The URL can be used to link to this page

Home My WebLink About494473 RELIASTAR LIFE INSURANCE COMPANY - CONTRACT - RFP - 7241 BENEFITS - MEDICALRELIASTAR LIFE INSURANCE COMPANY Houle Office, Mill ncapol is, Minnesota 55440 EXCESS RISK APPLICATION The Plan Sponsor hereby applies for the Excess Risk Insurance coverage as now in effect or later modified Name of Plan Sponsor (exact legal name) City of Port Collins Address (number and street, city, state, zip code) 215 Notch Mason Street, 2`" floor, Fort Collins, CO 80522 ❑ Corporation ❑ Partnership ❑ Sole Proprietorship ® Other (specify) h4unicipality Nature of Plan Sponsor"s Business: General Govei nn)ent SIC Code: 9190 ® No ❑ Yes (If "Yes," give names.) ' Number of Eligible Individuals: L'n)pinyoo Only Covemgc: 469 Lnlployees with Dcpendcnt Coverage: 924 ------ Number of Enrolled Individuals: ISnlployce Only Coverage: Gnlployces with Dependent Coverage: Number of Individuals Covered F.Isewbere: I?nlployce Only Coverage: linlployces with Dcpendcnt Covcntgc: Claim Administrator for coverages checked below for the Employee Benefit Plan: Name of Claim Administrator°(exact legal name of entity) UMR Address of Claim Administrator(number and street. city, state. rip code) I Swtt Street, Suite 100. Wausuu, WI 54409 "Claim -Administrator must be approved by lieli1Slar Lilo prior to acceptance of this Appticalion AGGREGATE EXCESS RISK ❑ YES ® NO BENErrrS To BE COVL'I2E�: ❑ Medical ❑ Vision ❑ Weekly Disability Income ❑ Dental INITIAL CONTRACT BASIS, ❑ Incurred and paid in 12 months ❑ Incurred in IS months and paid in 12 months ❑ Paid in 12 months Actively at Work requirement ❑ Waive ❑ Prescription Drugs ❑ Other (specify) _ ❑ Incurred in 12 months and paid in 15 months ❑ Incurred in months and paid in months ❑ Other: ❑ Do not Waive Deductible Adjustment Factor: Minimum Aggregate Deductible: See Excess Risk Schedule/Curiont Premium Rate Notification ReliaStar Life's Limit of Liability: $` per cone act period Optional: ❑ Terminal Liability RL-SL-APP-08-00 (5/08) INDIVIDUAL EXCESS RISK ® YES ❑ NO BENEFITS TO BE COVERED- ® Medical ® Other (please specify) prescription drugs INITIAL CONTRACT BASIS: ❑ Incurred and paid in 12 months ❑ Incurred in 15 months and paid in 12 months ❑ Paid in 12 months Actively at Work requirement ® Waive Individual Deductible: Individual Deductible: $215.000 per Individual True Family Deductible: $N/A per family ❑ Incurred in 12 months and paid in 15 months ® Incurred in 24 months and paid in 12 months ❑ Other: ❑ Do not Waive Lascred Individuals as identified in the disclosure process: N/A Claims for Lascred Individuals are excluded under Aggregate Excess Risk Insurance, if any. Aggregating Individual Deductible: $N/A (individual Excess Risk must be elected) Benefit Percentage: 100% RcliaStar Life's: Maximum Individual Contract Period Benefit: $Unlimited Maximum Individual Lifetime Benefit $Unlimited Optional: ❑ Terminal Liability ❑ Immediate Reimbursement Are retirees covered? ® Yes ❑ No Are retirees age 65 and over covered? ® Yes ❑ No If so, is Medicare Primary? ® Yes ❑ No Attached to and incorporated in this Application is a copy of the Employee Benefit Plan currently in effect for the provision of benefits by the Plan Sponsor to its eligible employees or members. The initial Contract Period is from 1/1/2012 to 12/31/2012. The Producer/Agent of Record (provided he/she is duly licensed as required by law) is: Merecr. This insurance is to be effective on 1/1/2012 at 12:01 a.m. Standard Time at the Plan Sponsor's place of business, provided that the first premium is paid in full and that the Claim Disclosure Statement and this Application are accepted by RcliaStar Life. An advance deposit of $74 309 is attached. (The deposit is to equal the first premium.) The deposit will be applied toward payment of the premiums on the insurance requested if the application is accepted by RcliaStar I-ife. If not accepted, the deposit will be refunded to the Plan Sponsor Applicant. It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Witness Date RL-SI, APP-08-CO PLAN SPONSOR APPLICANT Ci_ ty of For Collins 13y`J . 