HomeMy WebLinkAboutNational Insurance Services-6/9/2014 (2)NATIONAL INSURANCE SERVICES INSURANCE TRUST
JOINDER AGREEMENT FOR
GROUP TERM LIFE INSURANCE
The below named Employer hereby requests application for participation in group term life
insurance benefits under the Group Policy issued to the below named Group Policyholder (hereafter
referred to as "Policyholder", and underwritten by Madison National Life Insurance Company, Inc.
(hereafter referred to as "Insurer"). The term Group Policy means only the provisions of the Group
Policy that apply to the Employer, based upon the coverage requested under this Joinder Agreement.
Insurance and Benefit Information
A. Administrative
1. Policyholder:
2. Employer:
3. Employer Plan No:
4. Nature of Business:
5. Initial Plan Effective Date:
6. Revised Joinder Effective Date:
7. Evidence of Insurability Requirements:
8. Employee Classes:
01 Non -Bargaining Employees
National Insurance Services Insurance Trust
CITY OF WATERLOO
715 Mulberry Street
Waterloo, IA 50703
3184
Government
July 1, 1994
July 1, 2014
Applies to Late Enrollees, Increases in Benefits
and Amounts over Guarantee Issue Amounts
excluding Non -Bargaining Employees who work 29
hours or less at the Cedar Valley SportsPlex
02 Bargaining Employees
9. Minimum Hourly Work Requirement:
Class 01, 02: 20 hours per week
10. Waiting Period for Insurance Coverage:
Class 01, 02: None
11. New Employee Eligibility Date:
Class 01, 02: Upon completion of the Waiting Period
12. Leaves / Layoffs:
Class 01, 02: Coverage with premium payment while on FMLA leave; Coverage with
premium payment for up to 15 days while on Military Leave
13. Employee Premium Contribution:
Class 01, 02:
Employee Basic Insurance: 0%
Employee Supplemental Insurance: 100%
Dependent Basic Insurance: 100%
Dependent Supplemental Insurance: 100%
GTL -JA -0708 1
14. Participation Requirements:
Class 01, 02:
Employee Basic Insurance:
Employee Supplemental Insurance:
Dependent Basic Insurance:
Dependent Supplemental Insurance:
15. Insurance Reduction Schedule:
Class 01, 02:
Employee Basic Insurance:
Employee Supplemental Insurance:
Dependent Basic Insurance:
Dependent Supplemental Insurance:
B. Basic Life Insurance
Employee Basic Life
Class 01:
Guarantee Issue:
Maximum Issue:
Class 02:
Guarantee Issue:
Dependent Child Basic Life
Class 01, 02:
Age: 14 days to 6 months:
Guarantee Issue:
Age: 6 months through Limiting Age:
Guarantee Issue:
GTL -JA -0708
100%
0%
None
None
Basic Life and Basic AD&D Insurance does not
reduce and terminates at retirement.
Supplemental Life Insurance reduces to 65% upon
attainment of age 65, reduces to 45% upon
attainment of age 70 and terminates at retirement.
Dependent Child Basic Life Insurance terminates
upon the earlier of the Insured Child's attainment of
the Limiting Age or the Insured Employee's
retirement.
Dependent Spouse Supplemental Life Insurance
reduces to 65% upon the Insured Spouse's
attainment of age 65 and terminates upon the
Insured Spouse's attainment of age 70.
1 times Annual Salary, rounded to the next highest
$1,000; Minimum $20,000
$125,000
$125,000
$20,000
$20,000
$1,000
$1,000
$10,000
$10,000
C. Supplemental Life Insurance
Employee Supplemental Life
Class 01, 02:
Guarantee Issue:
Maximum Issue:
Spouse Supplemental Life
Class 01, 02:
Guarantee Issue:
Maximum Issue:
D. Additional Benefits
1. Conversion of Insurance Benefit:
2. Waiver of Premium Benefit:
3. Living Benefit:
$1,000 increments
$0 if participation is less than 25%; $75,000 if
participation is 25% or higher
$100,000
$500 increments
$0 if Employee Supplemental participation level is
below 25%; $25,000 if Employee Supplemental
participation is 25% or higher.
