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HomeMy WebLinkAbout2005-040 /o` P W , (� T C //�A/, I H y 44 x t ��e. ;�.. Y����5".Y� ; i .,� -TAS , sy, .�' ' .Y +#" , �y,k k $ s;. 4�'> yPit i '�' , 'C,'� 'i,. q � a.x 3� �#�,6 � aS l �xs+ .S �.£» '., �'� a � � Yom""g 4a ta� ��� e .a, �""�� � `#y� N y 5 5 ..§. Y� � rP ? Y .S µ �X�S� h F �C ' (,R T �# a� � t E' C � { y. m cam` t#t� ,+ . �� 'i"G � nib S '� +> t Fr. ".�vY x # '� r�� x"s" � . �;.�, �, �.� . .`xii s4, �_ =s� � �;b �, _�;, S"�`�:t3'F' A . *: ." k#` � � �.{ � �.� t ��� �` ' � ' t gar � � � z� �, ,.�„ � � � tip . h S A F E C 0 SAFECO Life Insurance Company 5069 -154th Place N . E. Redmond , Washington 98052 EXCESS LOSS INSURANCE POLICY MENNEN POLICY SPECIFICATIONS Policyholder: Bank of Newport , Trustee Policy Number : GT- EXL Policy Effective Date : May 15 , 2002 Premium Due Date : Premium is due on the Policy Effective Date and the first of each month beginning with June 1 , 2002 , Policy Anniversary : January 1st of each year beginning in 2003 . Governing Jurisdiction : This Policy is delivered in and governed by the laws of the state of Rhode Island . This Policy has been issued in consideration of the signed Participation Agreement and payment of premium . This Policy renews on each Policy Anniversary. SAFECO Life Insurance Company issues this Policy and agrees to pay the benefits of this Policy subject to its terms and conditions . SAFECO Life Insurance Company has , by its President and Secretary, executed this Policy as of the Policy Effective Date and caused it to be duly countersigned at Redmond , Washington . au C . B . Mead , Senior Vice President & Randall H . Talbot, President Secretary LGC 8800 11 /01 ® A registered trademark of SAFECO Corporation r TABLE OF CONTENTS Policy Specifications LGC 8800 Table of Contents LGC 8801 Schedule of Benefits LGC 8802 Definitions LGC 8803 Individual Excess Loss LGC 8804 Individual Excess Loss Advantage Provision LGC 8805 Individual Excess Loss Terminal Provision LGC 8806 Individual Excess Loss Transplant Provision LGC 8807 Individual Excess Loss Exclusions and Limitations LGC 8808 Aggregate Excess Loss LGC 8809 Aggregate Excess Loss Terminal Provision LGC 8810 Aggregate Excess Loss Monthly Aggregate Accommodation Provision LGC 8811 Aggregate Excess Loss Exclusions and Limitations LGC 8812 General Exclusions and Limitations LGC 8813 Employee Benefit Plan Changes LGC 8814 Claims Provisions LGC 8815 Surcharges Provision LGC 8816 Premium Provisions LGC 8817 Contract Termination and Renewal LGC 8818 General Contract Provisions LGC 8819 Medical Conversion Privilege LGC 8820 Participation Agreement LGC 8821 (a ) LGC 8801 03/02 ^ r SAFE SAFECO Life Insurance Company 5069454th Place N . E . Redmond , Washington 98052 EXCESS LOSS SCHEDULE OF BENEFITS A. Participating Employer: Indian River County Board of County Commissioners Policy Number: 16-010204-00 Effective Date of Coverage : October 1 , 2003 Participating Employer Anniversary Date : October 1st of each year beginning in 2004 Premium Due Date : Premium is due on the Effective Date of Coverage and the first of each month beginning with November 1 , 2003 Enrollment (at the beginning of the Policy Period) : Composite 1 . 548 B . This Schedule of Benefits applies to the Policy Period : from 10-01 -2003 to 10-01 -2004 C . Individual Excess Loss Insurance OYes ❑ No 1 . Individual Deductible per Covered Unit $ 200 , 000 2 , Alternate Individual Deductibles applicable ? ❑ Yes (See Excess Loss Alternate Reimbursement Endorsement) 0 No 3 , Covered Expenses ❑ Medical excluding all Prescription Drugs FVI Medical including Prescription Drugs defined as ONE of the following : 0 Rx Card and Mail Order ❑ Rx Card Only ❑ Rx Mail Order Only OR ❑ Rx as part of Medical Plan subject to a Deductible and Coinsurance ❑ Other 4 . SAFECO's Reimbursement Percentage 100 % of Covered Expenses in excess of the Individual Deductible . 5 , Individual Lifetime Reimbursement Maximum : $ 1 900U00 per Covered Unit 6 , Premium Rates Covered Units Composite $ 11 . 86 DP LGC 8802 03/02 1 of 3 0 A registered trademark d SAFECO Corporation 4 EXCESS LOSS SCHEDULE OF BENEFITS Applies to Policy Period : from 10-01 -2003 to 10-01 -2004 7 , Reimbursement Option : Covered Expenses incurred on or after the Effective Date of Coverage and paid during the Policy Period with : Run-in Period 0 months Run-in Limit $ N/A Run-out Period 3 months Run-out Limit $ Unlimited 8 , Individual Excess Loss Terminal Provision applicable? ❑ Yes ❑✓ No 9 . Individual Excess Loss Advantage Provision applicable? []✓ Yes ❑ No Individual Advantage Deductible $ 50 000 10 . Individual Advantage Deductible applies toward the Aggregate Attachment Point? oYes []✓ No 11 , Individual Excess Loss Transplant Provision ❑ Yes 0✓ No D . Aggregate Excess Loss Insurance 0✓ Yes ❑ No 1 . Covered Expenses : ❑ Medical excluding all Prescription Drugs ✓� Medical including Prescription Drugs defined as ONE of the following : 0✓ Rx Card and Mail Order ❑ Rx Card Only ❑ Rx Mail Order Only OR ❑ Rx as part of Medical Plan subject to a Deductible and Coinsurance p Vision ❑ Dental ❑ Short-Term Disability ❑ Other 2 , Aggregate Attachment Point will be set by SAFECO . 3 . SAFECO's Reimbursement Percentage 100 % of Covered Expenses in excess of the Aggregate Attachment Point, 4 . Aggregate Reimbursement Maximum per Policy Period $ 1 , 000 . 000 5 , Monthly Aggregate Accommodation Provision applicable? ❑ Yes 0✓ No 6 , Reimbursement Option : Covered Expenses incurred on or after the Effective Date of Coverage and paid during the Policy Period with : Run-in Period 0 months Run-in Limit $ N/A Run-out Period 3 months Run-out Limit $ Unlimited LGC 8802 03/02 2 of 3 EXCESS LOSS SCHEDULE OF BENEFITS Applies to Policy Period : from 10-01 -2003 to 10-01 -2004 7 . Minimum Aggregate Attachment Point 95 % of the first Monthly Aggregate Attachment Point X 12 8 , Monthly Aggregate Attachment Factors Covered Units Composite $665 .46 9 . Aggregate Excess Loss Terminal Provision applicable? ❑Yes 0 No 10 . Aggregate Excess Loss premium $ 1 . 