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HomeMy WebLinkAbout2000-101RESOLUTION NO. 2000- 101 A RESOLUTION OF THE BOARD OF COUNTY COMMISSIONERS OF INDIAN RIVER COUNTY, FLORIDA, ADOPTING THE FOURTH AMENDMENT TO THE INDIAN RIVER COUNTY BOARD OF COUNTY COMMISSIONERS PREMIUM CONVERSION PLAN. WHEREAS, the Board of County Commissioners ("Employer") has previously adopted the Indian River County Board of County Commissioners Premium Conversion Plan (the "Plan"); and WHEREAS, pursuant to Section 8.01 of the Plan, the Employer is authorized and empowered to amend the Plan; and WHEREAS, the Employer deems it advisable to amend the Plan. NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF COUNTY COMMISSIONERS OF INDIAN RIVER COUNTY, FLORIDA that Exhibit (A) — Group Plans of the Premium Conversion Plan is hereby amended as follows: Exhibit (A) Delete "2. Indian River County, Florida Group Employee Optional Life Insurance Plan." Delete "3. Indian River County, Florida Group Employee Optional Long -Term Disability." This Fourth Amendment to the Indian River County board of County Commissioners Premium Conversion Plan is made and entered into by the Indian River County Board of County Commissioners ("the Employer") this 12th day of September , 2000, and is effective for all purposes as of October 1, 2000. 9/00RESO (LEGAL)WGC/nhm 1 RESOLUTION NO. 2000- 101 IN WITNESS WHEREOF, this Fourth Amendment has been executed and is effective as of the date set forth above. The resolution was moved for adoption by Commissioner Macht , and the motion was seconded by Commissioner Gi nn , and, upon being put to a vote, the vote was as follows: Chairman Fran B. Adams Vice Chairman Caroline D. Ginn Commissioner Kenneth R. Macht Commissioner John W. Tippin Commissioner Ruth M. Stanbridge Ave Aye Aye _Aye_ The Chairman thereupon declared the resolution duly passed and adopted this 12th day of September , 2000. BOARD OF COUNTY COMMISSIONERS INDIAN RIVER COUNTY, FLORIDA By 5 Fran B. Adams, Chairman • ATTEST Jeffrey K. Barto : n, Clerk Deputy Clerk APPROVED AS TO FORM AND LEGAL SUFFICIENCY PAUL G. lNGE COUNTY ATTORNEY a 9/00RESO (LEGAL)WGC/nhm 2 O�c bi eQ.o c 11-6()-/o/ 1.1171•A FL (1197) //-F Application for Excess Loss Insurance • IMilNINI NMI MIN MN MI %,„.111 ANN MI ti•111•111••••1 1111.11111 i/ . // i LIFE INSURANCE COMPANY Home office: St. Louie Park, MN Executive office: 7300 Corporate Center Drive Miami, Florida 33126-1223 A Stock Company 11 IV J -1178-A (FL) 3/97 _ = John Alden Life Insurance Company Home office: Si. Louis Park, MN Executive office: 7300 Corporate Center Drive, Miami, FL 33126-1223 A Stock Company 1I APPLICATION FOR EXCESS LOSS INSURANCE .tor ,etiaww 1. NAME OF APPLICANT: INDIAN RIVER COUNTY BOARD OF COUNTY CAMMI SSTONERS ADDRESS: 1840 25th Street (STREET) Vero Beach Florida 32960 (CITY) (STATE) (ZIP CODE) 2. NAMES AND ADDRESSES OF SUBSIDIARIES TO BE COVERED: NO. OF Board of NAME CITY, STATE, ZIP CODE EMPLOYEES County Commissioners Sheriff's Department Prnperty AppraiRerR Clerk of the Courts Tax P.nllaetnr Sunervisor of Elections 3. TOTAL EMPLOYEES AT ALL LOCATIONS: Est. 1280 Fl.. Est. 70 Retirees, Multiple States 4. NAME OF THIRD PARTY ADMINISTRATOR: BLUE CROSS & BLUE SHIELD ADDRESS: 8400 N.W. 33rd Street (STREET) Miami Florida 33122 (CITY) (STATE) (ZIP CODE) 5. PROPOSED EFFECTIVE DATE: October 1, 2000 6. SPECIFIC EXCESS LOSS INSURANCE: a. Benefits Covered: $1,000,000.00 b. Benefit Period: Eligible Expenses Incurred from 10/1/2000 through 9/30/2001 ;and Eligible Expenses Paid from 10/1/2000 through 12/31/2001 c. Specific Deductible (per Covered Person): $ 100, 000.00 d. JALIC's percentage payable (Excess of the Specific Deductible): 100 % e. Maximum Specific Benefit payable by JALIC (per lifetime per Covered Person, while the Policy is in force): $ 900, 000.00 f. Monthly Premium Rate: Single Rate: $ Family Rate: $ Composite Rate: $ 23.27 J -1178-A (FL) 3/97 1 7. AGGREGATE EXCESS LOSS INSURANCE: a. Benefits Covered: gi Medical 0 Dental 0 Vision j1 Prescription Drugs 0 Weekly Disability Income 0 Other b. Benefit Period: Eligible Expenses Incurred from 10/1/2000 through 9/30/2001 ; and Eligible Expenses Paid from 10/1/2000 through 12/31/2001 . c. Aggregate Monthly Factor(s): Covered Units Medical Dental Single Family Composite $428.06 NA Included Rx Drugs (Other) d. JALIC's percentage payable (Excess of the Aggregate Deductible): e. Maximum Aggregate Benefit payable by JALIC: f. Aggregate Monthly Premium Rate (per Employee per month): g. Payment Mode: Monthly 8. OTHER BENEFITS: a. Monthly Cumulative Accommodation Yes O No IY b. Medical Conversion* Yes 0 No Q c. Terminal Liability Yes 0 No a 100 g(, $ 1,000.000.00 $ 1.78 • Premium: $ Premium Per Employee Per Month: $ Initial Premium: $ Election Premium: $ d. 0 Other *not avallabk la all states. 