COMMISSIONERS' COURT AGENDA REQUEST PLEASE FURNISH ONE ORIGINAL AND NINE COPIES OF THIS :EOUEST AND DOCUMENTS TO BE REVIEWED BY THE COURZ MADE BY: Pat Tinley OFFICE: County MEETING DATE: December 13, 2004 TIME PREFERRED: SUBJECT: Consider and discuss applications for Stop Loss and Life Insurance for Employee Health Benefit's Program, requesting and authorizing payment for Binder (s) on same and authorizing County Judge to execute applications. 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: THIS REQUEST RECEIVED BY: THIS REQUEST RECEIVED ON: 5:00 P.M. previous Tuesday. 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. APPLICATION TO MUTUAL OF OMAHA INSURANCE COMPANYIUNITED OF OMAHA LIFE INSURANCE COMPANY FOR STOP LOSS INSURANCE 1. UNDERWRITING COMPANY (Check Appropriate Box Below): ^ MUTUAL OF OMAHA INSURANCE COMPANY ~1 UNITED OF OMAHA LIFE INSURANCE COMPANY For Home Office :Use Only POLICY NUMBER ASSIGNED Home Office: Mutual of Omaha Plaza, Omaha, NE 68175 2. APPLICANT (Full Legal Name) Kerr County STREET ADDRESS 700 Main Street CITY Kc~ r rv i 1 1 P STATE '1'X ZIP CODE 7 R (l ~ R TELEPHONE NUMBER ( 30 ) ,7 °f 2 - 2.2;75 _. 3. The Applicant applies for stop loss insurance with the following terms and conditions, , This section may be updated by an addendum to this Application. The Application consists of this form and any written addendums to this Application, attached to this Application and signed by an officer of the underwriting company. 4. FINANCIAL CONDITION Within the last five (5) years, has the Applicant remained continually solvent? ~] Yes Does the Applicant reasonably expect to be solvent within the next 12 months? g] Yes If no to either question, please give details. ^ No ^ No Solvent means not having filed a voluntary or involuntary petition in bankruptcy, a reorganization or an arrangement with creditors, or a general assignment for the benefit of creditors, the ability to pay debts as they become due, not having a trustee, receiver or other custodian appointed on its behalf, or any other case or proceeding under any bankruptcy or solvency law, or the commencement of any dissolution or liquidation proceeding. Requested effective date of the policy: January 1 , 2005 This Application is submitted with the following advance payment: $ 10634GA-EZ 03 STOP LOSS . _ . ~._ .. - ~ ~ _ ~- . - ti understand that the underwriting company will rely and act upon the answers, statements and any misstatements or omissions of information that are made on this Application or given and used in the preparation of the Proposal upon which this Application is based. Erroneous information and :any material omission of information may result in the rescission, cancellation or rerating of coverage issued in reliance thereon. _ If this Application is not approved by an officer at the Home Office of the Underwriting Company, no coverage is in effect at any time and any advance payment received will be returned. _ If this Application is approved by an officer at the Home Office of the Underwriting Company, it will be attached to and made a part of the policy and any reissue of the policy which is approved by an officer at the Home Office of the U nderwriting Company. The effective date of the Policy is the effective date shown on the attached addendum, which is made a part of this Application. - - ~ - Receipt of the policy or any reissued policy, and payment of any subsequent premium for the policy or any reissued policy, will constitute the applicant's acceptance of the provisions of the policy or the reissued policy. e - o represent that no employee contributions or plan assets shall be used to pay premium or otherwise fund stop loss.coverage. - Stop loss reimbursements shall not be used to fund p-an benefits nor shall this stop loss insurance be considergd an asset to ~ ~- my plan. - Deposit of premium by the Underwriting Company does~not constitute an approval or acceptance of liability if issuance of the policy is not approved by the Underwriting Company. If issuance of the policy is not approved, the premium will be refunded - regardless of whether or not it was deposited. For Applicant: Accepted By Date 10634GA-EZ 03 STOP LOSS .:, - __ ~ ~ - - ~ - _ _ ,' •a ~ -• . . ~..._ -.