0510041.11
COMMISSIONERS' COURT AGENDA REQUEST
PLEASE FURNISH ONE ORIGINAL AND NINE COPIES OF THIS
REQUEST AND DOCUMENTS TO BE REVIEWED BY THE COURT.
MADE BY: Pat Tinley OFFICE: County Judge
MEETING DATE: May 10, 2004 TIME PREFERRED:
SUBJECT: (PLEASE BE SPECIFIC Review, discuss and consider approval and acceptance
of 2004 Excess Loss (Stop Loss) enclosed Insurance Policy as presented by Employee Benefit
Administrators.
EXECUTIVE SESSION REQUESTED: (PLEASE STATE REASON)
NAME OF PERSON ADDRESSING THE COURT: County Judge
ESTIMATED LENGTH OF PRESENTATION:
IF PERSONNEL MATTER -NAME OF EMPLOYEE:
Time for submitting this request for Court to assure that the matter is posted in
accordance with Title 5, Chapter 551 and 552, Government Code, is as follows:
Meeting scheduled for Mondays: 5:00 P.M. previous Tuesday.
THIS REQUEST RECEIVED BY:
THIS REQUEST RECEIVED ON:

All Agenda Requests will be screened by the County Judge's Office to determine if adequate
information has been prepared for the Court's formal consideration and action at time of Court
Meetings. Your cooperation will be appreciated and contribute towards you request being
addressed at the earliest opportunity. See Agenda Request Rules Adopted by Commissioners'
Court.
ivIC1NUMENTAL LIFE INSURANCE COMPANY ~~~
A Stock Company
Administrative Office: 1326 South Kidgewood Ave, Suite 11, Daytona Beach, Florida 32114
Phone: 1-888-800-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, Y'~110`1
Address (street, city, state, and zip}: 700 Main Street,~2, Kerrville, TX 78028
Key Contact: Telephone: 830-792-2255 Tax ID: ~_'~ /000 ('r(
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 t~
Requesting retiree coverage? ®YES 0 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 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 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
Common Accident Provision: n Yes ~ No
S ecific Premium Rates per 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:	$ NIA
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 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 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)
RATE PAGE FOR STOP LOSS COVERAGE
COBALT, INC.
Nome 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
Kcy 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 Datc: January 1, 2004
Affiliates or Subsidiaries:
N/A
Addresses of Affiliates or Subsidiaries:
NIA
SPECIFIC EXCESS LOSS INSURANCE: ®YES ^ NO
Benefit Period: Covered Expenses Incurred from January I, 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 NIA 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
Common Accident Provision: ^ Yes ®No
Gross S ecific Premium Rates er Month Includes underwritin fees and commission. Net risk remium rates on followin a e.
Em loyee	Number of lives: N/A	NIA _ _~_
__
Sin le	Number of lives:	$ 46.35 _ __
_ _ _
Famil	Number of lives:	$ 107.49 _
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 a ra
AGGREGATE EXCESS LOSS INSURANCE: ®YES ^ NO
^ NO Included
®NO N/A
® NO N/A
® NO N/A
tes z t 2
Benefit Period: Covered Expenses Incurred from January 1, 2004 through December 31, 2004, and Paid from January 1, 2004 thraugh
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 or N/A % of the
Annual Aggregate Deductible.
Covered Expenses under Aggregate Excess Loss Coverage: ®Mediral ^ 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 $ NIA
Minimum Annual Aggregate Deductible: $1.205,786 or 100% of the first Monthly Aggregate Deductible amount times 12, whichever is
greater. Gross Aggregate Premium Rate per employee per month, including underwriting fees and commission: $6.90
MLSL35A2 (12/O1)
r ~»;~, 1 r,ait per Covered Person $ 40,000
Aggregate Excess Loss Premium:
1. Aggregate Terminal Liability Endorsement
2. Aggregate Accommodation Endorsement:
Other Endorsement:
® Monthly ^ Annually 5.73 pepm
^ YE:S ®NO N/A
^ YE:S ®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	N/A	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	NIA
N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
Full Name of Third Party Administrator: Employee Benefit Administrators, Inc.
Address:. (street, city, state, and zip): 355 Spencer Lane, Suite 101, San Antonio, TX 78201
Key Contact: Telephone: Z10-738-1444 Fax: 210-738-9929
Agent or Broker: ~ C lrk ~~tt'vl~ t 1
SS No. or Tax ID: ~~ ~ Z7 Z l/ 5~ ~ T-Fo" 1O', .A~ ~ 7~ ~~ ~ U r{
Address: 35s 5~~~~ ~V.h~~ f
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 shalt 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 an~1 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 inforration 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, declarations 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 are 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
MLSL35 A2 (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, County of
Signa
Print 1
Date:
Signa
Print
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 Mexico, 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)
IMPORTANT NOTICE
To obtain information or to make a complaint:
You may call Monumental Life Insurance Company's
toll-free telephone number for information or to make
a complaint at:
1-888-500-EBUI (3284)
You may also write Monumental Life Insurance
Company at:
Monumental Life Insurance Company
Administrative Office
1326 South Ridgewood Ave, Suite 11
Daytona Beach, Florida 32114
You may contact the Texas Department of Insurance
to obtain information on companies, coverages, rights
or complaints at:
1-800-252-3439
You may write the Texas Department of Insurance at:
P.O. Box 149104
Austin, TX 78714-9104
FAX # (512) 475-1771
AVISO IMPORTANTE
Para obtener information o para someter una queja:
Usted puede Ilamar al numero de telefono gratis de
Monumental Life Insurance Company para information
o para someter una queja al:
1-888-500-EBUI (3284)
Usted tambien puede escribir a Monumental Life
Insurance Company:
Monumental Life Insurance Company
Administrative Office
1326 South Ridgewood Ave, Suite I1
Daytona Beach, Florida 32114
Puede comunicarse con el Departamento de Sequros de
Texas para obtener information acerca de companias,
coberturas, derechos o quejas al:
1-800-252-3439
Puede escirbir al Departamento de Seguros de Texas:
P.O. Box 149104
Austin, TX 78714-9104
FAX # (512) 457-1771
PREMIUM OR CLAIM DISPUTES: DISPUTAS SOBRED PRIMAS O RECLAMOS:
Should you have a dispute concerning your premium Si tiene una disputa concerniente a su prima o a un
or about a claim, you should contact the company first. reclamo, debe comunicarse con la compania primero. Si
If the dispute is not resolved, you may contact the no se resuelve la disputa, pude entonces comunicarse
Texas Department of Insurance. con el departamento (TDI).
ATTACH THIS NOTICE TO YOUR POLICY: UNA ESTE AVISO A SU POLIZA:
This notice is for information only and does not become Esto aviso es solo para propositio de information y no se
apart or condition of the attached document. convierte en parte o condition del documento adjunto.
Form No. ACN-TX-MP (8/95)
Monumental Life Insurance Company
MLI010712 -Kerr
A Stock Company
Administrative Office: 1326 South Ridgewood Ave, Suite 11, Daytona Beach, FL 32114
Phone:l-888-500-EBUI (3284)
Monumental Life Insurance Company ("Company"), agrees to reimburse the Insured as outlined under the provisions of
this Excess Loss Insurance policy ("Policy").
This Policy is legally binding between the Insured and Monumental Life Insurance Company. The consideration for this
Policy includes, but is not limited to, the Application and the Payment of premiums as provided hereinafter.
The Insured is entitled to the reimbursement described in this Policy if the Insured is eligible for insurance under the
provisions of this Policy. Reimbursement is subject to the terms and conditions of this Policy.
The first premium is due on the first (1st) day of the Policy Period. Subsequent monthly premiums are due on the first
(1st) day of each month thereafter. The premium is not considered paid until the premium payment is received by the
Company.
All periods of coverage will begin and end 12:01 a.m. local time at the principal office of the Insured.
1
This Pvlicy is delivered in and is governed by the laws of the state of issue.
This is not a policy of ~'i orkers' (:ompensation Insururce. The Insured does not become a subscriber to the
«'orkers' Cotpensation system by purchasing this Policy, and if the Insured is anon-subscriber, the Insured
loses certain common-law defenses as well as certain limitations on liability that would otherwise be available
under the ~i'orkers' Compensation law as it pertains to non-subscribers and the rc;yuired notifications that must
be tiled and posted.
The Insured understands the liability assutued under the portion of the employee benefit plan which it is self-
insuring and further understands that the Insured is exempted from Article 1.14-1 of the Texas Insurance Code
only if x yualiticd employee benefits plan has been filed and meets the requirements of ERISA.
IN WITNESS WHEREOF Monumental Life Insurance Company has caused this Policy to be executed by its
President and Secretary at our Home Office in Baltimore, Maryland.
/N~«y ~0
0
Secretary
MLSL25CTX (3/O1)
6~~'-~
President
EXCESS LOSS INSURANCE POLICY
MLI010712 -Kerr
TABLE OF CONTENTS
SCHEDULE OF EXCESS LOSS COVERAGE
DEFINITIONS
EFFECTIVE DATE OF COVERAGE
PREMIUM AND FACTORS PROVISIONS
REIMBURSEMENT PROVISIONS
TERMINATION PROVISIONS
REINSTATEMENT PROVISIONS
SUBSEQUENT POLICY PERIOD PROVISIONS
GENERAL PROVISIONS
GENERAL EXCLUSIONS PROVISION
SPECIFIC EXPEDITED REIMBURSEMENT ENDORSEMENT
CONT-1
DEFINITIONS
ACTIVELY AT WORK means the performance of all the regular duties of employment by the Covered Employee for
MLI010712 -Kerr
the Insured on a full-time basis (as specified in the Plan Document), at normal pay at the Covered Employee's normal
place of business. An employee will be considered Actively at Work on each day of a regular paid vacation or a regular
non-working day on which he or she is not disabled, if he or she was Actively at Work on his or her last scheduled work
day.
