HomeMy WebLinkAboutNational Insurance Services-6/9/2014NATIONAL INSURANCE SERVICES INSURANCE TRUST
JOINDER AGREEMENT FOR
LONG-TERM DISABILITY INSURANCE
WATERLOO CITY OF (the `Employer") hereby requests application for participation in National
Insurance Services Trust (the "Trust") for group long-term disability insurance benefits under a master
group policy underwritten by Madison National Life Insurance Company, Inc. (the "Insurer"). The
"Group Policy" means only the provisions of the master group policy that apply to the Employer, based
upon the coverage requested under this Joinder Agreement.
A. Administrative
1. Employer:
2. Plan Number:
3. Nature of Business:
4. Frequency of Billing:
5. Original Plan Effective Date:
6. Revised Joinder Effective Date:
B. Class and Benefit Summary
WATERLOO CITY OF
715 Mulberry Street
Waterloo, IA 50703
0378
Government
Monthly
July 1, 1994
July 1, 2014
Class Number:
01
02
Eligible Class:
All Other Eligible Employees Library Employees
excluding sworn Police and Fire
Employees and Employees who
work 29 hours or less at Leisure
Services
Employer Premium Contribution: 100% 100%
Initial Premium Rate:
.41% of covered payroll .41 % of covered payroll
Initial Premium Rate Guarantee: 24 months until July 1, 2016 24 months until July 1, 2016
Elimination Period:
90 consecutive calendar days 90 consecutive calendar days
Minimum Hourly Work
Requirement:
30 hours per week 20 hours per week
Waiting Period:
None
None
Evidence of Insurability:
Required for Late Enrollees, Required for Late Enrollees,
Increases and amounts exceeding Increases and amounts exceeding
the Guarantee Issue the Guarantee Issue
New Employee Eligibility Date: Upon completion of the Waiting Upon completion of the Waiting
Period Period
Minimum Participation
Required:
100%
100%
WATERLOO CITY OF
0378
Page 1
Class Number:
01
02
Eligible Class:
All Other Eligible Employees
excluding sworn. Police and Fire
Employees and Employees who
work 29 hours or less at Leisure
Services
Library Employees
Leaves and Sabbaticals:
Coverage with premium payment
while on FMLA leave
Coverage with premium payment
for up to one year while on Paid
or Unpaid Sabbatical
Coverage with premium payment
while on FMLA leave
Coverage with premium payment
for up to one year while on Paid
or Unpaid Sabbatical
Definition of Disability:
Partial
Partial
Own Occupation Period:
24 months following the end of 24 months following the end of
the Elimination Period the Elimination Period
Any Occupation Period:
From the end of the Own
Occupation Period to the end of
the Maximum Benefit Period
From the end of the Own
Occupation Period to the end of
the Maximum Benefit Period
Cumulative Elimination Period:
10 Working Days
10 Working Days
Recurrent Disability:
6 months
6 months
Predisability Earnings:
Base pay plus Longevity Pay
Base pay plus Longevity Pay
Maximum Monthly Covered
Salary:
$10,000
$10,000
LTD Benefit Percentage:
66-2/3%
66-2/3%
Maximum Monthly Benefit:
$6,667
$6,667
Guarantee Issue:
$6,667
$6,667
Minimum Monthly Benefit:
$50
$50
State Plan Disability Benefits:
No Application required for
IPERS
No Application required for
IPERS
Social Security Integration:
Full Family
Full Family
Freeze Type:
Social Security Freeze
Social Security Freeze
Pre -Existing Condition
Exclusion:
3 months/12 months
3 months/12 months
Mental Disorder Limitation:
None - Same as any Physical
Disease
None - Same as any Physical
Disease
Substance Abuse Limitation:
None - Same as any Physical
Disease
None - Same as any Physical
Disease
Claim Payment Method:
Monthly
Monthly
WATERLOO CITY OF
0378
Page 2
Class Number:
01 02
Eligible Class:
All Other Eligible Employees Library Employees
excluding sworn Police and Fire
Employees and Employees who
work 29 hours or less at Leisure
Services
Presumptive Disability: Included
Included
Rehabilitation Benefit:
Included Included
Survivor Benefit:
Included Included
Maximum Benefit Period:
Age at
Disablement
Benefit Duration
Any Age of
Disablement
24 months (including
the Elimination Period)
C. Payment of Premiums
1. Premium Due Date. Premium is due on the 1st of the month to which coverage for such premium
applies (e.g., premium for coverage in October would be due October 1st).
