HomeMy WebLinkAboutContract CAG-19-168
UNIMERICA INSURANCE COMPANY
A Stock Company
Administrative Offices: 11000 Upturn Circle, Eden Prairie,MN 55344
Phone: 1-800-454-0233
Unimerica Insurance Company("Company")agrees to reimburse the Policyholder as outlined under the
provisions of this Excess Loss Insurance Policy("Policy").
This Policy is legally binding between the Policyholder and Unimerica Insurance Company. The
consideration for this Policy includes,but is not limited to,the Application and the Payment of premiums as
provided hereinafter.
The Policyholder is entitled to the reimbursement described in this Policy if the Policyholder is eligible for
insurance under the provisions of this Policy. Reimbursement is subject to the terms and conditions of this
Policy.
The first premium is due on the first(1st)day of the Policy Period. Subsequent monthly premiums are due on
the first(1st)day of each month thereafter. The premium is not considered Paid until the Company receives
the premium payment.
All periods of coverage will begin and end 12:01 a.m. local time at the principal office of the Policyholder.
This Policy is delivered in and is governed by the laws of the state of issue.
IN WITNESS WHEREOF Unimerica Insurance Company has caused this Policy to be executed by its
President and Secretary.
Michelle M. Huntley, Secretary Brian D. Wenger, President
EXCESS LOSS INSURANCE POLICY
UMEREL-WA(02/02)
Unimerica Insurance Company
A Stock Company
Administrative Offices: 11000 Optum Circle,Eden Prairie,MN 55344
Phone: 1-800-454-0233
SCHEDULE OF BENEFITS
This Schedule of Benefits is only applicable to Excess Loss Insurance provided by the Company during the
Policy Period shown below.
Policyholder: City of Renton
Policy Number: UNI-202716
Effective Date:January 1,2018
Administrator: Healthcare Management Administrators, Inc. and EnvisionRx
Coverage specified herein is applicable only during the Policy Period from January 1,2018 to
January 1,2019,and is further subject to all terms and conditions of this Policy.
SPECIFIC EXCESS LOSS INSURANCE ®Yes ❑No
Benefit Period: Covered Expenses Incurred from January 1,2017 through December 31,2018 and
Paid from January 1,2018 through December 31,2018
Specific Deductible: $250,000 per Covered Person(Minimum Specific Deductible is 5%of expected
claims or$100,000 whichever is less)
Specific Percentage Reimbursable: 100%
Maximum Specific Benefit per Covered Person ®Unlimited ❑ Other
Specific Excess Loss Insurance includes:
® Medical ® Stand Alone Prescription Drug Program
Common Accident Provision: ®Yes ❑No
Common Accident means if more than one Covered Person in the same immediate family incurs Covered
Expenses as a result of the same accident,the Specific Deductible will be applied only once to all Covered
Expenses Paid because of that accident for all Covered Persons in the family during the same Benefit
Period.
Description Rates
Employee $29.85
Family $74.87
Specific Accommodation Reimbursement Endorsement ®Yes ❑No
Specific Terminal Liability Endorsement ❑Yes ®No
Aggregating Specific Deductible Endorsement ❑Yes No
Specific Step-Down Deductible Endorsement ❑Yes ®No
Independent Review Organization Extended Liability Endorsement ®Yes ❑No
UMEREL-WA(01/12)SCHED
AGGREGATE EXCESS LOSS INSURANCE ®Yes ❑No
Benefit Period: Covered Expenses Incurred from January 1,2017 through December 31,2018,and
Paid from January 1,2018 through December 31,2018.
Aggregate Excess Loss Insurance includes:
® Medical ® Stand Alone Prescription Drug Program ❑ Dental Care
❑Vision Care ❑Weekly(Disability) Income ❑Other
Aggregate Percentage Reimbursable: 100%
Maximum Aggregate Benefit: $1,000,000
Minimum Annual Aggregate Deductible: $18,305,220 or 100%of the first Monthly Aggregate
Deductible amount times 12,whichever is greater.
Maximum Covered Expenses per Covered Person accumulating toward the Maximum
Aggregate Benefit: $250,000
Monthly Aggregate Factors,per Washington statute 48.21.015,can not be calculated at any less
than 120%of expected claims.
