CM-05-01-002CnA-05-o,'--ooz.
Request for City Council/City Manager Action
Please submit this form when placing items on the council agenda or when submitting an item to the City Manager for approval.
Department: Human Resources Project Manager/Resource: Linda Gunther
Contact Person: Teresa Bledsoe
Council Meeting Date: City Manager Approval
Project Name: Stop -loss Reinsurance Funding Source:
ContractorNendor Name: AIG Life Insurance Company Assigned Attorney:
Amount: None
Is Funding Required?
Council Agenda Item
Submission to City Manager -
Yes El No
Yes 0 No ❑
Yes ElNoE
N/A
J. Kay Gayle
(contract, agreement,amendment,change order, purchase\order,etc.)
t ll
0.LVC/
6) r
CC -
(see required signatures below before submission to the City Manager)
Agenda Wording:
❑ Initial Construction Contract
❑ Construction Contract Amendment
❑ Change Order
Change in Quantity
nUnforeseen Circumstances
❑ Initial Professional Services Agreement
❑ Supplemental Professional Svcs. Agr. #
❑ Purchasing/Service Agreement
❑ Purchase Order
Item(s) to be purchased:
121
Amount
Other (Please clearly identify action on lines below)
i
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Renewing the City's existing excess loss indemnity policy (stop loss reinsurance.
For Submission to Cit Ma
Project Mgr. Signature:
Dept. Director Signature:
City Attorney Signature:
City Manager Signature:
Finance Approval
r only
Er
- Date:
Date:
Date:
Date:
al Approval is required for all items requesting City Manager's approval.
Finance -Date and Signature:
Purchasing -Date and Signature:
Budget -Date and Signature:
'I(1/41I0�
g/administration/cmgr-council action.xls 11-1-04
BLUE SHEET FORMAT
DATE:
SUBJECT: City Manager Approval
ITEM: Renewing the City's existing excess loss indemnity policy (stop loss
Reinsurance).
Department: Human Resources
Staff Person: Teresa Bledsoe, Human Resources Director
Justification: The stop loss reinsurance provides coverage for the City's health
benefit plan claim payments, which exceed limits the City has chosen
to self -insure. A change from the previous year's specific stop loss
coverage, which was $50,000, will be increased to $75,000. Staff
recommends renewal of the contract with AIG Life Insurance Company
to provide stop loss coverage for plan year 12-01-04 through 11-30-
05.
Funding:
Cost: The cost of this insurance is a function of the number of employees and
dependent units covered.
Source of funds: City contribution and employee paid premiums for dependent health
care.
Outside Resources: AIG Life Insurance Company
Background Information: This coverage protects the City's self-funded plan from
catastrophic financial losses.
Public Comment: N/A
Blue Sheet Format
Updated 01/20/04
The Excess Loss Disclosure Statement is to be completed by the Applicant and will be attached to and become a part of this
Application.
INSURANCE FRAUD WARNING
Any person who with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a
clan containing a false or deceptive statement, or conceals infonnation for the purpose of misleading, may be found guilty of
insurance fraud and may be subject to criminal and/or civil penalties.
The Applicant hereby applies for Stop Loss, Life, and/or other Insurance coverage and:
1. Represents that the answers included in this application, the attached questionnaires and the Excess Loss Disclosure Statement
have been reviewed and are true and complete to the best of the Applicant's knowledge and belief,
2. Understands and agrees that insurance applied for shall not become effective until the application for insurance is approved by the
Company.
3. Agrees that if the insurance applied for is approved by the Company, the Applicant will pay all premium due after the effective
date of insurance, including any premium which may aceumutatP between the effective date of the insurance and the date the
Policy is issued.
This Application, as it may be amended, will become part of the Policy, if issued.
Signed at: (Time of Signature)
This day of: (Day and Month of Signature)
Year:(Year of Signature)
ed by:
Title
RE :
FOR
Approved: 0 Yes
■
HOME OFFICE USE ONLY
No
Reviewed/Approved By:
Approved Date
M20006 -TX 4 of 4
Premium payment is due on th
payment is not received with 31
Group Name:
Division:
Reporting Month:
day of each month. As stated in the Policy, coverage automatically terminates if th the
ays of the due date.
Stop Loss Premium Statement
City of Round Rock
Type of
Coverage
Specific - Single
Specific- Family
Aggregate - Single
Aggregate- Family
Current Month'
Census X
Rate
Per Person
40.57
Policy Number:
Policy Year:
114.05
4.10
4.10
Totals:
Prior Adjustments (from below)
Payment Amount:
December 1, 2004
;ross Premiun
Due
:ommission 9 Net Premium
Amount Due
Month of
Adjustment
Type of
Coverage Added
Prior Adjustments
Gross
erminate Rate Premium :ommissioi
Amount
Due
Preparer Name:
Phone:
e-mail:
Please mail this completed form, along with your check, made payable to Medical Excess, to:
Mailing Address:
Medical Excess
Dept. 2173
Los Angeles, CA 90084-2173
Overnight Mailing Address:
Medical Excess
1200 West 7th Street, Suite L2-200
Los Angeles, CA 90017
Contact: Dagmar Nunes phone:(530) 477-0775 fax:(530) 477-1752 email: dagmar.nunes@aig.com
AIG
Medical Excess
Atlanta, GA 877-634-7285
Employer Medical Stop Loss Proposal
Employer:
Proposal:
Producer:
Claims Adm:
Carrier:
City of Round Rock
2"55232
Watson Wyatt Insurance Consulting, Inc.
Great West Life & Annuity Insurance Company
AIG Life Insurance Company A.M. BEST A++
Underwriter:
Sales:
Quote Date:
Quote Valid Until:
Effective Date:
Lorri Smith
Nyle Leftwich
January 07,2005
December 06,2004
December 01,2004
This proposal contemplates Me ufkia(ion of the above captioned Claims Administrator Any deviation is a material change of fact rendering this proposal null and void
Census (Exposure)
Specific : Single:
Aggregate: Single:
Specific Excess
Contract Basis
Retention Amount
Individual Maximum Liability
358
358
Family: 299
Family: 299
Total:
Total:
657
657
Commission:
Commission:
"" RX Card is not Included ""
Option 1
24/12
75,000
925,000
SiTQIe Family
$40.57 $114.05
Estimated Annual Premium: $583,500
0%
09
Aggregate Excess
Contract Basis
Reimbursement Percentage
Annual Maximum Liability
MD/RX/DT
24/12
100 %
1,000,000
Single Family
419.38 1068.71
Premium Rate
No Aggregate Accommodation Included
Estimated Annual Attachment:
Estimated Annual Premium:
$4.10
$5,636,188
$32,324
Underwriter Comments
Current plan.
No Coverage of any kind Is made effective by this quote transmitted Saks Representatives, and brokers oragents, have no authority to make effective coverage, or enter into
contracts on behalf or the Company. Coverage «111 be effective only after: (1) a quotation Is issued by the Company,- (2) a completed and signed application and disclosure is
rir oMed by me Company,; (3) Me application Is approved by Me Company; (4) Written notice confirming effective coverage is issued 6y the Company. This proposal supersedes
previously issued to you, and all other Proposals and Rate Quotations previously issued to you are void
Page 1 0(3
992
Medical Excess
AIG