2022-174A - Laserfiche WebLink

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AGGREGATE EXCESS LOSS INSURANCE: ® YES ❑ NO Benefit Period: Covered Expenses Incurred from October 1, 2021 through September 30, 2023, and Paid from October 1, 2022 through September 30, 2023. TRUE COPY RTIFICATION ON LAST PAGE P. SMITH, CLERK Covered Expenses under Aggregate Excess Loss Coverage: ® Medical ❑ Dental ❑ Vision ® Stand Alone Prescription Drug Program ❑ Other (Please Specify) Aggregate Percentage Reimbursable: 100% Maximum Aggregate Benefit: ❑ $500,000 ® $1,000,000 ❑ Other Minimum Annual Aggregate Deductible: $26,841,688 or 95% of the first Monthly Aggregate Deductible amount times 12, whichever is greater. Maximum Covered Expenses per Covered Person accumulating toward the Maximum Aggregate Benefit: $300,000 Aggregate Excess Loss Premium: $ 3.06 per Employee per month Aggregate Terminal Liability Endorsement: ❑ Yes ® No Aggregate Accommodation Endorsement: ❑ Yes ® No Independent Review Organization Extended Liability Endorsement ® Yes ❑ No Monthly Aggregate Factors: Covered Persons Medical Prescription Drugs Composite $ 1,426.99 Included It is understood and agreed by the undersigned that: 1. 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 are the undersigned's representations; that any Policy is issued in reliance upon the truth of such statements, declarations, and representations; and that such statements, declarations, and representations will form a part of the Excess Loss Insurance Policy. Any inaccuracy in such information or failure to disclose any such information, including all claims or possible claims, paid or pending, or which the Employer should otherwise know about, if discovered later, can result in rejection of this Application, or can change the terms, conditions or premiums, or can void coverage. 2. As a condition precedent to the approval of this Application, the undersigned shall furnish to the Company a copy of the executed Plan Document within 90 days after the date of this application describing the benefits provided by the Plan, which shall be kept on file in the office of the Company. If the Company does not receive the Plan Document within 90 days, the Company may refund all premium and the Application shall have been null and void when signed. No Excess Loss Insurance will be effective nor reimbursement made unless a Plan Document is received and accepted by the Company. 3. The Company will evaluate the undersigned's risk, as requested by this application, the underwriting data received and represented by the Plan and may require adjustments of rates, factors, and/or special limitations. 4. 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 the Plan Document and the underwriting requirements have been met and the required premiums paid. 5. The receipt by the Company of the first month's premium and deposit of any check drawn in connection with this Application shall not constitute an acceptance of liability. In the event the Company does not approve this application, its sole obligation shall be to refund such sum to the undersigned. 6. The undersigned will provide or employ an Administrator to administer the Plan and to process and pay claims according to the Plan Document. The undersigned acknowledges that the Administrator is the undersigned's agent and not the agent of the Company and that statements and answers given by the Administrator are binding on the undersigned. 7. Other: Rate Cap provision is included that will guarantee your Subsequent Policy Period beginning October 1, 2023 will not contain any new Specific Deductible greater than the group's standard Specific Deductible for any covered person. In addition, the Specific Monthly Premium Rate and Aggregating Specific Deductible (if applicable) will not increase more than 50%. The Rate Cap will not apply if the Company determines there is a material change to the Policyholder's Plan, the Excess Loss Insurance Policy, or the composition of the group. Continuation of the Rate Cap will be assessed annually. UMERAPP (01/12)