Contract - United Healthcare Insurance - 12/16/2021 UNITEDHEALTHCARE INSURANCE COMPANY
A Stock Company
185 Asylum Street,Hartford,Connecticut
Phone: 1-877-294-1429
APPLICATION FOR EXCESS LOSS INSURANCE
The undersigned Applicant requests the Excess Loss Insurance Benefits shown herein and provided by
UnitedHealthcare Insurance Company, and agrees to be bound by the terms and provisions of the Excess
Loss Insurance Policy.
Full Legal Name of Applicant: City of Round Rock
Address: 221 East Main Street,Round Rock,TX 78664
Key Contact: Valerie Francois Telephone:512-218-5494 Tax ID: 746017485
Applicant is a: Municipality
Nature of Business of the Group to be Insured: Government Executive Offices Requested
Effective Date: January 1,2022
Total number of eligible persons: Employees: 903 Retirees: 42
Are retirees covered: Y
Agent or Broker: Holmes Murphy
SS No.or Tax ID: 42985055
Address: 12712 Park Central Drive,Suite 100, Dallas,Texas 75251
SPECIFIC EXCESS LOSS INSURANCE:
Benefit Period:Covered Expenses Incurred from January 1,2021 through December 31,2022,and Paid
from January 1,2022 through December 31,2022.
Specific Deductible per Covered Person: $200,000
Specific Percentage Reimbursable: 100%
Maximum Specific Benefit per Covered Person:Unlimited
Covered Expenses Under Specific Excess Loss:
• Medical
• Stand Alone Prescription Drug Program
Specific Excess Loss Premium:$126.97 per subscriber per month
AGGREGATE EXCESS LOSS INSURANCE
Benefit Period:Covered Expenses Incurred from January 1,2021 through December 31,2022,and Paid
from January 1,2022 through December 31,2022.
Covered Expenses under Aggregate Excess Loss Coverage:
• Medical
• Stand Alone Prescription Drug Program
Aggregate Percentage Reimbursable: 100%
R-2o2(- 333
Maximum Aggregate Benefit:$1,000,000 per Policy Year
Minimum Annual Aggregate Deductible:$11,837,957 or95%of the first Monthly Aggregate Deductible
amount times 12,whichever is greater.
Maximum Covered Expenses per Covered Person accumulating toward the Maximum Aggregate
Benefit:$200,000
Monthly Aggregate Factors:
• Choice Plus Plan-$1,159.13 per subscriber
• Nexus Plan-$1,141.52 per subscriber
Aggregate Excess Loss Premium:$3.86 per subscriber per month
The premium amount reflected above includes the following:
• Aggregate Accommodation Endorsement
It is understood and agreed by the undersigned that:
a. The statements, declarations and representations made in this Application, any request for proposal,
the underwriting information provided by or on behalf of the undersigned and the Plan Document are
the undersigned's representations; that any Policy is issued in reliance upon the truth of such
statements, declarations, and representations; and that such statements, declarations, and
representations will form a part of the Excess Loss Insurance Policy. Any inaccuracy in such
information or failure to disclose any such information, including all claims or possible claims, paid
or pending, or which the Employer should otherwise know about, if discovered later, can result in
rejection of this Application,or can change the terms,conditions or premiums,or can void coverage.
b. As a condition precedent to the approval of this Application, the undersigned shall furnish to the
Company a copy of the executed Plan Document within 90 days after the date of this application
describing the benefits provided by the Plan,which shall be kept on file in the office of the Company.
If the Company does not receive the Plan Document within 90 days, the Company may refund all
premium and the Application shall have been null and void when signed. No Excess Loss Insurance
will be effective nor reimbursement made unless a Plan Document is received and accepted by the
Company.
C. The Company will evaluate the undersigned's risk, as requested by this application,the underwriting
data received and represented by the Plan and may require adjustments of rates,factors,and/or special
limitations.
d. Any coverage resulting from this Application shall be subject to the terms and provisions of the
Policy herein applied for.Coverage shall become effective on the date specified in this Application if
all requirements of the Company, including the Plan Document and the underwriting requirements
have been met and the required premiums paid.
e. The receipt by the Company of the first month's premium and deposit of any check drawn in
connection with this Application shall not constitute an acceptance of liability. In the event the
Company does not approve this application, its sole obligation shall be to refund such sum to the
undersigned.
The undersigned has read the entire Application for Excess Loss Insurance and understands that the
insurance requested herein is not in effect until this Application is approved and accepted by the
Company.
