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Home My WebLink About2014-141 Lf H Sun Life Assurance Company of Canada OCT Sun `�. ,;2r' '��14 I Application for Stop-Loss Insurance � �ica1' ' 1 Plan sponsor information Full legal name of plan sponsor Policy number(office use only) Indian River County Board of County Comissioners Street address Policy effective date 1801 27th Street _ 10/1/2014 City State i Zip code Vero Beach FL 32960 '2 Subsidiaries, affiliates, divisions and locations Please list all Subsidiaries, affiliates,divisions and locations to be covered under this policy: subsidiaries, affiliates, divisions, and locations 1 Indian River County Clerk of the Court to be covered under the 2. Indian River County Property Appraiser Stop-Loss policy. — 3 Indian River County Tax Collector 4 Indian River County Sheriffs Office 5 Indian River County Supervisor of Elections 6• 7 `3 Requested coverage Please select the ® Specific benefit coverages for which Specific benefit deductible you are applying. P ® Individual $ 275,000 ❑ Family Aggregating specific deductible (if applicable) $ 148,750 Specific benefit annual maximum eligible expenses $ UNLIMITED Specific benefit lifetime maximum eligible expenses OR ® No maximum N Aggregate benefit Aggregate benefit maximum Aggregate benefit maximum eligible expenses per covered person` $ 1,000,000 $ 275,000 * Individual or family option applies to all selected coverages Domiciliary State-Michigan XGR/2989 • Stop-Loss Application Page 1 of 4 Y '4 Proposed benefits: rates, covered lives, and aggregate deductible factors Specific Benefit Premium Rates: Single Family Other $ $ $ composite: $22.82 Specific Covered Benefits: ® Medical including Prescription Drug ❑ Medical excluding Prescription Drug Aggregate Benefit Premium Rates: ® Monthly rate ❑Annual rate(if applicable) ❑ Other: $ 1.50 $ $ Total Employees Total Family 1553 n/a composite rates Aggregate Deductible Factors(ADFs): Covered Benefit ADF ® Medical .. $691.34 ® Prescription Drug Plan $242.87 ❑ Dental $ ❑ STD $ ❑ Vision $ ❑ Other . ....... $ ❑ Monthly Aggregate Accommodation (MAA) '5 Claims Basis Specific Aggregate Contract Basis Benefit Benefit 12/12 Incurred and Paid ❑ ❑ 15/12 3 Month Run-In ❑ ❑ 18/12 6 Month Run-In ❑ ❑ 24/12 12 Month Run-In ❑ ❑ 12/15 3 Month Run-Out ❑ ❑ 12/18 6 Month Run-Out ❑ ❑ 12/24 12 Month Run-Out ❑ ❑ Incurred. ❑ NA Paid NA ❑ Other 36/12 Terminal Liability Option: ❑ ❑ ❑ 3 Months ❑ Other XGR/2989 • Stop-Loss Application Page 2 of 4 '6 For employers who are providers of medical services only ( i e hospitals, clinics, etc ) The Related Provider Reimbursement Percentage applied to Eligible Claims Expenses for Related Provider Services will be n/a %for the Specific Benefit and n/a%for the Aggregate Benefit. '7 Retiree information 1. Specific Benefit: Is retiree coverage included? ❑ No ® Yes 2. Aggregate Benefit: Is retiree coverage included? ❑ No ® Yes '8 Additional benefits (Must Be Underwriting Approved) These are programs and SunExcel®Transplant Program Clinical Trials Benefit Provision enhancements to your Stop-Loss coverage. ® Elect E]Decline EJ Elect ® Decline No New Special Conditions Rider at Renewal ® Elect ❑ Decline '9 Certification and Signature Please return this form This application does not bind coverage. The applicant agrees to provide Sun Life Assurance and all additional Company of Canada with a current census of all eligible individuals, disclosure of all special risks on required documentation the Special Risk Questionnaire and a complete Plan document no later than the effective date to your Sun Life specified in section 1. Upon approval of this application, Sun Life Assurance Company of Canada Financial Group Office. will issue a Stop-Loss insurance policy with insurance coverage to become effective on the effective date. This application will be attached to and made a part of the Stop-Loss policy. The policy will be void if the applicant has concealed or misrepresented any material fact or circumstance concerning the subject of this application. Please read the fraud warning below before signing this application. State law requires that we notify you of the following: [(If the applicant organization is headquartered in Colorado, District of Columbia, Florida, Kansas, Kentucky, Maryland, New Jersey, Oregon, Rhode Island, Tennessee, Vermont, Virginia, and Washington,please see Page 4)] Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Name of authorized representative of plan sponsor Title Joseph A. Baird County Administrator — i Signature of authorized re"sentat've Today's