HomeMy WebLinkAbout2006-264 02c00 (o � 6y
NOTIFICATION OF RENEWAL ( /' / SYMi T RA°°
FINANCIAL
Policyholder Name : _Indian River County Policy Number: 16-010204-00
Anniversary Date : _10-01 -2046
Please complete the appropriate section (s) below :
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
- - - - -
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
- - - - -
Excess Loss : The above account has renewed on the following terms :
Individual : Contract: 12/ 12 Paid Other: 12/15
Deductible Level : $200 , 000 .00 Individual Advantage Deductible : $549000 .00
Coverage Includes : X Medical X_ Prescription Drugs
Lifetime Maximum : _$ 1 ,000 ,000 . 00
Renewal Individual Rates : Single : ; Family: _Composite $ 14.03
Terminal Liability Coverage : Yes _; No _X_ (Note: Only available if purchased at policy inception)
Aggregate : Contract: 12/ 12 Paid Other: _12/15
Coverage Includes : _X_ Medical _X_ Prescription Drugs Other
Renewal Aggregate Factors : Single : Family : Composite : $731 . 77
Aggregate Premium : $ 1 . 80_ Lifetime Maximum : _$ 1 ,000 ,000 . 00
Monthly Aggregate Accounting : Yes _X_ No Rate :
Terminal Liability Coverage : Yes ; No _X_ (if yes , specify terminal liability factors below)
Terminal Liability Factors : Single : Family:
Managed Care Network(s )
BlueCross
Plan--Administrators S1 ature :
� , � rn nh�� rtn�l Date
Ag Sig tan ure: vL Date : 7 - ! 7 - zod�
Please forward to :
Symetra Financial APPROVED AS TO FO
Attn : Mary Hewitt AND LEGALS, FF 1 IN Y.
Mary. hewitt@symetra .com
FAX : (678) 728-1567 By
WILLIAM K . D B AAL
ASSISTANT COUNTY ATTORNEY
Symetra Life Insurance Company • Group Division • 3740 Davinci Court Suite 350 • Norcross, GA 30092 • vnw✓.symetra.com
Phone: 678-728-1549 FAX 678-728-1567 Toll Free: 800-746-6246
of nomas B1ueSbield EMPLOYER APPLICATION
�.� O of Florida
• Healtb Options. (True Group Application)
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❑ New Business 0 Renewal Business Other
1 . Group Information Group # ( BCBSF) : 90000 ( HMO) :
A . Name of Group : IINDIAN RIVER COUNTY (BD. OF CTY. COMMISSION)
Nature of Business : lGenerall government, nee SIC Code : 9199
Mailing Address : 11840 251111 STREET VERO BEACH, FI, 32960
Email Address :
List below Subsidiary or Attiliatecl Uompanies whose employees are to be eligible an included with this
application .
Name Address
B . Applicant hereby applies for issuance of a Group Policy (herein referred to as Policy) by Blue Cross and Blue
Shield of Florida, Inc. ( BCBSF) and/or Health Options , Inc. (HOI ) . Upon acceptance of this application by
BCBSF and/or HOI , it will become part of the Policy issued to the applicant named above.
C . Prior Health Carrier: Insurance JACORDIA INC.
HMO
D . The Policy excludes expenses for any service or supply to diagnose or treat any Condition from or in connection
with an Insured's job or employment (e. g . , any service or supply which is covered by Workers' Compensation
insurance) except for medically necessary services ( not otherwise excluded) for an individual who is not covered
by Workers ' Compensation and that lack of coverage did not result from any intentional action or omission by
that individual . The foregoing exclusion applies to an individual who elects exemption from Workers'
Compensation coverage and to an individual who foregoes Workers ' Compensation coverage available to
employees in the Group .
E. Workers Compensation Carrier is : JUNKNOWN
Il . Effective Date/ Eligibility Information
A . Effective Date of this Policy shall be 10/04/1996
Effective Date of this Change to the Policy shall be 111/01 /2006
This Policy may be terminated by the applicant or BCBSF/HOI by giving at least 45 days prior written notice to
the other party except in the case of non- payment of Premium .
B. Only eligible employees who regularly work a minimum of = hours each week and their eligible dependents ,
shall be eligible for coverage upon the Effective Date of this Policy.
C . Specify classification of enrollees for whom coverage is being requested , if other than eligible employees as
described in B above .
D . New eligible employees may be covered effective on the See Special Instructions I after 30 days
of employment , so long as the eligible employee submits an application to BCBSF/HOI within 30 days of the date
the individual first meets the applicable eligibility requirements.
E . At least 75 % of the eligible employees must be enrolled under the Policy on the Effective Date and "
throughout the term of the Policy and the Group must meet and continue to meet BCBSF/HOI 's participation
requirements .
F. BCBSF/HOI shall have the right to audit the applicant' s payroll records at any time to confirm eligibility for
coverage , including participation percentage criteria required by BCBSF/HOI . Applicant agrees to furnish any
such request.