Full Legal Name of Applicant:
City of Round Rock
Signature of t
rized Person:
Print Name: V Title:
Craig Morgan Mayor
Date:
12/16/2021
Signature of Agent or Broker:
Printed Name of Agent or Broker: License No.
FRAUD WARNING NOTICES: (Please review notice that applies in your state)
For applicants in Arkansas and Louisiana:
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for insurance,is guilty of a crime and may be
subject to fines and confinement in prison.
For applicants in Colorado:
It is unlawful to knowingly provide false, incomplete or misleading facts or information to an
insurance company for the purpose of defrauding or attempting to defraud the company. Penalties
may include imprisonment,fines,denial of insurance,and civil damages. Any insurance company or
agent of an insurance company who knowingly provides false, incomplete, or misleading facts or
information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the
policyholder or claimant with regard to a settlement or award payable from insurance proceeds,
shall be reported to the Colorado division of insurance within the Department of Regulatory
Agencies.
For applicants in District of Columbia:
WARNING: It is a crime to provide false or misleading information to an insurer for purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In
addition, an insurer may deny insurance benefits if false information materially related to a claim
was provided by the application.
For applicants in Florida:
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a
statement of claim or an application containing any false, incomplete, or misleading information is
guilty of a felony of the third degree.
For applicants in Kentucky,New Mexico,Ohio,and Pennsylvania:
Any person who knowingly and with intent to defraud any insurance company or other person riles
an application for insurance or statement of claim containing any materially false information or
conceals for the purpose of misleading, information concerning any fact material thereto commits a
fraudulent insurance act,which is a crime and subjects such person to criminal and civil penalties.
For applicants in Maine,Tennessee and Virginia:
It is a crime to knowingly provide false, incomplete, or misleading information to an insurance
company for the purpose of defrauding the company. Penalties may include imprisonment,fines,or a
denial of insurance benefits.
For applicants in New Jersey:
Any person who includes any false or misleading information on an application for an insurance
policy is subject to criminal and civil penalties.
For applicants in all other states:
If is a crime to knowingly provided false, incomplete, or misleading information to an insurance
company for the purpose of defrauding the company. Penalties may include imprisonment,fines,or a
denial of insurance benefits.
United Healthcare Insurance Company
STOP LOSS POLICY
FOR
City of Round Rock
Policy Number: GA-925175AL
Effective Date: January 1, 2022
State or other Jurisdiction of Issue: Texas
UNITEDHEALTHCARE INSURANCE COMPANY
A Stock Company
185 Asylum Street,Hartford,Connecticut
Phone: 1-877-294-1429
UnitedHealthcare Insurance Company("Company")agrees to reimburse the Policyholder as outlined under
the provisions of this Excess Loss Insurance Policy("Policy").
This Policy is legally binding between the Policyholder and UnitedHealthcare Insurance Company. The
consideration for this Policy includes, but is not limited to,the Application and the Payment of premiums
as provided hereinafter.
The Policyholder is entitled to the reimbursement described in this Policy if the Policyholder is eligible for
insurance under the provisions of this Policy. Reimbursement is subject to the terms and conditions of this
Policy.
The first premium is due on the first(1st)day of the Policy Period. Subsequent monthly premiums are due
on the first (1st) day of each month thereafter. The premium is not considered Paid until the Company
receives the premium payment.
All periods of coverage will begin and end 12:01 a.m. local time at the principal office of the Policyholder.
This Policy is delivered in and is governed by the laws of the state of issue.
IN WITNESS WHEREOF UnitedHealthcare Insurance Company has caused this Policy to be executed
by its President and Secretary.
4� 4 J.*A
William J Golden,President Timothy J.Burch, Secretary
EXCESS LOSS INSURANCE POLICY
UHIELIP-TX(07/06)
Have a complaint or need help?
If you have a problem with a claim or your premium, call your insurance company or
HMO first. If you can't work out the issue, the Texas Department of Insurance may be
able to help.
Even if you file a complaint with the Texas Department of Insurance, you should also file
a complaint or appeal through your insurance company or HMO. If you don't, you may
lose your right to appeal.
UnitedHealthcare Insurance Company
To get information or file a complaint with your insurance company or HMO:
Call: Customer Services at 1-800-454-0233
Toll-free: 1-800-454-0233
Email address:
nasc_oldsmar_admin@uhc.com
Mail: UnitedHealthcare Insurance Company
PO Box 30569
Salt Lake City, UT 84130-0569
The Texas Department of Insurance
To get help with an insurance question or file a complaint with the state:
Call with a question: 1-800-252-3439
File a complaint: www.tdi.texas.gov
Email: ConsumerProtection@tdi.texas.gov
Mail: MC 111-1A, P.O. Box 149091,Austin, TX 78714-9091
Stop Loss TX Notice(01/21)
-Tiene una queja o necesita ayuda?
