HomeMy WebLinkAboutStop Loss of Insurance Coverage
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ZURICH
APPLICATION FOR STOP LOSS INSURANCE COVERAGE
Applicant (Policyholder): City of Oshkosh
Proposed Effective Date:
January L 2005
Address
215 Church Avenue
Initial Premium Deposit: $
City, State, Zip Code
Oshkosh, WI 54903
Telephone Number (
)
Coverage Applied For:
Specific Stop Loss
SCHEDULE OF STOP LOSS INSURANCE
Enrollment at Effective Date: Employees QZL Single~
Policy Period ITom January 1, 2005 through December 31, 2005
Minimum number oflives and/or participation 50
EE+ One 184
Family 290
SPECIFIC STOP LOSS
SPECIFIC COVERAGE:
$100,000
$900,000
Yes X- No - Specific Deductible:
Lifetime Limit of Liability per Covered Person
Claims Basis: Incurred and Paid (12/12) Paid [gJ Other 12/15
Benefit Period: e Eligible Plan Benefits Incurred ITom January 1,2005 through December 31,2005
And Paid ITom January 1,2005 through March 30, 2006
Specific Percentage Reimbursable After Deductible: 100%
Specific Advance Funding: Yes X- No-
Losses Incurred prior to the Policy Period will be limited to $
Aggregating Specific Deductible: $ N/A
N/A
AGGREGATE STOP LOSS
Aggregate Coverage: Yes - No X--
Claims Basis: Incurred and Paid (12/12) Paid
Benefit Period: Eligible Plan Benefits Incurred from
And Paid ITom
N/A
N/A
Other
through
through
Aggregate Percentage Reimbursable:
Monthly Aggregate Deductible Factors:
Minimum Annual Aggregate Deductible: N/A based on number of initial Covered Units multiplied by the
number of months in the Policy Period multiplied by 90% multiplied by
the corresponding Monthly Aggregate Deductible Factors
U-MSL-307-A WI (3/02
Page 3 of 13
j.
, Tucker, Devpnne M.
From:
Sent:
To:
Cc:. .
Subject:
. Greg Bass [gbass@hcaresys.com]
Tuesday, January 04, 2005 9:54 AM
Rae Anne Beaudry
dtucker@cLoshkosh.wi.us; Andy Serio; Mary Skaleski
Fwd: Fw: City of Oshkosh - Application
City of Oshkosh 1.1.05
. Appli...
Please print out this.email and attach to the application. 've
advised DeVonhe that the application appears in order and correct to me,
butjust for security sake, to check the premiums stated against current
billed to check if the level of increase is what Andy was told. This
email confirms from Steve at PS that Zurich is on the risk and
therefore, may be important should any issue arise- Thanks-Greg
»> "Steve Graue" <sgraue@prairieontheweb.com> 01/04/0511 :55AM »>
Zurich has accepted the group. They know they group is renewing and
coverage is in place.
Zurich no longer uses a disclosure form for its groups. Instead, we
notify
them that the group will be renewing and they simply issue an
application
once the rates have been agreed upon. Devonne has it and will get it
signed
and return it to me. Zurich will issue the policy when they have the
app.
Please let me know if you have any questions about the what appears on
the
application.
Thanks
Steven R Graue
Prairie States Enterprises, Inc.
Sales & Marketing
(800) 232-2899
sgraue@prairieontheweb.com
----- Original Message -----
From: "Steve Graue" <sgraue@prairieontheweb.com>
To: <dtucker@ci.oshkosh.wi.us>
Sent: Tuesday, January 04, 2005 9:37 AM
Subject: Fw: City of Oshkosh - Application
> Devonne,
>
> Here is the application from Zurich. If you could please have it
signed
and
> returned to me, I'll get it to Zurich and they will issue the
policy.
>
> Please send a copy to
>
> Steve Grau
1
-, > "Prairie States Enterprises, Inc.
. > 101 W Grand Ave Suite 404
> Chicago, IL 60610
>. .
> Thanks for you help.
>
2