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O -O ./ CON .n eeJ Q a a) f0 ee N 2 2 2 a)W Y m x� c x E a d N c CO C u To n D VI o ma 3 a v c E E v O as c J U a s Q a w �` v v 0. 0 .`^ N V 61 a N K to a tail to vt to O C c N a L p M1. o C n n U c w ti a O O N J N O 3 'D O O O C O '� E '- c :' on K.' c E aL� .� - o c E N 42 a a s a C co O Q (o a a = E m > (a a-' m S > .n o .._ o .- o (CO o a) ? ro U cc p -° .+ a a E to a _E v) .-. .n N i Z of '."0' (j CO fp V 00 Y U CO CU K • J E U I 1 J I 1 to U N C OO C 0 ro L O U 2 m 7 U C N 2 co co 'c LL a V) y c IJ- p J E CU PO c > C a +: c v C > C C V a Q Q Q W a 4. Q -s 3 a U ' on o o c co co o o c c a .- a + v + v + 4 Z y O L a o n Q U U Q J oc U U Q oc as a) w v O v O v O = o N V) F- Z v 0 V) Q OC K LL V) F- V) F- V) Z e--i z 0 u lik SYM E T RA RETIREMENT I BENEFITS I LIFE Symetra Life Insurance Company 777 108th Avenue NE, Suite 1200 Bellevue,Washington 98004-5135 EXCESS LOSS SCHEDULE OF BENEFITS A. Policyholder: City of Renton Policy Number: 16-013912-00 Effective Date of Coverage: January 1, 2020 Policyholder Anniversary Date: January 1st of each year beginning in 2020. Premium Due Date: Premium is due on the Effective Date of Coverage and the first of each month beginning with February 1, 2019. Enrollment(at the beginning of the Policy Period): Single 256 Family 378 Retirees covered under Excess Loss: 0 Yes ❑ No Individual coverage only B. This Schedule of Benefits applies to the Policy Period: from 01-01-2020 to 01-01-2021 C. Individual Excess Loss Insurance: © Yes ❑ No 1. Individual Deductible per Covered Unit: $250,000 Note: The minimum Individual Deductible is $100,000 or 5%of expected claims, whichever is less. 2. Alternate Individual Deductibles applicable? L I Yes (See Excess Loss Alternate Reimbursement Endorsement) © No 3. Covered Expenses: ❑ Medical excluding all Prescription Drugs ® Medical including Prescription Drugs defined as ONE of the following: ❑x Rx Card and Mail Order ❑ Rx Card Only ❑ Rx Mail Order Only OR ❑ Rx as part of Medical Plan subject to a Deductible and Coinsurance ❑ Other: 4. Symetra's Reimbursement Percentage: 100% of Covered Expenses in excess of the Individual Deductible. as Page 1 LGC-12000/WA 09/06 Symetra®is a registered service mark of Symetra Life Insurance Company. EXCESS LOSS SCHEDULE OF BENEFITS Applies to Policy Period: from 01-01-2020 to 01-01-2021 5. Individual Lifetime Reimbursement Maximum: Unlimited per Covered Unit Policy Period Reimbursement Maximum: Unlimited per Covered Unit 6. Premium Rates: Covered Units Single $28.67 Family $81.41 7. Reimbursement Option: Covered Expenses incurred on or after the Policy Effective Date and paid during the Policy Period with: Run-in Period 24 months Run-in Limit Unlimited Run-out Period 0 months Run-out Limit N/A 8. Individual Excess Loss Terminal Provision applicable? ❑ Yes x❑ No 9. Individual Excess Loss Advantage Provision applicable? ❑ Yes ❑x No D. Aggregate Excess Loss Insurance: x❑ Yes ❑ No 1. Covered Expenses: ❑ Medical excluding all Prescription Drugs ❑x Medical including Prescription Drugs defined as ONE of the following: ❑x Rx Card and Mail Order ❑ Rx Card Only ❑ Rx Mail Order Only OR ❑ Rx as part of Medical Plan subject to a Deductible and Coinsurance ❑ Vision ❑ Dental ❑ Short-Term Disability ❑ Other 2. Aggregate Attachment Point will be set by Symetra. 3. Symetra's Reimbursement Percentage: 100% of Covered Expenses in excess of the Aggregate Attachment Point. 4. Aggregate Reimbursement Maximum per Policy Period: $1,000,000 5. Monthly Aggregate Accommodation Provision applicable? ❑ Yes IEI No Es Page 2 LGC-12000/WA 09/06 Symetra®is a registered service mark of Symetra Life Insurance Company. EXCESS LOSS SCHEDULE OF BENEFITS Applies to Policy Period: from 01-01-2020 to 01-01-2021 6. Reimbursement Option: Covered Expenses incurred on or after the Policy Effective Date and paid during the Policy Period with: Run-in Period 24 months Run-in Limit Unlimited Run-out Period 0 months Run-out Limit N/A 7. Minimum Aggregate Attachment Point: 90% of the first Monthly Aggregate Attachment Point x 12. Note: The minimum Aggregate Attachment Point may not be less than 120% of expected claims. 8. Monthly Aggregate Attachment Factors: Covered Units Single $1,415.04 Family $3,546.94 9. Aggregate Excess Loss Terminal Provision applicable? ❑ Yes ❑x No 10.Aggregate Excess Loss premium: $1.00 Paid: annually in advance 11. Net Claim Limit: $250,000 per Covered Unit E. Medical Conversion Privilege: ❑ Yes x❑ No F. Endorsements Included EJ Individual Excess Loss Advance Funding Endorsement ❑ Excess Loss Alternate Reimbursement Endorsement G. Additional Information: Claims determined to be eligible under the Employee Benefit Plan in final and binding external review by independent review organizations (IROs)will also be deemed Covered Expenses under the Policy. Claim exception requests pending and under IRO review at the end of the Policy Period will continue to be considered for coverage. City of Renton has been identified as a member of the Alliant Employer Dividend Program. Membership is subject to the Symetra-Alliant agreement dated October 3, 2016. H. Associated Companies: Name Effective Date Termination Date N/A Bs Page 3 LGC-12000/WA 09/06 Symetra®is a registered service mark of Symetra Life Insurance Company. SYMETRA RETIREMENT I BENEFITS I LIFE Consumer Privacy Statement Symetra is serious about keeping your personal information private and secure. This notice of our privacy policy explains how we use and protect your information. Symetra does not sell or rent information about you to others. Where we get The information we get about you comes from different sources, and may include: Information about • Information that you give to us on applications or other forms, such as your name, you address and Social Security number. • Information from your transactions with us, our affiliated companies or our business partners.This includes products and services you have purchased from us or information about your payment history or claims. • Information we receive from consumer reporting