Monthly Aggregate Factors
Medical Prescription Drugs
Composite $2,504.82 Included
Aggregate Excess Loss Premium: Annual $1.00
Aggregate Terminal Liability Endorsement Premium: ❑Yes ® No
Aggregate Accommodation Endorsement Premium: ❑Yes ®No
Independent Review Organization Extended Liability Endorsement ®Yes ❑No
SPECIAL CONDITIONS:
Under the Stand Alone Prescription Drug Program,Pay,Paid,Payment means the date purchased
by the Covered Person as it relates to Covered Expense.
Retirees are covered.
This Excess Loss Insurance Policy includes Experience Refund.
The above Specific rates include a feature which will guarantee your Subsequent Policy Period
beginning January 1,2019 will not contain any Specific Deductible greater than the group's standard
Specific Deductible for any covered person. Additionally,the Specific Monthly Premium Rates
will not increase more than 50%over the rate in force(the"Rate Cap").The Rate Cap will not
apply if the Company determines there is a material change to the Policyholder's Plan,the terms
or conditions of the Excess Loss Insurance Policy,or the nature or composition of the group to
whom the coverage is offered. *Optum reserves the right to remove the Rate Cap option once the
maximum Rate Cap has been applied for two consecutive Policy Periods.
UMEREL-WA(01/12)SCHED
DEFINITIONS
ADMINISTRATOR means a firm or person who has been retained by the Policyholder to provide
administrative services on behalf of the Policyholder/Plan. An Administrator shall, at all times,be the agent
of the Policyholder and shall not be deemed to be an agent of the Company.
ANNUAL AGGREGATE DEDUCTIBLE for any one Policy Period means the greater of: (a) sum of the
Monthly Aggregate Deductibles;or(b)the Minimum Annual Aggregate Deductible.
BENEFIT PERIOD means the period of time specified in the Schedule of Benefits in which a Covered
Expense must be Incurred by the Covered Person and Paid by the Plan to be eligible for reimbursement under
this Policy. This period does not alter the Effective Date, Policy Period, or waive this Policy's eligibility
requirements.
COVERED EXPENSE means medical or other expenses under the Plan to which this Policy applies, as
shown in the Schedule of Benefits, and which are not specifically excluded by the terms of this Policy.
Covered Expense does not include any payment for the cost of administrating the Plan or other Policyholder
contracted services.
COVERED PERSON(S) means each person covered under the Plan The types of Covered Persons and the
factors and premium rates for each type are shown in the Schedule of Benefits.
EFFECTIVE DATE is the date set forth in the applicable Schedule of Benefits.
INCURRED means with respect to medical services or supplies, the date on which the services are rendered
or supplies are purchased by the Covered Person and, with respect to disability income benefits if selected in
the Schedule of Benefits,the date each periodic benefit payment becomes payable to the Covered Person(not
the date the disability commences).
MONTHLY AGGREGATE DEDUCTIBLE means, with respect to a particular month,the total number of
Covered Persons for that given Policy month multiplied by the corresponding Monthly Aggregate Factors as
specified in the Schedule of Benefits.
PAY, PAID, PAYMENT means checks or drafts issued and deposited in the U.S. Mail or otherwise
promptly delivered to the payee,with sufficient funds on deposit to honor all outstanding drafts and checks.
PLAN means the self-funded health care plan established by the plan sponsor to provide certain benefits to
Covered Persons.
PLAN DOCUMENT means the written document approved by the Policyholder. A copy of the Plan
Document in effect on the Effective Date is attached to the application for Excess Loss Insurance.
POLICY PERIOD means the specified period in the Schedule of Benefits, however beginning no earlier
than the Effective Date of this Policy and continuing until coverage terminates in accordance with the
Termination Provisions.
SPECIFIC DEDUCTIBLE is set forth in the Schedule of Benefits. The Specific Deductible will apply
separately to each Benefit Period.
UMEREL-WA(02/02) DEF
REIMBURSEMENT PROVISIONS
NOTICE OF COVERED EXPENSE The Policyholder will give written notice of Covered Expenses to the
Company on the Company's customary proof of loss form,within thirty(30)days of the date the Policyholder
becomes aware of the existence of facts which would reasonably suggest the possibility that expenses covered
under the Plan will be Incurred which are equal to or exceed fifty percent(50%)of the Specific Deductible or
$50,000,whichever is less.
