ORDER NO. 28526
EMPLOYEE HEALTH INSURANCE
Came to be heard this the 12~' day of February, 2004 with a motion made by
Commissioner Letz, Seconded by Commissioner Williams, the Court unanimously
approved by a vote of 4-0-0 to approve the applications for excess loss insurance from
Cobalt, Inc and the application for excess loss insurance from Monumental Life
Insurance Company and authorize the Judge to sign the applications and contracts upon
arrival.
MONUMENTAL LIFE INSURANCE COMPANY
A Stock Company
Administrative Office: 1326 South Ridgewood Ave, Suite 11, Daytona Beach, Florida 32114
Phone: 1-888-500-EBUI (3284)
APPLICATION FOR EXCESS LOSS INSURANCE
The undersigned Applicant requests the Excess Loss Insurance Benefits shown herein and provided by Monumental Life Insurance
Company, and agrees to be bound by the terms and provisions of the Excess Loss Insurance Policy.
Full Legal Name of Applicant: Kerr, County of Rm, ~ (~"~
Address (street, city, state, and zip): 700 Main Street Kerrville TX 78028
Key Contact: Telephone: 830-792-2255 Tax ID: ~_'~ /000 'Y p 4
Applicant is a: ^ Corporation ^ Labor Union ^ Partnership ^ Association ^ Proprietorship ®Other: Municipality
Nature of Business of the Group to be Insured: Government Executive Offices
Total number of eligible lives: Employees 265 Dependents 60 Retirees
Requesting retiree coverage? ®YES Q NO
Requested Effective Date: January 1, 2004
Affiliates or Subsidiaries:
N/A
Addresses of Affiliates or Subsidiaries:
N/A
SPECIFIC EXCESS LOSS INSURANCE: ®YES ^ NO
Benefit Period: Covered Expenses Incurred from .Tanuarv 1, 2004 through December 31, 2004, and Paid from January 1, 2004 through
December 31, 2004; however, if the Policy is terminated before the end of the originally scheduled Policy Period set forth above, Covered
Expenses must be Incurred from January 1, 2004 through the termination date and Paid from January 1, 2004 through the termination date
to be eligible for reimbursement. However, Covered Expenses Incurred from N/A through N/A will be limited to N/A per ^ Covered
Person ^ Family.
Specific Deductible per ®Covered Person ^ Family: $40,000
Specific Percentage Reimbursable: 100%
Maximum Specific Benefit Per Covered Person per Lifetime(including Specific Deductible):
^ $500,000 ®$1,000,000 ^ $2,000,000 ^ Other $ N/A
Covered Expenses under Specific Excess Loss: ®Medical ®Stand Alone Prescription Drug Program
('ommon Accident Provision• ^ Yes ®No
S ecific Premium Rates er Month See item i on a e 2 of a lication fors ecial conditions
Em to ee	Number of lives: N/A	N/A
Sin le	Number of lives:	$ 38.47
Famil	Number of lives:	$ 89.22
N/A	Number of lives:	$ N/A
1. Specific Expedited Reimbursement Endorsement: ®YES
2. Specific Terminal Liability Endorsement: ^YES
3. Aggregating Specific Deductible Endorsement: ^YES
4. Other Endorsement: ^YES
Minimum Annual Specific Premium is 90% of the first month enrollments x ra
AGGREGATE EXCESS LOSS INSURANCE: ®YES ^ NO
^ NO Included
®NO N/A
® NO N/A
® NO N/A
tes x 12
Benefit Period: Covered Expenses Incurred from .Tanuarv 1, 2004 through December 31, 2004, and Paid from January 1, 2004 through
December 31, 2004; however, if the Policy is terminated before the end of the originally scheduled Policy Period set forth above, Covered
Expenses must be Incurred from .Tanuarv 1, 2004 through the termination date and Paid from .Tanuarv 1, 2004 through the termination date
to be eligible for reimbursement. However, Covered Expenses Incurred from N/A through N/A will be limited to $ N/A or N/A % of the
Annual Aggregate Deductible.
Covered Expenses under Aggregate Excess Loss Coverage: ®Medical ^ Dental ®Stand Alone Prescription Drug Program
^ Vision ^ Weekly (Disability) Income ^ Other (Please Specify) N/A
Aggregate Percentage Reimbursable: 100%
Maximum Aggregate Benefit: ^ $500,000 ®$1,000,000 ^ Other $ N/A
Minimum Annual Aggregate Deductible: $1,205.786 or 100% of the first Monthly Aggregate Deductible amount times 12, whichever is
greater.