5s 6 OrNe�t.t. Tr Name of signer (pleayript) nGo�e—�a'L.a Idle �'SS4et^-vh b (5/08) ING Employee Benefits Group Disclosure Agreement' Plan Sponsor: City of Fort Collins 1 N G " Policy Effective Date: 1/1/2012 EMPLOYEE BENEFITS For valuable consideration exchanged by and between the parties, this Agreement is entered into between ING Employee Benefits, a division of ReliaStar Life Insurance Company, and the Plan Sponsor identified above. ING Employee Benefits, a division of ReliaStar Life Insurance Company relies on its representatives to properly advise the Plan Sponsor on the importance of complete information Disclosure. As an underwriting consideration material to the acceptance of the Stop Loss Risk by ING Employee Benefits, the Claim Administrator, Utilization Review Firm(s), Case Management and Pharmacy Benefits Manager are required to review all records, includingbut not limited to pre -certifications, case management notes, claim files, and pharmacy benefit management files and notes prior to disclosing the following required information for both the current policy year and each year thereafter during which ING Employee Benefits provides Stop Loss coverage to Plan Sponsor. Plan Sponsor shall attach the following reports or data (include claimant name primary ICD 9 / diagnosis) ( hereinafter referred to as the Disclosure Reports-): Any individual with paid claims that has exceeded 50% of the stop loss deductible during the applicable current policy year (minimum 9 months): Any individual with denied and/or pended claims that has exceeded $25,000 during the applicable current policy year (minimum of 9 months): Any individual evaluated and/or listed for an organ, stem cell or bone marrow transplant: Any individual diagnosed with a condition, during the applicable current policy year, represented by any of the ICD-9 codes contained in the attached list including claim amounts, as well as any individual who is in case management during the applicable current policy year (minimum of 9 months): The Disclosure Reports must be provided to ING Employee Benefits within 75 calendar days prior to the Stop Loss Policy effective date or renewal date, as applicable. In the event the Disclosure Reports are not returned to and approved by ING Employee Benefits within 45 days following the effective date or renewal date of coverage, ING Employee Benefits shall retain the right to deny any claim, adjust the rates or its underwriting terms, or rescind the Plan Sponsor's stop loss coverage at any time, and such right shall not be impaired as a result of ING Employee Benefits' acceptance of premium in the absence of any such Disclosure Reports. The Disclosure Reports must be compiled within 30 calendar days of the date of completion by the Plan Sponsor. Should ING Employee Benefits require any additional information in order to approve the Disclosure Reports, ING Employee Benefits will notify the Plan Sponsor and/or its designated representative in wrifing no later than 20 calendar days following receipt of the Disclosure Reports . In the event the Plan Sponsor fails to disclose a known potential catastrophic claim in the Disclosure Reports, expenses related to the potential catastrophic claim will not be considered eligible excess risk expenses under the Stop Loss Policy. The Plan Sponsor acknowledges and agrees that its complete and accurate disclosure of known potential catastrophic claims is a condition precedent to obtaining stop loss coverage, that the Plan Sponsor has read, understands, and agrees to the terms and conditions contained in this Agreement, and represents that the individual signing this Agreement on behalf of the Plan Sponsor is authorized to do so. The Plan Sponsor represents and warrants that as of the date of signing there are no known potential catastrophic claims other than those disclosed on the Disclosure Reports. A third party executing this Agreement and or any of the Disclosure Reports on behalf of the Plan Sponsor represents and warrants that it has the authority to legally bind the Plan Sponsor. The Plan S sor verifies, to the best of its knowledge, that the information now and hereafter provided is and shall be accurate and complete Plan Spon or cr e f;2��fa2ce ��2CHsFbi�c�,r �Z$c/ti G i ci�� e. lCD-9 Codes for Disclosure Notification Please list all Plan Participants who have been diagnosed with or treated for any of the codes listed