Si tiene un problema con una reclamaci6n o con su prima de seguro, Ilame primero a su
compania de seguros o HMO. Si no puede resolver el problema, es posible que el
Departamento de Seguros de Texas (Texas Department of Insurance, por su nombre en
ingles) pueda ayudar.
Aun si usted presenta una queja ante el Departamento de Seguros de Texas, tambien
debe presentar una queja a trav6s del proceso de quejas o de apelaciones de su
compania de seguros o HMO. Si no to hace, podria perder su derecho para apelar.
UnitedHealthcare Insurance Company
Para obtener informaci6n o para presentar una queja ante su compania de seguros o
HMO:
Telefono gratuito: 1-800-454-0233
Correoelectr6nico: nasc_oldsmar_admin@uhc.com
Direcci6n postal:
United Healthcare Insurance Company
PO Box 30569
Salt Lake City, UT 84130-0569
Ell Departamento de Seguros de Texas
Para obtener ayuda con una pregunta relacionada con los seguros o para 2resenter una
queja ante el estado:
Llame con sus preguntas al: 1-800-252-3439
Presente una queja en: www.tdi.texas.gov
Correo electr6nico: ConsumerProtection@tdi.texas.gov
Direcci6n postal: MC 111-1A, P.O. Box 149091,l ustin, TX 78714-9091
Stop Loss TX Notice(01/21)
UnitedHealthcare Insurance Company
A Stock Company
185 Asylum Street,Hartford,Connecticut
Phone: 1-877-294-1429
SCHEDULE OF BENEFITS
This Schedule of Benefits is only applicable to Excess Loss Insurance provided by the Company during the
Policy Period shown below.
Policyholder: City of Round Rock
Policy Number: GA-925175AL
Effective Date: January 1,2022
Administrator: United HealthCare Services,Inc.
Coverage specified herein is applicable only during the Policy Period from January 1, 2022 through
December 31,2022,and is further subject to all terms and conditions of this Policy.
SPECIFIC EXCESS LOSS INSURANCE
Benefit Period: Covered Expenses Incurred from January 1, 2021 through December 31, 2022 and Paid
from January 1,2022 through December 31,2022.
Specific Deductible per Covered Person:$200,000
Specific Percentage Reimbursable: 100%
Maximum Specific Benefit per Covered Person:Unlimited
Specific Excess Loss Insurance includes:
• Medical
• Stand Alone Prescription Drug Program
Specific Excess Loss Premium:$126.97 per subscriber per month
AGGREGATE EXCESS LOSS INSURANCE
Benefit Period: Covered Expenses Incurred from January 1, 2021 through December 31, 2022 and Paid
from January 1,2022 through December 31,2022.
Aggregate Excess Loss Insurance includes:
• Medical
• Stand Alone Prescription Drug Program
Aggregate Percentage Reimbursable: 100%
Maximum Aggregate Benefit:$1,000,000 per Policy Year
Minimum Annual Aggregate Deductible: $11,837,957 or 95%of the first Monthly Aggregate Deductible
amount times 12,whichever is greater
Stop Loss TX Notice(01/21) 1 SCHED
Maximum Covered Expenses per Covered Person accumulating toward the Maximum Aggregate Benefit:
$200,000
Monthly Aggregate Factors:
• Choice Plus Plan-$1,159.13 per subscriber
• Nexus Plan-$1,141.52 per subscriber
Aggregate Excess Loss Premium:$3.86 per subscriber per month
The premium amount reflected above includes the following:
• Aggregate Accommodation Endorsement
Stop Loss TX Notice(01/21) 2 SCIIED
DEFINITIONS
ADMINISTRATOR means a firm or person who has been retained by the Policyholder to provide
administrative services on behalf of the Policyholder/Plan.
ANNUAL AGGREGATE DEDUCTIBLE for any one Policy Period means the greater of:(a)sum of the
Monthly Aggregate Deductibles;or(b)the Minimum Annual Aggregate Deductible.
BENEFIT PERIOD means the period of time specified in the Schedule of Benefits in which a Covered
Expense must be Incurred by the Covered Person and Paid by the Plan to be eligible for reimbursement
under this Policy. This period does not alter the Effective Date, Policy Period, or waive this Policy's
eligibility requirements.