2. The premium due on each Premium Due Date is the sum of the premiums for all Insured Persons
under the Group Policy. Premium rates for each Employer covered under the Group Policy are
shown in the Employer's Joinder Agreement.
3. The Employer determines the amount, if any, of each Insured Person's contribution toward the
cost of insurance.
4. Each premium is payable on or before its Premium Due Date directly to the Insurer at their home
office.
5. Premium is due for an Insured Person for each month in which such employee is covered under
the Group Policy. The Employer must notify the Insurer immediately whenever an employee
becomes eligible or ceases to be eligible for coverage. Effective dates of coverage or termination
dates which occur mid -month will be billed as follows:
a) If the effective date of coverage is between the 1st of the month and 1 5th of the month,
premium for an entire month will be due to the Insurer. If the effective date of coverage is
between the 16th of the month and the end of the month the Employer will be billed for the
next full month of coverage. The Insurer does not prorate premium.
b) If the date coverage ends is between the 1st of the month and the 15th of the month, no
premium will be due for that month. If the date of termination is between the 16th of the
WATERLOO CITY OF
0378
Page 3
month and the end of the month the Employer will be responsible for an entire month's
premium.
6. All premiums will be based upon information provided by the Employer in the Census Reports.
D. Changes in Premium Rates.
1. Special Circumstances. The Insurer may change premium rates, to be effective on the next
Premium. Due Date, if any of the following occur:
a) A change or clarification in a law or governmental regulation affects the amount payable
under the Group Policy. Any such change in premium rates will reflect only the change in the
Insurer's obligations.
b) One or more changes occur in the factors material to the underwriting risk the Insurer
assumed under the Group Policy with respect to the Employer, including, but not limited to,
the number of persons insured, age, Predisability Earnings, gender and occupational
classification.
c) The premium contribution arrangement for insured employees changes or varies from that
stated in the Employer's Joinder Agreement when issued or last renewed.
d) Plan design changes are requested by the Employer.
e) The Insurer and the Employer mutually agree to change premium rates.
2. In all other cases, and subject to a period for which the Insurer has provided the Employer with a
written rate guarantee, the Insurer may change premium rates upon 90 days advance written
notice to the Employer. Any such change in premium rates may be made effective on any
Premium Due Date, but no such change will be made more than once in any Contract Year.
Contract Years means successive 12 -month periods computed from the end of the initial rate
guarantee period, or from a time agreed to in writing by the Employer and Insurer.
E. Premium Adjustments. Premium adjustments involving a return of unearned premiums to an
Employer will be limited to the 12 months just before the date the Insurer receives a request for
premium adjustment.
F. information Required from Employer
1. The Employer will furnish all information reasonably necessary to administer the Group Policy,
including but not limited to the following:
a) At least one Census Report during each plan year, no later than six months prior to the next
plan renewal date. The Census Report means a written report providing the following
information for each Employee insured under the Group Policy: name, social security
number, date of birth, gender, occupational class, annual Pre -disability Earnings as defined
under the Group Policy and the amount of coverage.
b) A list of all eligible employees and documentation supporting employee eligibility under the
Group Policy.
c) Information about employees who become eligible, whose amounts of coverage change
and/or whose coverage ends.
d) Occupational information and any other information that may be required to manage a claim.
e) Notification of an Employer's change in legal status, expansion of business, dissolution,
merger, buyout or any other significant business operational change.
f) Notice of any additional eligible employee segment(s).
WATERLOO CITY OF
0378
Page 4
g) Any other information that may be reasonably required.
2. The Employer must provide such information to the Insurer or its agents in a regular and timely
manner as may be reasonably specified by the Insurer and/or its agents. The Insurer and its agents
have the right at all reasonable times to inspect the payroll and other records of the Employer
which relate to insurance under the Group Policy.
G. Grace Period and Termination for Nonpayment
1. If a premium is not paid on or before its Premium Due Date, it may be paid during the Grace
Period. The coverage under the Group Policy will remain in force during the Grace Period.
2. Grace Period means the 31 days following the Premium Due Date.
3. .If the premium for coverage is not paid during the Grace Period, the coverage under the Group
Policy will terminate automatically at the end of the Grace Period.
4. The Employer is liable for premium for coverage during the Grace Period. The Insurer may
charge interest at the legal rate for any premium which is not paid during the Grace Period,
beginning with the first day after the Grace Period.