AGGREGATE PERCENTAGE REIMBURSABLE is set forth in the Schedule of Excess Loss Coverage.
ANNUAL AGGREGATE DEDUCTIBLE for any one Policy Period means the greater of: (a) sum of the Monthly
Aggregate Deductibles; or (b) the Minimum Annual Aggregate Deductible.
BENEFIT PERIOD means the period of time specified in the Schedule of Excess Loss Coverage in which a Covered
Expense must be Incurred by the Covered Person and Paid by the Plan to be eligible for reimbursement under this
Policy. This period does not after the Effective Date, Policy Period, or waive this Policy's eligibility requirements.
COVERED EMPLOYEE means an employee of the Insured who is eligible for coverage under the Plan, and is
otherwise eligible for benefits under the Plan and covered under the Plan.
COVERED EXPENSE means medical or other expenses under the Plan to which this Policy applies, as shown in the
Schedule of Excess Loss Coverage, and which are not specifically excluded by the terms of this Policy. Covered
Expense does not include any payment for the cost of administrating the Plan or other Insured contracted services.
This Policy will reimburse, as a Covered Expense, the patient services tax as imposed by the New York Care Reform
Act of 1996 (HCRA) or the surcharge imposed by the Massachusetts Uncompensated Care Pool. Any other tax or
surcharge levied by any state or other governmental subdivision will not be considered a Covered Expense under this
Policy.
COVERED PERSON means (a) a Covered Employee, (b) a dependent of a Covered Employee which dependent is
eligible for coverage under the Plan, and is otherwise eligible for benefits under the Plan and covered under the Plan,
or (c) if requested in the application, a covered retired employee as defined by the Plan Document; however, unless
the Actively at Work/Disability requirement is waived as shown on the Schedule of Excess Loss Coverage, a
Covered Person does not include:
(1) any Covered Employee who is not Actively at Work either on the Effective Date or the effective date of his
or her coverage under the Plan, whichever is later, or eligible dependents of such Covered Employee, until
the Covered Employee returns to Actively at Work status; or
(2) any dependent of a Covered Employee if such dependent is, on the Effective Date or the effective date of
his or her coverage under the Plan, whichever is later, either hospital-confined or unable to perform the
normal activities of a person of like sex and age in good health, until the end of such confinement or
disability.
Waiver of the Actively at Work/Disability requirement does not affect the obligation of the Insured and the Third
Party Administrator to disclose information requested by the Company for underwriting purposes and does not affect
the Company's rights in event of failure to disclose such information.
COVERED UNIT means the following: (a) an employee covered as one individual under the Plan; (b) an employee
and dependents covered under the Plan; or (c) such other defined unit or units as agreed upon between the Company and
Insured. The types of Covered Units and the factors and premium rates for each type are shown in the Schedule of
Excess Loss Coverage.
EFFECTIVE DATE is the date set forth in the Schedule of Excess Loss Coverage.
EMPLOYEE BENEFIT PLAN (Also known as the PLAN) means the self-funded health care plan established by the
plan sponsor to provide certain benefits to Covered Persons.
INCURRED means with respect to medical services or supplies, the date on which the services are rendered or supplies
are purchased by the Covered Person; and, with respect to disability income benefits if selected in the Schedule of
Excess Loss Coverage, the date each periodic benefit payment becomes payable to the Covered Person (not the date the
disability commences).
DEF-1
INSURED means the entity requesting Excess Loss Insurance
LOSS, LOSSES means amounts actually Paid by the Plan for Covered Expenses.
MLI010712 -Kerr
LOSS LIMIT PER COVERED PERSON is set forth in the Schedule of Excess Loss Coverage. However, if claims
are Paid under the Plan for a Covered Person for benefits that are covered under Aggregate Excess Loss Insurance, but
not covered under Specific Excess Loss Insurance, the Loss Limit for that Covered Person will be increased by the
amount of such Payment.
MAXIMUM AGGREGATE BENEFIT is set forth in the Schedule of Excess Loss Coverage.
LIFETIME MAXIMUM SPECIFIC BENEFIT is set forth in the Schedule of Excess Loss Coverage.
MINIMUM ANNUAL AGGREGATE DEDUCTIBLE is set forth in the Schedule of Excess Loss Coverage.
MONTHLY AGGREGATE DEDUCTIBLE means, with respect to a particular month, the total number of Covered
Units for that given Policy month multiplied by the corresponding Monthly Aggregate Factors as specified in the
Schedule of Excess Loss Coverage. However, in the event of a reduction in the number of Covered Units under the
Plan, the Monthly Aggregate Deductible cannot be reduced to less than one twelfth of the Minimum Annual Aggregate
Deductible.
MONTHLY AGGREGATE FACTORS are set forth in the Schedule of Excess Loss Coverage
PAY, PAID, PAYMENT means checks or drafts issued and deposited in the U.S. Mail or otherwise delivered to the
payee, with sufficient funds on deposit to honor all outstanding drafts and checks.
PLAN DOCUMENT means the written document approved by the plan sponsor which describes the Plan. A copy of
the Plan Document in effect on the Effective Date is attached to the application for Excess Loss Insurance and made a
part of this Policy.
POLICY PERIOD means the specified period in the Schedule of Excess Loss Coverage, however beginning no earlier
than the Effective Date of this Policy and cuntinuing until coverage terminates in accordance with the Termination
Provisions.
SPECIFIC DEDUCTIBLE is set forth in the Schedule of Excess Loss Coverage. The Specific Deductible will apply
separately to each Benefit Period.
SPECIFIC PERCENTAGE REIMBURSABLE is set forth in the Schedule of Excess Loss Coverage.
THIRD PARTY ADMINISTRATOR means a firm or person who has been retained by the Insured to Pay claims
and/or provide administrative services on behalf of the Insured/Plan.
DEF-2
MLI010712 -Kerr
EFFECTIVE DATE OF COVERAGE
Coverage under this Policy is not effective until (a) payment of the first {1st) premium; (b) receipt of a signed
Application for Excess Loss Insurance; and (c) receipt, examination and acceptance by the Company of the Plan
Document and all other information which is material to underwriting or premium rating, whether or not specifically
requested.
PREMIUMS AND FACTORS PROVISIONS
PAYMENT OF PREMIUMS For coverage to remain in effect, any subsequent monthly premium must be received by
the Company by the first (151) day of each month. Premiums are not considered paid until the premium payment is
received by the Company.
Premiums or other payments made by the Insured to their Third Party Administrator or Agent or Broker shalt not be
deemed or considered payments to the Company until actually received by the Company.
GRACE PERIOD A Grace Period of thirty-one (31) days from the due date will be allowed for the payment of each
premium after the first. During the Grace Period, the coverage will remain in effect provided the full premium is paid
before the end of the Grace Period. Coverage will automatically terminate as of the end of the day on the due date of
any premium which remains unpaid at the end of the Grace Period. ~
PREMIUM AMOUNT The premiums will be calculated using rates determined by the Company as set forth in the
Schedule of Excess Loss Coverage. The amount of total premium due each month is the sum obtained by multiplying the
applicable premium rates shown in the Schedule of Excess Loss Coverage by the actual number of appropriate Covered
Units.
The Insured will be liable for any premium taxes assessed at any time against the Company beyond any taxes which may
be payable on the premium received 6y the Company.
All requests for adjustments, credits or refunds because of overpayment of premiums shall be reported, in writing, with
accompanying detail within sixty (60) days after termination of the applicable Policy Period.
The Company will not refund any portion of the premiums paid if this Policy terminates during the Policy Period.
SET OFF The Company shall be entitled to set off against reimbursements due the Insured under this Policy any
premiums due and unpaid, any overpayments or other reimbursements made in error or upon incorrect information, and
any other amounts due the Company.
PREMIUM RATE AND AGGREGATE DEDUCTIBLE FACTOR CHANGE The Company may change the
Insured's premium rates or factors as of any of the following:
a) the date when the terms of this Policy are changed;
b) the date the Plan Dcx;ument changes are accepted by the Company;
c) the date the Insured adds or deletes subsidiary or affiliated companies or divisions;
d) the date the number of Covered Units on any premium due date varies more than fifteen percent (15%) from
the number of Covered Units on the Effective Date; or
e) the date the Insured changes its Third Party Administrator.
The Company reserves the right to recalculate the premium rates and the Monthly Aggregate Factors retroactively for
the Policy Period, if there is more than a ten percent (10%) variance between:
a) the average monthly Paid claim cost per Covered Employee under the Plan for the last two (2} months of the
prior Policy Period; and
b}the average monthly Paid claim cost per Covered Employee under the Plan for the first [en (10) months of the
prior Policy Period.
PREFAC-1
MLI010712 -Kerr
REIMBURSEMENT PROVISIONS
NOTICE OF LOSS The Insured will give written notice of Losses to the Company on the Company's customary proof
of loss form, within thirty (30) days of the date the Insured becomes aware of the existence of facts which would
reasonably suggest the possibility that expenses covered under the Plan will be Incurred which are equal to or exceed
fifty percent (50%) of the Specific Deductible or $50,000, whichever is less.
PAYMENT BY PLAN
While the determination of benefits under the Plan is the sole responsibility of the Insured, the Company reserves the
right to interpret the terms and conditions of the Pian Document as it applies to this Policy. The Company will have the
sole authority to reimburse or deny reimbursement under this Policy.