G . Employer Contribution : Employee : 11111 % Dependents : 95 %
13123-995 SR (Rev 0805) 7/17/2006 10: 16:52AM
BlueCross
ofHoridaa BlueShield EMPLOYER APPLICATION
of Flori
• HealthOptlons• (True Group Application)
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III . Health Plan Summary Information (select the appropriate boxlsl ) :
Mandated Benefit Offerings: (Optional ) Applicant has been advised of the following benefit offerings mandated
by the Federal and/or State Law . Applicant's decision to accept or decline these benefits is indicated below .
Included in
product Accept Decline
ElEl Ex Mental & Nervous Disorder
QX El ❑ Alcohol & Drug Dependency
❑X ❑ Mammograms Waiver of Deductible & Coinsurance
0 El ❑ Enteral Formulas
0 Single Plan Blue Packages
Health Plan Name Rx Option (indicate copayments)
IBIueChoice PPO PhyCopay 704 - NStd Bluescript V 10/25/40 - Std
Calendar Year Deductible : Coinsurance:
Per Person $$00 In - Network / Participating 80 °U
Out-of- Network / Non - Participating
Per Family $600
Office Visit Copay:
Family Phy.
Pre-Existing Pre- ExistingApplies 3/ 12 $ IS
Rates. All Other Providers $35
Employee $64.(10 Employee/SpouseEmployee/Child ( ren Family $64.UU Other
See the Group Master Policy for a complete description of benefits .
IV. Health Saving Account ( HSA) Banking Arrangement (optional with HSA Compatible health plans)
A . Are you choosing BCBSF's integrated HSA banking arrangement? Yes No
( if left blank , the response is assumed to be No . )
V . Rate Information
A. Premium /Prepayment fee are payable monthly on or before the due date which will be : 1st.
B . Regular Billing- Employee applications should be submitted thirty (30) days prior to proposed Effective Date.
Employee cancellations must be submitted within 30 days of the Effective Date of the Termination .
C . The Rates established for this Policy will not be changed for the first twelve ( 12) months following the initial Effective
Date of Coverage unless there is a change in benefits or a 15% or more change in the composition of the group.
However, BCBSF/HOI may change the Rates that are to be effective after this initial twelve ( 12) month period of
coverage by providing notice to the employer of such changed Rates forty-five (45) days prior to their Effective Date .
D . Funding Arrangements : BCBSF: ASO 1
HMO :
E. Rate Comments :
13123-995 SR ( Rev 0805) 7/17/2006 10: 16:52AM
B1ueCross B1ueShield
ofnorida EMPLOYER APPLICATION
• • Health options. (True Group Application)
.e a.sm.ie .®ena.
V1 . Applicant Responsibilities
A . The applicant shall : 1 ) Notify each enrollee to the benefits selected by the applicant, their Effective Date , and
the termination date of coverage ( in this regard , applicant acts as the agent of the enrollee , and in no event
shall the applicant be deemed an agent of BCBSF/HOI for this or any other purpose , nor shall BCBSF/HOI be
responsible for such notification to retirees) . 2) Deliver to covered enrollees identification cards and certificates
of coverage furnished by BCBSF/HOI . 3) Notify BCBSF/HOI promptly of any changes in the eligibility of
enrollees covered under this Agreement. 4) List any absentees at the time of initial enrollment on the
appropriate BCBSF/H01 form . Applications from absentees will be accepted at BCBSF/HOI Corporate
Headquarters no later than thirty (30) days from the group's Effective Date . 5 ) Collect enrollee contribution , if
required , and remit Premium payment/prepayment fees to BCBSF/HOI as specified in this application .
B. By choosing the HSA Banking Arrangement, if applicable , I authorize BCBSF to exchange certain limited
information , for employees enrolling in a high deductible health plan designed for use with an HSA,
with BCBSF's preferred bank, for the purposes of initial enrollment in and administration of , HSAs .
I recognize that BCBSF does not provide banking services and that BCBSF is not responsible for the provision
of HSA services . HSA services are provided by the bank of your choice subject to the terms and conditions of
such arrangements , including fees the bank may charge .
C . Applicant hereby establishes an Employee Welfare Benefit Plan for the purpose of providing for its employees
or their beneficiaries medical , surgical , hospital care , or benefits in the event of sickness .
D . 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 .
V 11 . Final Premiums, Benefits and Effective Dates are Subject to Approval by
BCBSF Corporate Headquarters
Issuance of the Policy by BCBSF/HOI will be deemed acceptance of this application .
Date Siguanirc of Applic/a�nt Print/Type Name & Title
=)atcluc
A &L&4 Joseph A . Baird Count Administra or
lue Shi Id of Florida, Inc . and/or Health Options, Inc. Licensed Agent (Print)
Signature of Agent Agent License Identification Number
APPROVED AS TO FORM
ANDpJLEGALSUFFI C/
BY r+� r
WILLIAM K . DEBRAAL
ASSISTANT COUNTY ATTORNEY
13123-995 SR ( Rev 0805) 7/17/2006 10: 16:52AM
BlueC
oss
of
B1ueShield EMPLOYER APPLICATION
►�► V of Florida
• Health Options. (True Group Application)
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FINew Business 19 Renewal Business Other
1 . Group Information Group # (BCBSF) : 90000 (HMO) :
A . Name of Group : INDIAN RIVER COUNTY (PROPERTY APPRAISERS)
Nature of Business : lGeneral government, ncc SIC Code : 9199
Mailing Address : 184U 25TH STREN.1' VERO BEACH , EL 32960
Email Address :
List below Subsidiary or AffiliatedCompanies whose employees are to e e igi a an inc u e wit tis
application .
