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Home My WebLink AboutQBE Insurance/Auxiant-Alliance Benefit Group QBE INSURANCE CORPORATION STOP LOSS- renewal Administrative Address: QBSL—0123 (07-02) Wall Street Plaza QBE INS 88 Pine Street, 16th Floor CORPORATION New York, NY 10005 Renewal Amendment This Amendment is attached to and made part of the Policy specified below. It is subject to all of the Policy provisions that do not conflict with its provisions. Policyholder: City of Oshkosh Amendment Effective Date: 01/01/2014 Policyholder and We hereby agree that the Policy is amended as follows: A. The policy number of this policy is changed from: LGS00526-13 to LGS00526-14 B. This policy will continue in force for a new Policy Period, beginning on the Amendment Effective Date and ending on the Expiration Date shown below. C. The SCHEDULE FOR EXCESS POLICY is deleted and replaced with the following Schedule. 1. Policyholder's Principal Office Address: City Hall.215 Church Street Oshkosh WI 54903-1130 (street) (city) (state) (zip) 2. Expiration Date: 12/31/2014 3. Attached Endorsements: WI Endorsement QBSL-0130(09-02) 4. Third—Party Administrator(for purpose of claims administration under the Plan): Name: Auxiant-Alliance Benefit Group Medical Services Address: 2450 Rimrock Road,Suite 301 City, State,Zip: Madison, WI 53713 Telephone: (800)245-0533 5. COVERAGE The Coverage shown applies only during the Policy Period and is further subject to all the provisions of the Policy. A. SPECIFIC EXCESS LOSS COVERAGE ® Yes, included ❑ No, not included 1) Coverage to be included: Yes No ® ❑ Medical • ❑ Prescription Drugs ❑ ® Dental ❑ ® Vision 2) Specific Attachment Point(unless adjusted by Endorsement) ® Per Covered Person:$75,000 ❑ Per Covered Family: $0.00 ❑Aggregating Specific Deductible:$0.00 3) Specific Reimbursement Percentage: 100% QBSL—0123 (07-02) QBE INSURANCE CORPORATION Page 1 of 4 STOP LOSS ft& QBSL—0123(07-02) QBE INS CORPORATION 4) Specific Policy Period Maximum Reimbursement per Covered Person: Unlimited upon satisfaction of Specific Deductible. ® Of this amount, reimbursement for treatment of drug or alcohol abuse will be limited to: ®The terms,conditions and limits as stated in the accepted plan document. ❑ days ❑ days, up to$ ❑Treatment of drug or alcohol abuse considered as any other illness 5) Basis of Specific Excess Loss coverage benefit payment(Benefit Period): Plan Benefits Incurred from: 01/01/2014 through: 12/31/2014 And paid from: 01/01/2014 through: 03/31/2015 Plan Benefits Incurred prior to the Effective Date(Run-In-Period)will be limited to: ❑$N/A per Covered Person ❑$ N/A for all Covered Persons combined 6) Premium Rates (per month): Covered Unit Description Amount Single 159 $88.73 Family 400 $216.39 Total 559 7) Minimum Annual Specific Premium: N/A. Estimated specific annual premium based on quoted enrollment is$1,207,969.00. B.AGGREGATE EXCESS LOSS INSURANCE ® Yes, included ❑ No, not included 1) Coverage to be included: Yes No ® ❑ Medical ❑ ® Dental ❑ ® Vision ® ❑ Prescription Drugs ❑ ® Weekly Disability Income Maximum ,per covered employee per Policy Period ❑ ® Other: 2) Monthly Aggregate Factor: Weekly Covered Unit Prescription. Disability Description Medical Dental Vision Drugs Income Other Total Single: X X $762.22 Family:, X X $1.942.90 3) Number of Covered Units: ® Quoted ❑Actual Weekly Covered Unit Disability Description Medical Dental Vision Prescription Drugs Income Composite: 559 559 4) Minimum Annual Aggregate Attachment Point:$10,780,236(Estimated) (12 times Monthly Aggregate Factor(s),times total Number of Covered Units) QBSL—0123(07-02) QBE INSURANCE CORPORATION Page 2 of 4 STOP LOSS QBSL—0123 (07-02) QBE INS CORPORATION 5) Aggregate Reimbursement Percentage:100% 