9. A DEPOSIT of $ Self Accounting — Renewal is enclosed to apply to the first payment under the policy, if issued. 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. DATED AT Indian River County , the 19th day of September . !d(2000 I represent that each of the above statements and answers are correct and true to the best of my knowledge and belief. APPLICANT: Indian River County BY: QAA.--� Cly Fran B. Adams TITLE Chairman AGENT'S NAME (PRINT). Boyd Max Branham AGENT'S SIGNATURE' U4 aOt4yyL� FL LICENSE NO.: 7 i s5 7 9 - Please return the completed and signed application to: Alden Risk Management Services Self -Funded Markets P.O. Box 025472 Miami, Florida 33102-5472 • N`' -e -e 61t-0 - /0 AIPPEMNIMIMPI -��-J.)'.) -F The Company's Legal Name Indian River County Board of County Commissioners (Include punctuation and any abbreviations that apply) Mailing Address: 1840 25th Street Vero Beach, FL 32960 Effective Date: 10-1-2000 Employer Tax I.D.#: 59-6000674 Type of Organization: 0 Employer 0 Corporation a Government Segment O Trust 0 Association O Partnership O Sub -Chapter S Corporation❑ Other Q Divisions: 0 Subsidiaries: O Affiliates: Mums See Attached Address (City/State/Zip) • Please confirm sold rates: LTD STD T, 1 1 1 1% , S¢ 1 Life AD&D, Dental Dep. Life 45.3611 }naa}u:mx Billing Correspondent: Name' See Attached Listing Phone Number: Fax Number: Claim Correspondent Of different): Name' See Attached Listing Phone Number: Fax Number: Decision -maker for the company's employee benefits: BASIC MONTHLY EARNINGS: 0 Salary Only 0 Salary, Commissions & Bonuses* 0 W-2 w/Bonuses* Board of County Commissioners O Salary & Commissions O W-2 without Bonuses ❑ Salary & Bonuses* O Other (please specify) 4164 ,,`: fj/,G/, t: AMMOINIMMIla tf� sfV ittNe • • WAITING PERIOD: Present Employees; Are all aim& employees covered as of the effective date? 0 No lb Yes If no, do they have the same waiting period as future hires? 0 No 0 Yes Future Employees; Lf ojthe month coinciding with or next following: O days of active employment or 0 _,months of active employment 0 No Waiting Period Are employees in other states/countries covered? No ELIGIBILITY: a All Full -Time Active Employees Class 1: O Other: Class 3: The day followlne completion of: D 30 days of active employment 0 months of active employment Payroll Billed Cases Only First pay period following: 0 days of active employment or O _months of active employment 0 Yes - List employees by state/country on census. 30 Class 2: Class 4: Minimum number of hours the employees must work to be covered PRIOR COVERAGE: Does this plan replace other coverage? Sl Yes 0 No Type of Coverage Effective Date Termination Date Prior Carrier Name VLTD 10-1-94 10-1-2000 Florida Combined Life (Attach a copy of the prior plan's contract or employee booklet. CONTRIBUTIONS: 0 The EMPLOYER pays 100% of the cost SI The EMPLOYEES pay 100% of the cost 0 Both the employer and the employees pay for the plan: Percentage of Employer Contribution: % for employee coverage % for dependent coverage Forward Booklets to: 0 Policyholder 411 Broker 0 Other Physical Address for Delivery: The McCall Agency, Inc. 1120 20th Place, Vero Beach, FL 32960 ERISA Information: What is the plan number assign:A by the plan sponsor? PN5 How are the fiscal record maintained? 0 Calendar Year 0 Policy Year is last day of year 0 Fiscal Year is last day of year Day/Month Day/Month l Policyholder Signature Fran B. Adams, Chairman September 12, 2000 Date UNUM. UNUM Life Insurance Company of America Portland, Maine 04122 APPLICATION FOR GROUP INSURANCE Name of Applicant Indian River County Board of County Commiss i»Hers Address: 1840 25th Street Vero Beach (City) applies to the UNUM Life Insurance Company of America, for: O Group Life Benefits O Group Accidental Death and Dismemberment Benefits (Street) Florida 32960 (State) (Zip) di Group Long Term 0 Group Short Term Disability Benefits Disability Benefits 0 Group Long Term Care Benefits Is there any group life insurance plan In force or being applied for on some or all employees? 