Loading...
HomeMy WebLinkAboutCORRESPONDENCE - RFP - 7053 BENEFITS - LIFE AND DISABILITYPagel of 3 David Carey - RE: CIGNA Welcome Package -Life, Accident, and DisabilityCoverage From: "Knodel, Sherrie D 1200" <Sherrie.Knodel2@cigna.com> To: "David Carey" <DCarey@fcgov.com> Date: 11/24/2009 3:15 PM Subject: RE: CIGNA Welcome Package -Life, Accident, and DisabilityCoverage CC: "Savona, Randy 1200" <Randy.Savona@CIGNA.COM>, "Amy Sharkey" <ASharkey@fcgov.com>, "Jim O'Neill" <JONEILL@fcgov.com> Hello David, Everything looks good now: Please send the original documents to my attention at the address below. Thank you for your assistance with this! Have a wonderful Thanksgiving Holiday!! Regards, Sherrie Knodel Senior Implementation Coordinator CIGNA Group Insurance 13900 E-. Mexico Ave., Suite 1200 1 Denver, CO 80210 Office: 303.691.3126 Fax: 646.706.4221 sherrie.knodel2@cigna.com Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. @2009 CIGNA From: David Carey [mailto:DCarey@fcgov.com] Sent: Tuesday, November 24, 2009 3:00 PM To: Knodel, Sherrie D 1200 Cc: Savona, Randy 1200; Amy Sharkey; Jim O'Neill Subject: Re: CIGNA Welcome Package -Life, Accident, and Disability Coverage Sherrie, See attached file for revised ERISA Coverage WorkSheet. Has applicable exemption marked. Please replace in previous file sent. Thanks. David Carey, CPPB Buyer -City of Fort Collins Phone: (970) 416-2191 Fax: (970) 221-6707 E-mail: dcarey@fcgov.com >>> David Carey 11/24/2009 2:47 PM >>> Sherrie, file://C:\Documents%20and%20Settings\dcarey\Local%20Settings\Temp\GW) 00001.HT... 11 /25/2009 IV. MISCELLANEOUS Nothing contained herein shall be construed as creating any employment relationship between Payment Agent and any payee. All notices to Payment Agent should be sent to: CIGNA Group Insurance Tax Compliance Unit, LLTCU 900 Cottage Grove Road Hartford, CT 06152 IN WITNESS WHEREOF, and intending to be legally bound, the parties have signed this Agreement. LINA Benefit Pa ments, Inc. ("Payment Agent") 4 Date: September 30, 2009 ° �:CN►�. By: J n A. Scanlon Title ". Assistant Secretary ("Employer") Date: (� Z c (r' ` i� -� h�% C� By-- Title: -5- Copyright © 2003 - 2008, Life Insurance Company of North America, a CIGNA company City of Fort Collins LK 962251 SCHEDULE I - EMPLOYER TAX INFORMATION I. Exemption from Social Security/Medicare Taxes Select appropriate reason if your disability plan is exempt from Social Security and Medicare taxes: ❑ Religious Institution ❑ Charitable Institution ❑ Other (Specify): __ Indicate if Plan is issued to a anion, a creditor, or an association which is exempt from Social Security taxation if the employer is neither a party to the contract or a contributor to plan costs: ❑ Union ❑ Creditor ❑ Professional Association II. Employee Contribution Percentages Short Term Disability: ❑ All employees contribute % of disability policy pl•emium on a post -tax basis. o Employees contribute on a pre-tax basis (considered 100% employer contributions). X Employer contributes 100% of cost. ❑ Contribution percentage varies by benefit, plan or division (attach detail). Long Term Disability: ❑ All employees contribute .— % of disability policy premium on a post -tax basis. ❑ Employees contribute on a pre-tax basis (considered 100% employer contributions). ,)e Employer contributes 100% of cost. ❑ Contribution percentage varies by benefit, plan or division (attach detail). III. Tax Reporting of Self -Insured Benefits (Does not apply to "advice to pay") Benefits are paid from a trust (e.g. 501(c)(9) bust) which bears an insurance risk. Indicate the address where the ASO tax reimbursement check should be sent: Attention: Mailing Address: IV. Address to which tax reports should be sent o All reports should be sent to the following address: Attention: _j�� j/�j/ -P= Mailing Address: F1,io ❑ Reporting should be to multiple addresses. Attach information on a separate page. Include suffix/division code, coverage code, employee post -tax contribution percentage, federal EIN and employer address. Copyright © 2003 - 2008, Life Insurance Company of North America, a CIGNA company STD ASO APPLICATION For STD ASO Plaits written in conjunction with Insured LTD. PART I Legal Name of Applicant: City of Fort Collins Contact: Amy Sharkey Address: 215 N. Mason St., 2nd Floor Fort Collins CO 80522 Telephone: 970.416.2721 STD Agreement Number: SHD 961710 LTD Policy Number: LK 962251 Life Insurance Company of North America a CIGNA company Fax: Effective Date: 1 / 1 /2010 Effective Date: I/l/2010 U @ CIGNA PART II I hereby apply to the Life Insurance Company of North America for the following administrative services: SERVICES Full ASO with Banking COST $1.27 per employee per month The Applicant accepts the terms and conditions of the administrative services identified in the proposal and any attachments/modifications made to the proposal. It is agreed that the administrative services applied for shall not become effective unless this application is received and approved by the Company at its Home Office. If conflict exists between the proposal and the ASO agreement, when issued, the term of the ASO agreement will govern. We certify that the information provided to the Life Insurance Company of North America is true and correct to the best of our knowledge, information and belief. Applicant Signature Title �50 Insurance Company Representative Signature IV Subscription and Joinder Agreement TRUST: The Group Insurance Trust for Employers in the Public Administration Industry The Applicant adopts the above named Trust established for all employers in the same or related industry and subscribes to the Trust for the insurance requested in the attached Group Application. For the purposes of this agreement the Applicant will be known as the Subscriber. SUBSCRIBER: The Subscriber confirms the appointment of Wilmington Trust Company as Trustee and agrees to be bound by the terms of the Trust Agreement. By signing this agreement, the Subscriber joins as Co-Settlor of the Trust until its termination as a Subscriber and accepts the appointment of the Administrator. The Subscriber agrees to the following terms. The Subscriber agrees to promptly furnish the Trustee or its Administrator with records or other information required by them as needed to ensure proper administration of the insurance plans of the Trust. It further agrees to allow the Trustee or its Administrator to inspect all records that pertain to the insurance plans of the Trust. 