The Insured will Pay all eligible claims under the Plan within thirty (30) days from the date adequate proof of loss is
provided to the Insured. If the Insured fails to Pay a claim within the thirty (30) day time limit, that claim will not count
toward the satisfaction of the deductibles or be reimbursed under this Policy.
The Insured agrees to provide funds for payment of all eligible expenses under the Plan. If the Insured fails to provide
funds for timely payment: a) coverage under this Policy will immediately terminate; and b) any Aggregate and/or
Specific Deductible will be deemed not satisfied.
SPECIFIC EXCESS LOSS INSURANCE
The Schedule of Excess Loss Coverage indicates whether Specific Excess Loss Insurance is provided under this Policy.
If, while this Policy is in effect, the Losses for a Covered Person for the applicable Benefit Period exceed the Specific
Deductible, the Company will reimburse the Insured, subject to the terms and conditions of this Policy including the
limits set forth in the Schedule of Excess Loss Coverage, within thirty (30) days after:
(a) the Company's acceptance of the proof of loss as a satisfactory proof;
(b) the Company's receipt of proof of Payment of the benefits by the Insured under the Plan to, or on behalf of,
the Covered Persons; and
(c) completion of an audit of the claim, if requested by either the Insured or the Company, which payment by
the Insured is expressly agreed to be a condition precedent to payment.
The amount of the reimbursement will be equal to the Specific Percentage Reimbursable times the amount by which
Losses exceed the Specific Deductible amount, but will not exceed the Lifetime Maximum Specific Benefit. For
purposes of determining whether such Lifetime Maximum Specific Benefit has been exceeded, Losses Incurred or
Paid in any other period of excess loss coverage are included.
Losses for any Covered Person during the Policy Period will be determined according to the Benefit Period described in
the Schedule of Excess Loss Coverage. The Specific Deductible applies separately to each Covered Person during a
Benefit Period.
If Specific Excess Loss Insurance terminates before the end of the Policy Period, the Specific Deductible will not be
reduced.
AGGREGATE EXCESS LOSS INSURANCE
The Schedule of Excess Loss Coverage indicates whether Aggregate Excess Loss Insurance is provided under this
Policy. If the Losses for the applicable Benefit Period subject to the Loss Limit Per Covered Person, exceed the Annual
Aggregate Deductible for the Policy Period, the Company will reimburse the Insured, subject to the terms and conditions
of this Policy including the limits set forth in the Schedule of Excess Loss Coverage, within thirty (30) days after:
(a) the Company's acceptance of proof of loss as satisfactory proof;
(b) the Company's receipt of proof of Payment of eligible expenses under the Plan; and
(c) completion by the Company of a satisfactory on-site audit of the claims, eligibility and all records relevant to
a claim under Aggegate Excess Loss Insurance, if the Company elects to do so.
The amount of the reimbursement will be equal to the Aggregate Percentage Reimbursable times the amount by which
Losses exceed the Annual Aggregate Deductible amount, but will not exceed the Maximum Aggregate Benefit. The
Annual Aggregate Deductible for any one Policy Period means the greater of: (a) the sum of the Monthly Aggregate
Deductibles; or (b) the Minimum Annual Aggregate Deductible.
REIM-1
MLI010712 -Kerr
For purposes of determining amounts payable under this Aggregate Excess Loss Insurance, Losses pertaining to each
Covered Person during the Benefit Period will be limited to [he Loss Limit Per Covered Person. Losses will not include
any amounts reimbursed by the Company under any other provision of this Policy. Any Loss that is Incurred at a time
when the person to whom the Loss relates is not a Covered Person will not be eligible for Aggregate Excess Loss
Insurance and will not be considered for the purpose of satisfying the Annual Aggregate Deductible.
However, if coverage terminates before the end of the Policy Period, the Annual Aggregate Deductible will be
deemed not satisfied and the Company will not be liable for reimbursement of any benefits under this Aggregate
Excess Loss Insurance.
i
REIM-2
ML[010712 -Kerr
TERMINATION PROVISIONS
This Policy and coverage provided hereunder will terminate upon the earliest of:
a) the premium due date of any premium which remains unpaid at the end of the Grace Period;
b) the premium due date next following receipt by the Company of written notice from the Insured that this Policy
is to be terminated;
c) the date of termination of the Plan;
d) the date the Insured suspends active business operations or dissolves; or
e) the end of the Policy Period.
This Policy may also be terminated, at the Company's option on the earliest of:
a) the last day of the third (3`~) consecutive month during which there are less than fifty-one (51) employees
enrolled in the Plan, unless the Company agrees, in writing, to continue coverage; or
b) the date the Insured fails to comply with the terms of this Policy.
The Company will not refund any portion of the premiums paid if this Policy is terminated during the Policy Period.
REINSTATEMENT PROVISIONS
If this Policy terminates for any of the reasons set forth above, the Company may, at its option, approve the Insured's
request to reinstate this Policy. The Insured shall submit to the Company any forms and data the Company may require.
If this Policy is reinstated, the Insured shall pay to the Company the premiums due from the date this Policy terminated.
SUBSEQUENT POLICY PERIOD PROVISIONS
At the end of a Policy Period, a subsequent Policy Period may be agreed upon in writing by the Company and the
Insured. The terms and conditions for a subsequent Policy Period will be evidenced by the issuance of a new Schedule
of Excess Loss Coverage by the Company which shows the new premium rates, Benefit Period and other new terms.
This Policy is not automatically renewable.
TERM-1
MLI010712 -Kerr
GENERAL PROVISIONS
ARBITRATION Any dispute arising out of or relating to this Policy, or the breach thereof, shall be settled by
Arbitration in accordance with the rules of the American Arbitration Association, and judgement upon the award
rendered by the arbitrators may be entered in any court having jurisdiction. The arbitrators may not award any punitive
or exemplary damages. This provision will survive the termination or expiration of this Policy.
ASSIGNMENT Reimbursement under this Policy may not be assigned by the Insured, and the Company will not
recognize any such assignment.
AUDITS The Company will have the right: (a) to inspect and audit al] records and procedures of the Insured and Third
Party Administrator, developed and maintained for the Plan, that are applicable to the administration of this Policy; and
(b) to require, upon request, proof satisfactory to the Company that Payment has been made to the Covered Person or the
provider of such services or benefits which are the basis for any Loss by the Insured hereunder.
CHANGES TO THE PLAN DOCUMENT If the Plan Document in effect on the Effective Date is subsequently
amended, notice of the amendment will be given to the Company prior to the effective date of the change. If the
Company does not give written acceptance of the amendment, the Company will only provide coverage under this
Policy consistent with the Plan Document prior to amendment. The Company's reimbursement will be made
according to the amended Plan, once the notice is received and accepted.
i
CHANGES TO THE POLICY Only the President, a Vice President, or the Secretary of the Company have the
authority to alter [his Policy, or to waive any of the Company's rights and then only in writing. No such alteration of this
Policy shall be valid unless endorsed and attached to this Policy. No agent, broker, or Third Party Administrator has the
authority to alter this Policy or to waive any of its provisions.
CLERICAL ERROR Clerical errors, whether by the Insured or by the Company, in keeping or transmitting any
records pertaining to the coverage, will not invalidate or limit coverage otherwise validly in force nor continue coverage
otherwise validly terminated. Clerical error does not include any failure of the Insured, the Third Party Administrator or
any agent of the Insured: (a) to comply with the requirements relating to notice of claims or payment of claims; or (b) to
disclose underwriting information requested by the Company, whether or not intentional and regardless of the actual
knowledge of the person providing the information.
CONCEALMENT, FRAUD This entire Policy will be void (a) if, before or after a claim or Loss, the Insured, the
Third Party Administrator or any agent of the Insured has concealed or misrepresented any material fact or circumstance
concerning this Policy, including any claim, or (b) in any case of fraud by the Insured, the Third Party Administrator, or
any agent of the Insured relating to this Policy.
CONFORMITY WITH LAW If any provision of this Policy is contrary to any law to which it is subject, such
provision is hereby amended to conform to the minimum requirements of such law.
ENTIRE CONTRACT The Entire Contract between the Company and the Insured will consist of this Policy, the
application, approved amendments or endorsements, and a copy of the Plan Document which is on file with the
Company.
INSOLVENCY Nothing in this Policy shall either relieve an insolvent or bankrupt Insured from the obligation to pay
premiums when due or delay or abate cancellation of this Policy for failure to do so. The insolvency, bankruptcy,
financial impairment, receivership, voluntary plan of arrangement with creditors, or dissolution of the Insured or the
Insured's Third Party Administrator will not impose upon the Company any liability other than the liability defined in
this Policy. In particular, the insolvency of the Insured will not make the Company iiable to the creditors of the Insured,
including Covered Persons under the Plan.
INSURED REQUIREMENTS The Insured will submit by the twentieth (20th} day of each month ail proofs, reports,
and supporting documents required by the Company, including, but not limited to, a monthly summary of all eligible
claims Payments processed by the Insured and number of each type of Covered Units under the Plan during the prior
month. The Insured will be responsible for the investigation, auditing, calculating and the Payment of all claims under
the Plan.
GEN- I
LEGAL ACTION The Insured cannot file suit until ninety (90) days after the date on which proof of loss is given to
MLI010712 -Kerr
the Company. The Insured cannot file suit more than three (3) years after the date on which the Insured must give the
Company proof of claim. The three (3) year limitation is extended, if necessary, to agree with the period allowed by the
laws of the state of issue.