0 Yes 0 No If yes, complete the following or list the prior carriers: Employee Class Maximum Amounts Name of Carrier Effective Dates Termination Dates All Full Time Florida Combined Life Ins. Co 10-1-94 10-1-00 If the Insurance Company approves this application, a policy will be issued. The applicant agrees that acceptance of the policy will be an approval of the policy 'terms. The Policy Specifications will be made a part of the policy along with a copy o1 this form. Gated at on September 12, 2000 Producer Name: Ronald R. McCall, II (Please Print) SS//Tax ID/:65-0551801 State ID #: A169993 Policy Effective Date: 10-1-2000 Indian River County Board of County Commissior:ers (Applicant) By: QM A C Fran $. Adams, (Signature and Title) haiaeC��--� Producer Signature: / - ' PRODUCER INFORMATION: For commission purposes, please list the brokers/agents for this application. Use full names, including complete business names. To ensure proper payment of commissions, include each producer's tax identification number (social security number or corporate tax Id) and state identification number where applicable. If more than one producer, please be sure to specify the split %. For corporate producers, please specify the signing representative's name and ID /'s. PLEASE PRINT ALL INFORMATION CLEARLY Producer Name SSN / Tax IDN (Please print lull name) State IDN (where applicable) Split % age (Must total 100%) 1. Ronald R. McCall. II 65-0551801 A169993 100% 2. 3. 4. UNUM Producer N (II known) 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. 1361.96 it rr / b / ADDENDUM TO CARVE -OUT MENTAL HEALTH AND DUAL DIAGNOSIS SUBSTANCE ABUSE AGREEMENT DATED OCTOBER 20,1998 The term of the above -noted Agreement is hereby extended for two additional years with the following per employee per month rate guarantee: 2000-01 2001-02 $5.40 pepm $6.38 pepm If by mutual consent of the parties the above -noted Agreement is extended for a third year, namely to 2002-03, the guaranteed rate for the third year shall be $7.09 pepm. IN WITNESS WHEREOF, the parties hereto have executed this Addendum on the day and year below written. 926z.vt.-- sOiao,vsta Authorized Signature Indian River County BOCC Flan B. Adams, Cha man Witness September 12, 2000 Date • Chairman and CEO UniPsych Benefits of Florida, Inc. keiit-"Z Witness 05/00 Date 0—F 0 0 0 2f\ 4 bO /O / 111. Illu")10- EMPLOYER APPLICATION 1 (Tru. Group App.) ❑ New Business ® Renewal Business [] Other: CHANGE IN BENEFITS/RATES 1. APPLICANT INFORMATION 1-/ L ento 11 SII Group #: (BCSSFJ 00009 (HMO A. Nem* of Grou INDIAN RIVER COUNTY (BD. OF CTY. COMMISSION) Div.# [BCBSF)001,C01,R01,002,R02,003,001,005, R05,006 Nabs* of Busines WNW nee Sto Code: 9109 Div.# (HMO) Mailing Address 1240 25TH STREET I VERO BEACH FL 32960 List below Subsidiary or Affiliated Companies whose employees are to be eligible and Included with this applic NAME: WA ADDRESS B. Applicant hereby applies for coverage/membership through Blue Cross and Blue Shield of Florida, Inc. (BCBSF) and/or Health Options, Inc. (HOE) Group Contract (heroin referred to as the Contract). Upon acceptance of this application by BCBSF and/or H01, It will become part of the Contract Issued to the applicant named above. C. The Contract benefits do not cover any service or supply to diagnose or treat any Condition resulting from or In connection with a Insured's Job or employment (e.g., any service or supply which is covered by Worker's Compensation Insurance). Benefits will not be provided under the Contract to an Individual who elects and Is statutorily authorized for exemption from Worker's Compensation coverage. D. Werke?. Compensation carrier UNKNOWN National Union Fire Insurance Prior Cartier is: ACORDIA INC. (HMO) 11. EFFECTIVE DATE / ELIGIBILITY INFORMATION A. Effective Date of thls Contract shall be 10/01/2000 . This Contract may be terminated by the applicant or BCBSF/H01 by giving at (east 45 days prior written notice to the other party. B. Only active eligible employees who regularly work a minimum 30 hours each week and their eligible dependents. shall be eligible for coverage upon the Effective Date of this Contract. C. Specify classification of enrollees for whom coverage