COVERED EXPENSE means medical or other expenses under the Plan to which this Policy applies, as
shown in the Schedule of Benefits, and which are not specifically excluded by the terms of this Policy.
Covered Expense does not include any payment for the cost of administrating the Plan or other
Policyholder contracted services.
COVERED PERSON(S)means each person covered under the Plan.
COVERED UNITS(S)means the types of Covered Units and the factors and premium rates for each type
as shown in the Schedule of Benefits.
EFFECTIVE DATE is the date set forth in the applicable Schedule of Benefits.
INCURRED means with respect to medical services or supplies, the date on which the services are
rendered or supplies are purchased by the Covered Person.
MONTHLY AGGREGATE DEDUCTIBLE means,with respect to a particular month,the total number
of Covered Units for that given Policy month multiplied by the corresponding Monthly Aggregate Factors
as specified in the Schedule of Benefits.
PAY, PAID, PAYMENT means under the Specific Excess Loss, on the date the Policyholder's check of
Payment of a Plan benefit is issued by the Administrator or when a credit of funds for Payment of a Plan
benefit has been debited by the Policyholder's bank account. Under the Aggregate Excess Loss,on the date
the Policyholder's check for Payment of a Plan benefit has been presented through the collecting bank and
reported to the Administrator or when a credit of funds for Payment of a Plan benefit has been debited by
the Policyholder's bank account.
PLAN means the self-funded health care plan established by the plan sponsor to provide certain benefits to
Covered Persons.
PLAN DOCUMENT means the written document approved by the Policyholder. A copy of the Plan
Document in effect on the Effective Date is attached to the application for Excess Loss Insurance.
POLICY PERIOD means the specified period in the Schedule of Benefits,however beginning no earlier
than the Effective Date of this Policy and continuing until coverage terminates in accordance with the
Termination Provisions.
SPECIFIC DEDUCTIBLE is set forth in the Schedule of Benefits. The Specific Deductible will apply
separately to each Benefit Period.
Stop Loss TX Notice(01/21) 3 DEF
REIMBURSEMENT PROVISIONS
NOTICE OF COVERED EXPENSE The Policyholder authorizes the Administrator to file claims on its
behalf under this Policy. The Policyholder authorizes the Company to reimburse Covered Expenses to the
Administrator for deposit into the bank account maintained by the Policyholder for the funding of benefits
under the Plan.
PAYMENT BY PLAN While the determination of benefits under the Plan is the sole responsibility of the
Policyholder,the Company reserves the right to interpret the terms and conditions of the Plan Document as
it applies to this Policy. The Company will have the sole authority to reimburse or deny reimbursement
under this Policy.
SPECIFIC EXCESS LOSS INSURANCE
The Schedule of Benefits indicates whether Specific Excess Loss Insurance is provided under this Policy.
If, while this Policy is in effect, the Covered Expenses for a Covered Person for the applicable Benefit
Period exceed the Specific Deductible,the Company will reimburse the Policyholder, subject to the terms
and conditions of this Policy including the limits set forth in the Schedule of Benefits.
The amount of the reimbursement will be equal to the Specific Percentage Reimbursable times the amount
by which Covered Expenses exceed the Specific Deductible amount, but will not exceed the Maximum
Specific Benefit.For purposes of determining whether such Maximum Specific Benefit has been exceeded,
Covered Expenses Incurred or Paid in any other Policy Period under this policy are included.
Covered Expenses for any Covered Person during the Policy Period will be determined according to the
Benefit Period described in the Schedule of Benefits.
If Specific Excess Loss Insurance terminates before the end of the Policy Period,the Specific Deductible
will not be reduced.
AGGREGATE EXCESS LOSS INSURANCE
The Schedule of Benefits indicates whether Aggregate Excess Loss Insurance is provided under this Policy.
If the Covered Expenses for the applicable Benefit Period exceed the Annual Aggregate Deductible for the
Policy Period, the Company will reimburse the Policyholder, subject to the terms and conditions of this
Policy including the limits set forth in the Schedule of Benefits.
The amount of the reimbursement will be equal to the Aggregate Percentage Reimbursable times the
amount by which Covered Expenses exceed the Annual Aggregate Deductible amount,but will not exceed
the Maximum Aggregate Benefit.
Covered Expenses will not include any amounts reimbursed by the Company under any other provision of
this Policy. If the Policyholder's coverage terminates before the end of the Policy Period, the greater of the
Accumulated Annual Aggregate Deductible or the Minimum Annual Aggregate Deductible will apply.The
Minimum Aggregate Deductible will not be reduced.