Name Address
B . Applicant hereby applies for issuance of a Group Policy (herein referred to as Policy) by Blue Cross and Blue
Shield of Florida, Inc . (BCBSF) and/or Health Options, Inc. ( HOI ) . Upon acceptance of this application by
BCBSF and/or HOI , it will become part of the Policy issued to the applicant named above .
C . Prior Health Carrier: Insurance JACORDIA INC.
HMO
D . The Policy excludes expenses for any service or supply to diagnose or treat any Condition from or in connection
with an Insured 's job or employment (e .g . , any service or supply which is covered by Workers' Compensation
insurance) except for medically necessary services (not otherwise excluded) for an individual who is not covered
by Workers' Compensation and that lack of coverage did not result from any intentional action or omission by
that individual . The foregoing exclusion applies to an individual who elects exemption from Workers'
Compensation coverage and to an individual who foregoes Workers' Compensation coverage available to
employees in the Group.
E . Workers Compensation Carrier is : JUNKNOWN
It . Effective Date/ Eligibility Information
A . Effective Date of this Policy shall be 10/01 /1996
Effective Date of this Change to the Policy shall be 1 (1/01 /2006
This Policy may be terminated by the applicant or BCBSF/HOI by giving at least 45 days prior written notice to
the other party except in the case of non-payment of Premium .
B. Only eligible employees who regularly work a minimum of = hours each week and their eligible dependents ,
shall be eligible for coverage upon the Effective Date of this Policy.
C . Specify classification of enrollees for whom coverage is being requested , if other than eligible employees as
described in B above .
D . New eligible employees may be covered effective on the See Special Instructions after 30 days
of employment , so long as the eligible employee submits an application to BCBSF/HOI within 30 days of the date
the individual first meets the applicable eligibility requirements .
E . At least 75 % of the eligible employees must be enrolled under the Policy on the Effective Date and
throughout the term of the Policy and the Group must meet and continue to meet BCBSF/HOI 's participation
requirements .
F . BCBSF/HOI shall have the right to audit the applicant's payroll records at any time to confirm eligibility for
coverage, including participation percentage criteria required by BCBSF/HOI . Applicant agrees to furnish any
such request.
G . Employer Contribution : Employee : F_16-0-1 % Dependents : 95 %
13123-995 SR ( Rev 0805) 7/17/2006 10: 17:30AM
BlueC
of Florida
rBlueshield EMPLOYER APPLICATION
r � � of Flo
Health Options. (True Group Application)
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111 . Health Plan Summary Information (select the appropriate boxlsl ) :
Mandated Benefit Offerings: (Optional) Applicant has been advised of the following benefit offerings mandated
by the Federal and/or State Law. Applicant's decision to accept or decline these benefits is indicated below .
Included in
product Accept Decline
❑ ❑ R Mental & Nervous Disorder
❑X ❑ ❑ Alcohol & Drug Dependency
❑X ❑ ❑ Mammograms Waiver of Deductible & Coinsurance
0 ❑ ❑ Enteral Formulas
RSingle Plan ❑ Blue Packages
Health Plan Name Rx Option (indicate copayments)
13111eChoice PPO PlrvCopay 704 - NStd 6luescript V 10/25/40 - Std
Calendar Year Deductible : Coinsurance:
Per Person53011 In -Network / Participating
Out-of-Network / Non - Participating fi0u/,
Per Family 5600
Office Visit Copay:
Pre- ExistingFamily Phy.
Prc- Existing Applies 3/12 $ l5
Rates. All Other Providers S35
Employee S64A0 Employee/SpouseOEmployee/Child (ren Family 564.00 Othe �
See the Group Master Policy for a complete description of benefits .
IV. Health Saving Account (HSA) Banking Arrangement (optional with HSA Compatible health plans)
A. Are you choosing BCBSF's integrated HSA banking arrangement? Yes IR No
(if left blank , the response is assumed to be No. )
V. Rate Information
A. Premium /Prepayment fee are payable monthly on or before the due date which will be: 1st.
B . Regular Billing- Employee applications should be submitted thirty (30) days prior to proposed Effective Date.
Employee cancellations must be submitted within 30 days of the Effective Date of the Termination .
C . The Rates established for this Policy will not be changed for the first twelve ( 12) months following the initial Effective
Date of Coverage unless there is a change in benefits or a 15% or more change in the composition of the group .
However, BCBSF/HOI may change the Rates that are to be effective after this initial twelve ( 12) month period of
coverage by providing notice to the employer of such changed Rates forty-five (45 ) days prior to their Effective Date.
