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Home My WebLink AboutCNA Continental Assurance CoContinental Assurance Company CNA Plaza Chicago, Illinois 60685 A Stock Company Herein called the Company APPLICATION FOR EXCESS LOSS INDEMNITY COVERAGE Proposal Date: January ll, 2000 GENERAL INFORMATION , CNA Group Policy Number: L42707-132419-99 Full legal name of participating Unit: City of Carmel Principal Address: 1 Civic Square, Carmel, IN 46032 Nature of Business: Municipality ( ) Corporation ( ) Partnership ( ) Proprietorship (X) Other: City Govemment. Full Legal Name of Plan Supervisor: CoreSource, Inc. Address: P. O. Box 879, Anderson, IN 46015 If employee benefit plans of subsidiary or afffiiated companies (companies under common control through stock ownership, contract, or otherwise) are to be included, list legal names and addresses of such companies and the nature of their business. None Enter the full name of your Employee Benefit Plan(s) and enclose a copy with this request. City of Carreel - Employee Benefit Plan Excess Loss Indemnity Policy Provisions A. Aggregate Excess Risk Insurance (1) Company Limit of Liability: 100% of paid Aggregate Losses which are in excess of the Aggregate Attachment Point, subject to a maximum limit of $1,000,000. In addition, the amount per Covered Person chargeable to Aggregate Losses is subject to a maximum limit of $60,000. (2) Minimum Aggregate Attachment Point of $1.777.507 with an attachment factor of $217.83 per Single Employee per Month and $544.58 per Employee with Dependents per Month. (3) Premiums: Deposit Premium: $N/A Aggregate Premium Factor: $4,42 Minimum Premimn: $N/A L863-355 (Continued) -I- '(4) (5) (6) Claims Basis () () (x) () Paid during Policy Period; Incurred during Policy Period. Paid during Policy Period or during the __ months immediately thereafter; Incurred during Policy Period. Paid during Policy Period; Incurred during Policy Period, or during the 36 month period immediately prior thereto. (Payments for expenses incurred during the N/A month period preceding the effective date of coverage shall be limited to a maximum amount of $N/A, all covered persons combined.) Other (as indicated): __ Covered Plan Benefits (Applicable only if an entry is specified herein.) (X) Medical; ( ) Dental; ( ) Weekly Accident & Sickness; ( ) Prescription Drug Card; ( ) Other (as indicated). Loss Reduction For Insured Hospitals If the Participating Unit named herein is a licensed hospital, benefits payable under any applicable Employee Benefit Plan for expenses incurred as the restfit of services and charges of the Participating Unit shall be multiplied by N/A% when determining paid Aggregate Losses. B. Specific Excess Risk Insurance (1) Company Limit of Liability: 100% of paid Specific Losses which are in excess of a specific deductible of $60,000, subject to a maximum limit per Covered Person of $1,940,000. (2) Premiums - Speci~c premium factor of: $17.54 per Single Employee per Month $45.47 per Employee with Deps. per Month (3) Claims Basis: ( ) Paid during Policy Period; Incurred during Policy Period. ( ) Paid during Policy Period or during the months immediately thereafter; Incurred during Policy Period. (X) Paid during Policy Period; Incurred during Policy Period, or during the 36 month period immediately prior thereto. ( ) Other (as indicated): (4) Covered Plan Benefits (Applicable only if an entry is specified herein.) (X) Medical; ( ) Dental; ( ) Weekly Accident & Sickness; ( ) Prescription Drug Card; ( ) Other (as indicated) __ (5) Loss Reduction For Insured Hospitals If the Participating Unit named herein is a licensed hospital, benefits payable under any applicable Employee Benefit Plan for expenses incurred as the result of services and charges of the Participating Unit shall be multiplied by N/A% when determining paid Specific Losses. L863-355 (Continued) -2- '7. 'Medical Conversion Privilege ( ) Yes ( X ) No 8. Amount accompanying this Application as an advance payment on the premium for insurance applied for: $ 9. Inception Date: February 1. 