date X �' 09/29/2014 Sign re7frroker X Ct Print na a of ag nt/154 ---- Kurt N. Gehring Florida agent/broker license ID number Amount paid with A094973 this application Countersigned by licensed resident agent(when required by law) $0.00 X APPROVED AS AND LEGAL SUFFICIENCY BY DYLAN REINGOLD COUNTY ATTORNEY XGR/2989 • Stop-Loss Application Page 3 of 4 ' Fraud Warnings Please read the applicable State law requires that we notify you of the following: fraud warning before Please read the fraud warning below before signing this form. Where noted, state law requires that signing this application. we notify you of the following: Fraud Warning (except as specified below): Any person who knowingly and with intent to defraud any insurance company or other person files an Application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects that person to criminal and civil penalties. Fraud Warning for Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Fraud Warning for District of Columbia and Rhode Island: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Fraud Warning for Florida: 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. Fraud Warning for Kansas: Any person who knowingly and with intent to defraud any insurance company or other person files an Application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto may be guilty of insurance fraud as determined by a court of law. Fraud Warning for Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an Application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and subjects that person to criminal and civil penalties. Fraud Warning for Maryland: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Fraud Warning for New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Fraud Warning for Oregon: Any person who knowingly and with intent to defraud any insurance company or other person files an Application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto may commit a fraudulent insurance act, which may subject that person to criminal and civil penalties. Fraud Warning for Tennessee,Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Fraud Warning for Vermont: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. Sun Life Assurance Company of Canada is a member of the Sun Life Financial group of companies C 2010 Sun Life Assurance Company of Canada,Wellesley Hills, MA 02481 All rights reserved Sun Life Financial and the globe symbol are registered trademarks of Sun Life Assurance Company of Canada. XGR/2989 • Stop-Loss Application Page 4 of 4 6/10 Sun Life Assurance Company of Canada Sun��= Stop-Loss special risk questionnaire Life Financial Section 1 Who is a special risk? Your employee benefit A person is a special risk if he or she is: plan covers any or all • receiving total parenteral nutrition(intravenous feeding); of the following: • confined to a medical (acute, skilled, or rehabilitation)facility or receiving home nursing care for 4 or more hours per day; employees, dependents, • being, or has been, evaluated, considered,or listed for an organ,tissue, stem cell, or bone marrow transplant or has received such a transplant; retirees, and those • using a left ventricular assist device, ventricular assist device, or internal defibrillator; receiving coverage • experiencing a high-risk pregnancy as determined by your precertification or pregnancy management vendors; under COBRA. Some • ventilator dependent; of these people are or • an employee who is not actively at work due to disability, who has been absent from work for more than 10 consecutive days within the might be a special risk. past 12 months, or who is working reduced hours due to illness or injury; or You must disclose • being re-enrolled, or has been re-enrolled, in the employer's medical benefit plan following his or her prior exhaustion of benefits under these individuals. the plan. In addition,a person is a special risk if he or she has been diagnosed with or treated for any of the following conditions within the past 12 months: • major trauma(e.g.,accident with multiple injuries • mental health or substance abuse disorder • hemophilia;other blood-clotting or internal injuries);amputation;severe burns that has required inpatient confinement disorders; Fanconi's disease • intracranial or other head injury • heart disease;cardiomyopathy;congestive • amyotrophic lateral sclerosis(ALS)or • spinal cord injury heart failure;dysrhythmias multiple sclerosis • acquired immune deficiency syndrome(AIDS) • congenital heart defect . Gaucher's disease • cancer or malignant neoplasm • primary pulmonary