HomeMy WebLinkAboutInsurance/Stop Loss PolicyOG'I'-Z~-ZUU~ WkD UZ:bb HM HkBL'IH URK~ ~Y~'lk~
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6621Southpoiut!
3aoksonvill~
Phone(g04) 2gl-215
To: Aimcc~inn
From: T~a~ N~tten1<ampmr
l~.E.~ City of Oshkosh
Dn£e: J~ne ] 1, 2003
It Js our ple. amar~ to present you with thc AC]
Aggreg.~to aM/ur Spcdfio ~xcess Stop Lass
This documentation pertains to ~hc Stop Los.,
~v¢,Norlh #325
32216
L Fax(904) 281-0384
I American Insurance Company Policy for
PoXeyforCityofOr2~kosE
Ploa¢o haw the authorized r~lxc~cntative s/~ the ac~cptaucc form below and return to:
Norihwind M,C
Arm: Nikki Doughty
1595 Paoli Pike~ Suit~ 10~
Wc~ Chc.~t~, PA 19380
you for your assistance in this matmr,
Con. ct Acc~
(to be eomplae
Group Nmnc;
Policy N~mber:
City of Oshko~i
BSL NO 025630 4
t by the client)
By: Richard A. Nollangk
10/29/03
I hereby cerlify that the necessary provisions
have been made to pay the liability which will
accrue under this contract.
Gitg Gomptrollor
00%29-2003 ~IED 02:55 PH HEflLTH OflRE SYSTENS
---'--,:'-~vI-/o-/ug~ i gJ: u,1;;',1 yl'l
NO, 4147711870
h~,
EXCESS LOss INSURANCE POLICY
Underw 'itten by
ACE American Insurance Company
[Two Lib=dy piece
16ot Chestnut Street
P.O. Box 41484
Phi[eddphla, PA 19101-1484]
This Policy is issued by ACE American Insurance ?ompany (Company)
Policyholder; City of Oshkosh i
Poliu'y Number: ESL NO 035S30 4 ,
Effective Date', 0'110112003
to
The Company agrees to reimburse the Policyholder for certain Plan Benef'~ the Policyholder has
provided under a self-funded benefit plan (Plan). $~ch reimbursement will be subject to all the terms and
conditions o/this Policy,
This Policy Is issued in consideration of: I
('1) the application made,?,y the Pohcyholder; and
(2) the payment of the ind~al premium on ~he Effpctive Date of this Policy;
(3) the payment of all eubsequent premiums when due and
(4) the c~ntinual compliance by the Policyholder with all the terms and conditions of this Policy,
All periods of time under this Poli~ will begin ant
address.
This Policy is governed by the laws of the State of ~
The provislens on the following pages are a part Of ti
~im~eA for ACB American h~surance Company at Pb
end at 12:01 A.M, local time at the Policyholders
Isconsln,
~is Policy.
ledclphia, P~mm'ylvaeia
suSAN RIVERA, President
L tensed Res dent Agent
(if required by law in t~ls state)
25681
P, 03
uq
,00T~-29-2003 ~EI) 02:58 PR HEALTH OARE SYSTEHS FAX NO, 4147711870 P. 04
TABLE OF :ONTENT$
Page
' 3
Schedule o1' Insurance ................................................................................................................................
Definll:ior~s .................................................................... I ...................................................... 4
· 5
Speci'[io Excess LO~ .........................
~regate =xcess Loss ....... - ................................
Term of Policy .............................................................
Premiums and Aggregate Factors ..............................
Claim Provisions ..........................................................
Termination .................................................................
General Provisions ......................................................
00T,,-29-2003 NED 02:55 PH RERL?R CRRE $¥$?EI15 ?R× NO, 4147711870 P, 05
SCHEDULE 01~ INSURANCE
E~ellment al Effc'ctive Date,: Employees ~4 ~ln~le 202 ~mily
Policy Pe~l from 01/~11R~ ~mu~h j
SPECIFIC~C~S LOSS
SPeCIFiC COn.GE: ~Y~ ~ No ~pe~o De~o~ibl~ $ 100.000.~
U~eSme Lll~ of Uabili~ p~r Cove~ P~oon
Cinlm= D~: 1~1~ InDued a~d Paid X ~ Paid
R~filPr~: Elis/bio P~n B~efl~ InDuced ~r~ ~0110tl20~3 ~hm~h 12~112003
end Paid li~ ~01/o1~005
raga ~n0 S~fi= ~do~ S0.00 ' I
~m alln9 S~fi= Coffldo~ The ~t 0~ a~mb~t~bl= amoun~ tin to~l) of Plan
o~mo~ indivldual~ ceV~ed under ~e Plan du~ng ~e Po~ Pe~od. Thi~ amount will hal be reimbursed by
AGGREGATE I ;XCEDS LOSS
AGGREGATE COVERAGEI RYes
Ctnlmu Basis: Incun~d ~d p~d
~eflt Po~d; ~i~ible ~an Bene~t~ Inc~red from
Aggm~.qle Exr;ct~ Retanlion Faclor.
