HomeMy WebLinkAbout2022-174AA TRUE COPY
CERTIFICATION ON LAST PAGE
J R. SMITH, CLERK
UNIMERICA INSURANCE COMPANY
A Stock Company
Administrative Offices: 11000 Optum Circle, Eden Prairie, MN 55344
Phone: 1-800-454-0233
APPLICATION FOR EXCESS LOSS INSURANCE
The undersigned Applicant requests the Excess Loss Insurance Benefits shown herein and provided by Unimerica Insurance
Company, and agrees to be bound by the terms and provisions of the Excess Loss Insurance Policy.
Full Legal Name of Applicant: Indian River County Board of County Commissioners
Address: 1800 27" Street, Vero Beach, FL 32960
Key Contact: Suzanne M. BOVII Telephone: 772-226-1402 Tax ID:
59-6000674
Applicant is a: ❑ Corporation ❑ Labor Union ❑ Partnership ❑ Association ❑ Proprietorship ® Other: County Government
Nature of Business of the Group to be Insured: County Government Requested Effective Date: October 1, 2022
Total number of eligible persons: Employees: Retirees: Zg�,
Are retirees covered: ® Yes ❑ No.
Affiliates or Subsidiaries:
Addresses of Affiliates or Subsidiaries:
Full Name of Administrator: Blue Cross and Blue Shield of Florida Pharmacy Benefit Manager: RxBenefits, Inc. / ESI
Address: 4800 Deerwood Campus Parkway, Jacksonville, FL 32246
Key Contact: Jacklyn LoDuca Telephone: 727-643-2950
Agent or Broker: Lockton Companies
Tax ID:
Address: iloduca@lockton.com
SPECIFIC EXCESS LOSS INSURANCE ® Yes ❑ No
Benefit Period: Covered Expenses Incurred from October 1, 2021 through September 30, 2023 and
Paid from October 1, 2022 through September 30, 2023.
Specific Deductible: per Covered Person: $300,000
Specific Percentage Reimbursable: 100%
Maximum Specific Benefit per Covered Person: ® Unlimited ❑ Other
Covered Expenses under Specific Excess Loss: ® Medical ® Stand Alone Prescription Drug Program
Common Accident Provision: ® Yes ❑ No
I Description: I Specific Premium Rates per month
62.51
Specific Accommodation Reimbursement Endorsement [:]Yes ® No
Specific Step -Down Deductible Endorsement ❑ Yes ® No
Specific Terminal Liability Endorsement ❑ Yes ® No
Aggregating Specific Deductible Endorsement ® Yes ❑ No $100,000
Independent Review Organization Extended Liability Endorsement ® Yes ❑ No
UMERAPP (01/12)
AGGREGATE EXCESS LOSS INSURANCE: ® YES ❑ NO
Benefit Period: Covered Expenses Incurred from October 1, 2021 through September 30, 2023, and
Paid from October 1, 2022 through September 30, 2023.
TRUE COPY
RTIFICATION ON LAST PAGE
P. SMITH, CLERK
Covered Expenses under Aggregate Excess Loss Coverage: ® Medical ❑ Dental ❑ Vision
® Stand Alone Prescription Drug Program
❑ Other (Please Specify)
Aggregate Percentage Reimbursable: 100%
Maximum Aggregate Benefit: ❑ $500,000 ® $1,000,000 ❑ Other
Minimum Annual Aggregate Deductible: $26,841,688 or 95% of the first Monthly Aggregate Deductible amount times 12,
whichever is greater.
Maximum Covered Expenses per Covered Person accumulating toward the Maximum Aggregate Benefit: $300,000
Aggregate Excess Loss Premium: $ 3.06 per Employee per month
Aggregate Terminal Liability Endorsement: ❑ Yes ® No
Aggregate Accommodation Endorsement: ❑ Yes ® No
Independent Review Organization Extended Liability Endorsement ® Yes ❑ No
Monthly Aggregate Factors:
Covered Persons
Medical Prescription Drugs
Composite
$ 1,426.99 Included
It is understood and agreed by the undersigned that:
1. The statements, declarations and representations made in this Application, any request for proposal, the underwriting information
provided by or on behalf of the undersigned and the Plan Document are the undersigned's representations; that any Policy is
issued in reliance upon the truth of such statements, declarations, and representations; and that such statements, declarations, and
representations will form a part of the Excess Loss Insurance Policy. Any inaccuracy in such information or failure to disclose
any such information, including all claims or possible claims, paid or pending, or which the Employer should otherwise know
about, if discovered later, can result in rejection of this Application, or can change the terms, conditions or premiums, or can void
coverage.
2. As a condition precedent to the approval of this Application, the undersigned shall furnish to the Company a copy of the executed
Plan Document within 90 days after the date of this application describing the benefits provided by the Plan, which shall be kept
on file in the office of the Company. If the Company does not receive the Plan Document within 90 days, the Company may
refund all premium and the Application shall have been null and void when signed. No Excess Loss Insurance will be effective
nor reimbursement made unless a Plan Document is received and accepted by the Company.
3. The Company will evaluate the undersigned's risk, as requested by this application, the underwriting data received and
represented by the Plan and may require adjustments of rates, factors, and/or special limitations.
4. Any coverage resulting from this Application shall be subject to the terms and provisions of the Policy herein applied for.
Coverage shall become effective on the date specified in this Application if all requirements of the Company, including the Plan
Document and the underwriting requirements have been met and the required premiums paid.
5. The receipt by the Company of the first month's premium and deposit of any check drawn in connection with this Application
shall not constitute an acceptance of liability. In the event the Company does not approve this application, its sole obligation shall
be to refund such sum to the undersigned.