D . Funding Arrangements : BCBSF: ASO 1
HMO :
E . Rate Comments:
13123-995 SR (Rev 0805) 7/17/2006 10: 17:30AM
►.► 9BlueCro
of ssBlueShield EMPLOYER APPLICATION
of Flori
Health opd°""' (True Group Application)
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V1 . Applicant Responsibilitics
A . The applicant shall : 1 ) Notify each enrollee to the benefits selected by the applicant, their Effective Date, and
the termination date of coverage ( in this regard , applicant acts as the agent of the enrollee, and in no event
shall the applicant be deemed an agent of BCBSF/HOI for this or any other purpose , nor shall BCBSF/HOI be
responsible for such notification to retirees) . 2) Deliver to covered enrollees identification cards and certificates
of coverage furnished by BCBSF/HOI . 3) Notify BCBSF/HOI promptly of any changes in the eligibility of
enrollees covered under this Agreement. 4) List any absentees at the time of initial enrollment on the
appropriate BCBSF/HOI form . Applications from absentees will be accepted at BCBSF/HOI Corporate
Headquarters no later than thirty (30) days from the group's Effective Date. 5) Collect enrollee contribution , if
required , and remit Premium payment/prepayment fees to BCBSF,/HOI as specified in this application .
B. By choosing the HSA Banking Arrangement, if applicable, I authorize BCBSF to exchange certain limited
information , for employees enrolling in a high deductible health plan designed for use with an HSA ,
with BCBSF's preferred bank, for the purposes of initial enrollment in and administration of, HSAs.
I recognize that BCBSF does not provide banking services and that BCBSF is not responsible for the provision
of HSA services . HSA services are provided by the bank of your choice subject to the terms and conditions of
such arrangements , including fees the bank may charge .
C . Applicant hereby establishes an Employee Welfare Benefit Plan for the purpose of providing for its employees
or their beneficiaries medical , surgical , hospital care , or benefits in the event of sickness .
D . 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.
V1 1 . Final Premiums, Benefits and Effective Dates are Subject to Approval by
BCBSF Corporate Headquarters
Issuance of the Policy by BCBSF/HOI will be deemed acceptance of this application .
Dale Signature of Applicant Print/Type Name & Title
Joseph A . Baird . County Admin� r
Date uc Cross and Blue Shiel of Florida, Inc. and/or Health Options, Inc. Licensed Agent (Print)
7 <70 _
Signature ofAgent Agent License Identification Number
P4 O L,8 g Ll 2-
APPROVED AS TO XL
AND LEG SUFF CBY i�UTAM K . EB
.;aTY ATT:0 Fn1EV
13123-995 SR ( Rev 0805) 7/17/2006 10: 17:30AM
� � of Florida fueCrossB1ueSlvefd EMPLOYER APPLICATION
� o
• Health Options. (True Group Application)
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E] New Business ❑X Renewal Business FlOther
I . Group Information Group # ( BCBSF) : 900(10 ( HMO) :
A . Name of Group: I INDIAN RIVER COUNTY (SIIERIFF 'S DEPT.)
Nature of Business : lGeneral government, nec SIC Code: 9199
Mailing Address : 14055 41ST AVENUE VERO BEACII, FI, 32960
Email Address:
List below Subsidiary or i late ompanies w ose emp oyees are to e e igi e an inc u e wit t is
application .
Name Address
B. Applicant hereby applies for issuance of a Group Policy (herein referred to as Policy) by Blue Cross and Blue
Shield of Florida, Inc . (BCBSF) and/or Health Options , Inc. ( HOI ) . Upon acceptance of this application by
BCBSF and/or HOI , it will become part of the Policy issued to the applicant named above.
C . Prior Health Carrier: Insurance ACORDIA INC.
HMO
D. The Policy excludes expenses for any service or supply to diagnose or treat any Condition from or in connection
with an Insured 's job or employment (e . g . , any service or supply which is covered by Workers' Compensation
insurance) except for medically necessary services ( not otherwise excluded) for an individual who is not covered
by Workers' Compensation and that lack of coverage did not result from any intentional action or omission by
that individual . The foregoing exclusion applies to an individual who elects exemption from Workers'
Compensation coverage and to an individual who foregoes Workers' Compensation coverage available to
employees in the Group.
E Workers Compensation Carrier is : JUNKNOWN
H . Effective Date/ Eligibility Information
A . Effective Date of this Policy shall be 1 (1/01 / 1996
Effective Date of this Change to the Policy shall be 10/01 /20(16
This Policy may be terminated by the applicant or BCBSF/HOI by giving at least 45 days prior written notice to
the other party except in the case of non-payment of Premium .
B . Only eligible employees who regularly work a minimum of = hours each week and their eligible dependents ,
shall be eligible for coverage upon the Effective Date of this Policy.
C. Specify classification of enrollees for whom coverage is being requested, if other than eligible employees as
described in B above .
D . New eligible employees may be covered effective on the See Special Instructions I after 30 days
of employment , so long as the eligible employee submits an application to BCBSF/HOI within 30 days of the date
the individual first meets the applicable eligibility requirements .
E . At least 75 % of the eligible employees must be enrolled under the Policy on the Effective Date and
throughout the term of the Policy and the Group must meet and continue to meet BCBSF/HOI 's participation
requirements .
F . BCBSF/HOI shall have the right to audit the applicant's payroll records at any time to confirm eligibility for
coverage , including participation percentage criteria required by BCBSF/HOI . Applicant agrees to furnish any
such request.