•.r... ,. ' ' ~- • ~ Loss Insurance ~"'°'""' ~' r~~~"~~~ "Select Risk Questionnaire for Stop Pro osed Specific Deductible:$gQ-.,~Q _---- Proposed Effective Date: 1 t ~ 5 - p 45 calendar days prior to the Name of Applicant: b the Applicant no earlier than [ J This Select Risk Questionnaire ("Questionnaire") must be completed and returned to the Company y Proposed Effective Date, will rel on the information supplied to: ofic to the Applicant; The Company Y (a) evaluate and determine whether to issue a stop loss insurance p olic andlor dusts ecific deductibles for (or exclude losses undee any issuied stop oiss insurance pica) yondstsonsurance policy. ~ unless and until (b) a ~ P (c} waive performing normal activities requirements olic issued by the Company. Stop loss insurance will not begin d determine the premium rates and otherc me a part of any stop loss inisuranoce py issued stop o This information will be included in and shall beioss insurance. the Company approves the application for stop to ees, COBRA participants, FMLA or other continuees, retirees or Ian on the Proposed Effective Date: licant's self insured health care p char es not yet paid) exceeding [the Complete Attachment A of this Select wink Q ter aoandiexpected to be covered under to nAphe last 12 months (including any pending 9 dependents) satisfying any of the folio 9 licant's medical plan d g y ~ on the (a) Any individual who has reoeived benefit osed S tecificpDeductible; 0 of the Prop P ast 30 days or expected to be so confined at an time Burin the period commencing lesser of $20,000 or) [50 / ~ (b} Any individual confined in a medical facility or institution during the p date this Questionnaire is signed and onding on the 90th day after the Proposed Effecnivn~ v dual who is in good health on the day this Questionnaire is signed; or 'llness or injury on the day this Questionnaire is signed; (c) Any employee absent from work duet of the following diagnoses. (d} Any individual physically or mentally unable to perform all one ud ng b t notiliim'ited to any pia nosis (e) Any individual diagnosed with any serious illness or injury pia nosis 1cD-9_cod - - 582-588 Renai DiseaselFailurelDial is i :!~ ' ~ ICD-9 Code _, a ~,,,~,,,,,~ rnmrderslPsvcho-neurotic „ ,,,,, ,,,,_v~~ Hiah Risk Pre Want ICom ligtions 277 C stic Fibrosis 555-558, V e ~ ' 278 & 783. H . eralimentaGonlFeedin Disorders 570-519 Chronic LivedPancreatic DiseaseMe atitis 286 Hemo hilialBlood Disorders IlCant should Obtain and analyze, without to eetion, orts, subrogation reports; emp y .... . ement and other utilization reviewlmanagementrep acce table to the Company, that _.._. . ' in identi ing individuals who satisfy any of the cri~a(i a use managwhen completing Attachment Aicant may attach a report(s), p d{ive Date and To assist N recertification, 9 letin Attachment A, the App must be generated within [45] days of the Proposed E e pending claim reports, large claim reports, p attendance records, sick leavUe ted for Attachment A. If this lalternat ve~s chosen, tghe report(s) ... i;ohfain(sjttietnformation eq lied is.complete'ai~d. individualssatisfyingany of.theabove criteria must be highlighted on the report. . A licant, I hereby warrant and represent thatehe information included on-Attachment A or any reports sup d e that failure to disclose complete information, or providing inaccurate information, As-an authorized representative of the pP _ _. .. accurate and that nothing has been knowingly or intentionally omitted. I also ac now s reimbursements for losses related to (or therance t oficy ~orspecific deductibles for) certain individua s; lrtay result•ln the` °_ 8 , .. (a) denial of stop Ios_ issued stop foss insu P ._. ___...- (b) revision of the terms or conditions o any _. ,. - (c) rescission of stop loss insurance - _.._.. 