
%
$
CLMS
COST
%
JUN
$3,609
37
$97.54
62
$1,542
13
$118.58
22
JUL
$3,639
34
$107.03
52
$2,012
18
$111.78
27
AUG
$3,427
33
$103.86
52
$1,272
11
$115.62
17
SEP
$1,927
22
$87.58
42
$2,016
16
$126.03
31
OCT
$3,824
36
$106.23
54
$2,274
20
$113.68
30
NOV
$4,062
39
$104.14
57
$2,324
23
$101.03
33
DEC
$5,284
47
$112.42
56
$1,652
20
$82.62
25
JAN
$5,591
47
$118.97
47
$1,826
20
$91.32
20
FEB
$3,745
38
$98,56
56
$2,535
23
$110.21
34
MAR
$2,981
26
$114.67
50
$1,606
15
$107.09
29
APR
$3,131
36
$86.96
51
$1,163
10
$116.33
14
MAY
$2,934
26
$112.86
43
$1,424
16
$88.98
2$
TOT
$44,154
421
$104.88
52
$21,646
205
$106-59
25
Current Ct Contract nts
CC -CurrePassion for people. Vision for life. sM
CC
LTM - Last Twelve Afon the
FM - Year To Date
CLMS # AVG DPT SP+
$ CLMS COST % DEP%,
$1,071 10 $107.14 17 38
$1,499 14 $107.06 21 48
$1,936 20 $96.82 31 48
$1,370 14 $97.87 27 58
$858 11 $78.03 16 46
$757 7 $108.14 10 43
$1,210 14 $86.40 17 42
$3,319 34 $97.61 34 53
$531 7 $75.82 10 44
$1,155 11 $105.03 21 so
$2,343 25 $93.72 35 49
$2,032 19 $106,94 31 57
$18,081 186 $97.21 23 48
archive.TXT
01/03/03 - FRIDAY TIME 16:29 VISION SERVICE PLAN - COLORADO
PEXP3110/EXPB2331 PAGE 3
STATE: CO GROUP UTILIZATION REPORT
SUMMARY 2063997
2 GROUPS REPORTING FORT COLLINS COLORADO, CITY OF
------------------------------------------------------------------------------
------------------------------------------------
PERIOD NUMBER
GAIN/LOSS PLR AVG CLAIMS
GROSS
NBR
RETENTION
PAID REV/
RETN
NET
CLAIMS
$ %
COVERED
$
$
%
$
AMT
----------------------------------------------------------------------------------
------------------------------------------------
AMT
PAID
FREQ
MBR
1999
$0
7,439
$91,611
$16,297
18
$75,314
$75,314
100
$86.97
866
116
$2.19
2000
$0
8,071
$94,602
$17,351
18
$77,251
$77,251
100
$94.09
821
102
$2.15
2001
$0
100
8,262
$93,350
$17,754
19
$75,596
$75,596
$91.63
825
100
$2.15
BAL.
$0
100
23,772
$279,561
$51,401
18
$228,160
$228,160
$90.83
2,512
106
$2.16
7AN
$0
100
726
$102.28
$10,458
87
120
$1,560
$2.15
15
$8,898
$8,898
FEB
$0
100
697
$90.26
$7,010
61
88
$1,504
$2.16
21
$5,506
$5,506
MAR
$0
100
710
$92.15
$9,267
84
118
$1,526
$2.15
16
$7,741
$7,741
APR
$0
100
714
$101.74
$8,962
73
102
$1,535
$2.15
17
$7,427
$7,427
MAY
$0
100
713
$86.02
$8,758
84
118
$1,532
$2.15
17
$7,226
$7,226
]UN
$0
100
732
$103.70
$7,795
60
82
$1,573
$2.15
20
$6,222
$6,222
JUL
$0
100
720
$108.33
$8,697
66
92
$1,547
$2.15
18
$7,150
$7,150
AUG
$0
100
730
$103.67
$8,204
64
88
$1,569
$2.15
19
$6,635
$6,635
SEP
$0
100
718
$102.17
$6,875
52
72
$1,562
$2.18
23
$5,313
$5,313
OCT
$0
100
723
$103.82
$8,509
67
93
$1,553
$2.15
18
$6,956
$6,956
NOV
$0
100
735
$103.51
$8,721
69
94
$1,579
$2.15
18
$7,142
$7,142
DEC
$0
100
733 *
$100.57
$9,721 *
81
111
$1,575 *
$2.15
16*
$8,146
$8,146
LTM
$0
100
8,651 *
�$99.48
$102,977 *
848
98
$18,615 *
$2.15
18*
$84,362
$84,362
AD7
0
$0
$0
0
$0
$0
Page
1
$0
CUR CON 17,288 *
$0 100 $95.76
YTD 8,651 *
$0 100 $99.48
archive.TxT
$199,979 * $37,194 * 19*
1,700 98 $2.15
$102,977 * $18,615 * 18*
848 98 $2.15
$162,785
$84,362
$162,785
$84,362
------------------------------------------------------------------------------------
------------------------------------------------
*MEMBERSHIP
AVERAGES* 1
**********MEMBERS*********
*********SPOUSE*********
*********CHILD**********
REV/
CLM
IND.
PNL;
PERIOD CLM
#
AVG
MBR
CLM #
AVG SP
CLM
#
AVG CH DPT
PERIOD MBR
AMT
RATE
PCT;
AMT
CLMS
CLM
PCT
AMT
CLMS CLM
------------------------------------------------------------------------------------
PCT
AMT
CLMS CLM PCT PCT
------------------------------------------------
1999 $2.19
$10.12
$12.30
98:
7AN
$4,576
50
$91.52
57
$2,337
18 $129.83
21
$1,985
19
$104.47 22
43
2000 $2.15
$9.57
$11.72
99:
FEB
$2,587
27
$95.81
44
$1,525
16 $95.31
26
$1,394
18
$77.44 30
56
2001 $2.15
$9.15
$11.30
97:
MAR
$3,169
40
$79.22
48
$1,891
19 $99.52
23
$2,681
25
$107.24 30
52
QTR1 $2.15
$10.38
$12.52
97:
APR
$3,918
36
$108.83
49
$1,267
12 $105.58
16
$2,242
25
$89.68 34
51
QTR2 $2.15
$9.67
$11.81
98;
MAY
$4,328
48
$90.16
57
$2,300
28 $82.14
33
$598
8
$74.75 10
43
QTR3 $2.16
$8.81
$10.96
99:
7UN
$3,609
37
$97.54
62
$1,542
13 $118.61
22
$1,071
10
$107.10 17
38
QTR4 $2.15
$10.15
$12.29
97:
JUL
$3,639
34
$107.02
52
$2,012
18 $111.77
27
$1,499
14
$107.07 21
48
LTM $2.15
$9.75
$11.89
98:
AUG
$3,427
33
$103.84
52
$1,272
11 $115.63
17
$1,936
20
$96.80 31
48
CUR $2.15
$9.42
$11.55
97:
SEP
$1,927
22
$87.59
42
$2,016
16 $126.00
31
$1,370
14
$97.85 27
58
YTD $2.15
$9.75
$11.89
98:
OCT
$3,824
36
$106.22
54
$2,274
20 $113.70
30
$858
11
$78.00 16
46
NOV
$4,062
39
$104.15
57
$2,324
23 $101.04
33
$757
7
$108.14 10
43
DEC
$5,284
47
$112.42
58
$1,652
20 $82.60
25
$1,210
14
$86.42 17
42
214 $104.73
------------------------------------------------------------------------------------