MLSL35A2 (12/01)
Loss Limit per Covered Person $ 40,000
Aggregate Excess Loss Premium:
1. Aggregate Terminal Liability Endorsement:
2. Aggregate Accommodation Endorsement:
3. Other Endorsement:
® Monthly ^ Annually 5.73 seam
^ YES ®NO N/A
^ YES ®NO N/A
^ YES ®NO N/A
Monthly Aggregate Factors
	Medical	# of
lives	Prescription
Dru s	# of
lives	Dental	# of
lives	Vision	#of
lives
Employee	N/A	N/A	N/A	NIA	N/A	N/A	N/A	N/A
Single	277.35		Included		N/A	N/A	N/A	N/A
Family	727.09		Included		N/A	N/A	N/A	N/A
N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
Full Name of Third Party Administrator: Emaloyee Benefit Administrators. Inc.
Address:. (street, city, state, and zip): 355 Saencer Lane, Suite 101. San Antonio, TX 78201
Key Contact: Telephone: 210-738-1444 Fax: 210-738-9929
Agent or Broker: ~l-k ~io~n1~-~
SS No. or Tax ID: U ~h e ~.I~ 1 ~ ~' ~-~ , ?~ ~ ~'
Address: 3rjs S~pQ {^fi ~ >! i
It is understood and agreed by the undersigned that:
a. As a condition precedent to the approval of this Application, the undersigned shall furnish to the Company a copy of the executed
Plan Document describing the benefits provided by the Plan which shall be kept on file in the office of the Company. No Excess
Loss Insurance will be effective nor reimbursement made unless a Plan Document is received and accepted by the Company. In the
event of a material variance, in the judgement of the Company, between the Plan Document received by the Company and the Plan
benefit provisions upon which the terms and rates of the Aggregate and Specific Excess Loss Coverage were based, any Policy that
has been issued will not take effect unless a Plan Document is received, accepted, and on file in the Company's office.
b. The undersigned will provide or employ a Third Party Administrator (TPA) to administer the Plan and to process and pay claims
according to the Plan Document. The undersigned acknowledges that the TPA is the undersigned's agent and that statements and
answers given by the TPA are binding on the undersigned.
c. The receipt by the Company of the first month's premium and deposit of any check drawn in connection with this Application shall
not constitute an acceptance of liability. In the event the Company does not approve this application, its sole obligation shall be to
refund such premium to the undersigned.
d. Any Aggregate and/or Specific Excess Loss Insurance shall be described in the Policy issued.
e. Experience, census, and other information contained in the underwriting information as furnished by the Applicant directly, or
through its representative, are the primary data elements on which the Company's proposal was based. The undersigned will
provide any additional underwriting information required by the Company.
f. Any coverage resulting from this Application shall be subject to the terms and provisions of the Policy herein applied for. Coverage
shall become effective on the date specified in this Application if all requirements of the Company, including underwriting
requirements, have been met and the required premiums paid.
g. The undersigned represents that the statements, declazations and representations made in this Application, any request for proposal,
the underwriting information provided by or on behalf of the undersigned and the Plan Document accurately and completely reflect
the true facts. The undersigned understands that any Policy is issued in reliance upon the truth of such statements, declarations, and
representations; and that such statements, declarations, and representations aze part of this Application.
h. The Company will evaluate the undersigned's risk, and may require adjustments of rates, factors, and/or special limitations to
accommodate for abnormal risks.
i. Other: N/A
MLSL35A2 (12/01)
The undersigned has read the entire Application for Excess Loss Insurance and understands that the insurance requested herein is
not in effect until this Application is approved and accepted by the Company.
Full Legal Name of Applicant: Kerr Countv of
Signature of
Print Name:
Date: 7 - / Z - L~•O ~
Signature of Agent or Broker:
Print Name of Agent or Broker:
FRAUD WARNING NOTICES: (Please review notice that applies in your state)
For applicants in Arkansas and Louisiana:
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance, is guilty of a crime and may be subject to fines and confinement in prison.
For applicants in Colorado:
It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of
defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil
damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts
or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant
with regard to a settlement or award payable from insurance proceeds, shall be reported to the Colorado division of insurance within
the Department of Regulatory Agencies.
For applicants in District of Columbia:
WARNING: It is a crime to provide false or misleading information to an insurer for purpose of defrauding the insurer or any other
person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information
materially related to a claim was provided by the application.
For applicants in Florida:
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application
containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
For applicants in Kentucky, New Mexirn, Ohio, and Pennsylvania:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or
statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any
fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
For applicants in Maine, Tennessee and Virginia:
It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment, fines, or a denial of insurance benefits.
