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Home My WebLink AboutContract CAG-18-264 � ` �'� FOR OFFICE USE ONLY F �tract Type: New ❑12000 ❑11000(Rl only} S Y M E T R A ^ o�d ❑8800 c��st> ❑8900(Non-trust) RETIREMENT I BENEFITS I L�FE �I�A, �� . .. .. . ..... .. ..._.. .. . .. .... � r t _ . . . .... m SIC Code:9199 FEIN: 777 108 Avenue NE, Suite 1200 - Bellevue, Washington 98004-5135 ❑Revision ❑Correetion Eff. Date: 1-800-SYMETRA/(425)256-8000 PRELIMINARY EXCESS LOSS INSURANCE APPLICATION A. Applicant Legal Name of Applicant: City of Renton Business Address: 1055 South Grady Way Renton WA 98057 Street City State Zip Applicant is a: ❑Sole Proprietor ❑Partnership ❑Corporation ❑ Union �Other: governmental Applicant Mailing Address (if different than Business Address): Street City State Zip Business ContaCt: Wendy Rittereiser Title: HR Benefits Manager Phone: 425-430-7659 Fax: E-Mail: WRittereiser@rentonwa.gov Premiums Paid by: HMA Will there be multiple premium payments each month? ❑Yes �No (If yes, for each payment,a detailed allocation statement is required) Are premium statements needed?� No ❑Paper ❑Electronic/Portal: Associated Companies (List if Associated Companies are to be covered. Attach a separate sheet if necessary.) Legal Name #of employees Effective Date Termination Date B. Effective Date of Coverage: 01-01-2019 Policy Period: from 01-01-2019 to 12-31-2019 (No insurance is effective unless and until approved) Enrollment at the beginning of the Policy Period: Single 257 Family 369 Retirees covered under Stop Loss? Yes, Individual only AND under age 65 C. Claims Administrator(TPA/ASO/PBM) 1. Name: HMA Number: 2. Contact Name: Cole Harrison Street Address: 220 120th Avenue NE City: Bellevue State: WA Zip: 98005 Phone: 425-289-5236 Fax: Email: cole.harrison@accesstpa.com Symetra�is a registered service mark of Symetra Life Insurance Company. LG 1320 09l18 1 of 4 � .� � � D. Individual Excess Loss Insurance � Yes � No 1. Individual Deductible: , f $250,000 per Covered Unit (separate deductibl�applies for the employee and each covered dependent) $ per Covered Family Unit (one detiuCtit�le for the emp��enc(all covered dependents) k�• 2. Excess Loss Alternate Reimbursement Endorsement applicable? ❑ Yes m No 3. Eligible Covered Expenses (define by plan, if applicable) ❑ Medical excluding all Prescription Drugs � Medical including Prescription Drugs defined as the following: �Rx Card and Mail Order ❑ Rx Card ❑ Rx Mail Order ❑Rx as part of Medical Plan subject to a Deductible and Coinsurance ❑Other Rx Plan ❑ Other Covered Expenses 4. Symetra's Reimbursement Percentage: (Select one) � a, 100 % of Covered Expenses in excess of the Individual Deductible. ❑ b. % of the first of Covered Expenses in excess of the Individual Deductible; and °/o thereafter. ❑ c. °/o of Covered Expenses in excess of the Individual Deductible that are incurred at the Policyholder medical facility or any affiliated or subsidiary medical facilities of the Policyholder; and % of all other expenses in excess of the Individual Deductible. ❑ d. °/o of Covered Expenses that are incurred at the Policyholder medical facility or any affiliated or subsidiary medical facilities of the Policyholder; and % of all other Covered Expenses will apply toward the Individual Deductible. 5. Individual Lifetime Reimbursement Maximum:Unlimited per Covered Unit Policy Period Reimbursement Maximum: Unlimited per Covered Unit 6. Premium Rates: Covered Units Single $26.44 Family $75.02 7. Reimbursement Option: Covered expenses incurred on or after the Effective Date of Coverage and paid during the Policy Period with: Run-in Period 12 months Run-in Limit $ 0 Run-out Period 0 months Run-out Limit $ N/A Include "Gapless option"wording? ❑Yes mNo 8. Individual excess Loss Terminal Provision: Not applicable If any Lump Sum option selected, policyholder will be paying: 9. Individual Excess Loss Advantage Provision: ❑ Yes � No Individual Advantage Deductible: Individual Advantage Deductible applies toward the Aggregate Attachment Point? �Yes �No 10. Individual Excess Loss Advance Funding Endorsement included: mYes ❑No 11. Individual Excess Loss Transplant Provision? (8800/8900 only) �Yes �No If yes, effective date: LG 1320 09/18 2 of 4 E. Aggregate Excess Loss Insurance �Yes �No 1. Eligible Covered Expenses (define by plan, if applicable} ❑ Medical excluding all Prescription Drugs � Medical including Prescription Drugs defined as the following: ' m Rx Card and Mail Order ❑ Rx Card ❑Rx Mail Order ❑ Rx as part of Medical Plan subject to a Deductible and Coinsurance ❑ Other Rx Plan ❑ Short Term Disability ❑ Dental ❑ Vision ❑ Other Covered Expenses 2. Aggregate Attachment Point will be set by Symetra. 3. Symetra's Reimbursement Percentage: � a. 100 °/o of Covered Expenses in excess of the Aggregate Attachment Point. ❑ b. % of the first of Covered Expenses in excess of the Aggregate Attachment Point; and % thereafter. ❑ c. % of Covered Expenses in excess of the Aggregate Attachment Point that are incurred at the Policyholder medical facility or any a�liated or subsidiary medical facilities of the Policyholder; and % of all other expenses in excess of the Aggregate Attachment Point. ❑ d. % of Covered Expenses that are incurred at the Policyholder medical facility or any affiliated or subsidiary medical facilities of the Policyholder; and % of all other Covered Expenses will apply toward the Aggregate Attachment Point. 