2000 Expiration Date: February 1, 2001 10. It is understood and agreed as conditions precedent to the acceptance of this Application that the Participating Unit: A. Has conducted a thorough review of experience developed under its Employee Benefit Plan, and as a restfit thereof, represents that there are no covered persons with known disabilities, or other known conditions expected to restfit in paid claims in excess of the specific deductible amount during the policy period, other than those previously disclosed as the basis for proposed coverage. B. Represents that all undenvriting information provided to the Company, by or on behalf of the Participating Unit, is complete and accurate. C. Will provide a copy of the executed Employee Benefit Plan Document for incorporation into the Policy within 60 days of the coverage effective date. The Taurus II Trust accepts this Application for the above coverage. Coverage is in effect for the period shown in item 9. Renewal of this for a further period must be submitted on a new form. Accepted for the Company Participating Unit City of C armel Authorized Signature - ~I~ C c ,~X¢ d[~ c' Title Date Date -3- ADDENDUM NO. 1 TO APPLICATION FOR THE EXCESS LOSS INDEMNITY COVERAGE It is hereby understood and agreed that this Addendum forms a part of the Application for the Excess Loss Indemnity Policy issued by Continental Assurance Company to City of Carmel (herein called the Participating Unit), with a Policy Period of February 1, 2000 to February 1, 2001 (herein called the Policy). It is further agreed that: The Participating Unit certifies that, to the best of its knowledge, there are no unreported disabled persons under its Employee Benefit Plan who may cause the specific deductible mount for the Policy Period to be exceeded as of February 1, 2000. In the event the Participating Unit has knowledge of a potential catastrophic/chronic case claim, the Participating Unit shall notify and provide the information set forth below to the Professional Resource Network of lOA Re, Inc. within 10 business days. Catastrophic/chronic cases are those cases which will require intensive medical treatment or will require ongoing treatment of extended duration. Professional Resource Network shall supply the Participating Unit with a listing of diagnostic categories and descriptions of catastrophic/chronic case illnesses and injuries which must be reported. (Refer to the "ICD 9 Hit List" and "Immediate Report List"). Upon timely notification, Professional Resource Network will offer potential clinical and/or cost effective alternatives. Notification will consist of the claimant's name, diagnosis, proposed/actual treatment plan, claims paid-to-date in the Policy period in which they are incurred, and projected claims cost. 3. The Company reserves the right to re-evaluate this risk at any time if enrollment increases or decreases by more than 10% during the Policy Period. As a part of the Application for the Policy, this Addendmn modifies the terms and conditions of the coverage provided by the Policy to the extent stated herein. Signed for the Participating Unit by Date Authorized Signature City of Carmel June 28,2000 Ms. Kathy Lewis Senior Director of Client Relations CORESOURCE P.O. Box 879 Anderson, IN 46015 RE: Stoploss Contract Dear Ms. Lewis: Please find enclosed two (2) certified copies of the Application for Excess Loss Indenmity Coverage Contract signed by the Board of Public Works on June 21, 2000. Since it is our procedure that all original documents remain in the City of Carmel, Clerk- Treasurer's Office, I am unable to forward the original contract for your signature. Therefore, please fully execute one of the certified copies and return to me as soon as possible so we may have a eoml31ete contract in our office. For future reference, it is also our procedure that all documents going before the Board for approval already include the signatures of all other parties involved. Since that was not the case in this matter, we must resort to the format of certified copies of the contract. If you should ever want an original, fully executed document for your records, please note to always include two (2) original documents to submit before the Board for signatures. Thank you for your cooperation in this matter. If you have any questions or concems, please do not hesitate to contact our office. Sincerely, A. Groce Deputy Clerk Enclosures D:\Files\Letters\Lewis.62~.~CCIVIC SQUARE CARMEL, INDIANA 46032 317/571-2400