Minh~um AODfega~e Deductlble:$
~JNo
100%
Medical RxCard
$0 SD
0
LimlL, f LImbllily l'or ih e PoliCy Year $ 0
{ e'a$ L m t par parson l!nder A~grega~e $ 0
Losses In~rru~ pMar b lite Pormy P~od wll be mired to $0
O~or
03,~1/g004
Demrdl Vision WDI O~er
$0 $0 ~;0 $0
R~s~d on Inl~al Unll~ ~mes hum~ of mo~9 In Poli~ Pedad ~me~ 0%
~ Mon~ ~gmgsle Pmto~an ~on: ~Yes
PREMIUMS
I C~sua
[MonU'dy Aggn~Jate I~*o'~¢dl~ Option $
SPECIFIC: ~Medical
~Olher
DOther
DMt, nthly Ag~raoam protection
Eml~ yea
PLAN BENEFITS INCLUDED
Agg~oata;
DFree S~ndtng Drag Program
ENDORSEMEI~
DAggmgMeTerr
EXCLUSIONS Al
TS INCLUDED
· al Llabilily
LIMITATIONS
[3$padfio Torminal LiablIRy
~No
25681
.0CT.-29-2003 NED 02:55 PH HEP~LTH C,AI~E SYSTEI~S FP, X NO. 41477118?0 P. 06
DEFINrl
ACTIVELY AT WORK means:
(1) with respect to a Potlcyholder's employee or mar
performing his/her normal Job duties. Persons al
maternity leave will be considered Actively at Work
(2) with respect to a dependent - being able to parfem
same age arid sox and r~ot being confined in a pm~
ONS
tber- the employee/member Is present and capable of
~sent from work due to regularly scheduled vacation or
all the normal activities of a person in good health of the
ider facility because of injury or sickness,
Unless stated otherwise on the SCHEDULE OF INSUPJ',NCE, for persons not Actively at Work on tile Policy's
E~fec[ivo Date, any amount of Plan Benefits Paid by the Policyholder, for such person prior to one of the Deferred
EIfective Dates below will be disregarded for reimburaeme~ls under this Policy.
DEFERRED EFFECTIVE BATES means:
(1) with respect to a Policyholder's employees/mom!ers - the date he or she returns to work as a full-tlme
active employee or member; and
(2) with respect to a dependent - the fifth day follow}ni the date he or she has been discharged from a provider
facility
ANNUAL AGGREGATE DEDUCTIBLE for any one Pe ~yiPerled means the greater of:
(1) The c~lmulativc monthly total of Covered Units multiplied by the Monthly Aggregate Fac?s; or
(2) The Minimum Annual Aggregate DedueiJble.
BENEFIT PERIOD means the period of time in which a cl~
t ~e P an lo be eligible far reimbursement under this Policy
Policy Period, nor does It waive the eligibility reqU foments
POLICY PERIOD mean~ the specked pedod In the ,%h~
Effeclive Dale of this Policy end continuing until coverage
of this Policy.
COVERED PERSON meanS any one Individual entitled to
Im must be incurred by the Covered Person and Paid by
This period does not alter the Policy Effective Date and
~f this Policy.
lule of Insurance, however, beginning no earlier than the
terminates in accordance with the Termination provision
~aneflts under the Pellcyholder's Plan.
COVERED UNIT for the purposes of determining the prer~lums payable or the Annual Aggregate Deductible means
the frJllowlng Covered Person;
(I) Emproyee;
(2) Employee with dependents; or /
(3) Such other de~ined unit as agreed between the Co,~pany and the Policyholder,
PLAN means the Pelicyholder's self. funded benefit pan as described in its plan document. A copy of the plan
dormant is attached to this Po cy for the purpose of detelmining the company's liability under I. his Po[icy.
PLAN BENEFITS moans amounts properly Incurred and I~a[d under the P an to a Covered Person or to a provider
of services tea Covered person.
A Plan Benefit will be considered INCURRED as follows: ....
(1) with respect to services, the date on which the sar Ices ars rendered to the Covered Person; or
(2) with respect to supplies, the date on which the sup )lies are given to the C_~vered Person; er
(3) with respect to disability income benefits, on the late each periodic benefit payment becomes payable to
Ihe Covered Person.
A Plan Benelii will be ~onsidsred PAID on the date that 1 le Pelicyhalder's chad( or draft Is issued, subject to the
following:
(1) there are sufficient funds to cover such check or dl ~l~', alld
(2} the cheek or draft is placed in the United States m~ il or other means Of delivery to the payee; and
It Is paid upon presentation by the payee
Checks or drafts which are prepared but are not released or which de not adhere to the requirements
Immediately above shall not be considered paid, i
00T,-29-2003 ~EI) 02:56 PN HEALTH OP, RE SYSTEI~S FAX NO. 4147711870 P. O?