LIABILITY The Company will have neither the right nor the obligation under this Policy to directly pay any Covered
Person or provider of professional or medical services. The Company's sole liability is to the Insured, subject to the
terms and conditions of this Policy. Nothing in this Policy shall be construed to permit a Covered Person to have a direct
right of action against the Company. The Company will not be considered a party to the Plan of the Insured, or to any
supplement or amendment to it.
MISSTATED DATA The Company has relied upon the underwriting information provided by the Insured, the Third
Party Administrator or any agent of the Insured, in the issuance of this Policy. Should information in existence prior to
issuance of this Policy subsequently become known which would have affected the rates, deductibles, terms or
conditions for coverage, the Company will have the right to revise the rates, deductibles, terms or conditions as of the
Effective Date of issuance, by providing written notice to the Insured.
NOTICE FROM THE COMPANY TO THE INSURED For the purpose of any notice required from the Company
under the provisions of this Policy, notice to the Insured's Third Party Administrator shall be considered notice to the
Insured and notice to the Insured shall be considered notice to the Insured's Third Party Administrator.
OTHER COVERAGE The reimbursement provided by [his Policy is in excess of other coverage such as group
insurance, excess insurance, insurance, plan benefits, including insurance or plan benefits established by any federal,
state, or local law.
PARTIES TO THE POLICY The parties to this Policy are the Insured and the Company. The Company's sole
liability under this Policy is to the Insured. This Policy does not create any right or legal relation between the Company
and a Covered Person under the Plan. This Policy will not be deemed to make the Company a party to any agreement
between the insured and the Third Party Administrator.
RECORDS The Insured will maintain records of all Covered Persons under the Plan during the Policy Perod and for a
period of seven (7) years after the end of the Policy Period. The Insured will make all such records available to the
Company as needed to evaluate its liability under this Policy.
The Insured will maintain a separate record of any and all amounts Paid in excess of benefits eligible under the Plan.
SEVERABILITY CLAUSE Any clause deemed void, voidable, invalid, or otherwise unenforceable, whether or not
such a provision is contrary to public policy, will not render any of the remaining provisions of this Policy invalid.
TERMINATION OF THE INSURED'S PLAN The Insured will immediately notify the Company, if the Plan is
terminated.
THIRD PARTY ADMINISTRATOR The Insured may retain a Third Party Administrator to act as an agent for the
Insured in performing any or all of the duties as designated by the Insured. Without waiving any of its rights under this
Policy, and without making the designated Third Party Administrator a party to this Policy, the Company agrees to
recognize the Third Party Administrator as an agent of the Insured. The Insured will immediately notify the Company in
writing if the agreement between the Insured and the Third Party Administrator terminates.
THIRD PARTY RECOVERY The Plan shall undertake to pursue any and all valid claims that the Plan may have
against third parties arising out of any occurrence resulting in a payment by the Plan or the Company, and to account
for and pay to the Company any amounts recovered which were previously reimbursed by the Company to the
Insured under this Policy, regardless of whether this Policy is still in force on the date of recovery. Third party shall
mean another person, entity, or insurance company. Additionally, the Insured or Plan administrator shall GEN-2
notify the Company immediately upon discovering that a
claim against a third party may exist. Should the Insured fail to pursue any valid claims against a third party and the
Company becomes liable to reimburse the Plan, then the Company shall have the right to exercise and enforce all of
the Insured and/or Plan's rights against such third party.
Company shall also be assigned all rights of recovery if a payment is made for which the Plan is or becomes entitled
MLI010712 -Kerr
to receive payment from a third party.
If the Payment received from a third party is less than the total amount paid by the Plan on behalf of the Covered
Person, the Company is entitled to recover first, in full, any amount paid by the Company under this Policy as well as
any expenses of collection incurred by the Company. All remaining amounts shall be paid to the Insured.
GEN-3
MLI010712 -Kerr
GENERAL EXCLUSIONS PROVISIONS
The Company will not reimburse the Insured for any of the following:
(a) Any payment which does not strictly comply with the terms and conditions of the Plan Document;
(b) Any payment or expense caused by or resulting from war, declared or undeclared, invasion, acts of
foreign enemies, hostilities, civil war, rebellion, insurrection, military or usurped power, or martial law or
confiscation by order of any government or public authority;
(c) Any payment for litigation costs and expenses, extra-contractual damages, compensatory damages,
exemplary and punitive damages or liabilities, including but not limited to those resulting from
negligence, intentional wrongs, fraud, bad faith or strict liability on the part of the Insured, Plan, Third
Party Administrator or any agent or representative of the Insured, Plan or Third Party Administrator;
(d) Any payment or expense for accident or illness arising out of activities performed for profit, including
self-employment;
(e) Any payment for occupational accidents or illnesses which are also eligible expenses covered by Workers'
Compensation or Occupational Disease law, or similar legislation, whether or not coverage under such law is
actually in force;
(f) Any payment which is recoverable under the Plan Document's Coordination of Benefits provision;
(g) Any amount paid which is in excess of the Plan's benefits disclosed, in writing, to the Company;
(h) Expenses in connection with surgery or treatment classified by the Centers for Medicare and Medicaid
Services of the United States Department of Health and Human Services as "experimental" or
"investigational";
(i) Any payment under the Plan on account of a benefit which is not shown on the Schedule of Excess Loss
Coverage as a Plan benefit for which coverage is provided under this Policy; or
(j) Any payment under the Plan not reported to the Company within six (6) months after the end of the Benefit
Period.
EXCL- I
MLI010712 -Kerr
Specifc Expedited Reimbursement Endorsement
This Endorsement forms part of the Excess Loss Insurance Policy to which it is attached.
Insured: Kerr
Policy Number: MLI010712 Effective Date: January 1, 2004
SPECIFIC EXPEDITED REIMBURSEMENT OPTION
An additional provision is hereby added to the terms and conditions for Specific Excess Loss Insurance in
the Policy as follows:
SPECIFIC EXPEDITED REIMBURSEMF..NT Without waiving any rights under the Excess
Loss Insurance Policy, the Company hereby establishes Specific Expedited Reimbursement. The
additional terms and conditions under which Expedited Reimbursement will be provided for
Specific Excess Loss claims are as follows:
I
(A) The claim must be fully processed by the Third Party Administrator and must be ready for
payment under the Employee Benefit Plan within the Benefit Period during which the claim
was Incurred; and
(B} The Insured must have Paid under the Employee Benefit Plan, the Specific Deductible for the
Covered Person to whom the claim relates, plus, in addition to the Specific Deductible
Amount, at least [ $1,000]; and
{C) The claim, and supporting documentation satisfactory to the Company, must be received by
the Company no Later than [five (5) days prior to] the end of the Benefit Period during which
the claim was Incurred and processed; and
(D) { [The claim must be for more than $1,000.] }
If the foregoing requirements are satisfied, the Company will promptly send to the Insured
reimbursement for the amount that is eligible for reimbursement under Specific Excess Loss
Insurance. Upon receipt of the Expedited Reimbursement, the Insured must pay the Employee
Benefit Plan's payment within [five (5)] days. The Company's reimbursement may not be
deposited until the Employee Benefit Plan's payment has been paid. If the Insured does not pay
the Employee Benefit Plan's payment within the [five (5)] day period, the reimbursement must be
refunded to the Company.
If any portion of the Company's reimbursement is not used to pay the applicable benefits under
the Employee Benefit Plan, due to discounting or any other reason, such portion must be returned
to the Company within [five (5) working] days after it is received by the Insured by refund, credit,
or otherwise.
If the Insured fails to comply with all of the above conditions, the right to receive Specific
Expedited Reimbursement shall be rescinded.
Except as specifically set forth herein, all terms and conditions of the Excess Loss Insurance Policy shall
remain in full force and effect.
MLSPEX-1
Policy No. MLI010712 -Kerr
This Endorsement is intended solely to provide an optional expedited method of reimbursement between
the Company and the Insured, and shall not affect the Employee Benefit Plan or the Insured's obligations
under the Employee Benefit Plan in any way, and this Endorsement shall not create any rights in favor of
any third party.
All terms and conditions, other than as stated above, remain unchanged.
Executed at our Home Office.
Monumental Life Insurance Company
~~~ ~~
Secretary President
MLSPEX- l
Policy No. MLI010712 -Kerr
MONUMENTAL LIFE INSURANCE COMPANY
Administrative Office: 1326 S. Ridgewood Ave, Suite 11, Daytona Beach, FL 321 I4
Phone: 1-888-500-EB UI(3284)
SCHEDULE OF EXCESS LOSS COVERAGE
This Schedule of Excess Loss Coverage is only applicable to Excess Loss Insurance provided by the Company
during the Policy Period shown below.
Insured: Kerr, County of
Policy Number: MLI010712
Effective Date: January 1, 2004
Coverage specified herein is applicable only during the Policy Period from January 1, 2004 to January 1, 2005,
and is further subject to all terms and conditions of this Policy.
Actively at Work/Disability requirement. ^Applied ®Waived with Approved Disclosure
The Actively at Work/Disability requirement is explained in the definition of "Covered Person" in the Definitions
Section.
SPECIFIC EXCESS LOSS INSURANCE ®Yes ^ No
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.
Specific Deductible ® Per Covered Person ^ Per family $40,000
Aggregating Specific Deductible N/A
Specific Percentage Reimbursable 100 ~o
Lifetime Maximum Specific Benett Per Covered Person (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
Common Accident Provision Yes ^ No®
Common Accident means if more than one Covered Person in the same immediate family incurs Covered Expenses as
a result of the same accident, the Specific Deductible will be applied only once to ail Covered Expenses Paid because
of that accident for all Covered Persons in the family during the same Benefit Period.