the lesser of $50,000 or 50% of the Employee's
Supplemental Life amount
Included for all classes
Included in Class 01, 02
Included in Class 01, 02
E. Accidental Death and Dismemberment (AD&D) Insurance
1. Basic AD&D Insurance
Employee Basic AD&D Insurance
Class 01:
Guarantee Issue:
Maximum Issue:
Class 02:
Guarantee Issue:
1 times Annual Salary, rounded to the next highest
$1,000; Minimum $20,000
$125,000
$125,000
$20,000
$20,000
F. Premium
1. Rate:
Class 01, 02:
Employee Basic Life Premium Rate:
Dependent Basic Life Premium Rate:
Employee Supplemental Life Premium Rate:
Spouse Supplemental Life Premium Rate:
Employee Basic AD&D Premium Rate:
GTL -JA -0708
$0.21 per $1,000 of coverage
$1.50 per dependent unit
$0.27 per $1,000 of coverage
See Age Rates below
$0.03 per $1,000 of coverage
Spouse Supplemental Life:
Spouse Age Rate per $1,000
To age 29 $0.08
30-34 $0.09
35-39 $0.11
40-44 $0.15
45-49 $0.23
50-54 $.036
55-59 $0.54
60-64 $0.72
65-69 $1.30
2. Rate Guarantee: 31 months until July 1, 2016
3. Frequency of Billing Monthly
G. Benefits and coverage for Insured Persons are as agreed upon between the Insurer and the
Policyholder. All coverages and actual benefit amounts in effect, with respect to each Insured Person,
are described in the Certificates of Insurance issued by the Insurer to the Policyholder for distribution
to the Insured Persons or, directly to the Insured Persons. This includes any applicable Riders or
Endorsements which generally describe, without amending, superseding or changing the Policy in any
way, the essential features of the coverages Insured Persons are entitled to under the Group Policy and
this Joinder Agreement, and to whom the insurance benefits are payable in the event of a covered loss.
TERMS AND DEFINITIONS
All terms are as defined in the Certificates of Insurance (hereafter referred to as Certificate).
PREMIUMS, PAYMENTS AND TERMINATION
A. Payment of Premiums
1. Premiums are due on the 1st of the month of coverage for which the 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 this 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: Madison
National Life Insurance Company, Inc., Dept # 5581, PO Box 1170, Milwaukee, WI 53201-1170.
5. Premium is due for an Insured Person for each month the Insured Person 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 15th of the month,
premium for an entire month will be due to the Insurer. If the effective date of coverage is
GTL -JA -0708 4
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
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.
B. 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, gender and occupational classification.
c) The premium contribution arrangement for insured employees changes or varies from that
stated in this 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.
C. 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.
D. 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 Salary as defined under the Group
Policy and Certificate, 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.
GTL -JA -0708 5
e) Notification of the 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).
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.
E. Grace Period, Termination for Nonpayment and Reinstatement.
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.
5. Reinstatement. If any renewal premium is not paid and coverage is terminated, the Employer may
request a reinstatement by reapplying with the Group Policyholder and submitting the required
premium. Coverage will be reinstated upon the Insurer's approval, if the Employer requests
reinstatement within 31 days of termination date. The Insurer shall approve or disapprove the
reinstatement within 15 calendar days following receipt of the reinstatement request and premium.
The Insurer and Employer shall have the same rights hereunder as they did under the Policy
immediately before the due date of the defaulted premium, subject to any provisions endorsed
hereon or attached hereto in connection with the reinstatement.
F. Termination for Other Reasons
1. The Policyholder may terminate the Group Policy and the Employer may terminate coverage
under the Joinder Agreement by giving the Insurer at least 60 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 the 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 requirements provided for under this 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 60 days advance written notice.
d) On the date the Employer breaches any part of the Entire Contract.
GENERAL PROVISIONS
A. Certificates. The Insurer will prepare the Certificates 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
GTL -JA -0708 6
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 differ from the terms of the
Employer's coverage under the Group Policy, the latter will govern.
B. Limitation of Liability. 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,
Inc. The Policyholder and Employer hereby release, hold harmless and indemnify Madison National
Life Insurance Company, Inc. from any liability arising from or related to any negligence, error,
omission, misrepresentation or dishonesty of the Policyholder or Employer respectively, or any of
their respective representatives, agents or employees.