' '--'- '-'007-28-2003 ?LIE 03:24 PM FA]( NO, ?, o~J
P iR Benefits do not Include the fo owing:
(1 Pay ~ents nol a~ctly in compllanc~ with the terra,and conditions of the Plan; or
I21 Any amount far which there s any other group Ir~uranco, reinsurance, plan benefits Including insurance or
plan banel~ts established pursuant to federal, stat~ or ace eglslallon or regulation; or
(3) Cour~ costs, penalties, interest upon ]udgme ~n~, Inves~gatlon expense, adminis~"atve fees, or legal
expense; or ~
(4) Third Party Administrative fees; ar i
(5) EXemplary and punitive damages or liabilities, Ir~ciudi~l but not limited to those resulting from negligence,
intentional va'ongs, fraud, bad faith or strict lial~ility on the part of the Policyholder or the Policyholdar's
agent.
TH ED PARTY ADMINSTRATOR means a firm or
claims and/or provide other adm nbtratlve services en be
SPECIFIC E
The Company v/iii reimburse the Policyholder for
Deductible on a Covered Person during the Policy Peri
Benefit Period and all other coverage provtslnllS,
INSURANCE. Reimbursemenl~ to the Policyholder for a
sen which has been retained by the Policyholder to pay
~a~f of the Policyholder.
I(cEes LOSS
amount of any Plan I~enafits which exceed the Specific
~d. Such reimbursement will be made in accordance with
at}ons and exclusions as shown In the SCHEDULE OF
9y Specific Excess Loss prc~4ded under this Policy will be
it requires far payment of reimbursements (Proof of Loss),
made when the Company receives all of the Information
n order for Ihe Plan Ber~3fit to be considered for n imbursement under this Policy, Proof of Loss must be
satisfactory to the Company and received by the Comps ~y no later then thirty (30) days after the date Plan Benefits
are Paid In excess er the Specific Dedu~bls. ,
While the determination ~f banetits under the Plah is
reserves the right to I~l[e~pret the terms and conditions o~
sola authority to approve or deny reimbursements under
AGGREGAT~
the sole reapons~i[ity of ~he policyholder, the Company
the Plan as it applies [o this Policy. The Company has the
;his Policy.
EXCESS LOSS
Company will rslmbume the Policyholder for the l amount of any Plan Benefits whP~h exceed the Annual
AThegh~jregate Ded[ crib e during the po cy Period. Such reimbursement w I be made in accordance with ~neflt Period
and all ethel' coverage provisions, limitations and excisions as shown in the SCHEDULE OF INSURANCE. Plan
Benefits on each Covered Person in excess of the Lo~ Limit Per Person under Aggregate will not be {n¢luded for
purposes of deten'nlning the amount of the Aggregala Exbesa Loss reimbursement under this Policy.
Reimbursements to the Policyholder for any Aggregate -'xcess Loss provided under this Policy will be made after
the end of the Policy Period provided:
(11 the Company has received all ~ the information It requires (Proof of Loss); and
(2) the Compar~y has completed any audit it may d{ sm necessary.
In order for the Plan Benefrt to be qonsldered for :imb~rsement under this Policy, Proof of Loss, must be
satisfactory to the Company and received by the Comp ~ny no later than thirty (30) days after the end,of the Policy
Peri~d.
While the determination of benefits under the Plan is~the sole responsibility of the Policyholder, the Company
reserve-~ the right ta Interp[et the terms and oondltiohs ef [he Plan as It applies to this PoIicy. The Company has the
cole authority to approve or deny reimbursements under this Policy.
If this Policy or the Aggregat~ Excess of Loss Coverage Is terminated prior to the and of the Policy Period, the
Annual AgDregate Deductible will not be prorated !
TERM OF pOLICY
This Policy will be In force during the Policy Park
au~.omaticelly terminate at the end of the Policy Per
.... TERMINATION or unless the Company and the Pollcyf
event, the Company w~ll Issue to the Policyholder a Ran,
:l shown In the SCHEDULE OF INSURANCE and will
',d unless it has been terminated earlier as provided in
older have agreed upon terms to renew the Poli,~y, in such
~wal Endorsement and Schedule of Insurance,
25081 B
,00T¢29-2003 WED 02:56 P~ HEALTH OiRE SYSTEMS
UU'l'-~-~uu~ 'l'U~ U~;~ ff~
Ffi× NO. 4147711870 P.
~fl~ I'lO. Y. U~
PREMIUMS AND AG( iREGATE FACTORS
The SCHEDULE OF INSURANCE shows the Premium F~ates and Aggregate Factors for each coverage provided
h's Poll , The in rial remiUm is due on the Effeo§Ve Da · of this PoliCy and subsequent premiums are due
e~d~,retfl~st da~7~ each succePedlng month in the Po,icy P~riod. The entire amount ef the applicable premlum shall
=t or apply any premium paid which is less than the entire
be pad when due. The company Is not obligated ta aoc~
amount due for any period. Premium payments shall be ~edited first to any past due and unpaid premium, in the
Order In which due. Premiums are not considered paid un
A grace period of 31 days is allowed for the payment of ar
to npply any premium which Is received after the grac
payment. The payment of any premium will riel cause th~
il the premium payment is re~ived bythe Company.
y premium except the first. The Company. is not oblJg~tad
peri~ and may, at its discretion, return any premium
insurance under Ibis Poli~y to retie n n force beyond the
day before the next Premium Due Date. .