2. The Subscriber appoints the Administrator to represent it in dealings with the Trustee which have to do with the insurance fund. In the event of its termination as a Subscriber, no further claim, except as may be provided under any extended benefits provision of the policy, will be made against any funds accruing to any portion of the insurance fund. 3. The Subscriber agrees to pay the Trustee or its Administrator all premiums which become due and payable, and understands that any payment more than 31 days in default may cause the termination of this Agreement and suspension of all benefits as of the due date. 4. Either the Subscriber or the Trustee may terminate this agreement upon 30 days written notice to the other. Subscriber (Employer Name): City of Fort Collins OK 964764Pvc�-' FLX 963106 by: � 6—>cp--� < L :X - OF Name/Title Date Accepted: // — 2 41- D� Wilmington Trust Company (Trustee) by Life Insurance Company of North America (Administrator) Matthew G. Manders, President c Date i; CIGNA Group Insurance Life • Accident • Disability September 30, 2009 City of Fort Collins 215 N. Mason St., 2nd Floor Fort Collins, CO 80522 Dear Amy Sharkey: The purpose of this letter is to identify the contractual provisions that will be used in the event that the Agreement for Life Assistance Program Services (`LAP Agreement") with CIGNA Behavioral Health ("CBH") is not finalized and fully executed prior to the effective date of your coverage. Until the LAP Agreement is finalized and executed, all services provided by CBH shall be in accordance with the terms of CBH's standard LARAgreement. City of Fort Collins shall reimburse CIGNA Group Insurance for CBH services through the agreed upon combined product and behavioral health service rate. The parties agree to negotiate in good faith the terms of the definitive LAP Agreement, and to execute such Agreement as soon as practicable. Once the LAP Agreement is finalized, that agreement will supersede this letter agreement, and will apply retroactively to the effective date of CBH's administration of the Life Assistance Program services. Please sign below to indicate your acknowledgement of this arrangement and return an original to my attention. Sincerely, Sherrie Knodel Implementation Coordinator CIGNA Group Insurance Cc: Pam Gokey,Account Manager, CIGNA Group Insurance By: Name: J AYA d Vej L L X Title: b)R62*h9R eyF- PPRetr51AK RI S K Yn6'7- Date: 2 �z CIGNA Grotil) Insurance. CIGNA Secure Travel® I.i(c -Accident • Okaf li£v EMERGENCY TRAVEL ASSISTANCE SERVICES Services provided by Europ Assistance USA, Inc. Subscriber: City of Fort Collins Membership No.: 57 The following is a description of the Emergency Travel Assistance Services ("Services") provided by Europ Assistance USA, Inc. ("EA") through the CIGNA Secure Travel le program. The cost of these services is included within the premium for the Policy identified above. Services will be provided only while the Policy is in force and while the master agreement between EA and Life Insurance Company of North America ("Insurance Company") is in effect. The Insurance Company reserves the right to modify the scope or availability of services, or to terminate the master agreement between EA and the Insurance Company, upon written notice to the Subscriber. Subscriber ("Subscriber") is defined as a company that has purchased the CIGNA Secure Travel Program for its employees. Covered Members - Employees of the Subscriber insured under the Policy, including any dependents insured under the Policy, shall be eligible for CIGNA Secure Travel to services, whenever traveling 100 miles or more from their permanent residence ("Covered Members"). Service will also be available for pre -trip information just prior to a trip meeting the above requirements. Access To Services - To gain access to CIGNA Secure Travele services, a Covered Member must contact EA. Eligibility for Services- EA will verify eligibility via a roster provided by the Insurance Company. If the Subscriber is not listed in the roster, EA will verify with the Insurance Company's designated official that the Subscriber's employees are eligible for services. Once eligibility is verified, EA is authorized to provide services and the Covered Member shall be responsible for all third party costs incurred by EA in providing authorized services, with the exception of those costs incurred for the medical evacuation and repatriation services covered under the CIGNA Secure Travel program. If contact is made outside of business hours, EA will render services but shall not be responsible for any claim, damage, loss, cost, liability or expense which arises in whole or in part as a result of EA's inability to contact the Insurance Company's designated company official for any reason beyond EA's control. 