------------------------------------------------
25
$17,601
TOT
185
$44,350
$95.14 22
47
449
$98.78
53
$22,412
*ASTERISK INDICATES ESTIMATES DUE TO NON OR PARTIAL PAYMENT
24,421
Page 2
AIIC50 Enrollee and Dependents List 29/dUL/2003
Company C04 Anthem Life Insurance Company
Country 01 United States
Coverage: 090 Voluntary AD60
Group : 006513 0090 CITY OF FORSCOLLINS
Cerl Mo. Cep Name Effective Status Birthday Sex Relation
03/,01/2001 A 03J10j1924 M
O1/O1/1999 A 06/04/1953 M
01/01/1996 A 12/04/1354 M
O1/0-/1996 A 12/04/1946 M
O1/ol/1996 A 05/06/1960 M
08/01/2002 A 09/29/1997 M
03/01/1997 A 07/11/1970 M
06/01/2000 A 02/20/1972 F
12/01/1997 A 03/22/1971 M
O1/01/1996 A 11/21/1941 F
01/01/1996 A 02/19/1969 M
01101/199C A 12110/195, M
09/01/2002 A 12/10/1957 F
O1/01/1996 A 12/08/1951 M
10/01/2UC1 A 10/19/1912 M
01/01/1996 A 12/23/1967 F
01/01/1996 A 07/06/1952 M
01/01/2000 A 04/21/1965 M
01/01/1996 A 12/21/1946 M
06/01/1999 A 10/21/1963 F
01/01/2002 A OS/22/1912 F
01/02/1997 A 12/21/1966 M
01/01/1996 A 1202/1949 M
04/C1/1997 A 06/13/1967 M
06/01/2002 A 10/05/1962 -
01/01/1996 A 09/09/1964 F
01/01/1997 A 06/17/1936 F
06/01/2003 A 09/11/1970 F
O1/01/1996 A 05/09/1956 M
10/01/2002 A 10j21/1956 M
01/01/1996 A 09/17/1965 M
olfoil1996 A 06/32/1952 M
O1/01/199E A 10/13/1964 M
01/01/1996 A 09/23/197C M
01/01/1996 A 06/19/1969 M•
01/01/1996 A 09/11/1960 M
12/01/2002 A 02/15/1954 M
O1/e2/1996 A 12/07/1951 M
0110112DOI A 06/03/19,6 F
0l/01/1996 A 04/05/1950 M
a1(al/1996 A 12120119SI M
03/01/1996 A 06/16/1963 M
08/01/2003 A 07/DS/1966 F
02/01/2002 A 09/28/1950 M
01/01/1996 A 12/02/1951 M
Page 2
Terminated Class
E-type
03
P
03
F
01
F
03
F
03
F
03
S
03
F
03
F
03
5
03
F
03
S
01
5
03
F
03
F
C3
9
03
F
03
F
03
F
03
F
03
5
03
S
03
5
03
F
03
S
03
F
03
F
03
F
03
F
C3
F
I
S
03
S
03
F
03
S
03
S
03
F
03
F
03
F
03
F
03
S
03
F
03
F
03
F
03
S
03
S
03
F
Volume
ISO, 000.00
50, CD0.0C
3o,00a.c0
40,000.00
100.000.00
ISO, 000.Do
140,000.00
150,000.00
150,000.00
150,000.00
150,000.00
150. 000.DO
100,000.00
100,c0a-DO
90,000.00
50,000.00
150,000.00
150, DID. 00
80,000.00
50. 000.DO
150, ODD .00
50,000.00
150,OOe Go
150,000.00
100,000.00
150,000.00
50, 000.On
50,000.00
100.000.00
50,000.00
80,000.00
120, 000.00
100, OOC.00
30,000.00
40,000.00
100, OCO.50
100,000.00
100,000.00
100,000.00
100, 000.00
100,000,00
150,000.00
10.000.00
100, coo. of
07/01/03 07:46 FAX 121002
DeftDental Plan of Colorado 07r01103
Self -Funded Group Information
Group Number.
001857
Effective,
011011U
Group Name:
City Of Fort Collins
n
ry:
Annnivversaersa:
Jan
Admin
Number of
Number of
Month
Ellgibles
Fee
Claims
Paid Claims
Processed Claims
Jan 2001
984
2,570.50
33,566.84
345
415
Fab 2001
1,001
2,697.70
39.602.76
380
430
Mar 2001
991
2,602.65
45,592.70
418
492
Apr 2001
991
2,626.16
43,278.18
426
479
May 2001
991
2,679.16
40,814.87
385
441
Jun 2001
993
2,626.15
46,114.18
415
473
Jul 2001
1,011
2,761.30
33,090.89
364
411
Aug 2001
1,011
2,679.15
45,571.17
450
530
Sep 2001
1,006
2.636.75
40,087.20
333
374
Oct 2001
1,010
2,700.35
37,935.13
381
461
Nov 2001
1,016
2.718.90
42,698.17
411
458
Dec 2001
1,017
2,703.00
36,086.30
366
437
Total* for 12 mths. 12,028
S32o001.85
$M,338.39
4,674
51401
groupinfoaf.frx
07/01/03 07:46 FAb
la 003
Delta Dental Plan of Colorado 07/01/03
Self -Funded (croup Information
Group Number. 001667
Group Name; City Of Fort Collins
Effecflvs; OIMII97
Terminals;
Anniversary: Jan
Admin
Number of
Number of
Month
Eligibles
Fee
Claims
Paid Claims
Processed Claims
Jan
2002
1,033
2.990.35
43,219.71
356
410
Feb
2002
1,030
2,891.62
47,780.80
425
471
Mar
2002
1,083
3,371.94
52,446.70
434
493
Apr
2002
1,097
3,169.18
53,440.62
445
491
May
2002
1,099
3,116.71
56,476.39
467
536
Jun
2002
1.109
3,149.90
58,200.01
464
516
Jul
2002
1,109
3,105.70
52,026.16
433
480
Aug
2002
1,125
3.123.30
55,805.67
457
505
Sep
2002
1.127
3,135.94
45,449.75
383
433
Oct
2002
1,144
3,085-18
55,472.60
476
550
Nov
2002
1,136
3,180.89
51,837.70
457
500
Dec
2002
1,186
3,200.63
69,649.41
484
50
Totals for 12 mths. 13,276 $37,511.34 $636A"A2 SIM 5,930
QroWinfosf.frx
07/01/03 07:46 FAX
9 004
Delta Dental Plan of Colorado 07/01/03
Self -Funded Group Infonnation
Group Number.
001867
Effeews:
01/01/97
Group Name:
City Of Fort Collins
Terminate:
Anniversary:
Jan
Admin
Number of
Number of
Month
Eligibles
Fee
Claims
Paid Claims
Processed Claims
Jan 2003
1.167
3,812.48
49,647.20
411
466
Feb 2003
1,175
3.711.06
62.205.90
498
547
Mar 2003
1.151
3,733.32
40,213-35
322
361
Apr 2003
1,164
3,663.36
83,514-83
502
563
May 2003
1,153
3,666.54
53,24220
421
470
Totals for 5 mthe.
6,800 $18,386.76 $268,723.48 2,184 2,396
proupinfoaf.frx
07/01/03 07:46 FAX
-- - --- _.----- -- 0005
Delta Dental Plan of Colorado 07101/03
Self -Funded Group Information
Group Number.