The Company may change the premiums and aggregate f~ators on any of the following dates:
(1) The effective date that the Plan is amended; r
. · Polio holder adds or deletes subsidiary or affiliated companies or divisions; or
(2) The ~fl'ectivs date thai th Y · % in an one month or 25%
e an ncrease or decrease in the number of Covered Umts exceeds 15 ~( Y
(3) The dar I "
ever any period of three consecutive months; or
(4) The date that the Company ia informed of a Clerical Error or discovers material misrepresentation of
underwritir~g information. The Cnmpany's actloniwill be in accordance with the Misstated Data Provisions
under GENERAL, pROVISIONS ef this Poli~y, '
Thc Policylmldar will furnish to the Company any hfcrmation which the Company d~ems is necessary to allow te
determine tim ameur~t of premium due under this Poll:y. [The Company may, at [ts discretion, examine any records
of the Policyholder at any reasonable time to confirm that premiums ere being calculated and paid in accordance
with this Policy. j
The Company w refund te the policyholder any overp~ym.e.n! of ,p?,m!,um mad,e
made Ollly for ~ho overpaymenls made during the Po lay ~"erlon in WnlC, n the error ~s uncowr a n p
Company. CLAIM pR~OVI$1ONS
The Company will have no obligation under the terms of ihls Pollay for the settlement of claims incurred by Covered
Persons.
The Poticyholder warrants, upon presentation of a Plan Benefit for reimbursement, thaf. ell monies necessary to pay
for the Plan Benefit have been paid te the Covered Perso~ or the provider of serviceS to the Covered Person.
The Po syho der wilt pay each claim incurred under th~ Plan by a Covered Person within thirty (30) days that
ado uate proof of less is provided to the Poticyholdm'. If~he Po oyho der fa[is to pay the claim within this time limit,
the~q this Claim w not be a covered Plan Benefit un,er this Poloy. The Policyholder will provide funds
necessary ~ pay claims and failure to a'6 so will ca, sa th a Policy to a,~tomatically terminate as pro4i~ted
for in Termination.
The Poli~Jholder will maintain records showing the co plate details concerning any and all amounts paid for
benefits not provided under the terms of the plan. Thus
deten'nlning Plan Benefits reimbumable under this Pellcy~
The Po icybelder will give written noti~ of claims to the pempany on the Company's customary proof of loss form
within thirty (30) days of the date the Policyholder becomes aware of the existence of facts which would reasonably
suggest the possibility that Plan Benefits will be ncurred which are subject to this Policy or which are at least fifty
ercen~ (50%) of tl~o Specific Dsductlbta. The Po iuyhold~r wi a so comply with other claim reporting requirements,
~rovded that ~he Company sends writt.en not!.c.e..to ~he Pol~l_d_eZ ol these requirements and allows the
Policyholder thirty (30) days to begin complying with the
Failure to furnish written notice will not invalidate or red me any claim, If it was not reasonably possible to pravlde
such written notice within the time period required. Hew
submitted for reimbursement mere than twelve (12) mont
war, in no event will the Company be liable for any claims
after the end of the Poliw PeriOd.
O8
,007 2§-2003 02:56 HEhLTH O RE SYSTEMS Fh× NO, 4147711870 P, 09
'OUI-~-ZUU~ 'J'U~ g3;Zb Y~ ~fl~ NU, r, zu
q'hc Policyholder will submit by the t5~h day of each men
by the Company, including but not limited to, periodic e
summary of all eligible claim payments processed by
covered under ~he Plan during the prior month. The
caloUlaLing and paying ali claims incurred under tho Plan.
Ne reimbursements will be mode under this Policy for k
payor for payments for so,vices which are not covered
The Company Is not obligated te reimburse for experts
experimsmal or investigative procedures which are nol
Uni[erJ States Government as generally accepted etenda,
TEEM
ay the Policyholder
The. Policyholder may terminate this Policy on any
advance written notice.
By the Company
At ils splion, the Company may terminate thls Policy on t
ti) the date it is determined thor the Policyholder ha
h all proofs, reports and supporting documents requested
~timates of doles pending ,,oder [he Plan and a monthly
he policyholder and the total number ef Covered Units
c, yholder will be responsible for the investigating, auditing,
soos for which the policyholder is not legally obligated to
oder the Plan.
as which are not considered medically necessary; or are
recognized by the Food and Drug Administration of ~he
ds of medical practice.
I~ATION
'nium Due Date by giving the Company at least 31 days
~e data that any one of the foilo~ng occurs:
failed to perform any of its duties or obligations under this
Policy; or
il~e date a petition In bankruptcy is fled wth re'pact to the Plan or the policyholder, whether voluntary or
(2) Involuntary, or the Plan or the Policyholder be~o~e subject to liquidation, receivership or ~onservatorshtp.