G . Employer Contribution : Employee: F-10-0-1 % Dependents : 95 %
13123-995 SR (Rev 0805) 7/17/2006 10: 16:56AM
BlueC
� of rossBlueshiela EMPLOYER APPLICATION
of FloridaFlo
• • Health Options. (True Group Application )
�. w
IH . Health Plan Summary Information (select the appropriate boxjsj) :
Mandated Benefit Offerings: (Optional) Applicant has been advised of the following benefit offerings mandated
by the Federal and/or State Law. Applicant's decision to accept or decline these benefits is indicated below.
Included in
product Accept Decline
❑ ❑ R Mental & Nervous Disorder
0 ❑ ❑ Alcohol & Drug Dependency
Q ❑ ❑ Mammograms Waiver of Deductible & Coinsurance
Q ❑ ❑ Enteral Formulas
0 Single Plan ❑ Blue Packages
Health Plan Name Rx Option (indicate copayments)
BlueChoice PPO P111'Copay 704 - NStd Bluescript V 10/25/40 - Std
Calendar Year Deductible: Coinsurance:
Per Person $300 In-Network / Participating
Per Family
Out-of-Network / Non - Participating fi0
8600
Office Visit Copay:
Pre- Existingpp Family Phy.
1 re- Existin � Applies 3/ 12 $15
Rates. All Other Providers $35
Employee $64.(1(1 Employee/SpouseEmployee/Child (ren Family $64.00 Othei��
See the Group Master Policy for a complete description of benefits .
IV. Health Saving Account (HSA) Banking Arrangement (optional with HSA Compatible health plans)
A. Are you choosing BCBSF's integrated HSA banking arrangement?
( if left blank , the response is assumed to be No. ) ❑ Yes ❑X No
V. Rate Information
A . Premium/Prepayment fee are payable monthly on or before the due date which will be: Ist.
B. Regular Billing- Employee applications should be submitted thirty ( 30) days prior to proposed Effective Date.
Employee cancellations must be submitted within 30 days of the Effective Date of the Termination .
C . The Rates established for this Policy will not be changed for the first twelve ( 12) months following the initial Effective
Date of Coverage unless there is a change in benefits or a 15% or more change in the composition of the group.
However, BCBSF/HOI may change the Rates that are to be effective after this initial twelve ( 12 ) month period of
coverage by providing notice to the employer of such changed Rates forty-five (45) days prior to their Effective Date .
D . Funding Arrangements : BCBSF: ASO 1
HMO:
E . Rate Comments :
13123-995 SR ( Rev 0805) 7/17/2006 10: 16:56AM
BlueCross B1ueShleld
Florid
of Florida EMPLOYER APPLICATION
► ► �
Health Options. (True Group Application)
w awarvaie.wodam.
V1 . Applicant Responsibilities
A . The applicant shall : 1 ) Notify each enrollee to the benefits selected by the applicant, their Effective Date, and
the termination date of coverage ( in this regard , applicant acts as the agent of the enrollee, and in no event
shall the applicant be deemed an agent of BCBSF/HOI for this or any other purpose , nor shall BCBSF/HOI be
responsible for such notification to retirees) . 2) Deliver to covered enrollees identification cards and certificates
of coverage furnished by BCBSF/HOI . 3) Notify BCBSF/HCI promptly of any changes in the eligibility of
enrollees covered under this Agreement. 4) List any absentees at the time of initial enrollment on the
appropriate BCBSF/HOI form . Applications from absentees will be accepted at BCBSF/HOI Corporate
Headquarters no later than thirty (30) days from the group's Effective Date . 5) Collect enrollee contribution , if
required , and remit Premium payment/prepayment fees to BCBSF/HOI as specified in this application .
B . By choosing the HSA Banking Arrangement, if applicable, I authorize BCBSF to exchange certain limited
information , for employees enrolling in a high deductible health plan designed for use with an HSA ,
with BCBSF' s preferred bank, for the purposes of initial enrollment in and administration of , HSAs .
I recognize that BCBSF does not provide banking services and that BCBSF is not responsible for the provision
of HSA services . HSA services are provided by the bank of your choice subject to the terms and conditions of
such arrangements , including fees the bank may charge.
C. Applicant hereby establishes an Employee Welfare Benefit Plan for the purpose of providing for its employees
or their beneficiaries medical , surgical , hospital care , or benefits in the event of sickness .
D . 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 .
\11 1 . Final Premiums, Benefits and Effective Dates are Subject to Approval by
BCBSF Corporate Headquarters
Issuance of the Policy by BCBSF/HOI will be deemed acceptance of this application .
Date f Signature oApplicant Print/Type Name & Title
d
Date B e Cross and Blue Shield of Florida, Inc. and/or I lealth Options, Inc. Licensed Agent (Print)
/ �
Signature of Agent Agent License Identification Number
pv � A bZ e ,6 v- 2--
APPROVED AS TO F M
AND L E!' AL S FFICI Y
WILLIAM K . 0ESRAAL
ASSISTANT COUNTY ATTORNEY
13123-995 SR ( Rev 0805) 7/17/2006 10: 16:56AM
lueCross
ofRojlda B1ueShield EMPLOYER APPLICATION
of Flotda
Health Options. (True Group Application)
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EJNew Business 0 Renewal Business Other
1 . Grout) Information Group # (BCBSF) : 90000 (HMO) :
A . Name of Group : INDIAN IZIVER COUN'tY (ELECTION SUPVR. I
Nature of Business : lGeneral government, nec SIC Code: 9199
Mailing Address: 11840 251- 11 STREET VERO BEACH , Fl , 32960
Email Address :
List below Subsidiary or Affiliated Companies whose employees are to be ehgibl_eT_an_d_F7u_d_ea with this
application .