001858
Effeedve:
01/01/97
Group Name:
City Of Fort Collins
Terminate:
Anniversary:
Jan
Atlmin
Number of
Number of
Month
Eligibles
Fee
Claims
Paid Claims
Processed Claims
Jan 2001
302
79t.85
3,352.00
55
67
Feb 2001
293
752.60
3,544.30
71
84
Mar 2001
288
734.05
4,232.20
73
88
Apr 2001
288
763.20
4,144.46
61
75
May 2001
286
739.36
5,329.10
84
95
Jun 2001
281
742.00
4.124.70
70
79
Jul 2001
283
760.55
3,266.30
61
71
Aug 2001
283
752-60
6,145.52
92
106
Sep 2001
281
739.35
3,817.20
85
77
Oct 2001
282
749.96
4.896.20
78
88
Nov 2001
284
723.46
4,747.80
92
107
Dec 2001
284
760.66
3,69620
Be
78
Totals for 12 mths. 3,434 $9,015.30 $51tft4.93 871 1,015
Qzovpinfosf.fzx
07/01/03 07:46 FAX
9 006
Delta Dental Plan of Colorado 07101/03
Self -Funded Group Information
Group Number.
0018ti8
Effective:
01101/97
Group Now
City Of Port Collins
Terminate:
Anniversary:
Jan
Admin
Number of
Number of
Month
Eligibles
Fee
Claims
Paid Claims
Processed Claims
Jan 2002
285
805.84
6,129.42
72
85
Feb 2002
284
797,72
4,617.40
71
83
Mar 2002
263
584,26
3,867.30
58
68
Apr 2002
261
711A9
4,007.70
63
76
May 2002
200
715.11
4,407.70
65
79
Jun 2002
265
771.78
4,637.30
70
79
Jul 2002
265
748.59
3,706.40
55
66
Aug 2002
280
701.16
6,035.40
81
92
Sep 2002
260
726.03
4,137.32
68
73
Oct 2002
261
768.01
4.439.64
61
68
Nov 2002
260
729.70
3,558.90
57
65
Dee 2002
290
732.52
3,493.60
60
74
Totals for 12 nOw. 3,214
$81783.25
$511936.98
781
908
groupinfoef.fzx
.< .
07/01/03 07:47 FA%
16007
Della Dental Plan of Colorado
07/01/03
Self -Funded Group Information
Group Number. 001BBB
Effective:
0110 W
Group Name: City Of Fort Colilna
Terminate:
Anniversary:
Jan
Admin
Number of
Number of
Mort Blglbtes
Fee
Clelms
Paid Claims
Prooeemw Clalmc
Jan 2003 263
826.80
4,809.00
69
80
Feb 2003 266
830.34
5,43&30
83
92
Mar 2003 263
855,42
3,990.40
e1
69
Apr 2003 265
839.52
6.052.80
73
85
May 2003 263
842.70
2,675.10
45
55
Totals for 5 mths. 1,320
54,400.7E I
$229966.60
331
381
ADC50 Enrollee and Dependents
-----------------------------
List
29/JUL/2003
Page 1
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 090 Voluntary ADSD
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
O1/01/1996
A
02/12/1953
M
03
S
100,000.00
O1/01/2001
A
03/19/1960
M
03
S
150,000.00
06/01/2000
A
12/06/1964
M
03
F
100,000.00
O1/01/1996
A
08/08/1961
F
03
F
50,000.00
O1/01/1996
A
12/06/1952
M
03
F
150,000.00
O1/01/1998
A
12/11/1941
F
03
S
100,000.00
O1/01/1996
A
12/15/1942
M
03
F
100,000.00
O1/01/1996
A
12/30/1942
F
03
S
20o000.00
02/01/2000
A
04/30/1970
M
03
S
60,000.00
O1/01/1996
A
06/26/1951
M
03
F
50,000.00
O1/01/1996
A
12/06/1950
M
03
F
100,000.00
° 05/01/2002
A
05/20/1977
F
03
S
40,000.00
01/01/1996
A
03/23/1964
F
03
F
70,000.00
09/01/1999
A
05/27/1973
F
03
F
50,000.00
O110111996
A
12/29/1949
M
03
S
100,000.00
12/01/2000
A
06/07/1957
M
03
S
140,000.00
O1/01/1996
A
12/15/1964
F
03
S
100,000.00
O1/01/1996
A
12/27/1955
M
03
F
50,000.00
O1/01/1996
A
12/27/1956
M
03
F
120,000.00
01/01/1996
A
07/29/1969
M
03
F
40,000.00
O1/01/1996
A
04/04/1957
M
03
F
20,000.00
01/01/1997
A
12/31/1960
M
03
F
150,000.00
OS/01/1999
A
04/25/1969
M
03
S
100,000.00
01/01/1996
A
09/13/1954
M
03
F
100,000.00
O1/01/1996
A
08/02/1968
F
03
S
50, 000.00
05/01/1999
A
08/07/1961
M
03
F
100,000.00
08/01/2001
A
05/28/1963
F
03
F
100,000.00
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
O1/31/1947
F
03
F
60,000.00
O1/01/1998
A
11/16/1955
F
03
F
70,000.00
02/01/1997
A
06/28/1963
M
03
F
150,000.00
01/01/1996
A
12/05/1947
F
03
F
150,000.00
01/01/1996
A
05/27/1951
M
03
F
80,000.00
O1/01/1996
A
11/20/1953
M
03
F
100,000.00
01/01/2002
A
08/03/1946
F
03
F
10,000.00
O1/01/1996
A
12/14/1951
M
03
F
150,000.00
O1/01/1996
A
12/27/1942
F
03
S
60,000.00
05/01/1997
A
O8/26/1963
M
03
S
70,000.00
O1/01/1996
A
12/17/1947
M
03
S
100,000.00
O1/01/1996
A
03/19/1951
M
03
S
50,000.00
O6/01/2000
A
09/03/1944
M
03
F
50,000.00
O1/01/1996
A
03/20/1958
F
03
F
100,000.00
O1/01/1996
A
10/06/1958
M
03
S
100,000.00
12/01/2002
A
11/12/1964
M
03
S
100,000.00
ADC50 Enrollee and Dependents
_____________________________
List
29/JUL/2003
Page 2
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 090 Voluntary AD&D
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
03/01/2003
A
07/10/1974
M
03
F
O1/01/1999
A
06/04/1953
M
150,000.00
O1/01/1996
A
12/04/1954
M
03
F
50,000.00
O1/01/1996
A
12/04/1946
M
03
F
70,000.00
O1/01/1996
A
05/06/1960
M
03
F
40,000.00
08/01/2002
A
09/29/1957
M
03
F
100,000.00
03/01/1997
A
07/31/1970
M
03
S
150,000.00
06/01/2000
A
02/20/1972
F
03
F
140,000.00
12/01/1997
A
03/22/1971
M
03
F
150,000.00
O1/01/1996
A
11/21/1941
F
03
S
150,000.00
O1/01/1996
A
02/19/1969
M
03
F
150,000.00
°
01/01/1996
A
12/10/1954
M
03
S
150,000.00
09/01/2002
A
12/18/1957
F
03
S
150,000.00
'
01/01/1996
A
12/08/1951
M
03
F
100,000.00
10/01/2001
A
10/19/1972
M
03
F
100,000.00
O1/01/1996
A
12/28/1967
F
03
S
90,000.00
O1/01/1996
A
07/06/1952
M
03
F
50,000.00
O1/01/2000
A
04/21/1965
M
03
F
150,000.00
O1/01/1996
A
12/21/1946
M
03
F
150,000.00
08/01/1999
A
10/21/1963
F
03
F
80,000.00
O1/01/2002
A
08/22/1972
F
03
S
50,000.00
O1/01/1997
A
12/21/1966
M
03
S
150,000.00
O1/01/1996
A
12/02/1949
M
03
S
50,000.00
04/01/1997
A
06/13/1967
M
03
F
150,000.00
06/01/2002
A
10/05/1962
F
03
S
150,000.00
O1/01/1996
A
09/08/1964
F
03
F
100,000.00
01/01/1997
A
06/17/1935
F
03
F
150,000.00
06/01/2003
A
09/11/1977
F
03
F
50,000.00
"
01/01/1996
A
05/09/1956
M
03
F
50,000.00
10/01/2002
A
10/27/1956
M
03
F
100,000.00
01/01/1996
A
09/17/196S
M
03
S
50,000.00
O1/01/1996
A