Failure to furnish written notice will not invalidate or reduce any claim if it was not reasonably possible to
provide such written notice within the time period required. However,in no event will the Company be liable
for any claims submitted for reimbursement more than twelve(12)months after the end of the Benefit Period.
PAYMENT BY PLAN While the determination of benefits under the Plan is the sole responsibility of the
Policyholder,the Company reserves the right to interpret the terms and conditions of the Plan Document as
it applies to this Policy. The Company will have the sole authority to reimburse or deny reimbursement
under this Policy.
The Policyholder will Pay all eligible claims under the Plan within thirty (30) days from the date adequate
proof of loss is provided to the Policyholder. If the Policyholder fails to Pay a claim within the thirty(30)
day time limit, that claim will not count toward the satisfaction of the deductibles or be reimbursed under
this Policy.
SPECIFIC EXCESS LOSS INSURANCE
The Schedule of Benefits indicates whether Specific Excess Loss Insurance is provided under this Policy.
If, while this Policy is in effect, the Covered Expenses for a Covered Person for the applicable Benefit
Period exceed the Specific Deductible, the Company will reimburse the Policyholder, subject to the terms
and conditions of this Policy including the limits set forth in the Schedule of Benefits.
The amount of the reimbursement will be equal to the Specific Percentage Reimbursable times the amount
by which Covered Expenses exceed the Specific Deductible amount, but will not exceed the Maximum
Specific Benefit. For purposes of determining whether such Maximum Specific Benefit has been
exceeded, Covered Expenses Incurred or Paid in any other Policy Period are included.
Covered Expenses for any Covered Person during the Policy Period will be determined according to the
Benefit Period described in the Schedule of Benefits.
If Specific Excess Loss Insurance terminates before the end of the Policy Period, the Specific Deductible
will not be reduced.
AGGREGATE EXCESS LOSS INSURANCE
The Schedule of Benefits indicates whether Aggregate Excess Loss Insurance is provided under this Policy.
If the Covered Expenses for the applicable Benefit Period exceed the Annual Aggregate Deductible for the
Policy Period, the Company will reimburse the Policyholder, subject to the terms and conditions of this
Policy including the limits set forth in the Schedule of Benefits.
The amount of the reimbursement will be equal to the Aggregate Percentage Reimbursable times the
amount by which Covered Expenses exceed the Annual Aggregate Deductible amount,but will not exceed
the Maximum Aggregate Benefit.
Covered Expenses will not include any amounts reimbursed by the Company under any other provision of
this Policy. If the Policyholder's coverage terminates before the end of the Policy Period,the greater of the
Accumulated Annual Aggregate Deductible or the Minimum Annual Aggregate Deductible will apply.
The Minimum Aggregate Deductible will not be reduced.
UMEREL(02/02) REIM
PREMIUMS AND FACTORS PROVISIONS
PAYMENT OF PREMIUMS For coverage to remain in effect, any subsequent monthly premium must
be received by the Company by the first (15t) day of each month. Premiums are not considered Paid until
the Company receives the premium payment. Premiums or other payments made by the Policyholder to
their Administrator or Agent or Broker shall not be deemed or considered payments to the Company until
actually received by the Company. The entire amount of the applicable premium shall be paid when due.
The Company is not obligated to accept or apply any premium paid which is less than the entire amount
due for any period. Premium payments shall be credited first to any past due and unpaid premium, in the
order in which due.
GRACE PERIOD A Grace Period of thirty-one(31)days from the due date will be allowed for the payment
of each premium after the first. During the Grace Period,the coverage will remain in effect provided the full
premium is Paid before the end of the Grace Period. Should a premium otherwise due,not be Paid during the
Grace Period, this Policy will terminate without further notice as of midnight on the last day for which
premiums were Paid.
PREMIUM AMOUNT The premiums will be calculated using rates determined by the Company as set
forth in the Schedule of Benefits. The amount of total premium due each month is the sum obtained by
multiplying the applicable premium rates shown in the Schedule of Benefits by the actual number of
appropriate Covered Persons.
The Policyholder will be liable for any premium taxes assessed at any time against the Company beyond
any taxes which may be payable on the premium received by the Company.
All requests for adjustments, credits or refunds because of overpayment of premiums shall be reported, in
writing,with accompanying detail within ninety(90)days after termination of the applicable Policy Period.
