HomeMy WebLinkAboutBenefit Administrative/HR/Excess Loss Insurance SCHEDULE OF EXCESS LOSS INSURANCE
(Hereinafter referred to as "the Schedule")
POLICYHOLDER: City of Carmel
ADDRESS: One Civic Square, Carmel, IN 46032
ADMINISTRATOR: Benefit Administrative Systems, LLC
ADDRESS: 17475 Jovanna Drive Suite 1 B, Homewood, IL 60430
ALL AMOUNTS AND NUMBERS SHOWN IN THIS SCHEDULE APPLY ONLY TO THE POLICY YEAR IN
EFFECT. A NEW SCHEDULE WILL BE ISSUED FOR EACH NEW POLICY YEAR.
A. [X] AGGREGATE EXCESS LOSS INSURANCE:
1. BENEFITS COVERED:
X Medical _ Dental Weekly Income Vision X _ Prescription Drug Card
Other:
2. BENEFIT PERIOD:
Eligible Expenses Incurred from 01/01/2012 through 12/31/2013; and
Eligible Expenses Paid from 01/01/2013 through 12/31/2013.
If this Policy terminates prior to the Expiration Date, no Aggregate Excess Loss Benefits will be
payable and premium paid will not be refundable.
3. MINIMUM AGGREGATE ATTACHMENT POINT: $12,919.865
4. AGGREGATE LOSS LIMIT(per Covered Person): $150,000
5. AGGREGATE BENEFIT PERCENTAGE: 100%, however, eligible expenses incurred by
the Employer for retirees age 65 and older will be reimbursed under the Policy as
secondary to Medicare.
6. MAXIMUM AGGREGATE BENEFIT (WHILE COVERED, AND WHILE THIS POLICY IS IN
FORCE): $1,000,000
7. RUN-IN/RUN-OUT LIMIT: $N/A
8. MONTHLY AGGREGATE FACTOR(S)/ENROLLMENT:
FACTORS: COVERED UNITS/ENROLLMENT:
Single: $837.24 Single: 153
Family: $2,200.83 Family: 431
Composite:$N/A Composite: 584
9. AGGREGATE PREMIUM ([N/A] Annual/X Per Employee Per Month): $8.70
10. MINIMUM AGGREGATE PREMIUM ([N/A] Annual /[N/A] Monthly): $N/A
11. PREMIUM PAYMENT MODE: Monthly
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B. [X] SPECIFIC/INDIVIDUAL EXCESS LOSS INSURANCE:
1. BENEFITS COVERED: X Medical X Prescription Drug Card
2. BENEFIT PERIOD:
Eligible Expenses Incurred from 01/01/2012 through 12/31/2013; and
Eligible Expenses Paid from 01/01/2013 throughl2/31/2013.
If this Policy terminates prior to the Expiration Date, the Benefit Period will not extend past the
date of termination. In addition, the deductible per Covered Person will apply as if the Policy
were in force for the entire Policy Year.
3. DEDUCTIBLE(PER COVERED PERSON): $150,000
Except for the following:
a. N/A : $ N/A
4. SPECIFIC BENEFIT PERCENTAGE: 100%, however, eligible expenses incurred by the
Employer for retirees age 65 and older will be reimbursed under the Policy as secondary
to Medicare.
5. SPECIFIC BENEFIT LIMIT (PER LIFETIME, PER COVERED PERSON) WHILE THIS
POLICY IS IN FORCE: No Lifetime Maximum.
6. RUN-IN/RUN-OUT LIMIT:
a N/A : $ N/A
7. MONTHLY SPECIFIC PREMIUM RATE/ENROLLMENT:
RATE: COVERED UNITS/ENROLLMENT:
Single: $43.85 Single: 153
Family: $119.89 Family: 431
Composite: $N/A Composite: 584
8. MINIMUM SPECIFIC PREMIUM ([N/A] Annual /[N/A] Monthly): N/A
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[X] WAIVER OF ACTIVELY AT WORK ELECTED
[X] ADVANCED FUNDING ELECTED
[X] RETIREE EXPENSES INCLUDED Limited to: Refer to Paragraph A, item 5 and Paragraph B,
item 4 of Schedule of Excess Loss.
OPTIONAL RIDERS ELECTED:
[N/A] Aggregating Specific Rider
[N/A] Monthly Cumulative Accommodation For Aggregate Excess Loss Rider
[N/A] Aggregate Excess Loss Terminal Liability Rider
[N/A] Specific Excess Loss Terminal Liability Rider
NOTES:
Sagamore and PHCS is the PPO(s) network of choice.
LCM & UR will be handled by Medical Cost Mangement.
AGREED: City of Carmel
Policyholder/You
Signature: Sr Sr` *k..-•/
Name (please print):
Title:
Date:
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SL2004 iii 12-17-12
CITY OF CARMEL, INDIANA
By and through its Board of Public Works and Safety
Jame Brainard, Pres'I'ng Officer Date
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Mary n Burke, Board Member Date
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Lori Wa .•n, Board Member Date
ATTEST:
Diana Cordray('I • MC, Clerk-Treasurer Date
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