24 Hour Access - Covered Members will be able to reach EA's multilingual coordination center in Washington, D.C. toll -free by telephone, telex, and facsimile 24 hours a day, 365 days a year to confirm coverage and obtain access to the following services. -1- I. Informational Assistance Prior to a trip, Covered Members can contact EA for up-to-date information on the following: Inoculation and Visa Information - Information concerning visa and inoculation requirements of the foreign countries in which members are traveling. Cultural Information - information concerning cultural and special events, if available, in the areas to which Covered Members are traveling. Temperature and Weather Information - Weather forecasts and temperatures for major cities around the world as well as domestic and international ski reports for major ski areas. Embassy and Consular Referral - Addresses and telephone numbers of the nearest American Consulate and Embassies, as appropriate. Foreign Exchange Rates - Information on foreign exchange rates between the U.S. and most major currencies. These rates are updated on a daily basis. The rates may vary slightly from rates posted by local financial institutions and are meant as general guidelines. 11. Emergency Medical Assistance EA is responsible for providing the emergency medical assistance services described in this section. The Insurance Company is responsible for the reimbursement of all costs associated with the following services to EA: emergency medical transport, return of dependent children/ travel companion, visit of a family member/friend and repatriation services. Location of Medical Providers - Upon a Covered Member's request, EA will provide the names, addresses and telephone numbers of physicians, hospitals, dentists, and dental clinics in the area in which the Covered Member is traveling. EA will also attempt to confirm the availability of the provider, ascertain required payments which a Covered Member will be required to pay, and make an appointment for a Covered Member with the medical provider of the Covered Member's choice. Except as specifically provided in this agreement, expenses of medical care are not insured by the Insurance Company. Neither EA nor the Insurance Company guarantees the quality of the medical services provider or the medical facility and the Final selection of local physician or medical facility is the Covered Member's right and responsibility. Medical Monitoring- When notified of Covered Member's medical emergency resulting from an accident or sickness, EA's multilingual staff will, whenever appropriate in the judgment of EA or a physician designated by EA, attempt to contact the Covered Member and Covered Member's local attending medical personnel in order to attempt to obtain a full understanding of the Covered Member's situation and to attempt to monitor the Covered Member's condition. EA will continue to monitor the Covered Member's condition and will remain in communication with the Covered Member's family until the Covered Member's medical problem is resolved or the Covered Member has returned home. Emergency Medical Transport - In the event of a medical emergency, when a Covered Member requests, and a physician designated by EA in consultation with a local attending physician determines that it is medically necessary for a Covered Member to be transported under medical supervision to a different hospital or treatment facility or be repatriated to his/her place of residence for treatment, EA will arrange for the medical evacuation or repatriation under proper medical supervision. -2- As part of a medical evacuation, EA will also make all necessary arrangements for ground transportation to and from the hospital, as well as pre -admission arrangements, where possible, at the receiving hospital. All decisions as to the medical need for evacuation or repatriation, the means and timing of any evacuation, the medical equipment and the medical personnel to be used and the final destination are medical decisions that will be made by EA's designated physicians in consultation with a local attending physician based on medical factors and their decisions shall be conclusive in determining the need for such services. Costs of medical evacuation or repatriation are covered under the CIGNA Secure Travel program, provided the foregoing requirements are met. Return of Dependent Children — If any dependent children under the age of 16 traveling with a Covered Member are left unattended by an adult because the Covered Member is hospitalized, EA will arrange for their transportation home. Should transportation with an attendant be necessary, EA will arrange a qualified escort to accompany the children. The cost of these services are covered under the CIGNA Secure Travel program. Return of 'Traveling Companion — If a Covered Member's traveling companion loses previously made travel arrangements due to a delay caused by the Covered Member's medical emergency, EA will help arrange for the traveling companion's return to the companion's original destination. The costs of these services are covered under the CIGNA Secure Travel program. Visit of a Family Member or Friend — If a Covered Member is traveling alone and must be hospitalized for ten (10) or more consecutive days, EA will arrange for a round-trip economy class transportation for a member of the Covered Member's immediate family, or a friend designated by the Covered Member, from the family member's or friend's home to the place where the Covered Member is hospitalized. EA will also arrange for meals and accommodations (up to S 100 per day for up to 7 days) for the family member or friend while they are visiting the hospitalized Covered Member. The costs of these services are covered under the CIGNA Secure Travel program. Emergency Medical Payments — When necessary to obtain needed medical services for a Covered Member, upon request