Covered Expenses Incurred from N/A through N/A will be limited to $ NIA per ^Covered Person ^Famiiy
Specific Premium Rates Per Month
Covered Units	Number of Units on Effective Date	Rates er Covered Unit
Sin le	206	$ 38.47
Famil	62	$ 89.22
N/A	N/A	N/A
N/A	N/A	N/A
AGGREGATE EXCESS LOSS INSURANCE ®Yes ^ No
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, no reimbursement will be made under Aggregate Excess Loss Insurance.
Covered Expenses Incurred from N/A through N/A will be limited to $ N/A or NIA % of the Annual Aggregate
Deductible, whichever is greater.
Covered Expenses under Aggregate Excess Loss Coverage:
® Medical ®Stand Alone Prescription Drug Program
^ Dental Care ^ Weekly (Disability) Income
^ Vision Care ^ Other N/A
Aggregate Percentage Reimbursable 100 %
Maximum Aggregate Benefit: ^ $500,000 ®$1,000,000 ^ Other $ N/A
SCI-IED-1
MLI010712 -Kerr
Minimum Annual Aggregate Deductible: $1,226,564 or 100 0l0 of the first Monthly Aggregate Deductible amount
times 12, whichever is greater.
Loss Limit Per Covered Person: $ 40.000
Monthly Aggregate Factors
Covered Units	# on Effective Date	Medical	Prescription Drug	Dental
Single	206	$277.35	Included	N/A
Family	62	$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
Aggregate Excess Loss Premium ®per Covered Unit per month ^annual $5.73 pepm.
SPECIAL CONDITIONS:
N/A
ENDORSEMENTS ATTACHED TO AND MADE PART OF POLICY AT EFFECTIVE DATE:
PREMIUM
(a) SPECIFIC EXPEDITED REIMBURSEMENT ENDORSEMENT
(b) SPECIFIC TERMINAL LIABILITY ENDORSEMENT
(c) AGGREGATE ACCOMODATION ENDORSEMENT
(d) AGGREGATE TERMINAL LIABILITY ENDORSEMENT
(e) AGGREGATING SPECIFIC DEDUCTIBLE ENDORSEMENT
(f) OTHER N/A
ACCEPTED BY THE INSURED THIS DAY OF
Authorized Signature:
Printed Name:
®YES ^NO	Included
^YES ®NO	N/A
^YES ®NO	N/A
^YES ®NO	N/A
^YES ®NO	N/A
^YES ®NO	N/A
20
SCHED-2
MLI010712 -Kerr
IMPORTANT NOTICE
To obtain information or to make a complaint:
You may call Monumental Life Insurance Company's
toll-free telephone number for information or to make
a complaint at:
1-888-500-EBUI (3284)
You may also write Monumental Life Insurance
Company at:
Monumental Life Insurance Company
Administrative Office
1326 South Ridgewood Ave, Suite 11
Daytona Beach, Florida 32114
You may contact the Texas Department of Insurance
to obtain information on companies, coverages, rights
or complaints at:
1-800-252-3439
You may write the Texas Department of Insurance at:
P.O. Box 149104
Austin, TX 78714-9104
FAX # (512) 475-1771
AVISO IMPORTANTE
Para obtener informacion o para someter una queja:
Usted puede llamar al numero de telefono gratis de
Monumental Life Insurance Company para informacion
o para someter una queja al:
1-888-500-EBUI (3284)
Usted tambien puede escribir a Monumental Life
Insurance Company:
Monumental Life Insurance Company
Administrative Office
1326 South Ridgewood Ave, Suite 11
Daytona Beach, Florida 32114
Puede comunicarse con el Departamento de Sequros de
Texas para obtener information acerca de companias,
coberturas, derechos o quejas al:
1-800-252-3439
Puede escirbir al Departamento de Seguros de Texas:
P.O. Box 149104
Austin, TX 78714-9104
FAX # (512) 457-1771
PREMIUM OR CLAIM DISPUTES: DISPUTAS SOBRED PRIMAS O RECLAMOS:
Should you have a dispute concerning your premium Si tiene una disputa concerniente a su prima o a un
or about a claim, you should contact the company first. reclamo, debe comunicarse con la compania primero. Si
If the dispute is not resolved, you may contact the no se resuelve la disputa, pude entonces comunicarse
Texas Department of Insurance. con el departamento (TDI).
ATTACH THIS NOTICE TO YOUR POLICY: UNA ESTE AVISO A SU POLIZA:
This notice is for information only and does not become Esto aviso es solo para propositio de informacion y no se
apart or condition of the attached document. convierte en parte o condicion del documento adjunto.
Form No. ACN-TX-MP (8/95)
Monumental Life Insurance Company
MLI010712 -Kerr
A Stock Company
Administrative Office: 1326 South Ridgewood Ave, Suite 11, Daytona Beach, FI., 32114
Phone:l-888-500-EBUI (3284)
Monumental Life Insurance Company ("Company"), agrees to reimburse the Insured as outlined under the provisions of
this Excess Loss Insurance policy ("Policy").
This Policy is legally binding between the Insured and Monumental Life Insurance Company. The consideration for this
Policy includes, but is not limited to, the Application and the Payment of premiums as provided hereinafter.
The Insured is entitled to the reimbursement described in this Policy if the Insured is eligible for insurance under the
provisions of this Policy. Reimbursement is subject to the terms and conditions of this Policy.
The first premium is due on the first (1st) day of the Policy Period. Subsequent monthly premiums are due on the first
(1st) day of each month thereafter. The premium is not considered paid until the premium payment is received by the
Company.
All periods of coverage will begin and end 12:01 a.m. local time at the principal office of the Insured.
This Policy is delivered in and is governed by the laws of the state of issue.
This is not a policy of V4'arkers' Compensation Insurance. The Insured does not become a subscriber to the
Workers' Compensation system by purchasing this Policy, and if the Insured is anon-subscriber, the Insured
loses certain common-law defenses as «~ell as certain limitations on liability that would otherwise be available
under the Workers' Compensation law as it pertains to non-subscribers and the required notifications that must
be filed and posted.
The Insured understands the liability assumed under the portion of the employee benefit plan which it is self-
insuring and further understands that the Insured is exempted from Article 1.1.4-1 of the Texas Insurance Code.
only if x qualified employee beneFts plan has been filed and meets the requirements of ERISA.
IN WITNESS WHEREOF Monumental Life Insurance Company has caused this Policy to be executed by its
President and Secretary at our Home Office in Baltimore, Maryland.
a
Secretary President
EXCESS LOSS INSURANCE POLICY
MLSL25CTX (3/O1)
MLI010712 -Kerr
TABLE OF CONTENTS
SCHEDULE OF EXCESS LOSS COVERAGE
DEFINITIONS
EFFECTIVE DATE OF COVERAGE
PREMIUM AND FACTORS PROVISIONS
REIMBURSEMENT PROVISIONS
TERMINATION PROVISIONS
REINSTATEMENT PROVISIONS
SUBSEQUENT POLICY PERIOD PROVISIONS
GENERAL PROVISIONS
GENERAL EXCLUSIONS PROVISION
SPECIFIC EXPEDITED REIMBURSEMENT ENDORSEMENT
CONT-1
DEFINITIONS
ACTIVELY AT WORK means the performance of all the regular duties of employment by the Covered Employee for
MLI010712 -Kerr
the Insured on a full-time basis (as specified in the Plan Document), at normal pay at the Covered Employee's normal
place of business. An employee will be considered Actively at Work on each day of a regular paid vacation or a regular
non-working day on which he or she is not disabled, if he or she was Actively at Work on his or her last scheduled work
day.
AGGREGATE PERCENTAGE REIMBURSABLE is set forth in the Schedule of Excess Loss Coverage.
ANNUAL AGGREGATE DEDUCTIBLE for any one Policy Period means the greater of: (a) sum of the Monthly
Aggregate Deductibles; or (b) the Minimum Annual Aggregate Deductible.
BENEFIT PERIOD means the period of time specified in the Schedule of Excess Loss Coverage in which a Covered
Expense must be Incurred by the Covered Person and Paid by the Plan to be eligible for reimbursement under this
Policy. This period does not alter the Effective Date, Policy Period, or waive this Policy's eligibility requirements.
COVERED EMPLOYEE means an employee of the Insured who is eligible for coverage under the Plan, and is
otherwise eligible for benefits under the Plan and covered under the Plan.
COVERED EXPENSE means medical or other expenses under the Plan to which this Policy applies, as shown in the
Schedule of Excess Loss Coverage, and which are not specifically excluded by the terms of this Policy. Covered
Expense does not include any payment for the cost of administrating the Plan or other Insured contracted services.
This Policy will reimburse, as a Covered Expense, the patient services tax as imposed by the New York Care Reform
Act of 1996 (HCRA) or the surcharge imposed by the Massachusetts Uncompensated Care Pool. Any other tax or
surcharge levied by any state or other governmental subdivision will not be considered a Covered Expense under this
Policy.
COVERED PERSON means (a) a Covered Employee, (b) a dependent of a Covered Employee which dependent is
eligible for coverage under the Plan, and is otherwise eligible for benefits under the Plan and covered under the Plan,
or (c) if requested in the application, a covered retired employee as defined by the Plan Document; however, unless
the Actively at Work/Disability requirement is waived as shown on the Schedule of Excess Loss Coverage, a
Covered Person does not include:
(1) any Covered Employee who is not Actively at Work either on the Effective Date or the effective date of his
or her coverage under the Plan, whichever is later, or eligible dependents of such Covered Employee, until
the Covered Employee returns to Actively at Work status; or
(2) any dependent of a Covered Employee if such dependent is, on the Effective Date or the effective date of
his or her coverage under the Plan, whichever is later, either hospital-confined or unable to perform the
normal activities of a person of like sex and age in good health, until the end of such confinement or
disability.