Automatic
This Policy will automatically terminate without catJficatlot required upon the earliest of the following dates:
the dote the Plan terminates;
or at the end of any grace period when the prom um due remains unpaldi or
(2)
(3)
(4)
tS)
(7)
The date the Policyl~older has failed to provide fl
Delegation by the policyholder of ~ duties uno
been approved by Ihe Company;, or
Whenever tho percentage of employees pattie
prep,31d plans, or Insuran~ plans exceeds 40~
Company has agreed ia writing to continue cove
The date the Plan is found to be in violation of F,
Sixty (60) days after the Effective Date if tho
information or materials requested by [he Coral
nature to a Iow the .C.,ompany te determine its I~
cause, the Company s aole liabll~ will be to re
for this Policy and less any claims or other e
amounts paid by 1he Company are greater t
Policyholder shall pay the amount of the daf
nde for payment of claims under the Plan; or
~r this Policy to a Third Pady Adminlstreter which has not
paring in one er more H~lth Maintenance Organizations,
of employees eligible tn participate in the Plan, unless the
'age; or
~deral law; or
Policyholder has failed to furnish the Company with any
any, Snch Infarmetlon or materials must be of reasonable
~bllRy under this Policy, If the Policy is terminated for this
urn any monies given by the policyholder as consideration
,.peases paid by the Company under this Policy. If such
~on the amount of the refund due the Policyholder, [he
eli to the Company within thlrly days Df notice fi.om the
Company. If repayment in ~ll Is net made.wi hie this thirty day period, the Company will be entitled to ....
~sess monthly a late payment fee equal to [i.$%] of the outstanding balance. ~
EffeCt of Termination i
In the event thio policy is terminated pr or to the end ell the Policy Period. amou, nts shown in the SCHEDULE OF
NSURANCE will not be prorated. The Specifis and ~ggregate Deductib(es will be applied as if the Policy had
remained n effect for the eh§re original Policy Period. ~l'he Company will not refund any portions of premium paid
by tho Pslisyholder whose Plan terminated during the POlicy parted.
The Company has no obligation te reimburse the Polioyloldor for any Flan Benefits which are paid after the date
this Poflcy is terminaled.
25681 7
.00T-29-2003 NED 02:57 PM HEALTH OfiRE SYSTEMS
00T-28-2003 TUE 03:25 PM
FaX NO, 4147711870
P, 10
GENERAL p~,OVISIONS
Entire palicy ~
The entire policy con~,ists of this Policy, the attached copy =f the policyhoider's apptl~tion, the attached coPY ef the
Plan and any arnendrnents, riders or endorsements.
Changes te the Policy
This Policy may be cl~enged at e~y time by a ~iffen agr~
provisions of fl~ts policy may be ~an~d or wa~ed only I
Company end o~ly In ~ ng. The Company will not ~
olher p~on.
Th~ Company may change any one or more or all of t~ ~e items shown i~ t~ SCHEDULE OF INSU~CE by
endorsement during the Policy Period In ~ich any chang* Is made to any appli~ble s~to or Federal law
which 0~nBe, in the sole opinion of the Company, may at ecl the Company's liabilitY under this Policy.
Pallas to the policy
Thio Policy is a contract between the Policyholder and th,
reJaf, ionshlp between the company and any person cover
Policy is to the policyholder, Any and all reimbursems
policyholder. This policy will not be deemed to make th~
[ha Policyholder and a third party.
P an D~cument
The Pollcyl~older w provlde to the Company a complete
Denumbnt will he made part of this Po lcy, The Policyhc
change to the provisions of the Plan. This must be subl
effective dais of the proposed change. The Co,,mpanY. w
factors f the Company determine~ that its liability un(lot
the company and the po1 cyholder cannot reach agreerr
not affect the Company's liability under this Policy an
cha~cJed, The Company's liability under the p~licy will m
~,nd until the Company has sent its written approval of su
emant between the policyholder and the Company, The
,y the president, e Vice president or the secretary of the
bound by any premise or represan~tions made by any
Company, This Policy does not a'¢a~e any right or legal
~d under the Plan, The Company's sole liability under this
~ts payable under this Policy will be made solely to the
Company a party to any contract or agreement between
copy of the Plan Document governing tho Plan; such Plan
Ider vail submit tc the Company, in writing, any p, rapeced
~itted to the Company at least thirty (30) days poor to the
,I have the right to modify premium rates and/or aggregate
,hie Policy has been affected by the change in the Plan, If
~nt with respect to the plan changes, the Plan change
t the Policy will ba edminlstared as if the Plan had net
t be affected by any such charges made to the Plan unless
:h changes to the pb~tcyhblder or its agent.
Third party Administrator
The, policyholder may retslr~ a Third Party Administrator perform some or all of ~ duties under this Policy. ~uch
o must be named In the Application which is attached to and ma?e part of this Policy. ,T, he
Third Party Admlnlstrat r ............ ~.- ..-, ~,,~-,,holder s duties under this Pshcy,
· · to ust be approves my tee [.;o pony tu Hu,,u,,;,,. ....... ~.
Th rd P~rty Adminl?lra r ,_m, .... ,-~ ,- .........o,,,, o~in~ aaraement with the Third Party Administrator as well as a
The Pohcyholder will provlne [o u~: ,.,,,,,v,~-~ - - ,-~ , -~- -
copy of changes thereto. These documenb are NOT mi de part of this Policy.
