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HomeMy WebLinkAboutCORRESPONDENCE - RFP - P985 BENEFITS (2)Application for Stop Loss Coverage Connecticut General Life Insurance Company �® Mailing Address: Attn: Stop Loss Unit - B2STL 900 Cottage Grove Rd. Hartford, CT 06152 CIGNA The Applicant, whose representative has signed below, hereby applies to Connecticut General Life Insurance Company ("CG") for a stop loss insurance policy(ies) providing the insurance coverage as described below in connection with its self -funded health benefit plan. 1. NAME OF APPLICANT: City of Fort Collins ADDRESS: PO Box 580 Fort Collins CO 80522 2. AFFILIATED COMPANIES TO BE COVERED: Name Address (City and State) Affiliated companies must be part of a common control group as described in Internal Revenue Code §414(c) and the regulations thereunder. Generally, this means that in a parent -subsidiary relationship, the parent must own 80% or more of the subsidiary. In a brother -sister relationship, the same five or fewer people must own at least 80% or more of each company and when considering the smallest percentage interest each person has among the companies, the sum of the smallest interests must exceed 50%. The purpose of this rule is to prevent covering a multiple employer welfare arrangement (MEWA). Any MEWA that wishes to be covered must provide evidence that state law in each jurisdiction in which it has persons to be covered allows the MEWA to operate on a self -insured basis. 3. NUMBER OF EMPLOYEES AT ALL LOCATIONS LISTED ABOVE: 1405 INDUSTRY: 4. NAME OF CLAIM ADMINISTRATOR: Connecticut General Life Insurance Company ADDRESS: 5. PROPOSED EFFECTIVE DATE: 01/01/2011 6. ® INDIVIDUAL STOP LOSS COVERAGE Benefits covered by Individual Stop Loss Coverage: ® Medical ® Mental Health/Substance Abuse ❑ Pharmacy ❑ Other: PRODUCT FEATURES FOR INDIVIDUAL STOP LOSS COVERAGE: ❑ Tiered Pooling: High Pooling Point $ Low Pooling Point $ CG Liability Split % Applies to: ❑ All Claimants ❑ First Claimants ❑ Renewal Planner ❑ Renewal Advantage ❑ Bridge: ❑ ASO to ASO Bridge ❑ ASO to Shared Returns Bridge ❑ Other: CSL-APP CO (04/09) Page 1 of 3 INDIVIDUAL STOP LOSS LIMIT: $ 215,000.00 High Risk Individuals: ® N/A ❑ Yes, individual(s) will be treated as follows: ❑ A separate Individual Stop Loss Limit Applies: $ ❑ Other: MAXIMUM LIFETIME REIMBURSEMENT LIABILITY FOR INDIVIDUAL STOP LOSS: will be the individual lifetime maximum as set forth in the Benefit Plan less the Individual Stop Loss Limit or will be $ BENEFIT PERCENTAGE PAYABLE: 100% BENEFIT ELIGIBILITY BASIS: Initial Policy Period: 01/01/2011 to 12/31/2011 Unless additional options are selected below, claims must be both incurred and paid during the policy period. ❑ Incurred in months and paid in months ® Paid in 12 months (available only for previously CG administered customers) Run-in Provision: Claims incurred prior to the policy's effective date and paid during the policy period. © N/A ❑ months ❑ Run-in claims are limited to: $ [per individual] Run -out Provision: Claims incurred during the policy period and paid after termination of the policy. ® N/A ❑ months ❑ OTHER REQUESTED PROVISIONS: ESTIMATED MONTHLY INDIVIDUAL PREMIUM RATES: $ 71.47 Actual Rates will be contained in the Stop Loss Policy, if and when issued. 7. ❑ AGGREGATE STOP LOSS COVERAGE Benefits covered by Aggregate Stop Loss Coverage: ❑ Medical ❑ Mental Health/Substance Abuse ❑ Pharmacy ❑ Dental ❑ Vision ❑ Other: PRODUCT FEATURES FOR AGGREGATE STOP LOSS COVERAGE: ❑ Annual Reconciliation ❑ Other: EXPECTED MONTHLY ATTACHMENT FACTOR PER COVERED EMPLOYEE: $ ADDITIONAL MONTHLY ATTACHMENT FACTORS BY PRODUCT: MINIMUM ATTACHMENT POINT: (Applies to Annual Reconciliation only): $ (Minimum Attachment Point will be restated based on 1st month of enrollment if 1st month of enrollment is greater than projected enrollment.) MINIMUM ATTACHMENT PERCENTAGE: % MAXIMUM REIMBURSEMENT LIABILITY FOR AGGREGATE STOP LOSS: will be $ for the Policy Year BENEFIT PERCENTAGE PAYABLE: % CSL-APP CO (04/09) Page 2 of 3 BENEFIT ELIGIBILITY BASIS: Initial Policy Period: to Unless additional options are selected below, claims must be both incurred and paid during the policy period. ❑ Paid in 12 months (available only for previously CG administered customers) Run-in Provision: Claims incurred prior to the policy's effective date and paid during the policy period. ❑ N/A ❑ months ❑ Run-in claims are limited to: $ Run -out Provision: Claims incurred during the policy period and paid after termination of the policy. ❑ N/A ❑ months ❑ OTHER REQUESTED PROVISIONS: ESTIMATED MONTHLY AGGREGATE PREMIUM RATES: $ * Actual Rates will be contained in the Stop Loss Policy, if and when issued. 8. A DEPOSIT OF $ 0.00 IS ENCLOSED 9. The Applicant agrees that: a. The Applicant has read the entire Application and certifies that the underwriting information presented to CG, whether provided by the Applicant or any person acting on behalf of or at the direction of the Applicant, voluntarily or in response to CG's request, is complete and accurate. Such underwriting information, if any, is considered to be part of this Application. b. Any policy issued based on this Application, together with any of its Schedule of Insurance, amendments or riders, shall control the stop loss insurance coverage and terms and conditions of such insurance. In the event of a conflict between the Application and terms of the Policy, the Policy shall prevail. c. No person, other than a duly authorized officer of CG or its delegate has authority to accept and approve this Application, or otherwise alter any policy provisions or waive any of CG's rights or requirements. FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. DATED AT APPLICANT City of Fort Collins THIS DAY OF P`tiAVZ 20/1 BY TITLE_ (A plicant's designated individual's signature t— THIS APPLICATION IS REQUIRED /N ADDITION TO THE STANDARD GROUP APPLICATION. ONCE COMPLETED AND SIGNED, MAIL TO THE STOP LOSS CONTRACTING UNIT. Mailing Address: Connecticut General Life Insurance Company Attn: Stop Loss Unit - B2s,rL 900 Cottage Grove Rd. Hartford, CT 06152 CSL-APP CO (04/09) Page 3 of 3