under the following categories during the current Benefit Period: Neoplasms 140-239 Neoplasms Endocrine. Nutritional Metabolic immunity 277.0 Cystic Fibrosis Diseases of the Blood and Blood-Formin Organs 284.9 Aplastic Anemia NOS 286.286.9 Coagulation Defects and/or Hemophilia Diseases of the Nervous System and Sense organs 344.0-344.090uadriplegia and Quadriparesis 344.1 Paraplegia 348.0-348.9 Encephalopathy Diseases of the Circulatory System 410-410.9 Acute Myocardial infarction 411-411.89 Acute and Subacute Ischemic Heart Disease 414-414.05 Coronary Atherosclerosis (ASHD) 415-415.19 Acute Pulmonary Heart Disease 416-416.9 Chronic Pulmonary Heart Disease 417.1 Aneurysm of Pulmonary Artery 421-421.9 Acute and Subacute Endocarditis 424-424.9 Valve Disorders 425-425.9 Cardiomyopathy 427-427.9 Cardiac Dysrhythmias 428-428.9 Heart Failure 430,431 Subarachnoid / Intracerebral Hemorrhage 434.9 Occlusion of Cerebral Arteries 436 Acute Cerebrovascular Accident (CVA) 440-441.9 Atherosclerosis/Aortic Aneurysm Diseases of the Respiratory System 480-486 Pneumonia 490-496 Chronic Obstructive Pulmonary Disease (COPD), etc. 515 Postinflammatory Pulmonary Fibrosis 518-518.89 Pulmonary Collapse and/or Respiratory Failure Diseases of the Digestive System 555-555.9 Regional Enteritis (Crohn's Disease) 560.0-560.9 Intestinal Obstruction 5621 Diverticulitis of Colon 567-567.9 Peritonitis 569.0.569.9 Other Disorders of Intestine 570-571.9 Liver Diseases and Cirrhosis 572.8 Other Sequela of Chronic Liver Disease 573-573.9 Other Liver Disorders 577-577.9 Pancreas Diseases 578578.9 Gastrointestinal Hemorrhage Diseases of the GenitourinM System 584-584.9 Acute Renal Failure 585 Chronic Renal Failure 586 Renal Failure, Unspecified Complications of Pregnancy, Childbirth 651 Multiple Gestation Diseases of the Musculoskeletal S stem and Connective Tissue 730-730.9 Osteomyelitis and/or Periostitis Congenital Anomalies 747.2 Aortic Atresia / Stenosis 751.6 Biliary Atresia 759-759.9 Other and Unspecified Congenital Anomalies Conditions Originating in the Perinata! Period 765-765.1 Prematurity 769 Respiratory Distress Syndrome 770.0.770.9 Other Respiratory Conditions of Newborn injury and Poisoning 800-804.9 Fracture of Skull 805-805.9 Fracture of Vertebral Column 806-806.9 Fracture of Vertebral Column with Spinal Cord injury 828-828.1 Multiple Fractures 853-854.1 Intracraniai Injury 869-869.1 Internal injury 887-887.7 Traumatic Amputation of Arm and Hand 897-897.7 Traumatic Amputation of Leg 949-949.5 Burns 952-952.9 Spinal Cord Injury Complications peculiar to certain specified conditions V23 Supervision of Nigh Risk Pregnancy V42 - V58.9 Transplants, etc Important Information About Your Employee Benefits Insurance Thank you for considering ReliaStar Life Insurance Company (the "Company") for your employee benefits insurance needs. We offer various Employee Benefits insurance products that have different features, benefits and costs. We are confident that, working with your professional insurance agent, broker, or consultant you will find that one of our products is right for you. Your agent, broker, or consultant may work with many employee benefits insurance companies, and we are pleased that they are presenting one of our products to you. If you decide to purchase, or offer to your employees or members, a policy from us we would like you to understand how we will pay the selling agent, broker, or consultant. he ra_ P There are�g generally three ty a of paym is that maybe ade to agents, brokersa d consultants: �- ✓-? /�^-L'S `fT�/19�?-.'^-''C�-O`'F-'H"� J/Li..n-� / ,tPy�..ysy uz.- --uJ' 1. Co sions: Agents, brokers, or consultants may earn a commission for each Company policy so The commission is generally a percentage of the policy premiums paid. The percentage y be higher for agents, brokers, or consultants that sell a larger number of Company polici . The actual percentage and amount of commission paid will vary based on the specific circumstances of the product(s) purc ased. ' . //- 0n,,�/'JJ / -�-° /t^s, brokers, o cad "" naJ1m Tab �i'� 4 Ge 2. Bonuses: Agents, brokers, or consultants ay receive additional dimPensation bA don a perce age of policy premiums paid for each year a policy remains in force and as rewards for thing ice achieving certain sales volume levels, sales contest objectives, or other measures. a also may pay for agent, broker, or consultant education, training or attendance at conventions, and may pay bonuses, provide advance commissions and/or loans with an expectation that the advancement and/or loans be repaid as new policies are issued, reimburse expenses or provide other payments or benefits. 