6. The undersigned will provide or employ an Administrator to administer the Plan and to process and pay claims according to the
Plan Document. The undersigned acknowledges that the Administrator is the undersigned's agent and not the agent of the
Company and that statements and answers given by the Administrator are binding on the undersigned.
7. Other: Rate Cap provision is included that will guarantee your Subsequent Policy Period beginning October 1, 2023 will not
contain any new Specific Deductible greater than the group's standard Specific Deductible for any covered person. In addition,
the Specific Monthly Premium Rate and Aggregating Specific Deductible (if applicable) will not increase more than 50%. The
Rate Cap will not apply if the Company determines there is a material change to the Policyholder's Plan, the Excess Loss
Insurance Policy, or the composition of the group. Continuation of the Rate Cap will be assessed annually.
UMERAPP (01/12)
A TRUE COPY
CERTIFICATION ON LAST PAGE
J.R. SMITH, CLERK
The undersigned has read the entire Application for Excess Loss Insurance and understandsP#AS insurance requested
herein is not in effect until this Application is approved and accepted by the CompanyoJ��t..• Sipe,.
Full Legal Name of Applicant: 1ndiarHRtvVr County Board f County Comrl `si S
Signature of Authorized Person: R-
PrintName: Peter D. O'Bryan Title: Chairman �y;•' + c .\oQ:
Date: September 13, 2022 '`�GFgCOUttj1;�''•.
Signature of Agent or Broker:
Print Name of Agent or Broker:
FRAUD WARNING NOTICES: (Please review notice that applies in your state)
For applicants in Arkansas, Louisiana, New Mexico 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.
For applicants in 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.
For applicants in District of Columbia:
WARNING: It is a crime to provide false or misleading information to an insurer for purpose of defrauding the insurer or
any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false
information materially related to a claim was provided by the application.
For applicants in 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.
For applicants in Kentucky, New Mexico, Ohio, and Pennsylvania:
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 such
person to criminal and civil penalties.
For applicants in Maine, Tennessee and Virginia:
It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment, fines, or a denial of insurance benefits.
For applicants in 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.
For applicants in all other states:
It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment, fines, or a denial of insurance benefits.
UMERAPP (01/12)
Attest: Jeffrey R. Smith, Clerk of
Cir Court and Comptroller
!/
Deputy Cleric
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A TRUE COPY
CERTIFICATION ON LAST PAGE
J.R. SMITH, CLERK
EXPEDITED REIMBURSEMENT AGREEMENT
August 15, 2022
Indian River County Board of County Commissioners
Upon receipt of your signature below, Optum agrees to expedite reimbursement of a
potential Specific claim prior to adjudication by the Administrator under the following
conditions:
1) Client submits a request, including claimant name and amount of
reimbursement being requested, for a potential claim accompanied by a
Blue Cross/Blue Shield, Aetna, Cigna report(s) and/or PBM report
outlining the paid and/or pending claims included in the request.
2) Covered Expenses exceed the Specific Deductible by $10,000 or greater
initially, and $5,000 or greater for subsequent expenses.
3) Administrator and/or the Client will provide complete and detailed
information regarding the potential claim to Optum by the end of the
following month in which the reimbursement request is made.
4) If Optum determines the claim is not eligible under the Specific Excess
Loss Insurance, the Client understands and agrees that Optum will offset
the amount reimbursed against future claims. In the event there are no
future claims, the Client agrees to repay the expenses reimbursed within
30 days of Optum's request.
5) This agreement may be termirliated at any time by Optum upon written
notice. • oJ`�;�y:c ... s!o,��9s ..
Signature of Authorized Per n
.=?oi• � .•off;.;•
Peter D. O'Bryan cOU�s�Vtle. Chairman
Printed Name
September 13, 2022
Date
4 +
A, A- L
,lr
Attest: Jeffrey R. Smith, Clerk of
Cir Court and Comptroller
r t
Br. h /) Af 01C) Ll NTY A [70 R Z4 E";'
Deputy Clerk
Optum
August 15, 2022
STATE OF FLORIDA
INDIAN RIVER COUNTY
THIS 1 RTIFYTHAT THIS IS A TRUE Ahjo CORRECT
COPY T ORIAIN ON F17N THIS ICE.
JEFF A. IIT E
BY D.C.
DATE
EASY REPORTING AGREEMENT
Indian River County Board of County Commissioners
Upon receipt of your signature below, Optum will implement Easy Reporting for potential
Specific claims. The following will apply:
Optum will identify claims for reimbursement as a courtesy based on detailed paid claim
reports submitted by the Administrator(s) and/or PBM(s). Please note that responsibility for
identifying and submitting claims remains the Client's responsibility.
Optum will reach out to the designated stop loss contact(s) on file, if necessary, to obtain
additional information, including, but not limited to:
- Eligibility documentation, work status, COBRA
- Other insurance coverage
- Accident details/subrogation
- Any other information deemed necessary in order to fully adjudicate the stop loss claim
Claim submissions whether identified by the Administrator(s), the Client, the Broker or
Optum will be subject to the timely filing provision as outlined in the stop loss policy. All
claim submissions/paid claim reports must be submitted within 12 months after the end of
the Benefit Period in order to be eligible for reimbursement under the stop loss policy.
This agreement may be term inated,,4, .W'. -.Optum upon written notice.
;�Jd� 1�0
Signature of Authorized Pers
Peter D. O'Bryan +•9?9��fRCOIlN,rltle: Chairman
Printed Name
September 13, 2022
Date RPPA0VED NE) 70 FORM
Attest: Jeffrey R. Smith, Clerk of BY W =.o_.•�..
Circuit Court and Comptroller _ ;'a.�! i`'
00UN11YaM-TORNEY
ar:
Deputy Clerk