80 Paid : per employee per month E . Medical Conversion Privilege ❑Yes 0 No F . Endorsements Included ❑ Individual Excess Loss Advance Funding Endorsement ❑ Excess Loss Alternate Reimbursement Endorsement G . Additional Information N /A H . Associated Companies Name Effective Date Termination Date N/A LGC 8802 03/02 3 of 3 DEFINITIONS The following words and phrases are used throughout this Policy and have specific meaning for purposes of this Policy. AGGREGATE ATTACHMENT POINT means for the Policy Period , or any portion of the Policy Period , the amount of Covered Expenses for which the Participating Employer is responsible to pay. The Aggregate Attachment Point must be met in each Policy Period and will be determined at the end of each Policy Period . AGGREGATE REIMBURSEMENT MAXIMUM means the limit of SAFECO's liability in excess of the Aggregate Attachment Point per Policy Period , as shown on the Schedule . ALTERNATE INDIVIDUAL DEDUCTIBLE means the amount shown on the Policy page entitled Excess Loss Alternate Reimbursement Endorsement and is the amount for which the Participating Employer is responsible to pay. The Alternate Individual Deductible applies separately to each Covered Unit shown on the Excess Loss Alternate Reimbursement Endorsement. ASSOCIATED COMPANY means an affiliate or subsidiary of the Participating Employer, as shown on the Schedule . CLAIMS ADMINISTRATOR means a firm or person selected by the Participating Employer, having a written agreement with the Participating Employer to process Employee Benefit Plan benefits and provide administrative services . The term Claims Administrator" as as used in this Policy does not refer to the Plan Administrator used in the Employee Retirement IncomeSecurity Act (ERISA) of 1974 , as amended unless the Participating Employer has specifically appointed the Claims Administrator as such . COVERED EXPENSES means the eligible charges payable under the terms of the Employee Benefit Plan . Covered Expenses do not include charges that are : a . in excess of, or not covered by, the Participating Employer's Employee Benefit Plan ; or b , specifically excluded or limited by this Policy, the Participating Employer's Schedule , any endorsements , or any amendments . COVERED FAMILY UNIT means any eligible individual who becomes covered for benefits under the Employee Benefit Plan and that individual's dependents . COVERED UNIT means any eligible individual who becomes covered for benefits under the Employee Benefit Plan . DISABLED PERSONS are those Covered Units who , by reason of disability, are not actively at work or able to perform each of the usual and customary duties or activities of a person of like sex and age . DISCLOSURE STATEMENT means the written statement from the Participating Employer provided to and accepted by SAFECO that provides certain underwriting information regarding Covered Units , LGC 8803 11 /01 1 DEFINITIONS (continued ) EMPLOYEE BENEFIT PLAN means the employee welfare benefit plan established by the Participating Employer. The Employee Benefit Plan must be defined in written form and be in effect on the Effective Date of the Participating Employer's coverage under this Policy. A copy of the Employee Benefit Plan and any amendments must be provided to and approved by SAFECO . EMPLOYER means the Participating Employer, EXCESS LOSS refers to the coverage provided to the Participating Employer by SAFECO under this Policy. FINAL POLICY PERIOD means the Policy Period shown on the Schedule that is in effect when coverage is terminated . INCURRED means the date on which services for Covered Expenses were rendered for a Covered Unit or Covered Family Unit according to the terms of the Employee Benefit Plan . INDIVIDUAL ADVANTAGE DEDUCTIBLE means the amount shown on the Schedule for which the Participating Employer is responsible to pay. It applies collectively to each Covered Unit or Covered Family Unit for each Policy Period . INDIVIDUAL DEDUCTIBLE means the amount shown on the Schedule for which the Participating Employer is responsible to pay. The Individual Deductible applies separately to each Covered Unit or Covered Family Unit for each Policy Period . INDIVIDUAL LIFETIME REIMBURSEMENT MAXIMUM means the limit of SAFECO's liability as shown on the Schedule , in excess of the Individual Deductible for a Covered Unit or Covered Family Unit during the lifetime of that Covered Unit or Covered Family Unit. LARGE CLAIM means paid or pending Covered Expenses greater than or equal to 50% of the Individual Deductible , MONTHLY AGGREGATE ATTACHMENT POINT means the sum of the Monthly Aggregate Attachment Factors multiplied by the monthly Covered Units , The Monthly Aggregate Attachment Point is used to calculate the Aggregate Attachment Point. PAID CLAIM means that: a . the Covered Expense is adjudicated according to the terms of the Employee Benefit Plan ; b . a check is written and mailed or electronically deposited directly to the payee within the Policy Period ; and c . funds are available to honor the check. To be sure that funds are available , they must be on deposit no later than the first working day following the end of the Policy Period , PARTICIPATING EMPLOYER means the entity named on the Participation Agreement and the Schedule who has applied for coverage under this Policy. POLICY refers to the terms and provisions of this contract . POLICYHOLDER means the entity named as the Trustee for this Policy. LGC 8803 11 /01 2 DEFINITIONS (continued) POLICY MONTH means each calendar month within a Policy Period . If the effective date of this coverage is other than the first day of the calendar month , then the first Policy Month is from the effective date to the last day of the same month . POLICY PERIOD means the period of time shown on the Schedule . POTENTIAL LARGE CLAIM means any Covered Expense included on the list of Potential Large Claims shown in the claims provisions section . REIMBURSEMENT PERCENTAGE means the rate at which SAFECO will reimburse the Participating Employer, as shown on the Schedule . RUN -IN LIMIT means the maximum amount shown on the Schedule , paid by the Participating Employer for Covered Expenses incurred prior to the Policy Period , or during the Run-in Period which will be considered for reimbursement by SAFECO . RUN -IN