hypertension • chronic or acute liver disease; hepatitis • leukemia or lymphoma • chronic obstructive pulmonary disease • pancreatitis • cystic fibrosis • thrombocytopenia • acute or chronic renal disease • complications of pregnancy;multiple births; • cerebrovascular disease or stroke • regional enteritis premature birth;or newborn complications • arthritis(rheumatoid or osteoarthritis) • morbid obesity Section 2 How do you identify who is a special risk? There are two ways To identify who is or may be a special risk,you or your authorized representative should: to disclose special risk A. Attach any relevant reports(listed below)and highlight individuals falling into a special risk category(see above): individuals. Please read . pending claims report with diagnosis • report listing any participant who has incurred or is expected to this section carefully. . subrogated claims reports incur medical expenses(including prescription drug expenses) • precertification reports with diagnosis performed within equal to or greater than 50%of the specific benefit deductible the last 3 months Be sure to highlight special risks. Having a special risk individual simply appear on an attached report does not constitute disclosure. You may highlight special risk individuals by circling the name or by using an asterisk or other mark. XGR/1254 Stop-Loss special risk questionnaire Page 1 of 2 Section 2 How do you identify who is a special risk?, continued APPROVP0 T:) FORM AND LEGAL r -OR- B. List individuals falling into a special risk category directly on the reverse/second page of this form • • reviewing your employee attendance records, sick leave reports, and disability reports; and DYL/•ti*: FtCINGOLD�p�JNT�( ATT�RN�Y • consulting with your precertification, utilization review, and case management vendors. (Be sure to inc udd""e ransp ant can Idates.) Your medical management vendors may assist with the completion of this form. You may forward this form to any vendors Section 3 Identifying special risks Make sure you have read Name of plan sponsor Proposed effective date Today's date the directions on the Indian River Count Board of Count Comissioners 10/1/2014 9/16/2014 reverse/first page. Date of report Option A Attached reports must be within 30 days of proposed effective date Number of pages Attach the relevant ❑ Pending claims report reports and highlight(by ® Large claims report 50%of Specific deductible 8/20/2014 29 circling or using an ❑ Precertification report asterisk or other mark) ❑ Subrogated claims report special risk individuals. ® Other report(please describe) High Cost Claim Summary 8/20/2014 1 &Detail Report Option B List special risk Category- individuals directly Name or ID number E= Employee Total dollar on this form. of individual who is/may be C = COBRA amount of claims a special risk D = Dependent Sex paid within past IMPORTANT! attach addt'I pages if needed R= Retiree Date of birth M/F Diagnosis/medical condition Date of onset 12 months Individuals must either $ be:(A)highlighted on $ an attached report or $ (B)listed on this form. $ Section 4 Acknowledgment and signature Return this completed m form your broker We will use the information you provide on this form to underwrite the stop-loss insurance you have applied for and to determine the appropriate or Sun Life Financial coverage,deductibles,and premium rates for that insurance. If you fail to disclose any person as a special risk who should have been disclosed as a presentative within special risk and submit a claim relating to that person,we may decline or limit coverage with respect to that person,retroactive to the original re re days to the proposed effective date of your stop-loss policy with us. Your signature on this form represents to us that: policy effective date. I. You or your authorized representative provided the requested reports with special risk individuals identified; and 2. You or your authorized representative consulted with your precertification, utilization review, and case management vendors and with your third party administrator or former third party administrator to obtain the information required to complete this form; and 3. You or your authorized representative provided information about any individual who is eligible under your employee benefit plan as of the date you signed this form who is, or may be,a special risk. Sign re of authorized r resenPtive of plan sponsor Name(please print) Title(please print) Date signed �sr Joseph A. Baird County Administrator 09/29/14 XGR/1254 Stop-Loss special risk que nnaire Page 2 of 2 10/10