CNA 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
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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