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ZURICH
RENEWAL APPLICATION FOR STOP LOSS INSURANCE COVERAGE
Applicant (Policyholder): Citv of Oshkosh
. .
Proposed Effective Date: 01101/2006
Address
215 Church Avenue
Initial Premium Deposit: $
City, State, Zip Code
Oshkosh, WI 54903
Telephone Number (
)
Coverage Applied For: Specific Stop Loss and Aggregate Stop Loss
SCHEDULE OF STOP LOSS INSURANCE
Enrollment at Effective Date: Employees 652 Single 179
Policy Period from 01/0112006 through 12/31/2006
Minimum number oflives and/or participation 50
EE + One ~ Family ~
SPECIFIC STOP LOSS
SPECIFIC COVERAGE: Yes X- No
Specific Deductible: $100,000
Lifetime Limit of Liability per Covered Persou: $900,000
Claims Basis: 0 Iucurred and Paid (12/12) 0 Paid X Other 12/15
Benefit Period: Eligible Plan Benefits Incurred from 01101/2006 through 12/31/2006
And Paid from 01/01/2006 through 03/31/2007
Specific Percentage Reimbursable After Deductible: 100%
Specific Advance Funding: Yes X- No
Losses Incurred prior to the Policy Period will be limited to $ N/A
Aggregating Specific Deductible: $N/A
AGGREGATE STOP LOSS
Aggregate Coverage: Yes No K--
Claims Basis: 0 Incurred and Paid (12/12) 0 Paid 0 Other
Benefit Period: Eligible Plan Benefits Incurred from through
And Paid from through
Aggregate Percentage Reimbursable: N/A
Monthly Aggregate Ileductible Factors: N/A
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
Annual Aggregate Deductible for anyone Policy Period means the greater of:
(1) The cumulative monthly total of Covered Units multiplied by the Monthly Aggregate Deductible Factors; or
(2) The Minimu~ Annual Aggregate Deductible
Limit of Liability for the Policy Period N/ A
Loss Limit Per Person under Aggregate N/A
PREMIUMS
Specific: Monthly
Aggregate: . Monthly
Minimum Annual Specific Premium
$28.53 Single $53.17 EE + One $80.77 Family
N1A
$343,836
PLAN BENEFITS INCLUDED
Specific: L-Medical
.L-Free Standing Drug Program
_Other
Aggregate: ~Medical
_Free Standing Drug Program
_Dental
_Vision
_Other
Enhanced Transplant
ENDORSEMENTS INCLUDED
Third Party Administrator:
Prairie States EnterprisesJnc
If coverage is accepted, this SCHEDULE OF INSURANCE will become a part of the Policy.
INSURANCE FRAUD WARNING
Any person who with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application
or files a claim containing a false or deceptive statement, or conceals information for the purpose of misleading, is guilty of'
insurance fraud and is subject to criminal and/or civil penalties. -
The applicant hereby applies for STOP LOSS insurance coverage and:
1. Represents that the answers included in this Application for STOP LOSS Insurance Coverage have been reviewed and are true
and complete; and
2. Understands and agrees that the insurance applied for shall not become effective until the Application for STOP LOSS Insurance
Coverage is approved by the Company and the initial premium deposit is received; and
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 the insurance, including any premium which may accumulate between the effective date of the insurance and the date the
Policy is issued.
This Application for STOP LOSS Insurance Coverage, as it may be amended, will become part of the Policy, if issued.
Signed at aYOf~20Dc;
Signed by Title Dtver-kr Cff2 ~1/4f'Sfra+rVe..-
~aVf'-c..e,~
Approved: 0 Yes
o No By:
Date:
U-MSL-307-A WI (3/02
Page 4 of 13
APPENDIX A
FEE SCHEDULE AND
FINANCIAL ARRANGEMENT
FOR
CITY OF OSHKOSH
Fee Schedule For Period:
January 1, 2006 through December 31,2007 (Two Plan Years)
The Employer and the TP A hereby agree to the compensation schedules set forth below. as being the. sole
compensation to the TP A for any of its services that relate to the Plan. Fees shall be invoiced and funds transferred
electronically as a debit upon the first of the month or previous Friday should the first of the month fall within a
weekend or other federally recognized holiday. . .
Services
Fees
Fee Basis and Schedule
Medical Claims Administration
$16.50
per covered eligible employee or
COBRArecipient
Provider Data Maintenance
$1.00
per covered eligible employee or
COBRA recipient
Utilization Management
$4.50
per covered eligible employee or
COBRA recipient
Large Case Management
$125.00
per hour
Hospital Bill Audit/Negotiation
15%
of savings
Subrogation
25%
of recoveries
Plan Document
$2,500 plus Printing and Shipping
Three Month's Fee for processing incurred but notreported claims after termination of contract.
Check customization, . bank fees, special statistical reports other than those enumerated in this contract, medical
underwriting, new taxes assessed against the Plan, legal services, specifically installed phone lines, dedicated data
processing systems, Employer specific data programming, fees for obtaining medical records, plan documents, printed
materials (including but not limited toID cards) bearing the name of and/or logo ofthe Employer, materials or other
services mutually agreed upon, will be billed separately. . '.
Accepted this !1J1day of ~2005.
By:
V,y>tc.
. . . ,
Title:'.'-b~rC:Lkr err ~;'Mt<)fy~Rve- ~I/{Cc:s ,
Print Name:
12/9/05