0 as of the effective date of such insurance. Date: _ _ _ .. Applicant:_ _ - , Authorized Signature: Title: .-. Printed Narne: ~ _ _. _ . .____ -10634GI=SRQ-~Z ~3 __ .rte '~' IIIMMI NIIVV ~IIV 'f his Attachme"" . Applicant' ~ Title'. / ~ J Authorized Signature' printed Name ,. 10634~I~~RQ EZ 03 MUTUAL OF OMAHA INSURANCE COMPANY [ ] UNITED OF OMAHA LIFE INSURANCE COMPANY ( ] Mutual of Omaha Plaza Omaha, NE 68175 ~ Home Office Use Only Policy Number(s): Group Insurance Application Applicant (Full Legal Name) KP r r rnLtnt~ (the Policyholder) Address 700 Main Street City Kerrville State TX Zip 78p2g Requested Effective Date: ~7ani~ar~1, ~f10_5 ,subject to our acceptance of this application and payment of premium on or before such date. Coverage(sl being aanlied for: ® Life ®AD&D ^ Short Term Disability ^ Life and Dependent Life ^ AD&D and Dependent AD&D ^ Long Term Disability Active at work requirement: An employee must meet an Active at Work requirement to become insured. Will all proposed insureds meet the Active at Work requirement? [~ Yes ^ No If "No," please provide the name of the individual, date of birth, date of disability or confinement and nature of disability or confinement on a separate page. Certain states have enacted legislation that requires insurers to provide specific coverage for people residing in their states. Do you have employees residing in or working in other states? ^ Yes ®No If "Yes," which states: Financial Risk (If "Yes," to any part, please explain below) 1. Has the applicant ever filed for bankruptcy? ^ Yes [~ No 2. Does the applicant anticipate ceasing or materially reducing active business operations? Explanation: Application is made on the basis of the proposal, any available experience data and the information contained in this application. The applicant signing below agrees to accept the terms and provisions of the Master Policy for the coverages applied for above. Insurance will become effective on the requested effective date shown above, unless we send written notice o f a d ifferent e ffective d ate. I f t his a pplication i s not a pproved b y a n o fficer a t t he H ome O ffice o f t he underwriting company, no insurance is in effect at any time and any advance payment received will be returned. This application is submitted with the following advance payment $ Fraud Warning -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 p urpose o f misleading, i nformation c oncerning a ny fact material t hereto c ommits a fraudulent insurance a ct, which is a crime and subjects such person to criminal and civil penalties. For Applicant: Name of Broker, agent and/or insurance agency soliciting this coverage: By (Signature) (Title) (Date) 10634GA-EZ 04 ^ Yes ~ No [L/AD/D] ...b.. ....... Kerr County Judge/Commissioners' Court From: To: Cc: ; Sent: Thursday, December 09, 2004 9:08 AM Subject: First months' premium Here are the premium needed for the binder. they are the first month estimated premium and will be applied to the January bill. Total needed $21,498.30. The amount came directly form the proposals. I can provide the entire copies if you need them. The amounts below were cut and pasted from the proposal. CSM Life 261 X $4.40 + $1,148.40 monthly fee ~ ASO Feed Employee ~ 261 ~ $19.90 $5,193.90 ~ PPO Program Feed Employee ~ 261 ~ $2.49 $ 649.89 ~ Utilization~Employee ~ 261 ~ $2.40 $ 626.40 ~ Review Programs ~ ~ ~ ~ ~ Fee*~ ~ ~ ~ ~ ~ Healthy Employee ~ 261 $5.08 $1,325.88 ~ Reimbursements ~ ~ ~ ~ ~ Account Fee* *( ~ ~ ~ ~ ~ TOTALS ~ ~ $29.87 $7,796.07 ~ ~ Unit ~# ees ~ Monthly ( Monthly ~ ~ ~ ~ ~ Rate ~ Premium ~ ~ Specific Rates* ~ ~ ~ ~ ~ ~ ~ Employee ~ 195 $32.00 $6,240.00 ~ ~ Employee and Ones 66~ $78.62 $5,188.92 ~ ~ or More ~ ~ ~ ~ 12/9/2004 --o- ~ ~ Dependents ~ ~ ~ ~ ~ Annual Totals ~ ~ ~ $11,428.92 ~ __ ~~ ~ ~ Unit ~# ees ~ Monthly ~ Monthly ~ ~ ~ ~ ~ Rate ~ Premium ~ ~ Aggregate Fee* ~ ~ ~ ~ ~ ~ Employee With or ~ 261 ~ $4.31 ~ $1,124.91 ~ Without ~ ~ ~ ~ ~ ~ Dependents ~ ~ ~ ~ 12/9/2004