06/22/1952
M
03
S
80,000.00
'
01/01/1996
A
10/13/1964
M
03
F
120,000.00
O1/01/1996
A
09/23/1970
M
03
S
100,000.00
01/01/1996
A
06/19/1969
M
03
S
30,000.00
_
O1/01/1996
A
09/11/1960
M
03
F
40,000.00
12/01/2002
A
02/15/1954
M
03
F
100,000.00
' 01/01/1996
A
12/07/1957
M
03
F
100,000.00
O1/01/2001
A
06/08/1976
F
03
F
150,000.00
07/01/1996
A
04/05/1950
M
03
S
100,000.00
01/01/1996
A
12/20/1953
M
03
F
100,000.00
03/01/1996
A
06/16/1963
M
03
F
100,000.00
08/01/2003
A
07/08/1966
F
03
F
100,000.00
02/01/2001
A
09/28/1950
M
03
S
150,000.00
O1/01/1996
A
12/02/1951
M
03
S
10,000.00
03
F
100,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003 Page 3
_____________________________
___________ __________
Company : 004 Anthem Life Insurance Company
Country : 01 United States
Coverage: 090 Voluntary AD&D
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
12/01/2000
A
07/06/1950
M
03
F
150,000.00
O1/01/1996
A
12/10/1953
M
03
F
50,000.00
02/01/2002
A
05/09/1958
M
03
F
50,000.00
O1/01/1997
A
12/30/1948
M
03
F
100,000.00
01/01/1996
A
02/23/1974
M
03
S
50,000.00
O1/01/1996
A
12/19/1954
M
03
F
100,000.00
O110111996
A
12/09/1954
M
03
F
150,000.00
01/01/1996
A
12/18/1966
M
03
F
100,000.00
O1/01/1996
A
12/08/1952
F
03
F
150,000.00
12/01/2002
A
10/21/1969
F
03
S
100,000.00
O8/01/2002
A
09/06/1970
M
03
F
150,000.00
° 10/01/2000
A
02/01/1967
M
03
F
100,000.00
O1/01/1996
A
05/16/1971
M
03
S
150,000.00
10/01/2002
A
O8/17/1979
M
03
S
10,000.00
05/01/2002
A
11/24/1952
F
03
F
100,000.00
O1/01/1996
A
12/31/1964
M
03
F
100,000.00
O1/01/1996
A
09/13/1949
M
03
S
50,000.00
O1/01/1997
A
12/17/1941
F
03
F
130,000.00
O1/01/1996
A
07/14/1960
M
03
F
120,000.00
02/01/1996
A
12/27/1947
F
03
F
40,000.00
05/01/2003
A
11/02/1965
F
03
F
40,000.00
05/01/2002
A
10/29/1964
M
03
F
100,000.00
07/01/1997
A
06/25/1970
M
03
S
70,000.00
01/01/1997
A
12/03/1954
M
03
F
150,000.00
01/0111996
A
12/23/1959
M
03
F
30,000.00
03/01/2001
A
O8/09/1959
F
03
F
100,000.00
02/01/1996
A
07/25/1965
M
03
F
70,000.00
02/01/1996
A
02/20/1967
M
03
S
100,000.00
01/01/1996
A
11/23/1951
M
03
F
150,000.00
05/01/1999
A
05/20/1965
F
03
S
150,000.00
O1/01/1997
A
12/18/1968
M
03
F
100,000.00
O1/01/1997
A
04/16/1948
M
03
S-
50,000.00
01/01/1996
A
12/16/1946
M
03
F
110,000.00
O1/01/1996
A
12/11/1948
F
03
S
50,000.00
12/01/1997
A
12/18/1952
M
03
F
50,000.00
O1/01/1996
A
12/25/1951
F
03
S
100,000.00
03/01/1999
A
07/22/1957
F
03
F
90,000.00
01/01/1996
A
07/18/1942
M
03
F
20,000.00
09/01/1996
A
03/31/1962
F
03
F
50,000.00
O1/01/1997
A
03/06/1957
M
03
S
100,000.00
09/01/1999
A
04/21/1970
M
03
F
150,000.00
02/01/2002
A
O1/22/1970
F
03
S
30,000.00
O1/01/1999
A
12/27/1958
M
03
F
30,000.00
O1/01/1996
A
08/02/1971
F
03
S
50,000.00
O1/01/1999
A
08/14/1944
M
03
F
30,000.00
ADC50
------
Enrollee and Dependents
_____________________________
List
29/JUL/2003
-----------
Page 4
______-_-_
Company 004
Anthem Life Insurance Company
Country 01
United States
Coverage: 090
Voluntary AD&D
group 006518-0099
CITY OF FORT COLLINS
'affective
Status
Birthday Sex Relation
Terminated Class
E-type
2/01/1998
A
12/29/1959 M
03
F
1/01/1996
A
12/23/1953 M
03
F
1/01/2000
A
08/13/1947 F
03
S
1/01/2001
A
04/22/1954 M
03
F
9/01/1999
A
O1/14/1961 F
03
F
1/01/1996
A
12/25/1947 M
03
F
141
Volume
150,000.00
100,000.00
110,000.00
150,000.00
40,000.00
100,000.00
13.060.000.00
4DC50 Enrollee and Dependents List 29/JUL/2003
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 090 voluntary AD6D
Gaoup 036518-0099 CITY OF FORT COLLINS
Cart No. Dep Name Effective Status Birthday Sex Relation
12/01/2000 A 07/C6/1950 M
01/01/1996 A 12/10;1553 M
02/01/2002 A 05/09/1958 M
01/011199, A 12/30/1948 M
01/01/1996 A 01/23/1904 N
O S J01/1996 A 12/1911954 H
01/O1/1996 A 12/091,1554 N
O1/C1/1996 A 12118IL966 N
01/01/1996 A 12/08/1952 F
12/01/2002 A 10(21/1969 F
08/01/2002 A a9/06/1970 N
20/01/2000 A 02/01/1967 R
01/01/I996 A 05/16/1971 N
10/01/2002 A 00/17/1579 N
OS/O1/2002 A 11/24/1952 F
01/01/1996 A 12/31/1964 M
01/01/1996 A 09/13/1949 M
01/011199, A 12/17/1941 F
01/01/1996 A 07/14/1960 N
.: 02/01/1996 A 12/27/1947 F
05/01/2003 A 11/D2/1965 F
OS/01/2DO2 A 10/29/1964 N
07/01/1997 A 06/25/197C N
O1/O1/1990 A 12/03/1954 M
01/01/1996 A 12/23/1959 N
03/01/20D1 A 08/09/1959 F
02/01/1996 A O7/25/1965 M
02/01/1996 A 02/20/1967 N
01/01/1996 A 11(21(1951 M
05/01/1999 A 05/20/1965 P
OL(O1/1997 A 12118/1968 M
01/01/1997 A 04/16/1948 M
01/01/1996 A 12/16/1946 M
01/01/1996 A 12/11/1940 F
12/01/1997 A 12/18/1952 M
0:/01/1996 A 12/25/1951 F
03/01/1999 A 07/22/1957 F
01/01/1996 A 07/18/1942 M
09/01/:996 A 03/31/1962 F
01/01/1997 A 03/06/1951 N
09/01/1999 A 04/11/19?0 M
02/01/2002 A 01/22/1970 F
01/01/1999 A 12/27/1958 M
01/01/1996 A OB/02/1901 F
01/01/1999 A 08/14/1944 M
Page 3
Terminated C^lass
E-type
03
P
03
F
03
P
03
F
03
S
61
F
03
F
03
P
03
F
03
S
03
F
03
F
01
5
01
S
03
F
03
F
03
5
0]
F
03
F
03
F
03
F
03
F
0]
C3
F
C3
F
03
F
03
F
03
5
03
F
03
5
03
F
a)
S
03
P
03
S
03
F
03
5
03
F
03
F
03
F
03
S
0]
F
03
S
03
F
03
5
03
P
Volume
150,000.00
50, ODD .00
50, 000.00
100. 000.CC
so, 000.00
100,000.03
150.000.00
100, 300.00
ISO 000.00
100, coo. 00
_50,000.03
--00.000,00
150,000,00
10, OD0, 00
100, 000. Da
100.000.00
50,000.00
130. COO. 00
120,000. 00
40, 000.00
40, 000.00
100. 000-OC
70,000.00
150,000.00
30, Doe .00
100,000.00
10,000.00
100,000.00
150,000.00
150, ODD. 00
Iaa, 000.00
so, DOD 00
110, 000.00
50,000.Oa
50,000,00
100.000.00
90,000.00
20,000.00
50,000.CO
100,000,00
1S0,000.00
30, 000.00
30, 300.00
50,000.00
30,000,00