Stop Loss TX Notice(01/21) 4 REIM
PREMIUMS AND FACTORS PROVISIONS
PAYMENT OF PREMIUMS For coverage to remain in effect,any subsequent monthly premium must be
received by the Company by the first(1st)day of each month.Premiums are not considered Paid until the
Company receives the premium payment. Premiums or other payments made by the Policyholder to their
Administrator or Agent or Broker shall not be deemed or considered payments to the Company until
actually received by the Company. The entire amount of the applicable premium shall be paid when due.
The Company is not obligated to accept or apply any premium paid which is less than the entire amount
due for any period. Premium payments shall be credited first to any past due and unpaid premium, in the
order in which due.
A late payment charge may be assessed for any premiums not received within thirty-one(31)calendar days
following the due date. A service charge will be assessed for any non-sufficient-fund check received in
payment of premiums.The Policyholder will reimburse the Company for any attorney's fees and any other
costs related to collecting delinquent premiums.
GRACE PERIOD A Grace Period of thirty-one (31) days from the due date will be allowed for the
payment of each premium after the first. During the Grace Period, the coverage will remain in effect
provided the full premium is Paid before the end of the Grace Period.Should a premium otherwise due,not
be Paid during the Grace Period,this Policy will terminate without further notice as of midnight on the last
day for which premiums were Paid.
PREMIUM AMOUNT The premiums will be calculated using rates determined by the Company as set
forth in the Schedule of Benefits. The amount of total premium due each month is the sum obtained by
multiplying the applicable premium rates shown in the Schedule of Benefits by the actual number of
appropriate Covered Units.
The Policyholder will be liable for any premium taxes assessed at any time against the Company beyond
any taxes which may be payable on the premium received by the Company.
All requests for adjustments, credits or refunds because of overpayment of premiums shall be reported, in
writing,with accompanying detail within sixty(60)days after termination of the applicable Policy Period.
The Company will not refund any portion of the premiums Paid if this Policy terminates during this Policy
Period.The Company shall be entitled to reduce the reimbursements due the Policyholder under this Policy
against any premiums due and unpaid, any overpayments or other reimbursements made in error or upon
incorrect information,and any other amounts due the Company.
PREMIUM RATE AND MONTHLY AGGREGATE FACTOR CHANGE The Company may change
the Policyholder's premium rates or factors for any of the following:
a) the date when the terms of this Policy are changed;
b) the date the Plan Document changes are accepted by the Company;
c) the date the Policyholder adds or deletes subsidiary or affiliated companies or divisions;
d) the date the number of Covered Units on any premium due date varies more than ten percent (10%)
from the number of Covered Units as of the first month of the Policy Period.
Stop Loss TX Notice(01/21) 5 PREFAC
TERMINATION PROVISIONS
This Policy and coverage provided hereunder will terminate upon the earliest of:
a) the premium due date of any premium which remains unpaid at the end of the Grace Period;
b) the premium due date next following receipt by the Company of written notice from the Policyholder
that this Policy is to be terminated;
c) the date of termination of the Plan;
d) the date the Policyholder suspends active business operations or dissolves;
e) the end of the Policy Period;or
f) the date the administrative services agreement with the Administrator is terminated.
This Policy may also be terminated,at the Company's option on the earliest of:
a) the last day of the second(2nd)consecutive month during which there are less than twenty-five(25)
employees enrolled in the Plan,unless the Company agrees,in writing,to continue coverage;or
b) the date the Policyholder fails to comply with the terms of this Policy;or
c) on the Policy anniversary date by the Company giving sixty(60)days advance written notice that this
Policy will end,or such other notice as required by law.
The Company will not refund any portion of the premiums paid if this Policy is terminated during the
Policy Period.
SUBSEQUENT POLICY PERIOD PROVISIONS
At the end of a Policy Period,this Policy may have a Subsequent Policy Period only by mutual agreement
of the Policyholder and the Company and provided that the Company has not given a thirty (30) day
termination notice or such other termination notice as required by law.The Subsequent Policy Period may
be subject to new premium rates,factors,new underwriting terms,new Benefit Period and other new Policy
terns. The terns and conditions for a subsequent Policy Period will be evidenced by the issuance of a new
Schedule of Benefits by the Company, which shows the new premium rates, Benefit Period and other new
terms.
