Standard Security Life/HR/Policy STANDARD SECURITY LIFE INSURANCE COMPANY OF NEW YORK
(a New York Stock Life and Health Insurance Company)
Home Office:
485 Madison Avenue
New York, New York 10022
212-355-4141
POLICYHOLDER: City of Carmel
POLICY NUMBER: C-SSL-IHCRS-00114-14
EFFECTIVE DATE: 01/01/2014
EXPIRATION DATE: 12/31/2014
STATE OF DELIVERY: Indiana
This Policy is a legal contract. We issue it in consideration of: (1) Your Application, (2) Your Disclosure
Statement, and (3) Your payment of premiums when due. This Policy, Your Application, Your Disclosure
Statement, and a copy of the Plan form the entire agreement between You and Us.
In issuing this Policy, We have relied upon the information (including, without limitation, information in the
Disclosure Statement, Your Application, and the Plan) provided to Us by: (1) You, (2) Your Administrator,
and (3) Your agent or broker. We have also relied on this information being both complete and accurate.
If the information was incomplete or incorrect, We shall have the immediate right: (1) to modify the Policy
to reflect the complete or correct information, or (2) to terminate the Policy upon written notice.
We agree to make payments in accordance with the provisions of this Policy.
In this Policy, "You" and "Your" refer to the Policyholder, and "We", "Us", and "Our" refer to Standard
Security Life Insurance Company of New York.
This Policy is issued and governed by the laws of the state of delivery as indicated above.
Signed for Standard Security Life Insurance Company of New York as of the Effective Date.
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David T. Kettig Adam C. Vandervoort
President Secretary
EXCESS LOSS INSURANCE POLICY
Non-Participating
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SL2004 11/22/13
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 01/01/2013 through 12/31/2014; and
Eligible Expenses Paid from 01/01/2014 through 12/31/2014.
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: $13.095.341
4. AGGREGATE LOSS LIMIT(per Covered Person): $175,000
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: $890.61 Single: 157
Family: $2,326.29 Family: 409
Composite: $N/A Composite: 566
9. AGGREGATE PREMIUM ([N/A] Annual / X Per Employee Per Month):$9.50
10. MINIMUM AGGREGATE PREMIUM ([N/A] Annual / [N/A] Monthly): $N/A
11. PREMIUM PAYMENT MODE: Monthly
SL2004 i 11/22/13
B. [X] SPECIFIC/INDIVIDUAL EXCESS LOSS INSURANCE:
1. BENEFITS COVERED: X Medical X Prescription Drug Card
2. BENEFIT PERIOD:
Eligible Expenses Incurred from 01/01/2013 through 12/31/2014; and
Eligible Expenses Paid from 01/01/2014 throughl2/31/2014.
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): $175,000
Except for the following:
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; Benefit Period Maximum of $UNLIMITED•
per Covered Person for the Benefit Period shown above. .
6. RUN-IN/RUN-OUT LIMIT: • •• •
a N/A : $ N/A
7. MONTHLY SPECIFIC PREMIUM RATE/ENROLLMENT:
RATE: COVERED UNITS/ENROLLMENT:
Single: $41.11 Single: 157
Family: $110.84 Family: 409 .
Composite:$N/A Composite:566
8. MINIMUM SPECIFIC PREMIUM ([N/A] Annual/[N/A] Monthly): N/A •
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SL2004 ii 11/22/13
[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.
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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:
1. This Policy requires utilization of the GWH-Cigna PPO network, along with Cigna's Utilization
Management and LifeSource Transplant programs. Large Case Management will also be done by
Cigna. -
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AGREED: City of Carmel
Policyholder/You
Signature: •
-Name (pleas
Title: Signature Page Attached •
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Date:
SL2004 iii 11/22/13
CITY OF CARMEL, INDIANA
By and through its Board of Public Works and Safety •
/kmes Brainard, Presiding Officer Date
)71/ Ita.tt /, c/!
Mary A Burke, Board Member Date
Lori Watson; Board Member Date
ATTEST: /j��
qi( '_�" / 1 /—/Sc /
Diana Cordray, • C. Clerk-Treasurer Date
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