ADC50 Enrollee and Dependents List 29/JUL/2003 Page 5
------ ----------------------------- ----------- ----------
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 110 Voluntary Life - Employee
"6518-0099 CITY OF FORT COLLINS
ffective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
/01/1993
A
12/11/1959
F
03
N
100,000.00
/01/1992
A
12/19/1956
M
03
N
300,000.00
./01/1996
A
02/14/1959
M
03
T
70,000.00
3/01/2003
A
08/13/1972
F
03
N
100,000.00
2/01/2001
A
03/19/1960
M
03
N
150,000.00
1/01/1999
A
04/17/1947
F
03
N
10,000.00
1/01/1992
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
7/01/2000
A
12/06/1964
M
03
N
300,000.00
6/01/1992
A
12/27/1964
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
170,000.00
4/01/1992
A
12/03/1957
F
03
N
100,000.00
1?/01/1996
A
05/05/1965
M
03
N
250,000.00
i5/01/1992
A
12/06/1944
M
03
N
100,000.00
)7/01/2002
A
02/07/1965
M
03
N
150,000.00
)4/01/1992
A
12/11/1941
F
03
N
50,000.00
74/01/1992
A
12/15/1946
M
03
N
30,000.00
31/01/1995
A
04/11/1966
M
03
N
70,000.00
03/01/1994
A
12/15/1954
M
03
T
200,000.00
04/01/1992
A
12/15/1942
M
03
N
40,000.00
04/01/1994
A
02/24/1951
M
03
N
30,000.00
04/01/1992
A
12/28/1950
M
03
N
80,000.00
06/01/1998
A
10/03/1951
M
03
N
200,000.00
.06/01/1998
A
11/10/1958
M
03
N
300,000.00
12/01/2002
A
09/13/1972
M
03
N
300,000.00
04/01/1992
A
12/01/1947
F
03
N
120,000.00
02/01/2001
A
08/19/1949
F
03
N
50,000.00
04/01/1992
A
11/23/1959
M
03
N
160,000.00
02/01/1997
A
06/15/1964
F
03
N
40,000.00
04/01/2000
A
O1/18/1963
M
03
-N
30,000.00
O1/01/1995
A
10/31/1951
M
03
N
60,000.00
06/01/1992
A
12/29/1954
M
03
N
200,000.00
02/01/1993
A
12/06/1950
M
03
T
70,000.00
02/01/1996
A
06/27/1964
M
03
N
200,000.00
O1/01/1994
A
04/20/1961
F
03
N
300,000.00
02/01/1993
A
07/15/1960
M
03
N
300,000.00
04/01/1998
A
04/08/1966
M
03
N
300,000.00
04/01/1999
A
04/06/1972
F
03
N
250,000.00
04/01/1992
A
03/23/1964
F
03
N
160,000.00
O 01/1998
A
05/27/1973
F
03
N
200,000.00
06/01/1992
A
12/31/1954
M
03
N
100,000.00
04/01/1996
A
03/01/1957
M
03
N
300,000.00
04/01/1992
A
12/04/1948
F
03
N
30,000.00
Enrollee and Dependents List
-----------------------------
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 110 Voluntary Life - Employee
CITY OF FORT COLLINS
29/JUL/2003 Page 6
------------------ --
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
" /O1/1992
A
12/13/1959
F
03
N
40,000.00
/01/1992
A
12/29/1950
F
03
T
30,000.00
/01/1993
A
12/29/1949
M
03
T
70,000.00
/01/2001
A
06/07/1957
M
03
N
30,000.00
/01/1992
A
12/15/1964
F
03
N
100,000.00
i/01/1992
A
12/O6/1954
F
03
N
150,000.00
1/01/1992
A
12/27/1955
M
03
N
30,000.00
)/01/2000
A
12/15/1947
M
03
N
100,000.00
1/01/1992
A
12/27/1956
M
03
N
30,000.00
9/01/1993
A
12/18/1959
F
03
N
50,000.00
4/01/1992
A
12/24/1952
F
03
N
100,000.00
4/01/1992
A
12/29/1947
M
03
N
250,000.00
4/01/1992
A
12/08/1965
M
03
N
100,000.00
4/01/1992
A
12/30/1951
M
03
N
150,000.00
5/01/1992
A
12/16/1961
M
03
N
200,000.00
4/01/1992
A
12/26/1958
F
03
N
140,000.00
7/01/1992
A
12/11/1947
M
03
N
30,000.00
4/01/1992
A
12/20/1945
M
03
N
30,000.00
1/01/1996
A
06/22/1958
F
03
N
100,000.00
)4/01/1992
A
12/13/1958
M
03
N
200,000.00
.1/01/1994
A
07/05/1963
M
03
N
50,000.00
)1/01/1995
A
01/O8/1966
F
03
N
30,000.00
)3/01/1999
A
04/25/1962
F
03
T
100,000.00
)8/01/1992
A
12/15/1962
F
03
N
100,000.00
:)1/01/1994
A
12/06/1966
M
03
N
100,000.00
)4/01/1992
A
12/08/1962
M
03
N
30,000.00
04/01/1992
A
12/10/1964
F
03
N
30,000.00
04/01/1992
A
12/13/1967
F
03
N
100,000.00
04/01/2000
A
O1/30/1959
M
03
N
30,000.00
04/01/1992
A
12/17/1952
M
03
N
30,000.00
03/01/1994
A
12/01/1960
M
03
N
170,000.00
O1/01/1994
A
07/29/1969
M
03
N
150,000.00
02/01/1996
A
12/23/1965
F
03
N
30,000.00
06/01/1992
A
12/10/1966
M
03
N
300,000.00
03/01/1997
A
04/04/1957
M
03
N
110,000.00
05/01/1992
A
12/31/1960
M
03
N
100,000.00
O1/01/1994
A
07/23/1961
F
03
N
100,000.00
O1/01/2001
A
12/11/1951
M
03
N
80,000.00
05/01/1994
A
07/18/1955
M
03
N
200,000.00
04/01/1999
A
08/31/1968
M
03
N
150,000.00
05/01/1992
A
12/21/1943
F
03
N
30,000.00
03/01/2003
A
10/11/1965
M
03
N
300,000.00
04/01/1992
A
12/05/1961
M
03
N
100,000.00
l5/01/1992
A
12/13/1950
M
03
N
30,000.00
(8/01/1998
A
09/02/1972
M
03
N
100.000.00
ADC50 Enrollee and Dependents List 29/JUL/2003 Page 7
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 110 Voluntary Life - Employee
CITY OF FORT COLLINS
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
-^/01/2000
A
06/21/1956
M
03
N
250,000.00
/01/1992
A
12/02/1952
M
03
N
100,000.00
/01/1992
A
12/27/1947
M
03
N
50,000.00
/01/1992
A
12/23/1962
F
03
N
100,000.00
i/01/1992
A
12/03/1948
M
03
N
150,000.00
1/01/1992
A
12/13/1952
F
03
N
120,000.00
5/01/2002
A
02/25/1978
M
03
N
100,000.00
1/01/1994
A
10/07/1960
F
03
N
100,000.00
8/01/1993
A
12/26/1955
F
03
N
100,000.00
6/01/1994
A
03/06/1952
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
4/01/1992
A
12/26/1955
F
03
N
30,000.00
1/01/1995
A
07/07/1966
M
03
T
30,000.00
7/01/2000
A
04/19/1970
M
03
N
30,000.00
3/01/2002
A
04/02/1961
F
03
T
50,000.00
9/01/2001
A
05/28/1963
F
03
N
150,000.00
6/01/1992
A
12/07/1957
M
03
N
300,000.00
16/01/1992
A
12/04/1946
M
03
N
300,000.00
)9/01/1998
A
12/29/1964
F
03
N
60,000.00
)4/01/1992
A
12/17/1947
F
03
N
100,000.00
)3/01/1997
A
O1/31/1947
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
.)8/01/1998
A
11/16/1955
F
03
N
70,000.00
)4/01/1992
A
12/26/1961
M
03
N
300,000.00
)3/01/2002
A
10/08/1963
F
03
N
300,000.00
05/01/2001
A
03/29/1965
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
06/28/1963
M
03
T
40,000.00
•.