agencies to confirm or add to facts given by you. • Information we receive from your insurance agent, broker or financial advisor. This may include updated information about your policy or account. Sharing information In order to conduct our business and offer you the products and services that you may want,we may share your information as allowed or required by law. We may share your information with our affiliates or third parties outside the Symetra family of companies to service, market or underwrite our products and services to you. We may share your information with insurance agents, brokers and financial advisors who sell our products and services.We may also share your information with financial institutions that we have joint marketing agreements with to sell our products and services. Working with these businesses allows us to provide you with a broader selection of insurance and investment products and services from our companies.These businesses are legally obligated to keep your information private and secure, and to use it only for the services we request. If any sharing of your information would require us to give you the option to opt-out of or opt-in to the information sharing, we will provide you with this option. We will continue to follow our privacy policy as described in this notice even when you are no longer our customer. Medical information We obtain or share medical information only in connection with specific products and services.This may include underwriting a life insurance policy, processing a claim, or any other use that we disclose to you before the information is collected. About independent The independent insurance agents, brokers and financial advisors who sell our products insurance agents, and services are not our employees and are not subject to our privacy policy. brokers and They may have received personal information about you that we do not have. They may financial advisors use this information differently than we do. Contact your agent, broker or advisor to learn more about their privacy practices. SYM-1013 10/18 Keeping your We protect your personal information in a variety of ways. personal information We maintain physical, administrative and technical safeguards to protect this information safe from unauthorized access. Employees receive training to protect personal information, and are authorized to access this information only when they have a business need to do so.We expect the agents, brokers and advisors who sell our products and services to maintain a high regard for privacy and to safeguard customer information. We follow your state law when it protects your privacy more than federal law. Accuracy of your We need accurate information to provide you with the best possible service. information If you need to update your information, or if the information we have about you is inaccurate or incomplete, please contact us. Please be sure to include your name and policy number or contract number. • By telephone: You can call us at the telephone number shown on your account statement or on other information we have sent to you. You can also call us at 1-800-796-3872. • In writing: You can write to us at the address shown on your account statement or on other information we have sent to you. You can also write to us at P.O. Box 34690, Seattle,WA 98124-1690. You can also request a copy of the information that we have about you in our files to make sure it is correct. You must make your request in writing and send it to the address shown on your policy or contract or to the address shown above. We will send you the information within 30 business days of receiving your request.We will advise you of any person or group to whom we have given the information during the last two years. If you believe the information about you in our files is wrong, you can notify us in writing. We will review your file and respond to you within 30 business days. If we agree with you, we will change our records. This change will become part of the file. It will be sent to those that received inaccurate information from us. It will also be included in any later disclosures to others. If we disagree with you, we will explain why. You can provide us with a statement explaining why you believe the information is wrong. This statement will become part of the file. It will be sent to those that received the disputed information from us. It will also be included in any later disclosures to others. Privacy and This notice also applies to our websites. If you would like more information about Symetra's websites our website privacy and security practices, go to www.symetra.com and click on the Privacy link. The Symetra family This notice applies to the following companies: of companies • Symetra Life Insurance Company • Symetra Assigned Benefits Service • Symetra National Life Insurance Company Company • First Symetra National Life Insurance • Symetra Securities, Inc. Company of New York • Clearscape Funding Corporation Symetra Financial Corporation 777 h Avenue NE, S Y M E T R A Be lev0ue,WA 98004-5135 Suite 1200 RETIREMENT I BENEFITS I LIFE www.symetra.com Symetra®is a registered service mark of Symetra Life Insurance Company. Symetra Life InsuranceCompany 777 108th Avenue NEn,Suite 1200 Bellevue,WA 98004-5135 SY M E T R A Local Office:Benefits Division RETIREMENT I BENEFITS I LIFE Mail Stop KC-16 777 108th Avenue NE Suite 1200 Bellevue,WA 98004-5135 Phone 1-800-426-7784 Fax 1-866-532-1362 Re: Information for IRS Form 5500 www.symetra.com Dear Policyholder: As an Excess Loss policyholder with Symetra Life Insurance Company,we understand that you may need to file a Form 5500. We are happy to provide you with the information you need upon request (pursuant to ERISA§103(a)(2)). If, at the end of your plan year, you need information so that you can file Form 5500, please email your request to erisa ansymetra.com or contact us at 1-800-426-7784. Sincerely, Symetra Life Insurance Company Benefits Premium Administration LHE-1038/TB 1/13 Symetra®is a registered service mark of Symetra Life Insurance Company.