HomeMy WebLinkAboutCORRESPONDENCE - RFP - 7053 BENEFITS - LIFE AND DISABILITY (2)12/03/2010 14:03 FAX 3037826938 CIGNA Group Ins
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CONFIRMATION OF COVERAGE: 2011 Renewal — Life/AD&D/Disability
CARRIER/POLICY #:
Client / Legal name:
ERISA Plan name:
Eligible employees:
Client / Insured Address:
CIGNA
City of Fort Collins
City of Fort Collins
1,400
215 North Mason Street, 2"d Floor
Fort Collins, CO 80522
This document will confirm placement of the following coverage(s):
Basic Life
Basic AD&D
Voluntary Life/AD&D (Employee/Spouse/Dependent)
Voluntary STD (Advice to Pay)
LTD
Coverage will be effective on: 1/1/2011
For a period of: Rate guarantee until 12/31/2092
Rates / fees (including any subsequent period caps or guarantees) for the above -referenced
coverage(s) are:
Life. AD&D. LTD, STD Rates/Fees:
Life:
$0.120/$1,000
AD&D:
$0.025/$1,000
LTD:
36.5%/$100 of covered monthly payroll
STD:
$1.270 per employee per month (Advice to Pay fee)
Supplemental life Rates
Aqe
Rate Age Rate
<20
$0.028 50 — 54 $0.287
20 — 24
$0.044 55 — 59 $0.447
25 — 29
$0.044 60 — 64 $0.637
30 — 34
$0.053 65 — 69 $0.875
35 — 39
$0.068 70 — 74 $1.784
40 — 44
$0.112 75 — 79 $3.604
45 — 49
$0.185 80+ $7.160
MERCER
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12/03/2010 14:04 FAX 3037826938 CIGNA Group Ins 16 002
Supplemental Dependent Life Rate
Per dependent unit: $0.206/$1,000
Supplemental AD&D Rate (Spouse or Child
. $0.025/$1,000 /L
A description of benefits:
Basic Life. AD&D nG,t}�-
Life Schedule - 1 x earnings rounded to the Rawest $1,000
Guarantee Issue - The lesser of 1 x annual compensation to a maximum of $200,000
AD&D Amount -1 x earnings rounded to the next higher $1,000 -+o a- n,d�►rn�a„E o_q
Reduction Schedule - To 70% at age 65, to 50% at age 70, to 30% at age 75, to 20% at age 80
Supplemental Life, AD&D
Supplemental Life Schedule -
1 to 3 x annual compensation rounded to the eree 1,000 -F-", yt;5�IC50C
Guarantee Issue -
$100,000
Supplemental AD&D Schedule -
1, 2, or 3 x BAE to $400*, 06-4050i c—
Spouse Life - $10,000, $25,000, $50,000, $75,000, $100,000: Can't exceed 50% of employee
basic/supplemental coverage
Child Life - 14 days to 6 months: $500
6 months to 25 years: Units of $5,000
LTD
Benefit Percentage - 66.67%
Monthly Benefit Maximum - $7,500
Elimination Period - 90 Days
Benefit Duration - To age 65
Own Occupation - 24 months
STD
Weekly Benefit Percentage - 70%
Weekly Benefit Maximum - None
Maximum Benefit Duration -is-
90S �►� 0.- c ��-� y�-�
Day Benefits Begin - Accident = I*h consecutive day, Illness = 1.4"'*consecutive day
MERCER
MARSH MERCER KROLL
GUYCARDLNTER OU AWYMAN
12/03/2010 14:04 FAX 3037826938 CIGNA Group Ins U 003
Conditions of coverage(s): None
As an authorized representative, I accept this confirmation of coverage. By signing below, I
acknowledge agreement with the rates and benefits described above and that subsequent
contract(s) shall conform to this document unless otherwise agreed to in writing.
Authorized Representative:
Legal Name of Insurer/
Administrator
Signature:
Date:
This form must be signed and returned to Mercer H&B prior to the effective date of coverage.
MERCER
MAYS" MERCER K'-L
GtIYGR My- Ol1V6t NIYMAN