Waiver of the Actively at Work/Disability requirement does not affect the obligation of the Insured and the Third
Party Administrator to disclose information requested by the Company for underwriting purposes and does not affect
the Company's rights in event of failure to disclose such information.
COVERED UNIT means the following: (a) an employee covered as one individual under the Plan; (b) an employee
and dependents covered under the Plan; or (c) such other defined unit or units as agreed upon between the Company and
Insured. The types of Covered Units and the factors and premium rates for each type are shown in the Schedule of
Excess Loss Coverage.
EFFECTIVE DATE is the date set forth in the Schedule of Excess Loss Coverage.
EMPLOYEE BENEFIT PLAN (Also known as the PLAN) means the self-funded health care plan established by the
plan sponsor to provide certain benefits to Covered Persons.
INCURRED means with respect to medical services or supplies, the date on which the services are rendered or supplies
are purchased by the Covered Person; and, with respect to disability income benefits if selected in the Schedule of
Excess Loss Coverage, the date each periodic benefit payment becomes payable to the Covered Person (not the date the
disability commences).
DEF-1
INSURED means the entity requesting Excess Loss Insurance
LOSS, LOSSES means amounts actually Paid by the Plan for Covered Expenses.
MLI010712 -Kerr
LOSS LIMIT PER COVERED PERSON is set forth in the Schedule of Excess Loss Coverage. However, if claims
are Paid under the Plan for a Covered Person for benefits that are covered under Aggregate Excess Loss Insurance, but
not covered under Specific Excess Loss Insurance, the Loss Limit for that Covered Person will be increased by the
amount of such Payment.
MAXIMUM AGGREGATE BENEFIT is set forth in the Schedule of Excess Loss Coverage.
LIFETIME MAXIMUM SPECIFIC BENEFIT is set forth in the Schedule of Excess Loss Coverage.
MINIMUM ANNUAL AGGREGATE DEDUCTIBLE is set forth in the Schedule of Excess Loss Coverage.
MONTHLY AGGREGATE DEDUCTIBLE means, with respect to a particular month, the total number of Covered
Units for that given Policy month multiplied by the corresponding Monthly Aggregate Factors as specified in the
Schedule of Excess Loss Coverage. However, in the event of a reduction in the number of Covered Units under the
Plan, the Monthly Aggregate Deductible cannot be reduced to less than one twelfth of the Minimum Annual Aggregate
Deductible.
MONTHLY AGGREGATE FACTORS are set forth in the Schedule of Excess Loss Coverage.
PAY, PAID, PAYMENT means checks or drafts issued and deposited in the U.S. Mail or otherwise delivered to the
payee, with sufficient funds on deposit to honor all outstanding drafts and checks.
PLAN DOCUMENT means the written document approved by the plan sponsor which describes the Plan. A copy of
the Plan Document in effect on the Effective Date is attached to the application for Excess Loss Insurance and made a
part of this Policy.
POLICY PERIOD means the specified period in the Schedule of Excess Loss Coverage, however beginning no earlier
than the Effective Date of this Policy and continuing until coverage terminates in accordance with the Termination
Provisions.
SPECIFIC DEDUCTIBLE is set forth in the Schedule of Excess Loss Coverage. The Specific Deductible will apply
separately to each Benefit Period.
SPECIFIC PERCENTAGE REIMBURSABLE is set forth in the Schedule of Excess Loss Coverage.
THIRD PARTY ADMINISTRATOR means a firm or person who has been retained by the Insured to Pay claims
and/or provide administrative services on behalf of the Insured/Plan.
DEF-2
MLI010712 -Kerr
EFFECTIVE DATE OF COVERAGE
Coverage under this Policy is not effective until (a) payment of the first (lst) premium; (b) receipt of a signed
Application for Excess Loss Insurance; and (c) receipt, examination and acceptance by the Company of the Plan
Document and all other information which is material to underwriting or premium rating, whether or not specifically
requested.
PREMIUMS AND FACTORS PROVISIONS
PAYMENT OF PREMIUMS For coverage to remain in effect, any subsequent monthly premium must be received by
the Company by the first (ls`) day of each month. Premiums are not considered paid until the premium payment is
received by the Company.
Premiums or other payments made by the Insured to their Third Party Adnnistrator or Agent or Broker shall not be
deemed or considered payments to the Company until actually received by the Company.
GRACE PERIOD A Grace Period of thirty-one (31) days from the due date will be allowed for the payment of each
premium after the first. During the Grace Period, the coverage will remain in effect provided the full premium is paid
before the end of the Grace Period. Coverage will automatically terminate as of the end of the day on the due date of
any premium which remains unpaid at the end of the Grace Period.
PREMIUM AMOUNT The premiums will be calculated using rates deternuned by the Company as set forth in the
Schedule of Excess Loss Coverage. The amount of total premium due each month is the sum obtained by multiplying the
applicable premium rates shown in the Schedule of Excess Loss Coverage by the actual number of appropriate Covered
Units.
The Insured will be liable for any premium taxes assessed at any time against the Company beyond any taxes which may
be payable on the premium received by the Company.
All requests for adjustments, credits or refunds because of overpayment of premiums shall be reported, in writing, with
accompanying detail within sixty (60) days after termination of the applicable Policy Period.
The Company will not refund any portion of the premiums paid if this Policy terminates during the Policy Period.
SET OFF The Company shall be entitled to set off against reimbursements due the Insured under this Policy any
premiums due and unpaid, any overpayments or other reimbursements made in error or upon incorrect information, and
any other amounts due the Company.
PREMIUM RATE AND AGGREGATE DEDUCTIBLE FACTOR CHANGE The Company may change the
Insured's premium rates or factors as of any of the following:
a) the date when the terms of this Policy are changed;
b) the date the Plan Document changes are accepted by the Company;
c) the date the Insured adds or deletes subsidiary or affiliated companies or divisions;
d) the date the number of Covered Units on any premium due date varies more than fifteen percent (15%) from
the number of Covered Units on the Effective Date; or
e) the date the Insured changes its Third Party Administrator.
The Company reserves the right to recalculate the premium rates and the Monthly Aggregate Factors retroactively for
the Policy Period, if there is more than a ten percent (10%) variance between:
a) the average monthly Paid claim cost per Covered Employee under the Plan for the last two (2) months of the
prior Policy Period; and
b)the average monthly Paid claim cost per Covered Employee under the Plan for the first ten (10) months of the
prior Policy Period.
PREFAC-1
MLI010712 -Kerr
REIMBURSEMENT PROVISIONS
NOTICE OF LOSS The Inswed will give written notice of Losses to the Company on the Company's customary proof
of loss form, within thirty (30) days of the date the Inswed becomes aware of the existence of facts which would
reasonably suggest the possibility that expenses covered under the Plan will be Incurred which are equal to or exceed
fifty percent (50%) of the Specific Deductible or $50,000, whichever is less.
PAYMENT BY PLAN
While the determination of benefits under the Plan is the sole responsibility of the Inswed, the Company reserves the
right to interpret the terms and conditions of the Plan Document as it applies to this Policy. The Company will have the
sole authority to reimburse or deny reimbursement under this Policy.
The Insured will Pay all eligible claims under the Plan within thirty (30) days from the date adequate proof of loss is
provided to the Insured. If the Insured fails to Pay a claim within the thirty (30) day time limit, that claim will not count
toward the satisfaction of the deductibles or be reimbursed under this Policy.
The Insured agrees to provide funds for payment of all eligible expenses under the Plan. If the Insured fails to provide
funds for timely payment: a) coverage under this Policy will immediately terminate; and b) any Aggregate and/or
Specific Deductible will be deemed not satisfied.
SPECIFIC EXCESS LOSS INSURANCE
The Schedule of Excess Loss Coverage indicates whether Specific Excess Loss Inswance is provided under this Policy.
If, while this Policy is in effect, the Losses for a Covered Person for the applicable Benefit Period exceed the Specific
Deductible, the Company will reimbwse the Insured, subject to the terms and conditions of this Policy including the
limits set forth in the Schedule of Excess Loss Coverage, within thirty (30) days after:
(a) the Company's acceptance of the proof of loss as a satisfactory proof;
(b) the Company's receipt of proof of Payment of the benefits by the Inswed under the Plan to, or on behalf of,
the Covered Persons; and
(c) completion of an audit of the claim, if requested by either the Inswed or the Company, which payment by
the Inswed is expressly agreed to be a condition precedent to payment.
The amount of the reimbursement will be equal to the Specific Percentage Reimbursable times the amount by which
Losses exceed the Specific Deductible amount, but will not exceed the Lifetime Maximum Specific Benefit. For
purposes of determining whether such Lifetime Maximum Specific Benefit has been exceeded, Losses Incurred or
Paid in any other period of excess loss coverage are included.
Losses for any Covered Person during the Policy Period will be determined according to the Benefit Period described in
the Schedule of Excess Loss Coverage. The Specific Deductible applies separately to each Covered Person during a
Benefit Period.
If Specific Excess Loss Insurance terminates before the end of the Policy Period, the Specific Deductible will not be
reduced.
AGGREGATE EXCESS LOSS INSURANCE
The Schedule of Excess Loss Coverage indicates whether Aggregate Excess Loss Inswance is provided under this
Policy. If the Losses for the applicable Benefit Period subject to the Loss Limit Per Covered Person, exceed the Annual
Aggregate Deductible for the Policy Period, the Company will reimbwse the Inswed, subject to the terms and conditions
of this Policy including the limits set forth in the Schedule of Excess Loss Coverage, within thirty (30) days after:
(a) the Company's acceptance of proof of loss as satisfactory proof;
(b) the Company's receipt of proof of Payment of eligible expenses under the Plan; and
(c) completion by the Company of a satisfactory on-site audit of the claims, eligibility and all records relevant to
a claim under Aggregate Excess Loss Inswance, if the Company elects to do so.