EA will advance up to $5,000.00 to cover on -site medical expenses, upon receipt of satisfactory guarantee of reimbursement fi•om the Covered Member. Except as specifically provided in this agreement, expenses of medical care are not insured by the Insurance Company. Repatriation Special Services — In the event a Covered Member dies, EA will arrange for all necessary government authorization required by law, including a container appropriate for transportation and arrange for the repatriation of the remains to the Covered Member's place of residence for burial. The costs of these services are covered under the CIGNA Secure `travel program. Replacement of Medication — If a Covered Member has an unexpected need for prescription medication or loses, forgets, or runs out of prescription medication while traveling, EA will attempt to locate the medication or its equivalent and attempt to arrange for the Covered Member to obtain it locally, where it is available; or, if not available locally, to have it shipped to the Covered Member, at the Covered Member's expense, subject to local laws. The Covered Member will be provided with a cost estimate for the replacement medication and shipment costs, which shall be subject to Covered Member's approval. Except as specifically provided in this agreement, expenses of medical care are not insured by the Insurance Company. III. Travel: and Communication Assistance Telephone Interpretation Service — if a Covered Member needs help communicating in an emergency, EA will provide telephonic interpretation services in all major languages. In emergency situations which require extensive translation, EA will make referrals to local translators. —3— Transmission and Retention of Urgent Messages - In an emergency, EA will use its best efforts to transmit an urgent message for a Covered Member to the Covered Member's family, friends, or business associates. EA will also accept and retain messages for Covered Members at the Worldwide Assistance North American Coordination Center for up to fifteen (15) days. Travel Arrangements - In the event of an emergency, EA will help Covered Members make emergency travel arrangements, including airline, hotel, and car rental reservations. The Covered Member is responsible for payment for all tickets, accommodations and rentals arranged. Lost Luggage, Documents and Personal Items -- If a Covered Member's luggage, personal items or travel documents have been lost or stolen, EA will contact the appropriate authorities in order to locate the lost items and have them sent to the Covered Member. If requested, EA will help a Covered Member secure replacement items from home. All shipping and replacement costs are the responsibility of the Covered Member. Legal Assistance/Bail - In an emergency, EA will attempt to help a Covered Member secure and post bail bonds worldwide, where permitted by local law, from funds forwarded to EA fi•om the Covered Member's family or representative, or with a satisfactory guarantee of reimbursement. EA will also use its best efforts to provide a Covered Member with the names, addresses and telephone numbers of lawyers in the area in which the Covered Member is traveling in case of a car accident, traffic violations, and other offenses. However, the selection of and the expenses associated with a particular attorney are the responsibility of the Covered Member. Emergency Cash Advance -- In an emergency situation, and with the consent of the Covered Member, EA will advance up to $250.00, upon satisfactory guarantee of reimbursement. IV. Limitations The services described here are available in every country. Some countries, however, may present political and other obstacles that may render assistance services difficult or impossible and services cannot always be guaranteed. Should a Covered Member travel in any area in which there is a rebellion, riot, military uprising, war, labor disturbance or strike, EA will endeavor to provide such services as EA believes it can safely perform under existing conditions. The medical professionals or attorneys suggested or designated by EA who provide direct services pursuant to this agreement are not employees or agents of EA and, therefore, neither EA nor the Insurance Company is not responsible or liable for their negligence or other acts or omissions. -4- BINDER CHECK INVOICE Life Insurance Company of North America City of Fort Collins 215 N. Mason St., 2nd Floor Fort Collins, CO 80522 Policy Number Effective Date Description Total Due FLX 963106 1/1/2010 Group Term Life $10,750.00 OK 964764 I/l/2010 Basic & Voluntary AD&D $2,000.00 LK 962251 1/1 /2010 Group Long Tern Disability $118,583.00 TOTAL DUE: $31,333.00 Make check payable to Life Insurance Company of North America Include a copy of this invoice with your initial payment and mail to the address below. Life Insurance Company of North America P.O. Box 13701 Philadelphia, PA 19101-3701 PLEASE NOTIFY US IMMEDIATELY OF ANY CORRECTIONS IN THIS STATEMENT City of Fort Collins Welcome Package Table of'Contents CUSTOMER FORMS FOR SIGNATURE Welcome Package Purpose of Form Specific to Product Action Required Form Line CIGNA Group Insurance Needed for policy to be issued; fbrmal agreement All Applicable Pleasc have form signed by an Application between policyholder and insurance company that both Policies authorized Client Representative. parties accept the terms and conditions of the insurance coverage. ER1SA Coverage Ifyour employee benefit plans are not subject to LR1SA All Policies (when Please have Porn signed by an Workshect (tbr• example, if they are government plans or church applicable) individual authorized to amend tans), please indicate on workshect• the Plan. Limited Agency