For applicants in New Jersey:
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil
penalties.
MLSL35A2 (12/01)
RATE PAGE FOR STOP LOSS COVERAGE
COBALT, INC.
Home Office: 5468 Martha Loop, Coeur d'Alene, Idaho 83815
Phone:l-208-667-8750
APPLICATION FOR EXCESS LOSS INSURANCE
Full Legal Name of Applicant: Kerr, County of
Address (street, city, state, and zip): 700 Main Street, Rm 122, Kerrville, TX 78028
Key Contact: Telephone: 830-792-2255 Tax ID:
Applicant is a: ^ Corporation ^ Labor Union ^ Partnership ^ Association ^ Proprietorship ®Other: Municipality
Nature of Business of the Group to be Insured: Government Executive Offices
Total number of eligible lives: Employees 265 Dependents 60 Retirees
Requesting retiree coverage? ®YES ^ NO
Requested Effective Date: January 1, 2004
Affiliates or Snbsidiaries:
N/A
Addresses of Affiliates or Subsidiaries:
N/A
SPECIFIC EXCESS LOSS INSURANCE: ®YES ^ NO
Benefit Period: Covered Expenses Incurred from Jsnuary 1, 2004 through December 31, 2004, and Paid from Jsnuary 1, 2004 through
December 31, 2004; however, if the Policy is terminated before the end of the originally scheduled Policy Period set forth above, Covered
Expenses must be Incurred from January 1, 2004 through the termination date and Paid from Janusry 1.2004 through the termination date
to be eli ible for reimbursement. However, Covered Expenses Incurred from N/A through N/A will be limited to N/A per ^ Covered
Person [~] Family.
Specific Deductible per ®Covered Person ^ Family: 540,000
Specific Percentage Reimbursable: 100%
Maximum Specific Benefit Per Covered Person per Lifetime(including Specific Deductible):
^ 5soo,ooo ®51,000,000 ^ 52,000,000 ^ Other s wA
Covered Expenses under Specific Excess Loss: ®Medical ®Stand Alone Prescription Drug Program
Common Accident Provision- Yes No
Gross S ecific Premium Rates er Month ncludes underwritin fees and commission. Net risk remium rates on followin a e.
Em to ee	Number of lives: N/A	N/A
Sin le	Namber of lives:	5 46.35
Fam~1	Namber of lives:	$ 107.49
N/A	Namber of lives:	5 N/A
1. Specific Expedited Reimbursement Endorsement: ®YES
2. Specific Terminal Liability Endorsement: ^ YES
3. Aggregating Specific Deductible Endorsement: ^ YES
4. Other Endorsement: ^ YES
Minimum Annual Specific Premium is 90% of the first month enrollments x ra
AGGREGATE EXCESS LOSS INSURANCE: ®YES ^ NO
^ NO Included
®NO N/A
® NO N/A
®NO N/A
tes a 12
Benefit Period: Covered Expenses Incurred from January 1, 2004 through December 31, 2004, and Paid from January 1, 2004 through
December 31, 2004; however, if the Policy is terminated before the end of the originally scheduled Policy Period set forth above, Covered
Expenses must be Incurred from January 1, 2004 through the termination date and Paid from January 1, 2004 through the termination date
to be eligible for reimbursement. However, Covered Expenses Incun;ed from N/A through N/A will belimited to S N/A or N/A % of the
Annual Aggregate Deductible.
Covered Expenses under Aggregate Excess Loss Coverage: ®Medical ^ Dcntal ®Stand Alone Prescription Drug Program
^ Vision ^ Weekly (Disability) Income ^ Other (Please Specify) N/A
Aggregate Percentage Reimbursable: 100%
Maximum Aggregate Benefit: ^ $500,000 ®$1,000,000 ^ Other S N/A
Minunum Annual Aggregate Deductible: S1,205,786 or 100% of the first Monthly Aggregate Deductible amount times 12, whichever is
greater. Gross Aggregate Premium Rate per employee per month, inclading underwriting fees and commission: 56.90
MLSL35A2 (12/01)
ORDER NO. 28526
EMPLOYEE HEALTH INSURANCE
Came to be heard this the 12~' day of February, 2004 with a motion made by
Commissioner Letz, Seconded by Commissioner Williams, the Court unanimously
approved by a vote of 4-0-0 to approve the applications for excess loss insurance from
Cobalt, Inc and the application for excess loss insurance from Monumental Life
Insurance Company and authorize the Judge to sign the applications and contracts upon
arrival.