The Company will not refund any portion of the premiums Paid if this Policy terminates during this Policy
Period. The Company shall be entitled to reduce the reimbursements due the Policyholder under this
Policy against any premiums due and unpaid, any overpayments or other reimbursements made in error or
upon incorrect information, and any other amounts due the Company.
PREMIUM RATE AND MONTHLY AGGREGATE FACTOR CHANGE The Company may change
the Policyholder's premium rates or factors for any of the following:
a) the date when the terms of this Policy are changed;
b) the date the Plan Document changes are accepted by the Company;
c) the date the Policyholder adds or deletes subsidiary or affiliated companies or divisions;
d) the date the number of Covered Persons on any premium due date varies more than ten percent
(10%)from the number of Covered Persons from the immediate previous month,or
e) the date the Policyholder changes its Administrator.
UMEREL(02/02) PREFAC
TERMINATION PROVISIONS
This Policy and coverage provided hereunder will terminate upon the earliest of:
a) the premium due date of any premium which remains unpaid at the end of the Grace Period;
b) the premium due date next following receipt by the Company of written notice from the Policyholder
that this Policy is to be terminated;
c) the date of termination of the Plan;
d) the date the Policyholder suspends active business operations or dissolves;
e) the end of the Policy Period;or
f) the date the administrative services agreement with the Administrator is terminated.
This Policy may also be terminated,at the Company's option on the earliest of:
a) the last day of the second(2nd)consecutive month during which there are less than twenty-five(25)
employees enrolled in the Plan,unless the Company agrees,in writing,to continue coverage;or
b) the date the Policyholder fails to comply with the terms of this Policy;or
c) on the Policy anniversary date by the Company giving thirty(30) days advance written notice that
this Policy will end,or such other notice as required by law.
The Company will not refund any portion of the premiums paid if this Policy is terminated during the Policy
Period.
SUBSEQUENT POLICY PERIOD PROVISIONS
At the end of a Policy Period,this Policy may have a Subsequent Policy Period only by mutual agreement of
the Policyholder and the Company and provided that the Company has not given a thirty(30)day termination
notice or such other termination notice as required by law. The Subsequent Policy Period may be subject to
new premium rates, factors, new underwriting terms, new Benefit Period and other new Policy terms. The
terms and conditions for a subsequent Policy Period will be evidenced by the issuance of a new Schedule of
Benefits by the Company,which shows the new premium rates,Benefit Period and other new terms.
UMEREL(02/02) TERM
GENERAL PROVISIONS
ADMINISTRATOR The Policyholder may retain an Administrator to act as an agent for the Policyholder in
performing any or all of the duties as designated by the Policyholder. Without waiving any of its rights under
this Policy,and without making the designated Administrator a party to this Policy,the Company agrees to
recognize the Administrator as an agent of the Policyholder. The Policyholder will immediately notify the
Company in writing if the agreement between the Policyholder and the Administrator terminates.
ASSIGNMENT The Policyholder may not assign the Policyholder's interest in or reimbursement under this
Policy,and the Company will not recognize any such assignment.
AUDITS The Company will have the right:(a)to inspect and audit all records and procedures of the
Policyholder and Administrator,developed and maintained for the Plan,that are applicable to the
administration of this Policy;and(b)to require,upon request,proof satisfactory to the Company that Payment
has been made to the Covered Person or the provider of such services or benefits which are the basis for any
Loss by the Policyholder hereunder.
CHANGES TO THE PLAN DOCUMENT If the Plan Document in effect on the Effective Date is
subsequently amended,notice of the amendment will be given to the Company prior to the effective date of
the change. If the Company does not give written acceptance of the amendment,the Company will only
provide coverage under this Policy consistent with the Plan Document prior to amendment. The
Company's reimbursement will be made according to the amended Plan,once the notice is received and
accepted.
CHANGES TO THE POLICY Only the President,a Vice President,or the Secretary of the Company have
the authority to alter this Policy,or to waive any of the Company's rights and then only in writing. No such
alteration of this Policy shall be valid unless endorsed and attached to this Policy. No agent,broker,or
Administrator has the authority to alter this Policy or to waive any of its provisions.