PERIOD means the number of months immediately prior to the Policy Period as shown on the Schedule . RUN -OUT LIMIT means the maximum amount shown on the Schedule , paid by the Participating Employer during the Run -out Period for Covered Expenses incurred during the Policy Period which will be considered for reimbursement by SAFECO . RUN -OUT PERIOD means the number of months immediately following the Policy Period as shown on the Schedule . SCHEDULE means the Excess Loss Insurance Schedule of Benefits that is a part of this Policy. TERMINAL RUN -OUT PERIOD means the number of months immediately following the Final Policy Period as shown on the Schedule . LGC 8803 11 /01 3 INDIVIDUAL EXCESS LOSS This benefit applies only if indicated on the Schedule . INDIVIDUAL EXCESS LOSS BENEFIT Upon acceptance of proof of loss , SAFECO will reimburse the Participating Employer for payments SAFECO considers are Covered Expenses that the Participating Employer makes that exceed the Individual Deductible shown on the Schedule for Paid Claims that are : a . incurred while the Employee Benefit Plan is in force ; b , paid for Covered Units or Covered Family Units according to the terms of the Employee Benefit Plan ; and c. incurred during the Policy Period or during the Run-in Period shown on the Schedule and paid during the Policy Period or during the Run-out Period shown on the Schedule . Payments for Covered Expenses that are eligible for more than one Policy Period will apply toward the Policy Period in which the Covered Expenses were actually incurred . Reimbursements will be subject to the Run-in Limit and Run-out Limit shown on the Schedule . The benefit reimbursed by SAFECO will be at the Reimbursement Percentage shown on the Schedule and will not exceed the Individual Lifetime Reimbursement Maximum shown on the Schedule . i . LGC 8804 11 /01 INDIVIDUAL EXCESS LOSS ADVANTAGE PROVISION - This provision applies only if indicated on the Schedule . SAFECO will reimburse the Participating Employer for payments SAFECO considers are Covered Expenses that the Participating Employer makes that exceed the Individual Advantage Deductible shown on the Schedule . The Individual Advantage Deductible applies in addition to the Individual Deductible for Paid Claims that are : a , incurred while the Employee Benefit Plan is in force ; b . in excess of the Individual Deductible , shown on the Schedule ; c. paid for Covered Units or Covered Family Units according to the terms of the Employee Benefit Plan ; and d , incurred during the Policy Period or during the Run-in Period shown on the Schedule and paid during the Policy Period or during the Run-out Period shown on the Schedule . Payments for Covered Expenses that are eligible for more than one Policy Period will apply toward the Policy Period in which the Covered Expenses were actually incurred . Reimbursements will be subject to the Run-in Limit and Run-out Limit shown on the Schedule . Covered Expenses for more than one Covered Unit or Covered Family Unit may be combined to satisfy the Individual Advantage Deductible . Covered Expenses that apply toward the Alternate Individual Deductible shown on the Alternate Reimbursement Endorsement will not apply toward the Individual Advantage Deductible . The benefit reimbursed by SAFECO will be at the Reimbursement Percentage shown on the Schedule and will not exceed the Individual Lifetime Reimbursement Maximum shown on the Schedule . The Individual Advantage Deductible may be applied toward the Aggregate Attachment Point if indicated on the Schedule . LGC 8805 11 /01 INDIVIDUAL EXCESS LOSS TERMINAL PROVISION This provision applies only if indicated on the Schedule . If the Individual Excess Loss benefit terminates at the end of the Policy Period , Paid Claims will apply toward the Individual Deductible for the Final Policy Period only if they are : a , incurred while the Individual Excess Loss benefit is in force or during the Run-in Period , subject to the Run-in Limit ; and b . paid within the final Policy Period or the Terminal Run-out Period shown on the Schedule . This provision will not apply if the Individual Excess Loss benefit terminates before the end of the Policy Period , LGC 8806 11 /01 INDIVIDUAL EXCESS LOSS TRANSPLANT PROVISION , This provision applies only if indicated on the Schedule. SAFECO will reduce the Individual Deductible for transplant procedures that are : a . Covered Expenses ; and b . performed in a SAFECO approved transplant network facility. The amount of the reduction will be equal to the greater of $ 10 , 000 or 10 % of the deductible , not to exceed the amount of the Individual Deductible remaining to be satisfied at the time the transplant procedure becomes a Paid Claim . The reduction of the Individual Deductible is limited to a one-time reduction per transplant. The reduction will apply to the Policy Period in which the Covered Expenses for the approved transplant procedure become a Paid Claim . The reduction will not apply if any other discounts are applicable or if the hospital has any other contracts with SAFECO . The reduction does not apply to the Individual Advantage Deductible or to the Alternate Individual Deductible , LGC 8807 11 /01 _ w - : INDIVIDUAL EXCESS LOSS EXCLUSIONS AND LIMITATIONS The following exclusions and limitations apply to all Individual Excess Loss provisions . SAFECO will not reimburse the Participating Employer for Paid Claims that: a . have been reimbursed by another insurance company or reinsurance company; b . are incurred after the Participating Employer's Individual Excess Loss benefit terminates ; c. exceed SAFECO's Individual Lifetime Reimbursement Maximum as shown on the Schedule ; or d . have been excluded under the terms described in the Excess Loss Alternate Reimbursement Endorsement, LGC 8808 11 /01 AGGREGATE EXCESS LOSS This benefit applies only if indicated on the Schedule . AGGREGATE EXCESS LOSS BENEFIT Upon acceptance of proof of loss , SAFECO will reimburse the Participating Employer for payments SAFECO considers are Covered Expenses that the Participating Employer makes that exceed the Aggregate Attachment Point for Paid Claims that are : a . incurred