HomeMy WebLinkAboutCORRESPONDENCE - RFP - 7055 BENEFITS - VISIONCONFIRMATION OF COVERAGE: 2011. Renewal -Vision
CARRIER/POLICY #:
Client / Legal name:
ERISA Plan name:
Eligible employees:
Client / Insured Address:
VSP
City of Fort Collins
City of Fort Collins
1,400
215 North Mason Street, 2nd Floor
Fort Collins, CO 80522
This document will confirm placement of the following coverage(s): '
4 Vision
Coverage will be effective on: 1/1/2011
Fora period of: Rate guarantee -until 12/31/2012
Rates / fees (including any subsequent period caps or guarantees) for the above -referenced
coverage(s) are:
Fully Insured Rates
Employee Only
Employee plus Spouse
Employee plus Children)
Employee plus Family
Net of Commissions
$6.70
$13.41
` $13.41
$21.47
MERCER
MARSH MlRCRR KROLL
ONYCARKKIIR OUVFR WYMAN
Description of Benefits:
Plan Information
Exam Every: Every 12 Months
Lenses Every: Every 12 Months
Frame Every: Every 24 Months
Copayment
Exam $15.00
Materials $15.00
In Network Allowances
Retail Frame Value: $105.00
Elective Contact Lenses $105.00
Out of Network
Examination, up to: $30.00
Single Vision Lenses, up to: $30.00
Bifocal Leases, up to: $40.00
Trifocal Lenses, up to: $50.00
Frame, up to: $30.00
Elective Contact Lenses, up to: $80.00
1) Includes covering dependents to age 26
2) includes covering domestic partners
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: Devin Farrell
Legal Name of Insurer/
Administrator VSP .
Signature: g�..
Date: DecembOr 2, 2010
This form must be signed and returned to Mercer H&B prior to the effective date of coverage.
MERCER
MARSH MCRCRR KROLL
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