HomeMy WebLinkAbout2015-185AFond dJ YiYtln ems' U
An Independent Licensee of the
Blue Cross and Blue Shield Association
Please Type or Print — Must be completed in full. _
Administered by:
HM Life Insurance Company
Sales Administration
P 0 Box 535061, Suite P6411
Pittsburgh, PA 15253-5061
Tel: 800-328-5433
Fax: 412-544-3298
APPLICATION FOR STOP LOSS INSURANCE
• ' Il•T'TIsN
Full Legal Name of Group (to appear on Policy)
Indian River County Board of County Commissioners
-
Key Contact Person
Jason Brown
Tax ID Number
59-6000674
Business Telephone Number
772-226-1214
City
Fax Number
772-770-5331
Email
jbrown@ircgov.com
Internet
Address
1801 27th Street
Address
City
Vero Beach
State
FL
Zip Code + 4
32960
Delivery Address (if different than above)
City
State
Zip Code + 4
Nature of Business
General government, nec
SIC Code
9199
❑
•
Corporation ❑ Partnership
Government ❑ Other*:
*If an Association, Trust or Charitable Organization, a copy of the bylaws and/or trust is required with the submission of the application. If a union, or if
union employees are covered, a copy of the collective bargaining agreement is required with the submission of the application.
Affiliates to be insured? ❑ Yes* ■ No *If "yes," complete the table below, attaching additional sheets if necessary.
AFFILIATE#1 Full Legal Name
Nature of Business
Address
City
State
Zip Code
AFFILIATE #2 Full Legal Name
Nature of Business
Address
City
State
Zip Code
AFFILIATE #3 Full Legal Name
Nature of Business
Address
City
State
Zip Code
Do you have existing coverage? ❑ Yes* ❑ No *If "yes," who is the carrier.
23717-608 (R6/13)
Page 1 of 3
Applicant's Initials.
THIRD PARTY ADMINISTRATOR (TPA)
Full Legal Name of TPA
Florida Blue
Tax ID Number
Business Telephone Number
904-905-1723
Fax Number
904-565-6346
Address
4800 Deerwood Campus Parkway DCC 300-5
City
Jacksonville
State
FL
Zip Code + 4
32246
Delivery Address (if different than above)
City
State
Zip Code + 4
Key Contact Person
Lena Polomsky
Internet
Email Address
Jena polomsky@floridablue com
PRODUCER (Agent/Broker)
Name
The Gehring Group/Kurt Gehring
License Number(s) — Please attach a copy, if not on file.
A094973
Tax ID Number
65-0361295
Business Telephone Number
561-626-6797
Fax Number
561-626-6970
Email
brian.beatty@gehringgroup.com
Internet
Address
11505 Fairchild Gardens Ave Suite 202
City
Palm Beach Gardens
State
FL
Zip Code + 4
33410
Requested Effective Date
October 1, 2015
Estimated Initial Enrollment:
Single:
Family
.
Total:
1565
Premium Deposit of $ included. Estimated 1St month's premium must be attached to this application. The Premium Deposit will be
applied to the first premium when due. Make check payable to Florida Blue. Do not make the check payable to the agent or leave the "Payee" blank. If a
policy is not issued, the premium deposit will be refunded in full.
23717-608 (R6/13)
Page 2 of 3 Applicant's Initials:
FRAUD NOTICE (Please read carefully)• .:
In Florida, any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim for an
application containing any false, incomplete or misleading information is guilty of a felony of the third degree
APPLICANT UNDERSTANDS AND AGREES THAT
The stop loss insurance requested and requested effective date must be approved by Florida Blue as under our current rules and
practices All options and special requests are subject to approval from HM Life Insurance Company, administrator for Florida Blue
No insurance agent or broker has authority to guarantee acceptability of requested insurance coverage.
Our approval is subject to receipt of Disclosure Statement, the first month's premium, final census, and any other information
requested in connection with this application. Failure to do so will result in approval being denied or delayed until a later date
Receipt of a premium and its deposit in connection with the Application shall not constitute an acceptance of liability In the event that
Florida Blue, or our authorized agent, disapproves this Application, its sole obligation shall be to refund such sum to the Applicant.
Coverage will not be in effect until notified in writing from HM Life Insurance Company, administrator for Florida Blue. Do
not cancel prior coverage until so notified.
Final premium rates will be determined on the basis of Disclosure Statement, Claim Information and the actual composition of persons
covered by the underlying employee benefit plan on the requested effective date Should subsequent information become known
which, if known as of the date specified by Florida Blue, or our authorized agent, would have affected the rates, deductibles, terms or
conditions for coverage, we will have the right to revise the rates, deductibles, terms or conditions, by providing written notice to the
Applicant. The Policy, if issued, may be void, if whether before or after a claim or loss, any material fact or circumstance was
concealed or misrepresented on behalf of the Applicant, or if the Applicant or its Agent, committed fraud
A signed and dated summary plan document describing the underlying employee medical plan must be submitted within 60 days of
the Requested Effective Date to HM Life Insurance Company, administrator for Florida Blue. If the description of the benefits or plan
provisions differs from what was initially utilized to underwrite the risk, the premium rates and aggregate retention factors may be
subject to re -rating, retro -active to the requested effective date
The stop loss insurance which is the subject of this Application is a reimbursement contract, and the Applicant must first pay claims
and make funds available to pay claims as they become payable before submitting them for reimbursement. Oral statements not
expressly incorporated herein are not part of this Application.
Issuance of the Policy is in reliance of the data, including Disclosure Statement, census and Claim Information, submitted to us, and
payment of the first month's premium, subsequent premiums are due no later than the first day of each calendar month during the
Plan Year
I represent that the statements contained in this application are true and complete to the best of my knowledge and belief, and I
understand that they form the basis for Florida Blue's approval of the requested stop loss insurance.
Joseph A. Baird
Printed Name of Applicant's Authorized R
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resentative
10/05/2015 County Administrator
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