Name Address
B . Applicant hereby applies for issuance of a Group Policy (herein referred to as Policy) by Blue Cross and Blue
Shield of Florida, Inc. ( BCBSF) and/or Health Options , Inc. ( HOI ) . Upon acceptance of this application by
BCBSF and/or HOI , it will become part of the Policy issued to the applicant named above .
C . Prior Health Carrier: Insurance ACORDIA INC.
HMO
D . The Policy excludes expenses for any service or supply to diagnose or treat any Condition from or in connection
with an Insured 's job or employment (e. g. , any service or supply which is covered by Workers ' Compensation
insurance ) except for medically necessary services (not otherwise excluded) for an individual who is not covered
by Workers' Compensation and that lack of coverage did not result from any intentional action or omission by
that individual . The foregoing exclusion applies to an individual who elects exemption from Workers '
Compensation coverage and to an individual who foregoes Workers' Compensation coverage available to
employees in the Group.
E . Workers Compensation Carrier is : 11UNKNOWN
II . Effective Date/ Eligibility Information
A . Effective Date of this Policy shall be 10/111 /1996
Effective Date of this Change to the Policy shall be 10/Ill /2006
This Policy may be terminated by the applicant or BCBSF/HOI by giving at least 45 days prior written notice to
the other party except in the case of non -payment of Premium .
B. Only eligible employees who regularly work a minimum of 30 hours each week and their eligible dependents ,
shall be eligible for coverage upon the Effective Date of this Policy.
C . Specify classification of enrollees for whom coverage is being requested, if other than eligible employees as
described in B above.
D . New eligible employees may be covered effective on the See Special Instructions after 30 days
of employment, so long as the eligible employee submits an application to BCBSF/HOI within 30 days of the date
the individual first meets the applicable eligibility requirements .
E . At least 75 % of the eligible employees must be enrolled under the Policy on the Effective Date and
throughout the term of the Policy and the Group must meet and continue to meet BCBSF/HOI 's participation
requirements.
F. BCBSF/HOI shall have the right to audit the applicant's payroll records at any time to confirm eligibility for
coverage , including participation percentage criteria required by BCBSF/HOI . Applicant agrees to furnish any
such request .
G . Employer Contribution : Employee : 700 % Dependents : 95 %
13123-995 SR (Rev 0805) 7/17/2006 10: 17.43AM
BlueCross BlueShield
of Florida EMPLOYER APPLICATION
Health options. (True Group Application)
vtl PM 6AbItl.Wlnb..
111 . Health Plan Summary Information (select the appropriate boxlsl) :
Mandated Benefit Offerings: (Optional ) Applicant has been advised of the following benefit offerings mandated
by the Federal and/or State Law . Applicant's decision to accept or decline these benefits is indicated below.
Included in
product Accept Decline
❑ ❑ [xl Mental & Nervous Disorder
x ❑ ❑ Alcohol & Drug Dependency
x ❑ ❑ Mammograms Waiver of Deductible & Coinsurance
0 ❑ ❑ Enteral Formulas
Single Plan ❑ Blue Packages
Health Plan Name Rx Option (indicate copayments)
BlneChoice PPO PhyCopay 704 - NStd JBItiescript V 10/25/40 - Std
Calendar Year Deductible: Coinsurance:
Per Person IS300 In-Network / Participating fip Z
Out-of-Network / Non- Participating 60 %
Per Family $600
Office Visit Copay:
Pre- ExistingFamily Phy.
Pre- Existing Applies 3/ 12 $ 15
Rates. All Other Providers $35
Employee $64.1111 Employee/SpouseEmployee/Child (ren Family $64.00 Othe
See the Group Master Policy for a complete description of benefits .
V. Health Saving Account (HSA) Banking Arrangement (optional with HSA Compatible health plans)
A. Are you choosing BCBSF's integrated HSA banking arrangement?
( if left blank , the response is assumed to be No . ) ❑ Yes 0 No
V. Rate Information
A. Premium/Prepayment fee are payable monthly on or before the due date which will be : 1st.
B . Regular Billing- Employee applications should be submitted thirty (30) days prior to proposed Effective Date .
Employee cancellations must be submitted within 30 days of the Effective Date of the Termination .
C . The Rates established for this Policy will not be changed for the first twelve ( 12) months following the initial Effective
Date of Coverage unless there is a change in benefits or a 15% or more change in the composition of the group .
However. BCBSF/HOI may change the Rates that are to be effective after this initial twelve ( 12) month period of
coverage by providing notice to the employer of such changed Rates forty-five (45) days prior to their Effective Date .
