HomeMy WebLinkAbout2000-2681-H79 A IL (7197)
Appitcafion
for Excess Loss Insurance
f/ LIFE INSURANCE COMPANY
Home office: St. Louis Park, MN
Executive office: 7300 Corporate Center Drive
Miami, Florida 33126-1223
A Stock Company
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John Alden Life Insurance Company
Home office: Sl. I-ouis Park, MN
1 Executive ofOce: 7300 Corporate Center Drive, Miami, FL 33126.1223
A Stock Company
APPLICATION FOR EXCESS LOSS INSURANCE
1. NAME OF APPLICANT: INDIAN RIVER COUNTY BOARD OF COUNTY COMMISSIONERS
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
Prnnerty AnraiR ra
Clerk of the Courts
Tax Cnllentnr
Supervisor of Elections
3. TOTAL EMPLOYEES AT ALL LOCATIONS: Est. 1280 F1., 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
t. Monthly Premium Rate:
Single Rate: $
Family Rate: $
Composite Rate: $
23.27
J -1178-A (FL) 3197
7. AGGREGATE EXCESS LOSS INSURANCE:
a. Benefits Covered:
91 Medical O Dental ❑ Vision
JP Prescription Drugs ❑ Weekly Disability Income ❑ 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 Rx Drugs (Other)
Single
Family
Composite $428.06 NA _ Included
d. JALIC's percentage payable (Excess of the Aggregate Deductible): 100
e. Maximum Aggregate Benefit payable by JALIC: $ 11000,000.00
f. Aggregate Monthly Premium Rate (per Employee per month): $ 1.78
g. Payment Mode: Monthly
8. OTHER BENEFITS:
a. Monthly Cumulative Accommodation Yes O No a Premium: $
b. Medical Conversion' Yes O No O: Premium Per Employee Per Month: $
c. Terminal Liability Yes ❑ No a Initial Premium: $
Election Premium: $ _
d. ❑ Other
*not available in 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.
DATEDAT Indian River County the 12th day of Septembiilr , 02000
1 represent that each of 4hr a4oye statements and answers are correct and true to the best of my knowledge and belief.
APPLICANT: Indian River',Gounty
BY:L�-t1�
Fran' B., Adams
TITLE: Chaitman
AGENT'S NAW(PRINT)t:•Boyd Max Branham
AGENT'S SIGNATURE: Fl, LICENSE NO.: 5 TIx I
Please return the completed and signed application to:
Alden Risk Management Services
Self -Funded Markets
P.O. Box 025472
Miami, Florida 33102-5472
RESOLUTION 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
I 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.
9/00RES0 (LEGAQWGC/nhm 1
40
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 _Ginn_, and, upon being put to
a vote, the vote was as follows:
Chairman Fran B. Adams Aye
Vice Chairman Caroline D. Ginn Aye
Commissioner Kenneth R. Macht _Aye
Commissioner John W. Tippin Aye
Commissioner Ruth M. Stanbridge y
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
Fran B. Adams, Chairman
ATTEST: Jeffrey K. Barton, Clerk
1% ]'/X A6�
Deputy Clerk
APPROVED AS TO FORM
AND LEGAL SUFFICIENCY"
c -D . I . I
PAUL G. ANGEL
COUNTY ATTORNEY
9/OORESO (LEGAL)WGC/nhm 2