Stop Loss TX Notice(01/21) 6 TERM
GENERAL PROVISIONS
ADMINISTRATOR The Policyholder may retain an Administrator to act as an agent for the Policyholder
in performing any or all of the duties as designated by the Policyholder. Without waiving any of its rights
under this Policy, and without making the designated Administrator a party to this Policy, the Company
agrees to recognize the Administrator as an agent of the Policyholder. The Policyholder will immediately
notify the Company in writing if the agreement between the Policyholder and the Administrator terminates.
ASSIGNMENT The Policyholder may not assign the Policyholder's interest in or reimbursement under
this Policy,and the Company will not recognize any such assignment.
AUDITS The Company will have the right: (a) to inspect and audit all records and procedures of the
Policyholder and Administrator, developed and maintained for the Plan, that are applicable to the
administration of this Policy; and (b) to require, upon request, proof satisfactory to the Company that
Payment has been made to the Covered Person or the provider of such services or benefits which are the
basis for any Loss by the Policyholder hereunder.
CHANGES TO THE PLAN DOCUMENT If the Plan Document in effect on the Effective Date is
subsequently amended,notice of the amendment will be given to the Company prior to the effective date of
the change. If the Company does not give written acceptance of the amendment, the Company will only
provide coverage under this Policy consistent with the Plan Document prior to amendment.The Company's
reimbursement will be made according to the amended Plan,once the notice is received and accepted.
CHANGES TO THE POLICY Only the President, a Vice President, or the Secretary of the Company
have the authority to alter this Policy,or to waive any of the Company's rights and then only in writing.No
such alteration of this Policy shall be valid unless endorsed and attached to this Policy.No agent,broker,or
Administrator has the authority to alter this Policy or to waive any of its provisions.
CLERICAL ERROR Clerical errors, whether by the Policyholder or by the Company, in keeping or
transmitting any records pertaining to the coverage, will not invalidate or limit coverage otherwise validly
in force nor continue coverage otherwise validly terminated. Clerical error does not include any failure of
the Policyholder,the Administrator or any agent of the Policyholder: (a)to comply with the requirements
relating to notice of claims or payment of claims; or(b)to disclose underwriting information requested by
the Company,whether or not intentional and regardless of the actual knowledge of the person providing the
information.
CONFORMITY WITH LAW If any provision of this Policy is contrary to any law to which it is subject,
such provision is hereby amended to conform to the minimum requirements of such law.
ENTIRE CONTRACT The Entire Contract between the Company and the Policyholder will consist of
this Policy, Schedule of Benefits, application, approved amendments or endorsements, and a copy of the
Plan Document,which is on file with the Company.
INSOLVENCY Nothing in this Policy shall either relieve an insolvent or bankrupt Policyholder from the
obligation to pay premiums when due or delay or abate cancellation of this Policy for failure to do so.The
insolvency, bankruptcy, financial impairment, receivership, voluntary plan of arrangement with creditors,
or dissolution of the Policyholder or the Policyholder's Administrator will not impose upon the Company
any liability other than the liability defined in this Policy. In particular,the insolvency of the Policyholder
will not make the Company liable to the creditors of the Policyholder,including Covered Persons under the
Plan.
LEGAL ACTION The Policyholder cannot file suit until ninety(90)days after the date on which proof of
loss is given to the Company.The Policyholder cannot file suit more than three(3)years after the date on
which the Policyholder must give the Company proof of Loss.
LIABILITY The Company will have neither the right nor the obligation under this Policy to directly pay
any Covered Person or provider of professional or medical services. The Company's sole liability is to the
Policyholder,subject to the terms and conditions of this Policy.Nothing in this Policy shall be construed to
Stop Loss TX Notice(01/21) 7 GEN
permit a Covered Person to have a direct right of action against the Company. The Company will not be
considered a party to the Plan of the Policyholder,or to any supplement or amendment to it.
MISSTATED DATA,CONCEALMENT,FRAUD The Company has relied on the information provided
by the Policyholder,the Administrator or any agent of the Policyholder, in the issuance of this Policy, or
for any Subsequent Policy Period. In the event of a misrepresentation,concealment or omission of a fact,or
a mistake of fact (whether or not a mutual mistake), any of which materially affect the underwriting,
premium,rating or terms and conditions of this Policy,the Company may,at its option:
(a) increase premium rates, attachment points and/or otherwise change the terms and conditions of this
Policy. Such increase or change to be effective retroactively to the Effective Date or as of any
premium due date thereafter,or
(b) terminate this Policy as of the next premium due date.