while the Employee Benefit Plan is in force ; b . paid for Covered Units according to the terms of the Employee Benefit Plan ; and c. incurred during the Policy Period or during the Run-in Period shown on the Schedule and paid during the Policy Period or during the Run-out Period shown on the Schedule . Payments for Covered Expenses that are eligible for more than one Policy Period will apply toward the Policy Period in which the Covered Expenses are actually incurred . Reimbursements will be subject to the Run-in Limit and Run-out Limit shown on the Schedule . The benefit reimbursed by SAFECO will be at the Reimbursement Percentage shown on the Schedule and will not exceed the Aggregate Reimbursement Maximum shown on the Schedule . AGGREGATE ATTACHMENT POINT The Aggregate Attachment Point is equal to the greater of: a . the sum of the Monthly Aggregate Attachment Points for the Policy Period shown on the Schedule ; or b . the Minimum Aggregate Attachment Point shown on the Schedule . If the Aggregate Excess Loss benefit terminates before the end of the Policy Period , the Minimum Aggregate Attachment Point is equal to the greater of: a . the sum of the Monthly Aggregate Attachment Points to the date of termination ; or b . the Minimum Aggregate Attachment Point shown on the Schedule . LGC 8809 11 /01 1 AGGREGATE EXCESS LOSS (continued) CALCULATION OF MONTHLY AGGREGATE ATTACHMENT POINT Each Monthly Aggregate Attachment Point is calculated by multiplying the number of Covered Units for that month by the Monthly Aggregate Attachment Factor(s ) shown on the Schedule . The Monthly Aggregate Attachment Point in any Policy Month cannot be less than 95% of the Monthly Aggregate Attachment Point for the immediately preceding Policy Month . If any of the Participating Employer's employees are absent from work due to a strike , lock out , or work stoppage , the number of Covered Units will remain at the same level as for the month before such interruption began . The number of Covered Units used to calculate the Monthly Aggregate Attachment Point in the first month of the second or subsequent Policy Periods cannot be less than 95% of the number of Covered Units reported 90 days prior to the end of the immediately preceding Policy Period , LGC 8809 11 /01 2 AGGREGATE EXCESS LOSS TERMINAL PROVISION This provision applies only if indicated on the Schedule . If the Aggregate Excess Loss benefit terminates at the end of the Policy Period , Paid Claims will apply toward the Aggregate Attachment Point for the Final Policy Period only if they are : a . incurred while the Aggregate Excess Loss benefit is in force or during the Run-in Period , subject to the Run-in Limit; and b . paid during the Final Policy Period or the Terminal Run -out Period shown on the Schedule . The Annual Aggregate Attachment Point for the Policy Period will be increased by an amount equal to the average number of Covered Units during the last 3 months of the Policy Period multiplied by the terminal factor(s) shown in the Schedule . This provision will not apply if the Aggregate Excess Loss benefit terminates before the end of the Policy Period , LGC 8810 11 /01 AGGREGATE EXCESS LOSS MONTHLY AGGREGATE ACCOMMODATION PROVISION This provision applies only if indicated on the Schedule . SAFECO will reimburse the Participating Employer during the current Policy Period if, at the end of any month during that period, the Net Covered Expenses (defined below) exceed the sum of the Monthly Aggregate Attachment Points for the same period by $ 1 , 000 or more . Net Covered Expenses means the sum of the payments for Covered Expenses made by the Participating Employer: a . less Covered Expenses in excess of the Individual Deductible shown on the Schedule ; and b , less any applicable Monthly Aggregate Accommodation reimbursements made by SAFECO . The Monthly Aggregate Accommodation Provision will not apply during the last month of the Policy Period or during the Run-out Period . OVERPAYMENT BY SAFECO SAFECO may, at its option , require repayment of any previous Monthly Aggregate Accommodation reimbursement , and may also reduce subsequent Excess Loss reimbursements if at any time during the Policy Period the total of all : a . Monthly Aggregate Accommodation reimbursements ; and b . Individual Excess Loss reimbursements ; and c . Monthly Aggregate Attachment Points for the previous Policy Months in that Policy Period exceeds the total Paid Claims for the same Policy Months in that Policy Period . END OF POLICY YEAR RECONCILIATION At the end of the Policy Period , any Monthly Aggregate Accommodation reimbursement that exceeds the amount payable under the Aggregate Excess Loss provisions must be repaid within 31 days of written notice from SAFECO . LGC 8811 03/02 AGGREGATE EXCESS LOSS EXCLUSIONS AND LIMITATIONS The following exclusions and limitations apply to all Aggregate Excess Loss provisions . SAFECO will not reimburse the Participating Employer for Paid Claims that : a . have been reimbursed by another insurance company or reinsurance company; be are incurred after the Participating Employer's Aggregate Excess Loss benefit terminates ; c. have been reimbursed by SAFECO under Individual Excess Loss Insurance ; d . exceed SAFECO's Individual Lifetime Reimbursement Maximum or the Aggregate Reimbursement Maximum as shown on the Schedule ; or e , have been excluded under the terms described in the Excess Loss Alternate Reimbursement Endorsement , LGC 8812 11 /01 GENERAL EXCLUSIONS AND LIMITATIONS LIMITATIONS ON ELIGIBILITY FOR REIMBURSEMENT UNDER THIS POLICY SAFECO will not reimburse the Participating Employer for Covered Expenses incurred by Covered Units or Covered Family Units that qualify as Potential Large Claims , unless disclosed and accepted by SAFECO . In the event of nondisclosure by the Participating Employer, SAFECO reserves the right to : a . change or modify the premium rates , Monthly Aggregate Attachment Factors , or Individual Deductible amount(s ) ; or b . adjust the terms of the Aggregate and Individual Excess Loss benefit . EXCLUSIONS SAFECO will not reimburse any loss or expense caused by, or resulting from , any of the following : a . expenses for occupational accidents or illnesses or expenses that the Employee Benefit Plan covers that are covered or eligible for coverage by Worker's Compensation , including any payments made by Worker's Compensation carriers as exceptions or payments with no liability concerning Worker's Compensation coverage ; b , the cost of the administration of claims , payments , or other service (s ) provided by the Claims Administrator for consulting fees ; or c . payments for treatment or services which are considered experimental or investigational as defined by the Employee Benefit Plan . LGC 8813 03/02 EMPLOYEE BENEFIT PLAN CHANGES AMENDMENT TO THE EMPLOYEE BENEFIT PLAN SAFECO must be notified of any change to the Employee Benefit Plan . Notices of change must be in writing and provided to SAFECO prior to the effective date of the change . SAFECO must approve changes in writing before the benefits provided by the changes will be included as Covered Expenses . If notice is not received prior to the effective date of the change , SAFECO will determine the date , if any, the benefits that are provided by this change will be considered Covered Expenses . If SAFECO does not approve a submitted change , SAFECO will not consider the benefits provided by this change as Covered Expenses , Only Covered Expenses for benefits provided by the most current SAFECO approved Employee Benefit Plan will be considered for reimbursement. LGC 8814 11 /01 - _ CLAIMS PROVISIONS EMPLOYEE BENEFIT PLAN 'S CLAIMS ADMINISTRATION The Participating Employer must retain a Claims Administrator at all times . All Claims Administrator(s) must be approved by SAFECO . The Claims Administrator performs as the Participating Employer's agent, and SAFECO will not be held liable for any act or omission of the Claims Administrator. SAFECO will only reimburse the Participating Employer for claims paid by the Claims Administrator(s ) , The Claims Administrator will : a . supervise the administration and adjustment of all claims and verify the accuracy and computation of all claims in accordance with the terms of the Employee Benefit Plan ; b , maintain accurate records of all claim payments ; c . maintain separate records of expenses not covered ; and d . provide SAFECO with the following data for the preceding Policy Month on or before the 30th day of each succeeding Policy Month : 1 . number of Covered Units ; 2 . notice of claims that reach 50 % of the Individual Deductible ; and 3 . total amount of claims paid . MANAGEMENT OF LARGE CLAIMS AND POTENTIAL LARGE CLAIMS Notice of Large Claim The Participating Employer or the Participating Employer's Claims Administrator(s ) must notify SAFECO in writing within 10 business days of receiving information indicating that Covered Expenses qualify as a Large Claim . If the Participating Employer receives information that any claim may be or become a Large Claim , the Participating Employer will immediately notify the Participating Employer's Claims Administrator. Notice of Potential Large Claim The Participating Employer or the Participating Employer's Claims Administrator must notify SAFECO of any Potential Large Claim in writing within 10 business days of receiving any information indicating that the claim qualifies as a Potential Large Claim . See the List of Potential Large Claims below. If the Participating Employer receives information that any claim may be or become a Potential Large Claim , the Participating Employer will immediately notify the Participating Employer's Claims Administrator. LGC 8815 03/02 1 CLAIMS PROVISIONS (continued ) - LIST OF POTENTIAL LARGE CLAIMS Covered Expenses which qualify as Potential Large Claims are listed below. SAFECO retains the right to add to or delete from the list of Potential Large Claims with 30 days written notice to the Participating Employer. • Transplants , whether incurred or anticipated • Dialysis , home infusion or injection therapy other than insulin or vitamins 0 Cancer • Chemotherapy or radiation • Multiple trauma • Premature birth at less than 34 week gestation • Any inpatient confinement greater than 7 days including acute rehabilitation or skilled nursing • Brain or spinal cord injury or stroke • High risk pregnancy or pre-term labor CASE MANAGEMENT If SAFECO recommends alternative care and treatment that is not provided for in the Employee Benefit Plan and the Participating Employer allows charges for such recommended care and treatment to be considered eligible under the Employee Benefit Plan , these charges will be considered Covered Expenses under this Policy. NOTICE OF EXCESS LOSS CLAIM Aggregate Excess Loss Claim The Participating Employer will give written notice of Aggregate Excess Loss claims to SAFECO within 31 days of the date Covered Expenses have reached the Aggregate Attachment Point . Individual Excess Loss Claim The Participating Employer will give written notice of Individual Excess Loss claims to SAFECO within 31 days of the date the Covered Expenses , with respect to a Covered Unit or Covered Family Unit, have reached the Individual Deductible . The Participating Employer's failure to furnish written notice within 31 days will not invalidate or reduce any claim if it were not reasonably possible to provide written notice within such time . However, written notice must be furnished as soon as possible , but in no event later than 1 year after the date written notice is first required . The Participating Employer or the Participating Employer's Claims Administrator(s) will submit on a timely basis all proofs of loss , reports , and supporting documents that SAFECO may request. LGC 8815 03/02 2 CLAIMS PROVISIONS (continued ) AUDIT SAFECO , or its duly authorized representative(s ) , prior to making a reimbursement, will have the right to inspect and audit all of the Participating Employer's and the Participating Employer's Claims Administrator's records and procedures as well as any other records and procedures that pertain to this Policy. SAFECO will also have the right to require proof that payment of Covered Expenses has been made . SUBROGATION In the event of any payment(s) of Covered Expenses under the Employee Benefit