C. Agency. The Policyholder and Employer are not agents of the Insurer for any purpose under the
Policy.
D. Entire Contract, Changes: This Joinder Agreement, the Policy, including the Certificates and any
Riders, Amendments or attached papers, if any, constitutes the entire contract of Insurance. 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 Policyholder 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 the Joinder Agreement.
No agent has authority to change this Policy or waive any of its provisions.
We have authority to determine all questions arising in connection with the Policy, including its
interpretation. Our failure to enforce any provision shall not waive, modify or render such provision
unenforceable at any other time; at any given time; or under any given set of circumstances, whether
the circumstances are or are not the same.
E. Incontestability. All statements made by the Employer in the Application are, in the absence of fraud,
representations and not warranties. The Insurer cannot contest the Policy or this Joinder Agreement
after it has been in force for 2 years from its Date of Issue. No statement shall be used to contest the
validity of coverage or reduce benefits, unless it is in writing, signed by the Employer, and a copy of
such statement is furnished to the Employer.
F. Non -Participating: The Policy is non -participating. It does not share in Our profits or surplus earnings.
G. Conformity With State Laws: If any provisions of Our forms are contrary to any law to which it is
subject, such provision is hereby amended to conform to the minimum requirements of such law.
H. Workers' Compensation. The Policy is not in lieu of and does not affect any requirements for
coverage by any Workers' Compensation Act or similar law.
I. Misstatement. If Policyholder or Employer premiums for the Insured Person are based on age or
gender and the Insured Person's age or gender has been misstated, there will be a fair adjustment of
GTL -JA -0708 7
premiums based on his or her true age or gender. If benefits for the Insured Person is based on age or
gender and the Insured Person's age or gender has been misstated, there will be an adjustment of said
benefits based on his or her true age or gender. We may require satisfactory proof of age or gender
before paying any claim.
J. Clerical Error. A clerical error may be made by the Insurer, Employer or Policyholder in keeping
data. If so, when the error is found the premium and/or benefits will be adjusted according to the
correct data. An error will not end insurance validly in force, nor will it continue insurance validly
ended.
ACCEPTANCE AND SIGNATURES
The undersigned Employer adopts and agrees to be bound by the terms and conditions of this Agreement,
as amended from time to time and Group Policy. Copies of these documents are available for Employer
review at the Policyholder's place of business. The Employer may also contact the Insurer for further
information.
The Group Policy 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.
The Insurer, in performing its obligations under the Group Policy, is acting only as a life insurer with
respect to the Group Policy. The Trust Administrator, in performing its obligations under the Group
Policy, is acting only as a trust administrator with respect to the Group Policy. The Insured and Trust
Administrator are not in any way acting as a plan administrator, a plan sponsor or a plan trustee for the
purposes of the Employee Retirement Income Security Act of 1974 (ERISA), as amended, or any other
federal or state laws.
The signatures below constitute acceptance of the undersigned Employer as a participating member under
the Group Policy.
Signed into effect this 1 day of \JUflf✓ , 20 i 4
Signature of A thorized Signer for Employer
Suzy S6ACLVCs L�- Clerk
Printed Name & Title of Signer
Signature of Authorized Signer for Employer
Administrator:
National Insurance Services of Wisconsin, Inc.
By:
Bruce A. Miller, President
June 4, 2014
GTL -JA -0708 8
Printed Name & Title of Signer
4 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 Is Our Business - We value our relationship with
our customers and are dedicated to providing them with exceptional
service and competitive product offers. As part 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 protect that information.
What Information We Collect And How We Collect It - Depending
on the type of product, we collect nonpublic personal information about
insured individuals 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 intemet "cookies" (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 required to maintain the confidentiality of
nonpublic personal information and to follow policies we establish to
secure such confidentiality.
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 as
conducting and auditing our business, administering the business of
affiliated organizations, responding to requests from government
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 as 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 parties 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.
• Govemment 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 infonnation.
• 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 infonnation except as stated above or to otherwise
conduct the business of insurance.
About this Privacy Notice - The examples contained in this Privacy
Notice 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
IHCpn-IND-0509