# thout making the designated Third Party Administrator a
Ize the Third Par~y Adm nistrator as the agent for the
agorot of the Company. Notwithsf~nding its appointment of
[igsted to see to the timely performance af its duties and
llolder will hold the Company harmless from any liability
or malfeasance by the Third Party Administrator,
,tot. This must be submitted to the Company at least sixty
changes to the designated Third party Administrator
:susa this policy {o automatically terminate as provided
Without waiving any of Its rights under this Policy, and
l~rly to this policy, the company agrees to recog~
Policyholder. The Third party AdministratOr is NOT the
a Third Party Administrator, tl~e Policyholder is still ct
obligations under this 'policy, Furthermore, the Poli~
arising from or rela~d to any negligence, error, omisslor
'[he Policyholder may chang,= Its Third Party Admlnistn
(60) days prior to the effective date ~f ~hange. Any
without prior wri{ten approval by the Company will
for in TERMINATION,
Reporting
The policyholder will furnish the Company with any ir
covered under this Policy, Such information must be r,
satisfactory to the Company.
Records
' The policyholder will malntan records of all Covered
period of seven (?) years after term nation of the Policy
Company as needed for tho Company to determine its I
AuStt
formation required bY the Company portal,sing to the ds. ks.
~ceived by the Company in a form and during a time pence
~erson~ uhder the Plan during the Policy Period and for a
The Policyholder will make alt such records available Io the
ab ty un,derthls Poli~y.
25681
,00~-29-2003 WED 02:57 PH HEALTH OflRE SYSTEHS FflX NO, 4147711870 P, 11
--007-28-2003 TUE 03:26 P~ ~z Mu, r, ,~
-Fh~ company er its authorized representative w~l have
~ , , e Third Party Administrator or any other p
F eiicyhotder t ~ ,
artalnil~ tO the mat era which affect [he Compa.n. ys
i~aymentg~f any reimbursements under this Policy will
Company,
Clerical Error
Cieri~l error, whether by the Policyholder or the Comps
he right to audit, at its own expense, the records of {ho
rson who is responsible far the administration of the Plan
ability under this Polioy, The policyholder agrees that
~ondiUoned upon the results of any audit requested by the
~,y, in keep ng any records pertaining to the coverage, witl
tinue aoverage ethane[se vel dly terminated. Any clerical
the Company mUSt be corrected and prompUy reported to
not invalidate coverage olherwise validly in force nor cot
error in data that the Policyholder or its agent provided t~ 3f rer. eipt of corrected data decide the correotlve course of
toe Comp~my, The Company w II within fifteen (16) days
action under the terms of Misstated Data provision below,
Concealment, Fraud
'mis entire P011(~y will be void.;, - --t "-e IC, om"a~" determines that [he Poticyholder or ils agent
· an reimaurssm~n, [. . ,v - - '
1 if, before or a.Eer makingy f~t s c mstance concermng this Policy, mslud ng any
( ) has concea eo or misrepresented any material --r- or ir u
V, sses under the Plan; or agent.
(2) in any case of fraud bY the pollcyholder or its
Miss af~ed Dat,a ...... :.... lnfermati~,n ~rovidad by the policyholder or its agent in the issuance~
T~e Company nas relied upon [.ne un.ua~w,.u.u s" ~3~Tr; v~l ah, if known by the Company prior
af this Policy. I[ subsequent Imormation become
this Peil~y, wm~ld have effaced the premium rates, ;;legate factors, specific or aggregate deductibleS, terms or
any ether conditions [or coVerage, the Company will hav~ the right to
(1) rase[nd the Policy as of the Effect ve Date or I
u rates, aggregate factors, spastic or aggregate deductibles, terms or any other
(2) adjust ti~e prem~ m............. ['' ,..ovldinn written notice to the Policyholder.
conditions for coverage ss ot me ~]Tec[~,v= ~a,: ~, ~.
the Cam an s sole I ~ility will bs to return any mor~ies given by the Poli~holder
In the event of policy rescission, P Y .............. ~'~ b" the Oomaany under this Policy, If
" , · ' ' d less an oialms or mar ex~.~ ~.~,~ · r
aS consideration for th~s .P, ehcy_an Y ....,-- ,~-P~- the amount of the refund due the Policyholder, the
me uom any ars Broa~ -~ -
such amounts paid b~ .P ........... '-~ '~"-n" within thirty days of notice from the Company. if
Pa cyholder shall pay !ho a.m ...... .~ .... .~ m~ ComoanV will be entitled to assess monthly a late
repayment in full Is no[ maes Wlml~ u'~ts t,...ty.u.~x p,.,1~-, --- ~ -
payment fee equal to [1.5%] e[ the outstano~ng nalaoce.I
lose vsncy .......... '-Ivershi" voluntary p an of ,arrangement w[{h creditors, er
The insolvency, banKruptCy, Tinancta[ ~mpalrment r~ ~,r ..
