HomeMy WebLinkAbout2005-329 ADDENDUM TO CARVE-OUT MENTAL HEALTH AND
DUAL DIAGNOSIS SUBSTANCE ABUSE AGREEMENT
The term of the above-noted Agreement is hereby extended for three additional years with the
following per employee per month rate guarantee .
October 1 , 2005 through September 30 , 2008 . . . . . . . . . $6 . 75 per employee per month
IN WITNESS WHEREOF , the parties hereto have executed this Addendum on the day and
year written below .
r, s.
r
L y _ Authorizedrgnature Leo H . radman , Psy . D . President
Indial3iver County BOCC UniPsych Benefits , Inc .
t S . Lowther , Chairman
Witness Witness
October 4 , 2005
Date Date
APPROVED AS TO FORM
AND G SU FIC ' E
BY
WILL
K . DEBRAAL
ASSISTANT COUNTY ATTORNEY
NOTIFICATION OF RENEWAL
Policyholder: Indian River County SYMETRA .
Policy Number: 16 =010204 =00 F I N A N C I A L
Third Party Administrator: Blue Cross
Please complete the appropriate section ( s ) below :
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RENEWAL TERMS : The above account has renewed effective Oct 1 , 2005 on the following terms :
Specific : Contract : 12/ 12 Paid / 15 15/ 12 Paid Other: 12/ 15
Deductible Level - $200 , 000 Individual Advantage Deductible : $ 54 , 000
Lifetime Maximum : $ 1 , 000 , 000
Renewal Specific Rates : Single : Family : Composite : $ 14 . 03
Terminal Liability Coverage : Yes _ No _xx ( Note : Only available if purchased at policy inception )
Aggregate : Contract : 12/ 12 15/ 12 Paid Other : 12/15
Renewal Aggregate Factors : Single : Family : Composite : $ 665 . 46
Aggregate Premium : $ 1 . 80 Lifetime Maximum : $ 1 , 000 , 000
Monthly Aggregate Accounting : Yes or No Rate :
Terminal Liability Coverage : Yes No ( if yes , specify terminal liability factors below )
Terminal Liability Factors : Single : Family :
Managed Care Network(s ) : Blue Cross
Changes ( Formal signed amendment required ) & Additional Provisions :
Plan AdministratorsSOX
nature :
S . Lowther , Chairman
Date : 10 / 4 / 05
Agent ' s Signature .
ti, uo� Date : 3 3/ /0&03x"
This form needs to be completed and returned to SAFECO no later than 15 days following the
renewal effective date . Please forward to :
Symetra Financial
Attn : Mary Hewitt APPROVED AS TO FORM
SU CI
Mary. hewitt@symetra . com AND LEGAL
FAX : ( 678 ) 728 = 1567 BY &X
WILLIAM K . DEBRAAL
ASSISTANT COUNTY ATTORNEY
Symetra Life Insurance Company • Group Division • 3740 Davinci Court Suite 350 • Norcross, GA 30092 • www. symetra . com
Phone: 678-728- 1549 FAX: 678-728- 1567 Toll Free : 800-746-6246