Authorizes CIGNA to perform certain functions Short and/or Long- Please have completed and signed Agreement imposed upon the Policyholder under P.L. 96-601 and Tenn Disability by an authorized Client 97-123 with respect to preparation and Jilin of W-2's. Covet -age Representative. Lirnited Agency Authorizes CIGNA to perform certain functions Short and/or Long- Please have completed and signed Agreement with Elt imposed upon the Policyholder under P.L. 96-601 and Tenn Disability by an authorized Client PICA Services 97-123 with respect to preparation and filing of W-2's as Coverage Representative. well as the ) m to er PICA Match Services. STD ASO Application Agreement between policyholder and insurance Self Insured Short Please have form signed by an company that both panics accept the terms and 'Penn Disability authorized Client Representative. conditions of the set -vices being provided. Policies Subscription and Joinder Subscription agreements are used for policies that are All Policies issued Please have form signed by an Agreement sold through a trust. Needed for insurance to become through the trust authorized Client Representative. effective; formal agreement between policyholder and (when applicable) the trustee that both parties accept the terns and conditions of f is trust agreement. Letter of Intent — L,ific Letter of Intent between policyholder and insurance Life or Long -Term Please have completed and signed Assistance company that both parties will negotiate the terms and Disability Coverage by an authorized Client conditions orthe services being provided. Representative. F;mergency 'rravel Provides overview of the services being provided by Accidental Death & Please review, complete and have Assistance Services Lwrop Assistance USA, Inc. and agreement to provide Dismemberment signed by an authorized Client A regiment I these services to the policyholder. I Coverages Representative. CUSTOMER ITEMS TO PROVIDE Binder Check Invoice Invoice to support estimated binder check amount on All Coverages Supply Binder Check with copy basic coverages only. Binder amount will be applied to orthe provided Invoice first month's preliliunt. CUSTOMER FORMS FOR REVIEW Non -Standard ADI A Confirn request to use a schedule which reduces or Life Policies Please review Notice terminates benefits on the basis of age which differ from those provisions or schedules customarily used by L.INA. Privacy Notice Provides an overview of CIGNA Group Insurance's All Policies Please review. privacy policies CIGNA Group Insurance Life • Accident • Disability i September 30, 2009 City of Fort Collins 215 N. Mason St., 2nd Floor Fort Collins, CO 80522 RE: Group Policy Number - FLX 963106 Benefit Reduction Schedule(s) Dear City of Foil Collins: You have requested that the Life Insurance Company of North America ("L1NA"), a CIGNA company, issue a group insurance policy ("Policy") to City of fort Collins, which contains provisions or schedules reducing or terminating benefits on the basis of age which differ from those provisions or schedules customarily used by LIMA. The purpose of this letter is to confirm with you that your request has not been made on the basis of or in reliance on any representations or warranties provided by LINA that such provisions or schedules meet the requirements of any applicable federal or state employment discrimination laws, including the federal Age Discrimination in Employment Act. While it is recommended that you seek the advice of your legal counsel to ensure compliance with any applicable employment discrimination laws, you nonetheless agree to assume full responsibility for the compliance with the requirements of such laws to the extent they are applicable to the employee benefit plans of which the Policy is a part. Cordially, Sherrie Knodel Implementation Coordinator CIGNA Group Insurance 3900 E. Mexico Avenue, Suite 1200 Denver, CO 80210 Phone: 303.691.3126 Fax: 303.782.6938 Sherrie.Knodel2@CIGNA.com �-a CAGNA ,1 i31r Si r+r',55 uj C: urir>,�{. Important Privacy Notice — Please Read As a customer of a CIGNA company, we want to assure you that we recognize our obligation to keep our customers' protected information secure and confidential. This notice explains our privacy practices and it should answer questions about how we protect personal information. We will continue to safeguard the privacy of the information provided to us. Thank you for giving us the opportunity to serve you. (If you are an Employer or Group Sponsor, please make this information available for review by your employees or members as appropriate.) This notice applies to insurance products underwritten, or administered by, the Life Insurance Company of North America and CIGNA Life insurance Company of New York, Life and Disability products underwritten by Connecticut General Life Insurance Company, and insurance products underwritten by Insurance Company of Noah America administered by the CIGNA companies. Information is the key to our ability to provide you with best in class service. Regardless of whether you are a customer, applicant, insured, or former insured, we are committed to protecting and maintaining the privacy of any information in out, possession. COLLECTION AND USE OF INFORMATION We may collect protected information about our customers for use in the processing and evaluation of applications or eligibility for insurance, investigating a claim for benefits, and in developing financial plans. This information will be used by authorized company personnel solely for these purposes, and it may be integrated into our databases for statistical and audit purposes. Protected information means any non-public, personally identifiable information including financial