CLERICAL ERROR Clerical errors,whether by the Policyholder or by the Company,in keeping or
transmitting any records pertaining to the coverage,will not invalidate or limit coverage otherwise validly in
force nor continue coverage otherwise validly terminated.Clerical error does not include any failure of the
Policyholder,the Administrator or any agent of the Policyholder:(a)to comply with the requirements relating
to notice of claims or payment of claims;or(b)to disclose underwriting information requested by the
Company,whether or not intentional and regardless of the actual knowledge of the person providing the
information.
CONFORMITY WITH LAW If any provision of this Policy is contrary to any law to which it is subject,
such provision is hereby amended to conform to the minimum requirements of such law.
ENTIRE CONTRACT The Entire Contract between the Company and the Policyholder will consist of this
Policy,Schedule of Benefits,application,approved amendments or endorsements,and a copy of the Plan
Document,which is on file with the Company.
INSOLVENCY Nothing in this Policy shall either relieve an insolvent or bankrupt Policyholder from the
obligation to pay premiums when due or delay or abate cancellation of this Policy for failure to do so.The
insolvency,bankruptcy, financial impairment,receivership,voluntary plan of arrangement with creditors,
or dissolution of the Policyholder or the Policyholder's Administrator will not impose upon the Company any
liability other than the liability defined in this Policy. In particular,the insolvency of the Policyholder will not
make the Company liable to the creditors of the Policyholder,including Covered Persons under the Plan.
LEGAL ACTION The Policyholder cannot file suit until ninety(90)days after the date on which proof of
loss is given to the Company. The Policyholder cannot file suit more than three(3)years after the date on
which the Policyholder must give the Company proof of Loss.
UMEREL(02/02) GEN
LIABILITY The Company will have neither the right nor the obligation under this Policy to directly pay any
Covered Person or provider of professional or medical services.The Company's sole liability is to the
Policyholder,subject to the terms and conditions of this Policy.Nothing in this Policy shall be construed to
permit a Covered Person to have a direct right of action against the Company.The Company will not be
considered a party to the Plan of the Policyholder,or to any supplement or amendment to it.
MISSTATED DATA,CONCEALMENT,FRAUD The Company has relied on the information provided
by the Policyholder,the Administrator or any agent of the Policyholder,in the issuance of this Policy,or for
any Subsequent Policy Period. In the event of a misrepresentation,concealment or omission of a fact,or a
mistake of fact(whether or not a mutual mistake),any of which materially affect the underwriting,premium,
rating or terms and conditions of this Policy,the Company may,at its option:
a) increase premium rates, attachment points and/or otherwise change the terms and conditions of this
Policy. Such increase or change to be effective retroactively to the Effective Date or as of any
premium due date thereafter,or
b) terminate this Policy as of the next premium due date.
The Company may declare this Policy null and void in its inception if,whether before or after a claim,the
Policyholder,Administrator or any agent of the Policyholder has willfully or intentionally misrepresented,
concealed,omitted any material fact affecting terms,conditions,or underwriting of this Policy. In such event,
the Company's liability under this Policy shall be limited to refunding premiums paid by the Policyholder
after deducting there from the amount of any Covered Expenses reimbursed by the Company to the
Policyholder prior to the date of termination. If the amount of the Covered Expenses reimbursed by the
Company to the Policyholder exceeds the premiums paid by the Policyholder,the Policyholder shall pay the
Company the difference within thirty(30)days of the date the Company notifies the Policyholder of such
difference.
NOTICE FROM THE COMPANY TO THE POLICYHOLDER For the purpose of any notice required
from the Company under the provisions of this Policy,notice to the Policyholder's Administrator shall be
considered notice to the Policyholder and notice to the Policyholder shall be considered notice to the
Policyholder's Administrator.
NOTICE OF COMPLAINT,APPEAL,LEGAL ACTION As a condition precedent to the Company
reimbursing the Policyholder in any settlement or judgment for a disputed Covered Expense,the Policyholder
shall immediately inform the Company of any notice of appeal,notice of legal action,or objection,demand or
complaint which the Policyholder received regarding any Covered Expense that may be reimburse under this
Policy.
OTHER COVERAGE The reimbursement provided by this Policy is in excess of other coverage such as
group insurance,excess insurance,insurance,plan benefits,including insurance or plan benefits established
by any federal,state,or local law.