06/01/1992
A
12/24/1957
M
03
N
300,000.00
12/01/1993
A
12/05/1947
F
03
N
30,000.00
04/01/1992
A
12/17/1956
M
03
T
30,000.00
04/01/1992
A
12/27/1951
M
03
N
30,000.00
08/01/1993
A
12/08/1960
M
03
N
10,000.00
05/01/2002
A
08/03/1946
F
03
N
20,000.00
03/01/199S
A
07/06/1951
M
03
N
10,000.00
08/01/1992
A
12/14/1951
M
03
N
300,000.00
02/01/1993
A
12/25/1952
F
03
N
100,000.00
04/01/1992
A
12/27/1942
F
03
N
30,000.00
09/01/1997
A
08/26/1963
M
03
N
100,000.00
02/01/1993
A
08/28/1952
M
03
N
50,000.00
02/01/1993
A
05/14/1949
M
03
N
100,000.00
ADC50 Enrollee and Dependents List 29/SUL/2003 Page 8
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 110 Voluntary Life - Employee
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
07/01/1992
A
12/15/1953
M
03
N
200,000.00
09/01/2001
A
09/07/1973
M
03
N
100,000-00
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
100,000.00
06/01/1992
A
12/17/1947
M
03
T
30,000.00
04/01/1992
A
12/07/1947
M
03
N
150,000.00
02/01/1994
A
03/28/1962
M
03
N
100,000.00
06/01/1992
A
12/24/1961
M
03
N
300,000.00
11/01/1999
A
03/19/1948
M
03
N
100,000.00
04/01/1992
A
12/19/195i
F
03
N
30,000-00
° 04/01/1992
A
12/29/1949
M
03
N
250,000.00
10/01/1999
A
08/29/1967
F
03
N
250,000.00
10/01/1999
A
O1/05/1949
M SPOUSE
O1/01/1995
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
O1/01/1994
A
03/20/1958
F
03
N
100,000.00
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
O1/01/1994
A
09/12/1959
M
03
N
250,000.00
03/01/1998
A
O6/07/1957
M
03
N
300,000.00
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
04/01/1992
A
12/24/1949
M
03
N
20,000.00
04/01/1992
A
12/25/1956
M
03
N
250,000.00
02/01/1993
A
10/06/1958
M
03
N
80,000.00
04/01/2002
A
11/19/1960
M
03
N
300,000-00
06/01/2002
A
05/04/1966
M
03
N
150,000.00
04/01/1997
A
O1/29/1957
M
03
'N
300,000.00
09/01/1995
A
08/20/1958
M
03
N
150,000-00
04/01/1992
A
02/25/1955
M
03
N
10,000.00
11/01/1993
A
12/13/1965
M
03
N
50,000.00
04/01/1992
A
12/16/1946
M
03
N
30,000.00
03/01/1995
A
02/25/1952
M
03
N
140,000.00
11/01/1998
A
12/12/1956
F
03
N
30,000.00
06/01/1992
A
12/10/1943
M
03
N
30,000.00
04/01/1992
A
12/06/1950
M
03
N
100,000.00
10/01/2000
A
05/10/1971
F
03
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
04/01/2003
A
07/10/1974
M
03
N
300,000-00
ADC50 Enrollee and Dependents
List
29/SUL/2003
Page 9
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 110 Voluntary Life - Employee
Group 006518-0099 CITY OF FORT COLLINS
Cert^No. Dep Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
12/01/2000
A
07/06/1968
M
03
N
100,000.00
02/01/1996
A
09/05/1957
F
03
N
100,000.00
05/01/1995
A
12/01/1961
M
03
N
100,000.00
05/01/1992
A
12/25/1958
M
03
N
180,000.00
06/01/1993
A
12/04/1954
M
03
N
30,000.00
04/01/1992
A
12/29/1954
F
03
N
60,000.00
04/01/1992
A
12/20/1960
F
03
N
30,000.00
09/01/1997
A
05/11/1954
M
03
N
100,000.00
04/01/1992
A
12/24/1959
M
03
N
300,000.00
04/01/1992
A
12/21/1952
M
03
N
100,000.00
04/01/1992
A
12/12/1959
F
03
N
190,000.00
°
05/01/1992
A
09/20/1955
F
03
N
50,000.00
02/01/1999
A
06/04/1953
M
03
N
100,000.00
01/01/1999
A
10/07/1958
F
03
N
50,000.00
04/01/1992
A
12/15/1949
F
03
N
100,000.00
04/01/1992
A
12/05/1954
F
03
N
30,000.00
04/01/1992
A
12/07/1963
M
03
N
80,000.00
06/01/1992
A
12/24/1959
F
03
N
30,000.00
04/01/1992
A
12/04/1954
M
03
N
160,000.00
04/01/1992
A
12/10/1963
M
03
N
50,000.00
05/01/1998
A
07/10/1945
M
03
N
50,000.00
O1/01/1997
A
10/10/1950
M
03
N
60,000.00
10/01/2002
A
04/30/1971
M
03
N
70,000.00
01/01/1996
A
05/06/1960
M
03
N
100,000.00
04/01/1992
A
12/06/1946
F
03
N
30,000.00
O8/01/1993
A
12/03/1964
M
03
N
300,000.00
10/01/2002
A
09/29/1957
M
03
N
150,000.00
03/01/1993
A
12/19/1948
M
03
N
150,000.00
12/01/2002
A
02/24/1970
M
03
N
300,000.00
09/01/1995
A
03/20/1970
M
03
N
200,000.00
04/01/1997
A
07/31/1970
M
03
N
200,000.00
06/01/2000
A
02/20/1972
F
03
N
30,000.00
04/01/1992
A
09/02/1955
M
03
N
200,000.00
07/01/1994
A
10/20/1969
M
03
N
300,000.00
02/01/1998
A
03/22/1971
M
03
N
300,000.00
02/01/1997
A
11/11/196S
F
03
N
20,000.00
02/01/1996
A
08/16/1961
M
03
N
200,000.00
04/01/1992
A
12/13/1961
M
03
N
300,000.00
02/01/1996
A
09/24/1958
F
03
N
50,000.00
04/01/1992
A
12/27/1947
M
03
N
40,000.00
O1/01/1994
A
04/25/1946
M
03
N
100,000.00
04/01/1992
A
12/10/1954
M
03
N
30,000.00
10/01/2002
A
12/18/1957
F
03
N
50,000.00
03/01/2000
A
O1/24/1968
M
03
N
300,000.00
05/01/1996
A
02/08/1950
F
03
N
70,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003 Page to
----------------------------------- ----------- ----------
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 110 Voluntary Life - Employee
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
" "' "---'-"---
02/01/1993
A
12/30/1953
M
03
T
100,000.00
06/01/1999
A
09/28/1960
M
03
N
30,000.00
04/01/1992
A
12/08/19SI
M
03
N
60,000.00
04/01/1992
A
12/05/1951
M
03
N
150,000.00
O1/01/1997
A
11/06/1961
F
03
N
250,000.00
03/01/1995
A
07/31/1950
M
03
N
100,000.00
12/01/2000
A
04/02/1961
M
03
N
30,000.00
04/01/1992
A
12/13/1963
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
M
03
N
250,000.00
04/01/1992
