HomeMy WebLinkAboutEmployee Benefits Plan documentsSubsequent Policy Period Offer rev # 2
Sales Reps:
Date:
Underwriter:
Producer:
Life Carrier:
Stop Loss Carrier:
Effective Date:
Employer:
MATTHEW HAYWARD, NANCY PARKER
07/12/2011
HARTIGAN, TIM
JULIE NELSON
UNIMERICA INSURANCE COMPANY
AUGUST 01, 2011
DESCHUTES COUNTY
SPECIFIC COVERAGE
Specific Deductible Amount $225,000 $250,000
Option 1 Option 2
Aggregating Specific Deductible $100,000.00 $100,000.00
Specific Maximum Unlimited Unlimited
COMPOSITE 1,018 $26.59 $23.02
Total Lives/Annual Premium 1,018 $324,823.44 $281,212.32
Benefits Covered MED/RX MED/RX
Specific Contract Basis 36/12 36/12
Annual Aggregate Amount
AGGREGATE COVERAGE
$17,059,764 $17,172,888
COMPOSITE 1,018 $1,396.51 $1,405.77
Benefits Covered MED/RX MED/RX
Aggregate Contract Basis 36/12 36/12
Monthly Premium Per Employee $2.85 $2.85
Circle Coverages & Options Elected
Dated:
Signature:
Title:
CONDITIONS AND ASSUMPTIONS
~This offer directly reflects commission of 0 %. Other compensation or bonuses may be indirectly reflected in this quote. Contact your
broker/agent if you have any questions relating to their compensation for this offer.
~Assumes current plan design as stated in Plan Document.
~Assumes the plan will have PPO: First Choice Health Case Manager: Required TPA: EBMS
~Retirees are covered for medical benefits.
~The Subsequent Policy Period Offer is based on data submitted, plus other information furnished relevant to underwriting the risk,
including all claims or possible claims, paid, pending or denied pending additional information, or which the employer or its authorized
representative should otherwise be aware of. Any inaccuracy in the data submitted or failure to disclose any such information can
change the terms, conditions, rates or factors of this offer can void the offer and coverage.
~This document may contain Protected Health Information (PHI) and should only be shared with individuals designated to view such
information per HIPAA regulations.
~In executing this form, the employer or its authorized representative, is acknowledging acceptance of the new rates, factors and
terms. The employer or its authorized representative further acknowledges that all material facts, terms and conditions stated in the
employers plan document and the Policy/Agreement remain unchanged and in full force and effect, unless noted above.
~This Offer includes access to the OptumHealth Care Solutions network. Access is included to the Centers of Excellence Networks for
transplants, cancer, kidney disease and other complex medical conditions. With a pre-qualified service at a Center of Excellence
Network Facility the covered person's specific deductible will be reduced 15% the Policy Period the benefit is paid by the Plan.
~Specific Accommodation Reimbursement is available at no additional cost.
~Aggregate Liability Limit: $ 1,000,000 per policy period.
~Minimum Annual Aggregate Deductible is 100 % of the above Attachment Point or 100 % of the first monthly Aggregate Deductible
times twelve, whichever is greater.
~Claims that exceed the Specific Deductible up to the stated Aggregating Specific Deductible are not eligible claims under Specific or
Aggregate coverage.
~This policy will terminate when the total number of employee lives is less than 51 as outlined in the Excess Loss Policy.
~OMIP assessment for Oregon employees will be paid directly by Deschutes County. The Stop Loss carrier will not be
responsible for OMIP assessment for this county group.
Until we obtain the signed Subsequent Policy Period Offer, the rates and factors are subject to change as additional
information is received. This Offer is valid for the stated effective date noted above provided the employer or its authorized
representative elects one of the above options, signs the acknowledgment and we receive the completed Offer by 7/29/11.