3. Adminis tive/Service Fes: Agents, brokers, or consultants may provide administrative services an arketing support for a flat fee, a percentage of policy premiums paid, or, a fee e based on the ount of commissions earned from the initial sale. The agents, brokers or consultants ma be associated with other brokers or consultants that may provide administrative services and marketing support for similar fees. This is a general discussion of the compensation we pay for the sale of our policies. We pay commissions and other sales expenses from our general assets and revenues, including amounts we earn from fees and charges under our policies. The price of an insurance policy is set by the Company, and reflects the compensation we pay for the sale of our policies.- It also covers other costs to design, manufacture and service our policies, fees associated with the cost of any applicable guarantees, the investment management needed to build cash values and pay benefits, and our profits. We are committed to providing top-quality insurance products to our customers and are pleased that your professional insurance agent, broker, or consultant trusts us to deliver on your long term insurance needs. Product Name(s) IER - Individual Excess Risk - spec only Account Name City of Fort Collins Group Applicant/Sponsoring Organization Signature Group Applicant/Sponsoring Organization Printed Name Title r4(4f_CAD2 (�r'`vy✓ZC'i1�S7�y-�_ -T' kk`l(. Date `j / / (o Revised: 06/07 Page I of 1 David Carey From: Amy Sharkey Sent: Friday, September 16, 2011 9:46 AM To: Jim O'Neill; Steve Mason Cc: David Carey Subject: ING - 2012 Stop Loss Carrier Importance: High Attachments: ING Master Application 091311.doc; Rate Proposal - Final-UMR 091311.pdf; ING Disclosure Form 091311.doc; Broker Compensation Disclosure Form 091311.doc; image001.png We were able toter eta 2% reducl nrlia-aitministrative fees so new contract information is attached for Fe—v ew and signature. -- I have reviewed all documents and so has Mercer. Jim, 3 documents will need your signature. Please return those to me for submittal. Need soon as we have a deadline date with ING in order to secure the rates without submitting new claims information. Information from Mercer below about the documents. Please let me know if you have questions. Thanks, Amy ............................................................................... Master Application After reviewing the large claim detail that we sent them ING is willing to take 2% off of their initial quoted rates. I've attached a new master application with the updated first month's deposit. This document needs to be signed in order to secure coverage with ING. I am also including a finalized proposal (City of Fort Collins Proposal - Final-UMR.pdf) showing the final rates of $26.58 for single coverage and $66.93 for family coverage (2% below their initial rates). This proposal is for your records only and doesn't require signature. Disclosure Form (everything listed in the "box" has already been sent to ING — no further action required there as long as we get this signed within 30 days) Compensation Disclosure ING requires that all of their customers receive this information regardless of how the broker involved is being compensated. In this case, since Mercer is not receiving any additional compensation from ING, Todd Tyson confirmed that you could write in a comment to that effect before signing and returning. We weren't able to convince ING to alter the wording in that document since its one of their standard legal forms. JIM - you can write on the form, "The City's Benefits Consultant, currently Mercer, is not to receive commissions, bonuses, or administrative fees now or in the future on behalf of City of Fort Collins" Ci of Amy Sharkey, CCP, CBP, GRP Fort Collins 9 0-416-2721 Benefits, and HRIS Manager Nyman . R�Aa'(44 9/16/20I I