information, employment related information and medical information. Unless permitted by law, we will only collect information from sources other than our customers with authorization. DISCLOSURE OF INFORMATION We do not disclose any protected information about our customers or former customers to anyone except as permitted by law. We do not sell customer lists or other protected information. With some exceptions, we will not disclose protected information without written authorization. There are circumstances when we will disclose protected information related to medical underwriting or a claim investigation or other activities relating to your insurance plan without authorization to third parties or affiliates assisting us with these activities, as permitted by law. We will also disclose protected information to third parties without authorization as required by law, such as in the case of subpoenas and mandated governmental disclosures. PROTECTING YOUR INFORMATION We have internal policies to maintain the privacy of our• customers' protected information. These include but are not limited to policies related to the transmission, storage and disposal of paper and electronic information; the prevention of unauthorized access and damage to systems, including damage due to environmental hazards; and assigning and terminating user IDs. r "CIGNA" is a registered trademark licensed for the use of insurance company subsidiaries of CIGNA Corporation. All products and services are provided by insurance company subsidiaries and not the corporation itself. As used herein, "CIGNA" refers to these subsidiaries, which include the Life Insurance Company of North America, CIGNA Life insurance Company of New York and Connecticut General Life Insurance Company, LM-615961 d APPLICATION FOR GROUP INSURANCE Applicant (Full Legal Name): City of Fort Collins Address: 215 N. Mason St., 2nd Floor City: Fort Collins State: CO Zip Code: 80522 Taxpayer ID No.: 84-6000587 Phone Number: 970.416.2721 FAX Number: The Applicant confirms receipt of a proposal fi•om the Underwriting Company(ies) shown below and accepts the terms and conditions of the proposal and any attachments or modifications made to the proposal. The terms and conditions of the requested plan of insurance may, vary in certain states as required by the laws of those states. Further, it is agreed the insurance applied for will not become effective unless this application is received and approved by the Underwriting Company(ies). Acceptability of the application is determined by the Underwriting Company(ies) and is based on current underwriting rules and requirements. If conflict exists between the proposal and the policy(ies), when issued, the terms of the policy(ies) will govern. REQUESTED INSURANCE REQUESTED EFFECTIVE DATE COVERAGE: Group Term Life 1/l/2010 UNDERWRITING COMPANY: Life Insurance Company of North America COVERAGE: Basic & Voluntary AD&D 1/1/2010 UNDERWRITING COMPANY: Life Insurance Company of North America COVERAGE: Group Long Term Disability 1/1/2010 UNDERWRITING COMPANY: Life Insurance Company of North America If the number of eligible persons who enroll in the proposed insurance plan does not satisfy the participation requirements stated in the proposal, the Underwriting Company(ies) may, at its discretion, cancel the plan of insurance or adjust the rates or plan limits to reflect this difference. Premiums are payable as set forth in the policy(ies). If the Applicant collects premium from Insureds, Applicant will remit premium to the Underwriting Conpany(ies), or its Administrator, within 30 days. If premiums are not paid by the end of the Policy Grace Period coverage will end. Premiums are subject to change according to the terms and conditions set forth in the policy(ies). The Applicant agrees to the following additional terms. 1. For any insurance paid for in part, or wholly, by plan participants, the Applicant will support enrollment activities and allow all eligible persons an opportunity to enroll. 2. No brochures or material referencing the requested insurance will be published without the prior review and written approval of the Underwriting Company(ies). The Applicant assumes full responsibility for any liability resulting from the use of written materials not prepared or approved by the Underwriting Company(ies). 3. The Applicant is the agent of its eligible persons for transactions relating to the requested insurance and will assume full responsibility for and not hold the Underwriting Company(ies) liable for any of the Applicant's wrongful acts or omissions. TL 007141 4. The Applicant will promptly furnish any records or other information necessary to insure the proper administration of the insurance plans to the Underwriting Company(ies). The Applicant further agrees to allow the Underwriting Company(ics) or its Administrator to examine all records that pertain to the insurance plans. Any information furnished or obtained in connection with the administration of the insurance plan is confidential information. It shall not be released to any third party except as permitted by law and authorized by the party to which the information relates. That party will not use this information except in connection with the administration of the insurance plan. 5. If the Employee Retirement Income Security Act of 1974 (ERISA) applies, the Applicant is the Plan Administrator and Named Fiduciary of the employees' welfare benefit plan(s). Except as provided above or by ERISA and regulations thereunder, the Underwriting Company(ies) will provide no services in connection with ERISA compliance. 