HomeMy WebLinkAboutCORRESPONDENCE - RFP - P1129 FLEXIBLE SPENDING ACCOUNT ADMINISTRATOR�►1q
CONFIRMATION OF COVERAGE: 2011 Renewal - FSA
CARRIER/POLICY #:
Client / Legal name:
ERISA Plan name:
Eligible employees:
Client / Insured Address
ASI Flex
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):
� Flexible Spending Account Administration
Coverage will be effective on: 1/1/2011
For a period of: Rate guarantee until 12/31/2012
Rates / fees (including any subsequent period caps or guarantees) for the above -referenced
coverage(s) are:
Rate PEPM: $3.25
As an authorized representative, I accept this confirmation of coverage. By signing below,
acknowledge agreement with the rates and benefits described above and that subsequent
contract(s) shall conform to this document unless TIJ
rwise agreed to in writing.
Authorized Representative:
Legal Name of Insurer/
Administrator r oh
Signature:
Date: all L tl
This form must be signed and returned to Mercer H&6 pf to Yhe effective date of coverage.
MERCER
MARSH MERCER KROLL
'wK GUY CARPENTER OUVER W ~