H. Termination for Other Reasons
1. The Policyowner may terminate the Group Policy and the Employer may terminate coverage
under the Group Policy by giving the Insurer at least 31 days written notice. The effective date of
termination will be the later of:
a) The date stated in the notice; or
b) The Premium Due Date immediately following date the Insurer receives the notice.
2. The Insurer may terminate coverage under the Group Policy as follows:
a) On any Premium Due Date if the number of persons insured is less than the minimum
participation number or less than the minimum participation percentage provided for under
Employer's Joinder Agreement.
b) On any Premium Due Date if the Insurer determines that the Employer has failed to promptly
furnish any necessary information requested or has failed to perform any other obligations
relating to the Group Policy or coverage under the Group Policy.
c) On any Premium Due Date by giving the Employer at least 31 days advance written notice.
d) On the date the Employer breaches any part of the Entire Contract.
L Certificates. The Insurer will prepare Group Long Term Disability Certificates of Coverage setting
forth the main features of the Group Policy applicable to each Insured Person. The Insurer and
Employer may agree to distribute the Certificates to Insured Persons in paper format, or to make the
document available and accessible for review by Insured Persons on the Employer's website. The
Employer will be responsible for providing sufficient notice to the Insured Person of the existence and
availability of the Certificate, including instructions on how to view the document, and a statement
that a paper copy of the document will be made available upon request. Upon receiving such a request
from either the Employer or Insured Person, the Insurer will provide a written copy of the Certificate
to the Employer for distribution to the Insured Person. If the terms of the Certificate of Coverage
differ from the terms of the Employer's coverage under the Group Policy, the latter will govern.
WATERLOO CITY OF
0378
Page 5
J. Agency and Release. Individuals selected by the Employer to secure coverage under the Group Policy
or to perform their administrative function under it, represent and act on behalf of the person selecting
them and do not represent or act on behalf of Madison National Life Insurance Company. The
Policyowner, Employer and such individuals have no authority to alter, expand or extend the Insurer's
liability or to waive, modify or compromise any defense or right the Insurer may have under the
Group Policy. The Policyowner and Employer hereby release, hold harmless and indemnify Madison
National Life Insurance Company from any liability arising from or related to any negligence, error,
omission, misrepresentation or dishonesty of the Policyowner or Employer respectively, or any of
their respective representatives, agents or employees.
K. Notice of Suit. The Policyowner and Employer shall promptly give the Insurer written notice of any
Lawsuit or other legal proceedings arising under the Group Policy.
L. Entire Contract and Changes
1. The Group Policy, the Group Long Term Disability Insurance Certificate of Coverage, the
Employer Joinder Agreement, the applications of the Policyowner, Employers and employees and
any applicable riders, addenda and/or amendments constitute the Entire Contract.
2. The Group Policy may be changed in whole or in part. No change in the Group Policy will be
valid unless it is approved in writing by one of the Insurer's executive officers and given to the
Policyowner for attachment to the Group Policy. No change in an Employer's coverage under the
Group Policy will be valid unless it is approved in writing by one of the Insurer's executive
officers and given to the Employer for attachment to their Joinder Agreement. No agent has
authority to change the Group Policy or an Employer's coverage under the Group Policy or to
waive any provisions thereof.
M. Effect on Workers' Compensation, State Disability Insurance. The coverage provided under the
Group Policy is not a substitute for coverage under a Workers' Compensation or state disability
income benefit law and does not relieve the Employer of any obligation to provide such coverage.
N. The undersigned Employer adopts and agrees to be bound by the terms and conditions of National
Insurance Services Trust Agreement, as amended from time to time (the "Trust Agreement") and
master group policy. Copies of these documents are available for employer review at Madison
National Life Insurance Company, 1241 John Q. Hammons Drive, Madison, WI 53717.
0. The Trust is a vehicle for obtaining group insurance plans in which employers join together as a
single policyholder for the purchase and maintenance of group insurance policies.
P. The Trust's Administrator shall provide participating employers the necessary information for
applicable State and Federal compliance reporting requirements.
Q. The signatures below constitute acceptance of the undersigned employer as a participating member of
the Trust.
Signed into effect this -%f 9 -
day of
1''1 \Ci.(_l
WATERLOO CITY OF
0378
Page 6
Signature %f Authorized Employee of Employer Printed Name & Title of Authorized
Employee
Signature of Authorized Employee of Employer Printed Name & Title of Authorized
Employee
Administrator:
National Insurance Services of Wisconsin, Inc.