PARTIES TO THE POLICY The parties to this Policy are the Policyholder and the Company.The
Company's sole liability under this Policy is to the Policyholder.This Policy does not create any right or legal
relation between the Company and a Covered Person under the Plan.This Policy will not be deemed to make
the Company a party to any agreement between the Policyholder and the Administrator.
POLICYHOLDER REQUIREMENTS The Policyholder will submit by the twentieth(20`h)day of each
month all proofs,reports,and supporting documents required by the Company,including,but not limited to,a
monthly summary of all eligible claims Payment processed by the Policyholder and number of each type of
UMEREL(02/02) GEN
Covered Persons under the Plan during the prior month. The Policyholder will be responsible for the
investigation,auditing,calculating and Payment of all claims under the Plan.
The Policyholder agrees to provide funds for Payment of all eligible expenses under the Plan. If the
Policyholder fails to provide funds for timely Payment: (a)coverage under this Policy will immediately
terminate;and(b)any Aggregate and/or Specific Deductible will be deemed not satisfied.
RECORDS The Policyholder will maintain records of all Covered Persons under the Plan during the Policy
Period and for a period of seven(7)years after the end of the Policy Period. The Policyholder will make all
such records available to the Company as needed to evaluate its liability under this Policy.
The Policyholder will maintain a separate record of any and all amounts Paid in excess of benefits eligible
under the Plan.
SEVERABILITY CLAUSE Any clause deemed void,invalid,or otherwise unenforceable,whether or not
such a provision is contrary to public policy,will not render any of the remaining provisions of this Policy
invalid.
TERMINATION OF THE POLICYHOLDER'S PLAN The Policyholder will immediately notify the
Company,if the Plan is terminated.
THIRD PARTY RECOVERY The Policyholder shall cause the Plan to undertake to pursue any and all
valid claims the Plan or a Covered Person may have against third parties arising out of any occurrence
resulting in a payment by the Plan or reimbursement by the Company. The Policyholder will account for and
pay to the Company any amounts recovered which are reimbursable by the Company to the Policyholder
under this Policy,regardless of whether this Policy is still in force on the date of recovery. Third party shall
mean a person,entity or insurance company other than the Plan,the Policyholder or a Covered Person. An
insurance company shall include insurance companies providing third party liability coverage,or other
insurance coverage;i.e.no fault,uninsured,under insured or other similar coverage.
The Policyholder or Administrator shall notify the Company immediately upon discovering that a claim
against a third party may exist. Should the Policyholder or the Administrator fail to pursue any valid
claims against a third party,the Policyholder shall cause the Plan to assign its subrogation and third party
recovery rights to the Company so as to allow the Company to pursue third party recoveries for Covered
Expenses reimbursable to the Policyholder. In the event of such assignment,the Company shall have to
exercise and enforce all of the Policyholders and/or Plan's rights against such third party. The Policyholder
shall furnish such information,assistance,cooperation and execute and deliver such instruments,all as are
necessary for the Company to pursue third party recoveries pursuant to this provision.
The Company's right to third party recoveries, as provided for in this provision,shall constitute and impose
a trust and first-priority lien arising from any cause of action,settlement,judgment or arbitration award
against a third party.
The Policyholder shall pay the Company all amounts recovered,whether by suit,settlement, alternative
dispute resolution, including but not limited to arbitration or mediation,or otherwise,from any third party
or their insurer to the extent of Covered Expenses regardless of whether such recovery shall be a full or
partial recovery. If a third party recovery received by the Plan or Policyholder is less than the total amount
paid by the Plan on behalf of the Covered Person,the Company shall be entitled to recover first, in full,any
Covered Expense reimbursed by the Company under this Policy. The Company's recovery shall not be
reduced by any attorney's fees incurred by the Policyholder,Plan or Covered Person unless the Company
otherwise agrees in writing. All remaining amounts shall be paid to the Policyholder.
The Policyholder's failure to comply with this provision may result in the denial of a Covered Expense,in
addition to all other rights of the Company under this Policy.
WAIVER Failure of the Company to strictly enforce its rights under this Policy shall not waive any such
right,regardless of the frequency or similarity of the circumstances.
