HomeMy WebLinkAboutCORRESPONDENCE - RFP - 7049 EMPLOYEE ASSISTANCE PROGRAMCARRIER/POLICY #:
Client / Legal name
CONFIRMATION OF COVERAGE: 2011 - EAP
ERISA Plan name:
Eligible employees:
Client / Insured Address:
MHN
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This document will confirm placement of the following coverage(s).
Employee Assistance Program
Coverage will be effective on: 1/1/2011
For a period of: Rate guarantee until 12/31/2014
Rates / fees (including any subsequent period caps or guarantees) for the above -referenced
coverage(s) are:
Rate PEPIIII: $2.36
City of Fort Collins
City of Fort Collins
1,400
215 North Mason Street, 2nd Floor
Fort Collins, CO 80522
As an authorized representative, I accept this confirmation of coverage. By signing below, I
acknowledge agreement with the rates an'd benefits described above and that subsequent
contract(s) shall conform to this document unless otherwise agreed to in writing.
Authorized Representative: 5-�me/J0
Legal Name of Insurer/
Administrator �L
Signature:
Date: 7/3 /,0
This form must be signed and returned to Mercer H&B prior to the effective date of coverage.
MERCER
MARSN M[RCER KROLL
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