Plan due to an illness and/or injury to a Covered Unit or Covered Family Unit caused by a third party, the Participating Employer may be entitled to a recovery from such third party. SAFECO retains the right to pursue any recovery received by the Participating Employer and to collect any and all reimbursements made to the Participating Employer. In the event SAFECO recovers an amount greater than its reimbursement, the excess , reduced by the costs to obtain the recovery, will be returned to the Participating Employer. SAFECO is entitled to first recovery of payments as an offset to the deductible paid by the Participating Employer. If the Participating Employer receives a recovery prior to SAFECO reimbursing any Covered Expenses under the Policy, the Participating Employer must deduct these payments from any reimbursement request. If the Participating Employer receives a recovery after SAFECO has made reimbursement for some or all of a particular claim , then the Participating Employer must reimburse SAFECO to the extent of the reimbursement within 30 days . The obligation of the Participating Employer to reimburse SAFECO remains , regardless of whether the Policy is still in force on the date of recovery. In addition , this provision is applicable even if it is determined the amount of the Covered Unit' s or Covered Family Unit's recovery does not fully indemnify or make whole the Covered Unit or Covered Family Unit, The Participating Employer's payment to SAFECO may be reduced by the reasonable and necessary expenses incurred in recovering from the other party. LGC 8815 03/02 3 SURCHARGES PROVISION SAFECO will reimburse surcharges required by state statute and/or regulations . In order for surcharges to be considered Covered Expenses under the Excess Loss Policy, the provider bills must be for Covered Expenses according to the terms of the Employee Benefit Plan . EXCLUSIONS AND LIMITATIONS SAFECO will not reimburse any expenses that are : a . surcharges made on a per Covered Unit or Covered Family Unit basis ; or b , penalties or fines assessed by a state against the Participating Employer. LGC 8816 11 /01 PREMIUM PROVISIONS PAYMENT OF PREMIUMS Premiums for this Policy must be received on or before Premium Due Date , as shown on the Schedule , at SAFECO's Home Office . Payment of premium will continue Excess Loss coverage only until , but not I ncluding , the next Premium Due Date . If the Participating Employer chooses to use any third party to pay premium on its behalf, such third party is the agent of the Participating Employer and the Participating Employer is responsible for ensuring that the premium is received by SAFECO . SAFECO will not be held liable for any act or omission of the third party. GRACE PERIOD If premium is not received on the Premium Due Date , a 31 day grace period will be granted starting from and including the Premium Due Date . If premium is not received at the end of the 31 days , this Policy will terminate on the last date of coverage for which premium has been paid . CHANGES IN PREMIUM RATES AND MONTHLY AGGREGATE ATTACHMENT FACTORS SAFECO has the right to establish new Premium Rates and Monthly Aggregate Attachment factors on each Participating Employer Anniversary Date . SAFECO will provide the Participating Employer a 31 day advance written notice in the event of any change in premium rates or Monthly Aggregate Attachment Factors at renewal SAFECO has the right to establish new Premium Rates and new Monthly Aggregate Attachment Factors at any time during a Policy Period if: a . the number of enrolled Covered Units changes by more than 25 % from the Enrollment shown on the Schedule ; b . SAFECO discovers an individual who was not disclosed and whom SAFECO determines to be an unacceptable risk; c . an amendment is made to the Employee Benefit Plan ; or d , a change in the terms of Excess Loss coverage occurs . RENEWAL RATING PROVISION SAFECO reserves the right to change the Premium rates and/or Monthly Aggregate Attachment Factors for a Policy Period if the average Paid Claims for the last two Policy Months of the immediately preceding Policy Period exceeds 125% of the average Paid Claims for all prior Policy Months in that preceding Policy Period . LGC 8817 03/02 CONTRACT TERMINATION AND RENEWAL - TERMINATION BY THE POLICYHOLDER (TRUSTEE) The Policyholder may terminate this Policy at any time by giving SAFECO written notice . The Policy will end no sooner than 90 days after the date on which notice is received by SAFECO . TERMINATION BY THE PARTICIPATING EMPLOYER The Participating Employer may terminate its coverage under this Policy at any time by giving SAFECO 31 days advance written notice . TERMINATION BY SAFECO SAFECO may terminate the Participating Employer's coverage under this Policy by giving the Participating Employer 31 days written notice . SAFECO can only terminate for the following reasons : a . the Participating Employer fails to comply with a provision of this Policy; b . the Participating Employer fails to perform the obligations under this Policy in good faith ; c . the Participating Employer is covering fewer than 50 employees ; or d , in the event the Participating Employer fails to provide the information required in the Excess Loss Disclosure Statement . This Participating Employer's coverage under this Policy will automatically terminate if: a . the Participating Employer does not pay all premiums that are due by the end of the Grace Period ; b . the Participating Employer does not pay claims or make available funds to pay claims as required by this Policy ; c . the Participating Employer's Employee Benefit Plan terminates ; or d . the Policy is terminated by the Policyholder. RENEWAL SAFECO may refuse to renew the Participating Employer's coverage under this Policy by giving the Participating Employer 31 days advance written notice . Otherwise , the coverage under this Policy will automatically renew on each Participating Employer's Policy Anniversary Date if the Participating Employer continues to pay premiums at the rates set by SAFECO . LGC 8818 03/02 GENERAL CONTRACT PROVISIONS ENTIRE CONTRACT This entire contract consists of: a . the pages