By:Ca-`
Bruce A. Miller, President
May 16, 2014
WATERLOO CITY OF
0378
Page 7
THE IHC GROUP
Independence Holding Company
NOTICE OF PRIVACY PRACTICES AND PROTECTION
This Privacy Notice is provided for your information -- keep a copy of it for your records.
No response is required or requested
Customer Privacy fs Our Business - We value our relationship with
our customers and are dedicated to providing them with exceptional
service and competitive product offers. As pact of our dedication to
servicing their insurance needs, we are committed to protecting the
confidentiality of nonpublic personal information about our customers.
This Privacy. Notice will help you understand what type of information
we collect about insured individuals, how the information we collect is
used, and what measures we take to protectthat information.
What Information We Collect And Bow Wes Collect It - Depending
on the type of product, we collect nonpublic personal information about
insured indivirtrmis that may include:
• address,
• telephone number,
• social security number,
• account information.
• income,
• employment,
• health status, and
• other personal information relevant to their coverage.
We collect such information primarily from information we receive from
individuals on applications or other forms. We may also collect
information through telephone conversations or other electronic means,
such as internet "coolies" (data stored on a computer by an intemet
browser when you use the internet to access our website) that may be
used to track website usage, remember passwords customers create, and
provide customers with website content specific to their needs and
interests. We may also obtain information from third parties such as
employers, non-affiliated insurers, physicians, hospitals and other
medical providers.
How Information Is Protected - We restrict access to nonpublic
personal information to those employees who need to know that
information to provide products or services to our customers. We
maintain physical, electronic, and procedural safeguards that comply
with federal and state regulations to guard such information.
Information about insured individuals is accessed by our employees only
when such access is necessary to conduct our business. For example, we
may access information to offer other compatible products or services we
provide, to process customer requests, and to administer our products or
services. All employees are requiredto maintain the confidentiality of
nonpublic personal information and to follow policies we establish to
secure such oonfidentiality
Additionally, we require third parties to whom we disclose nonpublic
personal information, or who receive or handle such information on our
behalf; to adhere to our standard of privacy protection and to establish
information security procedures.
Disclosure - We do not disclose any nonpublic personal information
about our customers or former customers to anyone, except as permitted
by law. Information will only be disclosed for such purposes es
conducting and auditing our business, administering the business of
affiliated organizations, responding to requests from government
[FORM_NUMBER]
authorities, or as authorized or requested by an insured individual. Such
disclosures include, but are not limited to:
• Affiliates — we may provide information to affiliated companies to
enable them to provide business services for us such es claims
processing, underwriting, and maintenance of your accounts, and to
offer products and services we provide.
• Agents and Brokers —we may provide information to enable agents
and brokers to provide business services for us and to offer products
and services we provide.
• Joint Marketing — we may provide information to non-affiliated
third patties to jointly market insurance products or services.
• Lending Institutions — we may provide information to non-affiliated
lending institutions, such as banks and credit unions, to offer
products and services we provide, and to provide business services
for us,
Government Entities — we may provide information upon request
from a State Department of Insurance or other government entity.
The purpose for the request may be to prevent fraud, conduct an
audit of our business practices, or for any other reason for which the
government entity is legally permitted to request information.
• Servicing organizations - we may provide information to servicing
organizations such as TPAs, reinsurers, attorneys, accountants,
actuaries, underwriters, and other such organizations to enable them
to provide business services for us.
We do not share, trade, sell, exchange or in any other way disclose
nonpublic personal information except as stated above or to otherwise
conduct the business of insurance.
About this Privacy Notice - The examples contained in this Privacy
Notioe are provided as illustrations and are not a comprehensive account
of the rights of any party under applicable federal and state laws. The
policies and protections indicated in this Privacy Notice will remain
effective even after an individual's coverage is terminated, to the extent
we retain information about that individual. We may change this Privacy
Notice at any time and will inform you of any changes as required by
law. Other applicable privacy protections may exist under state laws and
we will comply with all applicable state laws when we disclose
information about individual insureds.
This Privacy Notice is distributed on behalf of the following
Independence Holding Company entities and their affiliated
organizations:
- Standard Security Life Insurance Company of New York
- Madison National Life Insurance Company, Inc.
- Independence American Insurance Company
For additional information, contact us at:
Attn: Privacy Committee
Post Office Box 5008
Madison, WI 53705
1HCpn--1ND-0509