6. The consideration for the requested insurance is the Underwriting Company(ies)'s acceptance of this application and the Applicant's payment of the required premium when due. Payment of the required premium after delivery of the policy(ies) acts as acceptance of the terms and conditions of the policy(ies). The Applicant represents that the information provided to the Underwriting Company(ies) to determine the terms of the insurance applied for is hue and correct and forms the basis of the requested insurance. IMPORTANT NOTE: Any person who, knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or statement of claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act. ACC NCE.. (a-E V L _ Date: (Signature 4nd T itle of Applicant's Authorized Representative) (City and State) TL-007141 CIfGNA Group Insurance Life • Accident - Disability ERISA COVERAGE WORKSHEET Use this worksheet to determine whether a policy is issued in conjunction with ERISA. Where a policy is issued in conjunction with ERISA, the following will apply: I. The insurance company will serve as the employer's named fiduciary for handling claims in accordance with ERISA regulations. The "Appointment of Claim Fiduciary" is required. 2. Certificates of insurance will be prepared with ERISA Summary Plan Description wording included. 3. Information will be provided for the ERISA Annual Report, Form 5500, Schedule A. 4. Claim -related correspondence will comply with ERISA requirements, including notification of rights granted by ERISA regulations. Name of Policyholder: Citv of Fort Collins PffectivP i)atf-'- Life Policy Nos : FLX 963106 1/I/2010 Accident Policy No(s): OK 964764 1/1/2010 Disability Policy No(s): LK 962251, SHD 961710 1/1/2010 In general, any group insurance policy issued to an employer to insure employees, or to a labor union to insure union members, is subject to ERiSA. All policies will be considered to be subject to ERISA unless one of the following exemptions applies. ❑ The policy is not issued to insure employees of an employer, or members of a labor union. ❑ The policy is a statutory disability policy (e.g. Hawaii, New Jersey, New York). ,wi The policyholder is a government employer (e.g. state, county, city, special services district, public school district, public hospital, state college or university). ❑ The policyholder is a church group (religious organization, or hospital, school, or college operated by a religious organization) which has not made an election under IRC Section 410(d) to be subject to ERISA. ❑ The plan is a short-term, uninsured salary continuance plan funded with general assets of the employer. ❑ The plan is voluntary, funded entirely with employee contributions, and is not enrolled or endorsed by the employer; employer participation is limited to permitting the insurance company to conduct enrollments, and handling payroll deductions. ❑ None of the above exemptions apply. The policy is issued as part of an ERiSA-covered employee benefit plan. If this is the case, then the Policyholder should sign the next page, "Appointment of Claim Fiduciary," instead of this page. Implementation Coordinator TL-007141 } �.. Policyholder Representative CIGNA Group [(t.SF.tr�ttlE.: Life - AcOderit • Disobi i ity LIMITED AGENCY AGREEMENT (Includes Employer FICA Services) IMPORTANT: This is a Limited Agency Agreement which, under Internal Revenue Service regulations, permits an insurance company or other payor of taxable sick pay to make deposits of the employer portion of FICA taxes using the payor's employer identification number (EIN). In accordance with IRS regulations, the insurance company cannot make payments of employer taxes unless and until the Limited Agency Agreement is in effect. The insurance company cannot begin to make deposits of employment taxes on behalf of the employer until this agreement is signed and returned. Until the agreement is in place, the employer is solely responsible for timely filing all employment taxes. -1- Copyright © 2003 - 2008, Life Insurance Company of North America, a CIGNA company LIMITED AGENCY AGREEMENT (Includes Employer FICA Services) Among: LINA Benefit Payments, Inc. ("Payment Agent"); And: Life Insurance Company of North America CIGNA Life Insurance Company of New York (collectively, "Company") And: City of Fort Collins ("Employer") Policies: LK 962251 Effective Date: l/t/2010 WHEREAS, Employer and Company have entered into one or more group disability insurance policies ("Policies") or Administrative Services Agreements ("ASO Agreements") under which Company, as Employer's agent, makes payments of taxable Sick Pay ("Sick Pay") to certain disabled employees of Employer; and WHEREAS, such Sick Pay payments are or may be subject to the provisions of various regulations adopted by the U.S. Internal Revenue Service, relating to the withholding and payment of employment taxes, collection of income tax at the source, and reporting of payments and withheld taxes; and WHEREAS, such regulations permit Employer and Payment Agent to enter into a Limited Agency Agreement under which Payment Agent will perform, as Employer's agent, certain specified services relating to the withholding and payment of employment taxes, collection of income tax at the source, and reporting of payments and withheld taxes; and WHEREAS, Payment Agent is agreeable to performance of certain of such functions under this Agreement, NOW, THEREFORE, in consideration of the mutual promises contained herein and in consideration of the issuance and continuance of the Policies and/or ASO Agreements, Payment Agent and Employer agree as follows, with respect to the Policies and/or ASO Agreements identified above: I. TERM OF AGREEMENT; TERMINATION 1.) This Agreement shall be effective as of the later of the Effective Date shown above, and the date of approval granted by the Internal Revenue