A
03/15/1954
M
03
N
100,000.00
• 04/01/1992
A
12/28/1967
F
03
N
300,000.00
02/01/1993
A
12/02/1944
M
03
N
100,000.00
06/01/1994
A
11/12/1956
M
03
N
100,000.00
04/01/1992
A
12/05/1954
M
03
N
150,000.00
O1/01/1994
A
08/10/1947
M
03
N
120,000.00
02/01/1996
A
09/18/1953
F
03
N
30,000.00
06/01/1992
A
12/02/1958
M
03
N
300,000.00
O8/01/1995
A
04/21/1965
M
03
N
300,000.00
;.�
08/01/1992
A
12/21/1946
M
03
T
130,000.00
10/01/1999
A
10/21/1963
F
03
N
120,000.00
04/01/1992
A
12/17/1963
M
03
N
200,000.00
03/01/2002
A
08/22/1972
F
03
N
200,000.00
04/01/1999
A
04/28/1970
M
03
N
300,000.00
04/01/1992
A
12/OS/1949
F
03
N
30,000.00
02/01/1998
A
12/21/1966
M
03
N
200,000.00
03/01/1999
A
O8/06/1971
F
03
N
200,000.00
04/01/1992
A
12/02/1949
M
03
N
100,000.00
-
07/01/1996
A
05/13/1962
F
03
N
40,000.00
03/01/1997
A
O1/21/1953
M
03
N
150,000.00
03/01/2002
A
09/22/1966
F
03
N
30,000.00
05/01/2003
A
02/08/1962
F
03
N
250,000.00
.,
04/01/2002
A
06/19/1975
M
03
N
20,000.00
04/01/1992
A
12/13/1951
M
03
N
30,000.00
06/01/2002
A
10/05/1962
F
03
N
50,000.00
09/01/1993
A
09/08/1964
F
03
N
150,000.00
02/01/1999
A
06/07/1958
M
03
N
200,000.00
O1/01/1996
A
04/23/1974
F
03
N
50,000.00
08/01/2000
A
07/23/1960
F
03
T
150,000.00
O1/01/1995
A
11/03/1945
M
03
N
100,000.00
06/01/2002
A
12/04/1958
M
03
N
210,000.00
08/01/1992
A
12/04/1955
M
03
N
200,000.00
05/01/1999
A
06/26/1967
M
03
N
300,000.00
04/01/1992
A
12/22/1946
M
03
N
60,000.00
06/01/1992
A
09/06/1956
M
03
N
300,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003 Page 11
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 110 Voluntary Life - Employee
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
-------
03/01/2000
A
O1/09/1966
F
03
N
130,000.00
06/01/2003
A
09/11/1977
F
03
T
100,000.00
04/01/1992
A
05/09/1956
M
03
N
250,000.00
04/01/1992
A
12/05/1941
M
03
N
30,000.00
O1/01/1994
A
10/31/1957
F
03
N
50,000.00
04/01/1992
A
12/03/1957
M
03
N
30,000.00
O1/01/1994
A
O1/15/1967
M
03
T
110,000.00
O1/01/1996
A
12/10/1949
M
03
N
60,000.00
11/01/2002
A
10/27/1956
M
03
N
40,000.00
03/01/1998
A
09/17/1965
M
03
N
300,000.00
04/01/1992
A
12/12/1956
F
03
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
03
N
100,000.00
06/01/1992
A
12/21/1952
F
03
T
200,000.00
O1/01/1994
A
06/22/1952
M
03
N
110,000.00
11/01/1999
A
08/18/1971
M.
03
N
300,000.00
02/01/1997
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
12/18/1949
M
03
N
50,000.00
03/01/2000
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
03
N
300,000.00
06/01/2000
A
O1/12/1973
M
03
N
300,000.00
11/01/1993
A
12/05/1955
M
03
N
70,000.00
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
04/01/1992
A
12/20/1954
F
03
N
300,000.00
04/01/1992
A
12/24/1946
M
03
N
280,000.00
06/01/1998
A
04/22/1966
F
03
N
200,000.00
O1/01/1996
A
12/12/1957
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
120,000.00
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
O1/01/1996
A
12/07/1957
M
03
T
100,000.00
ADC50 Enrollee and Dependents List 29/JUL/2003 Page 12
Company : 004 Anthem Life Insurance Company
Country : 01 United States
Coverage: 110 Voluntary Life - Employee
Group : 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name
Effective Status Birthday Sex Relation Terminated Class E-type Volume
01/01/2001 A 06/08/1976 F 03 T 100,000.00
04/01/1992 A 12/20/1942 M 03 N 40,000.00
02/01/1993 A 12/07/1959 M 03 N 40,000.00
04/01/1992 A 12/31/1956 M 03 N 100,000.00
04/01/1992 A 12/20/1953 M 03 N 100,000.00
08/01/1992 A 12/05/1954 M 03 N 180,000.00
12/01/1999 A 07/25/1951 F 03 N 70,000.00
04/01/1992 A 12/14/1949 F 03 N 40,000.00
02/01/1996 A 06/16/1963 M 03 N 300,000.00
02/01/1998 A 03/09/1956 F 03 N 130,000.00
01/01/1995 A 10/06/1964F 03 N 300,000.00
• 08/01/2003 A 07/08/1966 F 03 N 200,000.00
04/01/1992 A 12/13/1955 M 03 N 100,000.00
09/01/2001 A 08/07/1968 M 03 N 30,000.00
04/01/1992 A 12/02/1951 M 03 N 150,000.00
06/01/1992 A 12/15/1952 M 03 N 250,000.00
04/01/1995 A 02/26/1961 M 03 N 300,000.00
04/01/1992 A 12/23/1946 M 03 N 30,000.00
03/01/1994 A 04/29/1963 M 03 N 50,000.00
05/01/1996 A 09/10/1968 M 03 N 220,000.00
02/01/2002 A 03/29/1955 F 03 N 80,000.00
04/01/1995 A 07/23/1947 M 03 N 50,000.00
03/01/1998 A 10/05/1953 M 03 N 200,000.00
04/01/1992 A 12/10/1953 M 03 N 250,000.00
04/01/2002 A 05/09/1958 M 03 T 100,000.00
01/01/2003 A 01/21/1971 F 03 N 150,000.00
04/01/1992 A 12/14/1961 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 03 N 60,000.00
04/01/1992 A 12/28/1965 M 03 N 170,000.00
04/01/1992 A 12/30/1948 M 03 N 20,000.00
07/01/2001 A 11/16/1958 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
09/01/1992 A 12/19/1959 M 03 N 180,000.00
02/01/1999 A 02/23/1974 M 03 N 300,000.00
04/01/1992 A 12/25/1953 M 03 N 100,000.00
09/01/1996 A 06/24/1945 M 03 N 300,000.00
02/01/1993 A 12/19/1954 M 03 N 200,000.00
04/01/1992 A 12/29/1958 M 03 T 240,000.00
03/01/1999 A 07/06/1965 F 03 T 20,000.00
04/01/1992 A 12/27/1956 F 03 T 30,000.00
06/01/1996 A 08/19/1971 M 03 N 120,000.00
01/01/1995 A 06/10/1955 M 03 N 50,000.00
05/01/2003 A 12/29/1967 F 03 N 300 QQ�A-0 ,.