4. Aggregate Reimbursement Maximum $ $1,000,000.00 per Policy Period 5. Monthly Aggregate Accommodation Provision applicable? ❑Yes � No Monthly Aggregate Accommodation premium Paid: � annually in advance ❑ per employee per month ❑ monthly 6. Reimbursement Option: Covered expenses incurred on or after the Effective Date of Coverage and paid during the Policy Period with: Run-in Period 12 months Run-in Limit $ 0 Run-out Period 0 months Run-out Limit $ N/A 7. Minimum Aggregate Attachment Point: (Select one) 100 % of the first Monthly Aggregate Attachment Point x 12 ; or 8. Monthly Aggregate Attachment Factors Covered Units Single $1,620.34 Family $3,585.13 LG 1320 09/18 3 of 4 9. Aggregate Excess Loss Terminal Provision? ❑Yes � No Terminal Run-out Period months Monthly Aggregate Attachment Factors: Covered Units 10. Aggregate Excess Loss premium $1.00 (Do NOT include Monthly Agg Accommodation premium) Paid: �annually in advance ❑per employee per month � monthly 11. Net Claim Limit: $250,000 per Covered Unit Additional Information: Any person who knowingly, with intent to defraud any insurance company or other person, files an application of insurance 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. ��a��it�air Deposit of is enclosed to apply to the first premium payment under the P�,�f��tf�l,,� T % ,��y ,,,,,,�,��,,,,,, � `, Signed at: Date:_ ��C , �al � o l�'� ,,�' '';'�' �= Legal Name of Applicant: Denis Law, Mayor - : ��L - *' .*;, � '��a = =. � ,, �� - Applicant's Signature: ,,'%,��pA,,,,"��,,,,""'`t��.�� '`��h�ii�u��„��.�``�. . Agency Name: Agent's Signature: 7 Attes� � LG 1320 09/18 4 of 4 /�. CMC� l�l jCCI'�C �S Y M E T R A 3ymetra Life Insurance Company RETIREMENT I gENEF1T5�LIFE 777108th Avenue NE,Suite 1200�Believue,WA 98004-5135 Mailing Address:Benefits Division�PO Box 34690�Seattle,WA 98124-1690 Phone1-800-426-7784 ELECTRONIC CERTIFICATE USE AGREEMENT Electronic Certificate Use Agreement between Symetra Life Insurance Company ("Symetra") and (Policyholder Name) Policy No. IMPORTANT NOTICE REGARDING YOUR REQUEST TO RECEIVE ELECTRONIC CERTIFICATES: • The Policyholder has the right to request paper copies of current certificates at any time. • Symetra will continue to send electronic certificates until the contract terminates or the Policyholder cancels the request to receive electronic certificates. • The Policyholder has the right to cancet the request to receive electronic certificates at any time. • Electronic certificates will be sent to the Policyholder as email attachments. They will be in the form of PDF documents, so the Policyholder will need the ability to access and retain this type of document. Symetra agrees to the Policyholder's request to provide certificates in electronic form. The Policyholder agrees to the following: • The Policyholder will in no way modify the electronic certificate provided by Symetra. • Symetra will send the Policyholder a new electronic certificate when contract amendments require the certificate to change. It is the Policyholder's responsibility to make the correct electronic certificate available to insureds. Symetra is not responsible if the Policyholder makes an incorrect electronic certificate available to insureds. • It is the Policyholder's responsibility to inform all insureds when their certificates are modified due to contract amendments. • It is the Policyholder's responsibility to request paper certificates from Symetra and provide them to insured individuals who request them. The Policyholder must also maintain records of the insured individuals who request paper certificates. Symetra will provide paper certificate updates upon request. Symetra�is a.registered service mark of Symetra Lrfe Insurance Company. LG-1344/COC 9/18 Page 1 of 2 Electronic Certificate Use Agreement between Symetra Life Insurance Company ("Symetra") and (Policyholder Name) Policy No. • All claims will be paid based on the paper contract and amendments Symetra provides. In the event a certificate and the contract do not agree, the contract will prevail. • Except as required by applicable law or regulation, the electronic certificate provided to the policyholder by Symetra will be disseminated by the Policyholder only to the insured individuals entitled thereto. • To the extent permitted by law, the Policyholder agrees to defend and hold Symetra harmless from any liability resulting from the Policyholder's use of the electronic certificate. This agreement must be signed, dated and returned to Symetra at its Home Office in order for the Policyholder to receive electronic certificates. Agreed: i�� Margaret Meister President S etra Life Insuranc ompany Agreed: o r , I 2 a0 I� ( fficer) Denis Law (Ti le) ( ate) Attest: �' /' � (1) Sign and return to Symetra. J nA-Seth, C,CityCierk\��,�,�,�,�,,,,,�� (2) Retain copy with your policy. .�•�`�( OF �F�r'�',, ;�,�'� ,,.,,,�;�,�,,,,� r %, ;� ��, O '% _ %, y ; _ - ,�, - _ * = �EAI, = * � � � � = = LG-1344lCOC 9/18 Page 2 of 2 /�i�i��p 4�� I"11t,,,``�``O`�,\q�`� ��'��,��RAtED SEQ;\6`°`�.