D . Funding Arrangements : BCBSF: ASO 1
HMO :
E . Rate Comments :
13123-995 SR ( Rev 0805) 7/17/2006 10: 17:43AM
BlucCross
►�� Oofnoridaa B1ueShield EMPLOYER APPLICATION
of Flori
•
Health Options. (True Group Application)
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V1 . Applicant Responsibilities
A . The applicant shall : 1 ) Notify each enrollee to the benefits selected by the applicant, their Effective Date , and
the termination date of coverage ( in this regard , applicant acts as the agent of the enrollee, and in no event
shall the applicant be deemed an agent of BCBSF/HOI for this or any other purpose, nor shall BCBSF/HOI be
responsible for such notification to retirees ) . 2) Deliver to covered enrollees identification cards and certificates
of coverage furnished by BCBSF/HOI . 3) Notify BCBSF/HOI promptly of any changes in the eligibility of
enrollees covered under this Agreement . 4) List any absentees at the time of initial enrollment on the
appropriate BCBSF/HOI form . Applications from absentees will be accepted at BCBSF/HOI Corporate
Headquarters no later than thirty (30) days from the group's Effective Date. 5) Collect enrollee contribution , if
required , and remit Premium payment/prepayment fees to BCBSF/HOI as specified in this application .
B . By choosing the HSA Banking Arrangement , if applicable, I authorize BCBSF to exchange certain limited
information , for employees enrolling in a high deductible health plan designed for use with an HSA,
with BCBSF's preferred bank, for the purposes of initial enrollment in and administration of , HSAs .
I recognize that BCBSF does not provide banking services and that BCBSF is not responsible for the provision
of HSA services . HSA services are provided by the bank of your choice subject to the terms and conditions of
such arrangements , including fees the bank may charge.
C . Applicant hereby establishes an Employee Welfare Benefit Plan for the purpose of providing for its employees
or their beneficiaries medical , surgical , hospital care, or benefits in the event of sickness.
D . 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 .
Vll . Final Premiums, Benefits and Effective Dates are Subject to Approval by
BCBSF Corporate Headquarters
Issuance of the Policy by BCBSF/HOI will be deemed acceptance of this application .
Date Signature of Applicant Print/Type Name K Title
ak- Jose h A . Baird County Administrat r
Date ue Cross and Blue 1d of Florida. Inc . and/or Health Options, Inc . Licensed Agent (Print)
Signature of Agent Agent License Identification Number
APPROVED AS TO FORM
AND L GALS FFIC0XV
CY
B
WILLIAM WDKRAAL
ASSISTANT COUNTY ATTORNEY
13123-995 SR (Rev 0805) 7/17/2006 10: 17:43AM
oss
.� of Florida
B1ueShield EMPLOYER APPLICATION
� o
Healtbopr;°°,3• (True Group Application)
❑ New Business 0 Renewal Business Other
1 . Group Information Group # ( BCBSF) : 90000 (HMO) :
A . Name of Group : JINDIAN RIVER COUNTY (TAX COLLECTORS)
Nature of Business : lGeneral government, nec SIC Code : 9199
Mailing Address : 1925 14141 LANE VERO BEACH. FL 32960
Email Address :
List below Subsidiary or Affiliated Companies whose employees are to be e igi a an inc u e with this
application .
Name Address
B. Applicant hereby applies for issuance of a Group Policy (herein referred to as Policy) by Blue Cross and Blue
Shield of Florida, Inc . ( BCBSF) and/or Health Options , Inc. ( HOI ) . Upon acceptance of this application by
BCBSF and/or HOI , it will become part of the Policy issued to the applicant named above .
C . Prior Health Carrier: Insurance JACORDIA INC.
HMO
D . The Policy excludes expenses for any service or supply to diagnose or treat any Condition from or in connection
with an Insured 's job or employment (e. g . , any service or supply which is covered by Workers' Compensation
insurance) except for medically necessary services (not otherwise excluded) for an individual who is not covered
by Workers' Compensation and that lack of coverage did not result from any intentional action or omission by
that individual . The foregoing exclusion applies to an individual who elects exemption from Workers'
Compensation coverage and to an individual who foregoes Workers' Compensation coverage available to
employees in the Group.
E . Workers Compensation Carrier is JUNKNOWN
H . Effective Date/ Eligibility Information
A . Effective Date of this Policy shall be 10/Ul /1996
Effective Date of this Change to the Policy shall be 10/llf /2006
This Policy may be terminated by the applicant or BCBSF/HOI by giving at least 45 days prior written notice to
the other party except in the case of non - payment of Premium .
B . Only eligible employees who regularly work a minimum of = hours each week and their eligible dependents ,
shall be eligible for coverage upon the Effective Date of this Policy.
C . Specify classification of enrollees for whom coverage is being requested , if other than eligible employees as
described in B above .
D . New eligible employees may be covered effective on the See Special Instructions after = days
of employment, so long as the eligible employee submits an application to BCBSF/HOI within 30 days of the date
the individual first meets the applicable eligibility requirements .
E . At least 75 % of the eligible employees must be enrolled under the Policy on the Effective Date and
throughout the term of the Policy and the Group must meet and continue to meet BCBSF/HOI 's participation
requirements.