6) Individual Claim Limit: $75,000 7) Maximum Aggregate Reimbursement(per Policy Period): $1,000,000 8) Basis of Aggregate Excess Loss coverage benefit payment(Benefit Period): Plan Benefits Incurred from: 01/01/2014 through: 12/31/2014 And paid from: 01/01/2014 through: 03/31/2015 Plan Benefits Incurred prior to the Effective Date(Run-In-Period)will be limited to: ❑$N/A per Covered Person ❑$N/A per all Covered Persons combined 9) Premium Rates(per month): Covered Unit Description Amount Composite $2.40 10) Minimum Annual Aggregate Premium: N/A. Estimated annual aggregate premium based on quoted enrollment is$16,099.00 6. Eligible for coverage: Yes* No • El Retired Employees • ❑ COBRA Continuee • ❑ Disabled Persons • ❑ Employees who are not Actively at Work ❑ ® Late Entrants • ❑ Transplants(secondary El ® Other: *All "Yes"answers must be supported by current disclosure information you provide during the renewal underwriting period. 7. Additional Information a. Policy Information: 1. Your PPO Networks are Trilogy with HPS and First Health. 2. Your Utilization Review Provider is AHH.. 3. Eligible Expenses do not include any expenses for solid organ or tissue transplants that are covered under the National Union Fire, or that would have been covered in the event the Transplant Rider is no longer in force. Transplant coverage under the Excess Loss Policy is extended to the Plan as secondary. All notification provisions of the Policy shall apply. b. Special Limitations: N/A QBSL—0123 (07-02) QBE INSU.RANCECQRPORATION Page 3 of 4 STOP LOSS QBSL—0123 (07-02) QBE INS CORPORATION c. The definition of Specific Lifetime Maximum Reimbursement in the Definitions Section of this Policy, is deleted and replaced with: Specific Policy Period Maximum Reimbursement means the maximum amount WE will reimburse YOU with respect to any Covered Person under this Policy during the Policy Period shown in the Schedule. The Policy Period Maximum excludes the Specific Attachment Point amount. The Policy Period Maximum will not exceed the lesser of: 1. the amount shown in the Schedule;and 2. the maximum benefit amount set forth in the Plan. d. Section II, Specific Excess Loss Coverage,is deleted and replaced with the following: Section II,SPECIFIC EXCESS LOSS COVERAGE WE will reimburse YOU for Plan Benefits Paid in excess of the Specific Attachment Point, not to exceed the Policy Period Maximum Reimbursement amount shown in the Schedule. WE will reimburse YOU after YOU have provided an acceptable proof of loss and satisfactory proof of Paid Plan Benefits. The Specific Excess Loss benefit applies to a Policy Period or fraction thereof(due to termination). As determined with regard to each Covered Person, it is the lesser of: 1. the Policy Period Maximum Benefit;and 2. eligible Plan Benefit Payments made with regard to a Covered Person, less the Specific Attachment Point,the result of which is then multiplied by the Specific Reimbursement Percentage. In addition,the Specific Excess Loss Benefits Payable under this Policy will be reduced by the Aggregating Specific Deductible. 8. Minimum.Plan Enrollment: N/A Covered Units, or 75%of initial enrollment ACCEPTED BY THE POLICYHOLDER: /� /� f Signed at CSh kQS h f fri// L-1-1 07 Os n k0S L) City, State Policyholder(correct legal name) Date i i ' LI, / Z0 13 �� / i� By(Officer's name and title) g4 4j' Policyholder's Broker/Agent of Recor at Anne- i&e2.c >-7 - to Print Broker/Agent of Record I/i '� o ACCEPTED BY THE COMPANY: (�, �`�' Signed at �C�1 \\Q(ALlc 'CCI4 /X+of On behalf of the Com ny / QBE A&H, LLC Date I 0 I V-I Steven L.Gransburvc Senior Vice-President Head of Health &Accident QBE North America By(Officer's name and title) QBSL—0123(07-02) QBE INSURANCE CORPORATION Page 4 of 4