ts Third Party Admini-~atot will net Impose on the Company any liability ether tllan
',. ' of the policyholder or[ , - the Cam any liable to the
dt~,solut~ofl .......... ~,.~ u.~^~,~,~nv of the Po cyholder will not make p
the Ibbility ae. ne~ ,n. [,n~.~y.~,,,~:,:~t~;~,~'~d ~sons under the Plan.
creditors of the ~olloynolueh pamu-..,.,~ ]
Liability .......... obligation or newer uhder thls policy, to directly pay ~?Y
The Company will riot novu ~.y ~ _ ~r 4,.- ~ ~..~,aa,~, ~'~,ln tlabiJJN is to me 'r'OljCynolaer. r~uum~a
prevlder of services or supplies to a Coverecl i-,arson. Hm ,..o.,~,..~ .......-~
· rmit a Cove,'ed pemoM o~ any prey der of services or supplies to a Covered Person
this Policy will be o.o~sl, me,,d to pe, _, ,,.~. ,-. ...... The Comaany is not a party to the Plan or to a,..ny
· direCt ri n! oi action agama[ u~a ~..u..~...,,~ ..... . .
!~l~ue. aThe Paid'holder may not assign relmbursen'~snts under ,h,s Poi,c, and the C~mpany wi, no, resogn,ze
any sucl~ assignments.
Taxes
The payment of ralmbursementS under this policy will
('1) arty taxes which might be paid or payable by th~
(2) any tax liability, interest or penalty imposed by
The Polioyholder agrees
(ti hold harmless the Company from any tax li~
coverage provided under the Plan other than
this policy; and
(2) reimburse the Company for the amount of
Company as the result of such tax assessmer
Policyholder receives the Company's noUficatlc
insluda:
Policyholder; or
ny regutatacy or taxing au{herity,
bllity ass~sed against the Company on the basis of the
/ tax levied upon the Company for the premium due under
such tax ~ability interest, penalty or cost incurred by the
Such reimbursement shall be due and payable when the
that raimbursemer~t is due.
9
256~1
., .00 -29-2003 NED 02'.57 PN HE L'I'H OBRE 8¥STEH8 FA× NO, 4147711870 P. 12
.... '~J~l--co-,'003'""l'U~ U,li,"O ri1 rna, nv, "
No~ioe
For tho purpose of any notice required from the Compan
Party A~lministrator will be considered no§cu to the Pellc~
not ce to the Th rd Party Admin strator, For the pt~rpase ¢
provisions of this policy, neither notice fram the Pal cyh¢
under the provisions of this Policy, notice to the.?'hird. '
~older. and noti~ to the Policyholder will be eansloureo
any notice requirement from the policyholder under the
taler to the Third Party Administrator nar notice frem the
Third Party Administrator to the Policyholder will be cortaid
Other Insurance
Tho amounts otherwise payable under this Policy shall b
indemnity which the policyholder may be untitled to recetw
Waiver · ' dar
Failure of the Company to strictly enforce ~ rights un
freqLlen~ or similarity of the circumstances,
Arbitration
All disputes between the policyholder and the Compa
Policyholda~'s principB place of business. The Polieyhol
the two appointed arbitrators sh~ll appoint a th ~. E the
be made by un authorized officer of tho American Art
accordance wth the ru es of. tho Ameflean Arbitration
erbitrator~ may be entered in any coul't hay ng jurisdiction
this Policy.
Evidence Of Goad Health
Any a~/Iount of Plan BenefiL~ paid by the Policyholder
into thc Plan w{thin the ~ime period specified in the Plan
[his P~licy unless uvidenCe of goad health for such
Company prior to the date on whicl~ ~he Plan ~enef'~.was
red notice to the Company.
~ reduced by the amount of any ether reimbursement
~wlth respect lo the Company's Jiabilit~ under this Policy.
3la Policy shall not waive any such right, regardless of the
~y are to ba aecided by arbitration in the city of the
~r and the Company will each appmnt cna arbitrator and
va cannot agree on third arbi~ator, the appointment shelf
,itration AssoCiation. The arbitration shall be settled in
,escalation, Judgment upon the award rendered by the
This provision wilt a~rvive the termination or e~piration of
any employee/member or dependent who does not enreJJ
~or etlgiblll~ Will be disregarded for reimbursements under
,Ioyeeknember or dependent has been approved by the
~curred,
25681 10
~ ,00T~29-2003 ~IED 02:57 ?H HEALTH CARE SYSTEtlS FAX NO. 4147711870 P, 13
-- (J~T-28-200~"T~ 03;27 P~ I-~ ~u, ""
Exhibit
. . · . lationsh~pswRh~ustomcrs, Prol~Otmgthepdvacyof
~ha[ ln~or~aL~Otl i ~ ,. , ...... :.-- lhe ~urRy olnOnp~b~le p~rso~ ....... ~..~li~v a¢OllCS to all ACE
both ~lulo ACB Comp , · ~ - ..... ~+~- ACE ~U~ of Companl~.