F . BCBSF/HOI shall have the right to audit the applicant' s payroll records at any time to confirm eligibility for
coverage , including participation percentage criteria required by BCBSF/HOI . Applicant agrees to furnish any
such request.
G . Employer Contribution : Employee: F-1-071 % Dependents: = %
13123-995 SR ( Rev 0805) 7/17/2006 10: 17 08A
Bluecross B1ueShield
of Horida EMPLOYER APPLICATION
Health options. (True Group Application)
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III . Health Plan Summary Information (select the appropriate box [ si ) :
Mandated Benefit Offerings : (Optional) Applicant has been advised of the following benefit offerings mandated
by the Federal and/or State Law. Applicant's decision to accept or decline these benefits is indicated below .
Included in
product Accept Decline
❑ ❑ ❑X Mental & Nervous Disorder
❑X ❑ ❑ Alcohol & Drug Dependency
❑X ❑ ❑ Mammograms Waiver of Deductible & Coinsurance
❑X ❑ ❑ Enteral Formulas
Single Plan ❑ Blue Packages
Health Plan Name Rx Option (indicate copayments)
f3lueChoice PPO PliyCopay 704 - NStd Bluescript V 10/25/40 - Std
Calendar Year Deductible : Coinsurance :
Per Person $300 In - Network / Participating g0 %
Out-of- Network / Non - Participating
Per Family $600
Office Visit Copay:
Pre- ExistingFamily Phy.
Prtitixisting Applies 3/ 12 $ 15
Rates. All Other Providers $35
Employee $(,4 .00 Employee/SpouseEmployee/Child (ren Family $64.00 Other
See the Group Master Policy for a complete description of benefits .
IV. Health Saving Account (HSA) Banking Arrangement (optional with HSA Compatible health plans)
A . Are you choosing BCBSF's integrated HSA banking arrangement? Yes IR No
(if left blank , the response is assumed to be No . )
V. Rate Information
A . Premium/Prepayment fee are payable monthly on or before the due date which will be: 1st.
B. Regular Billing- Employee applications should be submitted thirty (30) days prior to proposed Effective Date .
Employee cancellations must be submitted within 30 days of the Effective Date of the Termination .
C . The Rates established for this Policy will not be changed for the first twelve ( 12) months following the initial Effective
Date of Coverage unless there is a change in benefits or a 15% or more change in the composition of the group .
However. BCBSF/HOI may change the Rates that are to be effective after this initial twelve ( 12) month period of
coverage by providing notice to the employer of such changed Rates forty-five (45 ) days prior to their Effective Date.
D . Funding Arrangements : BCBSF: ASO i
HMO :
E . Rate Comments : 1:
13123-995 SR (Rev 0805) 7/17/2006 1017:08AM
BlueCross
�
of Florida
IIlueShield EMPLOYER APPLICATION
of Flor
Health options' (True Group Application)
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we4,e adm a'a�.e.eau.an.,00e,
VI. Applicant Responsibilities
A . The applicant shall : 1 ) Notify each enrollee to the benefits selected by the applicant, their Effective Date , and
the termination date of coverage (in this regard , applicant acts as the agent of the enrollee, and in no event
shall the applicant be deemed an agent of BCBSF/HOI for this or any other purpose , nor shall BCBSF/HOI be
responsible for such notification to retirees) . 2) Deliver to covered enrollees identification cards and certificates
of coverage furnished by BCBSF/HOI . 3) Notify BCBSF/HOI promptly of any changes in the eligibility of
enrollees covered under this Agreement. 4) List any absentees at the time of initial enrollment on the
appropriate BCBSF/HOI form . Applications from absentees will be accepted at BCBSF/HOI Corporate
Headquarters no later than thirty (30) days from the group's Effective Date . 5) Collect enrollee contribution , if
required , and remit Premium payment/prepayment fees to BCBSF/HOI as specified in this application .
B. By choosing the HSA Banking Arrangement, if applicable , I authorize BCBSF to exchange certain limited
information , for employees enrolling in a high deductible health plan designed for use with an HSA ,
with BCBSF's preferred bank, for the purposes of initial enrollment in and administration of, HSAs.
I recognize that BCBSF does not provide banking services and that BCBSF is not responsible for the provision
of HSA services . HSA services are provided by the bank of your choice subject to the terms and conditions of
such arrangements , including fees the bank may charge.
C . Applicant hereby establishes an Employee Welfare Benefit Plan for the purpose of providing for its employees
or their beneficiaries medical , surgical , hospital care , or benefits in the event of sickness .
D . 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.
VII . Final Premiums, Benefits and Effective Dates are Subject to Approval by
BCBSF Corporate Headquarters
Issuance of the Policy by BCBSF/HOI will be deemed acceptance of this application .
Date Signature Of- Applicant Print/Type Name & Title
Joseph A . Baird , County Administrate r
Date ue Goss d Blue ' ield of Florida. Inc. and/or Health Options, Inc . Licensed Agent (Print)
SignaWre of Agent Agent License Identification Number
µ am �-
APPROVED AS TO FORM
AND LEGAL UFFIC y
By
�
WILLIAM . OEBRAAL
ASSISTANT COUNTY ATTORNEY
13123-995 SR (Rev 0805) 7/17/2006 10: 17: 08AM