Is being requested, If other than eligible employees as described in 8 D. New eligible employees may be covered afte 31ST DAY OF EMPLOYMENT of employment, so long as the eligible employee submits an application to BCBSF/H01 within 30 days of the date the Individual first meets the applicable eligibility E. At least 75 % of the eligible employees aryl 60 % of the eligible dependents must be enrolled under the Contract on the Effective Date and Mroughout the term of the Contract. F. 1Enrollment date Total Ineligible Total Number Percent Mulct Option Spli Employee Employees' Eligible Enrolled Enrolled ppO HMO Employees 1320 0 1320 #Error Employees with Dependents 935 0 935 #Error Employer Contribution EMP 100 DEP 95 *Please provide a Iist of name(s) and reason(s) for Ineligible employees and dependent G. BCBSF/H01 shall have the right to audit the applicant's payroll records at any time to confirm eligibility for coverage; applicant agrees to furnish any such records upon request. III. HEALTH PLAN SUMMARY INFORMATION (soled the appropriate box[s]): [BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC. [ 0 Standard ® Non -Standar A. Health Care Benefits Option BC PPO PhyCopay PLGLP704 L MANDATED BENEFIT OFFERINGS 1 B. Benefits: Co -Ins.: 60 % PPC 60 % Non -PPC (Optional) Applicant has been advised of the following benefit offerings as mandated by the S 200 Deductible Per Person Per Calendar Year Federal and/or State Law. Applicant's S 400 Family Aggregate Per Calendar Year decision to accept or decline these benefits Is $ 815/825 Copay: Per Office Visit Indicated below: Accept Decline 8 0/400 Per Adm. Deductible For All Non -PPC Hospitals $ 2000/4000 Maximum Out Of Pocket C. Rx YES BlueScript Copay: 85 Generi 815 Bran $30 NonFornular NO MedlScript Oral Contraceptive © Yes ❑ No El WI © ❑ Alcohol & Drug Dependency Mammograms Waiver of ❑ Deductible a Coinsurance J 0 Enteral Formulas PREEXISTING: Waled initial Enrollment Only Mental & Nervous Disorder r HEALTH OPTIONS ❑ Standard 0 Non -Standar A. Health Options Plan B. Rx CoPay: Generic rm _Brand _Nonfoulary C. Vision ❑Yes ®No D. Dental n Yes WI No E.Other SEE SPECIFICATION BENEFITS PAGE D. Dental: ❑ Standard ❑ Non -Standar With Orthodontics 0 Yes 0 No DentalEnrollment NIA IV. RATE INFORMATION A. Premiums/Prepayment fee are payable monthly on or before the due date which will be determined: Regular Billing - Employee applications should be submit thirty (30) days prior to proposed effective dat B. Funding Arrangements Administrative Services Only HMO: Dental Program: Employee Employee / Spouse Employee / Child(ren Employee / Family $49.99-_ Other Comments' PREMIUM IS PER EMPLOYEE PER MONTH Total Premium $49.99 The rates established for this Contract will not be changed for the first twelve (12) months following the Initial effective date of Coverage. However, BCBSF/H01 may change the rates which are to be effective after this Initial twelve (12) month period of coverage by providing notice to the employer of such changed rata forty-five (45) days prior to their effective date. `V. 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/H01 for this or any other purpose, nor shall BCBSF/HOE 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/HOE 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/HOE 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/H01 as specified above in Section IV. Rates. B. 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. C. My person who knowingly and with Intent to Injure, defraud, or deceive any insurer fifes a statement of claim or an application containing any false, incomplete, or misleading Information Is guilty of a felony of the third degree. (VI. FINAL PREMIUMS, BENEFITS AND EFFECTNE DATES ARE SUBJECT TO APPROVAL BY BCBSF CORPORATE HEADQUARTERS Issuance of the Contractby BCBwSF/H0l will be deemed ceptance of this applicat 09-12-2000 Oats Signature of Applicant Print / Type Name & Title I3ai�_ �lo513oc9 files Cross and -Blue Shield of Fbr4la, Inc. Licensed Ag Agent Li J Fran B. Adams, Chairman 13123996 SR (Rw 3pn lommomar cense Identification Number Mae Cres sed alae Shield of Florida, las. sad Health Options. Ina. are Independeol Licenses of Ik Blue Cron sestinas SNeld Association,. a REGISTERED MARK OF THE SLUE CROSS AND BLUE SHIELD ASSOCIATION. IGISTERED MARE OF BLUE CROSS AND SLUE SHIELD OF FLORIDA, INC. y.