The amount of the reimbursement will be equal to the Aggregate Percentage Reimbwsable times the amount by which
Losses exceed the Annual Aggregate Deductible amount, but will not exceed the Maximum Aggregate Benefit. The
Annual Aggregate Deductible for any one Policy Period means the greater of: (a) the sum of the Monthly Aggregate
Deductibles; or (b) the Minimum Annual Aggregate Deductible.
REIM-1
MLI010712 -Kerr
For purposes of determining amounts payable under this Aggregate Excess Loss Insurance, Losses pertaining to each
Covered Person during the Benefit Period will be limited to the Loss Limit Per Covered Person. Losses will not include
any amounts reimbursed by the Company under any other provision of this Policy. Any Loss that is Incur-ed at a time
when the person to whom the Loss relates is not a Covered Person will not be eligible for Aggregate Excess Loss
Insurance and will not be considered for the purpose of satisfying the Annual Aggregate Deductible.
However, if coverage terminates before the end of the Policy Period, the Annual Aggregate Deductible will be
deemed not satisfied and the Company will not be liable for reimbursement of any benefits under this Aggregate
Excess Loss Insurance.
REIM-2
MLI010712 -Kerr
TERMINATION PROVISIONS
This Policy and coverage provided hereunder will terminate upon the earliest of:
a) the premium due date of any premium which remains unpaid at the end of the Crrace Period;
b) the premium due date next following receipt by the Company of written notice from the Insured that this Policy
is to be terminated;
c) the date of termination of the Plan;
d) the date the Insured suspends active business operations or dissolves; or
e) the end of the Policy Period.
This Policy may also be terminated, at the Company's option on the earliest of:
a) the last day of the third (3`d) consecutive month during which there are less than fifty-one (51) employees
enrolled in the Plan, unless the Company agrees, in writing, to continue coverage; or
b) the date the Insured fails to comply with the terms of this Policy.
The Company will not refund any portion of the premiums paid if this Policy is terminated during the Policy Period.
REINSTATEMENT PROVISIONS
If this Policy terminates for any of the reasons set forth above, the Company may, at its option, approve the Insured's
request to reinstate this Policy. The Insured shall submit to the Company any forms and data the Company may require.
If this Policy is reinstated, the Insured shall pay to the Company the premiums due from the date this Policy terminated.
SUBSEQUENT POLICY PERIOD PROVISIONS
At the end of a Policy Period, a subsequent Policy Period may be agreed upon in writing by the Company and the
Insured. The terms and conditions for a subsequent Policy Period will be evidenced by the issuance of a new Schedule
of Excess Loss Coverage by the Company which shows the new premium rates, Benefit Period and other new terms.
This Policy is not automatically renewable.
TERM-1
MLI010712 -Kerr
GENERAL PROVISIONS
ARBITRATION Any dispute arising out of or relating to this Policy, or the breach thereof, shall be settled by
Arbitration in accordance with the rules of the American Arbitration Association, and judgement upon the award
rendered by the arbitrators may be entered in any court having jurisdiction. The arbitrators may not award any punitive
or exemplary damages. This provision will survive the ternunation or expiration of this Policy.
ASSIGNMENT Reimbursement under this Policy may not be assigned by the Insured, and the Company will not
recognize any such assignment.
AUDITS The Company will have the right: (a) to inspect and audit all records and procedures of the Insured and Third
Party Administrator, developed and maintained for the Plan, that are applicable to the administration of this Policy; and
(b) to require, upon request, proof satisfactory to the Company that Payment has been made to the Covered Person or the
provider of such services or benefits which are the basis for any Loss by the Insured hereunder.
CHANGES TO THE PLAN DOCUMENT If the Plan Document in effect on the Effective Date is subsequently
amended, notice of the amendment will be given to the Company prior to the effective date of the change. If the
Company does not give written acceptance of the amendment, the Company will only provide coverage under this
Policy consistent with the Plan Document prior to amendment. The Company's reimbursement will be made
according to the amended Plan, once the notice is received and accepted.
CHANGES TO THE POLICY Only the President, a Vice President, or the Secretary of the Company have the
authority to alter this Policy, or to waive any of the Company's rights and then only in writing. No such alteration of this
Policy shall be valid unless endorsed and attached to this Policy. No agent, broker, or Third Party Administrator has the
authority to alter this Policy or to waive any of its provisions.
CLERICAL ERROR Clerical errors, whether by the Insured or by the Company, in keeping or transmitting any
records pertaining to the coverage, will not invalidate or limit coverage otherwise validly in force nor continue coverage
otherwise validly terminated. Clerical error does not include any failure of the Insured, the Third Party Administrator or
any agent of the Insured: (a) to comply with the requirements relating to notice of claims or payment of claims; or (b) to
disclose underwriting information requested by the Company, whether or not intentional and regardless of the actual
knowledge of the person providing the information.
CONCEALMENT, FRAUD This entire Policy will be void (a) if, before or after a claim or Loss, the Insured, the
Third Party Administrator or any agent of the Insured has concealed or misrepresented any material fact or circumstance
concerning this Policy, including any claim, or (b) in any case of fraud by the Insured, the Third Party Administrator, or
any agent of the Insured relating to this Policy.
CONFORMITY WITH LAW If any provision of this Policy is contrary to any law to which it is subject, such
provision is hereby amended to conform to the minimum requirements of such law.
ENTIRE CONTRACT The Entire Contract between the Company and the Insured will consist of this Policy, the
application, approved amendments or endorsements, and a copy of the Plan Document which is on file with the
Company.
INSOLVENCY Nothing in this Policy shall either relieve an insolvent or bankrupt Insured from the obligation to pay
premiums when due or delay or abate cancellation of this Policy for failure to do so. The insolvency, bankruptcy,
financial impairment, receivership, voluntary plan of arrangement with creditors, or dissolution of the Insured or the
Insured's Third Party Administrator will not impose upon the Company any liability other than the liability defined in
this Policy. In particular, the insolvency of the Insured will not make the Company liable to the creditors of the Insured,
including Covered Persons under the Plan.
INSURED REQUIREMENTS The Insured will submit by the twentieth (20th) day of each month all proofs, reports,
and supporting documents required by the Company, including, but not limited to, a monthly summary of all eligible
claims Payments processed by the Insured and number of each type of Covered Units under the Plan during the prior
month. The Insured will be responsible for the investigation, auditing, calculating and the Payment of all claims under
the Plan.
GEN-1
LEGAL ACTION The Insured cannot file suit until ninety (90) days after the date on which proof of loss is given to
MLI010712 -Kerr
the Company. The Insured cannot file suit more than three (3) years after the date on which the Insured must give the
Company proof of claim. The three (3) year limitation is extended, if necessary, to agree with the period allowed by the
laws of the state of issue.
LIABILITY The Company will have neither the right nor the obligation under this Policy to directly pay any Covered
Person or provider of professional or medical services. The Company's sole liability is to the Insured, subject to the
terms and conditions of this Policy. Nothing in this Policy shall be construed to permit a Covered Person to have a direct
right of action against the Company. The Company will not be considered a party to the Plan of the Insured, or to any
supplement or amendment to it.
MISSTATED DATA The Company has relied upon the underwriting information provided by the Insured, the Third
Party Administrator or any agent of the Insured, in the issuance of this Policy. Should information in existence prior to
issuance of this Policy subsequently become known which would have affected the rates, deductibles, terms or
conditions for coverage, the Company will have the right to revise the rates, deductibles, terms or conditions as of the
Effective Date of issuance, by providing written notice to the Insured.
NOTICE FROM THE COMPANY TO THE INSURED For the purpose of any notice required from the Company
under the provisions of this Policy, notice to the Insured's Third Party Administrator shall be considered notice to the
Insured and notice to the Insured shall be considered notice to the Insured's Third Party Administrator.
OTHER COVERAGE The reimbursement provided by this Policy is in excess of other coverage such as group
insurance, excess insurance, insurance, plan benefits, including insurance or plan benefits established by any federal,
state, or local law.
PARTIES TO THE POLICY The parties to this Policy are the Insured and the Company. The Company's sole
liability under this Policy is to the Insured. This Policy does not create any right or legal relation between the Company
and a Covered Person under the Plan. This Policy will not be deemed to make the Company a party to any agreement
between the Insured and the Third Party Administrator.
RECORDS The Insured will maintain records of all Covered Persons under the Plan during the Policy Period and for a
period of seven (7) years after the end of the Policy Period. The Insured will make all such records available to the
Company as needed to evaluate its liability under this Policy.
The Insured will maintain a separate record of any and all amounts Paid in excess of benefits eligible under the Plan.
SEVERABILITY CLAUSE Any clause deemed void, voidable, invalid, or otherwise unenforceable, whether or not
such a provision is contrary to public policy, will not render any of the remaining provisions of this Policy invalid.
TERMINATION OF THE INSURED'S PLAN The Insured will immediately notify the Company, if the Plan is
terminated.
THIRD PARTY ADMINISTRATOR The Insured may retain a Third Party Administrator to act as an agent for the
Insured in performing any or all of the duties as designated by the Insured. Without waiving any of its rights under this
Policy, and without making the designated Third Party Administrator a party to this Policy, the Company agrees to
recognize the Third Party Administrator as an agent of the Insured. The Insured will immediately notify the Company in
writing if the agreement between the Insured and the Third Party Administrator terminates.