UMEREL(02/02) GEN
GENERAL EXCLUSIONS PROVISIONS
The Company will not reimburse the Policyholder for any of the following:
a) Any payment which does not strictly comply with the terms and conditions of the Plan Document;
b) Any payment or expense caused by or resulting from war, declared or undeclared or international
armed conflict;
c) Any payment for litigation costs and expenses, extra-contractual damages, compensatory damages,
interest, exemplary and punitive damages or liabilities, including but not limited to those resulting
from negligence, intentional wrongs, fraud, bad faith or strict liability on the part of the Policyholder,
Plan, Administrator or any agent or representative of the Policyholder,Plan or Administrator;
d) Any payment for occupational accidents or illnesses which are also eligible expenses covered by
Workers' Compensation or Occupational Disease law, or similar legislation, whether or not coverage
under such law is actually in force.
UMEREL(02/02) EXCL
UNIMERICA INSURANCE COMPANY
A Stock Company
Administrative Offices: 11000 Optum Circle,Eden Prairie,MN 55344
Phone: 1-800-454-0233
APPLICATION FOR EXCESS LOSS INSURANCE
The undersigned Applicant requests the Excess Loss Insurance Benefits shown herein and provided by Unimerica Insurance
Company,and agrees to be bound by the terms and provisions of the Excess Loss Insurance Policy.
Full Legal Name of Applicant: City of Renton
Address: 1055 South Grady Way,Renton,WA 98057
Key Contact: Wendy Rittereiser,HR Benefits Manager Telephone: 425-430-7659 Tax ID:91-6001271
Applicant is a: ❑Corporation ❑Labor Union ❑Partnership ❑Association ❑Proprietorship Other: governmental
Nature of Business of the Group to be Insured: municipality Requested Effective Date: January 1,2018
Total number of eligible persons: Employees: 529 Retirees: 80
Are retirees covered: ®Yes ❑No.
Affiliates or Subsidiaries: Addresses of Affiliates or Subsidiaries:
N/A
Full Name of Administrator: HMA Prescription Benefit Manager:EnvisionRx
Address: 220 120th Ave.NE,Bellevue,WA 98005 1100 Investment Blvd., El Dorado Hills, CA 95762
Key Contact: Christine Carroll 425-289-5241 Leticia Valego 916-941-3556
Agent or Broker: Douglas Evans,R.L. Evans Company 425-455-0501
Tax ID: 91-0849754
Address: 3535 Factoria Blvd SE,Ste 120,Bellevue,WA 98005
SPECIFIC EXCESS LOSS INSURANCE ®Yes ❑No
Benefit Period: Covered Expenses Incurred from January 1,2017 through December 31,2018 and
Paid from January 1,2018 through December 31,2018.
Specific Deductible:per Covered Person: $250,000
Specific Percentage Reimbursable: 100°b
Maximum Specific Benefit per Covered Person: ®Unlimited ❑Other
Covered Expenses under Specific Excess Loss: ®Medical ® Stand Alone Prescription Drug Program
Common Accident Provision: ®Yes ❑No
Description: Specific Premium Rates per month
Employee $ 29.85
Family $ 74.87
Specific Accommodation Reimbursement Endorsement ®Yes ❑No
Specific Step-Down Deductible Endorsement ❑Yes Z No
Specific Terminal Liability Endorsement ❑Yes ®No
Aggregating Specific Deductible Endorsement ❑Yes ®No
Independent Review Organization Extended Liability Endorsement Z Yes ❑No
UMERAPP(01 12)
AGGREGATE EXCESS LOSS INSURANCE: ®YES ❑NO
Benefit Period: Covered Expenses Incurred from January 1,2017 through December 31,2018,and
Paid from January 1,2018 through December31,2018.
Covered Expenses under Aggregate Excess Loss Coverage: ®Medical D Dental ❑Vision
®Stand Alone Prescription Drug Program
❑Other(Please Specify)
Aggregate Percentage Reimbursable: 100%
Maximum Aggregate Benefit: ❑$500,000 ®$1,000,000 ❑Other
Minimum Annual Aggregate Deductible:$ 18,305,220 or 100%of the first Monthly Aggregate Deductible amount times 12,
whichever is greater.