~NI~ORM~ dq~c~ding ~ ~ -'--. eoBeo~d w th rcsp~t to m~stom~r~
or purchased, ~nd may in~lu~e:
· ltfformation rcgarditxg a cosmmOr',q mmsactions with
as policy coverage, l',rcrake, payment histol7, moto~
' . others; such
ACB Compardos and t u.~ affihatcs, or with
v.hiele r~ordt; and
ch ;as a ~stc~ct"s c~cd[t h~sto~,
ACE Companies wit not dlscloso any pa sonal ~o~a ~u~er or ol.h~so as may be roqmred or pm m~ttcd by
. ' ,~ to tho
law, ·
AC[g Companies tony disclose :~ o'f fl~e information tl~at is r~Civ~ to companies fl~at perfo~ mt~kcting scrwcm
on out behalf or to othor flnaomal t~dtutlons w~tk w~gh wo have j omc marketing
. , - ...... cU~c~RMATI ON ~OI zEC'I'E~
RTGiI,~~ ~y'~ ;~, m -"
[ ...... :- :,--o~aaL A custom~ may rcwcw mid
. · ' ccur aud ~tvcn~ o[~siom~ mmmxa ......
Mamtmnmg tho a ~ ............. ~;o- of ACE ~.~a,ues,
con'~ot thoir personal ln[ongil, o~ m m* pu~o, 't
a claim or a c6minal or ~ivil pro. Ming.
~tl I,:NI'I M ,1Tv' &N r} SECtl [~ITV.
Co~npanio~, or others who haw a need to know t~t in
cloa ro~ic, and procudural safe. ar& s~g bo ~intai'
ACE American In,suranco Company
ACB American Lloyd~q Insurance Company
AC:t~ lJgh PriwcY Nottc~: 3/8/02
Irict~d to ACE employees, emBloyccs of affiliates o t'ACB
;onnation in order to staVic¢ a p:rtic~alar ae,couut, Pl?ioal,
led at all times to protect personal in fonmhon o£ ACI:
e ACE USA PrivacY policy may bo referred to ACId.
30K, P.O. Box 41484, Philadeyhia, PA 191 O1-1484,
h~mrance Company of Iqorth America
Pacific Bmployers Msuraace Company
. .0,0T=20-2003 WED 02:$8 Pti HEALTH CARE SYSTENS FAX HO. 4147711870 P, 14
; OLyl-_PS:.9003 '-ijE]]~:71 ~rl-- i~ft~ rtu, '
ACF, F. mploycrs Insurance Company
A~.E Fkc Underwriters l~urancc Compm~
ACE Indemnity Inm~rmtce Company
AC, E Prop~r~ ~ C~mally l~mm~ ~ Company
Baakol~ Standard Fire Matin: Company
Tllint)is Union lnsarancc C~xpany of NA
INA SUrl~lu~ It~urauec Company
lndcnmi~y Iuswance Compmy of NoxXh Amcfica
Industrial Undmmritcrs Insurm)co Compmw
We~tehester Fire Insurance Company
We~fl'~ester Surplus Lines Instance
',ore,any
~C~ Ammiean R~nsur~ce Company
~tu~ lndem~,i~ h~surancc Company
~tu~ Reiu~rm~ Compmw
~tlantie Employes lnsuran~ Company
kCE lnmrknco ~mpany of lllinois
kOE I~$~at~ee Company of~e Midwest
KCE ~ar~ Con,prow of Ohio
~CE lns~ Company of Tox~
ZACY ?OLICy
· ' mall a roeiate~ your busi.¢~ and want to make sure you know ~at we treat t?e
NortkWmd. I,l,C, ~ Y P~ ........ x ---~de~ti~lv. Federal and Stat~ laws restnet fl~e wa~ m
j llFo[mation yOU giVe US prol'cs~/oI~ally am* ~m,, ,~- ~ . ,
.... It is hnpo~t ~at you know how we intend m ~ao par~on d
wMeh client Information can be abated. '
hx~arm allen we m~ collect from you i~a tho nomml ]~urse of our doing baslncss and ia compllan~ w;th
, .. I -' '.-e--~at~oa about our eustomm's from thc
.... tc law~. We ma~ ~ll~t nonpuone g~sonTM :my.- , .... . ~
Pede~ aad Sla . ,~., ~ ....... ,: ...... ,-eeeive ~o~a~co~t do~m~tanon wmcn may m~l~a~.
condition. (2) I fformation about o~ customer's a-a~cfions wi~ u~, our a~liates and olhors. (3)
lnfom~ation we may roeolve from a ~stom~-'s reporting ageney,
oar policy not ~o ~iaelose ~tonpublio pn~onal i~o~atmn ~flaout our ~tomer s ( or fenner
eustmneCs ) ex.pt to our affiliates, or othem ~s pe :mitred by law, We haee policies m~d proeod~res in
about ot~r em~tom~"s ( or fenner ~stomer s ) wbtfl~
plnec to safe guard nonpublic personal infermation
include (B r~stdzfi~g a~s to such nonpub~ p~
el~tronie m~fl procedural .~afe~ard~ ~at ~mply ~
pemonnel infommtion,
rmmM io. fomaation trod (2) maintainiag physical,
ith legal r~uiremcats to safeguard 9uch nonpub)