Code with respect to a properly completed Form 2678 relating to the services to be performed herein. This Agreement shall commence with respect to calendar years beginning on or after such effective date. This Agreement may be terminated at any time by either party, upon 30 days' written notice to the other. Payment Agent may immediately terminate this Agreement on written notice to Employer, if Employer fails to make any payment required hereunder. Payment Agent shall continue to be responsible for the preparation of Forms W-2 for calendar years ending while this Agreement is in force, but not thereafter. -2- Copyright © 2003 - 2008, Life Insurance Company of North America, a CIGNA company 1I. DUTIFS OF PAYMENT AGENT 1.) Payment Agent agrees to act as agent for the Employer, as well as any employers whose employees have coverage under the Plan, for the following purposes: Preparation and filing of Form W-2, covering only Sick Pay paid by Company to payees under the Plan. Withholding of federal income taxes, at the rate applicable to payments of supplemental wages, with respect to the taxable portion of Sick Pay. Withholding of the employee portion of FICA taxes, with respect to the taxable portion of Sick Pay. Payment of the Employer's portion of FICA taxes, with respect to the taxable portion of Sick Pay. The Employer, or employers covered by the Plan, shall retain the sole and exclusive responsibility for all other duties required by any federal, state or local laws. 2.) Payment Agent shall: a. Deposit all withheld taxes with the appropriate federal depository on the due date thereof in accordance with the procedures under Section 6302 of the Code and the regulations thereunder, as now in effect or hereafter amended. b. Include such amounts so deposited in its Employer's Quarterly Federal Tax Return, Form 941. c. Prepare and file the annual Wage and Tax Statement, Form W-2 (and submit on magnetic tape), and mail each Employee with a copy of Form W-2 on or before January 31 of the year following the year in which the Sick Pay was paid. d. Prepare the required Federal Electronic filing and all appropriate state units of government or revenue authorities, and prepare and transmit any other forms or documents customarily prepared and transmitted in conjunction with such filing. 3.) Payment Agent shall use its own Employer Identification Number when making payments or filing reports or returns hereunder. 4.) Payment Agent agrees to make suitable arrangements for resolution of any questions raised by payees who receive Forms W 2 prepared by Payment Agent and, where appropriate, to issue revised Forms W-2. 5.) Payment Agent assumes no responsibility for the accuracy or inaccuracy of the information furnished to it by the Employer or any information which Payment Agent may include in any reports or filings which it prepares for Employer in reliance on such information. Employer shall indemnify and hold harmless Payment Agent from any and all liabilities imposed upon Payment Agent in the event such information furnished by the Employer proves to be incorrect. 6.) Payment Agent assumes no responsibility for any other duties, actions or requirements imposed upon the Employer or upon any employers whose employees have coverage under the Plan, under any other provision of local, state or federal tax law. -3- Copyright © 2003 - 2008, Life Insurance Company of North America, a CIGNA company III. DUTIES OF EMPLOYER 1.) Employer represents that the information contained in Schedule I hereof is true and correct. 2.) Employer shall notify Payment Agent of the portion of the disability payments made by Company which are excludable from gross income of payees at least sixty days before the beginning of the calendar year for which such portion is effective. Changes in such portion cannot be made at any other time. 3.) Employer agrees to provide Payment Agent on a timely basis with such information and documents as Payment Agent may reasonably need to discharge any functions which it assumes under this Agreement. 4.) With respect to any payments of Sick Pay made pursuant to ASO Agreements, Payment Agent shall withhold income taxes at the rate applicable to supplemental wages. Notwithstanding the foregoing, Employer may elect to determine the dollar amount of any income taxes to be withheld by Payment Agent and advising Payment Agent of such amounts. Where Employer elects to do so, Employer represents and warrants that it will correctly calculate the amount to be withheld, based on applicable federal withholding regulations, and based on net benefit amounts determined by Company to be payable. 5.) Unless the terms of the Policies provide that the Company waives its right to transfer liability with respect to the employer taxes imposed by IRS Regulation 32.1(e)(1), Employer shall provide Payment Agent with sufficient funds for the payment of Employer's portion of FICA taxes. Payment Agent may require a deposit of up to three months of estimated Employer FICA taxes and may create one or more bank accounts in which such funds shall be held. Payment Agent may draw upon such funds to reimburse itself for any Employer FICA taxes paid on Employer's behalf. Payment Agent shall not be required to pay Employer FICA taxes except from funds provided by Employer for this purpose. 6.) Payment Agent reserves the right to impose a charge for its services hereunder. Such charge may be set by Payment Agent with at least 30 days' written notice thereof prior to the start of any calendar year while this Agreement is in force, and shall, unless subsequently changed, be applicable to all calendar years thereafter. Copyright © 2003 - 2008, Life Insurance Company of North America, a CIGNA company