THIRD PARTY RECOVERY The Plan shall undertake to pursue any and all valid claims that the Plan may have
against third parties arising out of any occurrence resulting in a payment by the Plan or the Company, and to account
for and pay to the Company any amounts recovered which were previously reimbursed by the Company to the
Insured under this Policy, regardless of whether this Policy is still in force on the date of recovery. Third party shall
mean another person, entity, or insurance company. Additionally, the Insured or Plan administrator shall GEN-2
notify the Company immediately upon discovering that a
claim against a third party may exist. Should the Insured fail to pursue any valid claims against a third party and the
Company becomes liable to reimburse the Plan, then the Company shall have the right to exercise and enforce all of
the Insured and/or Plan's rights against such third party.
Company shall also be assigned all rights of recovery if a payment is made for which the Plan is or becomes entitled
MLI010712 -Kerr
to receive payment from a third party.
If the Payment received from a third party is less than the total amount paid by the Plan on behalf of the Covered
Person, the Company is entitled to recover first, in full, any amount paid by the Company under this Policy as well as
any expenses of collection incurred by the Company. All remaining amounts shall be paid to the Insured.
GEN-3
MLI010712 -Kerr
GENERAL EXCLUSIONS PROVISIONS
The Company will not reimburse the Insured for any of the following:
(a) Any payment which does not strictly comply with the terms and conditions of the Plan Document;
(b) Any payment or expense caused by or resulting from war, declared or undeclared, invasion, acts of
foreign enemies, hostilities, civil war, rebellion, insurrection, military or usurped power, or martial law or
confiscation by order of any government or public authority;
(c) Any payment for litigation costs and expenses, extra-contractual damages, compensatory damages,
exemplary and punitive damages or liabilities, including but not limited to those resulting from
negligence, intentional wrongs, fraud, bad faith or strict liability on the part of the Insured, Plan, Third
Party Administrator or any agent or representative of the Insured, Plan or Third Party Administrator;
(d) Any payment or expense for accident or illness arising out of activities performed for profit, including
self-employment;
(e) Any payment for occupational accidents or illnesses which are also eligible expenses covered by Workers'
Compensation or Occupational Disease law, or similar legislation, whether or not coverage under such law is
actually in force;
(f) Any payment which is recoverable under the Plan Document's Coordination of Benefits provision;
(g) Any amount paid which is in excess of the Plan's benefits disclosed, in writing, to the Company;
(h) Expenses in connection with surgery or treatment classified by the Centers for Medicare and Medicaid
Services of the United States Department of Health and Human Services as "experimental" or
"investigational";
(i) Any payment under the Plan on account of a benefit which is not shown on the Schedule of Excess Loss
Coverage as a Plan benefit for which coverage is provided under this Policy; or
(j) Any payment under the Plan not reported to the Company within six (6) months after the end of the Benefit
Period.
EXCL-1
MLI010712 -Kerr
Specific Expedited Reimbursement Endorsement
This Endorsement forms part of the Excess Loss Insurance Policy to which it is attached.
Insured: Kerr
Policy Number: MLI010712 Effective Date: January 1, 2004
SPECIFIC EXPEDITED REIMBURSEMENT OPTION
An additional provision is hereby added to the terms and conditions for Specific Excess Loss Insurance in
the Policy as follows:
SPECIFIC EXPEDITED REIMBURSEMENT Without waiving any rights under the Excess
Loss Insurance Policy, the Company hereby establishes Specific Expedited Reimbursement. The
additional terms and conditions under which Expedited Reimbursement will be provided for
Specific Excess Loss claims are as follows:
(A) The claim must be fully processed by the Third Party Administrator and must be ready for
payment under the Employee Benefit Plan within the Benefit Period during which the claim
was Incurred; and
(B) The Insured must have Paid under the Employee Benefit Plan, the Specific Deductible for the
Covered Person to whom the claim relates, plus, in addition to the Specific Deductible
Amount, at least [ $1,000]; and
(C) The claim, and supporting documentation satisfactory to the Company, must be received by
the Company no later than [five (5) days prior to] the end of the Benefit Period during which
the claim was Incurred and processed; and
(D) { [The claim must be for more than $1,000.] }
If the foregoing requirements are satisfied, the Company will promptly send to the Insured
reimbursement for the amount that is eligible for reimbursement under Specific Excess Loss
Insurance. Upon receipt of the Expedited Reimbursement, the Insured must pay the Employee
Benefit Plan's payment within [five (5)] days. The Company's reimbursement may not be
deposited until the Employee Benefit Plan's payment has been paid. If the Insured does not pay
the Employee Benefit Plan's payment within the [five (5)] day period, the reimbursement must be
refunded to the Company.
If any portion of the Company's reimbursement is not used to pay the applicable benefits under
the Employee Benefit Plan, due to discounting or any other reason, such portion must be returned
to the Company within [five (5) working] days after it is received by the Insured by refund, credit,
or otherwise.
If the Insured fails to comply with all of the above conditions, the right to receive Specific
Expedited Reimbursement shall be rescinded.
Except as specifically set forth herein, all terms and conditions of the Excess Loss Insurance Policy shall
remain in full force and effect.
MLSPEX-1
Policy No. MLI010712 -Kerr
This Endorsement is intended solely to provide an optional expedited method of reimbursement between
the Company and the Insured, and shall not affect the Employee Benefit Plan or the Insured's obligations
under the Employee Benefit Plan in any way, and this Endorsement shall not create any rights in favor of
any third party.
All terms and conditions, other than as stated above, remain unchanged.
Executed at our Home Office.
Monumental Life Insurance Company
~~t ~
~ ~`
Secretary President
MLSPEX- I
Policy No. MLI010712 -Kerr
MONUMENTAL LIFE INSURANCE COMPANY
Administrative Office: 1326 S. Ridgewood Ave, Suite 11, Daytona Beach, FL 32114
Phone: 1-888-500-EBUI(3284)
SCHEDULE OF EXCESS LOSS COVERAGE
This Schedule of Excess Loss Coverage is only applicable to Excess Loss Inswance provided by the Company
dwing the Policy Period shown below.
Insured: Kerr, County of
Policy Number: MLI010712
Effective Date: January 1, 2004
Coverage specified herein is applicable only during the Policy Period from January 1, 2004 to January 1, 2005,
and is further subject to all terms and conditions of this Policy.
Actively at Work/Disability requirement. ^Applied ®Waived with Approved Disclosure
The Actively at Work/Disability requirement is explained in the definition of "Covered Person" in the Definitions
Section.
SPECIFIC EXCESS LOSS INSURANCE ®Yes ^ No
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.
Specific Deductible ® Per Covered Person ^ Per family $40,000
Aggregating Specific Deductible N/A
Specific Percentage Reimbwsable 100 %
Lifetime Maximum Specific Benefit Per Covered Person (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
Common Accident Provision Yes ^ No®
Common Accident means if more than one Covered Person in the same immediate family incws Covered Expenses as
a result of the same accident, the Specific Deductible will be applied only once to all Covered Expenses Paid because
of that accident for all Covered Persons in the family during the same Benefit Period.
Covered Expenses Incurred from N/A through N/A will be limited to $ N/A per ^Covered Person ^Family
Specific Premium Rates Per Month
Covered Units	Number of Units on Effective Date	Rates er Covered Unit
Sin le	206	$ 38.47
Famil	62	$ 89.22
N/A	N/A	N/A
N/A	N/A	N/A
AGGREGATE EXCESS LOSS INSURANCE ®Yes ^ No
Benefit Period: Covered Expenses Incurred from .Tanuary 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, no reimbursement will be made under Aggregate Excess Loss Insurance.
Covered Expenses Incurred from N/A through N/A will be limited to $ N/A or N/A % of the Annual Aggregate
Deductible, whichever is greater.
Covered Expenses under Aggregate Excess Loss Coverage:
® Medical ®Stand Alone Prescription Drug Program
^ Dental Care ^ Weekly (Disability) Income
^ Vision Care ^ Other N/A
Aggregate Percentage Reimbwsable 100 %
Maximum Aggregate Benefit: ^ $500,000 ®$1,000,000 ^ Other $ N/A
SCHED-1
MLI010712 -Kerr
Minimum Annual Aggregate Deductible: $1,226,564 or 100 % of the first Monthly Aggregate Deductible amount
times 12, whichever is greater.
Loss Limit Per Covered Person: $ 40,000
Monthly Aggregate Factors
Covered Units	# on Effective Date	Medical	Prescription Drug	Dental
Single	206	$277.35	Included	N/A
Family	62	$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
Aggregate Excess Loss Premium ®per Covered Unit per month ^annual $5.73 pepm.
SPECIAL CONDITIONS:
N/A
ENDORSEMENTS ATTACHED TO AND MADE PART OF POLICY AT EFFECTIVE DATE:
PREMIUM
(a) SPECIFIC EXPEDITED REIMBURSEMENT ENDORSEMENT
(b) SPECIFIC TERMINAL LIABILITY ENDORSEMENT
(c) AGGREGATE ACCOMODATION ENDORSEMENT
(d) AGGREGATE TERMINAL LIABII.ITY ENDORSEMENT
(e) AGGREGATING SPECIFIC DEDUCTIBLE ENDORSEMENT
(f) OTHER N/A	®YES ^NO
^YES ®NO
^YES ®NO
^YES ®NO
^YES ®NO
^YES ®NO	Included
N/A
N/A
N/A
N/A
N/A
ACCEPTED BY THE INSURED THIS DAY OF		, 20
Authorized Signatwe:		
		
Printed Name:		
SCHED-2
MLI010712 -Kerr