The Company may declare this Policy null and void in its inception if,whether before or after a claim,the
Policyholder,Administrator or any agent of the Policyholder has willfully or intentionally misrepresented,
concealed, omitted any material fact affecting terms, conditions, or underwriting of this Policy. In such
event, the Company's liability under this Policy shall be limited to refunding premiums paid by the
Policyholder after deducting therefrom the amount of any Covered Expenses reimbursed by the Company
to the Policyholder prior to the date of termination. If the amount of the Covered Expenses reimbursed by
the Company to the Policyholder exceeds the premiums paid by the Policyholder, the Policyholder shall
pay the Company the difference within thirty (30)days of the date the Company notifies the Policyholder
of such difference.
NOTICE OF COMPLAINT, APPEAL, LEGAL ACTION As a condition precedent to the Company
reimbursing the Policyholder in any settlement or judgment for a disputed Covered Expense, the
Policyholder shall immediately inform the Company of any notice of appeal, notice of legal action, or
objection,demand or complaint which the Policyholder received regarding any Covered Expense that may
be reimburse under this Policy.
OTHER COVERAGE The reimbursement provided by this Policy is in excess of other coverage such as
group insurance,excess insurance,insurance,plan benefits,including insurance or plan benefits established
by any federal,state,or local law.
PARTIES TO THE POLICY The parties to this Policy are the Policyholder and the Company. The
Company's sole liability under this Policy is to the Policyholder. This Policy does not create any right or
legal relation between the Company and a Covered Person under the Plan.This Policy will not be deemed
to make the Company a party to any agreement between the Policyholder and the Administrator.
POLICYHOLDER REQUIREMENTS The Policyholder agrees to provide funds for Payment of all
eligible expenses under the Plan.If the Policyholder fails to provide funds for timely Payment:(a)coverage
under this Policy will immediately terminate; and (b) any Aggregate and/or Specific Deductible will be
deemed not satisfied.
RECORDS The Policyholder will maintain records of all Covered Persons under the Plan during the
Policy Period and for a period of seven(7)years after the end of the Policy Period.The Policyholder will
make all such records available to the Company as needed to evaluate its liability under this Policy.
The Policyholder will maintain a separate record of any and all amounts Paid in excess of benefits eligible
under the Plan.
SEVERABILITY CLAUSE Any clause deemed void,invalid,or otherwise unenforceable,whether or not
such a provision is contrary to public policy,will not render any of the remaining provisions of this Policy
invalid.
TERMINATION OF THE POLICYHOLDER'S PLAN The Policyholder will immediately notify the
Company,if the Plan is terminated.
Stop Loss TX Notice(01/21) 8 GEN
THIRD PARTY RECOVERY The Policyholder shall cause the Plan to undertake to pursue any and all
valid claims the Plan or a Covered Person may have against third parties arising out of any occurrence
resulting in a payment by the Plan or reimbursement by the Company. The Policyholder will account for
and pay to the Company any amounts recovered which are reimbursable by the Company to the
Policyholder under this Policy, regardless of whether this Policy is still in force on the date of recovery.
Third party shall mean a person, entity or insurance company other than the Plan, the Policyholder or a
Covered Person. An insurance company shall include insurance companies providing third party liability
coverage,or other insurance coverage;i.e.no fault,uninsured,under insured or other similar coverage.
The Policyholder or Administrator shall notify the Company immediately upon discovering that a claim
against a third party may exist. Should the Policyholder or the Administrator fail to pursue any valid claims
against a third party,the Policyholder shall cause the Plan to assign its subrogation and third party recovery
rights to the Company so as to allow the Company to pursue third party recoveries for Covered Expenses
reimbursable to the Policyholder. In the event of such assignment,the Company shall have to exercise and
enforce all of the Policyholders and/or Plan's rights against such third party.The Policyholder shall furnish
such information,assistance,cooperation and execute and deliver such instruments,all as are necessary for
the Company to pursue third party recoveries pursuant to this provision.
The Company's right to third party recoveries,as provided for in this provision,shall constitute and impose
a trust and first-priority lien arising from any cause of action, settlement,judgment or arbitration award
against a third party.
The Policyholder shall pay the Company all amounts recovered, whether by suit, settlement, alternative
dispute resolution, including but not limited to arbitration or mediation,or otherwise, from any third party
or their insurer to the extent of Covered Expenses regardless of whether such recovery shall be a full or
partial recovery.If a third party recovery received by the Plan or Policyholder is less than the total amount
paid by the Plan on behalf of the Covered Person,the Company shall be entitled to recover first,in full,any
Covered Expense reimbursed by the Company under this Policy. The Company's recovery shall not be
reduced by any attorney's fees incurred by the Policyholder, Plan or Covered Person unless the Company
otherwise agrees in writing.All remaining amounts shall be paid to the Policyholder.