of this Policy, including any amendments or endorsements ; b . the Participating Employer's Participation Agreement; c. the Disclosure Statement ; d . the Participating Employer's Employee Benefit Plan as approved by SAFECO ; and e . the Excess Loss Schedule of Benefits . LIABILITY AND INDEMNIFICATION SAFECO is not liable for any costs the Participating Employer incurs because of any disputes or contested claims under the Employee Benefit Plan . SAFECO is not liable for punitive , exemplary or consequential damages . The Participating Employer must hold SAFECO harmless from damages of any kind which are not caused by SAFECO's own acts or omissions . The Participating Employer must indemnify SAFECO for all expenses of litigation , including attorney fees , that SAFECO incurs in defending claims or lawsuits brought against SAFECO by a Covered Unit or Covered Family Unit under the Employee Benefit Plan . OBLIGATION SAFECO is acting only as a provider of insurance to the Participating Employer. SAFECO is not and will not be considered a fiduciary. SAFECO assumes no obligations required by the Employee Retirement Income Act ( ERISA) of 1974 , as amended . SAFECO has no responsibility or obligation to directly reimburse any Covered Unit or Covered Family Unit, This Policy will not create any right or legal relationship between SAFECO and any Covered Unit or Covered Family Unit . SAFECO's sole obligation under this Policy is to the Participating Employer, ASSOCIATED COMPANIES Excess Loss Insurance is extended to the Participating Employer's Associated Companies listed on the Schedule . Additions and terminations may only be made by amendment to coverage under this Policy. Termination of an Associated Company is treated as termination of coverage for that company only. NOTICE For purposes of any notice required under this Policy, notice to the last known Claims Administrator will be considered notice to the Participating Employer. Notice to the Participating Employer will be considered notice to the Claims Administrator, LGC 8819 03/02 1 GENERAL CONTRACT PROVISIONS (continued ) - RECORDS The Participating Employer must: a . keep appropriate records regarding administration of the Employee Benefit Plan ; b . allow SAFECO to review and copy, during normal business hours , all records affecting SAFECO's liability ; and c . ensure that SAFECO receives monthly status reports and other data as requested under the Claims Provisions of this Policy. CLERICAL ERROR Clerical error, whether by the Participating Employer or SAFECO , will not invalidate coverage validly in force or affect coverage validly terminated . Clerical errors should be reported and corrected . SAFECO will make appropriate adjustments in the premiums due for claims eligible for reimbursement under this Policy. Refunds and credits are limited to the 12 month period prior to the request for adjustment. LEGAL ACTION No legal action may be brought to recover on this Policy within 60 days after written proof of loss has been furnished . No legal action may be brought after 3 years from the time written proof of loss is required to be furnished . AMENDMENTS TO THIS POLICY This Policy or the Participating Employer's coverage under this Policy may be amended at any time by mutual consent between the parties , Such modification must be by written agreement signed by SAFECO's President, Vice President or Secretary. Only these Officers have the authority to modify coverage under this Policy, waive any of SAFECO's rights or requirements , or make any promise with respect to benefits under this Policy. TAXES If premium taxes should be assessed against the Participating Employer, with respect to claims paid under the Participating Employer's Employee Benefit Plan , the Participating Employer shall hold SAFECO harmless from any tax liability, If premium taxes should be assessed against SAFECO with respect to Employee Benefit Plan benefits paid , the Participating Employer must reimburse SAFECO the amount of the premium tax liability, interest, penalty, and costs incurred by SAFECO as a result of the tax assessment , LGC 8819 03/02 2 MEDICAL CONVERSION PRIVILEGE This benefit applies only if indicated on the Schedule . An employee whose coverage under the Employee Benefit Plan ends solely due to termination of employment or change in classification may be eligible for an individual medical conversion policy. A dependent whose coverage under the Employee Benefit Plan ends solely due to loss of dependency status or change in classification may also be eligible . Eligibility for conversion is determined as follows : a . the person must have been covered for medical benefits under the Employee Benefit Plan for at least 3 months ; b . proof of good health will not be required ; c. the person must be under the age of 65 ; d , the person must be a resident of the United States ; e . the person 's coverage under the Employee Benefit Plan must end prior to termination of the Participating Employer's coverage under this Policy ; and f. the person must not currently have an individual medical conversion policy issued through SAFECO . SAFECO , or its designee , will issue an individual medical conversion policy, subject to the following : a . the eligible person must apply for conversion , and the application and first premium payment must be received by SAFECO at its Home Office within 31 days after the date coverage under the Employee Benefit Plan terminates ; b , a then current individual medical conversion policy will be issued at the rate in use on the conversion effective date ; and c , the effective date of the individual medical conversion policy will be the day after coverage terminates under the Employee Benefit Plan . LGC 8820 03/02 SA F ECO " SAFECO Life Insurance Company 5069-154th Place N . E . Redmond , Washington 98052 PARTICIPATION AGREEMENT Policy Number: 16-010204-00 The Participating Employer: Indian River County Board of County Commissioners (Legal Name) has received a SAFECO contract which consists of: (a ) the SAFECO Excess Loss Policy, including any amendments or endorsements ; (b ) the Excess Loss Schedule of Benefits ; (c) the Employee Benefit Plan document, approved by SAFECO ; and (d ) the Disclosure Statement and has approved and accepted the terms of this contract . No reimbursement under this Policy will be paid until such time as this Participation Agreement has been executed and received by SAFECO . 