Maximum Covered Expenses per Covered Person accumulating toward the Maximum Aggregate Benefit: $250,000
Aggregate Excess Loss Premium: $ 1.00 per Employee per month
Aggregate Terminal Liability Endorsement: ❑Yes ®No
Aggregate Accommodation Endorsement: ❑Yes ®No
Independent Review Organization Extended Liability Endorsement ®Yes ❑No
Monthly Aggregate Factors:
Covered Persons Medical Prescription Drugs
Composite $2,504.82 included
It is understood and agreed by the undersigned that:
1. The statements,declarations and representations made in this Application,any request for proposal,the underwriting information
provided by or on behalf of the undersigned and the Plan Document are the undersigned's representations; that any Policy is
issued in reliance upon the truth of such statements,declarations,and representations;and that such statements,declarations,and
representations will form a part of the Excess Loss Insurance Policy. Any inaccuracy in such information or failure to disclose
any such information, including all claims or possible claims, paid or pending, or which the Employer should otherwise know
about, if discovered later,can result in rejection of this Application,or can change the terms,conditions or premiums,or can void
coverage.
2. As a condition precedent to the approval of this Application,the undersigned shall furnish to the Company a copy of the executed
Plan Document within 90 days after the date of this application describing the benefits provided by the Plan,which shall be kept
on file in the office of the Company. If the Company does not receive the Plan Document within 90 days, the Company may
refund all premium and the Application shall have been null and void when signed. No Excess Loss Insurance will be effective
nor reimbursement made unless a Plan Document is received and accepted by the Company.
3. The Company will evaluate the undersigned's risk, as requested by this application, the underwriting data received and
represented by the Plan and may require adjustments of rates,factors,and/or special limitations.
4. Any coverage resulting from this Application shall be subject to the terms and provisions of the Policy herein applied for.
Coverage shall become effective on the date specified in this Application if all requirements of the Company, including the Plan
Document and the underwriting requirements have been met and the required premiums paid.
5. The receipt by the Company of the first month's premium and deposit of any check drawn in connection with this Application
shall not constitute an acceptance of liability. In the event the Company does not approve this application, its sole obligation shall
be to refund such sum to the undersigned.
6. The undersigned will provide or employ an Administrator to administer the Plan and to process and pay claims according to the
Plan Document. The undersigned acknowledges that the Administrator is the undersigned's agent and not the agent of the
Company and that statements and answers given by the Administrator are binding on the undersigned.
7. Other:
• This Excess Loss Insurance Policy includes Experience Refund.
• The above Specific rates include a feature which will guarantee your Subsequent Policy Period beginning January 1,
2019 will not contain any Specific Deductible greater than the group's standard Specific Deductible for any covered
person.Additionally,the Specific Monthly Premium Rates will not increase more than 50%over the rate inforce(the
"Rate Cap").The Rate Cap will not apply if the Company determines there is a material change to the Policyholder's
Plan,the terms or conditions of the Excess Loss Insurance Policy,or the nature or composition of the group to whom the
coverage is offered. *Optum reserves the right to remove the Rate Cap option once the maximum Rate Cap has
been applied for two consecutive Policy Periods.
UMERAPP(01'12)
The undersigned has read the entire Application for Excess Loss Insurance and understands that the insurance requested
herein is not in effect until this Application is approved and accepted by the Company.
Full Legal Name of Applicant: t e Y.
i
Signature of Authorized Person: �ty
Print Name: .J E'Yl(`J Lau) Title: f
Date: e-LyYli g.„..�`.
Signature of Agent or Broker: •
Print Name of Agent or Broker: Douglas Evans, President
FRAUD WARNING NOTICES: (Please review notice that applies in your state)
For applicants in Arkansas,Louisiana,New Mexico and Rhode Island:
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance,is guilty of a crime and may be subject to fines and confinement in prison.
For applicants in Colorado:
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.
For applicants in District of Columbia:
WARNING: It is a crime to provide false or misleading information to an insurer for purpose of defrauding the insurer or
any other person. Penalties include imprisonment and/or fines. In addition,an insurer may deny insurance benefits if false
information materially related to a claim was provided by the application.
For applicants in Florida:
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an
application containing any false,incomplete,or misleading information is guilty of a felony of the third degree.
For applicants in Kentucky,New Mexico,Ohio,and Pennsylvania:
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.
For applicants in Maine,Tennessee and Virginia:
It is a crime to knowingly provide false,incomplete,or misleading information to an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment,fines,or a denial of insurance benefits.
For applicants in New Jersey:
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal
and civil penalties.
For applicants in all other states:
it is a crime to knowingly provide false,incomplete,or misleading information to an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment,fines,or a denial of insurance benefits.
UMERAPP(01/12)