y.Y
•+eK
ADC50 Enrollee and Dependents List 29/JUL/2003 Page 13
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 110 Voluntary Life - Employee
Group 006518-0099 CITY OF FORT COLLINS
Cert No. Dep Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
11/01/1995
A
10/07/1970
M
03
N
30,000.00
02/01/2003
A
06/10/1967
M
03
N
300,000.00
04/01/2003
A
08/06/1971
M
03
T
200,000.00
07/01/1992
A
12/09/1954
M
03
N
200,000.00
02/01/1995
A
07/24/1964
F
03
N
50,000.00
02/01/2000
A
10/04/1949
M
03
N
50,000.00
11/01/2001
A
07/17/1953
F
03
N
100,000.00
06/01/1992
A
12/18/1966
M
03
N
100,000.00
11/01/1993
A
12/09/1958
F
03
N
150,000.00
04/01/1992
A
12/26/1951
M
03
N
100,000.00
05/01/1999
A
01/01/1980
M
03
N
300,000.00
04/01/1992
A
12/08/1952
F
03
T
30,000.00
08/01/1992
A
12/06/1959
M
03
N
200,000.00
06/01/1992
A
12/19/1950
M
03
N
200,000.00
06/01/1995
A
09/06/1970
M
03
N
200,000.00
04/01/1992
A
12/11/1958
F
03
N
30,000.00
12/01/2000
A
02/01/1967
M
03
N
100,000.00
04/01/1992
A
12/14/1959
M
03
N
30,000.00
04/01/1992
A
08/20/194S
M
03
N
50,000.00
O1/01/1994
A
06/11/1957
F
03
N
50,000.00
04/01/1993
A
12/06/1959
M
03
N
300,000.00
04/O1/1992
A
12/18/1952
M
03
N
30,000.00
04/01/1992
A
12/31/1964
M
03
N
100,000.00
O1/01/1997
A
09/13/1949
M
03
N
50,000.00
04/01/1992
A
12/17/1957
M
03
N
30,000.00
08/01/1992
A
12/30/1952
M
03
N
160,000.00
04/01/1992
A
12/02/1950
M
03
N
30,000.00
04/01/1992
A
12/11/1962
M
03
N
120,000.00
04/01/1992
A
12/12/1955
F
03
N
100,000.00
04/01/1992
A
12/25/1958
M
03
N
200,000.00
05/01/1992
A
12/19/1947
M
03
N
160,000.00
02/01/1999
A
06/20/1964
F
03
N
140,000.00
01/01/1997
A
11/21/1960
M
03
N
50,000.00
04/01/1992
A
12/04/1955
F
03
N
100,000.00
11/01/1994
A
03/20/1949
M
03
N
70,000.00
11/01/1993
A
12/17/1941
F
03
N
100,000.00
04/01/1992
A
12/27/1947
F
03
N
10,000.00
05/01/2003
A
OS/08/1968
M
03
N
120,000.00
03/01/1995
A
OS/28/1968
M
03
N
100,000.00
04/01/1992
A
12/17/1956
F
03
N
30,000.00
07/01/2002
A
10/29/1964
M
03
N
200,000.00
02/01/1998
A
04/04/1954
M
03
N
100,000.00
04/01/1992
A
12/26/1953
M
03
N
300,000.00
02/01/1993
A
12/21/1955
F
03
N
200,000.00
04/01/1992
A
06/01/1963
F
03
N
120,000.00
DC50 Enrollee and Dependents List 29/JUL/2003 Page 14
---------------------------------- ---- — ----- ----------
Company 004 Anthem Life Insurance Company
Country 01 United States
Coverage: 110 Voluntary Life - Employee
Group 006518-0099 CITY OF FORT COLLINS
^^-« N^ Den Name
Effective
Status
Birthday
Sex Relation
Terminated Class
E-type
Volume
04/01/1992
A
12/21/1963
M
03
T
200,000.00
04/01/1992
A
12/03/1954
M
03
N
150,000.00
02/01/1997
A
03/04/1948
M
03
N
100,000.00
04/01/1992
A
12/24/1940
M
03
N
100,000.00
04/01/1992
A
12/23/1959
M
03
N
30,000.00
04/01/1992
A
08/09/1959
F
03
N
60,000.00
11/01/1995
A
10/05/1968
F
03
N
200,000.00
08/01/2000
A
04/22/1951
F
03
N
30,000.00
05/01/1994
A
11/28/1966
F
03
N
100,000.00
os/oi/1992
A
12/09/1954
M
03
N
100,000.00
05/01/1992
A
12/05/1957
F
03
N
30,000.00
° 10/01/1995
A
02/14/1959
M
03
N
30,000.00
04/01/1992
A
12/15/1961
M
03
N
30,000.00
-
04/01/1992
A
12/05/1952
M
03
N
60,000.00
04/01/1992
A
12/16/1960
M
03
N
100,000.00
02/01/1996
A
02/20/1967
M
03
N
100,000.00
10/01/1992
A
12/13/1944
M
03
N
100,000.00
01/01/1994
A
06/22/1951
M
03
N
200,000.00
10/01/1992
A
10/23/1969
M
03
N
250,000.00
;n
10/01/2002
A
10/18/1965
F
03
N
200,000.00
02/01/2003
A
11/30/1967
F
03
N
300,000.00
04/01/2002
A
10/14/1951
F
03
N
100,000.00
04/01/1992
A
12/18/1968
M
03
N
300,000.00
04/01/1992
A
12/22/1964
M
03
N
80,000.00
03/01/2000
A
10/10/1967
F
03
N
150,000.00
02/01/1997
A
04/16/1948
M
03
N
50,000.00
04/01/1992
A
12/16/1946
M
03
N
30,000.00
05/01/1992
A
12/11/1948
F
03
N
200,000.00
05/01/1999
A
11/11/1968
M
03
N
300,000.00
01/01/1994
A
10/31/1963
M
03
N
100,000.00
01/01/1995
A
12/18/1952
M
03
N
150,000.00
04/01/1992
A
12/25/1951
F
03
N
100,000.00
04/01/1992
A
12/28/1949
M
03
N
150,000.00
04/01/1992
A
12/23/1953
M
03
N
120,000.00
10/01/2002
A
07/12/1970
M
03
N
100,000.00
04/01/1992
A
12/11/1954
M
03
N
80,000.00
09/01/1999
A
07/22/1957
F
03
N
120,000.00
04/01/1992
A
12/09/1954
M
03
N
100,000.00
03/01/1993
A
12/11/1955
M
03
N
300,000.00
03/01/1993
A
12/03/1961
F
03
N
300,000.00
06/01/2002
A
06/03/1957
F
03
N
40,000.00
04/01/1992
A
12/13/1954
M
03
N
30,000.00
05/01/1999
A
08/11/1959
F
03
N
100,000.00
06/01/2000
A
06/25/1960
M
03
N
300,000.00
04/01/1992
A
12/04/1956
M
03
N
180,000.00