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 . Name : Thomas S . Lowther Title : Chairman (Please Print Name of Signatory) (Please Print) By: QL, s L (Signature of Participating Employer) Signed at: Vera NO On : February 1 , 2005 i ( Date) Witnes . `"" f 77 Title : DEPUTY CLERK re) (Please Print) Instructions to Parte ` tii yJoyer: (1 ) Sign and return original to SAFECO . (2) Retain copy with your Policy. APPROVED AS TO FOIA AND LEGAL SUFFI IE • PROVED : s WILLIAM K . DEBRAAL ASSISTANT COUNTY ATTORNEY C my Ad inistrator LGC 8821 (a) 10/02 8 A registered trademark of SAFECO Corporation ,M Safeco Life Insurance Company 5069 154th Place NE Redmond, WA 98052 www.safeco.com CN-0022 Safeco° and the Safeco logo are trademarks of Safeco Corporation 6/03 SAF ECO * SAFECO Life Insurance Company 5069-154th Place N . E . Redmond , Washington 98052 EXCESS LOSS SCHEDULE OF BENEFITS A. Participating Employer: Indian River County Board of County Commissioners Policy Number: 16-010204-00 Effective Date of Coverage : October 1 , 2003 Participating Employer Anniversary Date : October 1st of each year beginning in 2004 Premium Due Date : Premium is due on the Effective Date of Coverage and the first of each month beginning with November 1 , 2003 Enrollment (at the beginning of the Policy Period) : Composite 1 . 590 B . This Schedule of Benefits applies to the Policy Period : from 10-01 -2004 to 10-01 -2005 C . Individual Excess Loss Insurance ✓❑ Yes El No 1 . Individual Deductible per Covered Unit $ 200 , 000 2 , Alternate Individual Deductibles applicable? ❑ Yes (See Excess Loss Alternate Reimbursement Endorsement) No 3 , Covered Expenses ❑ Medical excluding all Prescription Drugs ❑✓ Medical including Prescription Drugs defined as ONE of the following : ✓❑ Rx Card and Mail Order ❑ Rx Card Only ❑ Rx Mail Order Only OR ❑ Rx as part of Medical Plan subject to a Deductible and Coinsurance ❑ Other 4 . SAFECO's Reimbursement Percentage 100 % of Covered Expenses in excess of the Individual Deductible . 5 . Individual Lifetime Reimbursement Maximum : $ 1 , 000 . 000 per Covered Unit 6 , Premium Rates Covered Units Composite $ 12 . 97 he LGC 8802 03/02 1 of 3 0 A registered trademark of SAFECC Corporation EXCESS LOSS SCHEDULE OF BENEFITS Applies to Policy Period : from 10-01 -2004 to 10-01 -2005 7 , Reimbursement Option : Covered Expenses incurred on or after the Effective Date of Coverage and paid during the Policy Period with : Run -in Period 0 months Run-in Limit $ N/A Run-out Period 3 months * Run-out Limit $ Unlimited * See Section G: Additional Information 8 . Individual Excess Loss Terminal Provision applicable? ❑ Yes ❑✓ No 9 . Individual Excess Loss Advantage Provision applicable? ❑✓ Yes ❑ No Individual Advantage Deductible $ 50 , 000 10 . Individual Advantage Deductible applies toward the Aggregate Attachment Point? ❑ Yes ❑✓ No 11 . Individual Excess Loss Transplant Provision ❑ Yes ❑✓ No D . Aggregate Excess Loss Insurance ❑✓ Yes ❑ No 1 . Covered Expenses : ❑ Medical excluding all Prescription Drugs ❑✓ Medical including Prescription Drugs defined as ONE of the following : ❑✓ Rx Card and Mail Order ❑ Rx Card Only ❑ Rx Mail Order Only OR ❑ Rx as part of Medical Plan subject to a Deductible and Coinsurance ❑ Vision ❑ Dental ❑ Short-Term Disability ❑ Other 2 . Aggregate Attachment Point will be set by SAFECO . 3 . SAFECO's Reimbursement Percentage 100 % of Covered Expenses in excess of the Aggregate Attachment Point. 4 , Aggregate Reimbursement Maximum per Policy Period $ 1 . 000 . 000 5 , Monthly Aggregate Accommodation Provision applicable? El Yes ❑✓ No 6 , Reimbursement Option : Covered Expenses incurred on or after the Effective Date of Coverage and paid during the Policy Period with : Run - in Period 0 months Run-in Limit $ N/A Run-out Period 3 months * Run-out Limit $ Unlimited * See Section G: Additional Information LGC 8802 03/02 2 of 3 I Y Y EXCESS LOSS SCHEDULE OF BENEFITS Applies to Policy Period : from 10-01 -2004 to 10-01 -2005 7 . Minimum Aggregate Attachment Point 95 % of the first Monthly Aggregate Attachment Point x 12 8 . Monthly Aggregate Attachment Factors Covered Units Composite $665 .46 9 . Aggregate Excess Loss Terminal Provision applicable? ❑Yes 0 No 10 . Aggregate Excess Loss premium $ 1 . 80 Paid : per employee per month E . Medical Conversion Privilege E]Yes 0 No F . Endorsements Included ❑ Individual Excess Loss Advance Funding Endorsement ❑ Excess Loss Alternate Reimbursement Endorsement G . Additional Information " Run-out Period (s ) do not apply if this Policy terminates prior to the end of the Policy Period H . Associated Companies Name Effective Date Termination Date N/A LGC 8802 03/02 3 of 3 SAFECO " SAFECO Life Insurance Company 5069-154th Place N . E . Redmond , Washington 98052 PARTICIPATION AGREEMENT Policy Number: 16-010204-00 The Participating Employer: Indian River County Board of County Commissioners ( Legal Name) has received a SAFECO contract which consists of: (a ) the SAFECO Excess Loss Policy, including any amendments or endorsements ; ( b ) the Excess Loss Schedule of Benefits ; (c) the Employee Benefit Plan document, approved by SAFECO ; and (d) the Disclosure Statement and has approved and accepted the terms of this contract . No reimbursement under this Policy will be paid until such time as this Participation Agreement has been executed and received by SAFECO. 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 o the third degree . Name : Thomas S . Lowther Title :_ Chairman ( Please Print Name of Signatory) (Please Print) By: ---�� 5. L (Signature of Participating Employer) Signed at : + On : FPhrliary 1 . 2nn5 e fq (Date) Witness . Title : DEPUTY CLERK (Please Print) 4 f� Yru ..PC�Aa Of Instructions toN , f �fiployer: (1 ) Sign and return original to SAFECO . (2) Retain copy with your Policy. ru d . JAPROVED . APPROVED AS T FO ` AL F y y Ad inistrator BY t WIL IAM K . DEBRAAL ASSISTANT COUNTY ATTORNEY