HomeMy WebLinkAboutWellmark-6/25/2012ark
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1. General information
City of Waterloo
Application For Group Insurance
Please type or print. Must be completed in full.
Indicate "NA" if item does not apply.
Full Legal Name of Group
42-6005327
Tax I.D. Number
715 Mulberry Street
Address
Waterloo IA
City, State
http:www.wplwloo.lib.ia.us/waterloo
Internet Address
Municipality
Nature of Business
2. Requested Effective Date: 7/1/2012
( 319 )291-4522 ext 3008
Business Telephone Number
( 319 )291-4571
Fax Number
50703
Zip Code
suzy schares@waterloo-ia.org
E -Mail Address
9111
SIC Code
3. Number of Eligible Employees: Number of Participating Employees:
4. Stop Loss Benefits / Premiums: 0 New Group
Aggregate Coverage
Aggregate Stop Loss: Yes (Yes / No)
Aggregate Contract: 24/12 (15/12, 12/18, other)
Employee Benefit Plan expenses will be Incurred from 7/1/2011 through 6/30/2013 , and Paid from
7/1/2012 through 6/30/2013
658
Renewal
Aggregate Stop Loss Eligible Expenses Include:
Aggregate Stop Loss Deductible:
Aggregate Stop Loss Premium (per contract per month):
Aggregate Attachment Points:
Benefit Description/Plan
New Alt 1
125%
$2.38
$0.00
$2.38
Health
Prescription
Premium Amount
Broker Fee / Commission
Total Aggregate Premium
Single Family
Amount Enrollment Amount Enrollment
$676.09 148 51,690.23 510
Annual Minimum Aggregate Deductible:
Maximum Aggregate Reimbursement:
Aggregate Run-in, if applicable:
Calculated upon execution of agreement
Unlimited
NA
EE/Sp
Amount Enrollment
Dental
Other
EE/Ch
Amount Enrollment
Individual Coverage
Individual Stop Loss: Yes (Yes / No)
Individual Contract: 24/12 (15/12, 12/18, other)
Employee Benefit Plan expenses will be Incurred from 7/1/2011 through 6/30/2013 , and Paid from
7/1/2012 through 6/30/2013
Individual Stop Loss Eligible Expenses Include: Health
Prescription
Individual Stop Loss Deductible (per person): • $100000.00
Aggregating Individual Deductible (if applicable): $0.00
Individual Stop Loss Premium (per contract per month):
$93.12 Premium Amount
$0.00 Broker Fee / Commission
$93.12 Total Individual Premium
O Dental
❑ Other
Individual Stop Loss Lifetime Maximum (per person): $t.00
5. Policy Limitations:
Individuals requiring separate Individual Stop Loss Deductible (please list by Social Security number and relationship to employee)
Social Security Number Relationship Individual Stop Loss Deductible Excluded? Diagnosis
NA
10/2009
Page 1
Other Policy Limitations:
Claims in excess of the group's Individual Stop Loss deductible level will not be covered under the
Aggregate Stop Loss coverage.
Reimbursement of Third Party Fees, related to negotiation of out of network bills, is limited to 30% of the
amount saved.
Retirees over age 65 are not eligible for stop loss coverage under the group plan. Active employees and
their spouses who are age 65 and older and exercising their rights under TEFRA/DEFRA are eligible only
if they elect the account's group coverage as primary to Medicare. If Medicare is chosen as primary,
employees and spouses are not eligible for group benefits.
Advanced Funding: Yes (Yes / No)
6. Administration
Case Management: Wellmark Blue Cross Blue Shield of Iowa
Ship to: Stop Loss Policy FAI
Special Instructions:
I represent the statements contained in this application are true and complete to the best of my knowledge and belief, and I
understand they form the basis for Wellmark Blue Cross Blue Shield of Iowa's approval of the coverage requested.
Name ofApplican s Authorized -Representative
4_� 7
nt's Authorized Represent ive
t~ ^ tr'
Location, ( ity/State `f
Gregg -Anne Lowe
Date
Name of Resident Agent
Signature of Resident Agent
0009427007
Resident Agent License Number
10/2009
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