The Policyholder's failure to comply with this provision may result in the denial of a Covered Expense, in
addition to all other rights of the Company under this Policy.
WAIVER Failure of the Company to strictly enforce its rights under this Policy shall not waive any such
right,regardless of the frequency or similarity of the circumstances.
Stop Loss TX Notice(01/21) 9 GEN
GENERAL EXCLUSIONS PROVISIONS
The Company will not reimburse the Policyholder for any of the following:
(a) Any payment which does not strictly comply with the terms and conditions of the Plan Document;
(b) Any payment or expense caused by or resulting from war, declared or undeclared or international
armed conflict;
(c) Any payment for litigation costs and expenses, extra-contractual damages, compensatory damages,
interest, exemplary and punitive damages or liabilities, including but not limited to those resulting
from negligence,intentional wrongs,fraud,bad faith or strict liability on the part of the Policyholder,
Plan,Administrator or any agent or representative of the Policyholder,Plan or Administrator;
(d) Any payment for occupational accidents or illnesses which are also eligible expenses covered by
Workers'Compensation or Occupational Disease law,or similar legislation,whether or not coverage
under such law is actually in force.
Stop Loss TX Notice(01/21) 10 EXCL
AGGREGATE ACCOMMODATION ENDORSEMENT
Policyholder: City of Round Rock
Effective Date: January 1,2022
In consideration for the premium shown in the Schedule of Benefits, the Company will provide advance
Aggregate Excess Loss Insurance subject to the special terms and conditions of this provision. This
Endorsement will continue in full force and effect for the duration of that Policy Period and each
subsequent Policy Period.
Covered Expenses will be determined on the same basis as under the Aggregate Excess Loss Insurance;
however, if such Covered Expenses exceed the Aggregate Accumulated Accommodation Point, the
Company will provide an advance to the Policyholder equal to the amount by which Covered Expenses
exceed the Aggregate Accumulated Accommodation Point, less the amount of any prior advances not
repaid.
Aggregate Accumulated Accommodation Point for any one Policy Period means:
• the sum of the Monthly Aggregate Deductibles to date, calculated by multiplying the Monthly
Aggregate Factors as set forth in the Schedule of Excess Loss times the monthly Covered Units
TERMS AND CONDITIONS Any advance provided under this provision will at all times be considered
funds of the Company. Except as set forth in this provision, all terms, conditions, and provisions of the
Policyholder's Excess Loss Insurance will apply.
The advance includes an obligation of repayment by the Policyholder to the Company under the terms and
conditions as provided in the Repayment Provision.
No advance will be paid during any month until all premium due for the month has been received by the
Company.
In the event the Policyholder's coverage terminates before the end of the Policy Period, the Policyholder
will immediately repay to the Company any advance outstanding on the date the Policyholder's Excess
Loss Insurance Policy terminates.
REPAYMENT PROVISION If the Policyholder's Covered Expenses under the Aggregate Excess Loss
Insurance are less than the Aggregate Accumulated Accommodation Point,the Policyholder must promptly
make repayment to the Company equal to the amount that the Aggregate Accumulated Accommodation
Point exceeds the Policyholder's Covered Expenses under the Aggregate Excess Loss Insurance.
After an advance is made, and until it is fully repaid, the Policyholder's repayment will be considered
outstanding in any month during which the Policyholder's Covered Expenses under the Aggregate Excess
Loss Insurance are less than Aggregate Accumulated Accommodation Point.
The Company will have preference over all other claimants for the return of any advance made under this
provision. Further,the Policyholder will be liable for all costs and expenses(including reasonable attorney
fees) incurred in the collection of any advance outstanding. If the Policyholder fails to make repayment
when due,the Company,at its option,may;
a) deduct the outstanding advance due from any reimbursement due from the Policyholder's Specific or
Aggregate Excess Loss Insurance;or
b) terminate this provision,or at the Company's option,terminate the Excess Loss Insurance Policy.
AGAC(07/06) 1
At the end of the Policy Period,the Policyholder's repayment obligation to the Company will equal the sum
of all advances made during the Policy Period less the amount due under the Policyholder's Aggregate
Excess Loss Insurance. A final repayment of any balance due must be made within thirty (30)days of the
end of the Policy Period.
All other provisions of the Excess Loss Insurance Policy remain unaffected by this Endorsement.
William J Golden,President Timothy J.Burch, Secretary
AGAC(07/06) 2
UHIAPP(12/01)